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Prof. M.A.M.

Khan Consultant Psychiatrist, 297 Adarshnagar, Hyderabad cell 9849534010 The Psychology of Telangana suicides
Suicide is now a new language neither comprehensible to the suicider nor to the survivors . It is a modern - psycho-socio-political weapon of communication. It is a silent protest but has the potential of loudest public outcry. It is an individual's macabre sacrifice for perceived continued denial of justice. When hopelessness reaches its nadir, life becomes meaningless and self consummated death seems to be the only way to register an immortal protest. It is partly altruistic and partly expression of personalised unbearable grief. Though suicides are age old methods of protests , the new waves of suicides are unnerving. Teen suicides are on the rise all over the world. According to the latest statistics from Centres for Disease Control, USA, teen suicide is the third leading cause of death, after accidents and homicide. The glorification of suicides and its instant media coverage is having intoxicating affect on vulnerable youth all over the world. World Health Organisation recently reported very high suicide rates amongst the young women of Tamil Nadu, ten times higher than the global suicidal rate. However, telengana strife culminating in youth suicides, has a long history of mounting frustration, with wounded identity. Telengana suicides need to be seen in the context of its geo-sociopolitical climate of the region as compared to the enhancing opulence of its Andhra counterpart . We need to recall the fast unto death of Potti Sriramulu, whose statue adorns the heart of the city. This is the glory every suicider dreams of, a sudden rise from anonymity to fame. But, why was he allowed to continue to fast unto death? Why did Rajgopalchari not end his fast forcibly as is done now, is a moot question. Perhaps, he really did not want to die but was not saved. That conveys the apathy of the authorities. History seems to be repeating itself. Where one man's suicide accomplished the demands of the people, more than 700 telengana suicides are not shaking the authorities out of their complacency. The emerging phenomenon of Telangana suicides defies simple explanations. I would like to dwell deeper into the psyche of these people, who themselves may not have known the underlying psychopathology of their pre- suicide grief. We should know that for every completed suicide there are many who may be contemplating ,

but have not picked up enough determination to take the final plunge. Many feel the same pain, but are just helpless. Telengana suicide phenomenon is the culmination of seven decades of mounting frustration, with promise of true democracy, which by design has been denied to them. When, I was a school going child around 1946,in Telengana, I was aware of the unrest in north telengana, which had got terribly mired into many armed conflicts tearing the society apart in many directions simultaneously. It was a multilingual state with a muslim ruler and hindu subjects in majority. On one side, there was Razakar movement and on the other, the newly emerged liberated India at . Locally, revolutionaries had waged armed revolt against land-lords. That strong communist armed struggle was led by comrades like Ravi Narayan Reddy, Maqdoom Mohiuddin and Raj Bahadur Gour, and many others, who are now revered.

The Times Of India Oct 7, 2011 wrote: Raj Bahadur Gour was a pioneer of the Communist movement in the erstwhile Hyderabad state. Maqdoom Mohiuddin and Raj were instrumental in the founding of the Comrades Association in 1939 and later the All Hyderabad Trade Union Congress in 1946 which coincided with the start of the Telangana Armed Struggle. The activities of the Communists were declared anti-state and evoked reprisals from the Nizam's government. Things went from bad to worse after the Police Action when the Indian Union came down heavily against the Communists, labelling them 'terrorists' and declaring them to be a greater threat to the country than the feudal setup which they opposed. The operations of the Union forces encouraged the old landlords to return and reclaim their holdings. A sustained anti-communist propaganda campaign left the masses confused, resulting in a rapid erosion of support for the Armed Struggle. Possibly the most despicable act of the administration was to bring in a ruthless police officer (Nanjappa) from the Madras Presidency area, and unleash him on the Communists. This blatantly undemocratic and violent action of a party sworn to ahimsa proved instrumental in further subduing the masses who were shocked by the barbaric reprisals which were even worse than any witnessed under the earlier regime This historical back-ground is essential to know the bleeding psyche of telenganites from 1939 onwards. The loyalties had to be shifted with

every turn of the policy of the prevailing government. Trust became the constant casualty. Another interesting historical fact is that the communits movement was rife in telengana region as well as in Andhra region, but not in the districts which were bordering Maharashtra an Karnataka. Of-course Hyderabad remained altogether on a different footing. Telengana communists were demanding Vishal Andhra and one can imagine the splitting of ideas into various inclinations, is responsible for the bleeding psyche, which is evident to-day. When the rule of Jagirdars, Deshmukhs and their samasthans started to crumble , the same people soon returned to power by successfully embarking upon the path of political popularity through electoral doors. The past oppressors became political rulers of the day. In the meantime, the hindu muslim divided identity, which is still visible is the confused reaction to a bizarre patchwork of history. Swami Ramanand Tirth had waged a rebellion against the muslim rule under the banner of Hindu Mahasabha. The communists were carrying out their crusades but preferred to call themselves as a newly formed Andhra Sabha, may be because their main outfit was proscribed. Hyderabad muslims have been wary of various combinations and permutations and began to suspect all and sundry and even thought that Andhra Mahila Sabha could be a communal organisation. Mutual Trust became the casualty for all sections of society even to-day. Finally, in 1949 came the annexation of the Hyderabad state to the Indian Union and the minds were ripe for national integration, the final destination, under the banner of a united India. We all became Indians and aspired for continued newly acquired true democracy and equality. We could hardly adjust to this new sense of unity and identity, when the vociferous demand for breakaway from Madras state by Andhras made no sense to us, hardly realising that there was going to be a further reorganisation of states. Reorganisation of thought needed time and everybody remained nonplussed at the fast developments of events. We had trusted our leaders and never thought that we could be led up a dream garden path. We felt cheated and remained subjects subservient to Andhras who came to Hyderabad not as equal partners but as rulers, through their government administrators and political bosses. They

assumed the role of new Doras The successive chief ministers turned out to be ruthless rulers and paid only lip service to the welfare of telengana. In every walk of life, people from Telengana were treated as inferior and the arrogance became intolerable.

The evolution of a telengana personality.


For the development of a healthy individual personality, one needs to have a loving and caring environment. The same is true for the development of the personality of any changing society. An individual requires as much bonding as a society. Personalities are dynamic processes both for an individual and a given society. Historically, the overall personality of a given society is influenced by the positive developments and upheavals in a particular era. Telengana has witnessed and went through cataclysmic changes in the past 70 to 75 years, Let us look at the evolution of the personality of people born in Telengana districts in the past 50-75 years. For control, compare this with the fairly stable personalities of their counterpart region, namely Andhra areas. There are very noticeable individual differences even in the different regions. Personality of people from Krishna district cannot be compared with that of Nellore or Kurnool. Same way, Mahboobnagar culture and thinking is different from that of Adilabad or Nizamabad. Most of these areas have retained basic character of their personalities, except the city of Hyderabad, which stands on its own with very distinctive characteristics of its personality, which truly does not reflect the personality of any of the other telengana areas. Many of the poor city dewellers are actually migrants from Bihar, Uttar Pradesh,Karnataka and Maharashtra. It is an amalgamated structure of personality and has to be seen independent of the regions, both Andhra and Telengana. Gordon Allport a well known American Psychologist defined personality as "the dynamic organization within the individual of those psychophysical systems that determine his characteristic behaviour and thought This 120 year old definition still holds true of the development of an individual's or the society's personality Historically speaking one has to learn about the mentality of the region as a whole. By mentality, I use the accepted definition. The attitudes of ordinary people towards everyday life. Henri Tajfel's greatest contribution to psychology was social identity theory. Social identity is a person's sense of who they are based on their group membership(s).

Tajfel proposed that the groups which people belonged to were an important source of pride and self-esteem. Groups give us a sense of social identity: a sense of belonging to the social world. Telengana and Andhra remained two distinct social groups , Andhra being considered superior and rich in all manners of life, culturally and linguistically too. In order to increase our self-image we enhance the status of the group to which we belong. We can also increase our self-image by discriminating and being prejudiced against the out group (the group we don't belong to). Therefore we divided the world into them and us based through a process of social categorization. The divide between them and us started to grow. Mentality is by no means a derogatory expression. Imagine the mentality of people in telengana region 50 years ago. People had no premonition of how the future would unfold for them, but the promise was for better quality of life, as good as that of their adopted brothers, Andhras. In the erstwhile Nizam state, people were struggling to survive the rigours of life and life expectancy was not beyond 50. End of second world war saw the world order changing and the birth of League of Nations, followed by the emergence of widely spreading democracy, which made people realise the value of individual life. These progressive changes were sweeping all over the world and were also reflecting in the lives and thinking of ordinary people. Radio was enhancing the power of news transmission and Telengana did not remain unaffected. Against this global background of betterment of life, let us see, what was happening on the national scene in India. Post-partition, it was the most turbulent time in Indian history both politically and socially. Migration of people from Pakistan to India and vice versa had added a new dimension to the already bruised personalities of Hyderabadis, particularly muslims. There were some families who chose to migrate to Pakistan and some families remained divided. The Hindus of Hyderabad were jublilant about the annexation of Nizam state into the Indian Union. The psyche of muslim minority community was wounded because they thought they were a defeated nation. Whereas, the majority community developed a strong sense of union with all Hindu brethren, regardless of language or provincialism. Every one had developed strong nationalistic fervour and political parties particularly Congress party, became stronger at the national level. At that time thinking about any regional party was an anathema and considered anti-national.

Congress party had become the natural successor to the British Raj, having won the independence from them. Then came the bomb shell from Andhra region wanting separation from Madras state and demand for division on linguistic basis was started and newly formed independent Hyderabad state again got divided into three parts and Telugu speaking region was merged with Andhra region, forming Andhra Pradesh with its capital city in Hyderabad. The personality of Telenganites never got a chance to get consolidated and remains fragile to this day. Bonding between two regions never was attempted and hence could not be achieved. As a matter of fact, positive alienation was created, nurtured and promoted by the official machinery strongly supported by the political bosses. Telenagana senior officers were overnight became juniors to their Andhra junior counterparts who authoritatively ruled and overruled them and some dejected officers had to finally go to supreme court to get their grievances redressed. This has happened in each and every government department and sowed the seeds of resentment against Andhra officers. The youth of to-day is not aware of all these historical facts and see no future for them with the Andhras. This explains the multiple reasons for discontent and the formation of a bruised telengana personality of the youth who are going through a phase of depression. With the rise of regional parties, one should understand the psychology of separation as a means of betterment of life. The youth must realise that separate Telengana will be a reality and in the meantime, they must have patients to live and compete as an Indian.

Dr. K.Harish Chandra Reddy,MD(Psy), Sahara Hospital, Karimnagar.

RECENT DEVELOPMENTS IN NEURO PSYCHIATRIC IMAGING AND TESTING


The Human Connectome Project The science journal, on 30-04-2012, published a report on one of the most important finding in neuro anatomy, which allows studies of the living, developing and adapting brain. The Human Connectome Project Scanner's diffusion MRI can visualize the networks of crisscrossing fibers by 10-fold higher detail than conventional scanners. This instrument brings a sharper focus on astonishingly simple architecture showing brain growth. The mature brain has three primary pathways established in embryonic development. As the brain develops, its connections form along perpendicular pathways running horizontally, vertically and transversely. This grid structure appears to guide connectivity like lane markers on a highway which would limit options of growing fibers to change direction. The new scanner markedly boosts resolving power by magnifying magnetic fields with stronger copper coils, called gradients. The Connectome scanner's gradients are seven times stronger than those of conventional scanners. Scans that would previously take hours and thus, would have been impractical with living human subjects can be now performed in minutes. Eye tracking Test Early identification and treatment is critical for good patient outcome, and thus clearly and accurate identification of traumatic brain injury, as well as assessment of its severity, are more paramount in the treatment of mild traumatic brain injured (mTBI) patients. The development of rapid yet sensitive and reliable measures to continuously assess dynamically changing attention states is of critical importance in order to detect subtle cognitive impairments due to mTBI and to generate accurate diagnoses for mTBI patients. It is an established fact that Smooth Pursuit Eye Movement (SPEM) correlate with cognitive performance. Some of the modern technical advancement in this field to development of devices to immediately assess brain trauma such as Immediate Post-Concussion and Cognitive Testing (ImPACT) by Dr.Mark Lovell in late 1990s. This computer program challenges the test-taker to complete a series of tasks that measure attention, memory, response speed and decision making. Newest technology includes DETECT, the Display Enhanced Testing for Concussions and mild TBI system created by the Georgia Institute of Technology, is intended for use right on the sidelines of a sports field. The visor, reminiscent of a virtual-reality headset, blocks out distractions while the wearer focuses on a series of digital neuropsychological tests. Eye-Tracking test, developed by Jamshid Ghajar, Brain Trauma Foundation, has developed a concussion test that can be used in combat settings.

Functional Near-Infrared Spectroscopy (fNIRS)


Most of the mental disorders and its neurological correlates are studied using Functional magnetic Resonance Imaging (fMRI). Unfortunately Meta-Analysis of fMRI studies still now does not give consistent results in many conditions. One reason is the methodology itself. Since the patient has to be in supine position in fMRI scanner, much of the real life processes cannot be studied completely. A new technique, fNIRS, has been developed to solve this problem especially to study the prefrontal area, an area of interest for Psychiatrists. It is a non-invasive, safe portable and lowcost method of indirect and direct monitoring of brain activity. It allows functional imaging of brain activity through monitoring of blood oxygenation and blood volume in the pre-frontal cortex. This is done by measuring changes in the concentration of oxy- and deoxy-hemoglobin (Hb) as well as changes in the redox state of Cytochrome-c-Oxidase (Cyt-Ox) by their different specific spectra. The fNIRS sensor is attached to the subject's forehead and can be monitored either connected to a computer or a portable device that records the subject's data as he/she engages in specific tasks. The data is recorded and then analyzed for changes in the blood flow or its oxygenation levels of the brain before, during and after the task.

Conclusion
From centuries to decades, Psychiatry is progressing and approach to studying the brain is changing into a better science rather than hypothesis and assumption. We are well equipped for future, and are still not losing our humanitarian approach of empathy and compassion. For correspondence: Dr. K. Harish Chandra Reddy, MD(Psy),Sahara Hospital,Karimnagar, dr_harishreddy@yahoo.com

Reference
1. F.Irani, S.Platek, S.Bunce, A.Ruocco and D.Chute, Applications of functional Near Infrared Spectroscopy (fNIRS) to neurobehavioral disorders , Clin.Neuropsychologist, Neuropsychology Technology 2. R. Contreras R.Kolster, H.U.Voss, J.Ghajar, S. bahar 2008, Eye-Target Synchronization in Mild Traumatic Brain-injured patients: J. Biological Psychiatry 2008 3. Shirley m Coyle, Thomas E Ward and Charles M Markham 2006, Brain-computer inter face using a simplified functional near-infrared Spectroscopy system, Journal of Neural Engineering. 4. Suh M, Kolster R, Sarkar R, Mc Candliss B; Deficits in predictive smooth pursuit after mild traumatic brain injury, Neuro Science Lett. 401(1-2), 108-13, 2006.

Dr. K.Bhagya Reddy, Senior Consultant Psychiatrist, Karimnagar. Former President, IPS, AP Chapter.

The Psychology of Politics


Psychology of Politics and group behavior are intertwined. Contrary to popular belief to the question, which comes first, politics or psychology, surprisingly it is psychology. The ideology depends on the circumstances and social pattern. Each one of us has different personality, some are introverted, some are extroverted and some are more emotional. The working class family will vote left, the wealthy family will vote conservative regardless of political ideology.

Origin of Politics in the Society


In Indian epics, the emphasis has been focused on the family feud and internal politics of the ruling class, such as the Kauravas and the Pandavas. There was no democracy or voice for the common man and the authority was supreme. The psychology of group behavior of passion, revenge and retaliation was the instrument in the whole story of the two feuding families; then came the imposing ethics and morals such as, who is right and who is wrong as depicted in THE BHAGAWAD GITA. The complexity of psychological conflicts and clashes between personalities and psychopathology of certain individuals led to the great war, the Kurukshetra. The group and mass behavior which laid the emphasis of the importance of the common man (which includes the working class and peasants) who led a bloody revolution in France and Russia. The Russian revolution led to total authority to the common man, whereas, the French revolution, although demolished the monarchy, led to democracy by the Universal, Adult, Franchise. In England however, there was no revolution, but there exists democracy. Abraham Lincoln's famous phrase of democracy, of the people, by the people, for the people is practiced in several parts of the world, including India. Aristotle, the great Greek philosopher and disciple of Plato, is considered by many as the father of political science. His philosophy of politics derived from Greek term polis (city-state) which he imposed on city states like Athens and Sparta, which were small and cohesive units in which political, religious and cultural concerns were intertwined.

The most important task of a politician, according to Aristotle, is the role of a law giver. It involves enduring laws, customs, institutions of moral education and military science for the protection of citizens. Aristotle distinguishes several types of rule, by which one individual or group can rule over another, based on the nature of the soul of the ruler and of the subject. He first considers despotic rule, which is exemplified in the master-slave relationship. Aristotle thinks that this form of rule is justified in the case of natural slaves who lack a deliberative faculty and thus need a natural master to direct them .Although a natural slave allegedly benefits from having a master, despotic rule is still primarily for the sake of the master and only incidentally for the slave. He next considers paternal and marital rule, which he also views as defensible: the male is by nature more capable of leadership than the female, unless he is constituted in some way contrary to nature, and the elder and perfect than the younger and imperfect. The distinction between correct and deviant ruling is combined with the observation that the government may consist of one person, a few, or a multitude. Hence, there are six possible constitutional forms. Correct One Ruler Kingship Few Rulers Aristocracy Many Rulers Polity Deviant Tyranny Oligarchy Democracy

Current view on the Psychology of politics Given the intense passions that political issues elicit and the striking contrasts between different individuals' deeply held political values and beliefs, it seems only natural for us to turn our attention to political behavior, the personality traits of politicians, the psychology of voting, and even the different views of morality held by political liberals and conservatives. Do politicians have particular personality traits? One of the most common traits that clinicians talk about is that of narcissism. In effect, narcissism refers to a very fragile and unstable sense of self. In order to compensate for their fragile self esteem, narcissistic people become preoccupied with their self image and intensely sensitive to perceived shame or humiliation. Typical narcissists have a grandiose sense of self, with an inflated sense of self importance and an elevated need for attention, status and recognition.

Why do people vote? Voter turnout is essential to a democracy, but from a classic rationalist view of costs and benefits, one can argue that it doesn't make much sense to vote. Voting takes time, energy and even money, if you have to miss a day of work to get to the polling place. Yet any single person's vote is unlikely to change the outcome of an election. Nonetheless people do vote and their participation in electoral politics remains critical for the survival of the democratic system. The possible motivations for voting include among other factors; the role of habit, social pressure, altruism, and even genetics. James Fowler and Laura Baker have conducted a series of studies on voting behavior in families. They found that the party affiliation of adopted children tended to be similar to that of their adopted parents and siblings, suggesting that party affiliation was culturally transmitted and also found that voter turnout are related to genetics, while party affiliation is related to environment. The understanding of morality differs from liberals to conservatives. Jonathan Haidt found that political liberals valued harm/care and fairness/reciprocity more than the conservatives; whereas, authority/respect, ingroup/loyalty and purity/sanctity were value of conservatives. This also depends on age, gender, education and income. That is the reason people with strong moral convictions may vehemently disagree on political issues like abortion, capital punishment and flag burning.

Conclusion
One of the fundamental psychological differences between liberals and conservatives is their perception of human nature, and nature at large. Liberals are more inclined to see humans as basically good and only prone to moral failure if the world has led them in that direction. As such, everyone is redeemable. Conservatives, on the other hand, see people as basically bad, and it takes internal strength and discipline to do the right thing. The question is: which came first? Did adopting a particular political outlook influence psychology? Or did the psychology influence the political outlook? The evidence is strongly in favor of psychology coming first. As such, we don't choose to be liberal or conservative; instead we discover that we're already liberal/conservative or middle of the road. For Correspondence: Dr. K. Bhagya Reddy, Sahara Hospital, Karimnagar. drbhagyareddy@yahoo.com References: 1. Fowler, J.H., Baker, L.A., and Dawes, C.T. (2008). "Genetic Variation in Political Participation," American Political Science Review, 102,232-48. 2. Haidt, J. and Graham, J. (2007). When morality opposes justice: Conservatives have moral intuitions that liberals may not recognize, Social Justice Research,20, 98-116. 3. Hill, R.W., and Youssey, G.P. (1998). "Adaptive and Maladaptive Narcissism among University Faculty, Clergy, Politicians and Librarians." Current Psychology: Developmental, Learning, Personality, Social, 17:163-169. 4. Barker, Ernest. The Life of Aristotle and the Composition and Structure of the Politics. Classical Review 45 (1931) 5. Smith, Nicholas D. and Robert Mayhew. Aristotle on What the Political Scientist Needs to Know. In K. I. Boudouris (ed.) Aristotelian Political Philosophy, vol. 1.

INTRODUCTION
Unlike other medical specialties, psychiatry relies almost exclusively on patient interviews and on observation for diagnosis and treatment monitoring. With the absence of specifi c physical or biomarker fi ndings in psychiatry, the mental status examination (MSE) represents our primary diagnostic instrument. MSE provides a framework to collect the affective, behavioral, and cognitive symptoms The of psychiatric disorders. Often, the MSE provides enough detail for psychiatrists to categorize symptom clusters into recognized clinical syndromes, and to initiate appropriate treatment. some settings, the MSE alone is insuffi cient to collect a complete inventory of patient In symptoms or to yield a unifying diagnosis. Diagnostic rating scales provide validated measures of symptom severity in psychiatric disorders. scales may be employed in both clinical and research settings. Rating Ratings can supply either global assessments of function or disorder-specifi c measurements. format of psychiatric rating scales varies widely in content, length, and administration. The information provided by diagnostic rating scales can be useful in differentiating closely related The diagnoses, selecting symptom-appropriate treatment, and monitoring treatment effects. Rating scales may serve as an adjunct to the diagnostic interview, or as stand-alone measures (as in research or screening milieus).

General Considerations In The Selection Of Diagnostic Rating Scales


Reliability - For a given subject, are the results consistent across different evaluators, test conditions, and test times? Validity -Does the instrument truly measure what it is intended to measure? How well does it compare to the gold standard? Sensitivity -If the disorder is present, how likely is it that the test is positive? Specifi city -If the disorder is absent, how likely is it that the test is negative? Positive predictive value -If the test is positive, how likely is it that the disorder is present? Negative predictive value- If the test is negative, how likely is it that the disorder is absent? Cost- and time-effectiveness -Does the instrument provide accurate results in a timely and inexpensive way? Administration- Are ratings determined by the patient or the evaluator? What are the advantages and disadvantages of this approach? Training requirements -What degree of expertise is required for valid and reliable measurements to occur?

General Diagnostic Instruments


Can provide a standardized measure of psychopathology across diagnostic categories. These instruments are frequently used in research studies to assess baseline mental heath. PANSS- Positive and Negative Syndrome Scale BPRS- Brief Psychiatric Rating Scale -Scale for the Assessment of Positive Symptoms SAPS SANS- Scale for the Assessment of Negative Symptoms -Schedule of the Defi cit Syndrome SDS Abnormal Involuntary Movement Scale AIMS BARS- Barnes Akathisia Rating Scale Simpson-Angus Extrapyramidal Side Effects ScaleAnxiety Disorders EPS HAM-A- Hamilton Anxiety Rating Scale BAI- Beck Anxiety Inventory Y-BOCS- Yale-Brown Obsessive Compulsive Scale BSPS- Brief Social Phobia Scale CAPS- Clinician Administered PTSD Scale CAGE- CAGE questionnaire MAST- Michigan Alcoholism Screening Test DAST- Drug Abuse Screening Test FTND -Fagerstrom Test for Nicotine Dependence MMSE --Mini-Mental State Examination CDT- Clock Drawing Test DRS- Dementia Rating Scale No diagnostic rating scale can replace a thorough interview, a carefully considered differential diagnosis. However, rating scales can finetune each of these components by providing focused information in a time- and cost-effi cient manner, by revealing subtle elements of psychopathology that have important treatment implications. Also provide standardized measures that ensure the integrity and homogeneity of subject cohorts in clinical investigations, improving the reliability and validity.

Substance Abuse Disorders

Cognitive Disorders

SUMMARY

REFERNCES
1. Kirkpatrick B, Buchanan RW, Ross DE, et al: A separate disease within the syndrome of schizophrenia, Arch Gen Psychiatry 58:165- 171, 2001. 2. Bear L, Jacobs DG, Meszler-Reizes J, et al: Development of a brief screening instrument: the HANDS, Psychother Psychosom 69:35-41, 2000. 3. Mischoulon D, Fava M: Diagnostic rating scales and psychiatric instruments. In Stern TA, Herman JB, editors: Massachusetts General Hospital psychiatry update and board preparation, ed 2, New York, 2004, McGraw-Hill. 4. Roffman JL, Stern TA: Diagnostic rating scales and laboratory tests. In Stern TA, Fricchione GL, Cassem NH, et al, editors: Massachusetts General Hospital handbook of general hospital psychiatry, ed 5, Philadelphia, 2004, Mosby. 5. Zarin DA: Considerations in choosing, using, and interpreting a measure for a particular clinical context. In Rush AJ, Pincus HA, First MB, et al, editors: Handbook of psychiatric measures, Washington, DC, 2000, American Psychiatric Association. 6. Perkins DO, Stroup TS, Lieberman JA: Psychotic disorders measures. In Rush AJ, Pincus HA, First MB, et al, editors: Handbook of psychiatric measures, Washington, DC, 2000, American Psychiatric Association. 7. Atbasoglu EC, Ozguven HD, Olmez S: Dissociation between inattentiveness during mental status testing and social inattentiveness in the Scale for the Assessment of Negative Symptoms attention subscale, Psychopathology 36:263-268, 2003. 8. Carpenter WT, Heinrichs DW, Wagman AMI: Defi cit and nondefi cit forms of schizophrenia: the concept, Am J Psychiatry 145:578-583, 1988. 9. Shear MK, Feske U, Brown C, et al: Anxiety disorders measures. In Rush AJ, Pincus HA, First MB, et al, editors: Handbook of psychiatric measures, Washington, DC, 2000, American Psychiatric Association. 10. Rounsaville B, Poling J: Substance use disorders measures. In Rush AJ, Pincus HA, First MB, et al, editors: Handbook of psychiatric measures, Washington, DC, 2000, American Psychiatric Association. 11. Salmon DP: Neuropsychiatric measures for cognitive disorders. In Rush AJ, Pincus HA, First MB, et al, editors: Handbook of psychiatric measures, Washington, DC, 2000, American Psychiatric Association

Dr. S Lakshmi Sravanti, nd 2 year post graduate (MD Psychiatry, PESIMSR, Kuppam)

A CASE OF BRIEF RECURRENT PSYCHOSIS


ABSTRACT Although the term zycloiden psychosen was first used by Karl Kleist in 1926 to group together disorders that were described up to that point which had presented with sudden onset, brief episodic course, polymorphous psychotic symptomatology and good inter-episode recovery, its origin can be traced back to 1880s. Despite its existence for so long in the community, the diagnosis of cycloid psychosis is only seldom made, making it a unique disorder. Hence, there seems to be lack of awareness of this rare entity even among the psychiatrists. Here we describe a case of psychosis which doesn't satisfy the criteria for schizophrenia or affective illness. The closest it resembles is cycloid psychosis, meeting Perris criteria, but for one. Keywords: Brief recurrent psychosis, Cycloid Psychosis, Perris Criteria, Leonhard Nosology INTRODUCTION Zycloiden Psychosen, a term coined by Karl Kleist and elaborated by Leonhard, remains unfamiliar to many psychiatrists despite its mention in the literature. This group of disorders is believed to be different from both schizophrenia and manic-depressive psychosis and is characterized by sudden onset, rapid recovery, episodic course and complete recovery in the 1 inter-episode period. Karl Leonhard in 1957 described cycloid psychosis and the three forms of cycloid psychosis. The first one is anxiety-blissfulness psychosis, which may resemble agitated depression, i.e. in which affective symptoms predominate (on one pole, there are periodic states of overwhelming anxiety and paranoid ideas of reference and sometimes hallucination. The blissful phase/pole presents with expansive behavior and grandiose ideas). The second type is called excitedinhibited confusion psychosis, in which thought disorder is dominant and presents with anxiety, distractibility, and a degree of speech incoherence out of proportion to the severity of flight of ideas. The clinical picture varies between excitement and a state of under-activity with poverty of speech. The third is motility psychosis, in which the striking changes are psychomotor activity (akinetic- which presents similar to catatonic stupor and hyperkinetic-which resemble catatonic excitement). Although it has not found a place in the DSM system, ICD-10 maintains the concept of cycloid psychosis. Another term, 'acute polymorphic psychotic disorder' (F23.0, F23.1) is used for cycloid psychosis with an emphasis on the polymorphic syndrome rapidly changing and variable 2 psychotic symptoms and emotional states as a cardinal feature . We describe here a case of a 3 woman who meets the diagnostic criteria for cycloid psychosis as elucidated by Perris .

Diagnostic criteria for 'cycloid psychosis' (Perris and Brockington, 1981) 1. An acute psychotic condition, not related to the administration or the misuse of any drug, or to brain injury, occurring for the first time in subjects aged 15-50 years. 2. The condition has a sudden onset with a rapid change from a state of health to a full-blown psychotic condition within a few hours or at the most a few days. 3. At least four of the following must be present: a. Confusion of some degree, mostly expressed as perplexity or puzzlement b. Mood-incongruent delusions of any kind, mostly with a persecutory content. c. Hallucinatory experience of any kind, often related to themes of death. d. An overwhelming, frightening experience of anxiety, not bound to particular situations or circumstances (pan-anxiety). e. Deeper feelings of happiness or ecstasy, most often with a religious coloring. f. Motility disturbances of an akinetic or hyperkinetic type, which are mostly expressional. g. A particular concern with death. h. Mood swings in the background, and so pronounced as to justify a diagnosis of affective disorder. 4. There is no fixed combination of symptoms; in contrast, the symptoms may change frequently during an episode and show bipolar characteristics. CASE REPORT A woman 35 years of age, farmer by occupation was admitted to the medical ward with history of alleged consumption of organophosphorus compound at home about 24hrs ago, when she was first taken to a private hospital in Bangalore where she received emergency care treatment and after a short stay there she was brought here for further management. Her husband reports that she was doing well until three days prior to the attempt when she suddenly became socially withdrawn and neglected self-care. She would spend the time lying in bed all day and not interacting with others. She had no head injury, was not abusing alcohol or drugs and was not taking any medication. She had no family history of psychiatric illness or seizures. She had previously been admitted to hospital once about a year and a half ago for a short, sudden-onset episode of social withdrawal, not attending for work, irritability, aggressive behavior, reduced self-hygiene and remain preoccupied with death. Her hospitalization lasted five days and the illness resolved during the hospital stay, while she was on treatment with antipsychotic medication, Olanzapine. Although she was advised to continue the medication, compliance was poor and she was not on regular treatment. During one year period after being diagnosed with a psychotic illness, she had four episodes of social withdrawal, aggressive behavior, reduced self-hygiene and sometimes she even went around in disheveled clothing. Each episode lasted for three days and resolved spontaneously. On one of the occasions, in addition to the above mentioned features, she wandered away from home in the middle of the night, when the family members went in search for her and found her near a temple. She was brought back home and the episode of abnormal behavior subsided in two days. The subsequent episode she had, lasted for a week when she became very aggressive, broke furniture and television at home and assaulted her husband, as they couldn't physically restrain and handle her, they consulted a psychiatrist and it resolved immediately with treatment. Patient's family members reported that results of hematological tests and biochemical profile were reported to be normal by the doctors during her admission. Every episode, her remission was rapid and complete. Although she was not on regular treatment, she had been completely well in between the episodes.

Mental status examination revealed mutism and negativism. About five days later, she paced around, walked out of ward and rolled on the floor when she was prevented from going out. She was not co-operative for cognitive testing. Physical examination revealed no abnormalities and a detailed neurological examination proved to be negative. Hematologic and biochemical profiles including renal function tests and urine examination were all within normal ranges. Serum electrolytes, serum calcium, serum magnesium and serum phosphorus were within normal limits as well. Chest x-ray and CT scan (brain) showed no abnormalities. At the end of the week, the patient was partially co-operative for Rorschach test. She was not willing to complete the test due to fear of taking Card.6. Responses for first five cards suggested psychosis. She received olanzapine and lorazepam during her hospital stay. She improved rapidly, mutism and negativism resolved, her memory for events surrounding her admission remained hazy though. She was pleasant, appeared euthymic and her behavior was appropriate. Delusions and hallucinations could not be elicited. She mentioned that she wanted to go home, get back to farming and look after her children. Within two weeks of onset of symptoms her family confirmed that she had returned to her normal self. She was sent home with advice to continue olanzapine and lorazepam and come for review after a week. She was brought for follow-up, a week after discharge she maintained the improvement, however husband reported she appeared relatively dull for two days prior to the visit. She was started on escitalopram, advised to continue olanzapine and dosage of lorazepam was reduced. The patient has not turned up for follow-up ever since. DISCUSSION One and a half years ago patient had first episode of psychosis which subsided rapidly and she was not on regular treatment thereafter. Although the patient had several episodes of abnormal behavior since then, she was not taken to hospital due to spontaneous remissions, usually within three days, except for one occasion when she became aggressive and they consulted a psychiatrist and this time also. On admission to our hospital, the family members claimed, she had attempted a suicide by consuming poison previous night at home. Her husband tried to abort the attempt, however he claimed that she had already taken about 15ml of pesticide and she was immediately rushed to a hospital. There was no loss of consciousness following consumption of poison. After complete recovery she claimed it was not an intentional attempt to commit suicide or harm herself and she was not aware of the consequences of the act at that time. No identifiable cause for her episode of abnormal behavior was found during her stay in the hospital or prior admission elsewhere. This patient meets the following of Perris's criteria for cycloid psychosis, viz. 1. Acute psychotic condition not related to the administration or the misuse of any drug, or to brain injury, occurring for the first time in 33yr old woman. 2. The condition had a sudden onset with a rapid change from state of health to a full-blown psychotic condition within a few hours or at the most few days. 3.a. Probable confusion as evidenced by her hazy memory for the event. 3.f. Motility disturbances as evidenced by akinesia. 3.g. A particular concern with death as evidenced by her attempted suicide. 4. There was no fixed combination of symptoms; in contrast, the symptoms may change frequently during an episode.

Theoretical roots of cycloid psychosis can be traced back to the work of Augustin Morel and to its concept of degeneration that was subsequently elaborated by Magnan. It was Magnan in the 1880s who first published a thorough description of a psychopathological disorder characterized by a sudden onset, polymorphous psychotic symptomatology, and recurrent course (bouffes delirantes de les degenerees). The notion of degeneration psychoses won acceptance in Germany, although it is no longer linked to the degeneration hypothesis, and laid the foundation for the concept of cycloid psychoses4. The main contributions to the internationalization of the concept of cycloid psychosis were carried out by the Swedish psychiatrist Carlo Perris in co-operation with authors in other countries, such as Ian Brockington in Great Britain and Mario Maj in Italy5.

CONCLUSION We do come across entities, other than schizophrenia and affective disorders in our community. Therefore one must keep an open mind and have high index of suspicion to recognize them, as the diagnosis predicts the prognosis and helps in assessment and management of future episodes.

REFERENCES 1. Leonhard K. The classification of endogenous psychosis. 5 ed. New York: Irvington Publishers; 1979. 2.Lee J W Y. Cycloid psychosis, catatonia, and periodic catatonia. Aust N Z J Psychiatry 2004 38:975. 3. Perris C. The concept of cycloid psychotic disorder. Psychitr Dev 1988;6(1):37-56. 4. Peralta V, Cuesta J, Zandio M. Cycloid Psychosis: An examination of the validity of the concept. Current Psychiatry Reports 2007, 9:184-192 5. Marneros A, Pillmann F. Acute and Transient Psychosis. Cambridge: Cambridge University Press; 2004.
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DR.SANTHOSH,M.D(PSY) nd 2 yr.P.G,PIMS, KARIMNAGAR.

One of the sad truths in our society is how empty many people feel, and the confusion their emptiness causes others through their resulting addictive behavior. We have all heard about the sexual acting-out of Anthony Weiner, Arnold Schwarzenegger,Tiger Woods, Bill Clinton and John Edwards. We all know about the many famous people who end up in treatment centers for alcohol and drug addiction. The question is: why? Why would someone who seemingly has everything destroy their own life, and the lives of those they are close to, with their addictions to sex, alcohol or drugs? It's true that these high-profile people seem to have everything that our society deems important for happiness and self-esteem - money and all that money can buy, relationships and fame. What is it that creates the desperate need to act out addictively when they have so much? While they have much externally, internally they are bereft - empty. And the cause of this inner emptiness is one thing only - a lack of love. But it is not a lack of love from others. These people often have the love of many people, such as spouse, children and friends. Inner emptiness is caused by the lack of love that comes from a narcissistic, entitled mindset. The lack of love that results from trying to get love, rather than be loving to oneself and with others. When a person's intention is to get love, attention, and approval externally, they create their own inner emptiness. While the sex or the alcohol or the drugs might fill them temporarily,or give them a feeling of aliveness and wellbeing temporarily, it can never truly fill them in any deep and consistent way. The thing that all of these people lack is an intent to take responsibility for loving themselves for filling themselves with love so they have love to share with others. They have learned to substitute their various addictions - sex and other processes, alcohol and other substances - inplace of genuine love. But because sex and alcohol, drugs, food, and other addictions are not love, the person never feels full inside. And because they are not loving themselves, their hearts are closed to others' love. When our intent is to take responsibility for our own feelings and learn to be loving to ourselves, our heart opens. When our heart is open, we can genuinely experience love from others, and, more importantly, from our Source. Our Source IS love. Love is what we live in. Love is the intelligence of the universe, and is available to all of us when we open to it. But love from your Source cannot fill you when your heart is closed.

What Opens the Heart to Love and Fills the Emptiness? Whether your heart is open or closed to love depends on your intent. At any given moment you are either intent on: - Protecting against your painful feelings with some form of addictive, controlling behavior, or - Learning about what is loving to yourself and others - about what is in your own highest good, and the highest good of others. The intent to protect against painful feelings closes the heart, leaving you feeling empty and alone inside. It takes courage to be willing to compassionately feel your painful feelings of life - your loneliness and heartbreak - but unless you have the courage to learn to feel and lovingly manage these painful feelings, you will turn to addictions as a way of avoiding them. The intent to learn about what is loving opens your heart to love. The intent to learn and love leads to taking loving action in your own behalf and in behalf of others, such as being kind and compassionate toward yourself and others. When your intent is to get something from others - sex, approval, caring or compassion you will feel empty. When your intent is to give love, caring and compassion to yourself and others, you will feel full. This is what heals addictions and fills the emptiness.

Dr.N.D.Sanjaykumar Lecturer, Department of Psychiatry. Prathima Institute of Medical Sciences,Nagunur Road, Karimnagar Andhrapradesh

Thinking out of the box- 'Positive Psychiatry'- the beginning of a new era
Psychiatry as a discipline has come a long way since Johann Reil coined the term in 1808. Mental disorders and mental health issues have existed much before that but the term psychiatry did not come into medical parlance until Johann Reil coined the term as such. Psychiatry now is an established science with many sub specialties emerging under it in the past couple of decades. The primary goal of psychiatry has long been the relief of suffering associated with symptoms of mental disorder. Psychiatrists drew on a combination of empirical ( research and/ practice based) evidence about mental illness and its treatment, together with their own professional knowledge, on the assumption that this enables the best available treatment for people suffering from psychiatric morbidity. This is an important task but there is considerable unmet needs still existing. At the same time, however, the wider society has become concerned about positive mental health and well being. This may be partly because the issue of how people feel- especially their level of or degree of happiness- is now taken seriously by many in the broad scientific community, with more than three thousand studies on this subject of happiness and subjective well-being being published since 1960. The answer to this above much interest evoked area in the last decade is Positive Psychiatry. If we reflect upon the limitations of psychiatry has been its focus on the disease model/ disorder model concept. Here the major emphasis is on what goes wrong in human affairs. So there are a plethora of studies on mental illness, aggression, failure and so on. While it is essential to study and contain such pathologies, it is equally important to understand those aspects of human expressions that make life worth living. In an effort to understand the mentally ill and help them (which is a noble cause) have we as psychiatrists neglected the vast majority of human population who might benefit by leading a full and enhanced life. This has been the core for positive psychiatry which is an emerging sub discipline under the parent psychiatry. It should achieve a scientific understanding and devise interventions to build thriving individuals, families and communities. Psychiatry should not only treat mental illness but also include the vital function of enhancing human potential, help in nurturing genius and talent and to make normal life more fulfilling for the vast majority of human race there by adding positivism to the profession.

Positive psychiatry at the subjective level is about positive subjective experience; well being and satisfaction (past); flow, joy, the sensual pleasures, and happiness (present); and constructive cognitions about the future- optimism, hope and faith. At the individual level it is about positive personal traits- the capacity for love and vocation, courage, interpersonal skill, aesthetic sensibility, perseverance, forgiveness, originality, future mindedness, high talent and wisdom. At the group level it is about the civic virtues and institutions that move individuals towards better citizenship, responsibility, nurturance, altruism, civility, moderation, tolerance and work ethic. Another domain in positive psychiatry could be prevention of mental disorders to a large extend by strengthening the positive human traits (courage, future mindedness, optimism, interpersonal skill, faith, work ethic, hope, honesty, perseverance, the capacity for flow and insight etc) which acts as a buffer against psychopathology. The limitation of this domain of psychiatry is that not many studies exist on human strength and virtue, but we need to do the appropriate longitudinal studies and experiments to understand how these strengths grow or are stunted. We need to develop and test interventions to build these strengths. Across the psychiatric community there are a number of stalwarts who are backing this new domain of Positive psychiatry such as Dr. Cloninger CR and Dr. George E. Valliant. In fact, the latest president of American Psychiatric Association happens to be an Indian- Dr. Dilip Jeste who wants to lead APA into the era of positive psychiatry. 'We should not be satisfied merely with treating symptoms in patients with metal illness but also with improving their overall well being' he told recently to Medscape medical news. There are many studies that have shown positive traits like optimism and social engagement are associated with a significant decrease in mortality. Morbidity and mortality are more strongly related to the absence of positive emotions than to the presence of negative emotions. This implies that positive health can be promoted by enhancing positive traits and a significant finding to incorporate into psychotherapy and psychosocial interventions. This can be done only by conducting more research on the positive emotions- awe, love (attachment), trust (faith), compassion, gratitude, forgiveness, joy and hope. The psychotherapeutic approach should shift its focus from working on negative emotions to enhancing positive emotions. This will help us as psychiatrists- in not just treating patients that comprise just the minority of the world population, but in improving the quality of life of the larger human population, by enhancing courage, improving interpersonal skill, developing rationality, insight, optimism, honesty, perseverance, realism and capacity for pleasure. This will in turn help them in putting their day to day problems into perspective there by developing better problem solving skills, future mindedness and in finding purpose in life. Finally to conclude no discipline is complete with negatives but it has to be balanced with positives as well. Psychiatry is not just the study of disease, weakness and damage; it also is the study of strengths and virtues. Treatment is not just fixing what is wrong; it also is building what is right. Positive psychiatry as a sub discipline would be a step in the right direction at the right time. The following quote of Christian D. Larson would best sum up the sentiment of positive psychiatry: Promise yourself to be so strong that nothing can disturb your peace of mind. Look at the sunny side of everything and make your optimism come true. Think only of the best, work only for the best and expect only for the best. Forget the mistakes of the past and press on to the greater achievement of the future. Give so much time to the improvement of yourself that you have no time to criticize others. Live in the faith that the whole world is on your side as long as you are true to the best that is in you

DEPRESSION IN PATIENTS OF CEREBROVASCULAR ACCIDENTS AND SIDE OF LESION LOCATION:A HOSPITAL BASED CROSS SECTIONAL STUDY Dr.Jagadish kumarM.D (PSY)FINAL YR(.P.G),PIMS(Karimnagar) Background: Depression is a common neuro-psychiatric manifestation after stroke,the prevalence of PSD has range from 30-50% of patients in several cross sectional fter a stroke.Many studies show that in addition to the psychosocial stress,neurobiological factors such as site of infarcts and brain atrophy may also be related to PSD.The aim of this study is to weigh the importance of lesion location in PSD,oweing to the conflicting results obtained in this area of research and paucity of data published in Indian literature. Method: Cross sectional study of 40 subjects with their first ever stroke were interviewed using a mini plus interview.Scales of BDI used to measure severity of depression,MMSE to assess to measure cognitive impairment and Barthel index to measure Activities of dialy living.Neuro-imaging including CT scan of brain,MRI of brain provided information on site and side location.collected data was analysed using SPSS version 20.Tests of significance(chi-square test)were obtained to evaluate the association between demographic characteristics and clinical characteristics and the outcome of depression. Results: PSD was diagnosed in 18 subjects among which 17 had strong association with left hemisphere lesion, 1 had right hemisphere lesion.Out of 18 subjects,10 subjects had lesion in the cortical area and 8 subjects with lesion in the subcortical area.In that 18 subjects, 15 subjects had lesion in the anterior part of the brain and 3 subjects had lesion in the posterior part of the brain was found to be statistically significant. Discussion: Results are in keeping with previous landmark studies.Differences in emotional reactions depending on hemisphere and site of the infarct as shown in this study suggest an organic basis for post stoke depression. Conclusion: By knowing etiological basis would allow clinician to assess the risk of developing PSD it gives early detection and treatment and will lead to improving their quality of life.

Tetrafol
L-methylfolate 7.5 mg