Comorbid Schizophrenia and Anorexia nervosa in an adolescent male

Schizophrenia is serious illness with high comorbidity of other psychiatric illnesses such as substance abuse disorders, depression and anxiety disorder. The dual diagnosis of schizophrenia and anorexia nervosa in an adolescent male is a rare occurrence and is understudied. The case presented is of a 12-year-old boy with complaints of auditory hallucinations, odd behaviors, paranoid delusions and suicidal attempt along with body image distortion, dread of fatness, food restriction and very low Body mass Index. This case report, describe the comorbidity of schizophrenia and anorexia nervosa by highlighting its assessment and treatment in light of available literature

Frequency of depression among patients with Type-I diabetes in a developing country, Pakistan

Objective: To determine the frequency of depressive symptoms among young people with Type-I diabetes

Methods: This cross sectional study was conducted at Baqai Institute of Diabetology and Endocrinology, Karachi, Pakistan from February to December 2015. All People aged between 12-20 years with Type-I diabetes for at least 1 year attending the OPD were included in the study. Information about participants' demographic characteristics, co morbidities and Complications, current treatment and medications were obtained. Acylated hemoglobin [HbA1C] levels were checked in all People. The Center for Epidemiologic Studies Depression [CES-D] scale was used to assess the depressive symptoms in the study participants. A cut off value of >/= 16 was used to screen for depression. SPSS 19 was used to analyze the results

Results: Out of 104 people with Type-I diabetes, depressive symptoms were observed in 44 [42.3%] participants. Depressive symptoms were more frequent in females [28/55, 50.9%]. Depressed people had more episodes of DKA [11/44, 25%], hypoglycemia [12/44, 27.3%] or hospitalization [7/44, 15.9%] in the last six months which were not statistically significant

Conclusion: Depressive symptoms are quite common in people with Type-I diabetes. Health care professionals should consider screening youth with diabetes for depression regularly. Further large scale studies are needed to validate our findings

Illness perceptions in patients of schizophrenia: a preliminary investigation from Lahore, Pakistan

Background and Objective: Patient's perception of their illness influences their healthcare decisions

The objectives of this study were to explore patient's own beliefs about their illness [Schizophrenia] and perceived social support, and its impact on their attitudes toward pharmacological treatment in Lahore, Pakistan

Methods: This study was conducted at Mayo Hospital Lahore from March to September 2016. Hundred individuals suffering from Schizophrenia completed four questionnaires; a socio-demographic questionnaire, the Illness Perception Questionnaire for Schizophrenia [IPQ-S], Drug attitude Inventory-10 [DAI] and Multidimensional Scale of Perceived Social Support [PSS]

Results: Stress, family problems, lack of friends fit financial worries were endorsed strongly by patients as cause of their mental illness. Ambiguity regarding their mental illness duration and personal control was observed. Patients' perceived significant negative consequences, negative emotional response, as well as had poor understanding of their mental illness and treatment effectiveness. Statistically significant gender differences in treatment control and illness coherence subscales of IPQS were observed. Drug attitude inventory was positively correlated with Treatment control subscale [p < 0.01] and negatively correlated with Illness coherence subscale of IPQS [p < 0.05]. The negative consequences subscale and perceived social support was negatively correlated [p < 0.01]

Conclusion: Patient's perception about their own illness is predictor of their drug taking attitude and perceived social support. Study results should help to develop new interventions to correct inaccurate beliefs in patients with schizophrenia to improve illness outcome

Mother's perceptions of child mental health problems and services: a cross sectional study from Lahore

Objective: To assess the perceptions of mothers regarding child mental health problems, its causes, preferred treatment options, and to determine whom they would consult, if their child had a psychiatric illness

Methods: Following informed consent, a questionnaire covering perceptions regarding various aspects of child mental illness was used for data collection from mothers. They were asked to identify the symptoms and behaviours they considered psychopathological in children, which treatments they would prefer, where they would turn for help with a mentally ill child, and their understanding of the causes of child psychiatric disorders in addition to ways to increase awareness of child psychiatric issues in the society

Results: Ninety one mothers participated in the study. They equally perceived emotional, behavioural and cognitive symptoms as suggestive of mental ill health in childhood. Mothers perceived multiple causes of child mental health problems, including family problems, economic difficulties, social adversity and possession by evil spirits. A substantial proportion preferred medication, recitation of Holy Quran and psychotherapy as the preferred treatment options. Overall, mothers preferred consulting health professionals than religious scholars and faith healers. They were keen for steps to increase mental health awareness within their society

Conclusion: Despite different cultural perspective, mothers exhibit good understanding of symptoms of child mental health issues and appear open to various services and treatment options. Understanding parental perceptions and expectations from child psychiatric services are crucial in increasing families' engagement in treatment

Frequency of ICD-10 psychiatric diagnosis in children with intellectual disability in Lahore, Pakistan and caregivers perspective

Association between Intellectual disability [ID] and psychiatric disorders in children and adolescents is well established but there is a paucity of published studies from Pakistan on this topic. The main aim of the study was to assess the frequency of ICD-10 psychiatric diagnosis in the hospital outpatient sample of children with ID in Lahore, Pakistan as well as to find out which challenging behaviors, caregivers find difficult to manage in this setup. Socio-demographic information was collected, Wechsler Intelligence Scale for Children-Revised and ICD-10 diagnostic criteria was used to assess children [age range 6–16 years] with suspected ID along with identification of behaviors found to be difficult to manage by caregivers. 150 children were assessed with mean age of 10.7 years [males 70%]. Majority [72%] had mild ID while 18.7% and 9.3% had moderate and severe ID respectively. Thirty percent of children met the criteria for any psychiatric diagnosis, the most common being Oppositional Defiant Disorder [14%] and Hyperkinetic Disorders [10%]. Verbal and physical aggression, school difficulties, socialization problems, inappropriate behaviors [e.g. disinhibition], sleep and feeding difficulties were the significant areas identified by the caregivers as a cause of major concern. Significantly high prevalence of ICD-10 psychiatric diagnosis in children with ID was found in Lahore, Pakistan. Support services for these children should be responsive not only to the needs of the child, but also to the needs of the family

Student's perceptions of educational environment across multiple undergraduate medical institutions in Pakistan using DREEM inventory

To objectively assess whether the medical education environment across Pakistan was at an acceptable standard and to determine factors influencing its perception. The cross-sectional study was conducted from August to November 2012 at six undergraduate medical institutions across Pakistan. The Dundee Ready Education Environment Measure [DREEM] inventory having five subscales of perceptions of learning, teachers, atmosphere, academic self-perceptions and social self-perceptions was administered anonymously to all the consenting medical students. Data was analysed using SPSS 17. Of the 3045 questionnaires distributed, 2084[68.4%] were returned duly filled. Of all the respondents, 1311[63%] were females. Overall mean score found positive was 105.0 +/- 25.8 [Max: 200]. Corresponding scores in the subscales were: student's perception of learning 25.1 +/- 7.2 [Max: 48]; social self-perception 15.4 +/- 3.9 [Max: 28]; academic self-perception17.2 +/- 6.5 [Max: 32]; perception of teachers being in need of some re-training 22.5 +/- 7.1 [Max: 44]; and perception of atmosphere as having many issues needing a change 24.8 +/- 7.0 [Max: 48]. Female students and pre-clinical year students perceived environment as more positive than male students [108.6 +/- 23.0 vs. 98.8 +/- 28.9 [p<0.001]] and students belonging to clinical years [108.0 +/- 24.0 vs. 03.3 +/- 26.5 [p<0.001]]. Highest score was found in the domain of student's social self-perceptions and lowest in the domain of student's perception of teachers. Results can be used as a basis for planning and executing remedial measures needed to improve undergraduate medical education environment in Pakistan

Health ethics education: knowledge, attitudes and practice of healthcare ethics among interns and residents in Pakistan

To assess the knowledge, attitudes, and practices among interns and residents about healthcare ethics in an attempt to assist in development of ethics curriculum in Pakistan. Four hundred respondents comprising of interns, junior and senior postgraduate trainees were recruited from two Public sector teaching institutions in different provinces of Pakistan for this cross sectional study. A self- administered questionnaire was used to collect data. Data was analysed using SPSS-17. More than half of the respondents in all three groups encountered ethical problems on daily basis. These ethical issues were being discussed with the clinical supervisor in only 25% of the instances. Unethical behaviour of seniors towards junior doctors and patients were observed by more than three quarter of the respondents. A very high proportion of respondents [57%] had no knowledge of code of ethics of Pakistan Medical and Dental council. Helsinki declaration was known only to a few individuals. There were difference between interns, junior and senior residents with respect to their views about adherence to patient's wishes, paternalistic attitude of physicians, treatment of children without parental consent, euthanasia, confidentiality and treatment of noncompliant patients. Junior doctors representing different levels of training in Pakistan face ethical dilemmas on a regular basis but their current teaching and training in ethics is insufficient to help them deal with these competently.

Educating tomorrow's doctors: a cross sectional survey of emotional intelligence and empathy in medical students of Lahore

Medical education in Pakistan traditionally emphasizes physician's biomedical knowledge with less emphasis on interpersonal skills and ability to relate to the patients. This study explored the emotional intelligence and empathy of undergraduate medical students and investigated its relationship with various factors to act as baseline for future work in this area. The Schutte Emotional Intelligence scale and Davis' Interpersonal Reactivity Index in addition to socio demographic questionnaire were administered to first year and final year medical undergraduates of two medical Institutions in Lahore, Pakistan. Data was analyzed by using SPSS 17 version. The overall mean scores for medical students both on emotional intelligence and empathy is significantly lower than that found in previous literature, highlighting that medical students do not appear to fare better than average people in EQ. Women showed statistically significant higher scores on Appraisal of emotions, Regulation of emotions, Empathic concern Scale and Personal distress scale. Comparison of EI and IRI of students according to medical college year did not show any statistical significance. Current medical curriculum and training in Pakistan does not appear to increase EI abilities which are building blocks that may allow students and residents to develop competence. Medical educators in Pakistan should look for ways to incorporate emotional intelligence in medical curriculum which will ultimately contribute towards patient centered practice, patient satisfaction as well as effective communication skills

Audit of in patient prescriptions in psychiatry ward in a teaching hospital

An audit of inpatient prescriptions in a Psychiatric ward in a teaching hospital was conducted. Audit identified important shortcomings in prescription writing and recording. Intervention resulted in significant improvements in most of these areas. It is concluded that continuous evaluation and feedback by means of regular audits can be used as an effective tool in improving prescriptions writing and thus indirectly patient care in our setup

Brain drain: a harsh reality, international migration of Pakistani medical graduates

To explore final year students and fresh graduates' intentions to train abroad, identify the influencing factors for this decision and understand their attitudes towards conditions in Pakistan and abroad. Following informed consent, respondents were asked to complete a self administered structured questionnaire to collect demographic and educational information, their plans for post graduation training abroad, factors influencing decision to migrate abroad or stay in Pakistan as well as attitudes towards prospects in Pakistan and abroad. Data was entered and analyzed by SPSS 17.0. Among the 275 respondents, 176 [60.4%] intended to go abroad for postgraduate training. Professional excellence [25.5%], easier career settlement [10.2%] and financial prosperity [7.6%] were some of the goals respondents wish to achieve through training abroad while required process of certifications i.e exams and tests [37.5%], expenses [24.4%] and visa problems [21.5%] were identified as barriers for migration abroad. Agreement among various groups [general public, patients, healthcare institutions, academic community] considering doctors trained abroad as more qualified than doctors trained in society and government attitude towards doctors as well as living standards in Pakistan. Positive attitudes were identified towards doctors' status, living standards, and ability to cope with working conditions, political and social circumstances abroad. A significant percentage of medical graduates intend to migrate abroad for post graduate training. Apart from better economic prospects, unhelpful view towards conditions in Pakistan also contribute for increasing trend of migration among physicians from our homeland

Children's mental health: pattern of referral, distribution of disorders and service use in child psychiatry outpatient setting

To determine the pattern of referrals, socio-demographic factors, frequency of psychiatric diagnosis, and help offered to children presenting in Child Psychiatry Department outpatient clinic of a tertiary care hospital in Lahore. A cross sectional study of children attending child psychiatry outdoor in a tertiary care hospital in Lahore was conducted. Following informed consent from the parent/ legal guardian, 1000 consecutive new referral to the department were assessed by interviewing the parent and the child. A Structured proforma was used for data collection. ICD-10 criteria were used for the diagnosis of psychiatric illness. Record was made of the interventions offered to the child and family.Total sample size was 1000 children with predominant male gender [65%] and mean age of 8.46 [S.D 4.51].More than half [54.5%] of the children in our sample were not enrolled in school and 19% had family history of psychiatric illness. Among the various sources of referral, self-referral was the highest [84.7%] followed by referral from Pediatrics [8.4%]. Psychiatric diagnosis observed were Speech Related Difficulties [including speech delay, articulation problems and specific developmental delays of speech and language [46.5%], Learning Disability [43.3%], Behavior Problems [26.3], Epilepsy [12.6%], Dissociative Disorders [10.1%], Attention Deficit Hyperactivity Disorder [4.5%], Autism [3.2%], Depression[2.4%], Anxiety[1.7%], Psychosis [1%] and Tics [1%]. Co-morbidities were found in 44.7 percent of the children. The various interventions offered included medications, referral to psychologist [for family therapy and individual work], play therapist and speech therapist. Majority of children presenting to the child psychiatry clinic have multiple and complex needs due to high frequency of learning disabilities and co morbidities. The findings illustrate the importance of multidisciplinary approach and to assess the different dimensions of psychopathology in children for future service planning

Unhappy doctors in Pakistan: what are the causes and what can be done?

To determine if the general perception of doctors being unhappy is true as well as to explore the underlying causes for this phenomena. This is a cross sectional study that was conducted over a six months period in two tertiary care hospitals in Lahore. Data was collected by using a structured questionnaire. Demographic information and data assessing perception of overall physicians being unhappy in Pakistan, and their own personal level of satisfaction in life was collected. Possible reasons for unhappiness among doctors from a list of factors was also explored. Finally the respondents were asked about their intentions for near future of remaining/ leaving Pakistan. The data was analyzed by using the statistical package for the social sciences [SPSS version 17]. Six hundred and one [49% males] with the mean age of 28 years [s.d 5.95] participated in a self-reported survey. Majority of the participants [393; 65%] were junior doctors. Fifty nine percent of respondents believe that overall Physicians in Pakistan are unhappy. When asked directly about their own level of unhappiness, respondents gave almost equivocal reply [43% dissatisfied vs 42% satisfied]. Low pay [87%], increase workload [73%], no positive feedback [70%], job insecurity [64%] and poor mutual support [47%] being the most significant causes responsible for this unhappiness. High proportion of doctors [55%] would prefer to be in any other country than Pakistan. This study demonstrated that unhappy doctors are a worldwide phenomenon, Pakistani Doctors being no exception. High proportion of doctors intending to leave Pakistan is a source of concern for the health services. We need to accept the causes and take steps to address the issues identified

Psychological problems in children of parents with mental illness: a comparative study from Lahore, Pakistan

Mental illness in parents and its link with adverse outcomes for children has been well reported in western literature, but there is a paucity of published studies from Pakistan on this issue. The aim of our study was to determine the prevalence of psychological problems in children of parents having mental illness and to compare it with children of parents without any diagnosed psychiatric problems in urban area of a developing country. A case control study was conducted from January to April 2008 in Lahore. Following informed consent, cases were recruited through interviewing psychiatric patients. Controls were children of parents with no diagnosed psychiatric illness and were recruited through a school. A structured questionnaire for demographic information, and Strengths and Difficulties Questionnaire [SDQ] were filled in by parents. Seventy- six parents were recruited to get a sample of 200 children. [100 cases, 100 controls]. The mean age of children was 9.7 years and 111[55.5%] were boys. Children of parents with psychiatric problems had almost two times higher rate of mental health problems compared to controls [55% versus 28%; P value <0.001]. Emotional difficulties [P=0.028] and conduct problems [P=0.025] were found to be statistically significant. Boys were more likely to be hyperactive and have conduct and social difficulties. Girls had higher rates of emotional problems. Children of parents with mental illness are at much higher risk of childhood psychiatric problems. Risk was higher for males than females. Majority of parents had not sought any help for their children difficulties

AUTISM: assessment and management

Autism and the related pervasive developmental disorders are characterized by patterns of delay and deviance in the development of social, communicative and cognitive skills, which arise in the first years in life. Differential diagnosis includes other psychiatric and pervasive developmental disorders, deafness and profound hearing loss. Autism is frequently associated with fragile X syndrome and tuberous sclerosis. Common co-morbidities include Mental Retardation, Seizure Disorder and Psychiatric disorders such as depression and anxiety. Early detection and intervention significantly improve outcomes, with about one third of autistic persons achieving some degree of independent living. Various treatment modalities administered by Multidisciplinary team are helpful. [e.g. Pharmacotherapy, special education, speech, communication therapy, and behavior modification]. A Medline search dating back to 1970 was done, to look at the literature related to autism. Based on this search, up to date review of autism has been discussed with special emphasis on assessment and management

Attention deficit hyperactivity syndrome: An update on assessment and management

Attention Deficit Hyperactivity Disorder [ADHD] is the most common neurodevelopmental disorder of childhood and makes up 30-40% of referrals to child mental health practitioners. It is associated with significant impairments and frequently persists in adulthood. Because of limited numbers of trained child Psychiatrists in Pakistan, most of these children present to paediatricians and Adult Psychiatrists. Competency in diagnosis and treatment of ADHD requires in depth understanding of its presentation, comorbidities and various management options. An attempt has been made in this write up to review ADHD along with update on Assessment and Management issues in accordance with International Guidelines. This manuscript was prepared following detailed search on various databases including Pubmed, Psychinfo as well as information on websites of American Association of Child and Adolescent Psychiatry [AACAP] and National Institute of Clinical Excellence, [NICE] UK

stigmatization of psychiatric illness: what attitudes do medical students and family physicians hold towards people with mental illness?

To examine the attitude and opinions of doctors and medical students towards people with mental illness. It is a cross-sectional survey carried out at Mayo Hospital and Fatima Memorial Hospital Lahore Pakistan, from May-July 2006. An anonymous Questionnaire based on previous research in this area was distributed among Family Physicians attending a CME programme, House Officers in four units of a Teaching Hospital, as well as Medical Students. Four hundred thirty four of 500 questionnaires were returned [86.8%]. Schizophrenia, mania, alcohol and drug addiction produced more negative responses than other disorders and more than 60% respondents considered people with these illnesses as dangerous. For depression, anxiety, alcohol and drug addiction, around half the respondents considered that people were to blame for their problems or that they can pull themselves together. People with dementia and schizophrenia were considered to have the worst long term prognosis. Almost 98% of sample felt that psychological factors play an important role in physical illnesses and 383[88.2%] agreed that management of emotional issues is a medical responsibility. This study showed that there were more stigmatizing views towards people with mental illness in our country's medical professionals than in other countries and even in comparison to general public in developed world. Comparison with other groups in our country would be useful in planning how to reduce the stigmatization of people with mental illness