The Psychological Burden of Chronic Dermatological Diseases

The psychological burden of skin diseases should not be ignored as it can potentially affect the overall disability experienced by the patient. The relationship between skin diseases and psychiatric illness is bidirectional and is manifested as cause as well as effect. Dermatological disorders like acne, alopecia areata, psoriasis and vitiligo often have a severe form that causes disability and exclusion from a normal life .Psychiatric disorders like stress, anxiety and depression are seen to be instrumental in development and progression of dermatological diseases and this study is to ascertain the association between depression and anxiety with various dermatological diseases. Methods: A total of 100 patients, visiting the Out Patient Department of Dermatology, who are referred to Department of Psychiatry for the evaluation of Psychiatric symptom, were included in the study after obtaining written informed consent. Psychiatric morbidities were screened using Brief Psychiatric Rating Scale (BPRS), Hamilton Depression Rating Scale (HAM-D) and Hamilton Anxiety Rating Scale (HAM-A). Results: The present study envisaged to explore a relationship between chronic dermatological diseases and psychiatric morbidities. Prevalence of psychiatric comorbidities was maximum in psoriasis (75%) followed by urticaria and Acne Vulgaris(65% each), Alopecia Areata(60%) and Vitiligo (50%). Depression with anxiety disorder (27%) followed by moderate depression with anxiety disorder (23%), anxiety disorder (10%) and severe depression with anxiety disorder (3%) were the most common psychiatric comorbidity. Conclusion: The present study was carried out to evaluate the prevalence of psychiatric morbidities among patients with different dermatological illnesses. The growing relationship between skin and psychiatry has given birth to a new branch of medicine, i.e. psychodermatology, which marks the mutual relationship and interaction between psychiatry and dermatology.

Quality of Life and Suicidality in Obsessive Compulsive Disorder as Evaluated by WHO BREF

Obsessive Compulsive Disorder (OCD) is a chronic, distressing, anxiety disorder associated with significant functional impairment. Patient with OCD often suffer from one or more co-morbid disorders. Major depression has been the most common co-morbid syndrome. OCD in association with comorbid depressive and anxiety symptoms, increased severity of obsessions, feelings of hopelessness and past history of suicide attempts have been associated with worsening levels of suicidality. As per data Thirty-six percent of the patients of OCD report lifetime suicidal thoughts and 11% have a history of attempted suicide. There is a reasonable probability that the patient of OCD has suicidal thoughts, plans or a suicidal attempt in the past. Methods: This study was conducted on 50 patients diagnosed with OCD as per ICD 10 criteria, both outpatient & indoor, from department of psychiatry, Teerthanker Mahaveer Medical College & Hospital, Moradabad, Uttar Pradesh, India. A socio-demographic proforma, Hamilton Depression rating scale, Yale Brown Obsessive Compulsive Scale and WHOQOL-BREF-Hindi version were administered. Results: The majority of the patients suffering from OCD were below 40 years of age. The prevalence of OCD was maximum in housewives and they mostly belonged to 25-34 years age group. All the patients who had current suicidal ideation showed low scores on all the domains of Quality of life. Also, the patients who had attempted suicide in the past showed same low scores on all domains of Quality of life and both results were statistically significant. Conclusion: Hence the assessment of Quality of life in OCD patient is a strong predictor of suicidality in these patients

Somatization disorder: Are we moving towards an over-generalized and over-inclusive diagnosis in DSM-V?

Introduction: The confusion around the diagnosis of ‘medically unexplained symptoms’ has lead to a paradigm shift in criteria for diagnosis of somatization disorder. Aims: 1. To compare the socio-demographic variables in patients of somatization disorder 2. To compare the levels of depressive and anxiety scores of patients of somatization disorder along with the severity of disorder. Material and Methods: Somatization patients visiting the psychiatry outdoor of TMMC & RC, were randomly selected and diagnosed as per DSM-IV TR. After obtaining informed consent and applying exclusion criteria, demographic and clinical details were obtained on a self designed Performa. The HAM-A scale and MADRS scale were applied to calculate anxiety and depression scores. Results: The prevalence of somatization disorder was 2.35% in men and 6.7% in women. Females were significantly higher in number. Headache was the chief complaint. The anxiety scores and MADRS scores were highest in patients complaining of chest pain. The HAM-A and MADRS scores increased significantly as number of complaints increased. Female patients and patients belonging to rural background had significantly higher number of complaints. Illiterate patients had a significantly higher duration of illness. Conclusion: Somatization disorder comprises unique group of patients with high co-morbidities and longer duration of illness. It is imperative to identify and clarify severity of this subgroup as treatment decisions need to be modified accordingly.

Tuberous Sclerosis with Bipolar Disorder Mania: Genetic Perspective.

Tuberous sclerosis or tuberous sclerosis complex (TSC) is a rare multi-system genetic disease that causes non-malignant tumors to grow in the brain and on other vital organs such as the kidneys, heart, eyes, lungs, and skin. Non specific psychiatric symptoms occur in substantial number of patients with Tuberous Sclerosis. Tuberous Sclerosis is a rare disorder and most of patients present with behavioural changes, which may be mistaken for variety of psychiatric disorders, though Mania has been rarely reported. Here we report a case of Tuberous Sclerosis with classic radiological findings and manic features. Skin showed typical facial angiofibromas and Ash leaf macules and MRI displayed classic Tubers. There have been very few case reports of Bipolar disorder manic phase and all studies have till now proposed the anatomical relation of tubers in the brain as the underlying mechanism of this psychopathology. The neuroanatomical abnormalities found in this patient could be a possible explanation of his manic symptoms.

Role of Personality and Stress in the Genesis of Bipolar Disorder - Mixed States: "Could it be a solution to the Diagnostic confusion prevailing in this disorder? (Part II)" .

Role of temperamental predisposition in the development of Mixed States is a relevant factor. Mania seems to arise from a hyperthymic background and Mixed States seems to arise from a depressive disposition. Aims: To compare the personality pathology and distribution of stress of patients of mixed states distributed according to the number of standardized criteria fulfilled and with the pure manic group. Materials and methods: Out of 214 bipolar disorder- current episode manic patients diagnosed as per DSM IV TR ,admitted in psychiatry ward of P.B.M. Hospital, Bikaner from 1st Jan 2007 to 31st Dec 2007,64 patients were randomly selected. Young’s Mania Rating Scale and Montgomery Asberg Depression Rating Scale were applied to these patients and 32 patients were assigned to mixed states on displaying one or more depressive symptom on MADRS, excluding decreased sleep. Rest 32 patient were assigned to pure manic group displaying no depressive symptoms. Presumptive Stressful Life Event Scale was applied to find out any stress in the lifestyle of the sample and International Personality Disorder Examination was applied on the third follow up visit. Results: Patients with personality psychopathology and stress met 3 or more criteria as compared to those with personality psychopathology without stress (p<0.01). Disorder level personality psychopathology, especially anxious disorder level personality, was significantly higher in mixed group patients as compared to pure manic patients(p<0.02).Meeting more criteria for mixed mania also meant higher scores on MADRS(p<0.01) Also patients meeting more than 3 criteria for mixed states had a significantly higher duration of hospital stay than those meeting less than 3 criteria(p<0.02) Conclusion: Mixed states is a dimensional diagnosis, higher the vulnerability in terms of disorder level personality psychopathology higher is the MADRS scores and greater episode duration.

Major Depressive Disorder: Part-I: Personality and Phenomenology.

Objectives: To study the phenomenological variations in context of personality psychopathology in Major Depressive Disorder patients. Methods:36 indoor patients of psychiatry ward of tertiary level service out of total 168 admitted patients from Ist January 2008 to 31st Dec. 2008 diagnosed as Major Depressive Disorder (as per DSMIV TR) . Socio-demographic data on a self-designed Performa, Montgomery Asberg’s Depression Rating Scale (MADRS), Hamilton Anxiety rating scale (HARS)and Presumptive Stressful Life Event Scale(PSLE) were applied to these patients and they were observed every alternate day till discharge. International Personality Disorder Examination (IPDE) was applied on their third follow-up visit, which ranged from 6 to8 weeks. Results: Sociodemographic variables by enlarge didn’t make a difference in MADRS score. MADRS score was significantly higher with increasing episodes of illness. Personality disorder patients had significantly higher MADRS score than Double traits (t=3.47, df=27, p<0.01) and Single trait (t=4.056, df=23, p<0.001) personality psychopathology. Higher level of depression in Personality disorder patients in all components of depression like sadness, reduced sleep pessimistic and suicidal thought etc were reported. Presence of stress with personality psychopathology added greater severity to depression. Conclusion: Our study brings out constitutional vulnerability with adverse environmental conditions were associated with higher level of psychopathology.

Major Depressive Disorder: Part-II -Comorbid Anxiety Disorders.

Objective: To demonstrate that Anxiety Disorder comorbidity is reflection of underlying common risk factors (Anxiety proneness) in Major Depressive Disorder patients and may not be a separate disorder. We hypothesized that “Anxious personality traits or disorders under stress take the form of state that is Anxiety Disorders”. Methods:36 indoor patients of psychiatry ward of tertiary level services, out of total 168 admitted patients from Ist January 2008 to 31st Dec. 2008 diagnosed as Major Depressive Disorder (as per DSMIV TR). Socio-demographic data on a self-designed Performa, Montgomery Asberg’s Depression Rating Scale (MADRS), Hamilton Anxiety rating scale (HARS) and Presumptive Stressful Life Event Scale (PSLE) were applied to these patients and they were observed every alternate day till discharge. International Personality Disorder Examination (IPDE) was applied on their third follow-up visit, which ranged from 6 to8 weeks. Results: High level of co-existence of Anxiety disorder 29(80.5%) in the study sample, 11 patients (30.55%) of Major Depressive Disorder had personality disorder level of psychopathology and 18(50%) patient of Major Depressive Disorder had double or more personality traits psychopathology and there were 7(19.45%) patients of Major Depressive Disorder had only single trait personality psychopathology. Conclusion: This work support the gene environmental diathesis where vulnerable person under stress develop Axis I disorder which are considered currently as co morbid disorders.

Co-Morbidity of Personality Disorders and its Impact on Phenomenology and Treatment Response in Bipolar Disorder Patients.

Aim:To study the comorbidity of personality disorders and its impact on phenomenology and treatment response in bipolar patients. Methods:40 indoor patients of psychiatry ward of P.B.M. General Hospital out of total 437 admitted patients diagnosed as Bipolar Disorder – Manic or Mixed were randomly selected. Young’s Mania Rating Scale (YMRS), Montogomery Asberg Depression Rating Scale (MADRS) and Presumptive Stressful Life Event Scale (PSLE) were applied to these patients and they were observed every alternate day till discharge.. International Personality Disorder Examination (IPDE) was applied on their first follow-up visit after recovery. Since the major aim was to observe the routine response pattern of phenomenology in Bipolar I patients and considering wide variabilities in treatment strategies of clinicians, we decided to consider the naturalistic method, the response to the best treatment considered by the treating physician Results : Borderline disorder level personality psychopathology was noticed in 32.5% of the whole sample .Anxious and Impulsive traits came a close second with 30% of the sample demonstrating the combined trait. Anxious disorder was seen in 3 patients that is 7.5% of the sample and Anxious, Impulsive and Anti-social traits were seen in 3 patients (7.5%).5 patients (12.5%) demonstrated anxious traits,3 patients (7.5 %)had impulsive traits and 1 patient had histrionic traits. Hospital stay of patients with Borderline personality disorder versus others with trait level psychopathology was significantly higher. (t=9.40, d.f. =38, p<0.000) Electro- Convulsive Therapy was administered to a significantly higher number of patients with personality disorder level psychopathology than to trait level personality psychopathology (X2=6.856, d.f.=1, p<0.01). Borderline Disorder patients had significantly higher YMRS score than single (t=3.348, d.f.=20, p< 0.001) and double trait t=3.58, d.f.=26, p<0.001) patients.

Bipolar Disorder - Mixed States: A Diagnostic Dilemma (Part-I).

There is a large difference in classifying Mixed States according to the prevailing standardized classifications because of the differential focus of the various criteria in identifying Mixed States. Aims: To assign the Mania With Depressive symptoms patients in different groups and to compare the phenomenology, personality profiles and psychiatric co-morbidities of these various groups so generated. Material and Methods: 64 patients were randomly selected from the 214 Bipolar Disorder – Current episode Manic (as per DSM IV TR9) patients admitted in Psychiatry ward of P.B.M. General Hospital,Bikaner from 1st Jan 2007 to 31st Dec. 2007. After recording socio-demographic data on a self-designed Performa, Young’s Mania Rating Scale (YMRS)and Montgomery Asberg Depression Rating Scale (MADRS) were administered on day 1,3,5,7 and 9 till discharge.32 patients were assigned to Mania with Depressive Symptoms on displaying 1 or more depressive symptom, excluding decreased sleep.32 patients were assigned to Pure Mania group who displayed no Depressive symptoms. Results: 30 patients(94%) could be assigned to Mixed states according to Vienna Criteria,25(78%) could reach the diagnosis of Mixed States as per Cincinnati criteria, another 17(53%) were assigned to Mixed States as per Pisa San Diego Criteria.ICD-10 could identify 5 patients(16%) and DSM IV TR appeared to identify the least that is 3 patients(9%) Conclusion: Concept of MS couldn’t be better explained with these existing criteria because some patients meeting one criterion are not meeting others.

Rheumatoid Arthritis: Phenomenology, Personality Profile, Stress and their Inter-Relationship.

The purpose of this study was to study the psychiatric morbidity of Rheumatoid Arthritis and to look for an association between disease parameters and personality dimensions of Rheumatoid Arthritis patients. Methods: 40 patients were selected from Rheumatoid Clinic of P.B.M.Hospital,Bikaner as per Association of Rheumatoid Arthritis (A.R.A.) revised criteria. The ICD-10 Module of International Personality Disorder Examination (IPDE),Social And Occupational Functioning Assessment Scale (SOFAS),Hamilton’s Rating Scale for depression(HAM-D),Presumptive Stressful Life Events Scale(PSLE) were administered to these patients .Bivariate statistical methods were used to find association between illness variables and psychological dimensions. Group differences were analyzed by students T-test and ANOVA. Results: Rheumatoid Arthritis patients with psychiatric morbidity showed higher R.A. severity (p<0.02), swan neck and valgus deformity (p< 0.05), more number of joints involved (p<0.01), smaller joints (metacarpo-phalangeal and inter-phalangeal) involvement (p<0.05), presence of C - reactive protein in blood samples (p<0.01). Majority of patients who had personality psychopathology also reported stress in preceding one year period. Personality level psychopathology either alone or in combination is present in 17 patients that is 42.5 % of the sample. Patients with single personality trait psychopathology were better in comparison to severe personality psychopathology in terms of number of joints involved, joint deformities, social and occupational functioning and psychiatric morbidity. Conclusion: Preliminary findings suggest that the severity of Rheumatoid Articles correlates with psychiatric morbidity.

Personality Profile, Stress and their Inter-Relationship.

The purpose of this study was to study the psychiatric morbidity of Rheumatoid Arthritis and to look for an association between disease parameters and personality dimensions of Rheumatoid Arthritis patients. Methods: 40 patients were selected from Rheumatoid Clinic of P.B.M.Hospital,Bikaner as per Association of Rheumatoid Arthritis (A.R.A.) revised criteria. The ICD-10 Module of International Personality Disorder Examination (IPDE),Social And Occupational Functioning Assessment Scale (SOFAS),Hamilton’s Rating Scale for depression(HAM-D),Presumptive Stressful Life Events Scale(PSLE) were administered to these patients .Bivariate statistical methods were used to find association between illness variables and psychological dimensions. Group differences were analyzed by students T-test and ANOVA. Results: Rheumatoid Arthritis patients with psychiatric morbidity showed higher R.A. severity (p<0.02), swan neck and valgus deformity (p< 0.05), more number of joints involved (p<0.01), smaller joints (metacarpo-phalangeal and inter-phalangeal) involvement (p<0.05), presence of C - reactive protein in blood samples (p<0.01). Majority of patients who had personality psychopathology also reported stress in preceding one year period. Personality level psychopathology either alone or in combination is present in 17 patients that is 42.5 % of the sample. Patients with single personality trait psychopathology were better in comparison to severe personality psychopathology in terms of number of joints involved, joint deformities, social and occupational functioning and psychiatric morbidity. Conclusion: Preliminary findings suggest that the severity of Rheumatoid Articles correlates with psychiatric morbidity.

Catatonic Syndrome – A Review.

Catatonia is common in clinical practice, though prevalence of affected patients has decreased over time. It is a syndrome with varies etiologies. Causative factors range from schizophrenia, depression, drug induced adverse effects to organic causes. It may present in two forms: stuporous and excited. Schizophrenia is thought to the most common cause, however, evidence suggest that it is more common in depression. Successful treatment of catatonia with lorazepam supports it.