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Bengal Journal of Private Psychiatry

Review Article

Gadget addiction, Technostress & Internet addiction:

Upcoming challenges
Bhattacharyya Ranjan1, Ghosal Malay2, Chakraborty Kaustav3, Mandal Supriya Kumar4

1. Assistant Professor & HOD, Deptt of Psychiatry, Murshidabad Medical College & Hospital, West Bengal, India.
2. Assistant Professor, Deptt of Psychiatry, College of JNM & Hospital, Kalyani, West Bengal, India.
3. Assistant Professor, Deptt of Psychiatry, Murshidabad Medical College & Hospital, West Bengal, India.

Corresponding Author: Dr Ranjan Bhattacharyya. MD, DNB (Psychiatry), PhD trainee,

Asst Professor & HOD, Deptt of Psychiatry,Murshidabad Medical College & Hospital,West Bengal, India.
Mob: 9433053389. Email: Website:

Background: The modern gadgets and technology have become predominant determinants of socioeconomic
status and not only is restricted to teenagers but is spreading fast across generations.
Introduction: Addiction to technology is causing significant loss of productivity as well as problems in
interpersonal relationships.
Materials & Methods: It has been postulated that rather than a separate entity, internet addiction is a
manifestation of a variety of depression, anxiety, impulse control disorders or pathological gambling. .
Results: There have been rehabilitative measures to correct internet overuse.
Discussion: Technophobia is the fear or dislike of modern technology particularly computers.
Conclusions: Let us welcome the technological revolutions with a widespread awareness of its potential danger.
The generation of today needs to move ahead with bright vision and better tomorrow.

BACKGROUND: relationships. 'Emotions' have been replaced by

The list of modern day gadgets is exhaustive and includes Emoticons. It would not be wrong to say that Man has
Laptops, iPads, iPods, Video games, Smart phones and become slaves to the modern day gadgets. In the words
playstations. These modern gadgets and technology have of the Michael Condry the chief operating and
become predominant determinants of socioeconomic development officer of Sledgehammer Games. All these
status and is not only vastly popular amongst teenagers and gadgets, the phone and the computer, they expose the
young adults but is fast spreading across all generations. inside of your brain in a way that's bad. People prefer to
This increasing dependence on technological gizmos has spend their weekends and spare time at home in front of
far-reaching consequences. these gadgets. Children spend hours and hours in front of
Parents often complain that their son or daughters are laptops playing video games and social networking. Even
increasingly addicted to their mobile phones or play video pornography, erotica, dating websites and sex games are
games and watch television the whole day. Human just a small'click' away. The parents are not fully aware of
intelligence has evolved, so have our gadgets and the the provisions of family filter , internet site selection, and
internet. Mechanised communications in social networking channel selection in televisions. As a result children are
sites have largely replaced warm interpersonal interactions often exposed to the harmful effects of these materials.
that once formed the basis of lasting bonds and Children are becoming lazy, inactive and more aggressive.

Bengal Journal of Private Psychiatry

They are addicted to video games which often contain Judicious use of internet is always advisable. Google can
materials of extreme violent nature. Tender childly act as a gold mine of information for all kinds of people,
emotions have been replaced by rudeness adamance and young and old. The patterns of internet addiction across
defiance. The nuclear family structure and busy modern various generations are different. Selfies or "photographing
day schedule of working parents have made the of the self" and posting the pictures in the internet are the
opportunity of priceless human interactions bleaker.In new trends in the social media. The internet is flooded with
today's world, people are preferring to socialize on the pictures of models, actors and actresses who upload their
internet more and more rather than face-to-face. There are personal photographs for public view. The practice is no
frequent brawls between the parents and children. more confined to the celebrities. The generation Y has
Children no longer respect their parents and more than adopted this trend in no time. A recent study has explored
often parents view children as their competitors rather than the relationship between selfie-posting, photo-editing and
their predecessors.Albert Einstein once expressed his personality disorders.1
concern that technology will surpass human interaction. It explored the inter-relationship between self-
That day has arrived. objectification and the three traits (known as the Dark triad
of narcissism, psychopathy and machiavellianism). The
Internet Explorer - Logoff Warning study concluded that posting of higher number of selfies in
the social media were directly related to narcissism and
psychopathy. Addiction to technology is causing significant
loss of productivity as well as problems in interpersonal
relationships. The internet has paved the way for the waves
of globalisation to spread its claws in the smallest
households of the country. It's high time to formulate a
comprehensive approach to curb the unrestricted use of
the internet. Recently an incident where a teenager
committed suicide on losing his mobile phone has shaken
the nation to its root. Such slavery for gadgets are indeed
worrisome. We often witness people crossing busy roads
and busy intersections and railway tracks listening to ipods
or talking over the phone. This has lead to increase in the
number of accidents.

Over-use of mobile phones can affect social and
psychological well-being and health.The article was about
a teenager boy from china who sold his "kidney" just to buy
an iPhone for himself. Corresponding incidences and
trends in developing nations like India are also on the rise.2
Enormous amount of research has been directed in the last
decade on mobile phone use and its influence on the human
mind and body. It has been concluded that excessive
mobile phone users may encounter increased stress,
Fig 1: Technological dependence and impact on disturbances in sleep and symptoms of clinical depression.
relationships. These symptoms are especially prominent in young adults3

Bengal Journal of Private Psychiatry

Internet addiction disorder (IAD) or more commonly diagnosis of Internet addiction was difficult since 86% of
called Problematic Internet Use (PIU) or Compulsive study subjects presented with symptoms pertaining to
Internet Use (CIU) or even iDisorder.4,5,6 The various other mental health disorders.15 Young explained
nomenclature was originally proposed in a satirical hoax by "Internet addiction" as a broad term that include addiction
Ivan Goldberg, M.D., in 1995. However, some time later, to 'cyber sex', 'cyber relationships', 'net compulsions',
it started to be used as a more generalised term denoting 'information and research' and 'computer gaming'. 'Internet
excessive uncontrolled use of the internet. He used the Addiction' is actually addiction to the 'content' available
model of pathological gambling (diagnosed by the online like gaming, shopping, gambling cyber-relations
Diagnostic and Statistical Manual of Mental Disorders and anonymity, hence internet serves as the tool necessary
(DSM-IV) as his model for the description of IAD.Lack to fuel these addictions.16 Thus, excessive Internet users
of standardization in identifying PIU seems to be the major are actually not Internet addicts per say. Another study by
barrier in classifying this as a psychiatric disorder.7 Young elaborated that the new users of the internet were
IAD can be categorised into subtypes by the type of the ones who were addicted more than regular users who
activity, like gaming; online social networking; blogging; have been using the internet over a period of a year and
email; viewing Internet pornography in excess; or even were largely nondependant, conforming to the concept
Internet shopping (shopping addiction). However, all that internet addiction may wane over time.17 Young the
compulsive behaviors may not be necessarily addictive.8 A founding member of The Centre for On-Line Addiction
recent study suggests that the prevalence of Internet claims Internet addiction covers five principal subtypes of
addiction varies considerably among different countries behavioural and impulse control disorders that include:
and is inversely related to the quality of life.9 Addiction 1. Cybersexual addiction: addiction to cybersex and
researchers, psychologists, healthcare providers as well as cyberporn
older adolescents have contributed data to build a 2. Cyber-relationship addiction
conceptual model of PIU.10,11 3. Obsessive online gambling, shopping or day-trading
That study put forward seven concepts, or clusters such 4. Compulsive and over-excessive web surfing or
as: Psychosocial risk factors; Physical, Emotional, as well database searches
as Social and Functional impairments; Risky Internet use; 5. Obsessive computer gaming18
Impulsive Internet use; and Internet use dependence.12 Hypersexuality and Internet pornography use has come
Risky Internet use are those behaviors that increase the under the scanner in recent years.19,20 Internet
risk of harmful consequences. Harmful effects include pornography is very common in the West.21 There has
difficulty in memory and concentration, emotional been a dramatic rise in mental disorders as an aftermath of
turbulence, anxiety, insomnia, compulsive disorders as well pervasive internet pornography addiction.22,23
as depression. The impulsive use is the inability to control Joshua B. Grubbs, a specialist in Addictive Behavior
internet use in day-to-day life. Finally, dependent use Patterns, that at present there is no single prevalent
describes extreme situations like withdrawal symptoms.10 consensus regarding Internet pornography addiction and
Internet addiction disorder is not yet listed in the latest hence the defining Internet pornography use as an
DSM manual (DSM-5, 2013), which is commonly used addiction is very much controversial.24 The current
by psychiatrists all over the world.13 The only behavioural Diagnostic and Statistical Manual of Mental Disorders
(non-substance related) addiction included in DSM-5 is (DSM-5) does not classify Internet pornography as an
gambling disorder. However excessive Internet gaming is addiction. However, hypersexuality is mentioned while
listed in an appendix as a disorder requiring further study.14 discussing other disorders.25 But there is no independant
entity as hypersexual disorder in DSM-5. While
THE NOSOLOGY AND CHANGING TRENDS: pornography is mentioned in DSM-5, pornography is not
Jerald J. Block, a leading psychiatrist observed that identified as a mental health problem. Cyber-Relationship

Bengal Journal of Private Psychiatry

addiction has been defined as an impulse-control problem internet has enabled excellent resolution in video calling,
within Internet Addiction Disorder; it has been described multimedia messaging (also popular as "MMS"). These
as an addiction to social networking in all forms.26,27 have truly made any place in the universe "accessible" and
Cyber-Relationships are in essence a virtual relationship or "within the reach" which previously was unimaginable.
form of communication between two people. Anonymity Thus Internet has its fair share of goodness as well.31
and privacy in relationships are something that are
cherished by many.Over time virtual online friends win MEASURING INSTRUMENTS:
importance over time to real-life family and friends. People Two scales, a 20-item self-reported Problematic Use of
who experience social phobia and anxiety issues can find a Mobile Phones (PUMP) scale and Mobile Phone
suitable vent for their emotional necessities.However, Problem Use Scale (MPPUS), estimated the prevalence
these virtual relationships have more than often devastated of avid internet users among British adolescent population
real lives. Criminal intentions are always in search of weak and found it to be approximately 10% among those aged
unsuspecting minds. The fake profiles and its dire 1114 years and corresponding figures in India were
consequences had been cinematized in the movie named estimated to be 39-44%.28,32,33,34 In contrast, the
"catfish" after the famous documentary film released in prevalence of Internet addiction was 4.9-10.7% in Korea
2010. These fake profiles are often created in the social and is a serious public health concern.34
networking sites with vile intentions and people are often Addictive behaviour is more common among women as
tricked into false relationships. Robbery, thefts, compared to men.35 Women tend to use mobiles more for
kidnappings, blackmailings and even murders have been social purposes than men do. Older people tend to use
the aftermath of such intentions. Many people have mobiles the least for social purposes. This is the largely due
suffered irretrievable personal losses due to internet social to lesser popularity and greater self-regulation among
networking addiction. elders.36 In another survey by Gazelle, 44% participants
The term addiction or habituation has largely been reported anxiety and irritability on being unable to interact
replaced by the term "dependence" Mobile phone with their phones for a week.37
addiction has been added in the long list of psychoactive Approximately, 70% people use their mobile phones
substance abuse, alcohol and tobacco under ICD 10.28,29 within the first hour of getting up in the morning. 56% of the
subjects check their phones before going to bed. 51%
Shambare et al. claim that cell-phone use is "possibly the
check their phones constantly even during holidays. A
biggest non-drug addiction of the 21st century;"30 The
study in Egypt showed that the risk of transmitting micro-
results of two studies aimed to explore the behavioral
organisms by medical staff via mobile phones is much
aspects associated with the use of excessive use of mobile
phones clearly showed that college students, as well as non
Although substantial evidence is still lacking, there has
students, reported problematic mobile phone use and their
been speculation that overuse of mobile phones can lead to
behavior fulfilled a number of the addiction criteria. Mobile
cancer, specially brain cancer. In 2011, the International
phone use has been attributed to increasing number of Agency for Research on Cancer of the World Health
accidents and accidental deaths. Mishaps occur due to Organisation suggested that radiofrequency can be a
negligence not only on the part of the driver but also on the probable human carcinogen. Links were established
part of the pedestrian. In majority of accidents, talking between use of mobile phones and the potential risk of
over phone while crossing roads or driving cars are developing glioma.39
responsible for these mishaps. Mobiles have replaced the Headaches, impaired memory and concentration, fatigue ,
warm personal interaction that once formed the basis of a dizziness and sleep disturbance has been associated with
healthy familial relationship. However it has also fostered radiation sickness.40,41 A study links insomnia to the use of
increased connectivity across huge distances. High speed cell phone before bed.In 2014, 58% WHO states issued

Bengal Journal of Private Psychiatry

guidelines to the general population to cut down Changes in the brain ultra-structure were also found in
radiofrequency exposure below heating guidelines. The internet addicts as revealed by a 2009 study and these
major recommendation was to use hands-free kits and to neurobiological correlates are similar to chemical addiction
reduce call time duration, apart from using text messaging as evidenced by MRI studies which revealed that internet
and avoiding calls with low signals or using phones with addicts had impaired grey and white matter integrity in the
low SAR.42 In 2015, Taiwan banned toddlers from using orbitofrontal cortex of the prefrontal regions of the
mobile phones and France withdrew wifi from toddlers' brain.50,51
nurseries.43,44 The orbitofrontal cortex is important to execute functions
The genera of mobile phone that are used for multitasking like planning and prioritization, remembering details as well
could be called as "Smartphone" and had the features of as controlling our mention.52,53 It has been postulated that
PDA (Personal Digital Assistant). In todays world, rather than a separate entity, internet addiction is a
smartphones have touchscreen, user-interface, camera, manifestation of a variety of depression, anxiety, impulse
media player, radio, innumerable apps, motion sensors and control disorders or pathological gambling. Parallels have
even independant GPS navagation unit. Nowadays been drawn between internet addiction and food disorders
smartphones have been operating high speed mobile where overeating acts as a relief from depression and
broadband 4G LTE internet and mobile bill payment anxiety; or impulse control disorders where the person is
solutions. addicted to bidding, pornography, gaming and gambling,
Nomophobia or "no-mobile-phobia" is a new term that has whether or not they are online or offline.54,55
gained popularity. The psychological factors like low self- Byun et al. asserted the fallacies of most of the studies as
esteem and lack of self confidence are the basis of this they have inconsistent criteria for defining net addicts
behaviour. It is likely that these individuals suffer from resulting in conspicuous sampling bias and investigates
social phobia, social anxiety disorder and/or panic degree of association rather than causal relationships.56
disorder and this kind of behaviour is an external Pathological use of the internet can lead to increase in job
manifestation of underlying phenomena based on the study losses, divorce rates, financial debts and academic failures
that investigated the anxieties suffered by 2163 mobile according to a Korean study. 70% of internet users play
phone users in Britain.45,46 online games, and 18% among them are addicts of online
Kathy Scherer,a psychologist from the The University of gaming. The gamers documented that addiction to online
Texas at Austin asserted that,"13% of college internet games helped them to avoid stress in real life. Kimberley
users fit the criteria for Internet addicts" .In her study, Youngs questionnaire was used in this study.57,58
Scherer enrolled 531 college students. Further it was Young discusses the findings of Dr. Maressa Hecht-
revealed that "72% of the Internet addicted students were Orzack of McLean Hospital whose set up for computer
men".47 and internet de-addiction, received patients with
Cyber dependency was found on an average 5% and 10% depression and bipolar depression in its full depressive
of Web surfers in a study and depression and anxiety swing. Also patients were largely referred from different
disorders are common among internet addicts. 48 clinics throughout the hospital rather than direct self-
Compulsive Internet use has been linked to morphological referrals.59 The instrument used to assess cyber abuse was
changes in the brain. A study among Chinese college cyber the Internet Addiction test by Kimberly Young classified
addicts found reductions in the sizes of the dorsolateral addictive behaviour into mild, moderate and severe
prefrontal cortex,rostral anterior cingulate cortex, impairment. Available in three different languages, English,
supplementary motor area and parts of the cerebellum Italy and French, this was the first global psychometric
Although these changes can signify learning type cognitive measure.60
adaptations for efficient cyber use, there was impairment The Compulsive Internet Use scale(CIUS) developed in
of short-term memory and decision-making skills.49 2009 consists of 14 items and rated on a 5-point scale

Bengal Journal of Private Psychiatry

from 0=Never and 4=Very often. Some other scales are net addicts that offers a 45-day program to wean people
Problematic and Risky Internet Use Scale (PRIUSS). The from pathological internet use. 68
Chen Internet Addiction Scale(CIAS) is a 4-point Likert A somewhat harsher measure was invented in August
scale with 26 items, with a higher total score indicating 2013 by researchers at the MIT Media Lab, USA who
greater severity of net addiction and is applicable to both developed a USB connected keyboard accessory that
adults and adolescents.61,62,63 In a Hong Kong based "punishes" net addicts with a small electrical jolt every time
study, 18% Chinese adolescents were reported to be net there is excess time spent on a particular website.
addicts.64 Some proponents commented that those who Pathological gambling, according to David Hodkins,
are lonely and depressed develop a preference for online professor of psychology at the University of Calgary , is a
interaction rather than face-to-face rendezvous. This can separate entity altogether. The surge of globalisation has
lead substantial negative outcomes like mood swings and created a desperation for 'fast' money, particularly among
withdrawal symptoms when they were away from the young teenagers. The option of online gambling is
internet.The intrinsic deficit is not healed, but in turn its attractive due to lack of any social inhibition and the
severity gets exacerbated.65 widespread use of the internet where the gambling sites are
Mark D. Griffith proposed six criteria for Internet just one click away.
addiction and are as follows:66 Online stock trading , according to Brian Bloch is very
1. Salience: Internet use pre-occupies individuals addictive due to the sense of empowerment it generates as
personal life and thought process. traders have the ownership over when and how stocks are
2. Mood modification: The positive experience is a traded and money distributed . The environment is free
consequence of engaging to the cyberworld and from arrogant bosses or hectic schedules that the individual
helps in avoiding situations in life that are difficult to encounters in a day-to-day life. They are enthralled into a
deal with. cycle of imperishable desire to win money that often leads
3. Tolerance: Increasing the use of the internet helps to to repeated losses and bankruptcy. Video game addiction
achieve a desired level of mood elevation. has drawn significant attention since the past decade.70
4. Withdrawal symptoms: Substantial unpleasant use on With the advancement of technology, it has gained
discontinuation or reduction of internet use and phenomenal proportions. Online video games flood the
consist of physical symptoms like tremors, mood cyberspace. Cyber game addicts range from children to
disorders or irritability. adults. Andrew Doan, with a background in neuroscience
5. Conflict: Interpersonal conflict,conflicts with other research had to fight with his mammoth internet addiction
essential activities like job, social life or even within whereby he spent approximate 20,000 hours of game play
the individual may result from net addiction. spread over a period of nine years.
6. Relapse: Recurrence of behavioral patterns Online Gamers Anonymous, a non-profit organisation was
previously observed after periods of abstinence or developed in 2002 for de-addiction support for avid
control. gamers include an array of discussion forums, online chat
Some researchers found on longitudinal follow up that sessions, skype communications to help recover from the
Internet addiction corrects itself over time.Some of the deleterious effects of internet games.71
correction measures include softwares to restrict the Jim Rossignol, a finance journalist who, similar to Andrew
content, cognitive and behavioural therapy.Rather than Doan, was a game addict himself, is now a well known
total abstinence, control over the internet usage is reporter of internet gaming and gaming culture.72
There have been rehabilitative measures to correct internet DISCUSSION:
overuse. One of such endeavour is ReSTART, a center for Social network addiction is a behavioural problem that
residential therapy based on Seattle, Washington, USA for necessitates a constant urge to communicate with other

Bengal Journal of Private Psychiatry

people on the social media even though there is no aspect of the employee. There should be workshops
immediate necessity for such interaction. Facebook has organised for employees not only to impart knowledge and
created a wave of communication addiction. It has enhance their technical skills but also to make them aware
become a platform for social communication, fostering of the deleterious effects of technostress. IT
relationships as well as a source of unbound entertainment. troubleshooters should help maximise the system
People update their status on their facebook page, accessibility and strive to make the employees more
sometimes even minute details of day to day life are comfortable with the system.
updated. Some people are in the habit of uploading their The principal causes of technostress are
own self-clicked pictures in the urge of getting noticed by Fast pace of technological change with lesser time for
their peers. Sharing personal moments are very much in acclimatisation
vogue. Friends in social networking sites are seldom Lack of adequate training
friends in real life. Having large numbers of friends and Phenomenal workload
followers in social networking sites are regarded as indices Absence of standardization within technologies
of high social quotient. This has lead to this "virtual world Reliability of hardware and software
addiction". Presently this addiction is limited to interactive Technophobia (from Greek techn, "art, skill, craft" and
visual media for example social media like facebook. But phobos, "fear") is the fear or dislike of modern technology
scientists predict the future of virtual reality to be a particularly computers.According to Dr. Larry Rosen,
computer stimulated pseudo-environment that can have research psychologist and professor at the California State
extreme potential for addiction.73 University describes that there are three types of
There is one TV addict in every household.Around 70% of technophobes- the "uncomfortable users", the "cognitive
Americans are TV addicts.This is still on the rise, thanks to computerphobes", and "anxious computerphobes".76
the modern television technological advancement. LED, World War II and the bombings of Hiroshima and
Plasma TVs with mammoth screens and concept of home Nagasaki worked as catalysts to the existing fear and
theatres have created a revolution in the television world. phobia .War technologies such as napalm, explosives, and
People are more and more drawn inside the comforts of gases during the Vietnam War further escalated the
their homes, keeping the time for healthy social interactions situation.77 The British Luddites protested the application
completely at bay. Addictions have lead to the loss of of the machines and argued that the skills of human labour
valuable work hours in total laziness and lethargy. needed protection from destructionby the autonomy of
However TV addiction is not classified as a separate machines.78
condition in DSM-IV.Technostress is the negative impact New technologies often encounter conflict with established
of the modern technology and includes altered work habits beliefs. They contradict personal values of simplicity and
that is brought about by the use of these technologies at modest lifestyle. Technophobic ideas can be found in
office and home situations.74,75 various forms of art, from creative literature such as
There exists a range of symptoms that people experience Frankenstein to science fiction drama like Metropolis.
from technostress. Some of these are headache, mental These works mainly portray the evil side of technology as
exhaustion, panic, helplessness, insomnia, loss of temper, perceived by the technophobic. With the technologies
irritability, anger and frustration. Hours infront of the becoming increasingly complicated, people are more and
computer can lead to physical symptoms like backache, more likely to harbor anxieties relating to the use of these
stiffness in the neck, shoulder and reduced job satisfaction advanced technologies.With the advent of modern
and productivity. Jobs that have increased likelihood of medicine and the likes of Louis Pasteur, Charles Darwin,
developing technostress should employ adequate Gregor Mendel, Michael Faraday, Henri Becquerel, and
preventive measures like periodic assessments to check Marie Curie, and inventors such as Nikola Tesla, Thomas
the effects of technostress on the physical and emotional Edison and Alexander Graham Bell, world was changing

Bengal Journal of Private Psychiatry

rapidly. The Romantics tended to believe in imagination other discrepant perceptions concerning risk and benefit of
over reason, the "organic" over the. Poets like William facebook. According to recent studies, late adolescents
Wordsworth and William Blake harboured the thoughts who are victims of cyber bullying, are at higher risk of
that the technology was polluting the perfect and pure depression of problematic alcohol use. IA prevalence is
nature in more than singular ways. Let us welcome the inversely associated with quality of life reflected by
technological revolutions with a widespread awareness of subjective (life satisfaction) and objective (environmental)
its potential danger to get addicted by limited fruitful use of indicators. According to studies, avoidant coping and
modern day gadgets the generation of today needs to coping inflexibility are the cause of psychological
move ahead with bright vision and better tomorrow. maladjustments in Internet Addicts. Texting while driving
Digital amnesia symptoms are the habit of automatically has become a cultural artefact, which conflicts with driver
going online to get answers to questions. The trend to look safety as well as laws prohibiting texting while driving.
up information before even try to recall it prevents the build Recent studies suggest that online gaming is negatively
up of long term memories. The loss of data stored in smart correlated with college engagement and academic
phones causes immense distress, particularly among performance of college going students. Recent studies
women and people under 35. Selfitis is an obsessive suggest that the extent of social anxiety is a predictor of
compulsive desire to take selfie and post them on social preference for online social interaction & IAD
media to make up for the lack of self-esteem and to fill a Cybersexual addiction is defined as a type of IAD where
gap in intimacy. Acute selfitis is defined as taking photos of the addict spends excessive time on websites for cybersex
one's self at least three times a day and posting each of the or cyberporn. Data suggests that approximately 20%
photos to social media. Chronic selfitis is the internet addicts are engaged in some form of online sexual
uncontrollable urge to take photos of one's surroundings activities. Problematic and repetitive sexual behaviour
round the clock and posting the photos more than six times serves as a means to escape stress and tension, becoming
a day. Selfie obsession is attributed to low self-esteem as a way to handle the problems. Cyberchondria is defined as
people try to find a way to boost themselves. It could be anxiety induced by health related excessive online search
attributed to gain attention from the society. In India 74% causing hypochondriasis. Cyberchondria is caused by
of adolescents are found moderately addicted to their excessive information; patient tries to convince himself that
smartphones. Smartphone dependence may cause stress, he is suffering from illnesses, causing anxiety and
depression, anxiety, insomnia, delinquency and depression. Individual searching for reassurance online
aggressiveness.(Int J of Preventive Medicine).According may experience anxiety as a result of escalating search
to researchers, the presence of ADHD increases the risk behaviour.
of Internet addiction. Research suggests that adolescents "A person who never made a mistake never tried anything
with IAD have more aggressive dispositions than others. new."
Early psychiatric intervention may prevent IAD. According -Albert Einstein
to recent studies on school going adolescents, boys are
more likely to have internet dependency. Secondary
school students, who suffer from IAD, may have
psychological behavioural problems like restlessness,
palpitation, tremors etc. Recent studies provide evidence
of compromised prefrontal cognitive control over
emotional interference in adolescents. Increased internet
use predicted higher levels of social support, reduced
loneliness & psychological well-being among older adults.
A survey of facebook overusers demonstrated novel self-

Bengal Journal of Private Psychiatry

Edison and Alexander Graham Bell, world was changing

rapidly. The Romantics tended to believe in imagination
over reason, the "organic" over the. Poets like William
Wordsworth and William Blake harboured the thoughts
that the technology was polluting the perfect and pure
nature in more than singular ways. Let us welcome the
technological revolutions with a widespread awareness of
its potential danger to get addicted by limited fruitful use of
modern day gadgets the generation of today needs to
move ahead with bright vision and better tomorrow.
Acknowledgements: Nil
Conflictcs of interest: Nil.
Ethical Clearance: Has been taken from the Chirman of
Institutional Ethics committee: Taken.

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Bengal Journal of Private Psychiatry
Original Article

Depression With Somatizationis HDRS Useful In Such Situations?

A Pilot Study
Sinha Mousumi1 Das Debasish2

1 Ex. Associate Professor,M.D. Midnapore Medical College, Former Resident, Calcutta National Medical College
2 Debasish Das, DPM, Consultant Psychiatrist, District Mental Health Programme, South 24 Parganas, Former
Resident, Calcutta National Medical College

Consecutive patients attending Psychiatric OPD meeting ICD-10 criteria for Depressive Episode were
included in the study provided their age were within 18-65 years and no associated general medical conditions
was present. HDRS scores were lower in patients presenting with somatic complaint and may be a cause of
somatisation. Most significant finding of our study was that, although HDRS total scores were more in
depressed patients, it had little discriminating power to distinguish depression from somatoform disorders.
The scores were heavily influenced by co-morbidity with specific gender related difference. Principal
presenting problem does not bear any relationship with HDRS score. QUEST analysis indicated only Iteam12
of HDRS-17 (Somatic Symptoms, Gastrointestinal) was best variable in differentiating between depressive
disorders and somatoform disorders. The research indicates need to study reasons for the above findings,
especially analysis to detect inherent problems of HDRS in our clinical and cultural perspective.

INTRODUCTION 1) Lack of awareness about depression amongst

Until very recently, mental diseases were neglected common people and primary care physicians.
worldwide perhaps because of limited mortality. 2) Stigma attached to mental illness.
However, recent studies assessing disability-adjusted 3) Somatic presentation of depression.
life years (DALYs) lost due to various diseases show Somatization is important in clinical practice because
that psychiatric conditions account for about 22% of it is very common. Study conducted by De Leon et al
DALYs lost. Depression is by far the commonest (1987) on consecutive series of patients referred to
amongst the psychiatric causes (WHO, 1999; Murray psychiatric liaison service from other hospital
& Lopez, 1996). Depression has been projected to departments found that nearly 50% were somatizers
become the second-ranked cause of lost DALYs by the and 15% had somatoform disorders. In another study,
year 2020.Even presently the morbidity and disability Katon et al (1984) found that 48% of somatisers had
due to depression exceeds that of common medical depressive illness and 29% had somatoform disorder.
conditions like hypertension, arthritis, diabetes, Another issue that is likely to be complicated by the
chronic lung diseases (Judd 1994). Worldwide, issues is measurement of severity of depressive
depression is principal or associated reason for disorder. The most commonly used rating scale for this
attending primary care clinics in about 20-30% cases purpose is Hamiltons Depression Rating Scale
(Ustun and Sartorious, 1995; Goldberg &Huxley, (Hamilton, 1960). However, this scale has many
1992). shortcomings. According to Maier & Philipp (1985)
Despite the importance of depression and availability the shortcomings are- 1) Heterogeneous scale items, 2)
of highly effective treatments, the remains mostly Unstable factor- analytic structure, 3) Missing general
undetected and untreated. Main causes for this are- factors, 4) Missing course validation and 6) Neglect of

Bengal Journal of Private Psychiatry

self-reported feelings of distress in favour of assessment of Table1 shows the mean age of patients according to sex
behavioral symptoms and somatic complaints. Indeed, to and diagnosis.
Maier & Philipp (1985) an Hedlund & Vieweg (1979),
Montgomery-Asberg Depression Rating Scale (MADRS) DEVIATION
(Montgomery & Asberg, 1979) is more suitable in the
presence of physical disorders with an increased somatic Depressive Episode FEMALE 24 33.42 7.37
element. Thus, HDRS might not yield good results in our without somatic MALE 14 34.14 9.09
cultural context, where somatic manifestation has been TOTAL 38 33.68 7.93
found common. Depressive Episode FEMALE 16 36.19 10.86
Keeping in view the importance of these issues in clinical with somatic MALE 11 49.64 9.09
practice, we decided to explore the following things- TOTAL 27 41.67 12.05
1) To compare their symptom profile of depression with FEMALE 40 34.52 8.91
or without somatic symptoms. MALE 25 40.96 11.87
2) To explore whether HDRS total score or individual TOTAL 65 37 10.54
item scores can assist in differentiating between
Depressive Episode without somatic syndrome and
Patients of Depressive Episode with somatic syndrome
Depressive Episode with somatic syndrome.
were older in age ( than patients suffering
3) To explore whether HDRS is an effective measure of
from Depressive Episode without somatic syndrome
depression in our cultural milieu of somatic presentation.
(33.687.93). In both the diagnostic groups, female
patients were of younger age. The observed differences in
age between the diagnostic groups and sexes was found to
Consecutive patients attending Psychiatric OPD, Calcutta
be highly significant statistically using ANOVA (both
National Medical College, meeting ICD-10 criteria for
individually and in interaction. hence, due to the difference
either Depressive Episode without somatic syndrome OR
in age between sexes, we shall use age as a co-variant in
Depressive Episode with somatic syndrome were included
our subsequent analysis.
in the study provided their age was within 18-65 years and
Table-2 Anova of Age of Patients with Diagnosis & Sex As
no associated general medical conditions was present.
Each patient was asked to mention their principal problem
which made them attend OPD and this information was Source Type III Sum d.f. Mean F Sig
of Squares Squares
recorded in a standardised format. The patients were then
administered the HDRS (17-item version) i.e. HDRS-17, Corrected
2189.469a 3 729.823 9.048 <0.001***
using the structured questions (translated into Bengali) as
Intercept 88277.979 1 88277.979 1094.385 <0.001***
laid down by Williams (1988). The study period was
Diagnosis 1251.710 1 1251.710 15.517 <0.001***
between June 2007 to August 2008. Appropriate
ststistical analysis was done using SPSS vesion 10.0 and Sex 753.955 1 753.955 9.347 0.003**
Diagnosis x
Answer Tree version 2.0.1 . Sex 607.369 1 607.369 7.530 0.008**
RESULTS Error 4920.531 61 80.664
Sixty-five patients were included in the study, 40 females Total 96095.000 65
and 25 males.38 patients were suffering from Depressive Corrected
7110.000 64
Episode without somatic syndrome while 27 suffered Total
from Depressive Episode with somatic syndrome. a. R2 =0.308, (Adjusted R2 =0.274).

Bengal Journal of Private Psychiatry

Table-3 shows the diagnostic break-up of patients TABLE-5 shows the result of ANOVA conducted on the
according to Sex. HDRS-17 scores of Table-4.
Table-5 Anova Of HDRS-17 Scores Of Patients With
DIAGNO- SEX Diagnosis & Sex As Factors
Source Type III Sum d.f. Mean F Sig
Depressive of Squares Squares
Episode Corrected
without 24 (63.2, 60.0, 36.9) 14 (36.8, 56.0, 21.5) 38 (100.0, 58.5, 58.5) 1148.524a 4 287.131 6.689 <0.001***
Intercept 552.156 1 552.156 12.863 <0.001***
Age 27.435 1 27.435 0.639 0.427, N.S.
Depressive Diagnosis 763.312 1 763.312 17.782 <0.001***
Episode 16(59.3, 40.0, 24.6) 11 (40.7, 44.0, 16.9) 27 (100, 41.5, 41.5) Sex 33.075 1 33.075 0.770 0.384, N.S.
with somatic Diagnosis x
syndrome Sex 65.832 1 65.832 1.534 0.220, N.S.
TOTAL 40 (61.5, 100, 61.5 ) 25 (38.5, 100, 38.5) 65 (100, 100, 100) Error 2575.630 60 42.927
Total 21503.000 65
Apparently, Depressive Episode without somatic Corrected 3724.154 64
syndrome is far more common in female than males, but
a. R2 =0.308, (Adjusted R2 =0.262).
the difference is not statistically significant. Levenes Test of Equality of Error Variances, F (3, 61) <0.001.
Table-4 shows the HDRS-17 scores in the two diagnostic
It shows the differences statistically significant with respect
groups along with gender-wise break-up.
to diagnosis, but not with respect to sex (both alone and in
NUMBER MEAN STANDARD combination with diagnosis).
HDRS- DEVIATION Figure 1 shows the result (i.e. ANSWER TREE) of
17 QUEST Analysis done to probe which of the many
Depressive Episode FEMALE 24 20.00 3.49
variables (i.e. HDRS-17 individual item and total score,
without somatic MALE 14 19.43 2.82
principal presenting problem, co-morbidity, age, sex) is
TOTAL 38 19.79 3.23 best in distinguishing between Depressive Episode without
SOMATOFORM FEMALE 16 10.00 5.13 somatic syndrome and Depressive Episode with somatic
DISORDERS MALE 11 14.82 13.51 syndrome patients.
TOTAL 27 11.96 9.55 Figure-1 Answer Tree Showing The Distiguishing Variable
TOTAL FEMALE 40 16.00 6.47 For Diagnosis After Quest Analysis
MALE 25 17.00 9.26 ICD -10 DIAGNOSIS
TOTAL 65 16.54 7.63
Item12 of HDRS-17
As expected HDRS-17 score was higher in Depressive (p-value=0.0000; F=66.9340; d.f. =1,63)
Episode without somatic syndrome (20.003.49) patients
than Depressive Episode with somatic syndrome patients
(11.96 9.55). HDRS-17 sores were higher in female Score 1.1169 Score 1.1169
Depressive Episode without somatic syndrome patients Without 5(13.16%) with somatic [without 33(86.84%)
while reverse was true in Depressive Episode with somatic 24(88.89) with somatic 3(11.11%)]
syndrome patients. Indeed, HDRS-17 scores was quiet It can be seen that Item 12 of HDRS-17 (Somatic
high in male Depressive Episode with somatic syndrome Symptoms, Gastrointestinal) is best variable in this respect.
patients, 33 (86.84%) of depressed patients scored above 1.12

Bengal Journal of Private Psychiatry

(approx.) while only 5 (13.16%) of depressed patients Various hypotheses have been advocated to explain
scored below that score on that item. Somatization.
These include-
DISCUSSION 1) Lack of linguistic skills to express their emotional
Our study also shows that HDRS scores are lower in experience (Alexithymia) (Prince, 1987). In our
patients presenting with somatic complaint. Though not study also, patients whose chief presenting problem
statistically significant, this might itself explain somatisation could not be categorized (the other category),
as described below. However, strong viewpoint expressed showed high HDRS scores, perhaps due to similar
by (Gelder et al, 1996) that presentation of less severe failure to communicate distress.
depressive disorders seems to be influenced by culture 2) Influence of culture in altering disease experience.
does not seem to hold in our study. (Raguram, 1996)
Most significant finding of our study is that, although 3) In some patients somatisation is a result of an
HDRS scores are more in depressed patients, it has little unspoken contract with their doctor and may be
discriminating power to distinguish depression from related to the physicians tending to organize his
somatoform disorders. The scores are heavily influenced patients distress into mutually preferred disease.
by co-morbidity with specific gender related difference. (Brown & Freeling, 1976)
Principal presenting problem does not bear any 4) According to Kirmayer (1984) stigma attached to
relationship with HDRS score. HDRS has been given a mental illness (i.e. its emotional distress) causes the
status of very effective instrument due to its strong depressive experience to be reconstructed through
psychometric properties as well as due to its somatisation to make it less socially stigmatizing.
comprehensive coverage of depressive symptoms and 5) The Cartesian disjunction of mind and body, which
related psychopathology (Rehm & OHara, 1985). Many shaped Western philosophy and scientific thinking,
studies, mostly in Western set-ups, have shown the total has caused mind to recede far from medical thinking,
HDRS score to be reliable and to have high degree of (Eisenberg,1977) thus not considering physical
concurrent and differential validity (Carroll et al, 1973). manifestation of psychological problem to be normal,
However, our study seems to support the objections about even in such Eastern cultures where the mind body
HDRS as expressed by Maier & Philipp (1985). dichotomy is not a part of philosophy.
QUEST analysis indicated only 12 of HDRS-17 (Somatic Main shortcomings of our study are-
Symptoms, Gastrointestinal) are best variable in 1) Small study size, hence insufficient power to detect
differentiating between depressive disorders and small differences.
somatoform disorders. 33 (86.84%) of depressed patients 2) No parallel instrument to measure depression (like
scored above 1.12 (approx.) while only 5 (13.16%) of MADRS) were used, hence comparison could not
depressed patients scored below that score on that item. be made.
This is not surprising considering the fact that anorexia has 3) Follow-up analysis to see the pattern of symptom
been considered to be amongst the most reliable indicators change in both the diagnostic groups was not
of depression provided medical disorders are ruled out attempted.
(Akisal, 1995). Cicchetti & Prusoff (1983) and Miller et al To conclude, considering the importance of depression as
(1985) have mentioned the fact that most of the individual a disease, follow-up study to clarify the issues raised is
items of HDRS have poor discriminative validity. We definitely needed. Such knowledge will perhaps contribute
believe that HDRS, which is frequently used in drug trials, in formulating Defeat depression like campaign in our
needs a fresh study and analysis to detect inherent country and help millions of distressed in a more
problems specially in our clinical and cultural perspective. comprehensive manner.

Bengal Journal of Private Psychiatry

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Bengal Journal of Private Psychiatry
Review Article

Expressive Therapy as a Psychotherapeutic Adjunct : Myth, Miracle

or a Mere coincidence.?
Chakraborty Suddhendu
Consultant Psychiatrist
West Bengal Health Service

Recent surge in the quest for alternative modes of drama , music and art therapy dates back to the Egyptian
psychotherapy led to a retrospect into different forms of civilization. (Fleshman and Fryrear 1981; Gladding,
expressive therapy as an adjunct. However this mere 1992)The mythological contexture of music therapy dates
consideration is not beyond intercept as these areas for back to its reference in the chapter of king Saul.(1
years have been known to stay in the interface between Samuel,16:23)According to the Italian philosopher de
arts and science. The argument in favour of different Feltre ,dance and play is central to a childs growth and
modalities of art therapy suggests action within therapy development(Coughlin, 1990).In 1923,during the world
and life is rarely limited to a specific mode of expression. war era, Joseph Munroe attempted the application of
(Mc Niff) While the proponents of expressive therapy tend monodrama to treat people suffering from post war
to emphasise the miraculous after effects, there arises trauma. His ventures were promising which led to
considerable debate when these effects stamped contemporary physicians to term his monodramatic
miraculous are scrutinized under a statistical spectre. approach as a miracle cure. The psychodiagnostic
Also a lack of protocol and series of randomized control, importance of expressive therapy was first enquired
cohort, and other statistically sound and cohesive studies in comprehensively by Florence Goodenough who
this field leads many purists to consider these forms of attempted draw therapy amongst children to explore
expressive therapy as a mere coincidental approach or a their inner conflicts. The other advances included use of
soft psychological cheese cake. This brief discussion sand play and sandtray as a form of therapy (vick, 2003),
would attempt to investigate into this complex logical play therapy (Margaret Lowenfeld,1969), talking cure
labyrinth. (Menninger Clinic in Kansas and St. Elizabeths in
Human mind is full of expressions. Art and other modalities Washington DC).Use of image therapy in debriefing,
of human expression has been considered for centuries to resolution while dealing with children and post trauma
mould human character and mind. Confucius in around stress disorder patients have also been brought under the
500 BC, wrote Character is the backbone of our human realm of expressive therapy (Malchiodi, 2001 ;
culture. Music is the flowering of character. Tolerance, Pennebaker, 1997 ).
love, social harmony and creative mind have been But as Abraham Maslow correctly said, If the only tool
attempted to be correlated philosophically and artistically. you have is the hammer, every problem starts to look like a
It is only till recent date after advancement of psychiatry as nail. The exploration of different facets of expressive
a promising medical discipline that the different houses therapy does not necessarily ensure its universal usage. But
considered loosely yet so far as an expressive therapy this redundancy has been one of the biggest fallacies of
needed to be defined.In brief, expressive therapy may be using these modes as a psychotherapeutic tool. A child
defined as the Use of art, music, dance/movement, having no interest in poetry and not even a mere inclination
drama, poetry/creative writing, play and sandtray within would be an absolute waste candidate for poetry therapy
the context of psychotherapy, counseling, rehabilitation and so on. Moreover the limitation of applicability of these
and health care. (Mc Niff ;1981, 1992) The definition different forms of expressive therapy has led to a shrinkage
also includes an integrated art approach with multimodal in the target cohort which led to the question of validity as
facets for psychotherapeutic venture. The history of use of well. Are we really dealing with an orphan approach that

Bengal Journal of Private Psychiatry

can be deemed damn insignificant in psychiatry? The controlled use of music in the treatment, rehabilitation,
loopholes lie in the lack of expertise of most of the education and training of children and adults suffering from
therapists to some extent. (Agell ;1982) Lack of physical, mental and emotional disorders.This use of the
authentication of the approach led to establishment of word controlled does baffle an interpreter as to whether
numerous associations that lacked necessary expertise, the entire process is therapist controlled. Perhaps this led
Infrastructure and insight required to be considered American Music Therapy pioneer Don Nichet to point out
scientific. However the potential power of expression of that the definition of music therapy is not self evident. Sadly
this therapeutic approach remains beyond doubt. enough, this opinion is applicable not only to music, but
Augmentation in the process of self extrapolation by art also the other forms of expressive therapy as well.
therapy (Gladding 1992),a cathartic approach (Rothschild However, despite all misfortunes, expressive therapy has
2000), expressing post traumatic experience in children proved to some extent its effectiveness as an adjunct
(Eliana Gil 1998) have been documented. But apart from a beyond myths and mere miracles. In a study conducted by
spontaneous release of creative energy (Adrian Hill), Leibmann in 1994 among young offenders in prison, art
expressive therapy failed to clear the hurdle of myths and therapy proved to be an effective mode of cathartic
miracles. expression. Lizzatto used art therapy amongst substance
abusers in a study in 1989 to show a significant rise in
The significant pitfall that fails expressive modes to prove
motivation, self esteem and abstinence. However both the
its effectiveness as a principal form of therapy is its lack of
studies were more subjective than statistical. Considering
statistical reliability and validity. While studies conducted
Jungs concept of Collective unconscious and Viktor
with Schizophrenia, Bipolarity, and Acute psychosis failed
Frankls logotherapeutic approach, the modalities of
to show any noticeable statistical outcome on application
expressive therapy should better not to be judged by
of these approaches (Group art therapy as an adjunctive numerics. Of late Silber et al investigated the value of song/
treatment for people with schizophrenia; multicentre poetry writing with patients (aged 6284 yrs) diagnosed
pragmatic randomized trial; Crawford et al; BMJ with Alzheimers disease. 1224 men and women
2012;344;e846 pub 28 Feb 2012),lack of proper participated in the group activity. A music therapist
structuring and model of execution led to difficulties in facilitated the writing exercise by proposing the themes,
conducting on field validation trials (A Systematic Review choosing music, writing the patients dictated text,
of Music Therapy Practice and Outcomes with Acute suggesting the use of metaphors and/or analogies, and
Adult Psychiatric In-Patients Catherine Carr et deciding when the concluding sentence had to be written. August 2013, Vol 8, Issue 8, Patients wrote songs based on descriptions and images of
e70252). Another block encountered is the prevalence of seasons and the themes of love and stages of life. Results
therapist bias while inferring into the results. Also the suggest that, based on the preservation of memory for
debate that whether expressive therapies be used as a tunes and melodies, patients were able to write songs and
principal psychological tool or a prognostic indicator poetry when assisted by appropriate stimuli and provided
remains. The recent advances in the sphere of biological encouragement (Silber, Fanny; Hes, Jozef Ph.Music
psychiatry further threatens them towards the path of Therapy Perspectives, Vol 13(1), 1995, 31-34;
oblivion. A recent debate in a social networking sight on an PSYCINFO). But yet again, the logical representation of
issue that whether human mind should be called merely a data failed to satisfy the statistical need and expectations
biological model with a few biometric dimensions leads me that would lead music therapy to be considered a serious
to think whether any form of expressive therapy can ever adjunct in the module for treating dementia patients. In a
bridge the gap between coefficients and probabilities! To nutshell, though expressive therapies continue to
add to the nightmare comes the debacle of defining the mesmerize poetic minds of a researcher, clinical data
different modes as therapy. In an attempt to define music suggests, there is still a long path to prove them as an
therapy, Avin (1975) opined Music therapy is the effective adjunctive therapeutic maneuver towards treating

Bengal Journal of Private Psychiatry

psychiatric illness. However, day to day subjective Handbook of Art Therapy; 2003; Guilford Press, NY,
experiences continue to argue us the fact that pg243-253
nonquantifiable attributes like faith, expression, creativity 11. Kelly J;What is Art Therapy and how do we know it
do have some role towards the process of healing in mental works;An Australian perspective on the need for more
illness. Thus there still remains scope for future serious research;International Journal of Interdisciplinary
structured studies in this field overcoming economic Social Sciences;2010;vol5;issue5;pg 255-259
constraints and therapeutic bias that may unveil a new 12. LeardiD;PietrolettiR;Angeloni G et al;Randomised
domain of psychiatry that would establish human mind to Clinical Trial examining the effect of music therapy in
be beyond a mere biological model. The quest remains and stress response to day surgery; BJP2007; vol.95;
so does the hope. issue8
13. Levine E;On the Playground:Child psychotherapy and
REFERENCES: expressive art therapy:Theoretical and clinical
1. Agell, G;The place of art in Art Therapy:American perspective;London;Kingsley;1999;pg.257-273
Journal of Arts Therapy1982;21,15-18 14. Liebmann M;JS Tumim;Art Therapy with
2. Benson,H;TimelessHealing:The power and biology of offenders;;1994;Jessica Kingsley
belief;1996;New York Scribners
15. LowenfeldM;Understanding Childrens Sand
3. Carr et al;A Systematic Review of Music Therapy
Play:Lowenfelds World Technique;Sussex Academic
Practice and Outcome with Acute adult psychiatry in
16. Mc Niff Shaun; Art based Research; Jessica Kingsley
4. Catherine C;D.Lisa;CherylK;DiMicoli Sue et
Publications; 1998
al;Supportivea expressive group therapy and distress
17. O Sarid; EHuss; Trauma and Acute Stress disorder:
in patients with Metastatic Breast Cancer;a
A Comparison between cognitive behavioural
randomised clinical trial;JAMAPsychiatry,May
intervention and art therapy; The Arts in
Psychotherapy 2010; Elsevier
5. Coughlin,E;Renewed appreciation of connection
18. P Luzzatto;GabrielB;The Creative journey:A model
between mind and body stimulates researchers to
for short term group art therapy with post treatment
harness the healing power of the arts;Chronicles of
cancer patients;Art Therapy2000;Taylor and France
Higher Education1990;36,9
19. Silber F; HessJ; Music Therapy perspectives;
6. Crawford et al;Group Art Therapy as an adjunctive
PSYCINFO 1995; vol 13(1); 31-34
treatment for people with Schizophrenia: a multicentric
20. Susan J Kelley; The use of Art Therapy with Sexually
pregmatic randomised trial; BMJ 2012; 344;
Abused Children; Journal of Psychosocial Nursing
and mental Health; 1984; vol 22, issue 12; 12-18
7. Donna J,Betts;Art Therapy assessments and rating
21. Tally Tripp MA; A Short Term Therapy Approach to
instruments: Do they measure up?; The Arts in
processing trauma; Art therapy and bilateral
Psychotherapy 2006; vol.33 (5); 422-434
stimulation; Archives of General Psychiatry; 2007; vol
8. E.Gil; Essential of Play Therapy with Abused
24; 53
Children; Guilford Publication, inc.72, 1998; NY;
22. TalwarN; Crawford Mike J; MaratosA; Music
Therapy for in patients with Schizophrenia; BJP; 2006;
9. FleshmanB; FryrearJ; NelsonH; Michael H Sac; The
189(5); 405-409
Arts in Therapy; Payne Whitney Psychiatric Clinic,
23. TinninL; Transforming the placebo effect in art therapy;
vol 33, issue 1, pg 64b, 65
American Journal of Art Therapy; 1994;32(3);
10. Gladding ST, NewsoneDW; Art in counselling:

Bengal Journal of Private Psychiatry
Original Article

Study of Psychotic Like Experiences In Mental Illness Free

College Students
Dutta Salil Kumar - Phd.
Lecturer, Department of Anthropology, Haldia Government College, Debhog, Purbamedinipur, West Bengal
Chakraborty Suddhendu, DPM, Consultant Psychiatrist, West Bengal Health Service

Background - Psychotic like experiences (PLE) have often been viewed as categorical phenomena(i.e., either
present or absent in an individual). However, the literature shows that PLEs can be found in the general population
which might support dimensional viewpoint of a continuum of psychotic phenotype, with the psychotic disorder at its
extreme end.
Aims - To determine the prevalenceof PLEs in a nonpsychotic clinical sample .
Settings and Design - Subjects from a Government college. Observational cross-sectional study was done
Methods and Material - A random sample of 306(210 male,96 female, mean age=19.82.7 years)college
students who were screened to exclude mental illness using SRQ-24 were assessed to measure PLEs using validated
local language version of CAPE-42(Community Assessment of Psychiatric Experiences).
Results - 96% endorsed at least one psychotic experience at least Sometimes, 45% endorsed at least one experience
Often or Almost always. 42% endorsed at least one experience Often or Nearly always. 3-factor structure best
represented the data and accounted for 44.8% of the explained variance. Factor 1 (6 items) - Bizarre Experiences,
Factor 2(4items )- Persecutory Ideas, Factor 3 (3 items)- Magical Thinking were found.
Conclusions - Presence of psychotic experiences in non clinical populations may represent the phenotypic expression
of the increased pronenessor risk for the development of psychotic disorders.

Key Words - Psychosis Continuum Symptoms, Psychotic like experiences, Normal population

INTRODUCTION viewpoint of a continuum of psychotic phenotype, with

Blood pressure and glucose tolerance are continuously the psychotic disorder at its extreme end. (Rose & Barker,
distributed characteristics in the general population, but 1978,Strauss 1969; Claridge 1997; Peters et al.1999;
because the clinical decision to treat is dichotomous, terms Stefanis et al. 2002;Verdoux and van Os 2002).2-7
such as hypertension and diabetes are used in medicine The supposition of a psychosis continuum does not
The psychosis phenotype is generally thought of as a necessarily imply that there is a continuum of disorder. For
dichotomous entity that can have Psychotic like example, in the US National Comorbidity Survey,
experiences (PLE) have often been viewed as categorical approximately 28% of individuals endorsed psychosis-
phenomena (i.e., either present or absent in an individual). screening questions. However, when clinicians made
Operationalised criteria derived from clinical observations diagnoses, the rate of even broadly defined psychosis was
on individuals with severe illness separate non-medicalised only 0.7% (Kendler, Gallagher, Abelson, & Kessler,
experiences in the general population services (Tien, 1996)8,9. This suggests that the clinical definition of
Costa, & Eaton, 1992).1 psychosis may represent only a minor selection of the total
However, the literature shows that PLEs can be found in (not necessarily clinical) phenotypic continuum.
the general population which might support dimensional The existence of lesser states on a distributed continuum in

Bengal Journal of Private Psychiatry

the population a risk factor for what clinicians would If you ticked sometimes , often or nearly
call disorder (Claridge, 1997)4. In epidemiological terms, always please indicate how distressed you are by
this argument can be explored by examining the possible this experience:
combinations of underlying causes of the presumed Please tick
psychosis continuum in relation to the predicted Not distressed A bit distressed Quite distressed
distribution of the trait Very distressed


To determine the prevalence of PLEs in a To determine the prevalence of psychotic-like
nonpsychotic college student sample . experiences, the participants responses were
To explore nature of this PLEs dichotomized. Responses were recoded to 0 (never) and
1 (At least sometimes).
METHODS AND MATERIAL SPSS-15 was used for analysis-descriptive
Settings and Design- measures-frequency,mean,sd,factor analysis of CAPE
Subjects from a Government college from Purba
Medinipur District, West Bengal. Observational cross- RESULTS
sectional study was done 96% endorsed at least one psychotic experience at
A random sample of 306(210 male,96 female, mean least sometimes, 45% endorsed at least one experience
age=19.82.7 years)college students who were screened often or almost always. 42% endorsed at least one
to exclude mental illness using SRQ-24 were assessed to experience often or nearly always. 3-factor structure
measure PLEs using validated local language version of best represented the data and accounted for 44.8% of the
CAPE-42(Community Assessment of Psychiatric explained variance. Factor 1 (6 items)- Bizarre
Experiences). Experiences, Factor 2(4 items )- Persecutory Ideas,
The CAPE (Community Assessment of Psychiatric Factor 3 (3 items)- Magical Thinking were found.
Experiences) (Stefanis et al,2002)6 is a 42-item self-report
two dimensional scales. The first scale scores the FACTOR SCALE ITEMS
frequency of the experience (measured on a 4-point scale NAME
from never,sometimes,often to nearly always, to FACTOR 1 Do you ever feel as if the thoughts in
avoid ticking the middle box bias) and the second scale Bizarre your head are not your own?
scores the degree of distress (measured on a 4-point scale Experiences Do you ever feel as if you are under
from not distressed, a bit distressed,quite distressed the control of some force or power
to very distressed). The CAPE provides an overall score other than yourself?
and a total score per dimension by adding up the number Do you ever hear voices when you
of positive answers to the frequency question, and it are alone?
provides a distress score by adding up the scores of the Have your thoughts ever been so
distress questions. vivid that you were worried other
people would hear them?
Sample Item of CAPE - 42 Do you ever feel as if the thoughts in
Do you ever feel as if there is a conspiracy against your head are being taken away from
you? you?
Never Sometimes Often Nearly always Do you ever hear voices talking to
If you ticked never, please go to question 11 each other when you are alone?

Bengal Journal of Private Psychiatry

FACTOR SCALE ITEMS Importance in producing illness and help-seeking

NAME behaviour. In this context, (Strauss, 1969) suggested four
criteria for defining the boundaries of clinical psychosis.
FACTOR 2 Do you ever feel as if you are being These were: the degree of the persons conviction of the
Persecutory persecuted in some way? objective reality of the unusual experience, the degree to
Ideas Do you ever feel as if there is a which cultural or stimulus determination of an experience
conspiracy against you? was absent, the amount of time spent preoccupied with the
Do you ever feel as if people seem to experience and the implausibility of the experience. The
drop hints about you or say things evidence suggests that the implausibility of experiences and
with a double meaning? degree of conviction may not be related to illness status
Do you ever feel as if some people (Garety&Hemsley, 199414). However, the cultural context
are not what they seem to be of psychotic experiences and degree of preoccupation and
distress do seem to be important factors
FACTOR 3 Do you believe in the power of
Magical witchcraft, voodoo or the occult? LIMITATIONS OF THIS STUDY
Thinking Do you think that people can 1) Small sample size
communicate telepathically? 2) Conducted on college students alone may not be
Do you ever feel that you are a very generalized
special or unusual person? 3) Self reported CAPE may overestimate PLE-need for
interview as check
4) Need to compare with clinical samples
DISCUSSION 5) Longitudinal follow-up
High prevalence of PLEsimilar to reports using
CAPE-Yung et al, 2009Between 10.9% - 91.5% CONCLUSION
reported some psychotic symptoms at least sometimes, Presence of psychotic experiences in nonclinical
Between 0.9% - 9.1% reported some psychotic populations needs further exploration so as to
symptoms always/nearly always understand psychotic phenomena better and help
We have found three-factor solutions, namely: patients by possible prevention and early detection.
1) Positive symptoms, 2) Negative symptoms, and
3) Conceptual disorganisation or Social impairment REFERENCES
(Liddle 1987; Venables and Rector 2000; Vollema and 1) Tien, A. Y., Costa, P. T., & Eaton, W. W. (1992).
Hoijtink 2000,10-12similar structure to our study reported Covariance of personality, neurocognition, and
by Yung et al,200613-though item constituting individual schizophrenia spectrum traits in the
factors differs. community. Schizophrenia Research, 7 (2),
Transition from having one or more psychotic 149-158.
symptoms to becoming a patient with a If there is a 2) Rose, G., & Barker, D. J. P. (1978). What is a
discontinuous relationship, what are the factors that are case? Dichotomy or continuum. British Medical
additionally important in bringing about an abrupt change Journal, ii, 873874.
resulting in need for care? Symptoms vary in terms of 3) Strauss, J.S., 1969. Hallucinations and delusions
frequency, degree of conviction, preoccupation, influence as points on continua function. Rating scale
on behaviour, distress, and secondary attributions, all of evidence. Arch. Gen. Psychiatry 21, 581586.
which may be of crucial 4) Claridge, G. (1997). Schizotypy: Implications for

Bengal Journal of Private Psychiatry

illness and health. New York, NY: Oxford 8) Kendler KS1, Gallagher TJ, Abelson JM, Kessler
University Press. RC.( 1996 ) Lifetime prevalence, demographic risk
5) Emmanuelle R. Peters, Stephen A. Joseph, and factors, and diagnostic validity of nonaffective
Philippa A. Qarety .(1999)Measurement of psychosis as assessed in a US community sample.
Delusional Ideation in the Normal Population: The National Comorbidity Survey. Arch Gen
Introducing the PDI (Peters et aL Delusions Psychiatry. Nov;53 (11) : 1022-31.
Inventory) Schizophrenia Bulletin, 25(3):553-576 9) Liddle PF(1987)The symptoms of chronic
6) N. C. Stefanis, M. Hanssen, N. K. Smirnis, D. A. schizophrenia. A re-examination of the positive-
Avramopoulos, I. K. Evdokimidis, C. N. Stefanis, negative dichotomy. Br J Psychiatry. 1987
H. Verdoux and J. Van Os (2002). Evidence that Aug;151:145-51
three dimensions of psychosis have a distribution 10) Venables PH, Rector NA.(2000) The content and
in the general population. Psychological Medicine, structure of schizotypy: a study using confirmatory
32, pp 347-358. factor analysis. Schizophr Bull. 2000;26(3):
7) Verdoux H, van Os J. (2002) Psychotic symptoms 587-602.
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of psychosis. Schizophr Res. 2002 Mar 1;54 Journal of Clinical Psychology (1999), 38,
(1-2):59-65. 113154

Bengal Journal of Private Psychiatry
Review Article

Tolvaptan Use by PsychiatristsNeed for Caution

Chakraborty Suddhendu, DPM, Consultant Psychiatrist, West Bengal Health Service

Tolvaptan is a selective,competitive vasopressin receptor 2 antagonist used to treat hyponatremia(low

blood sodium levels) associated with congestive heart failure, cirrhosis, and the syndrome of inappropriate antidiuretic
hormone (SIADH) and slowing disease progression of Autosomal dominant polycystic kidney disease. Tolvaptan was
approved by the U.S. Food and Drug Administration (FDA) on May 19, 2009, while this medicine is not a psychotropic
drug, it is being marketed among Psychiatrists for treatment of hyponatremia,which is often encountered among dementia
subjects. Being oral preparation, it is being advocated as way to avoid hospitalization. It is expensive with cost per tablet
ranging from Rs. 35-50 However, Psychiatrists possibly needs to exercise more caution about this medicine. This small
review tries to share some information for Psychiatrists about this drug.
Hyponatremia, defined as a serum sodium concentration below 135 meq/L. Figure 1 below gives a simple algorithm for
diagnosis of cause of hyponatremia.

Swap osmoles for Na+

Low Serum Na+

Glyceine washout for

TURP of hysteroscopy

ECF volume ECF volume ECF volume

Increased Normal Decreased

Urinary Sodium Urinary Sodium

Uninary Na+ Uninary Na+ Osmolality Osmolality Uninary Na+ Uninary Na+
<20 mmol/L >20 mmol/L Urine < Serum Urine > Serum <20 mmol/L >20 mmol/L

Increased Interstitial - Renal failure Water Intoxication SIADH PRE-RENAL RENAL

salt - Cerebral salt wasting
Intake related In presence of Na+ loss in excess of Salt and water lost
- Liver failure Drugs: Urine Na+>20 water through kidneys
- Cirrhosis - Hypertonic saline - Tea and toast diet - Hyponatremia - Diarrhoea - Kidneys failing
- Hepato-renal - Steroids - Beer diet - Euvolemia - Sweat - Addisons
Syndrome - Early diuretics - Psychogenic - Vomiting
- CCF Polydipsia If absence of: Diuresis
- Nephrotic syndrome - Hypovolemia - Burns - Renal failure
Water overload - Hypothyroidism - Fistula (diuretic stage)
- Lune disease - SBO - Osmotic diuresis
- Cirrhosis (Raised glucose and
Cause - Heat exposure urea)
- Drugs - Diuretics (Thiazides)
- CNS - Villous Adenoma of
- Chest rectum
- Malignancy

Figure 1 of interest to Psychiatrist is Syndrome of inappropriate ADH secretionwhose causes include Amiodarone,
Carbamazepine, Cerebral disorders (e.g., tumor, meningitis), Chest disorders (e.g., pneumonia, empyema),
Chlorpromazine, Thorazine,, Ectopic antidiuretic hormone secretion, Selective serotonin reuptake inhibitors.

Bengal Journal of Private Psychiatry

Standard protocol to treat hyponatremia as per American These drugs increased thirst, which may limit the rise in
Academy of Family Physicians-2015 is serum sodium
Dose scheduleAdapted from Lexicomp,2016
CLINICAL RECOMMENDATION 15 mg once daily; after at least 24 hours, may increase to
30 mg once daily to a maximum of 60 mg once daily
In patients with severe symptomatic hyponatremia, the rate titrating at 24-hour intervals to desired serum sodium
of sodium correction should be 6 to 12 mEq per L or less concentration. Avoid fluid restriction during the first 24
in 48 hours hours of therapy.following dose titration is recommended
(at 24-hour intervals):Change <5 mEq/L in 24 hours and
A bolus of 100 to 150 mL of hypertonic 3% saline can be serum sodium <130 mEq/L:
given to correct severe hyponatremia Day 2: Consider titration to 30 mg once daily.
Day 3: through discontinuation: Consider titration to 60
Vaptans appear to be safe for the treatment of severe mg once daily.m
hypervolemic and euvolemic hyponatremia but should not Change >5 mEq/L in 24 hours:
be used routinely Day 2: Consider maintenance dose of 15 mg once daily.
Day 3: through discontinuation: Consider maintenance of
Chronic hypernatremia should be corrected at a rate of 0.5 prior current dose.
mEq per L per hour, with a maximum change of 8 to 10 Change >8 mEq/L in 8 hours or >12 mEq/L in 24 hours:
mEq per L in a 24 hour period Day 2 through discontinuation: Considerwithholding dose
and/or increase hypotonic fluid intake; monitor sodium
Where does Tolvaptan fit in
Vaptans (conivaptan and tolvaptan) are vasopressin-
Serum sodium >140 mEq/L at any time: Discontinue
receptor antagonists approved for the treatment of
therapy and consider increasing hypotonic fluid
hospitalized patients with severe hypervolemic and
Tolvaptan can be taken before or after food intake
euvolemic hyponatremia .However, their use in the
management of hyponatremia is controversial.
Tolvaptan is available as 15 mg tablet. Dose
Tolvaptan is contraindicated in patients with hepatic injury
schedule - Guidelines advocate that Tolavaptan
and dehydration induced hypovolemia. Do not co-
should be started in hospitals only where serum sodium
administer Tolvaptan with hypertonic saline.
can be closely monitored. Indeed, if a patient stops
taking tolvaptan for any length of time, it should not Other drug interactions Tolvaptan may interact with
be restarted at home.Initiate and reinitiate tolvaptan in rifampin, rifapentin, carbamazepine, rifabutin, barbiturates,
patients only in a hospital Too rapid correction of cyclosporine, anticoagulants, anti-platelet drugs,
hyponatremia (eg, more than 12 mEq/L per 24 hours) can hyperkalemia causing drugs, itraconazole, diltiazem,
cause osmotic demyelination, resulting in dysarthria, verapamil, aprepitant, erythromycin, clarithromycin and
mutism, dysphagia, lethargy, affective changes, spastic NSAIDs.
quadriparesis, seizures, coma,and/or death. In susceptible Do not consume grapefruit, grapefruit juice or grape
patients, including those with severe malnutrition, wine while taking Tolvaptan.Tolvaptan may interact
alcoholism, or advanced liver disease, slower rates of with St. Johns wort.
correction may be advisable.Tolvaptan should not be used FDA has determined that (tolvaptan should not be
to treat hyponatremia and neurological symptoms due to used for longer than 30 days and should not be used
other causes. in patients with underlying liver disease because it

Bengal Journal of Private Psychiatry

can cause liver injury, potentially leading to liver 8. Shchekochikhin DY, et al. Outcome differences in
failure. community- versus hospital-acquired hyponatremia
Other side effects include loss of appetite, Itching, in patients with a diagnosis of heart failure. Circ
abdominal pain, diarrhoea, frequent urge to urinate, Heart Fail. 2013;6(3):379386.
nausea, yellow discoloration of skin, fatigue, headache, 9. Hagino T, et al. Hyponatremia at admission is
feeling of discomfort, dry mouth, constipation, excessive associated with in-hospital death in patients with hip
thirst, fainting, dizziness, vomiting, dark colored urine fracture. Arch Orthop Trauma Surg.
CONCLUSION 10. Korkmaz I, et al. Baseline characteristics and the
Psychiatrists should be cautious about using Tolvaptan. association between hyponatraemia and pulmonary
embolism prognosis. J Pak Med Assoc.
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ThoracCardiovasc Surg. 2013;145(6):1589 146[subscription required]. Accessed October 8,
1594, 1594e11594e2. 2014.
7. Vaishya R, et al. Mortality predictions in severe 17. Imbriano LJ, et al. Normal fractional urate excretion
hyponatraemia in emergency inpatients. J Indian identifies hyponatremic patients with reset
Med Assoc. 2012;110(2):9497. osmostat. J Nephrol. 2012;25(5):833838.

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Original Article

Successful Treatment of Major Depressive Disorders

By SSRI In A Patient of Platelet Disorders Namely
Thromboxane A2 Receptor Deficiency
Ghosh Malati
Mukherjee Bhaskar & Sanyal Debasish

The following case report highlights about successful treatment of Major Depressive disorders in a patient of Thromboxane
A2 receptor. The treatment period was uneventful with no bleeding diathesis and all the laboratory coagulation parameters
were within normal limit.

INTRODUCTION unmarried he was in stable relationship with a girl of his

Platelets play a major role in normal hemostasis. They also locality for last 2 yrs. But his girlfriend had a very negative
have a pivotal role in inflammation & atherosclerosis. Platelet feeling about patients choice of work & persuaded him
disorders can happen when there is defective platelet many a times to change job. That disapproval had a
function or number or both. tremendous effect on their relationship & its been a
stalemate for last 6 months. Patient also revealed that his
CASE HISTORY depression has really started after this relational dispute and
A 35 yr old male presented to outdoor of psychiatry gradually progressed due to that fact only.
department with low mood, loss of appetite and insomnia While corroborating patients history with his family
for last 4 months. He was referred to psychiatry department members (parents) it was revealed that patient had
by his general physician on account of excessive irritability impulsivity and frequent temper outbursts from adolescence.
& avoidance of work. Patient used to work in Indian Forest But no other history of deliberate self harm before this
Service & was very much involved with his work before. depressive episode was found. Neither there was history
During initial interview patient also admitted having of other cluster B personality traits. Both his parents recalled
heaviness of head which gradually increased during the day many episodes of prolonged bleeding from seemingly
for the same 4 months duration. He also admitted having insignificant injuries but none of those episodes were severe
feeling of helplessness & hopelessness for last 3-4 months. enough to demand medical attention.
He also revealed having symptoms of lack of energy, Physical examination of patient was perfectly normal. On
forgetfulness, difficulty in maintaining prolonged mental status examination it was found had depressed mood
concentration during his professional activities. He also & mood congruent affect, suicidal ideation & intent. No
admitted about having suicidal intent & about committing 2 other significant disorders were found.
previous suicidal attempts by taking sedatives On past treatment records we found he was treated by
(benzodiazepines) within last 4 months. Both the time the TCAs (amitryptylin) and NASSAs (mirtazapine) by
amount of sedative taken was low so appropriate treatment psychiatrists, but none of the drugs suited patient well and
could be given. so he discontinued all drugs after taking them for 1 weeks.
When detailed history was taken some interesting findings As general protocol patients blood was sent for lipid profile,
came forward. It was revealed that though patient was liver function test, blood sugar estimation (both fasting and

Bengal Journal of Private Psychiatry

post prandial), urea and creatinine estimation and electrolyte sessions regularly due to his job profile. And his depression
estimation. Keeping his bleeding episodes in mind we took was too severe to be treated by CBT alone.
opinion of haematologist who adviced complete blood count This situation leaves us with no option but to continue
including platelet count and morphology, platelet function escitalopram in current dose (20mg od). We kept patient
tests, PT, APTT & TT along with simple bleeding time & under strict observation & monitor his platelet activity while
clotting time. he is under SSRI treatment by measuring repeated bleeding
While these reports were pending we prescribed the patient time after every 2 weeks. During the whole treatment period
Escitalopram (10 mg daily initially, gradually escalating to his bleeding time was never unusually prolonged to our
20mg daily over the period of 2 weeks) and clonazepam relief. He did quite well under escitalopram and his
(2 mg daily in divided doses, gradually tapering to 0.5mg at depression responded well. Presently he is on 9th month of
night over the period of 2 weeks). therapy & he has again regained his normal personality. His
Patients reports came with some astonishing findings. His professional life is also going quite well. His personal life
lipid profile, liver function test, blood sugar levels, urea & troubles also improved and he has been able to make peace
creatinine levels and electrolyte level were all within normal in the relationship front. He has undergone an operation
limits. His complete blood count was also normal so was during this treatment procedure in the form of laparoscopic
platelet count and morphology. But his bleeding time was cholecystectomy due to chronic cholecystitis. The operation
prolonged and so was platelet aggregation in response to was uneventful and recovery was uneventful in post
arachidonic acid metabolites and collagen. His coagulation operative period in terms of any significant bleeding episode.
pathway was normal as evident by normal clotting time, Though he received 2 units of platelet transfusion as
normal PT, APTT & TT. He was diagnosed to have TXA2 precautionary measure.
receptor deficiency by Haematology Department.
Meanwhile although patient improved on escitalopram after DISCUSSION & CONCLUSION
finding that he has platelet functional disorder we tried to Safety of SSRIs in platelet disorder is a much debated topic.
change treatment regimen for patient, as safety of SSRI Close liason with Haematologist may be helpful.
and SNRI in platelet disorder is doubtful. We gave patient
a choice between different treatment options after explaining REFERENCES
his platelet function disorder to him & the risks that it possess 1) de Abajo FJ. Effects of selective serotonin reuptake
in the treatment of his depression. Patient refused ECT and inhibitors on platelet function: mechanisms, clinical
also refused treatment with TCAs & NASSA on the ground outcomes and implications for use in elderly
of previous tolerability issue. His depression was too severe patients. Drugs Aging. 2011 May 1;28(5): 345-67.
to give NARI (reboxetine). Patient also refused CBT and 2) Demian Halperin, Guido Reber Dialogues Clin
any other psychotherapy because he cant attend those Neurosci. 2007 Mar; 9(1): 47-59.

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