Szja 43 1

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 i
ii Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Official Publication of
Indian Psychiatric Society
South Zonal Branch
Volume 43 | Issue 1 | January 2021 | www. journals.sagepub.com/home/szj

MANAGED BY JOURNAL OF PSYCHOLOGICAL MEDICINE AND RESEARCH. SAGE PUBLICATIONS
EDITOR-IN-CHIEF Psychopharmacology Roy Abraham Kallivayalil EXECUTIVE COMMITTEE OF INDIAN PSYCHIATRIC

Shahul Ameen Sreejayan K TSS Rao SOCIETY, SOUTH ZONAL BRANCH
Varun Mehta TV Asokan
President Journal Tribunal Smitha CA
CHIEF ASSOCIATE Community Psychiatry YC Janardhan Reddy
Dr. K Ramakrishnan Committee (Co-Chairman)
EDITORS Anindya Das Suresh Kumar M Endumathi R
INTERNATIONAL ADVISORY Vice President
Samir Kumar Praharaj Ramkumar GS BOARD (Chairman) Niveditha S
Dr. Ramanan Earat
Vikas Menon Cyberpsychiatry MS Reddy Preethi Pai
Brendan D Kelly Hon. General Secretary
Badr Ratnakaran Dinesh Bhugra Suresh Badamath Legal Advise
CHIEF EDITORIAL Dr. Suresh Kumar
Shijo John Joseph Kyooseob Ha Research Capacity Committee
ADVISORS Gunapalli
Neuromodulation Lakshmi Yatham Building & PG Studies Raveesh Gowda
Chittaranjan Andrade Hon. Treasurer
G. Venkatasubramanian Matcheri Keshavan Committee (Chairman)
MS Reddy Dr. K. Gangaram
Clinical Psychology Michael Jann Ashok MV (Chairman) Jayaprakashan KP
Mohan Issac Hon. Editor Indu PV (Co-Chairman) (Co-Chairman)
ASSOCIATE EDITORS Manjula M
Pichet Udomratn Dr. Shahul Ameen Nageswara Rao N Naresh Vadlamani L
Thomas Kishore
Anju Kuruvilla Rajiv Radhakrishnan Immediate past Kannan PP Malaiappan M
Indu PV Psychotherapy Yella Vijay Kumar
Rajiv Tandon President & Awards Publication Committee
Janardhanan N Monica Mongia
Roy Chengappa Committee Rajasekar B (Chairman) Spirituality & Yoga
Mahesh Gowda Prasanta Roy
Russell D’souza Kishan P (Chairman) Vikas Menon Committee
Rajshekhar Bipeta Psychiatric Social Work Thambu Maniam Chandrashekar H (Co-Chairman) Prasad Rao G
Sai Krishna Tikka Anekal C Amaresha Sudhakar TP
STATISTICAL Vidhukumar K (Chairman)
Sandeep Grover Kamlesh Kumar Sahu Varghese P Punnoose Anil Kakunje
CONSULTANTS Ramanarao GV
ASSISTANT EDITORS Scale Development Gopalakrishnan G Adiseshamma T (Co-Chairman)
Immanuel Thomas Binukumar Bhaskarapillai Kailash S
Guru S Gowda Constitution Committee Community Awareness
Sreekumaran Nair Sunil Kumar Giriyappa
Jayant Mahadevan Qualitative Research Nambi S (Chairman) Committee
Pranab Mahapatra DESIGN Abhay Matkar Kadiveti Uday Kumar Patil
Pooja Patnaik
Sujit Sarkhel CONSULTANT (Co-Chairman) (Chairman) Website Committee
EDITORIAL BOARD George Reddy V
Vijaya Lakshmi Abhilash Chacko Arun B Nair Mohan Sunil Kumar
Abhishek Ghosh Chandra Balaji NRP (Co-Chairman)
Vishal Akula State Executive Council
Anamika Sahu COVER IMAGE Joseph Vargese Sivasailam S Members
SECTION EDITORS Himani Kashyap Abhina PV Vishal Akula
C.M.E. Committee Andhra Pradesh
Neuropsychiatry Naren P Rao Aravind VK (Chairman) Bhandary PV
ILLUSTRATION P. Lokeswara Reddy
Jayakumar Menon Parthasarathy R Lokeswara Reddy P Suicide Prevention Vishal Indla
Siddharth Sarkar Ayisha Shamna (Co-Chairman)
Addiction Psychiatry Committee Karnataka
Suhas Ganesh Shaji Ankan Dayal Narayan KTP
Sourav Khanra Suresh Kumar PN Somashekhar Bijjal
Tarun Verma Sreya Saleem Rajesh Raman
Arpit Parmar (Chairman) Raveesh BN
Umesh Shreekantiah Sai Krishna P
Schizophrenia DISTINGUISHED Satish Babu Kerala
Uvais NA
Rishikesh Behere PAST EDITORS Tribunal & Ethics (Co-Chairman) Anoop Vincent
Venugopal Duddu
Shobit Garg Committee Prabhakar Y Mohan Roy G
Abraham Vergese
NATIONAL ADVISORY Sathyanathan R Mohan Raj Tamil Nadu
Geriatric Psychiatry Palaniappan
BOARD (Chairman) Alok Ghanathe J Babu Balasingh
Ravi Philip Rajkumar Karri Rama Reddy
Ajit Avasthi Indla Rama Subba Women Empowerment C Pannerselvam
S Shaji G Prasad Rao
BN Gangadhar Reddy Committee Telangana
John Mathai
Mood Disorders Ashok Reddy K Minhajzafar Nasirabadi
E Mohandas E Mohan Das Radhikareddy V
Muralidharan Kesavan M Umashankar
G. Prasad Rao TSS Rao (Chairman)
Child Psychiatry Gautam Saha MS Reddy
Preeti Jacob IRS Reddy
Rajeev Ranjan K Chandrasekhar
Perinatal Psychiatry K Kuruvilla
Balaji Bharadwaj KS Shaji
Sreelaxmi Pingali PSVN Sharma
Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 iii

General Information
Official Publication of
Indian Psychiatric Society
South Zonal Branch
MANAGED BY JOURNAL OF PSYCHOLOGICAL MEDICINE AND RESEARCH
Indian Journal of Psychological Medicine was started in 1978. It is a peer-reviewed, open access journal published by Indian
Psychiatric Society, South Zonal Branch. The journal publishes articles on psychiatry, psychology and allied disciplines. It is published
bimonthly in January, March, May, July, September and November.
ISSN: 0253-7176; Online ISSN: 0975- 1564
Please read the manuscript submission £477. For orders from Pakistan, Bangladesh, Claims
guidelines, then visit the journal's Sri Lanka and the Maldives, SAARC rates Claims for undelivered copies may be made
peer-review and submission system apply: individuals $115; institutional no later than three months following the
[https://peerreview. sagepub.com/szj] rate $160. Prices include postage. Print month of publication. The publisher will
to create account/log in to upload your subscriptions are available for institutions supply replacement issues when losses
manuscript. Please note that manuscripts at a discounted rate. have been sustained in transit and when
not conforming to the guidelines may reserve stocks permit.
be returned. To view the manuscript Orders from the Americas should be sent
submission guidelines, please visit journals. to SAGE Publications Inc, 2455 Teller Road, Change of Address: Four weeks’ advance
sagepub.com/home/szj and click on the Thousand Oaks, CA 91320, USA (Tel: 00 800 notice must be given when notifying
`Submit Paper' tab. 818 7243/E-mail: journals@sagepub.com). change of address. Please send the
old address label to ensure proper
Abstracting and indexing Orders from the UK, Europe, the Middle East, identification. Please specify the name of
information Africa and Australasia should be sent to the journal and send change of address
SAGE Publications Ltd, 1 Oliver’s Yard, 55 notification to the SAGE office through
Abstracting and Indexing: Please visit City Road, London, EC1Y 1SP, UK (Tel: 0207 which you subscribe to the journal.
http://journals.sagepub.com/home/szj and 324 8500/ E-mail: subscription@sagepub.
click on the ‘More’ button (under ‘About co.uk).
this journal’), then click on the Abstracting/ Copyright
Indexing tab to view a full list of databases Inquiries from India/South Asia about
in which this journal is indexed. This journal single issue rates, availability of back Copyright © 2021 Indian Psychiatric
is included in the following abstracting and issues, print rates for institutions, and Society - South Zonal Branch. All rights
indexing databases. permission requests should be sent to reserved. No portion of the contents may be
• Clarivate Analytics: Emerging Sources SAGE Publications India Private Limited, reproduced in any form without permission
Citation Index (ESCI) B1/I-1, Mohan Cooperative Industrial Area, in writing from the publisher.
• PubMed Central (PMC) Mathura Road, New Delhi 110 044 (Tel: 91-
• Scopus 11-40539222/Fax: 91-11-40539234/E-mail: Printed and published by Vivek Mehra
• UGC-CARE (GROUP II) customerservicejournals@sagepub.in). on behalf of Indian Psychiatric Society,
• Indian Science Abstracts Inquiries from the Americas should be sent South Zonal Branch at SAGE Publications
to the California address (above), while India Pvt Ltd, B-1/I-1 Mohan Cooperative
Annual Subscription those from the UK, Europe, the Middle East, Industrial Area, Mathura Road, New Delhi
Africa and Australasia should be sent to the 110044. Printed at Sai Printo Pack Pvt Ltd, A
Individual rate (print only) ` 4,320; London address (above). 102/4, Sanjay Colony, Okhla Phase II, Okhla
institutional print-only ` 7,150, $883, and Industrial Area, New Delhi, Delhi 110020.
RNI No. MAHENG/2011/38799 Editor: Dr. Shahul Ameen
iv Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Contents
with Executive Dysfunction in Mental-Illness-Related Stigma

Editorial Schizophrenia in Health Care in South India:
Do the Criteria of Our BR Sahithya, Shweta Rai, Mixed-Methods Study
Rishikesh V. Behere
Best-Paper Awards Need Thenral Munisami, Rajesh Kannan
24 Namasivayam, Arunkumar Annamalai
Revision?
58
Shahul Ameen, Vikas Menon, Adapting to People
Samir Kumar Praharaj
P1
With Schizophrenia: A Exploratory Factor Analysis
Phenomenological Study on a of Young’s Internet Addiction
Rural Society in Indonesia Test Among Professionals from
Review Article
Retno Lestari, Ah Yusuf, Rachmat Hargono, India: An Online Survey
Spotlight on Oculogyric Febri Endra Budi Setyawan, Mamidipalli Sai Spoorthy,
Ridhoyanti Hidayah, Ahsan Ahsan
Crisis: A Review Lokesh Kumar Singh, Sai Krishna Tikka,
31 Suchandra Hari Hara
Pankaj Mahal, Navratan Suthar,
65
Naresh Nebhinani
P5
Quantifying and Categorizing
ADRs in Psychiatric Residential Viewpoints
Long-Stay Patients Utilizing
Grief in the COVID-19 times:
UKU-SERS Scale
Are we looking at complicated
Original Articles Joelin Mathew, Amruta Varghese,
grief in the future?
Manjusha Sajith
Caregivers’ Experiences of 38 Prateek Varshney, Guru Prasad,
Aggressive Persons with Prabha S. Chandra, Geetha Desai
Schizophrenia Effect of a Video-Assisted 70
Neha A., Sailaxmi Gandhi, Manjula M., Teaching Program About ECT
Padmavathi N. Mental Illness in Indian
on Knowledge and Attitude
10 Hindi Cinema: Production,
of Caregivers of Patients with
Representation, and Reception
Nature and Correlates of Major Mental Illness
Before and After Media
Executive Dysfunction in Padmavathi Nagarajan,
Gomathi Balachandar, Vikas Menon, Convergence
Schizophrenia: An Exploratory Balachandar Saravanan Abhijit Pathak, Ramakrishna Biswal
Study 45 74
Joseph Noel, Shonima A Viswanathan,
Anju Kuruvilla Identifying Emotional Facial
16 Expressions in Practice:
A Study on Medical Students
Thought Disorder on Object
Alapan Bandyopadhyay, Sarbari
Sorting Test Is Associated Sarkar, Abhijit Mukherjee, Sharmistha
Bhattacherjee, Soumya Basu
51
Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 v

Contents
Practical Psychotherapy Letters to the Editor Escalating Suicide Rates

Behavior Therapy for the Safeguarding the Frontier Among School Children
Treatment of Tourette’s Covidians During the During COVID-19 Pandemic
Disorder in India: A Patient COVID-19 Pandemic: Scuffles and Lockdown Period: An
Series from an Indian General and Proposed Strategies Alarming Psychosocial Issue
Hospital Psychiatric Unit Bibin V. Philip
Vijay VR, Nadiya Krishnan, Alwin Issac,
Jaison Jacob, Shine Stephen, Rakesh VR, 92
Natarajan Varadharajan,
Harmeet Kaur Kang, Manju Dhandapani
Subho Chakrabarti, Swapnajeet Sahoo,
Srinivas Balachander 89 List of Reviewers 2020
81 94
COVID-19 and Right to
Learning Curve Die With Dignity: Time to
The Inconvenient Truth About Reevaluate Policies Over the
Convenience and Purposive Practice of Last Rites?
Samples Vikas Menon, Jigyansa Ipsita Pattnaik,
Susanta Kumar Padhy
Chittaranjan Andrade 90
86
vi Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Editorial
Do the Criteria of our best-Paper Awards Need
Revision?
Shahul Ameen1, Vikas Menon2, Samir Kumar Praharaj3
I
n India, where not many psychia- and the presentation. In the J. C. Marfatia published papers, and for which the
trists pursue PhD and few opportu- Award of the Indian Association for Child conference presentation part is absent,
nities exist for funded research in and Adolescent Mental Health (IACAM), the division is as follows:
psychiatry, most research in the specialty 50% of the marks are for the written 1. Topic, title, its relevance, and meth-
is conducted as postgraduate theses. The paper, 30% for the presentation, and odology: 20 marks.
only recognition available to those who 20% for answering the post-presentation 2. Survey of literature, references, and
do exceptional theses is the awards in- queries. bibliography: 20 marks.
stituted by professional organizations, For IPS Poona Psychiatrists Associ- 3. Presentation of the results and dis-
such as the Indian Psychiatric Society ation Awards I & II, given for the best cussion: 20 marks.
(IPS). Hence, the criteria to decide the
winners of such awards should be bal-
anced and equitable and help pick the
best studies from a scientific perspective.
We surveyed the websites of the major
professional organizations in Indian psy-
chiatry to check if their awards criteria
are valid enough. Here are our findings:
Weightage for Various

Components
For most awards, 60% of the total marks
are allotted for the written manuscript
and the remaining 40% for the oral pre-
sentation during the conference (n = 11,
Box 1). Only the North Zone of the IPS
(IPS-NZ) has provided details of how
these marks are further divided (Table 1).
Four awards follow a division of 75% and
25%, respectively, for the written version
1
Dept. of Psychiatry, St. Thomas Hospital, Changanacherry, Kerala, India. 2Dept. of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and
Research, Puducherry, India. 3Dept. of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India.
HoW To CITe THIS ARTICle: Ameen S, Menon V, Praharaj SK. Do the Criteria of Our Best-Paper Awards Need Revision?. Indian J Psychol
Med. 2021;43(1): 1–4.
Address for correspondence: Shahul Ameen, Mise En Scene, Behind Submitted: 19 Nov. 2020
Anandashramam, Changanacherry, Kerala 686101, India. E-mail-shahulameen@ Accepted: 19 Nov. 2020
yahoo.com Published Online: 27 Dec. 2020
Copyright © 2020 Indian Psychiatric Society - South Zonal Branch
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCeSS THIS ARTICle oNlINe
Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/)
Website: journals.sagepub.com/home/szj
which permits non-Commercial use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub. DOI: 10.1177/0253717620979475
com/en-us/nam/open-access-at-sage).
Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 1

Ameen et al.
Box 1.
entire introduction section of an article
is to emphasize and argue how well the
Weightage Allotted to Written Part and Presentation study achieves this. Unfortunately, our
1. 60% for the written version and 40% for the presentation survey reveals that this important crite-
a. Indian Psychiatric Society (https://ancips2020.com/awards.php)
rion is either entirely ignored or given
i. Marfatia Award only minor importance. (For the two
ii. Bhagwat Award poster awards of IPS, when the contes-
b. Indian Psychiatric Society North Zone* (http://ipsnz.org/awards-fellowship/) tants initially submit the abstract, the
i. Dr. A.K. Kala Award suggested section headings are “aims/
ii. Dr. Buckshey Award objectives”, “methodology,” etc.; the much
iii . Dr. G.C. Boral Award important “Background” is not asked for.)
c. Indian Psychiatric Society West Zone (http://www.ipswzb.net) As per our experience, when students
i. Dr. Anil. V. Shah Best Paper Award plan their thesis topic, more importance
d. Indian Association of Biological Psychiatry (https://anciabp.com/ashawards.php) is given to the ease of collecting the
i. The Asha Award sample and finishing the study on time.
e. Indian Association for Child and Adolescent Mental Health (https://www.childindia.org/ Many guides, too, consider the thesis
award.php) to be merely an exercise in teaching the
i. The Luke Clack Award student the basics of medical research
ii. The Niloufer Award
and statistics. However, as we mentioned
2. 75% for the written version and 25% for the presentation in the beginning, postgraduate theses
a. Indian Psychiatric Society form the bulk of the psychiatric research
i. The Bombay Psychiatric Society Silver Jubilee Year Award conducted in India. It is only fitting,
therefore, that we ensure that every
b. Indian Association of Social Psychiatry (https://iasp.org.in/awards/)
i. Dr. G C Boral Award such study also advances knowledge.
ii. Dr. J K Trivedi Award Including this as an awards criterion may
iii. Dr. Anil Malhotra Award encourage the students and guides to
iv. Dr. B B Sethi Award (poster)
pay more attention to this aspect. More-
*Details of the breakup are available (Table 1).
over, when we recently analyzed why the
manuscripts submitted to this journal
Table 1. get rejected, lack of novelty emerged as
The Breakup of the Marks in the Awards of Indian Psychiatric the commonest reason.2 Hence, giving
novelty its due importance in the awards
Society North Zone
criteria may help enhance the publica-
Written Manuscript 60 Marks tion worthiness of our studies as a whole.
1 Topic, title, its relevance, and methodology 12 marks As the contestants may miss to cite or
2 Survey of literature, references 12 marks even intentionally hide better quality
studies on their topic, to assess the orig-
3 Presentation of results and discussion 12 marks
inality of a study, the judges may have
4 Conclusions and how far the study substantiates them 12 marks
to search online academic databases.
5 Clarity, lucidity, precision of language, and overall elegance of the paper 12 marks Hence, it may not be possible for the
Presentation During the Conference 40 marks floor judges to assess novelty – this task
1 Style, clarity, compactness of expression, and presentation 20 marks should be entrusted to the judges who
2 Use of audiovisual aids (if any): appropriateness, quality, visibility, compre- 10 marks evaluate the written manuscript.
hensibility, and novelty
3 Response to the points raised in the discussion 10 marks The Quality of the Methods
The scientific rigor and appropriateness
of the study methods, too, are not given
4. Conclusions and how far the study Two Undervalued Vital sufficient prominence. It is highly unfair
substantiates them: 20 marks.
5. Clarity, lucidity, precision of lan- Aspects to bestow any award to studies with
guage, and overall elegance of the flawed methods. Judges of the written
paper: 20 marks.
Contribution to the Field manuscripts should screen them for
The two poster awards of IPS (Professor The essential criterion in determining the errors in methods, specifically major
K.C. Dube Poster Session I award and value of a study, in any field, is the extent ones such as wrong study design, and
Professor M. Murugappan Poster Session to which it advances knowledge, i.e., including the ones we had earlier iden-
II award) also follow the above criteria. its originality or novelty.1 Science grows tified as common in submissions to this
No marks are granted for the presenta- incrementally; each new study should journal, such as assessing the prevalence
tion, unlike in the poster awards of the improve upon the previous research on of a disorder using a screening tool,
IPS West Zone and Indian Association of that topic and advance the knowledge in using a cross-sectional design to deter-
Social Psychiatry (IASP). that area to some degree. The role of the mine causality, lack of a priori sample
2 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021
Editorial
size calculation, using instruments that in a year.” The IPS-NZ stipulates that “no the paper covers. The help of respec-
are not validated, absence of a control paper shall be eligible to contest for an tive zonal or national journal editors
group when one is essential, etc.3 award where a member who has won may be sought to identify appropri-
Most organizations stipulate a bench- that award in the immediately preceding ate subject experts.
mark---papers will be allowed floor year appears as an author or co-author.” 5. The judges of the written version
presentation or granted the award only Though well intended, such restrictions may check the manuscripts against
if they get a specified minimum percent- may prevent students and those who the equator network’s relevant check-
age of the marks for the written version recently passed from major institutions list (https://www.equator-network.
or the total marks (Table S1). Likewise, a from contesting, as some other paper in org/reporting-guidelines/) to assess
provision can be added that papers with which their guide is a co-author may be the completeness of reporting.
grossly erroneous methods will not be contesting in the same year or have won 6. For some of the awards for which
moved to the second stage. in the previous year. People who win detailed breakup is available, dispro-
While it may be fine to choose judges awards may mentor others; why deprive portionately high marks are given for
for the floor presentation from a larger their mentees from contesting just the conclusions and how far they are
pool, comprising both people inside and because of their names on the papers? In substantiated by the study---includ-
outside academia, for the written draft, this regard, the clauses by The Luke Clack
ing a whopping 20% for the two Poo-
the judges should be carefully hand- Award of IACAM (“The award can only be
na Psychiatrists Association Awards
picked from experienced researchers, won once by any member of the society as
for published papers. This should be
preferably with expertise in the particular the principal author.”) and most research
reduced to about 5%, to free up room
subspecialty (e.g., child psychiatry, social awards of IASP (“No person shall win
for allotting more marks for novelty
psychiatry). To facilitate this, suggestions the award more than once as principal
and study methods.
may be sought from journal editors as author.”) are apt.
7. In most awards, the response to ques-
they would know good peer reviewers For the Bhagwat Award of IPS, the
tions in floor presentation is given
competent in research methodology and presenting author and all co-authors
have to be under 35 years of age. This is disproportionately high marks. (J.
statistics. Also, those who are nominated
unfortunate, as, in most centers, it will C. Marfatia Award of IACAM even
as judges should be given the option
not be feasible for younger faculty and says that “If no questions are asked
upfront to voluntarily recuse themselves
residents to conduct research without then the presenter will get at least 10
if they feel they are not competent in
the involvement and support of the more marks in this area.”) We feel that the
research methodology or do not have the
senior and experienced faculty. question-answer session needs not be
requisite sub-specialty expertise.
allotted more than 5% marks. In any
Further Steps Needed in Other Areas for case, there are practical difficulties in
standardizing the difficulty level of
This Regard Improvement questions posed to different candi-
The exact percentage of marks to be allot- 1. To be considered for any award, a dates. Moreover, our observation is
ted for novelty and methods must be study should have ethics approval, that more than the accuracy of the an-
determined through broader discussions and the contestants should submit a swers, it is the candidate’s personali-
involving reputed researchers, senior copy of the approval certificate along ty that usually gets assessed, just as
practitioners, journal editors, experienced with the written paper---this was not in a conventional viva voce session.4
peer reviewers, and past contestants and specifically mentioned in any of the A possibility of the contestants and
winners. Systematic, interactive methods websites we surveyed. their buddies rigging the discussion
to arrive at a consensus, such as the Delphi 2. The award committees should do a section exists, too.
method, or other techniques, may be suit- plagiarism check of all submissions. 8. Criteria for the posters should be dif-
able for this purpose. We feel that these 3. Only IPS-NZ says that if most of the ferent from those for the papers pre-
two aspects together deserve at least 50% judges feel that no paper is of high sented orally. Here too, some marks
of the total marks. Moreover, as it may enough merit, there will be no award should be allotted for study novelty,
not be easy to quantify and accurately that year. This clause can be adopted innovation, and scientific quality,
rate the degree of advancement of the by other organizations too. just as in the oral papers. In addition,
field in studies on diverse areas,1 a guide- 4. The Indian Academy of Pediatrics marks should also be awarded for the
line in this regard too has to be developed (https://iapindia.org/pdf/8297-IAP- poster’s ability to stand alone, its or-
through detailed discussions. AWARD-RULES-2020.pdf ) specifies ganization, balance between text and
that the papers will be judged by a figures, clarity, brevity, visual appeal,
Restrictions on Contestants panel of four judges, of which two quality of graphics, and oral presen-
IPS’ The Poona Psychiatrists Association members will be experts in the par- tation and discussion of the findings
Awards I & II and the Professor K.C. ticular field. This can be taken up by in the poster.5 For the poster award
Dube Poster Session I award demand that psychiatric organizations too---the of the west zone of IPS, the judges
“no more than two papers where a partic- written manuscripts, at least the assess the full written papers for a to-
ular member appears as an author or co- ones selected for floor presentation, tal of 60 marks (out of the total 100).
author may be submitted for either award may be sent to experts on the topic This is an imitable policy, we feel.
Ameen et al.
9. IASP insists that the winning articles zonal branches of IPS. Hence, we References
should be submitted to its journal were unable to include their details
1. Shibayama S and Wang J. Measuring orig-
within two weeks of the conference. in this analysis.
inality in science. Scientometrics 2020;
IPS-NZ even specifies that all the 2. The respective award committees may
122: 409–427.
papers submitted for awards will be sharing more information about 2. Menon V, Varadharajan N, Praharaj
become the property of the organi- the division of marks to the judges, in SK, and Ameen S. Why do manu-
zation for publication in its journal. addition to what is mentioned on the scripts get rejected? A content analysis
Such clauses may be essential for websites. We did not have access to of rejection reports from the Indian
many of our journals to survive, as those details and also did not actively Journal of Psychological Medicine.
they may be finding it difficult to fill try to procure them for inclusion in Indian J Psychol Med November 2020.
the pages and bring out the issues this analysis. (We indeed had access to doi:10.1177/0253717620965845
on time. However, this thwarts the some of them as we have been judges 3. Ameen S, Praharaj SK, and Menon V. A
major aim of the awards, i.e., identi- year on: The changes we introduced and
on some occasions; but, to respect con-
fying and appreciating the best work the common mistakes we encountered.
fidentiality, we did not include them
Indian J Psychol Med 2019; 41: 1–5.
done in the organization’s geograph- in our analysis.)
4. Ghosh A, Mandal A, Das N, Tripathi SK,
ical area or subspecialty, because re-
Biswas A, and Bera T. Students’ perfor-
searchers who feel that their articles Declaration of Conflicting Interests
mance in written and viva-voce compo-
are good enough to get published in The authors declared no potential conflicts of
nents of final summative pharmacology
journals of better repute may decide interest with respect to the research, authorship,
and/or publication of this article. examination in MBBS curriculum: A
to stay away. critical insight. Indian J Pharmacol 2012;
Funding 44: 274–275.
Limitations of the Survey The authors received no financial support for the
5. International Genetically Engineered
research, authorship, and/or publication of this Machine competition. Judging/Poster
1. Details of the breakup are not avail-
article. Guidelines, http://2014.igem.org/Poster_
able online for the awards of the
Guidelines (2014, accessed November 18,
Indian Association of Private Psy- Supplemental Material 2020).
chiatry, the Dr. V K Varma Award of
Supplemental material for this article is available
IASP (which is for best published pa- online.
per), and the awards given by many

Review Article
Spotlight on Oculogyric Crisis: a Review
Pankaj Mahal1, Navratan Suthar1, Naresh Nebhinani1
ABSTRACT such as antipsychotics, antiemetics, or obsessive ideas may also accompany

antidepressants, antiepileptics, and an OGC experience.3
Background: Oculogyric crisis (OGC) is a antimalarials. OGC can adversely impact Besides antipsychotics, other medi-
form of acute dystonia characterized by the compliance and prognosis of the
sustained dystonic, conjugate, and upward cations such as antiemetics, antidepres-
primary illness. Hence, it needs to be
deviation of the eyes. It was initially managed at earlier stages with appropriate sants, antiepileptics, and antimalarials
reported in patients with postencephalitic medication, primarily anticholinergics. are also associated with OGC.4 It is also
parkinsonism. But later, other factors such seen with various genetic or metabolic
as medications, movement disorders, Keywords: OGC, oculogyric crisis,
disorders that affect dopamine produc-
metabolic disorders, and focal brain lesions blepharospasm, acute dystonia
tion, storage, or reuptake. The exact in-
were also found to be associated with OGC. Key Message: Practitioners must know the cidence of OGC is currently unknown,
common risk factors and etiopathogenesis
Methods: The literature regarding OGC though one study reported it to be
of OGC. It would help them in choosing
was searched via PubMed, Google Scholar, around 5.3%,5,6 whereas the incidence of
appropriate medication as well as timely
and through citations in relevant articles OGC with antipsychotics is in the range
identification and management.
till December 2019, with keywords
O
0.9%–3.4%.7 It is important to distin-
including OGC, oculogyric eye movements, culogyric Crisis (OGC) is a form
tonic eye movement, neuroleptics and guish OGC from other similar present-
of dystonic movement disor-
OGC, antipsychotics and OGC, and all ing conditions such as epileptic seizures,
der characterized by paroxys-
combinations of these. Only original paroxysmal tonic upgaze syndrome, or
mal, conjugate, and typically upward
articles (abstract or full text) that were oculogyric tics.8–10 In this review, we pro-
deviation of the eyeball, which occurs
published in the English language were vide an overview of the various causes,
reviewed. for seconds to hours.1,2 Onset of OGC is
risk factors, pathophysiology, diagnosis,
generally acute, but sometimes it may
Results: Hypodopaminergic state is differentials/mimickers, and manage-
develop after a few weeks or months of a
implicated in the pathogenesis of OGC. ment of OGC.
precipitating event. Additionally, the pa-
Common risk factors are younger age, male
sex, severe illness, high neuroleptic dose,
tient may have increased blinking of the Materials and Methods
parenteral administration of neuroleptics, eyes, neck dystonia, tongue protrusion,
blepharospasm, and autonomic signs The literature regarding OGC was
high potency of neuroleptic drugs,
abrupt discontinuation of anticholinergic such as perspiration, increased blood searched via PubMed and Google Schol-
medication, and family history of dystonia. pressure, tachycardia, pupillary dilation, ar and through citations in relevant arti-
facial flushing, salivation, and difficulty cles till December 2019, with keywords
Conclusion: OGC is an acute dystonic
reaction leading to tonic upward deviation in micturition.1–3 Psychiatric symptoms including OGC oculogyric eye move-
of eyes. It is associated with various such as anxiety, visual hallucinations or ments, tonic eye movement, neurolep-
neurometabolic, neurodegenerative, and illusions, auditory hallucinations, cata- tics and OGC, antipsychotics and OGC,
movement disorders and medications tonic phenomena, transitory delusions, and various combinations of these. An
Dept. of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
1
HOW TO CITe THIS aRTICle: Mahal P, Suthar N, Nebhinani N. Spotlight on oculogyric crisis: A review. Indian J Psychol Med.
2021;43(1):5–9.
Address for correspondence: Navratan Suthar, Dept. of Psychiatry, All India Submitted: 18 Mar. 2020
Institute of Medical Sciences, Jodhpur, Rajasthan 342005, India. E-mail: navratan- Accepted: 23 Jun. 2020
suthar86@gmail.com Published Online: 3 Sep. 2020
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative aCCeSS THIS aRTICle ONlINe

Mahal et al.
additional search was performed for in most patients.16 Brain dopamine–sero- antipsychotics, relatively uncommon
specific topics under this review. Only tonin vesicular transport disease, which with atypical antipsychotics,36 and rarely
original articles (abstract or full text) that occurs due to novel mutation in the reported with clozapine.37 A few cases of
were published in the English language monoamine transporter gene SLC18A2 acute dystonic reaction, including OGC,
were reviewed. More than 200 articles (p.Pro237His), leads to hypotonia, bra- have been associated with anesthetic
related to the topic were found, out of dykinesia, epilepsy, autonomic dysfunc- agents like propofol, sevoflurane, nitrous
which the articles relevant to psychiatry tion, and OGC.17 6-pyruvoyl-tetrahydrop- oxide, and fentanyl administration.38
are primarily included here. Most of the terin synthase deficiency, which results In recent times, most of the literature is
publications related to OGC are either in hyperphenylalaninemia along with associated with varied causes of OGC be-
case reports or case series. In this review, dopamine and serotonin depletion in longing to either neurometabolic disor-
we have focused on the adult population the central nervous system, usually pres- ders such as AADC deficiency, sepiapter-
with OGC and its association with psy- ents with hypotonia, seizures, OGC, and in reductase deficiency, TUBB4A-related
chiatric symptoms/diagnosis. developmental delay.18,19 PLA2G6 associ- leukodystrophy39 or medications (apart
ated neurodegeneration (PLAN), which from what mentioned in Table 1) like
Results occurs due to a homozygous mutation of anti-tubercular drugs,40 or clebopride, a
PLA2G6, is a rare cause of OGC.20 non-selective benzamide with antidopa-
Etiology of OGC minergic activity.41
Some neurodegenerative disorders are
Though the exact pathogenesis of OGC also found to be associated with the oc-
is not certain, various factors that con- currence of OGC, such as mutations in Mechanism of OGC
tribute to its occurrence have been re- the GRIN1 gene, which affects the func- The exact mechanism of OGC is not clear.
ported. tion of both N-methyl-D-aspartate and Most of the brain lesions that lead to
OGC is seen with different kinds of dopamine D1 receptors, leading to ocu- OGC are found in the nigrostriatal path-
movement disorders such as tongue pro- lomotor dystonic reactions;21,22 Neuronal way.2 Besides, several hypotheses have
trusion, lip-smacking, blepharospasm, intranuclear hyaline inclusion disease, a been given for drug-induced OGC such
choreoathetosis, anterocollis, and retro- multisystem degenerative disorder that as striatal cholinergic hyperactivity,42
collis.11 Various neurological disorders involves both central and peripheral striatal dopaminergic hypoactivity (com-
are also found to be associated with nervous systems, causing diffuse muscle monly reported),43 or the rarely reported
OGC, such as Parkinson’s disease, fa- spasms, dysarthria, dysphagia, tremors, striatal dopaminergic hyperactivity.44
milial Parkinson’s–dementia syndrome, ataxia, OGC, progressive muscle weak- The majority of the conditions are relat-
dopa-responsive dystonia, parkinson- ness, and atrophy23; Rett syndrome, ed to dopaminergic dysfunction, includ-
ism with basal ganglia calcifications progressive neurodegenerative disorder ing disorders of dopamine metabolism
(Fahr’s disease), neurosyphilis, multiple in females, leads to gait disturbance, leading to low dopamine levels, such as
sclerosis, ataxia–telangiectasia, Wilson bruxism, OGC, parkinsonism, and dys- TOH deficiency and AADC deficiency.13,25
disease, and acute herpetic brain-stem tonia24 and tyrosine hydroxylase (TOH)
encephalitis.11 deficiency, an inborn error of catechol- Table 1.
Various genetic, neurometabolic dis- amine biosynthesis causing dystonia Drugs Commonly Implicated
orders also play a part in the etiology of along with tremor, hypersensitivity to in Oculogyric Crisis2,43,57
OGC. Hereditary dopamine transporter levodopa therapy, OGC, akinesia, and ri-
deficiency syndrome, in which, due to gidity.25,26 Other autosomal recessive dis- Drugs Classification Drugs
novel homozygous SLC6A3 gene muta- orders that rarely present with OGC are First-generation an- Haloperidol
tions, there would be orolingual dyski- Kufor Rakeb,27 haemophagocytic lym- tipsychotics (FGA) Fluphenazine
Flupentixol
netic movements and OGC.12 As a result phohistiocytosis,28 sepiapterin reductase
Perphenazine
of aromatic L-amino acid decarboxylase deficiency,29,30 and GTP cyclohydrolase I Chlorpromazine
(AADC) deficiency, a rare autosomal re- deficiency.31 Zuclopenthixol
cessive neurometabolic disorder charac- Some brain lesions are also associat- Second-generation Risperidone
terized by a deficit of the AADC, which is ed with OGC, such as lesions in periaq- antipsychotics Amisulpride
involved in serotonin and dopamine bio- ueductal and midbrain tegmentum,32 (SGA) Aripiprazole
Olanzapine
synthesis,13,14 the patient may have devel- brainstem,33 or substantia nigra34 and Quetiapine
opmental delay, autonomic symptoms, cystic glioma in the region of the poste- Clozapine
hypotonia and movement disorder in- rior third ventricle.35 Ziprasidone
cluding OGC, dystonia or hypokinesia.15 Finally, medications which would Lurasidone
In GLUT1 deficiency syndrome, which is increase the risk of developing OGC Antidepressants Imipramine
Escitalopram
due to mutation in the SLC2A1 gene on include various groups such as antipsy-
Fluvoxamine
chromosome 1p35-31.3 and often presents chotics, antiemetics, anticonvulsants,
Anticonvulsants Carbamazepine
with mental retardation, epilepsy, parox- and antidepressants (Table 1). Acute Lamotrigine
ysmal exercise-induced dyskinesia, OGC dystonic reactions are commonly seen Gabapentin
can occur as an early sign of the disease with the use of high-potency typical

Review Article
Table 2.
drug-induced OGC (e.g., antipsychotics),
generally, the first approach is to taper
Proposed Criteria for the Diagnosis of Oculogyric Crisis43 down the causative drug. On the per-
Required Criteria Supportive Criteria sistence of OGC on reducing the dose,
• T onic, conjugate deviation of eyes • P receded by anxiety, discomfort discontinuation of the offending agent
• Minutes to hours in duration • The patient is aware of and bothered or is advised, with shifting to other agents
• Consciousness preserved disabled by the ocular deviations with a lesser propensity to cause dyston-
• Associated dystonia
• Associated with a low dopamine state and ic reactions.3,43
improved by anticholinergics or dopaminer- For the management of cases where
gic medication the mentioned strategy would not cause
improvement, other pharmacological
management options should be tried.
Figure 1.
In OGC, primarily anticholinergics such
Approach to a Patient with OGC-Like Phenomenon as trihexyphenidyl, benztropine, ben-
Presence of possible OGC ( confirmation with meticulous history and thorough examination) zhexol, biperiden, procyclidine, or other
centrally acting anticholinergic drugs or
antihistaminergic agents (e.g., diphen-
Rule out the possible mimickers ( epileptic seizures, paroxysmal tonic upgaze syndrome or hydramine, phenhydramine, chlorphe-
niramine, promethazine) are commonly
oculogyric tics, psychogenic movements ) used.51 In most cases of acute dystonic
reactions, the intravenous route is the
preferred route of choice as it leads to
Rule out the possible medications improvement within 10 minutes. Alter-
natively, intramuscular (if you cannot
access intravenous line) or oral (most
Rule out the other genetic/metabolic/traumatic causes unreliable, due to extensive gut first-pass
OGC: Oculogyric crisis.
metabolism) route can be used.54 Some-
times benzodiazepines2 and rarely do-
An imbalance between dopaminergic weeks of initiating neuroleptics,51 meta- pamine agonists are also used.3 To avoid
and cholinergic neurotransmission in bolic conditions (e.g., hypocalcemia, hy- recurrence, it is recommended to contin-
the striatum has also been proposed for perthyroidism, hyperparathyroidism),51 ue the management of OGC for at least
drug-induced OGC.45 recent cocaine use,51 and family history a week but sometimes for longer peri-
Hypersensitivity of striatal dopamine of dystonia.44 ods in case of tardive OGC. If the above
receptors due to chronic dopamine recep- line of treatment fails, then clozapine
tor blockage, neurodegeneration of stri- Diagnosis of OGC remains a promising option2 as it works
atal interneurons, dysfunction of striatal Diagnosis of OGC is clinical, based on typ- via the stimulation of M4 muscarinic re-
gamma-aminobutyric acid (GABA)-ergic ical symptoms such as paroxysmal, conju- ceptors, which results in inhibition of D1
interneurons, or maladaptive synaptic gate, and typically upward deviation of the receptors or the direct blockade of D1 re-
plasticity are reported to be the causes eyeball for seconds to hours. Slow et al.43 ceptors.43 But rarely, in some cases, OGC
of tardive involuntary movements.46 An- has proposed the required and support- has been reported with the use of clozap-
tidepressants-induced OGC is explained ive criteria for diagnosing OGC (Table 2). ine.37 Electro-convulsive therapy can also
with hyperstimulation of 5-HT2 recep- Whenever clinicians encounter an OGC- be given in tardive OGC cases with psy-
tors, inhibition of dopaminergic activity, like phenomenon, they should approach chotic disorders.55
and alteration of cholinergic and GAB- in a manner as suggested in Figure 1. Prophylactic use of anticholinergic
Aergic activity.47 drugs for 1–2 weeks is indicated in pa-
Differential Diagnosis/ tients with greater vulnerability for OGC
Risk Factors of OGC
Mimickers of OGC with certain antipsychotics, though the
Certain characteristics of patients would available guidelines are inconsistent for
make them more vulnerable for the Several clinical entities look similar to the duration of use of such prophylactic
emergence of OGC, such as younger OGC. Therefore, meticulous history and agents.49 Levodopa may be useful in Par-
age,48,49 male sex,48 greater severity of thorough clinical examination should be kinson’s disease with OGC. Anticholin-
illness,49 greater baseline psychopathol- done for differentiating other phenome- ergics are also found to be beneficial in
ogy,50 increasing neuroleptic dose,48 par- na from OGC (Table 3). OGC associated with focal brain lesions.
enteral administration of neuroleptics,51 The dystonic reactions are associated
high potency of neuroleptic drugs,52
Management of OGC with considerable physical and psycho-
abrupt discontinuation of anticholin- The mainstay of treatment of OGC is social consequences such as increased
ergic medication within the first few based on its etiology.2 In the case of psychiatric comorbidity,56 poor compli-

Mahal et al.
program. J Clin Psychopharmacol 2015;

Table 3.
35(6): 715–718.
Common Differential Diagnosis for OGC8–10resulting in sustained 8. Wyllie E, Lüders H, Morris HH, Lesser RP,
unnatural positioning and Dinner DS. The lateralizing signifi-
cance of versive head and eye movements
Differentials Description during epileptic seizures. Neurology 1986;
Seizures Repetitive, clonic, or tonic eye movements 36(5): 606–611.
It is usually associated with loss of consciousness or impaired responsiveness, 9. Salmina C, Taddeo I, Falesi M, et al. Parox-
with other seizure phenomena such as tongue bite, incontinence, fall, confu-
ysmal tonic upgaze in normal children: A
sion, and EEG changes
Seizures are primarily cortical, while the OGC is primarily subcortical-striatal in case series and a review of the literature.
etiology. Eur J Paediatr Neurol 2012; 16(6): 683–687.
Video-EEG monitoring can help in differentiating from OGC.53 10. Jankovic J and Stone L. Dystonic tics in
Paroxysmal Upward eye deviation lasting seconds to hours patients with Tourette’s syndrome. Mov
tonic upgaze Reported in children only Disord 1991; 6(3): 248–252.
Ocular dyski- Repetitive, upward gaze usually lasting only a few seconds 11. Gold DR. Eye movement disorders: Con-
nesias Associated with L-dopa-induced dyskinesias and tardive dyskinesias. Gener- jugate gaze abnormalities [Internet]. In:
ally, short-lasting, not associated with anxiety, and the patient often remains Liu GT, Volpe NJ and Galetta SL (eds) Liu,
unaware of the eye movements. Volpe, and Galetta’s Neuro-Ophthalmology. 3rd
Ocular tics Brief ocular deviations ed. Elsevier; 2019 [cited Mar 26, 2020], pp.
It is associated with other tics and can be suppressed 549–84, http://www.sciencedirect.com/
Psychogenic Distractible ocular movements and associated with other functional move- science/article/pii/B978032334044100016X
ments, and other functional findings (accessed July 27, 2020).
OGC: Oculogyric crisis. 12. Yildiz Y, Pektas E, Tokatli A, and Haliloglu
G. Hereditary dopamine transporter defi-
ance,57 increased fatigue, and sleep dis- ciency syndrome: Challenges in diagnosis
Funding
turbances, leading to decrease quality and treatment. Neuropediatrics 2017;
The authors received no financial support for the 48(1): 49–52.
of life.58 OGC and blepharospasm can
research, authorship, and/or publication of this
significantly affect daily living activi- 13. Portaro S, Gugliandolo A, Scionti D, et
article.
al. When dysphoria is not a primary
ties such as driving, shaving, combing,
or dressing. These effects are more pro- References mental state: A case report of the role of
the aromatic L-aminoacid decarboxylase.
nounced with tardive dystonia cases and 1. Solberg M and Koht J. Oculogyric crises. Medicine (Baltimore) 2018; 97(22): e10953.
can even lead to social avoidance, isola- Tremor Hyperkinetic Mov [Internet] 2017 14. Lee LK, Cheung KM, Cheng WW, et al. A
tion, and stigmatization.59 Hence, both [cited Apr 17, 2019]; 7, https://www.ncbi. rare cause of severe diarrhoea diagnosed
non-motor and motor features associat- nlm.nih.gov/pmc/articles/PMC5623758/ by urine metabolic screening: aromatic
ed with dystonia should be managed in (accessed July 27, 2020) L-amino acid decarboxylase deficiency.
order to improve the quality of life. 2. Barow E, Schneider SA, Bhatia KP, and Ga- Hong Kong Med J 2014; 20(2): 161–164.
nos C. Oculogyric crises: Etiology, patho- 15. Wassenberg T, Molero-Luis M, Jeltsch K,
Conclusion physiology and therapeutic approaches. et al. Consensus guideline for the diag-
Parkinsonism Relat Disord 2017; 36: 3–9. nosis and treatment of aromatic l-amino
The timely diagnosis and early identifi- 3. Abe K. Psychiatric symptoms associated acid decarboxylase (AADC) deficiency.
cation of the causative medication play with oculogyric crisis: A review of litera- Orphanet J Rare Dis 2017; 12(1): 12.
an important role in the course and man- ture for the characterization of antipsy- 16. De Giorgis V, Varesio C, Baldassari C, et al.
agement of OGC. It can cause extreme chotic-induced episodes. World J Biol Atypical manifestations in Glut1 deficien-
agitation, which can mimic worsening Psychiatry 2006; 7(2): 70–74. cy syndrome. J Child Neurol 2016; 31(9):
of psychosis in psychiatric patients.2 4. Koban Y, Ekinci M, Cagatay HH, and Ya- 1174–1180.
Treatment of OGC is mainly causal, as its zar Z. Oculogyric crisis in a patient taking 17. Jacobsen JC, Wilson C, Cunningham V,
etiology is multifactorial, involving both metoclopramide. Clin Ophthalmol 2014; et al. Brain dopamine-serotonin vesic-
dopaminergic and cholinergic systems. 8: 567–569. ular transport disease presenting as a
5. Lewis K and O’Day CS. Dystonic reactions severe infantile hypotonic parkinsonian
Doctors must be aware of the varied pre-
[Internet]. In: StatPearls. Treasure Island, disorder. J Inherit Metab Dis 2016; 39(2):
sentation of OGC, as recurrent dystonic
FL: StatPearls Publishing; 2019 [cited Apr 305–308.
reactions have obvious implications on 17, 2019], http://www.ncbi.nlm.nih.gov/ 18. Leuzzi V, Carducci CA, Carducci CL, et al.
medication adherence and course and books/NBK531466/ (accessed July 27, 2020). Phenotypic variability, neurological out-
prognosis of primary disorders. OGC 6. Spina E, Sturiale V, Valvo S, et al. Preva- come and genetics background of 6-pyru-
should be managed with meticulous lence of acute dystonic reactions associat- voyl-tetrahydropterin synthase deficiency.
history, examination, serial assessments, ed with neuroleptic treatment with and Clin Genet 2010; 77(3): 249–257.
medications, and regular follow-up. without anticholinergic prophylaxis. Int 19. Almannai M, Felemban R, Saleh MA, et
Clin Psychopharmacol 1993; 8(1): 21–24. al. 6-Pyruvoyltetrahydropterin synthase
Declaration of Conflicting Interests 7. Gardner DM, Abidi S, Ursuliak Z, et al. deficiency: Review and report of 28 Arab
The authors declared no potential conflicts of Incidence of oculogyric crisis and long- subjects. Pediatr Neurol 2019; 96: 40–47.
interest with respect to the research, authorship, term outcomes with second-generation 20. Rohani M, Shahidi G, Vali F, et al.
and/or publication of this article. antipsychotics in a first-episode psychosis Oculogyric crises in PLA2G6 associated

Review Article
neurodegeneration. Parkinsonism Relat 33. Matsumura K and Sakuta M. Oculogyric aptic plasticity: A hypothesis. Mov Disord
Disord 2018; 52: 111–112. crisis in acute herpetic brainstem enceph- 2012; 27(10): 1205–1215.
21. Pironti E, Granata F, Cucinotta F, et al. alitis. J Neurol Neurosurg Psychiatry 1987; 47. Prisco S and Esposito E. Differential
Electroclinical history of a five-year-old 50(3): 365–366. effects of acute and chronic fluoxetine ad-
girl with GRIN1-related early-onset epi- 34. Leea JH, Lyoob CH, Leec JG, and Leeb ministration on the spontaneous activity
leptic encephalopathy: a video-case study. MS. Oculogyric crisis associated with of dopaminergic neurones in the ventral
Epileptic Disord Int Epilepsy J Videotape disulfiram-induced pallidonigral lesion. J tegmental area. Br J Pharmacol 1995;
2018; 20(5): 423–427. Mov Disord [Internet] [cited Apr 21, 2019], 116(2): 1923–1931.
22. Ohba C, Shiina M, Tohyama J, et al. http://www.e-jmd.org/journal/view. 48. Keepers GA and Casey DE. Prediction
GRIN1 mutations cause encephalopa- php?number=85 (accessed July 27, 2020). of Neuroleptic-Induced Dystonia. J Clin
thy with infantile-onset epilepsy, and 35. Heimburger RF. Positional oculogyric Psychopharmacol 1987; 7(5): 342.
hyperkinetic and stereotyped movement crises: Case report. J Neurosurg 1988; 49. Aguilar EJ, Keshavan MS, Martínez-
disorders. Epilepsia 2015; 56(6): 841–848. 69(6): 951–953. Quiles MD, et al. Predictors of acute dys-
23. Parker JC, Dyer ML, and Paulsen WA. 36. Nebhinani N and Suthar N. Oculogyric tonia in first-episode psychotic patients.
Neuronal intranuclear hyaline inclusion crisis with atypical antipsychotics: A case Am J Psychiatry 1994; 151(12): 1819–1821.
disease associated with premature coro- series. Indian J Psychiatry 2017; 59(4): 499. 50. Chakos MH, Mayerhoff DI, Loebel AD,
nary atherosclerosis. J Clin Neuroophthal- 37. Nebhinani N, Avasthi A, and Modi M. Alvir JM, and Lieberman JA. Incidence and
mol 1987; 7(4): 244–249. Oculogyric crisis with clozapine: A case correlates of acute extrapyramidal symp-
24. FitzGerald PM, Jankovic J, and Percy AK. report and review of similar case reports toms in first episode of schizophrenia.
Rett syndrome and associated movement in the literature. Indian J Psychol Med Psychopharmacol Bull 1992; 28(1): 81–86.
disorders. Mov Disord 1990; 5(3): 195–202. 2015; 37(3): 342. 51. Sachdev PS. Neuroleptic-induced move-
25. Grattan-Smith PJ, Wevers RA, Steenber- 38. Jitprapaikulsan J and Srivanitchapoom P. ment disorders: An overview. Psychiatr
gen-Spanjers GC, et al. Tyrosine hydrox- Acute dystonic reaction following general Clin North Am 2005; 28(1): 255–74, x.
ylase deficiency: Clinical manifestations anesthetic agent use. Tremor Hyperkinet- 52. Jhee SS, Zarotsky V, Mohaupt SM, Yones
of catecholamine insufficiency in infancy. ic Mov N Y N 2017; 7: 514. CL, and Sims SJ. Delayed onset of oculo-
Mov Disord 2002; 17(2): 354–359. 39. Nahhas N, Conant A, Hamilton E, et al. gyric crisis and torticollis with intramus-
26. Pons R, Serrano M, Ormazabal A, et al. TUBB4A-Related Leukodystrophy [Inter- cular haloperidol. Ann Pharmacother
Tyrosine hydroxylase deficiency in three net]. In: Adam MP, Ardinger HH, Pagon 2003; 37(10): 1434–1437.
Greek patients with a common ances- RA, et al. (ed) GeneReviews®. Seattle, WA: 53. Jamal Omidi S, Fernandez BacaVaca G,
tral mutation. Mov Disord 2010; 25(8): University of Washington, 1993 [cited Apr Lacuey N, et al. Episodic gaze deviation
1086–1090. 24, 2020], http://www.ncbi.nlm.nih.gov/ in multiple sclerosis: Versive seizures or
27. Williams DR, Hadeed A, al-Din ASN, books/NBK395611/ (accessed July 27, 2020). oculogyric crises? J Clin Neurosci 2018;
Wreikat A-L, and Lees AJ. Kufor Rakeb 40. Wong LH and Tan E. Anti-tuberculosis 58: 201–203.
disease: Autosomal recessive, levodopa-re- medication-induced oculogyric crisis and 54. Tianyi F-L, Agbor VN, and Njim T.
sponsive parkinsonism with pyramidal the importance of proper history taking. Metoclopramide induced acute dystonic
degeneration, supranuclear gaze palsy, Int Med Case Rep J 2017; 10: 341–344. reaction: A case report. BMC Res Notes
and dementia. Mov Disord 2005; 20(10): 41. Choi JK and Hong JY. Acute cervical 2017; 10(1): 32.
1264–1271. dystonia induced by clebopride. Case Rep 55. Cheng K-J, Yeh T-C, Ku S-C, Tseng Y-T, and
28. Taipa R, Moreira B, França M, and Maia Neurol Med 2017; 2017: 2834349. Liang C-S. Electroconvulsive therapy for
LF. A case of haemophagocytic syndrome 42. Jacob S, Ly H, Villenueva RJ, and Gupta anticholinergic and benzodiazepine non-
presenting with oculogyric crises. J Neurol HV. Acute dystonic reaction in a patient responsive tardive oculogyric crisis: A case
Neurosurg Psychiatry 2010; 81(4): 469–471. with Parkinson’s disease after diphen- report. Am J Ther 2020; 27: e412-e413.
29. Friedman J, Roze E, Abdenur JE, et al. Se- hydramine withdrawal. Acta Neurol Belg 56. Zurowski M, McDonald WM, Fox S, and
piapterin reductase deficiency: A treatable 2017; 117(1): 345–356. Marsh L. Psychiatric comorbidities in
mimic of cerebral palsy. Ann Neurol 2012; 43. Slow EJ and Lang AE. Oculogyric crises: dystonia: Emerging concepts. Mov Disord
71(4): 520–530. A review of phenomenology, etiology, 2013; 28(7): 914–920.
30. Koht J, Rengmark A, Opladen T, et al. pathogenesis, and treatment. Mov Disord 57. Das S and Agrawal A. Lurasidone-induced
Clinical and genetic studies in a family 2017; 32(2): 193–202. oculogyric crisis. Indian J Psychol Med
with a novel mutation in the sepiapterin 44. Schneider SA, Udani V, Sankhla CS, and 2017; 39(5): 719–720.
reductase gene. Acta Neurol Scand Suppl Bhatia KP. Recurrent acute dystonic reac- 58. Wagle Shukla A, Brown R, Heese K, et al.
2014; (198): 7–12. tion and oculogyric crisis despite with- High rates of fatigue and sleep distur-
31. Horvath GA, Stockler-Ipsiroglu SG, drawal of dopamine receptor blocking bances in dystonia. Int J Neurosci 2016;
Salvarinova-Zivkovic R, et al. Autosomal drugs. Mov Disord 2009; 24(8): 1226–1229. 126(10): 928–935.
recessive GTP cyclohydrolase I deficien- 45. Aramideh M, Bour LJ, Koelman JH, Speel- 59. Skokou M, Tsermpini E-E, Giamarelou A,
cy without hyperphenylalaninemia: man JD, and Ongerboer de Visser BW. Gogos A, and Gourzis P. Tardive dystonia
Evidence of a phenotypic continuum Abnormal eye movements in blepharo- due to D2 antagonists and other agents.
between dominant and recessive forms. spasm and involuntary levator palpebrae Dystonia - Differ Prospects [Internet]
Mol Genet Metab 2008; 94(1): 127–131. inhibition: Clinical and pathophysiolog- 2018 [cited Apr 24, 2020], https://www.
32. Devinsky O. Neuroanatomy of Gilles de la ical considerations. Brain J Neurol 1994; intechopen.com/books/dystonia-differ-
Tourette’s syndrome: Possible midbrain 117 ( Pt 6): 1457–1474. ent-prospects/tardive-dystonia-due-to-d2-
involvement. Arch Neurol 1983; 40(8): 46. Teo JT, Edwards MJ, and Bhatia K. Tardive antagonists-and-other-agents (accessed
508–514. dyskinesia is caused by maladaptive syn- July 27, 2020).

Original Article
Caregivers’ experiences of aggressive
Persons with Schizophrenia
Neha A.1, Sailaxmi Gandhi2, Manjula M.3, Padmavathi N.2
ABSTRACT the caregivers, and the coping methods of as 0.64% and that it was 2–3 times more
the caregivers. common in urban than rural areas.3
Background: Understanding the caregivers’
Conclusion: This study explored the The World Health Organization es-
experiences of aggressive persons with
mental disorders is very important from experiences of the caregivers living with timates that 40%–90% of persons with
the public health point of view. Only a few the aggressive patients. The results show schizophrenia live with their relatives.2
Indian studies have focused on this. No the need for care and support to the Even though caring for a person with
Indian studies could be found that explored caregivers. The themes can guide mental schizophrenia may be a positive experi-
the caregivers’ experiences of aggressive health professionals while developing
ence for some, it is also frequently associ-
persons with schizophrenia. This study was culture-specific tools and interventions
for future research as well as suggest ated with a negative impact on the care-
conducted to explore the same. givers’ life.4
them standard operating procedures for
Methods: A qualitative phenomenological prevention and management of aggressive In addition to the positive symptoms
study was conducted in the outpatient and patients in the psychiatric hospitals. associated with schizophrenia, patients
inpatient settings at a tertiary care mental also present with other associated symp-
health institute at Bengaluru, Karnataka. Ten Keywords: experiences, caregiver,
schizophrenia, aggression, violence toms such as aggression, agitation, and
participants meeting the eligibility criteria
anxiety.5 According to a study, verbal ag-
were selected using purposive sampling. Key Messages: Caregivers of aggressive
Data collection was done by individual, persons with schizophrenia experience gression and violence were the behaviors
in-depth, face-to-face, semi-structured negative impact because of the different that caused most difficulty to the care-
interviews using topic guide along with types of aggression from the patients. givers.6 Even though aggression among
subjective observation and field notes. Each The reasons for the aggression vary from persons with schizophrenia is a major
interview was audio-recorded, transcribed, patient to patient. The caregivers adopted problem faced by the caregivers, limited
translated, and coded. A total of five master different coping strategies to deal with qualitative studies have been done to ex-
themes and 22 subthemes were derived from their patients’ aggression. plore the experiences of caregivers of ag-
S
the codes by using the qualitative research
chizophrenia is a mental disorder gressive patients with schizophrenia. A
software ATLAS-Ti.
that affects millions around the large majority of these studies were con-
Results: The themes derived based on the world, both males and females.1 It ducted in Western countries.6–17 It is diffi-
experiences of caregivers living with their
has a global prevalence of 0.3%–0.7%, cult to generalize the results to caregivers
aggressive persons with schizophrenia
with three million Indians suffering from in India because of cultural differences.
were the aggressive behaviors of the
patients, reasons for the aggression of the it.2 National Mental Health Survey of In- Therefore, this study was undertaken to
patients, dealing with the aggression of dia (2015–2016) recorded the prevalence describe the caregivers’ experiences of
the patients, the impact of aggression on of schizophrenia and other psychoses aggression by their family member with
Dept. of Mental Health Nursing, Jubilee Mission College of Nursing, Thrissur, Kerala, India. 2Dept. of Nursing, NIMHANS, Bengaluru, Karnataka, India.
1
Department of Clinical Psychology, NIMHANS, Bengaluru, Karnataka, India.

3
HOW TO CITe THIS aRTICle: Neha A, Gandhi S, Manjula M, Padmavathi N. Caregiver’s experiences of aggressive persons with
schizophrenia. Indian J Psychol Med. 2021;43(1):10–15.
Address for correspondence: Neha A., Kavil House, West Yakkara, Palakkad, Kerala Submitted: 11 Feb. 2020
678001, India. E-mail: nehaniku0@gmail.com Accepted: 4 Jun. 2020
Published Online: 4 aug. 2020

Original Article
schizophrenia. This study would provide lected using a brief participant profile One of the researchers (NA) interpret-
a more holistic and rich description of the prepared by the researcher. A semi-struc- ed the data initially by making filters
phenomenon of caring for the aggressive tured interview using a topic guide, about own concepts or ideas regarding
persons with schizophrenia. The results which was prepared by the researcher the data without diminishing the quality
could provide insights to mental health and validated by five experts, was done or significance of the analysis.
professionals while developing need- with each individual. The topic guide in-
based interventions to empower family cluded the following questions: Individual Case Analysis
caregivers in handling aggression in per- 1. What could be the reasons for the ag- Each interview was individually ana-
sons with mental illness. gressive behavior of your patient? lyzed in depth. All audio recordings were
2. How do you feel when your patient translated from the languages Malay-
Materials and Methods becomes aggressive? alam, Tamil, and Hindi to English and
This phenomenological study was con- 3. How did you react when your pa- transcribed verbatim. The two research-
ducted at a tertiary care mental health tient became aggressive? ers (NA, PN) read the lines of text by lis-
institute at Bengaluru from April 2017 4. What do you do to reduce the aggres- tening to the recording several times and
to April 2018. The study was approved by sive behavior of your patient? corrected the text for any errors. After
the ethics committee of the institution. 5. How do you manage the feelings this, coding was done to identify top-
Ten participants were selected from psy- evoked by the aggressive behavior of ics, issues, similarities, and differences
chiatric wards (n = 5) and the outpatient your patient? revealed through the participants’ nar-
department (n = 5) using purposive sam- 6. What are the changes you experi- ratives and they were interpreted by the
pling technique. Primary caregivers, both enced in your life due to the aggres- researchers with a hard copy of the tran-
male and female above 18 years of age, liv- sive behavior of your patient? script. The qualitative data management
ing with the patients with schizophrenia Each participant was interviewed for software, ATLAS-Ti was used to analyze
for the past six months, who had experi- approximately 30–45 minutes in one the transcriptions and code the data. The
enced aggressive behavior during the last session. Interviews were audiotaped and credibility of the coding was maintained
one year were selected. Caregivers other field notes were written by the research- by involving three naive coders. It was
than family members of persons with er to complement the audiotaped inter- also supervised by two research experts
schizophrenia and caregivers suffering views. After clarification of the themes, (**SG, MM). This helped in the revision
from any kind of sensory deficits or men- the researcher (NA) gave psycho-educa- of the codes and to clarify the results.18
tal illness were excluded. The adequacy of tion on homecare management that can
the sample size was evaluated by the qual- be applied when the patient becomes ag- Emergent Themes
ity and completeness of information progressive.
Each code and transcript were thorough-
vided by the participants. Data collection ly examined and brought together as
continued till saturation occurred.
Results the patterns emerged. These emerging
The caregivers who signed the in- The sociodemographic details of the par- patterns were stated as themes. Some of
formed consent were enrolled and then ticipants and the clinical details of the the themes clustered together and some
sociodemographic information was col- patients are given in Table 1. emerged as master themes.
Table 1.
Sociodemographic Profile of Participants

Proxy Age Gender Marital Education Occupation Place Family Religion ES Rela- Duration Diagnosis DOI/NAE
name status type tionship of care of Patient
with taking on ICD 10
patient
Ayna 38 Female Married Higher Home maker Rural Nuclear Muslim APL Mother 7 years F 20.0 7 years/7
secondary
Amala 51 Female Married Graduation Home maker Urban Nuclear Hindu APL Mother 8 years F 20.0 8 years/30
Monika 52 Female Married Primary Home maker Urban Nuclear Christian APL Wife 30 years F 20.3 30 years/60
Padma 55 Female Married Illiterate Home maker Rural Nuclear Hindu APL Mother 9 years F 20.0 9 years/20
Mari 70 Male Married Illiterate Agriculture Rural Nuclear Hindu BPL Father 10 years F 20.3 10 years/25
Sumi 42 Female Married Primary Home maker Urban Nuclear Muslim APL Mother 5 years F 20.0 5 year/20
Sandhya 30 Female Widow Primary Home maker Rural Joint Christian APL Sister 1 year F 20.0 1 year/6
Nadhu 56 Male Married Graduation Pharmacist Urban Nuclear Hindu APL Father 7 years F 20.0 7 years/10
Kala 54 Female Married Graduation Home maker Urban Nuclear Hindu APL Mother 7 years F 20.0 7 years/40
Selvan 66 Male Married Graduation Doctor Urban Nuclear Christian APL Father 18 years F 20.0 18 years/30
ES: economic status, DOI: duration of illness of patient, NAE: number of aggressive episodes of patient, APL: Above Poverty Line, BPL: Below Poverty Line.

Neha A et al.
Cross Case Analysis of aggression (verbal aggression, physi- ers believed that the patients’ delusions
cal aggression, and damage to property). and hallucinations, along with their
A list of the themes for all the ten inter- Similar findings were shown by some wish to fulfil their desires and needs,
views was drawn up and patterns were studies which revealed that aggression were leading to the patients’ aggressive
identified across the themes. These were could take the form of verbal threats, behavior.6, 7, 9
then clustered into master themes and threats with knives, punches, wrestling, Dealing with the aggressive behavior
subthemes (Table 2). and damage to property.6–8 of patients with schizophrenia was a dif-
The reasons for aggression vary from ficult situation for the caregivers. They
Discussion patient to patient. Caregivers reported were confused about what to do when
This qualitative study explored the lived- that their patient’s aggression was main- their patients with schizophrenia became
in experiences of caregivers of aggressive ly because of them denying the patient, aggressive. They were not aware whether
patients with schizophrenia. The care- their likes, saying no to their demands of what they did to their patients was right
givers reported one or the other kind of wanting to do certain activities, and chal- or wrong. Some showed a reaction simi-
aggressive behavior from their patients. lenging their own way of thinking and lar to what the patient expressed to them,
Most of them experienced multiple types perception. In other studies, the caregiv- while the others became silent, moved
Table 2.
Themes Derived
Verbatim
Master theme Subtheme (proxy names are used to narrate the verbatim)
The aggressive Verbal aggression “He (patient) likes to sit in his room 24 hours a day engaged in watching programs on TV or mobile
behaviors by the phone. If my husband or I go inside his room for cleaning or to call him to have food, he gets angry and
patients shouts at us and sometimes he uses abusive words. He also says he will harm us for entering his room
without his permission.” (Kala)
“If I won’t agree for unnecessary demands of my daughter (patient) such as going out and buying a
costly dress, she gets angry and scolds my husband and me very badly.” (Padma)
Physical aggression “Whenever she (patient) sees a boy with me, whom others or I can’t see, she shouts and beats me
hardly. There are redness and markings all over my body because of getting frequent beatings from my
daughter.” (Ayna)
“My husband (patient) gets attracted to ladies easily. He gives money to widows as gifts, which we
don’t even know, and after some time when he needs money, he goes to their houses to get the money
back. If I ask him why he gave them the money in the first place, he gets angry, locks me up in a room,
asks me to kneel down with hands up, and beats on my face for questioning him.” (Monika)
Damage to properties “He likes to have food from hotels every day. For this, money is needed. If his papa doesn’t give him
money, he breaks things in his room, including the TV, by throwing them to the floor.” (Amala)
“She (patient) shouts and throws things such as flower vases towards images that only she can see, to
get away from them.” (Sumi)
Reasons for the Hearing a “no” from “She (patient) gets angry and quarrels with me when I disagree with her or say no when she asks me to
aggression by the the caregiver go out and buy costly dress and ornaments.” (Padma)
patients “He (patient) gets angry easily when we say no to any of his wishes.” (Amala)
Desire for patient’s “He (patient) demands money from me for buying cigarettes and visiting prostitutes. If I don’t obey, he
likes starts to beat me up till I give money.” (Selvan)
“He (patient) loves non-vegetarian food, especially chicken. He demands chicken curry for food every
day. I do not have money to buy chicken daily. Even if I try to make him understand it, he won’t listen. He
will continuously ask for chicken until he gets it. Otherwise, he gets angry and beats me.” (Mari)
Being compelled to “He (patient) gets angry when we tell him to take bath in time or have food in time.” (Kala)
do activities of daily “He (patient) sleeps till 12 pm every day. After waking up, he will eat nicely and spend time with mobile
living phone and TV. If I ask him to wake up in the morning, brush, and take bath, he gets angry and shouts at
me.” (Nandhu)
Odd way of thinking “He (patient) scolds and threatens whoever comes to our house because he thinks that they are coming
and perception to our house and speaking with us to make a plan to kill him. I don’t know how to control his aggressive
behavior towards others.” (Nandhu)
“My sister (patient) used to tell me that others are listening to whatever we speak with each other.
Hence, she approaches those seen near our house, quarrels with them, and uses abusive words for
hearing what we had spoken.” (Sandhya)
Dealing with the Equal and opposite “I feel angry towards my daughter (patient) whenever she gets angry and beats me. I beat her back to
aggression by the reaction towards generate fear in her so that she won’t beat or hit me again. Then I lock her inside her room.” (Ayna)
patients patient

Original Article
Verbatim
Remaining away from “When he (patient) is angry and beats me hard, I used to run away from our house and hide somewhere
the patient away.” (Mari)
Keeping silent “Whatever he (patient) does to me when he is angry, I should tolerate it and remain silent.” (Monika)
Accepting the pa- “If we allow him (patient) to go out and have food from the hotel, he won’t show his anger towards us
tient’s demands and he won’t break things in our home.” (Amala)
Providing medications “I used to give medications to (patient’s name) when she is angry by mixing it with milk or juice, which
will help her to get out of her anger and behave normally.” (Sandhya)
The impact of Emotional distur- “I feel angry towards my daughter (patient) when she gets angry and beats me. I have beaten her and
aggression on the bances locked her in a room to be safe from her aggressive behavior. But after that I feel really guilty for what I
caregivers did. I know she is not getting angry intentionally and that it’s because of her illness.” (Ayna)
“I am much disturbed by thinking about his (patient) condition. Even when I go to work, I always worry
about my son as he may make problems with the villagers. When I see him after my return, then only
my mind gets relaxed.” (Mari)
“By thinking about him (patient), I get tensed. I want him to lead a normal life with normal behavior.
Till that, my mind will be in distress. I used to feel bad about our life as my son always shows anger.”
(Nandhu)
“I can’t predict what all he (patient) will do when he is angry. I am really afraid even to speak to him
after an episode of his aggression.” (Amala)
“I felt really bad for my daughter (patient). I used to cry a lot by thinking about my daughter’s illness
and aggressive behavior. I used to think why it happens only to my daughter and our family. We didn’t
do anything bad to others, and we didn’t hurt anyone. Then why we are suffering because of my daugh-
ter’s aggressive behavior.” (she started crying) (Sumi)
Health issues “Every time he (patient) gets angry, he will beat me hardly after locking me in a room. I lost my health. I
am weak.” (Monika)
“Because of my daughter’s (patient) anger, me and my husband’s health got declined. We got admitted
in a hospital for treatment of elevated blood pressure after worrying a lot about her. We always think
about her fluctuating behavior and get tensed.” (Padma)
Financial burden “I am spending a huge portion of my pension for fulfilling the demands of my son (patient) and to
escape from his aggression.” (Selvan)
“She (patient) is the only regular employee from our family. If she does not come out of her illness and
anger, she can’t go back to the job. Now our family is suffering because of some financial issues due to
her hospitalization and treatment. If this situation continues, we can’t even get her a proper treatment.”
(Sandhya)
Non-acceptance by “Relatives and neighbors don’t understand our situation. They isolated us because of my daughter’s
society (patient’s) aggressive behavior. No one is there to support us.” (Padma)
“Everyone avoids my daughter (patient) and our family because of her aggressive behavior. We are
alone now. Our relatives and neighbors say that some spirit is there inside my daughter’s body; that’s
why she becomes aggressive frequently. They are there to blame us, not help us.” (Sumi)
Perceived stigma “I don’t want others to know about our son’s (patient) illness and anger outbursts. I am afraid that they
may think bad about my family, and my son won’t be able to get married in the future. So, I won’t share
anything about my son to my relatives or neighbors.” (Kala)
“We can’t take him (patient) to public places or any functions, because we don’t know when he will get
angry and make some problems. It will be really embarrassing for us.” (Selvan)
Disgraced because of “Every time, we have to explain to others about his illness and aggressive behavior, to get out of
patient’s aggression situations created by him (patient). Because of him, our family’s name is getting spoiled in the society.”
(Nandhu)
“When he (patient) is angry, he will scold whoever comes in front of him. He doesn’t even think about
his parents when he makes problems with others. My husband and I need to go after each person to
solve the problems that he makes with them, by telling them sorry. It is really a shameful situation for
me and my husband who are living in the society with a good name.” (Kala)
The coping Pray to God “I used to go to every temple and pray to God to make him (patient) good and get out of his illness and
methods of the aggressive behavior.” (Amala)
caregivers “I used to ask God why only my daughter (patient) is always suffering from excessive anger. I pray
together anger removed so that she can lead a normal life.” (Padma)
Support from others “I share my feelings with my family members. They all know about my husband’s (patient) illness and
his aggressive behavior. So, they support me mentally and financially.” (Monika)
“My brothers support me and our sister (patient). Because of their mental support only I am standing
here for my sister’s treatment. We all want our sister back without any illness and anger.” (Sandhya)

Neha A et al.
Verbatim
Accepting the pa- “I know he (patient) is getting angry because of his illness. Whatever he does to me in anger is not
tient’s aggression really him; it is the illness within him. Now I accept the way he is, and I learned to tolerate his anger.”
(Monika)
“Whenever he (patient) gets angry, not only my wife and I, even my brothers and the members of their
families go to own rooms to escape his scolding. We all understand his illness, live according to his
mood, and accept his aggressive behavior.” (Nandhu)
Engaging in own work “To get relief from my feelings, I used to engage in my household work.” (Ayna)
“When I feel so sad after fighting with my daughter, I feel heaviness in my heart. To release that heavi-
ness, I engage in household work such as cooking, washing, cleaning, etc. After that, I feel a relief from
the heaviness in my heart.” (Sumi)
away, or accepted the patient’s demands. perhaps, a greater depth would have 3. Gururaj G, Varghese M, Benegal V, et al.
Others gave medications. Some previous been obtained by adding more explor- National mental health survey of India,
studies too had revealed the practices atory questions. The study cannot claim 2015–16: summary. Bengaluru: National
Institute of Mental Health and Neurosci-
caregivers adopt to deal with or prevent to represent the full picture of the experi-
ences, 2016.
the aggressive behaviors of their patients, ences of caregivers of aggressive patients 4. Kulhara P, Kate N, Grover S, et al. Positive
such as close observation, giving advice with schizophrenia. aspects of caregiving in schizophrenia: a
and reasoning, communication tactics, The study needs to be replicated us- review. World J Psychiatr 2012; 2: 43.
and taking help from others.9–11 ing a mixed methodology and a bigger 5. Buckley P, Citrome L, Nichita C, et al.
The caregivers experienced emotion- sample size, adding the perceptions of Psychopharmacology of aggression in
al disturbances, health issues, financial professionals, patients, and caregivers schizophrenia. Schizophr Bull 2011; 37:
burden, non-acceptance from society, per- of patients with other mental illnesses, 930–936.
ceived stigma, and disgrace because of 6. Hsu MC and Tu CH. Adult patients with
and taking into account the patient’s du-
schizophrenia using violence towards
their patient’s aggression. Different stud- ration of illness and number of episodes
their parents: a phenomenological study
ies had revealed similar findings—that of aggression. There is also a scope for of views and experiences of violence in
the aggression had impact on the care- further studies with a focus on socioeco- parent–child dyads. J Adv Nurs 2014; 70:
giver’s emotional, financial, social, and nomic, demographic, and cultural varia- 336–349.
family functioning, including having to tions; the difference in perceptions based 7. DiBenedetti DB, Brown MT, and
manage disruptions by the patient during on the caregivers’ living arrangements; Danchenko N. Assessing patient and
family gatherings, stress over decisions and planning and evaluating interven- caregiver experiences with symptoms and
to commit the patient to hospitalization, behaviors associated with schizophrenia.
tions to manage the aggressive behavior
non-acceptance by the society, prejudice, J Depress Anxiety 2016; 5: 2167–1044.
of patients with schizophrenia.
8. Nordstrom A, Kullgren G, and Dahlgren
and stigma.7, 12–14 Jose reported that the This study explored the experiences of L. Schizophrenia and violent crime: the
caregivers expressed off-putting personal- the caregivers living with their aggres- experience of parents. Int J Law Psychiatr
ity elements like asociality or introversion, sive patients. The results show the need 2006; 29: 57–67.
passive attitude, low frustration tolerance, for care and support to the caregivers. 9. Napa W, Tungpunkom P, Sethabouppha
and low self-esteem and also presented H, et al. A grounded theory study of Thai
with troubling stressors like comorbidi- Declaration of Conflicting Interests family caregiving process for relatives
ties and familial, financial, and legal issues The authors declared no potential conflicts of with first episode psychosis. Pac Rim Int J
due to their patient’s aggression.15 interest with respect to the research, authorship, Nurs Res 2017; 21: 158–170.
and/or publication of this article. 10. Sadath A, Muralidhar D, Varambally S, et
To cope with the aggressive behavior
al. Caregiving and helping seeking in first
of their patients, they were praying to
Funding episode psychosis: a qualitative study. J
God, accepting support from others, ac- Psychosoc Rehabil Ment Health 2014; 1:
The authors received no financial support for the
cepting patient’s aggression, and engag- 47–53.
ing in their own work. Likewise, other article. 11. Jagannathan A, Thirthalli J, Hamza A,
studies had revealed that contacting et al. A qualitative study on the needs of
family, friends, psychiatrists, and neigh- References caregivers of inpatients with schizophre-
bors; compassionate feelings; faith in nia in India. Int J Soc Psychiatr 2011; 57:
1. Meenu V, Karakkattu J, Thambi SP, et al. 180–194.
God; self-help approach; acceptance and
Prescribing patterns in schizophrenic 12. Ganguly KK, Chadda RK, and Singh TB.
finding a solution; supportive handling;
patients attending a tertiary care hospital Caregiver burden and coping in schizo-
hopefulness; and religious participation at Kerala. Int J Pharm Sci Rev Res 2016; phrenia and bipolar disorder: a qualita-
were helpful in coping with the aggres- 41: 27–32. tive study. Am J Psychiatr Rehabil 2010;
sion of the patients.12, 16, 17 2. World Health Organization. Nations for 13: 126–142.
This was a qualitative research study mental illness: schizophrenia and public 13. Stillwell K. Caring over the lifespan: experienc-
that resulted in rich data; however, health. Geneva: WHO, 1998. es of caring for a sibling with schizophrenia

Original Article
[doctoral dissertation]. London, UK: in schizophrenia: a systematic review. po, South Africa: University of Limpopo
University of East London, 2016. Asian J Psychiatr 2015; 14: 13–18. (Turfloop Campus), 2013.
14. John NR. Stigma perception among primary 16. Ferriter M and Huband N. Experiences of 18. Polit DF and Beck CT. Essentials of
caregivers of inpatients with schizophrenia parents with a son or daughter suffering nursing research: appraising evidence
[postgraduation dissertation]. Bengaluru: from schizophrenia. J Psychiat Ment for nursing practice. Philadelphia, PA:
National Institute of Mental Health and Health Nur 2003 Oct; 10: 552–560. Lippincott Williams & Wilkins, 2009.
Neurosciences, 2017. 17. Negota AJ. Experiences of mothers caring for
15. Jose D, Lalitha K, Gandhi S, et al. Consum- children with schizophrenia in Vhembe District,
er perspectives on the concept of recovery South Africa [doctoral dissertation]. Limpo-

Original Article
Nature and Correlates of executive
Dysfunction in Schizophrenia: An
exploratory Study
Joseph Noel1, Shonima A Viswanathan1, Anju Kuruvilla1
ABSTRACT
C
and unemployed. The mean dose of ognitive symptoms are common
antipsychotic medication was 618.57 in schizophrenia and are known
Background: Executive function (EF) mg (SD: 282.08) of chlorpromazine to be relatively stable over the
impairment has been demonstrated in equivalents per day. Impairment was found
patients with schizophrenia. This study course of the illness. These deficits are
in the different sub-components of EF. On present even before the onset of positive
attempted to examine the clinical and
multivariate analysis, factors significantly
demographic correlates associated with and negative symptoms and persist be-
associated with executive dysfunction
the different components of EF in these yond them.1,2 Although all domains of
were lower education, unemployment,
patients using a comprehensive battery of cognition are affected in schizophrenia,
neuropsychological tests. lower income, positive PANSS score,
higher antipsychotic dose, and history of the severity of the impairment varies,
Materials and Methods: Consecutive treatment with electroconvulsive therapy. and deficits in executive functions (EFs),
inpatients with schizophrenia in remission verbal learning and memory, psycho-
were recruited. The following instruments Conclusion: EFs encompass a wide range
motor speed, and vigilance are found be
were administered: (a) Positive and of cognitive processes that influence an
individual’s ability to adapt and function more prominent than deficits in other ar-
Negative Syndrome Scale (PANSS), (b)
World Health Organization Disability in the society. These are often impaired in eas of cognition.1
Assessment Schedule 2.0, (c) Tower of patients with schizophrenia. Clinicians need EFs consist of those capacities that
London, (d) Stroop Test, (e) Controlled to be aware of these deficits and factors enable a person to engage successfully
Oral Word Association Test, (f) Animal associated with them, to plan appropriate in independent, purposive, and self-serv-
Names Test, and (g) Verbal N-Back Test. and effective remedial measures. ing behavior.3 It is an umbrella term that
Sociodemographic and clinical details involves the regulation and control of
were also recorded. Data was analyzed Keywords: Schizophrenia, executive
functions, cognitive dysfunction processes such as working memory, rea-
using standard bivariate and multivariate
statistics. soning, task flexibility, problem solving,
Key Messages: Executive function
planning, and execution.4 These func-
Results: A total of 50 patients were impairment in schizophrenia affects all
domains of the individual’s functioning. tions enable a person to develop and
recruited. The mean age of the population
Potentially modifiable factors such carry out plans, solve problems, adapt
was 30 years (standard deviation [SD]:
7.74). The majority were male, literate, as the dose of antipsychotics and to unexpected circumstances, perform
single, from a rural background, from electroconvulsive therapy can significantly many tasks simultaneously, and adjust
a middle socioeconomic background, affect EF. in the society. Deficits in EFs are not only
1
Dept. of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India.
HOW TO CiTe THiS ArTiCle: Noel J, Viswanathan SA, Kuruvilla A. Nature and correlates of executive dysfunction in schizophrenia:
An exploratory study. Indian J Psychol Med. 2021;43(1):16–23.
Address for correspondence: Shonima A Viswanathan, Dept. of Psychiatry, Submitted: 7 May 2019
Christian Medical College, Vellore, Tamil Nadu 632002, India. E-mail: shonima@ Accepted: 10 Apr. 2020
cmcvellore.ac.in Published Online: 10 Aug. 2020
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCeSS THiS ArTiCle ONliNe

Original Article
present in patients with schizophrenia5 excluded. The details of the study were profiles across cultures in adult popu-
but are also known to be present in ad- explained and written informed consent lations. It assesses disability across six
olescents who are at risk of developing was obtained from each participant and domains: cognition, mobility, self-care,
schizophrenia and in the first degree rel- caregiver. Following recruitment, partic- getting along, life activities, and partici-
atives of patients with schizophrenia.6 ipants were assessed at a single point in pation. For this study, the 12-item version
They can result in longer hospital stays, time. All patients received treatment as of the WHODAS 2.0 was used.
difficulties in everyday functioning, unusual. Sociodemographic details were Tower of London (TOL): It measures the
employment, poor treatment adherence, collected by the principal investigator subjects’ ability to plan and to anticipate
and increased medical comorbidities.1 (JN), who also administered the tests of the results of their actions to achieve
There are conflicting reports regard- EF. Assessments of the severity of psy- a predetermined goal.23 It consists of
ing the relationship between executive chopathology and disability were car- two identical wooden boards, each con-
dysfunction and variables like gender, ried out by the coinvestigator (SAV). The sisting of three pegs of different height
age, duration of illness, and severity of Institutional Review Board and Ethics and three wooden balls. It requires the
psychopathology. While some studies Committee approved the study protocol. subject to rearrange the balls to match a
reported no significant associations,7 model board in as few moves as possible.
other studies showed that demograph- Assessment For this study, the NIMHANS version24
ic and illness-related factors do have an The following instruments were em- was utilized.
impact.8 ployed. Stroop Test: It measures response in-
Studies from India have examined EF The Positive and Negative Syndrome Scale hibition, which is the ease with which
impairments in patients with schizo- (PANSS): It was used to rate the symptom a person can maintain a goal in mind
phrenia in comparison to normal con- severity.21 The PANSS is a clinician-rated and suppress a habitual response in fa-
trols, those with bipolar disorder, and scale considered as the gold standard to vor of a familiar one.25 In this study, the
delusional disorder.9,10 Associations be- assess the clinical symptoms of schizo- Stroop Test from the NIMHANS Neuro-
tween EF and sociodemographic, psy- phrenia. It consists of 30 items across psychological battery, standardized for
chopathology, insight, suicide attempts, three subscales: positive, negative, and the Indian population, was used.24 The
and functioning have been studied.11–16 A general psychopathology. The positive test consists of 176 words printed across
follow-up study reported deterioration and negative scales have seven items 16 rows and 11 columns in four colors,
in executive functioning in the ten years each, and the general psychopathology with the color of the print occasionally
of treatment following diagnosis,17 while scale consists of 16 items. All items are corresponding with the color designated
improvement in EF has been reported scored from 1 to 7 based on severity. by the word. It involves two trials: first,
following yoga therapy.18 World Health Organization Disability reading the words as fast as possible col-
While many studies are limited by the Assessment Schedule 2.0 (WHODAS)22: The umn-wise, and second, naming the color
lack of a range of tests done to assess EF, WHODAS is a scale developed by the the word is printed in, rather than the
this study used a comprehensive battery World Health Organization. It pro- word. The score taken is the difference in
of tests to evaluate different aspects of vides standardized disability levels and time in seconds between the time taken
EF with a focus on clinical correlates that
can potentially be altered to improve the
patient functioning. Figure 1.
Relationship Between Controlled Oral Word Association Test

Materials and Methods Score and Education
Participants
This was a cross-sectional exploratory
study conducted between June 2013 and
October 2014 in a tertiary care hospital.
Consecutive inpatients who satisfied
the International Classification of Dis-
eases-10 (ICD-10)19 diagnostic criteria for
schizophrenia and were in remission20
were contacted for possible recruitment
to the study. Subjects between the ages of
18 and 65 years who were able to read En-
glish or Tamil were eligible to take part.
Patients with severe language disorder;
intellectual, visual, or hearing impair-
ment; primary mood disorder; substance
use disorder or organic disorder were

Noel et al.
to read the words from the time taken to Table 1.

name the colors.
Controlled Oral Word Association Test
Sociodemographic and Clinical Characteristics of Study Sample
(COWAT): It measures phonemic or lex- Characteristic Mean (SD) Frequency (%) Range
ical fluency. It requires the examinee to Age (in years) 30 (7.74) 19–62
generate a list of words beginning with a Gender: male 39 (78)
specific alphabet in a minute. The letters
Marital status: never married 34 (68)
F, A, and S were used for English-speaking
Residence: rural 27 (54)
individuals, and the consonants “Ka,”
“Pa,” and “Ma” were used for Tam- Able to read and write 49 (98)
il-speaking individuals. Proper nouns Schooling (in years) 13.74 (2.66) 6–20
and names of numbers were excluded. Occupation: unemployed 30 (60)
The score taken was the average number Family income (in rupees) 24787.23 (28279.80) 2,000–1,50,000
of words across the three trials.24 Alcohol use 14 (28)
Animal Names Test: It measures categor- Medical illness 10 (20)
ical fluency and requires the subject to Age of onset of illness (in 24.98 (7.14) 11–47
name as many different animals as pos- years)
sible, excluding the names of fish, birds, Duration of illness (in months) 63.98 (58.48) 2–300
and snakes, in one minute. The total Number of psychotic episodes 1.48 (1.22) 1–7
number of words generated is taken as Number of hospitalizations 1.92 (1.58) 1–8
the score.24 Antipsychotics: monotherapy 33 (66)
Verbal N-Back Test: It measures verbal Antipsychotic dose: chlorprom- 618.57 (282.08) 250–1,450
azine equivalent (in mg)
working memory. The 1 Back and 2 Back
History of treatment with ECT 19 (38)
versions of the test were used.24 It con-
Number of ECTs received 4.22 (5.94) 0–24
sists of 30 random consonants that are
Duration since last ECT (in 223.66 (731.29) 2–3,600
read out, of which nine are repeated ran- days) (n = 19)
domly. In N-Back 1, the subject responds PANSS positive score 8.36 (1.85) 7–14
whenever a consonant is repeated con- PANSS negative score 14.84 (4.46) 8–27
secutively, and in N-Back 2, whenever a PANSS general psychopathol- 24.42 (4.04) 16–32
consonant is repeated after an interven- ogy score
ing consonant. The score is the number PANSS total score 47.24 (7.60) 34–66
of hits and errors in each. Depressive index 5.92 (2.06) 3–11
Pro forma for Sociodemographic and Clin- WHODAS total score 27.22 (7.84) 14–46
ical Variables: Information related to so- SD: standard deviation, ECT: electroconvulsive therapy, PANSS: Positive and Negative Syndrome Scale, WHODAS:
ciodemographic variables and clinical World Health Organization Disability Assessment Schedule.
details (duration and severity of illness,
treatment variables, etc.) were recorded Figure 2.
in this.
Relationship Between Controlled Oral Word Association Test
Statistical Analysis Score and Income
Mean and SD were employed to describe
continuous variables, while frequency
distributions were obtained for categor-
ical data. Student’s t-test was used to
assess the significance of associations
between categorical and continuous
variables, and Pearson’s correlation was
used to assess the correlation between
continuous variables. Multiple linear
regression was done to adjust for age,
education, and the number of sessions
of electroconvulsive therapy (ECT). SPSS
version 16 was used for analysis.
Results
Fifty patients and their caregivers were
contacted, and all consented to participate

Original Article
Table 2.
in the study. The sociodemographic and
clinical characteristics of the sample are
Tests of Executive Functions shown in Table 1. The results of the tests
Test Mean (SD) Range of EF are shown in Table 2.
Lexical fluency by COWAT: average new words 9.82 (4.92) 3–21.67 Table 3 shows the factors associated
Categorical fluency by ANT: average words 11.36 (3.71) 5–23 with lexical fluency as measured by the
COWAT score. On bivariate analysis, lex-
Verbal working memory by Verbal N-Back 1: hits 7.44 (1.76) 3–9
ical fluency score was positively correlat-
Verbal working memory by Verbal N-Back 1: errors 2.6 (2.6) 0–9
ed with years of schooling (Pearson’s r =
Verbal working memory by Verbal N-Back 2: hits 4.48 (2.44) 0–8
0.36, P = 0.010), family income (r = 0.45, P
Verbal working memory by Verbal N-Back 2: errors 5.88 (3.24) 1–17 = 0.001), PANSS positive symptom score
Stroop Test: time taken for naming colors 349.92 (140.20) 193.60–855.36 (r = 0.28, P = 0.047), and depressive index
Stroop Test: time taken for naming words 101.41 (26.59) 59.29–194.82 score (r = 0.28, P = 0.05), and negatively
Stroop effect 248.52 (130.91) 95.45–746.24 correlated with the total antipsychotic
Planning and problem solving by TOL: no. of problems 8 (2.1) 3–13
dose (r = –0.32, P = 0.022) and number of
solved in minimum moves ECTs received (r = –0.31, P = 0.031).
SD: standard deviation, COWAT: Controlled Oral Word Association Test, ANT: Animal Names Test, TOL: Tower of Figures 1 and 2 show the relationship
London. that the COWAT score has with educa-
tion and income. Those who were em-
Table 3. ployed as professionals (t = –2.11, df = 48,
P = 0.041), who were not using alcohol
Factors Associated with Lexical Fluency: COWAT Score
currently (t = 4.14, df = 10.70, P = 0.002)
Multivariate Statistics (Adjusted for and from an urban habitat (t = 2.07, df =
Bivariate Statistics Age, Education, and Number of ECTs) 48, P = 0.044) had higher scores on the
Factor r/t df P Value β 95% CI P Value COWAT.
Years of schooling 0.36 – 0.010 0.32 0.09 to 1.09 0.023* The factors that remained significantly
Occupation: professional –2.11 48 0.041 0.11 –2.70 to 5.64 0.482 associated with lexical fluency after mul-
Residence: urban 2.07 48 0.044 –0.23 –4.89 to 0.38 0.092 tivariate analysis using linear regression
Family income 0.45 – 0.001 0.38 0.000–0.000 0.007*
were years of schooling (β = 0.32, 95% CI
(in rupees) = 0.09–1.09, P = 0.023), income (β = 0.38,
Current alcohol use 4.14 10.70 0.002 –0.22 –8.94 to 0.98 0.113 95% CI = 0.000 - 0.000, P = 0.007), and
PANSS positive score (β = 0.26, 95% CI =
PANSS positive score 0.28 – 0.047 0.26 0.004 to 1.39 0.049*
0.004–1.39, P = 0.049).
Depressive index score 0.28 – 0.05 0.19 –0.22 to 1.10 0.183
Categorical fluency score based on per-
Antipsychotic dosage –0.32 – 0.022 –0.27 –0.010 to 0.95 formance on the Animal Names Test was
(chlorpromazine equiva- 0.001
lents in mgs) found to correlate negatively with anti-
psychotic dose (r = – 0.29, P = 0.040) and
Number of ECTs received –0.31 – 0.031 –0.25 –0.43 to 0.2 0.068
the number of ECTs received (r = –0.40,
COWAT: Controlled Oral Word Association Test, r: Pearson’s correlation coefficient, t: t value on independent
t-test, df: degrees of freedom, CI: confidence interval, ANT: Animal Names Test, TOL: Tower of London, ECT: elec- P = 0.004). Those who were profession-
troconvulsive therapy. als had higher scores (t = –2.79, df = 48,
P = 0.008). Only the number of ECTs re-
Table 4. mained significant on multivariate anal-
ysis (β = –0.36, 95% CI = –0.39 to 0.06, P =
Factors Associated with Categorical Fluency: Animal Names Test
0.009) (Table 4).
(ANT) Table 5 shows the factors associated
Multivariate Statistics Adjusted for Age, with verbal working memory as mea-
Bivariate Statistics Education, and Number of ECTs sured by the N-Back 1 and 2. There was
Factor r/t df P Value β 95% CI P Value a negative correlation between the num-
Occupation: profes- –2.79 48 0.008 0.270 –0.32 to 5.72 0.079 ber of hits on N-Back 1 and the number of
sional ECTs (r = – 0.29, P = 0.035), and a positive
Antipsychotic dos- –0.29 – 0.040 –0.14 –0.006 to 0.408 correlation between the number of psy-
age (chlorpromazine 0.003 chotic episodes and errors on N-Back 1. A
equivalents in mgs) higher score was found in those who had
Number of ECTs –0.04 0.008 –0.36 –0.39 to 0.06 0.009* never been married (t = 2.26, df = 48, P
received
= 0.03). A negative correlation was noted
r: Pearson’s correlation coefficient, t: t value on independent t-test, df: degrees of freedom, CI: confidence interval, between the antipsychotic dose and the
ECT: electroconvulsive therapy.
number of correct responses in N-Back

Noel et al.
Table 5.
The following factors were not signifi-
cantly associated with EFs: age, gender,
Factors Associated with Verbal Working Memory: N-Back 1 and 2 medical illness, age of onset and dura-
Multivariate Statistics Adjusted for tion of illness, number of hospitaliza-
Factor Bivariate Statistics Age, Education, and Number of ECTs tions, and the disability score on WHO-
P P DAS.
r/t df Value β 95% CI Value
N-Back 1: Number of ECTs –0.29 – 0.035 –0.26 –0.16 to 0.068 Discussion
hits 0.006
This study adds to the existing litera-
N-Back 1: Never married 2.26 48 0.03 –0.31 –3.32 to 0.08 0.04* ture regarding the correlates of EFs in
errors
No. of psychotic 0.28 – 0.047 0.25 –0.13 to 1.21 0.112 patients with schizophrenia. Several
episodes cognitive functions have been included
N-Back 2: Antipsychotic –0.40 – 0.004 –0.35 –0.006 to 0.037* under the label of EFs. Many of them
hits dosage (chlor- 0.000 are independent of each other, are often
promazine equiv-
multidimensional, and encompass sev-
alents in mgs)
eral sub-component processes. This is
N-Back 2: Antipsychotic 0.38 – 0.007 0.35 0.00–0.00 0.040* evident in this study, as factors that in-
errors dosage (chlor-
promazine equiv- fluence the performance on one test of
alents in mgs) EF did not always have a similar effect on
r: Pearson’s correlation coefficient, t: t value on independent t-test, df: degrees of freedom, CI: confidence interval,
the other tests.
ECT: electroconvulsive therapy. A few studies have reported greater
deficits in some aspects of cognitive and
Table 6. EFs in males with schizophrenia.26,27
However, this study did not find gen-
Factors Associated with Response Inhibition and Problem Solving
der-specific differences, and one earlier
Factor Bivariate Statistics Multivariate Statistics Adjusted for Age, study too had similar findings.28
Education, and Number of ECTs Most studies have demonstrated that
r P Value β 95% CI P Value in older patients with schizophrenia,
Stroop effect cognitive impairment is more severe,
Family income (in –0.32 0.030 –0.25 –0.003 to 0.000 0.080 with a significant decline in EFs.6,29
rupees) However, no significant correlation was
Number of ECTs 0.34 0.016 0.31 0.81 to 12.99 0.027* found between age and deficits in EFs
received in this study, similar to some earlier re-
Tower of London ports.7,30
Antipsychotic dosage –0.37 0.008 –0.29 –0.005 to 0.000 0.087 Higher levels of education are thought
(chlorpromazine equiv- to reduce the risk of cognitive decline in
alents in mg)
people as they age, by increasing the cog-
Number of ECTs –0.34 0.017 –0.34 –0.22 to 0.02 0.018* nitive reserve, maintaining the neuronal
received
function, stimulating neural growth,
r: Pearson’s correlation coefficient, CI: confidence interval, ECT: electroconvulsive therapy. and recruiting alternate neural path-
ways to maintain cognitive function.
2 (r = –0.40, P = 0.004), while there was correlated with the number of ECTs re- Therefore, regular involvement in intel-
a positive correlation between the drug ceived (r=0.34, P=0.016); the latter remained lectual activity during one’s lifetime has
dose and N-Back 2 error score (r=0.38 P = significant on multivariate analysis (β = been considered a successful preventive
0.007). Factors that remained significant –0.31, 95% CI = 0.81–12.99, P = 0.027). intervention to reduce the risk of demen-
on linear regression were marital status On bivariate analysis, problem solv- tia.31,32 This has also been shown to be
with N-Back 1 errors (β = –0.31, 95% CI ing score, as measured by the number of applicable in schizophrenia, where low-
= –3.32 to 0.08, P = 0.04), antipsychotic problems solved in minimum moves on er education predicted more cognitive
dose with N-Back 2 hits (β = –0.35, 95% the Tower of London test, was found to decline and years of education showed a
CI = –0.006 to 0.000, P = 0.037) and anti- be negatively correlated with both an- positive correlation.33 Murray et al. pos-
psychotic dose with N-Back 2 errors (β = tipsychotic dosage (r = –0.37, P = 0.008) tulated that better premorbid education-
0.35, 95% CI = 0.00–0.00, P = 0.04). and the number of ECTs received (r = al attainment may compensate for defi-
On bivariate analysis, response inhibi- –0.34, P = 0.017). Number of ECTs re- cits that occur as a result of the illness.34
tion score as measured by the Stroop Test mained significantly associated on linear This matches with the findings of the
was negatively correlated with family in- regression (β = –0.34, 95% CI = –0.22 to present study, where years of education
come (r = –0.32, P = 0.030) and positively 0.02, P = 0.018) (Table 6). had a positive correlation with all tests of

Original Article
EF, and the relationship was significant schizophrenia, there is emerging litera- es of antipsychotics, higher doses and
in the case of lexical fluency. This specific ture regarding the possibility that these polypharmacy may be deleterious and
association may reflect the larger mental drugs may contribute to the genesis magnify disease-related deficits, further
lexicon or store of organized words that of some of the abnormalities usually interfering with the patient’s function-
an individual acquires with a greater du- attributed to the disease.42 In the pres- al recovery.45 Our results highlight the
ration of formal education. ent study, the dose of medication was fact that antipsychotics can affect EF in a
This study also found a significant significantly correlated with the differ- dose-dependent fashion and emphasizes
association between categorical flu- ent aspects of EFs, with higher doses the need to prescribe the lowest possible
ency and occupation; those who were associated with greater dysfunction in dose of medication to prevent or mini-
employed as professionals had higher lexical and categorical fluency, verbal mize such cognitive side effects.51,52
scores on this test. While the cross-sec- working memory, and problem solving. The literature on the effects of ECT
tional nature of this study does not al- The negative influence of higher doses of on cognitive functions in general and
low us to conclude the direction of this antipsychotics and anticholinergics on EFs in particular is limited. Most have
association or causality, this finding has executive and other cognitive functions shown that ECT improves several neu-
been reported by other researchers also have been previously reported.43,44 The rocognitive domains, without evidence
who found that the relationship persist- use of antipsychotic medications with of worsening of any cognitive func-
ed even when the effect of education was more anticholinergic effects and higher tions.53,54 Many reviews suggest that any
controlled for.35–37 lifetime antipsychotic dose-years have cognitive adverse effects that may occur
In this study, lexical fluency scores been found to be significantly associat- are short-lasting and rarely persistent.55
were found to be positively correlated with a poorer cognitive composite However, a few studies have reported
ed with income. A similar relationship score, with no difference between the persistent memory loss after treatment56
between cognitive function and socio- typical and atypical antipsychotics.45,46 and lower scores on tests of phonetic ver-
economic outcomes has been demon- Cognitive remediation programs have bal fluency, which was significantly asso-
strated in some38 but not other studies.30 found that such interventions are more ciated with the number of ECT sessions.57
Findings on the relationship between effective in patients who are on a small- Tielkes et al. reported impairment in
the different symptom groups of schizo- er amount of antipsychotics and less learning verbal information and execu-
phrenia and EFs have been varied. Most beneficial to those on high doses or poly- tive functioning in older patients given
studies have noted that the severity of pharmacy.47 The cognitive effects of the maintenance ECT over a year, though
negative symptoms correlates with poor medication have been attributed to sev- the global cognition remained stable.58
performance on measures of EF, while eral mechanisms. Anticholinergic add- We found ECT to be significantly associ-
almost no correlation has been found on drugs and antipsychotic medication ated with executive dysfunction, with no
between positive symptoms and EFs.7 with significant anticholinergic prop- correlation with the time elapsed since
We found an association between the erties inhibit postsynaptic muscarinic the last ECT session. Our findings draw
positive symptom score and lexical flu- receptors concentrated in the prefrontal attention to the importance of making
ency scores on bivariate and multivariate cortex and hippocampus, areas thought attempts to minimize cognitive side-ef-
analyses. Bagney et al. noted a correla- to be concerned with EF and memory. fects of this very effective and useful
tion between negative symptoms and EF A second mechanism postulated is the treatment modality by practicing uni-
deficits, which varied with the duration antipsychotic related dopamine recep- lateral stimulation techniques and ul-
of schizophrenia.39 tor blockade, which, in addition to the tra-brief pulse stimulations.
We did not find any association be- beneficial effects on the positive symp- There was no statistically significant
tween the duration of illness and EF defi- toms of schizophrenia, may contribute relationship between EF and scores on
cits, similar to that reported by Sabeshan to impaired cognition.48 It has also been the disability scale in the present study,
et al.7; contrasting findings have been suggested that cognitive impairment in similar to some earlier studies59,60 and
reported of greater EF impairment in pa- schizophrenia may be related to the met- in contrast with others.61,62 The lack of a
tients with longer periods of untreated abolic comorbidity that is seen with the relationship has been attributed to so-
psychosis2,40 and shorter illness duration use of atypical antipsychotics.44 The dis- ciocultural aspects such as family sup-
being associated with stronger improve- continuation of anticholinergic agents, port available in countries like India that
ment during cognitive remediation.41 In as well as a reduction to the lowest effec- serve as protective factors despite the pa-
this study, patients with three or more tive dose of the antipsychotic drug, is tient’s cognitive impairments.59
psychotic episodes were found to show recommended to reduce adverse effects, While the cross-sectional nature of this
more severe deficits in lexical fluency including the cognitive effects attribut- study precludes conclusions on the direc-
and working memory in comparison to able to the medication.49,50 The results of tion of causation, the results indicate an
those with fewer episodes, but this did this study reiterate the findings of Rehse association between EFs and some socio-
not remain significant on linear regres- et al. that care should be taken in the pre- demographic and clinical factors. As this
sion analysis. scription of antipsychotic agents. While was an exploratory study with a view to
While antipsychotic medications small positive effects on cognitive func- investigate and identify potential rela-
remain the mainstay of treatment in tions are seen with normal or lower dos- tionships with EF, multiple correlations

Noel et al.
were studied, increasing the possibility 4. Denckla M. A theory and model of follow-up study. Indian J Psychiatry 2010
of a type I error (false positives). Further executive function: A neuropsychological Oct; 52(4): 320–326.
studies are needed to confirm our results. perspective. In: Lyon G and Krasnegor N, 18. Verma M, Bhargav H, Varambally S, et
eds. Attention, memory and executive function. al. Effect of integrated yoga on anti-psy-
Future research should also include
Baltimore: Brookes, 1996. chotic induced side effects and cognitive
longitudinal studies to examine the im-
5. Thai ML, Andreassen AK, and Bliksted V. functions in patients suffering from
pact of variations in sociodemographic
A meta-analysis of executive dysfunction schizophrenia. J Complement Integr Med
and clinical factors on EFs. These prelim- in patients with schizophrenia: Different 2018 Jun 26; 16(1). DOI:10.1515/jcim-2017-
inary findings, however, emphasize the degree of impairment in the ecological 0155.
need to individualize and tailor pharma- subdomains of the behavioural assess- 19. World Health Organization. The ICD-
cological management, cognitive reme- ment of the dysexecutive syndrome. 10 classification of mental and behavioural
diation, and other psychosocial interven- Psychiatry Res 2019; 272: 230–236. disorders: Clinical descriptions and diagnostic
tions, such as social skills training and 6. Orellana G and Slachevsky A. Executive guidelines. Geneva: World Health Organi-
supported employment, to the specific functioning in schizophrenia. Front Psy- zation, 1992.
EF deficits identified. chiatry 2013; 4: 1–15. 20. Andreasen N, Carpenter W, Kane J, et al.
7. Sabhesan S and Parthasarathy S. Execu- Remission in Schizophrenia: Proposed
The study was limited by the small
tive functions in schizophrenia. Indian J criteria and rationale for consensus. Am J
sample size. While no patient with a clin-
Psychiatry 2005; 17: 21–26. Psychiatry 2005; 162: 441–449.
ical diagnosis of intellectual deficiency
8. Srinivasan L and Thara R. Cognitive 21. Kay S, Opler L, and Fiszbein A. The Posi-
was included, formal assessment of the dysfunction and associated factors in pa- tive and Negative syndrome scale (PANSS)
premorbid intelligence was not carried tients with chronic schizophrenia. Indian for schizophrenia. Schizophr Bull 1987; 13:
out. The effect of benzodiazepines and J Psychiatry 2005; 47: 139–143. 261–276.
anticholinergics, which some patients 9. Trivedi JK, Goel D, Sharma S, et al. Cogni- 22. World Health Organization. Measuring
were prescribed, was not controlled for. tive functions in stable schizophrenia & health and disability: Manual for WHO
The strengths include the use of consecu- euthymic state of bipolar disorder. Indian Disability Assessment Schedule (WHO-
tive sampling, standard assessments, two J Med Res 2007 Nov; 126(5): 433–439. DAS 2.0). Geneva: WHO, 2010.
independent assessors, and multivariate 10. Grover S, Nehra R, Bhateja G, et al. A 23. Shallice T. Specific impairments of plan-
comparative study of cognitive deficits ning. Philos Trans R Soc Lond B Biol Sci
analysis to adjust for confounders.
in patients with delusional disorder and 1982; 298: 199–209.
Conclusion paranoid schizophrenia. Ind Psychiatry J

2011 Jul; 20(2): 107–114.
24. Rao S, Subbakrishna D, and Gopukumar
K. NIMHANS neuropsychology battery—2004
The dose of antipsychotic medication, 11. Choudhury S, Khess CR, Bhattacharyya R, manual. Bangalore: NIMHANS Publica-
ECT, education, employment, and income et al. Insight in schizophrenia and its as- tion, 2004.
are associated with EFs. Knowledge of sociation with executive functions. Indian 25. Strauss E, Sherman E, and Spreen O. A
the nature of EF deficits and the associat- J Psychol Med 2009 Jul; 31(2): 71–76. compendium of neuropsychological tests:
12. Hegde S, Thirthalli J, Rao SL, et al. Cogni- Administration, norms and commentary.
ed factors can help clinicians address the
tive deficits and its relation with psycho- 3rd ed. New York: Oxford University
individual patient’s problems and needs
pathology and global functioning in first Press, 2006.
in order to improve his or her ability to episode schizophrenia. Asian J Psychiatry 26. Han M, Huang XF, Chen DC, et al. Gender
adapt and function in the community. 2013 Dec; 6(6): 537–543. differences in cognitive function of
13. Bhatia T, Garg K, Pogue-Geile M, et al. patients with chronic schizophrenia. Prog
Declaration of Conflicting Interests Executive functions and cognitive deficits Neuropsychopharmacol Biol Psychiatry
The authors declared no potential conflicts of in schizophrenia: Comparisons between 2012; 39: 358–363.
interest with respect to the research, authorship, probands, parents and controls in India. J 27. Urbanek C, Neuhaus AH, Opgen-Rhein C,
and/or publication of this article.
Postgrad Med 2009 Jan–Mar; 55(1): 3–7. et al. Attention network test (ANT) reveals
14. Srinivasan L and Tirupati S. Relationship gender-specific alterations of executive
Funding between cognition and work functioning function in schizophrenia. Psychiatry Res
This study was funded by a Grant from the Chris- among patients with schizophrenia in an 2009; 168: 102–109.
tian Medical College, Vellore.
urban area of India. Psychiatr Serv 2005 28. Gogos A, Joshua N, and Rossell SL. Use of
Nov; 56(11): 1423–1428. the Repeatable Battery for the Assessment
References 15. Verma D, Srivastava MK, Singh SK, et of Neuropsychological Status (RBANS) to
1. Schretlen D. The nature and significance al. Lifetime suicide intent, executive investigate group and gender differences
of cognitive deficits in schizophrenia. Adv function and insight in schizophrenia and in schizophrenia and bipolar disorder.
Stud Med 2007; 7: 124–131 schizoaffective disorders. Schizophr Res Aust N Z J Psychiatry 2010; 44: 220–229.
2. Joyce E, Hutton S, Mutsatsa S, et al. Exec- 2016 Dec; 178(1–3): 12–16. 29. Loewenstein DA, Czaja SJ, Bowie CR,
utive dysfunction in first episode schizo- 16. Grover S, Sahoo S, Nehra R, et al. Associa- et al. Age-associated differences in
phrenia and relationship to duration of tion of neurocognitive deficits and insight cognitive performance in older patients
untreated psychosis: The West London in schizophrenia. Asian J Psychiatr 2018 with schizophrenia: A comparison with
study. Br J Psychiatry 2002; 181: 38–44. Aug; 36: 112–117. healthy older adults. Am J Geriatr Psychi-
3. Lezack M, Howieson D, Bigler E, et al. 17. Shrivastava A, Shah N, Johnston M, et atry 2012; 20: 29–40.
Neuropsychological assessment. 5th ed. New al. Predictors of long-term outcome of 30. Talreja, BT, Shah S, and Kataria L. Cog-
York: Oxford University Press, 2012. first-episode schizophrenia: A ten-year nitive function in schizophrenia and its

Original Article
association with socio-demographics schizophrenia. Neuropsychiatr Dis Treat 52. H. Takeuchi. Long-term brain effects of
factors. Ind Psychiatry J 2013; 22: 47–53. 2006; 2: 531–536. antipsychotics—balancing harm and ben-
31. Vemuri P, Lesnick TG, Przybelski SA, et 42. Ho BC, Andreasen NC, Ziebell S, et al. efit. The effect of antipsychotic dose-re-
al. Association of lifetime intellectual Long-term antipsychotic treatment and duction on cognition. Eur Psychiatry
enrichment with cognitive decline in the brain volumes: A longitudinal study of 2015; 30: 66.
older population. JAMA Neurol 2014; 71: first-episode schizophrenia. Arch Gen 53. Seow LSE, Subramaniam M, Chan YWC,
1017–1024. Psychiatry 2011 Feb; 68(2): 128–137. et al. A Retrospective study of cognitive
32. Lee WJ, Liang CK, Peng LN, et al. Pro- 43. Atake K, Nakamura T, Ueda N, et al. The improvement following electroconvulsive
tective factors against cognitive decline impact of aging, psychotic symptoms, therapy in schizophrenia inpatients. J
among community-dwelling middle-aged medication, and brain-derived neuro- ECT 2019 Sep; 35(3): 170–177.
and older people in Taiwan: A 6-year trophic factor on cognitive impairment in 54. Vuksan Ćusa B, Klepac N, Jakšić N, et al.
national population-based study. Geriatr Japanese chronic schizophrenia patients. The effects of electroconvulsive therapy
Gerontol Int 2017; 17: 20–27. Front Psychiatry 2018 May 29; 9: 232. augmentation of antipsychotic treatment
33. Rannikko I, Murray GK, Juola P, et al. 44. MacKenzie NE, Kowalchuk C, Agarwal on cognitive functions in patients with
Poor premorbid school performance, but SM, et al. Antipsychotics, metabolic treatment-resistant schizophrenia. J ECT
not severity of illness, predicts cognitive adverse effects, and cognitive function in 2018; 34: 31–34.
decline in schizophrenia in midlife. schizophrenia. Front Psychiatry 2018; 9: 55. Gazdag G and Ungvari GS. Electroconvul-
Schizophr Res Cogn 2015; 2: 120–126. 622. sive therapy: 80 years old and still going
34. Murray GK, Corlett PR, and Fletcher PC. 45. Rehse M, Bartolovic M, Baum K, et al. strong. World J Psychiatr 2019; 9: 1–6.
The neural underpinnings of associative Influence of antipsychotic and anticho- 56. Rose D, Fleischmann P, Wykes T, et al. Pa-
learning in health and psychosis: how linergic loads on cognitive functions in tients’ perspectives on electroconvulsive
can performance be preserved when brain patients with schizophrenia. Schizophr therapy: Systematic review. BMJ. 2003;
responses are abnormal? Schizophr Bull Res Treatment 2016; 2016: 8213165. 326: 1363.
2010; 36: 465–471. 46. Husa AP, Moilanen J, Murray GK, et al. 57. Rami-González L, Bernardo M, Portella
35. Chang WC, Man Tang JY, Ming Hui CL, Lifetime antipsychotic medication and MJ, et al. Assessment of frontal functions
et al. Clinical and cognitive predictors cognitive performance in schizophrenia in psychiatric patients during mainte-
of vocational outcome in first-episode at age 43 years in a general population nance electroconvulsive therapy. Actas
schizophrenia: A prospective 3-year birth cohort. Psychiatry Res 2017; 247: Esp Psiquiatr 2003; 31: 69–72.
follow-up study. Psychiatry Res 2014; 220: 130–138. 58. Tielkes CE, Comijs HC, Verwijk E, et al.
834–839. 47. Vita A, Deste G, De Peri L, et al. Predictors The effects of ECT on cognitive function-
36. Midin M, Razali R, Zamzam R, et al. Clin- of cognitive and functional improvement ing in the elderly: A review. Int J Geriatr
ical and cognitive correlates of employ- and normalization after cognitive reme- Psychiatry 2008; 23: 789–795.
ment among patients with schizophrenia: diation in patients with schizophrenia. 59. Krishnadas R, Moore BP, Nayak A, et al.
A cross-sectional study in Malaysia. Int J Schizophr Res 2013; 150: 51–57. Relationship of cognitive function in
Ment Health Syst 2011; 5: 14. 48. Saeedi H, Remington G, and Christensen patients with schizophrenia in remission
37. McGurk SR and Meltzer HY. The role of BK. Impact of haloperidol, a dopamine to disability: A cross-sectional study in an
cognition in vocational functioning in D2 antagonist, on cognition and mood. Indian sample. Ann Gen Psychiatry 2007;
schizophrenia. Schizophr Res 2000; 45: Schizophr Res 2006; 85: 222–231. 6: 19.
175–184. 49. Sathienluckana T, Unaharassamee W, 60. Ross N, Malla A, Cortese L, et al. Symp-
38. Ohi K, Sumiyoshi C, Fujino H, et al. Ge- Suthisisang C, et al. Anticholinergic toms and cognition as predictors of
netic overlap between general cognitive discontinuation and cognitive func- community functioning: A prospective
function and schizophrenia: A review tions in patients with schizophrenia: A analysis. Am J Psychiatry 1999; 156:
of cognitive GWASs. Int J Mol Sci 2018; pharmacist-physician collaboration in the 400–405.
19(12): 3822. outpatient department. Integr Pharm Res 61. Palsetia D, Chandrasekhar K, Reddy MS,
39. Bagney A, Rodriguez-Jimenez R, Marti- Pract 2018; 7: 161–171. et al. Executive function in patients with
nez-Gras I, et al. Negative symptoms and 50. Kawai N, Yamakawa Y, Baba A, et al. schizophrenia based on socio-occupation-
executive function in schizophrenia: Does High-dose of multiple antipsychotics and al impairment: A cross-sectional study.
their relationship change with illness cognitive function in schizophrenia: The Ind Psychiatry J 2018 Jul–Dec; 27(2):
duration? Psychopathology 2013; 46: effect of dose-reduction. Prog Neuropsy- 181–189.
241–248. chopharmacol Biol Psychiatry 2006; 30: 62. Greenwood KE, Landau S, and Wykes T.
40. Bora E, Yalincetin B, Akdede BB, et al. 1009–1014. Negative symptoms and specific cogni-
Duration of untreated psychosis and neuro- 51. Omachi Y, Sumiyoshi T. Dose reduction/ tive impairments as combined targets
cognition in first-episode psychosis: A me- discontinuation of antipsychotic drugs for improved functional outcome within
ta-analysis. Schizophr Res 2018; 193: 3–10. in psychosis: Effect on cognition and cognitive remediation therapy. Schizophr
41. Bowie CR and Harvey PD. Cognitive functional outcomes. Front Psychiatry Bull 2005; 31: 910–921.
deficits and functional outcome in 2018; 9: 447.

Original Article
Thought Disorder on Object Sorting Test Is
associated with executive Dysfunction in
Schizophrenia
BR Sahithya1, Shweta Rai2, Rishikesh V. Behere3
ABSTRACT associated with focused attention, behavior. Classic descriptions of schizo‑

sustained attention, planning, set shifting, phrenia1 considered thought disorder
Background: Thought disorder is perseveration, and concept formation. to be central to the core disturbances in
considered to be central to the core
disturbances in schizophrenia and was Conclusion: Several correlations, schizophrenia. However, this concept
described by Goldstein as aberrant among performance on OST and receives lesser prominence in contem‑
“concept formation.” Executive neuropsychological tests, suggest that porary classificatory systems such as
dysfunction is another core deficit in patterns of responses on OST can point DSM‑5 2 and ICD 10.3 Thought disorder is
schizophrenia. With a greater emphasis to underlying executive dysfunction. Both now understood using the term “formal
on psychopathology in nosological thought disorder and executive dysfunction
thought disorder” (FTD),4 which refers
systems, the classical thought disorder mirror similar constructs. This similarity
receives less prominence. The present to disorganized thinking as evidenced
represents a conceptual bridge between the
study aimed to understand the association classical and contemporary descriptions of by disorganized speech.5
between classical thought disorder the core deficits in schizophrenia. Classical thought disorder refers to
(aberrant concept formation and concrete aberrant concept formation and con‑
abstraction) and executive dysfunction. Keywords: Thought disorder, object sorting
test, executive function, schizophrenia crete abstraction. In schizophrenia, it is
Methods: Thirty patients with schizophrenia seen as a breakdown in the mechanisms,
Key Messages: In patients diagnosed with
and thirty healthy subjects, matched on rules, or laws of governing the orderly
schizophrenia, performance on OST is
age, gender, education, and socioeconomic and logical sequence of thinking.6 Payne7
associated with performance on tests of
status, were screened using MINI 5.0, and Goldstein8 considered abnormal‑
following which they were assessed on executive functions. Deficits in attention,
working memory, and perseveration ity of concept formation as a cause of
object sorting test (OST) and selected tests
for executive functions (EFs). predict impoverished response on OST, and thought disorder in schizophrenia. Cam‑
deficits in divided attention predict peculiar eron9 considered thinking problems in
Results: Individuals with schizophrenia responses on OST. The pattern of responses schizophrenia to be due to an inability
were found to have significantly decreased in OST can give an overview of executive to maintain conceptual boundaries. OST,
performance on all domains of EFs and dysfunction in patients with schizophrenia. as described by Rapaport,10 is a measure
S
OST. Total peculiar scores on OST were
significantly associated with mental speed, chizophrenia is a severe psychiatric of sorting behavior and is an expression
focused attention, and divided attention. Total disorder that alters an individual’s of concept formation. It is similar to Kas‑
impoverished scores on OST was significantly perception, thoughts, affect, and anin and Hanfmann’s11 block sorting test.
1
Dept. of Clinical psychology, Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India. 2Dept. of Clinical Psychology, Manipal College
of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India. 3KEM Hospital Research Center, Pune, Maharashtra, India.
HOW TO CITe THIS aRTICle: Sahithya BR, Rai S, Behere RV. Thought disorder on object sorting test is associated with executive
dysfunction in schizophrenia. Indian J Psychol Med. 2021;43(1):24–30.
Address for correspondence: Shweta Rai, Dept. of Clinical Psychology, Manipal Submitted: 16 Feb. 2020
College of Health Professions, Manipal Academy of Higher Education, Manipal, Accepted: 20 Jun. 2020
Karnataka 576104, India. E-mail: shwetaraisrcp@gmail.com Published Online: 20 aug. 2020

Original Article
Using this test, Kasanin and Hanfmann11 4 undifferentiated), and 30, age (±1 year), is based on the information obtained
reported that in schizophrenia, there is a gender, education, and socioeconomic through interviews, observations made
reduction in the ability to form new con‑ status matched, healthy control sub‑ during a standard clinical interview, and
cepts, which is apparent even in patients jects. The schizophrenia group (SG) was discussions with close associates such as
with previous high intellectual abilities recruited from outpatient and inpatient family members.
and educational attainment. They con‑ services and rehabilitation center of the Tests of Executive Functioning
cluded that in schizophrenia, there is a psychiatry department of a tertiary care from NIMHANS Neuropsychological
regression from conceptual thinking to hospital (Kasturba Medical College Hos‑ Battery29: The tests for EFs were taken
lower levels, such as found in children. pital, Udupi, Karnataka). The inclusion from NIMHANS neuropsychological
Cognitive impairments are at the very criteria are as follows: (a) DSM IV-TR25 battery, which has been standardized on
core of the dysfunction in schizophre‑ diagnosis of paranoid or undifferentiat‑ the Indian population. The tests of exec‑
nia.12 Emerging evidence from neuropsy‑ ed schizophrenia, (b) on a stable dose of utive functioning used are as follows.
chological and neuroimaging studies in antipsychotics in the last six weeks, (c) Digit Symbol Substitution Test
schizophrenia demonstrates executive age range of 18–50 years, and (d) had no (DSST): The DSST measures mental
dysfunction and frontal lobe deficits observable side effects interfering with speed. The subject is asked to substitute
in schizophrenia.13–15 We now consider test performance. Subjects with comor‑ each digit with a symbol, using a num‑
schizophrenia as a “cognitive disorder.”16,17 bid Axis I psychiatric disorders, history ber-symbol key given at the top of the
Hence the concept of thought disorder as of receiving electroconvulsive therapy page, row by row, after a practice trial for
described by Bleuler1 or Cameron9 may or cognitive rehabilitation in the last the first ten squares. The raw score of the
mirror closely the deficits seen as dysexec‑ one-month, serious medical conditions, time taken in seconds to complete the
utive syndrome in schizophrenia. neurological disorders, acute agitation, test was taken for analysis.
Studies attempting to find correlations suicidal tendencies, or catatonic features Controlled Oral Word Association
between thought disorder and executive were excluded. The diagnosis of schizo‑ (COWA) Test: COWA test is a measure
function (EF) have reported strong as‑ phrenia was made based on clinical in‑ of phonemic fluency. The subject is asked
sociations between thought disorder in terview and examination independently to generate words beginning with the
schizophrenia and tests of verbal mem‑ by two psychiatrists. letters F, A, and S for 1 minute each. The
ory, attention, abstraction, and EF.18–21 The participants in the healthy con‑ average number of new words generat‑
In recent years, studies have exclusively trol group (HCG) were recruited from ed over the three trials was taken for the
focused on Andreason’s4 concept of FTD the same catchment area through conve‑ analysis.
and have reported it to be associated with nient sampling. Those in whom screen‑ Animal Names Test (ANT): ANT is
semantic and executive dysfunction.22–24 ing revealed Axis I psychiatric disorders, a measure of category fluency, which is
These studies suggest a potential the‑ serious medical conditions, neurological another form of verbal fluency. The sub‑
oretical association between the two disorders, or presence of the family his‑ ject is asked to generate the names of as
concepts; however, there have been no tory of psychosis in first-degree relatives many animals as possible in 1 minute.
studies examining associations between were excluded. The total number of new words generat‑
classical thought disorder as assessed by ed forms the score.
OST with neuropsychological test perfor‑
Tools Digit Vigilance Test (DVT): The DVT
mance. Hence, the present study aimed Sociodemographic and clinical informa‑ measures sustained attention. The test
to examine this gap by identifying those tion was collected on a semistructured consists of numbers 1–9 randomly or‑
deficits in EFs that are implicated in the pro forma, which also included Global dered and placed in rows on the sheet.
poor performance in OST. The main ob‑ Assessment of Functioning (GAF) scale The subject is asked to scan the sheet
jective of this study was to assess EFs as from DSM-IV-TR.2 Cross-sectional as‑ and cancel the target numbers 6 and 9 by
measured by standardized neuropsycho‑ sessments were performed on SG and drawing “/” mark on them as fast as pos‑
logical tests and their association with HCG on the following tools. sible, without missing the targets or can‑
thought disorder as assessed by OST in Mini-International Neuropsychiat- celing the wrong numbers. The analysis
patients with schizophrenia. ric Interview (MINI) 5.0 26: MINI was was done on the raw score of time taken
administered on SG to confirm the diag‑ in seconds to complete the test.
Materials and Methods nosis of schizophrenia and to rule out co‑ Color Trails Test (CTT): This test
Study Design morbid psychiatric disorders. The MINI measures focused attention. The sub‑
screen was administered on HCG to rule ject is presented with a sheet of paper
A time‑bound cross‑sectional research out the presence of psychiatric disorders. in which 25 printed circles are scattered,
design was used. Purposive sampling Scale for the Assessment of Nega- each enclosing one of the numbers 1–25,
was adopted for data collection. tive Symptoms (SANS)27 and Scale for and is asked to join the circles in numer‑
the Assessment of Positive Symptoms ical order as quickly as possible. The
Participants (SAPS)28: SANS and SAPS were admin‑ time taken in seconds to complete Trail
The participants included 30 stable istered to assess negative and positive 1 forms the score. Both color Trail 1 and 2
schizophrenia patients (26 paranoid and symptoms respectively in SG. The rating were administered, but since many par‑

Sahithya et al.
ticipants could not complete the color one red triangle, two green stars, three idiosyncratic thinking, personal signifi‑
Trails 2 task, the data was not used in the yellow crosses, and four blue circles and cance, and symbolization. Each response
analysis. a deck of 128 cards that are placed in is classified into the appropriate category
Triads Test: This assesses divided at‑ front of the subject. The subject is told and the quantitative score is assigned
tention. The subjects are given a verbal to take one card at a time from the deck as per the severity of the thought disor‑
triad task and tactual number identifica‑ and match it with the stimulus cards. der. In this analysis, we have considered
tion task simultaneously. In the former, Feedback is provided for each response total peculiar scores and total impover‑
they have to name the odd word, and in as “correct” or “wrong” response. A raw ished scores. We have not included fused
the latter, they have to identify the num‑ score of the number of errors, perse‑ scores as they are mostly seen in patients
ber written on their nondominant hand. verative responses, and the number of with bipolar disorder. Higher pecu‑
The number of errors committed on the conceptual responses was taken for the liar and impoverished scores indicate
tasks was taken for analysis. analysis. thought disorder.30 The protocol of each
Verbal and Visual N-Back: N-back Stroop Color Word Interference subject was first scored by the principal
tests are a measure of verbal and visual Test: Stroop test is a test of response investigator and cross-checked by an ex‑
working memory. In the verbal 2-back inhibition and is used as a primary mea‑ perienced clinical psychology consultant
test, 30 randomly ordered consonants sure of response conflict. The subject is (second author). The discrepancies in the
common to multiple Indian languages asked to read the stimuli column wise as scoring were discussed and the scores
are presented auditorily at the rate of 1 fast as possible. The time taken to read were finalized. This was done to reduce
per second. The subject responds when‑ all the columns is noted. Next, the sub‑ the subjectivity in the scoring. Inter-rater
ever a consonant is repeated after an in‑ ject is asked to name the color in which reliability by raters blind to the diagnosis
tervening consonant. The visual 2-back the word is printed, and the time taken was 0.78 for qualitative scoring and 0.90
test consists of 36 cards, each with one to name all the colors is noted down. for quantitative analysis.30
black dot placed randomly. Each card is Stroop effect was calculated by subtract‑
individually presented to the subject. ing the time taken to read the words
Procedure
The subject is told to respond whenever from the time taken to name the colors. The study was carried out from Septem‑
the location of the dot repeats after an Object Sorting Test (OST)30: Indian ber 2012 to April 2013 after obtaining
intervening card. The number of correct adaptation of OST was administered to clearance from the Institutional Ethics
responses forms the score in each test. assess thought disorder, which refers Committee. Subjects who consented to
Tower of London Test (TOL): TOL is to overlapping conceptual boundaries, participate were recruited for the study
a test of planning and evaluates the sub‑ concrete thinking, idiosyncratic associ‑ and screened using MINI 5.0. SG was
ject’s ability to plan and anticipate the ations, and symbolic thinking. The test also assessed on GAF, SANS, and SAPS.
results of their actions to achieve a pre‑ comprises of 30 objects and has two Following this, both groups were as‑
determined goal. The test consists of two phases: active and passive phase. The ac‑ sessed for EFs (selected tests of NIM‑
sets of boards, each with three pegs and tive phase has ten trials in which the sub‑ HANS neuropsychological battery) and
three different colored balls. The subject ject is provided with a stimulus object thought disorder (OST). The tests were
is presented with goal state of the ar‑ and is told to add objects to the stimulus administered in two sessions of 1 hour
rangement of the three balls and is told object to make a meaningful group and each on the same day, with a short break
to arrange the balls in the other board in explain the principle behind it. The pas‑ in between the sessions.
the same way by following certain rules. sive phase has 16 trials in which the ex‑
The raw score of the number of moves aminer makes sort of the objects, and the
Statistical Analysis
made to attain the goal state on the fifth subject is asked if the group is congruent Data were analyzed using Statistical
trial was taken for the analysis. Perfor‑ or incongruent, and if congruent, what Package for Social Sciences, Version 20.0.
mance on the fifth task on TOL was tak‑ makes it so. The responses are classified Armonk, NY: IBM Corp. On the Kolm‑
en into consideration because most par‑ as adequate, fused, impoverished, and ogorov Smirnoff test, the variables were
ticipants successfully performed the first peculiar. A response is scored as adequate normally distributed. Scores of the per‑
four tasks. The fifth step, which involves when the concept used to explain the sort formances on the neuropsychological
a more complex level of planning, best is adequate, and there is an appropriate tests are reported as mean and standard
discriminated between patients and con‑ fit between the verbalized concept and deviation. Group differences in scores
trols, and hence is reported and also used the sorted objects. A response is scored were compared on Student’s t-test. Pear‑
in further regression analysis. fused if multiple concepts or subcon‑ son’s product moment correlation was
Wisconsin Card Sorting Test cepts are fused under a single response. applied to assess the association between
(WCST): WCST measures concept for‑ The impoverished type is characterized executive functioning and thought dis‑
mation, abstract reasoning, persevera‑ by poverty of association and this score is order in the SG.
tion, and set shifting, which is the ability given when the meaning ascribed to the
to shift cognitive strategies in response sort is trivial and inconsequential. Pecu‑
Results
to changing environment. WCST con‑ liar concepts involve unrealistic or far‑ Table 1 summarizes the sociodemo‑
sists of four stimulus cards consisting of fetched use of objects, dramatic contexts, graphic characteristics of the two groups,

Original Article
i.e., SG and HCG. The two groups were Table 1.

comparable as they were group matched
on age, gender, education, and socioeco‑
Sociodemographic Characteristics of the Two Groups
nomic status. Variable SG (n = 30) HCG (n = 30) t P
The SG had a mean ± SD duration of Mean 37.90 37.30 0.30 0.77
illness of 14.27 ± 6.04 years. The mean Age (in years)
SD 7.80 6.90
scores on SAPS and SANS were 23.6 ± 14.1
Percentage % (f) c2 value P value
and 21.1 ± 12.9, respectively. The GAF mea‑
Male 67 (20) 67 (20) <0.001 1.00
sured at the time of assessment during Gender
Female 33 (10) 33 (10)
the interview for sociodemographic pro
forma was 42.33 ± 9.2, indicating mod‑ School education 10 (3) 10 (3) <0.001 1.00
Education
erate impairment in socio-occupational College education 90 (27) 90 (27)
functioning. Lower middle 13 (4) 0 (0) 4.29 0.11
SES
All subjects were able to follow in‑ Upper middle 87 (26) 100 (30)
structions and complete the OST tasks. P ≤ 0.05 considered significant. SG, schizophrenia group; HCG, healthy control group; SES, socioeconomic status.
The SG performed poorly on all scores
of OST (both active and passive phase
Table 2.
scores) (Table 2). On neuropsychologi‑
cal assessments, the SG had significantly Comparison of Performance on OST Between the Two Groups
greater impairment in all domains of EFs HCG (n = 30) SG (n = 30)
Variables # P
(Table 3). Mean (SD) Mean (SD)
On Pearson’s correlation analysis (Ta- Total peculiar scores 1.30 ± 1.72 13.53 ± 19.17 3.48 <0.001
ble 4), there were significant associations Total impoverished scores 0.00 ± 0.00 1.53 ± 3.17 2.65 0.01
between thought deviance on OST and
Grand total scores 2.90 ± 2.68 19.10 ± 20.11 4.37 <0.001
EFs. Total peculiar scores on OST signifi‑
Total adequate scores 31.47 ± 5.58 17.73 ± 9.13 7.02 <0.001
cantly correlated positively with the time
P ≤ 0.05 significant. # = t-test value. SG, schizophrenia group; HCG, healthy control group; OST: object sorting test.
taken on DSST (mental speed, P = 0.02),
CTT (focused attention, P = 0.03), and the
number of errors in triad test (divided at‑ Table 3.
tention, P = 0.004). Only raw scores from Comparison of Performance on Tests of Executive Functions
Trails 1 of CTT were used for the analysis
HCG (n = 30) SG (n = 30) t
of focused attention, as most participants Variables P
Mean ± SD Mean ± SD
from SG were unable to complete Trails 2.
Mental speed 204.96 ± 73.92 341.4 ± 156.59 4.32 <0.001
Total impoverished scores on OST sig‑
nificantly correlated positively with the Phonemic fluency 13.56 ± 2.88 8.98 ± 3.29 5.73 <0.001
time taken on CTT (focused attention, Category fluency 14.80 ± 2.00 12.13 ± 4.22 3.12 0.003
P = 0.03) and DVT (sustained attention, Focused attention 59.90 ± 19.13 84.13 ± 27.28 3.98 <0.001
P = 0.005), number of moves in fifth trial
Sustained attention 463.50 ± 106.72 662.00 ± 233.45 4.24 <0.001
of TOL (planning, P = 0.004), and number
Divided attention 1.97 ± 1.29 6.47 ± 5.00 4.77 <0.001
of errors (P = 0.03) and number of perse‑
verative responses on WCST (P = 0.005) Verbal working memory 3.13 ± 1.47 5.73 ± 3.92 3.340 0.001
and negatively with the number of con‑ Visual working memory 5.13 ± 1.59 9.57 ± 4.26 5.34 <0.001
ceptual responses on WCST (P = 0.02). For Planning 2.50 ± 0.82 1.17 ± 0.74 6.59 <0.001
planning, only the fifth trial of TOL was
Set shifting 14.16 ± 8.88 55.83 ± 27.18 7.98 <0.001
used, as the first four tasks were easy and
Perseveration 9.63 ± 5.04 46.77 ± 35.05 5.74 <0.001
were successfully performed by most par‑
ticipants. The fifth step is complex and in‑ Concept formation 65.83 ± 8.92 48.77 ± 26.82 3.31 0.002
volves complex planning and, hence, only Response inhibition 71.53 ± 27.01 105.13 ± 47.25 3.38 0.001
those final scores were considered. SG, schizophrenia group; HCG, healthy control group.
Grand total scores of OST, which are
the sum total of peculiar, impoverished, WCST (set shifting, P = 0.01) and neg‑ mic fluency, P = 0.04) and animal name
and fused responses, correlated positive‑ atively with the number of conceptual test (category fluency, P = 0.03) and neg‑
ly with the time taken on DSST (mental responses on WCST (P = 0.03). atively with the number of errors in triad
speed, P = 0.02), CTT (focused attention, Total adequate scores on OST, which test (divided attention, P = 0.003) and
P = 0.02), and DVT (sustained attention, is the total number of correct responses, WCST (set shifting, P = 0.01).
P = 0.04) and number of errors in triad correlated positively with the number of Stepwise linear regression analysis
test (divided attention, P = 0.001) and correct responses in COWA test (phone‑ was carried out after controlling for

Sahithya et al.
age, duration of illness, and education. Table 4.

To test for collinearity, correlation coef‑
ficients and variation inflation factor
Correlation Between Executive Functions and Thought Disorder in
(VIF) were examined. As the correlations the SG
between the variables did not exceed Total Pecu- Total Impoverished Grand Total Total Adequate
Variables
0.8, tolerance values were less than 0.1, liar Scores Scores Scores Scores
and VIF values were below 2, the rela‑ Mental speed
0.41* 0.22 0.43* –0.32
tionships between the variables will not (time taken on DSST)
pose problems in the regression analysis. Phonemic fluency
Regression analysis was carried out for (number of correct responses –0.25 –0.04 –0.31 0.37*
in COWA test)
total impoverished scores, total peculiar
scores, and grand total scores separately Category fluency
(number of correct responses –0.23 –0.05 –0.22 0.39*
(Table 5).
in ANT)
The results indicate that perseveration
Focused attention
(b = 0.34, P = 0.03, 95% CI: 0.01 to 0.06), (time taken in CTT)
0.39* 0.39* 0.41* –0.16
working memory (b = 0.78, P < 0.001,
Sustained attention
95% CI: 0.78 to 1.55), sustained attention 0.36 0.50** 0.38* –0.31
(time taken in DVT)
(b = 0.71, P < 0.001, 95% CI: 0.01 to 0.02), Divided attention
and age (b = 0.32, P = 0.01, 95% CI: 0.04 to (number of errors in triad 0.51** 0.17 0.56** –0.52**
0.25) were independently associated with test)
or predicted total impoverished scores on Verbal working memory
OST. R2 for the model was 0.70, explaining (number of correct responses –0.10 0.06 –0.16 0.04
more than half the variance of the impov‑ in verbal N-back 2 test)
erished responses. Total peculiar scores Visual working memory

(number of correct responses –0.21 –0.18 –0.26 0.24
were associated with or independently
in visual N-back test)
predicted by divided attention (b = 0.80,
Planning
P < 0.001, 95% CI: 1.72 to 4.43) and edu‑ (number of moves on fifth 0.06 0.52** 0.13 0.15
cation (b = 5.2, P = 0.01, 95% CI: 10.53 to trial of TOL)
54.83). Here, R2 was 0.45, suggesting that Set shifting
0.36 0.39* 0.45* –0.45*
45% of the variance was explained by this (number of errors on WCST)
model. Perseveration (b = 0.31, P = 0.04, Perseveration
95% CI: 0.01 to 0.34), divided attention (number of perseverative 0.21 0.50** 0.32 –0.27
(b = 0.78, P < 0.001, 95% CI: 1.81 to 4.49), responses in WCST)
and education (b = 0.52, P = 0.01, 95% Conception formation
CI: 12.06 to 57.06) were independently (number of conceptual –0.30 –0.41* –0.40* 0.40
responses on WCST)
associated with or predicted grand total
Response inhibition
scores on OST. R2 for the model was 0.53,
(time difference in Stroop 0.29 0.31 0.33 –0.18
explaining more than half the variance of test)
the grand total responses. Significant Pearson’s correlation r values at *P ≤ 0.05, **P ≤ 0.01; n = 30. SG, schizophrenia group; DSST, digit
symbol substitution test; COWA, controlled oral word association; ANT, animal name test; CTT, color trails test;
Discussion DVT, digit vigilance test; TOL, tower of London; WCST, Wisconsin card sorting test. Time taken on all the tests was
recorded in seconds.
Schizophrenia patients performed poor‑
ly on all domains of OST and neurocogni‑ grand total scores on OST (which is the patients, perhaps, an inference about ex‑
tive functions as compared to the control sum of peculiar, impoverished, and fused ecutive dysfunction can be drawn based
group. There were significant correla‑ responses) were predicted by deficits in on their performance on OST.
tions between variables of thought dis‑ divided attention and perseveration. As This study revisited the old construct
order as measured by OST and EFs, im‑ those patients with schizophrenia who of thought disorder as defined by Gold‑
plying an association between thought performed poorly on tasks of attention, stein.8 The study findings demonstrate
disorder and EFs. Deficits in sustained working memory, and perseveration that classical descriptions of thought
attention and working memory and per‑ also tended to exhibit thought disorder disorder (deficits in concept formation
severation independently predicted im‑ on OST, perhaps, the utility of OST can and abstraction) are closely associated
poverished responses, whereas divided be extended beyond the assessment of with cognitive deficits (executive dys‑
attention independently predicted pecu‑ thought disorder to be an indicator of function). This observation suggests that
liar responses in SG. This suggests that deficits in EFs. Currently, OST is used both thought disorder and executive dys‑
performance on tests of neuropsycho‑ as a part of diagnostic psychometry as‑ function mirror similar constructs.
logical functions may be differentially sessment, and since neuropsychologi‑ In the current scenario, with the emer‑
related to performance on OST. Further, cal assessment is not carried out on all gence of the concept of “formal thought

Original Article
Table 5.
ments of schizophrenia. With our study
observations, we would like to highlight
Regression for Performance on OST as the Dependent Variable that clinicians need to be aware of the
and Executive Functions as Predictors After Controlling for Age, importance of concept formation and
Education, and Duration of Illness abstraction to the clinical description
95.0% Confidence
of schizophrenia. The presence of this
Interval for B thought disorder may make the clinician
Predictors in the Model B SE B β t P aware of possible underlying cognitive
Lower Upper
Bound Bound dysfunction, with consequent implica‑
Dependent variable: total impoverished scores tions for prognosis and planning reha‑
bilitative strategies.
Perseveration 0.03 0.01 0.34 2.36 0.03 0.01 0.06
The strengths of the study are that we
Working memory 1.17 0.19 0.78 6.18 <0.001 0.78 1.55
used Indian adaptation of OST suitable
Sustained attention 0.01 0.01 0.71 4.80 <0.001 0.01 0.02 for use in our population, with estab‑
Age 0.15 0.05 0.32 2.85 0.01 0.04 0.25 lished criteria as defined by Rapaport10 in
R2 0.70 scoring the results. Neurocognitive tests
F for change in R2 12.14
standardized for use in the Indian pop‑
ulation were administered. The study
Sig. <0.001
observations may have been influenced
Dependent variable: total peculiar scores by the SG patients who had thought dis‑
Divided attention 3.07 0.66 0.80 4.67 <0.001 1.72 4.43 order as measured by OST and scored
Education 32.68 10.79 0.52 3.03 0.01 10.53 54.83 higher on all OST scores. The sample size
R2 0.45 of the thought disorder positive group in
our study was small, and hence, we could
not perform further subgroup analysis.
Sig. <0.001
However, the regression analysis sug‑
Dependent variable: grand total scores gests that the observed associations were
Divided attention 3.15 0.65 0.78 4.83 <0.001 1.81 4.49 significant. Given that there are hardly
Perseveration 0.18 0.08 0.31 2.16 0.04 0.01 0.34 any reports in the literature studying
Education 34.56 10.95 0.52 3.16 0.01 12.06 57.06 the associations between performance
on classical measures, such as OST and
R2 0.53
contemporary neuropsychological tests;
these preliminary observations are en‑
Sig. <0.001 couraging. Nevertheless, these prelimi‑
Stepwise linear regression. OST, object sorting test. nary study findings need to be corrobo‑
rated on a larger sample of patients with
disorder,” which gives importance only thinking.32 The tasks in the OST are not schizophrenia. Future studies may need
to the form of thought by assessing the as language-dependent as other mea‑ to compare associations of performance
speech output, the original concept of sures of thought disorder and may be in language-dependent tasks of formal
thought disorder as an aberrant concept better suited to assess these aspects of thought disorder versus OST, with neu‑
formation and concrete abstraction is thought. The current study has attempt‑ ropsychological performance. These
being sidelined and OST has become an ed to review the original concept as well observations could be strengthened by
outdated tool. Although studies using as extend the utility of the OST. evidence from neuroimaging studies
the bizarre-idiosyncratic thinking rating Executive dysfunction in schizophre‑ examining underlying neurobiological
system; abstract concrete rating system; nia includes problems with planning substrates that mediate the influence of
and thought, language and communica‑ and is reflective of frontal lobe patholo‑ EF deficits on thought disorder.
tion scale as measures of thought disor‑ gy. In the present study, we found that
der have found associations with atten‑ classical thought disorder, as measured
Conclusion
tion, verbal memory, EFs,20 the methods through OST, is associated with several This study demonstrated a significant
used for assessment of thought disorder EF deficits, and hence, thought disorder association between thought disorder
have been largely language-dependent.31 as measured by OST may be a sign of ex‑ as measured by OST (concept formation
However, in the presence of negative ecutive dysfunction and, therefore, a re‑ and abstraction) and EFs. The study ex‑
thought disorder (impoverishment of flection of frontal lobe pathology. tends the utility of the OST tool beyond
content and speech), language-depen‑ With the focus of contemporary classif‑ its current usage in psychometry; the
dent assessments may not elicit the icatory systems on psychopathology, the pattern of responses in OST can point
underlying core disturbances of aberra‑ evaluation for classical thought disorder toward underlying executive dysfunc‑
tion in concept formation and concrete has fallen out of favor in clinical assess‑ tion in patients with schizophrenia.

Sahithya et al.
Clinicians should be mindful of deviance DC: American Psychiatric Publishing 19. Nestor PG, Shenton ME, Wible C, et al. A
in concept formation in schizophrenia as Inc, 2008. neuropsychological analysis of schizo‑
their presence may point to underlying 6. Bhattacharyya K, Guha P, Ghosal M, et phrenic thought disorder. Schizophr Res
cognitive deficits. Both thought disorder al. Association of thought disorder with 1998; 29: 217–225.
cognitive dysfunctions in schizophrenia a 20. Subotnik KL, Nuechterlein KH, Green
and executive dysfunction mirror similar
cross-sectional study in a tertiary centre in MF, et al. Neurocognitive and social
constructs. This similarity represents a
Kolkata, India. German J Psychiatry 2013; cognitive correlates of formal thought dis‑
conceptual bridge between the classical 16: 137–142. order in schizophrenia patients. Schizo‑
and contemporary descriptions of the 7. Payne RW, Mattussek P, and George EI. phr Res 2006; 85: 84–95.
core deficits in schizophrenia. An experimental study of schizophrenic 21. Marengo JT, Harrow MM, Lanin-Ketter‑
thought disorder. J Ment Sci 1959; 105: ing I, et al. Evaluating bizarre-idiosyn‑
Acknowledgments 627–652. cratic thinking: a comprehensive index of
We appreciate all who helped us in this research 8. Goldstein K. Functional disturbances in positive thought disorder. Schizophr Bull
from Department of Psychiatry, Department of brain damage. In: Arieti SE, ed. American 1986; 12: 497–511.
Clinical Psychology, and Department of Biosta- handbook of psychiatry. New York: Basic 22. Stirling J, Hellewell J, Blakey A, et al.
tistics, Manipal University, Manipal, India. Books, 1959: 770–794. Thought disorder in schizophrenia is
9. Cameron N. Experimental analysis of associated with both executive dysfunc‑
Data Sharing schizophrenic thinking. In: Kasanin JS, tion and circumscribed impairments in
Deidentified individual participant data will be ed. Language and thought in schizophrenia. semantic function. Psychol Med 2006; 36:
made available in SPSSS format. The data will be Berkeley, CA: University of California 475–484.
made available upon publication to researchers
Pres, 1944: 50–64. 23. Docherty NM, Hawkins KA, Hoffman RE,
who provide a methodologically sound propos-
al for use in achieving the goals of the approved 10. Rapaport D, Gill M, and Schafer R. Diag- et al. Working memory, attention, and com‑
proposal. Proposals should be submitted to sa- nostic psychological testing. Chicago, IL: Year munication disturbances in schizophrenia.
hithyabr@gmail.com Book Publishers, 1945. J Abnorm Psychol 1996; 105: 212–219.
11. Kasanin J and Hanfmann E. An exper‑ 24. Tan EJ and Rossell SL. Formal thought
Declaration of Conflicting Interests imental study of concept formation in disorder and neurocognition in schizo‑
The authors declared no potential conflicts of schizophrenia: I. Quantitative analysis phrenia: the question of individual mech‑
interest with respect to the research, authorship, of the results. Am J psychiatry 1938; 95: anisms. Schizophr Res 2017; 190: 189–190.
and/or publication of this article. 35–52. 25. American Psychiatric Association. Diagnos-
12. Elvevag B and Goldberg TE. Cognitive tic and statistical manual of mental disorders.
Funding impairment in schizophrenia is the core 4th ed. Text revision. Arlington, VA:
The authors received no financial support for the of the disorder. Crit Rev Neurobiol 2000; American Psychiatric Publishing, 2000.
research, authorship, and/or publication of this 14: 1–21. 26. Sheehan DV, Lecrubier Y, Sheehan KH,
article. 13. Reichenberg A and Harvey PD. Neuropsy‑ et al. The Mini-International Neuropsy‑
chological impairments in schizophrenia: chiatric Interview: the development and
References integration of performance-based and
brain imaging findings. Psychol Bull
validation of a structured diagnostic psy‑
chiatric interview for DSM-IV and ICD-10.
1. Bleuler E. Dementia praecox or the group of 2007; 133: 833–858. J Clin Psychiatry 1998; 59: 34–57.
schizophrenias. New York: International 14. Minzenberg MJ, Laird AR, Thelen S, et al. 27. Andreasen NC. The scale for the assessment of
Universities Press, 1958. Meta-analysis of 41 functional neuroim‑ negative symptoms. Iowa City, IA: Universi‑
2. American Psychiatric Association. Diagnos- aging studies of executive function in ty of Iowa, 1983.
tic and statistical manual of mental disorders. schizophrenia. Arch Gen Psychiatry 2009; 28. Andreasen NC. Scale for the assessment of
5th ed. Arlington, VA: American Psychiat‑ 66: 811–822. positive symptoms. Iowa City, IA: University
ric Association Publishing, 2013. 15. Palmer BW, Dawes SE, and Heaton RK. of Iowa, 1984.
3. World Health Organization. The ICD- What do we know about neuropsycholog‑ 29. Rao SL, Subbakrishna DK, and Gopaku‑
10 classification of mental and behavioural ical aspects of schizophrenia? Neuropsy‑ mar K. NIMHANS neuropsychological battery.
disorders: clinical descriptions and diagnostic chol Rev 2009; 19: 365–384. Bengaluru: NIMHANS Publications,
guidelines. Geneva: World Health Organi‑ 16. Kahn RS and Keefe RS. Schizophrenia is a 2004.
zation, 1992. cognitive illness: time for a change in fo‑ 30. Gonsalvez CJ and Lobo ML. The object
4. Andreasen NC. Thought, language, and cus. JAMA Psychiatry 2013; 70: 1107–1112. sorting test and thought deviance in
communication disorders: clinical assess‑ 17. Snyder PJ, Nussbaum PD, and Robins DL. schizophrenics. J Personal Clin Stud 1988;
ment, definition of terms, and evaluation Clinical neuropsychology: a pocket handbook 4: 215–222.
of their reliability. Arch Gen Psychiatry for assessment. 2nd ed. Washington, DC: 31. Hart M and Lewine RR. Rethinking thought
1979; 36: 1315–1321. American Psychological Association, 2006. disorder. Schizophr Bull 2017; 43: 514–522.
5. Hales RE, Yudofsky SC, and Gabbard 18. Solovay MR, Shenton ME, Gasperetti C, et 32. Holzman PS. Thought disorder in schizo‑
GO, eds. The American psychiatric publishing al. Scoring manual for the thought disor‑ phrenia: editor’s introduction. Schizophr
textbook of psychiatry. 5th ed. Washington, der index. Schizophr Bull 1986; 12: 483–496. Bull 1986; 12: 342–347.

Original Article
adapting to People With Schizophrenia:
a Phenomenological Study on a Rural
Society in Indonesia
Retno Lestari1,4, Ah Yusuf2, Rachmat Hargono1, Febri Endra Budi Setyawan3,
Ridhoyanti Hidayah4, Ahsan Ahsan4
ABSTRACT in-depth interviews conducted were audio-re- barriers during community treatment.
corded and transcribed. In addition, thematic Spiritual leaders play a powerful role as
Background: The growing prevalence of analysis was carried out using the interpre- change agents in determining the way
schizophrenia in Indonesia requires the tive phenomenological analysis method. members of the community ultimately adapt.
S
consideration of the families, caregivers,
health care professionals, and the entire Results: The majority of the participants chizophrenia is a chronic, severe
society, to serve as a support and coping assumed that PWS prompt the feeling of mental illness known to affect
resource for the patients. The process of alertness over fear. In addition, the partici- approximately 23 million people
recovery is rather difficult, especially in the pants revealed a feeling of indecisiveness in
worldwide.1 In addition, the disease prev-
absence of a decent place to live. Hence, related situations and emphasized the value
alence has substantially increased from
there is the need to provide a supportive of keeping up traditional beliefs and practices
and the effectiveness of a demonstration of 1.7 to 7.0 cases per 1,000 persons in Indo-
environment that facilitates recuperation
from psychotic symptoms, enhances indifference. They explained the need to com- nesia, from 2013 to 2017.2 Some studies
interaction with others, promotes self- bine traditional and modern health practices have investigated the major contributing
expression of thoughts and feelings, and as recommended by the spiritual leaders. socioeconomic and environmental fac-
helps deal with daily stress and challenges. Conclusion: Societal adaptation to PWS tors, including poverty in the rural areas,
There are currently no studies on the entails the understanding of how to believed to force the occurrence of migra-
framework of societal adaptation for people deal with the disease’s uncertainty and tion as well as working abroad and leav-
with schizophrenia (PWS). The aim of this
complexity. It is important to create a ing family members behind.3–5 Beside the
research, therefore, was to explore the
supportive environment to promote mental demographic factors, stigma may inhibit
experiences of rural society inhabitants in
health and wellbeing. people with schizophrenia (PWS) from
adapting to PWS in Indonesia.
Keywords: adapt, people with schizophrenia, seeking and maintaining jobs, as many
Methods: The study uses a qualitative re-
phenomenological study, rural society employers consider them less productive
search design and implements an interpretive
phenomenological approach. A total of ten Key Messages: Learning about the societal and incurring higher healthcare/insur-
society members were recruited from the adaptations to people with schizophrenia ance costs than other employees.6,7 The
community by purposive sampling, and the is an important step to overcome the social stigmatization received from the society,
1
Doctoral Program of Public Health, Faculty of Public Health, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia. 2Faculty of Nursing, Universitas Airlangga,
Mulyorejo, Surabaya, Indonesia. 3Faculty of Medicine, University of Muhammadiyah Malang, Malang, Indonesia. 4Study Program of Nursing Science, Faculty of
Medicine, University of Brawijaya, Malang, Indonesia.
HOW TO CITe THIS aRTICle: Lestari R, Yusuf A, Hargono R, Setyawan FEB, Hidayah R, Ahsan A. Adapting to people with
schizophrenia: A phenomenological study on a rural society in Indonesia. Indian J Psychol Med. 2021;43(1):31–37.
Address for correspondence: Retno Lestari, Faculty of Public Health, Universitas Submitted: 13 Feb. 2020
Airlangga, Jl. Mulyorejo, Surabaya, Jawa Timur 60115, Indonesia. E-mail: retno. Accepted: 22 apr. 2020
lestari-2017@fkm.unair.ac.id Published Online: 12 Jul. 2020

Lestari et al.
especially friends and families, common- obtain an explanation, understand the ten participants until achieving data
ly known as the not-in-my-backyard meanings attributed to the experienc- saturation. Table 1 shows the individ-
phenomenon, poses a major challenge es, and convert these observations into ual characteristics.
and discourages the pursuit of adequate questions on the means to study and un- Data were collected after receiving
treatment and recovery.8 derstand these relations. permission and ethical clearance. The
Society support is a very powerful This study was conducted in Septem- participants were informed about the
factor in the recovery of PWS. There are ber–October 2019. Ten society mem- study and asked for the willingness to
eight domains of recovery from mental bers were recruited from a community share their experiences. The consent
illness, which include the abilities to within a limited geographical area in forms included the study aim, the use
work/seek learning programs, engage in the South-East corner of Java Island, of the recording device, duration of the
social activities, establish daily routines, Indonesia, by purposive sampling. interviews, and the right to withdraw
perform independent activities, under- This location was selected because of from the research at any given time with-
stand and accomplish tasks and projects, the current inhabitation of 120 PWS, out penalty. The principle of beneficence
improve wellbeing, decide goals, and many of them living with families in was attained by the implementation of
manage the symptoms with psychoso- forest regions. Most of the PWS were pseudonyms to reduce the likelihood of
cial therapies.9 The society could provide migrant workers, left-behind fami- revealing the participants’ identities.
a collective and supportive environment ly members, and unemployed people There was a briefing on the benefits and
for dealing with daily stress and social who had schizophrenia. Interviewers risks and, then, opportunities were pro-
changes. A sense of belonging, trust, and were community mental health work- vided for questions, before conducting
self-confidence, which are the results ers and university researchers work- the interviews, which occurred at home,
of community engagement, embodies ing in the community mental health based on request. This process spanned
PWS’ social attachment, social engage- program. Prior to the study, written approximately 30–45 minutes, and the
ment, and participation in communities. informed consent was obtained after data were digitally recorded and noted.
The growing prevalence of schizo- informing the purpose of the study, The following questions were raised:
phrenia in Indonesia needs to be possi- their rights, potential risks and ben- ● How do you feel about living near
bly addressed through an adequate con- efits to participants, duration of the PWS?
sideration of family, caregivers, health study, and the confidential nature of ● Why do you think it is difficult to mo-
care professionals, and members of the the information they provide. The bilize societies to help PWS?
whole society, to serve as supportive interviews were audio-recorded and ● Describe how societies can adapt to
coping resources for the patients. The transcribed, followed by the conduc- PWS.
process of recovery is rather difficult, es- tion of thematic assessment using the Rigor was established in this qualitative
pecially in the absence of a decent place interpretive phenomenological analy- study by creating four domain strate-
to live, hence the need to provide a pos- sis (IPA) method.10 The inclusion crite- gies, including credibility, dependabil-
itive environment for managing daily ria were being members of the society ity, confirmability, and transferability.
stress and challenges. Currently, there is who have interactions with PWS for at The development of credibility required
no study on the frameworks of societal least two hours per week, and aged > the possession of adequate knowledge
adaptation to PWS. Using data assim- 21 years. The researchers interviewed and skills to perform the designated
ilation from the participants’ verbatim
responses help researchers create cer- Table 1.
tain guidelines on societal adaptation. Characteristics of Participants
The aim of this study, therefore, was to
Duration of interaction
explore the experiences of societies in
Age in with PWS
adapting to PWS in a rural area, as well No. years Education Role in society (hours/week)
as the different forms of support provid-
1 35 High School Health cadre 3
ed in Indonesia.
2 28 High School Local government 2
leader
Subjects and Methods
3 50 High School Spiritual leader 2
An interpretive phenomenological de- 4 40 Diploma Health cadre 2
sign was used to investigate the lived ex-
5 30 High School Local resident 1
periences of participants, in an attempt to
6 38 Diploma Spiritual leader 2
recognize interpretative human stories
7 41 Diploma Local government 1
as a form of sense-making mechanism. leader
In addition, in-depth semi-structured
interviews were used to investigate the
9 40 High School Health cadre 3
societal experiences in adapting to PWS
in Indonesian rural communities. Mean-
PWS: people with schizophrenia.
while, phenomenology was adopted to

Original Article
roles. All the team members engaged in experiences.10,11 The resultant themes, presence of PWS. They have to be pre-
regular meetings to establish confidence sub-themes, and categories were as fol- pared when PWS ask for help in various
in the truth of the research’s findings. lows (Table 2). activities, even though they feel anxious
Dependability was achieved by creating or afraid. Additionally, they need to de-
a well-defined preparation system on Theme 1: Turning Fear into velop self-esteem and self-confidence to
details of the study protocol, therefore Alertness overcome the fear. Therefore, it needs a
maintaining the accuracy of coding and proper strategy to overcome the fear and
the data track record. The triangula- Feeling Frightened to communicate effectively with PWS.
tion technique is another way to obtain The feeling of fright when participants “Sometimes he asked us to help fix
trustworthiness, which involves the are faced with PWS was described as the something in his house, because he
confirmation of the study through sev- fear of being attacked at unpredictable couldn’t do it alone. Yes…I helped
eral data sources, researchers, and theo- and unexpected situations. Numerous him…. But I also try to overcome my
retical frameworks. Data triangulation other emotions were experienced while fears…though I can communicate with
was achieved by gathering data using a interacting with PWS, including the feel- him…in a better way than other people
variety of participants, including neigh- ing of shock, conversing with anxiety, can….” (Participant 1)
bors, health cadres, and public figures.11 terrified of being attacked, and harbor- “Our mental health professionals
Investigator triangulation strength- ing an uneasy feeling. The participants taught us how to interact with them,
ened the researchers’ standpoint. Thus, stated the following: and to also not force a communication if
the team that conducted this study “You know, suddenly he came … I was they were not ready. Therefore, it is nec-
comprised of researchers from different so shocked, unprepared to engage in a essary to provide a safe space when they
disciplinary backgrounds, with vary- conversation, and did not know what to are interested in having a conversation.
ing attitudes and motivations. Hence, talk about, because I was alone at the time This is important as we need to under-
a combination of diverse professionals …. Then he asked for my help, as he need- stand the way they speak, the topic, and
helped establish a positive environment ed a job, and I said I had none…. Then he how to promote the feeling of comfort
to facilitate and ensure successful group just walked away….” (Participant 5) during a conversation….” (Participant 9)
communication and effective individ- “I didn’t know I could be so scared….
ual contributions.10,12,13 Meanwhile, the People told me to ignore him as he was a Theme 2: Feeling Indecisive
provision of all the detailed operational dangerous man, with the capacity to give with the Situations
and theoretical data was important in a punch in the face and pull hair…. This
ensuring transferability.12 Feeling the Inability to Respond
took away from me the courage to en-
The warranty of trustworthiness in gage in an interaction….” (Participant 7) Members of the society identified a range
an IPA is achieved by seeing things from of emotions regarding the experience of
the participants’ perspectives. Therefore, Worried Something Bad Will Happen
adapting to PWS. There was a feeling of
the transcripts were analyzed in order Participants described that PWS present deficiency in the level of competence to
to ensure data accuracy, up to the point in the community affect the entire societal help, despite the actual desire to render
where all researchers met a consensus, life. This was identified as a feeling of anx- assistance. This occurs because of the
as better interpretation is realized by iousness when near to patients who are fear associated with PWS and a percep-
attaining a thorough understanding of angry or show any psychotic symptoms, tion that it is not their personal responsi-
the participants’ experiences. hence the need to show concern for safety. bility to help them.
“They make me anxious, and that “As neighbors, it is important to ren-
Results worsens my inability to interact, due to der assistance, but I do believe I lack the
Data were transcribed verbatim into Ba- the expectation of a sudden anger for no ability to do so….” (Participant 6)
hasa and analyzed using the IPA meth- apparent reason. Meanwhile, I have no “Despite the desire to help, I think it
od. Smith explained seven stages of this idea of how to deal with the situation, was not our duty but that of other mem-
methodology, including (a) reading and and I do not want something bad to hap- bers of the society and mental health
re-reading the transcripts and familiar- pen….” (Participant 8) professionals to provide psychological
izing with the data, (b) noting and ob- “I just had to think about my own safe- support, and that should be funded by
serving content that is relevant to the re- ty. I need the help of someone during an the government….” (Participant 2)
search topic, (c) identifying themes with interaction with them, as it is impossible
Feeling Powerless
the capacity to characterize key aspects of for me to do it alone…I mean it…. Their
participants’ experiences, (d) developing presence affects our lives and the society, Living next to PWS caused the participants
connections between emergent themes, as we sometimes feel a bit worried….” to feel helpless, as they lacked the ability to
(e) moving to the next transcripts and (Participant 10) respond appropriately and also felt incapa-
repeating the same analytical process, (f) ble of communicating effectively.
Increasing Alertness over Fear
searching for certain themes across cas- “Sometimes, I feel helpless, being un-
es, and (g) evaluating themes and look- Feeling frightened was also accompa- able to interact when they ask for food,
ing for the meaning of the participants’ nied by an increase in alertness in the but in a moment, they change the topic

Lestari et al.
Table 2.
Themes, Sub-themes, and Categories

Themes Sub-themes Categories
Turning fear into alertness Feeling frightened Participants have generally experienced emotions, such as:
• Feeling shocked
• Being afraid of PWS
• Terrified of having attacks
• Scared to interact with them
Worried something bad will happen Participants described that the presence of PWS in the community will affect
the whole life of society, identified as:
• Feeling anxious if they are angry or showing any psychotic symptoms.
• Having concerns about own safety.
Increasing alertness over fear Feeling frightened was also accompanied by increasing their alertness in the
presence of PWS, such as:
• To be prepared if they ask for help in daily activities
• To be ready for any strategies if PWS are trying to attack or make any
trouble.
Feeling indecisive with the Feeling the inability to respond Society members identified a range of emotions with regard to the experience
situations of adapting to PWS. They felt things like:
• Having no competence to help
• Having the desire to help but scared
• It is not their responsibility to help
Feeling powerless Living next to PWS makes them feel:

• Helpless; they did not know how to respond to them appropriately.
• Incapable to communicate effectively.
Needing other people’s help • Need support from health centers to manage the treatment.
• Professional therapies have better ability to manage.
Keeping up traditional Trusting traditional healers • Relying on traditional treatment

beliefs and practices • A strong belief that traditional healers can “cure” disease
Prioritizing cultural factors • Prefer local practices

• Belief in spiritual leaders
Combination with medical practices • Implementing both medical practices and traditional remedies.
Being indifferent towards Disengaging from difficult conversa- • Taking time to think about behaving properly.
them tions • Standing back and avoiding arguments
Turning conflicts into humor • Using humor to overcome problems

• Interacting playfully with them.
Keeping a comfortable distance • Maintaining emotional distance

• Setting healthy boundaries with PWS
PWS: people with schizophrenia.
to education, and I do not know how to Theme 3: Keeping Up Prioritizing Cultural Factors
respond…. It is a really difficult experi-
ence….” (Participant 6) Traditional Beliefs and Participants explained that local healing
practices were the first attempt to “cure”
“Yes, I know it is difficult to talk to Practices PWS and the need to believe in the sug-
them, and we lack the ability to commu-
nicate effectively….” (Participant 7) Trusting Traditional Healers gestions of spiritual leaders.
“Initially, my neighbor was taken to
Needing Other People’s Help Participants lived in rural areas and
traditional healers, and the symptoms
relied mainly on traditional treatment improved, not screaming at night, and
Participants expressed the need for sup-
for the management of mental health we felt glad…hence…we believe the spir-
port from societies to help PWS, as pro-
issues, following local attitudes and itual leaders’ advices….” (Participant 7)
fessional therapies deliver treatment
with better effectiveness. beliefs.
“We live in a rural area…hence the Combining with Medical Treatments
“We need to render support, as they
need our help to survive, and also the ap- belief in the ability of local traditional Managing PWS living in a rural area is
propriate treatment from mental health treatment to help these people….” (Par- not very easy. The participants described
professionals….” (Participant 4) ticipant 3) the need to implement both medical and

Original Article
traditional remedies in order to manage Discussion Studies have shown that strong social
the psychotic symptoms. stigma and discrimination toward PWS
“In this rural society, it is acknowl- The findings from this study showed the cause internalized shame related to the
edged that traditional healers can help inability of society to avoid any form of possession of severe mental illness. In
in most problems…. But we also visit consequences associated with living near addition, a majority of the population
the community integrated health center PWS, as they have been living together tends to harness negative attitudes and
to get medications….” (Participant 3) for years, thereby significantly impact- beliefs towards PWS, including a percep-
ing the lives of the entire neighborhood. tion that they are dangerous and should
Theme 4: Being Indifferent Furthermore, it is not possible to avoid be avoided.18,19 A previous study report-
the consequences as PWS need the help
Towards the Patients and support of others. The participants
ed that 5.1% of society members avoid
mentally ill individuals, while 2.1% treat
Disengaging from Difficult believed that it is better to prepare ad- them in an unfair manner. Establishing
Conversations aptation strategies and to consider effec- a positive attitude after the delivery of
tive means to control or react towards an anti-stigma program has been asso-
Participants stated that sometimes they
the challenges that would be faced in ciated with lower odds of avoidance be-
need to take a break so that they can plan
everyday life. Despite the initial nega- havior (OR = 0.95, 95% CI = 0.91–0.99,
their responses to the patient appropri-
tive responses to the presence of PWS, P < .05).20 Also, a lack of understanding
ately and that, in other situations, it is
participants make efforts to adapt to the is common in individuals with poor ed-
necessary to stand back and avoid argu-
situations, which were supported by lo- ucational backgrounds, those who are
ments.
“I remember a day when stepping cal leaders, health cadres, mental health unable to seek mental health informa-
back was the best response for me to professionals, as well as the local govern- tion, and those with no family history of
his demonstration of anger…and… ment. Specifically, the health cadres were severe mental illness.21
in another five minutes, we interacted observed to have better abilities to deal Despite the feeling of hopelessness
again, and he was fine…yes…we need with PWS, compared to other members and the absence of competence to help
to create the time to communicate ap- of the society. PWS, the community must deliver cer-
propriately, in order to gain trust….” Managing the PWS in the commu- tain support programs, including activ-
(Participant 10) nity is the key to living a balanced life, ity-based therapies and other health ser-
both mentally and physically. In this vices, for promoting recovery.22–24 A study
Turning Conflicts into Humor community, people feel safe, loved, and suggested the need for mental health
Old philosophers report the use of hu- protected by local resources. People in- workers to acknowledge attitudes, val-
mor as one of the most powerful med- teract with each other to support PWS, ues, and beliefs in order to enhance com-
icines to support physical and mental assist them in maintaining and gaining petence and render assistance.25
health. PWS easily become upset or an- independence in daily activities. How- Even though the participants felt in-
gry, and this causes muscle tension and ever, the connection of all these aspects decisive, they were still trying to man-
emotional outburst. The participants requires the support of society, local age the problems, and it made them feel
agreed on the ability of humor to help government, and policymakers.14,15 The alert to the presence of PWS. Also, mem-
overcome interaction problems. participants reported that it takes time bers of the rural society depend largely
“One day, I used jokes to release the to gain the confidence to adapt to the on spiritual leaders for advice and guid-
tension, and he laughed…so we feel… consequences of living next to PWS. Im- ance, due to their ability to instill hope,
maybe this is a good strategy to foster proving the understanding of the behav- encourage personal and societal devel-
interactions….” (Participant 9) ior of PWS was one of the ways to over- opment, and improve general wellbeing.
come the fear towards them.16 Spiritual leaders have a strong ability to
Keeping a Comfortable Distance PWS are affected by a lack of interest motivate oneself and others to enhance
Maintaining an emotional distance in activities, a feeling of disconnection productivity and promote positive be-
with PWS was described as an effective from the reality, difficulty concentrating, havior.25,26 These are key personalities
way to sustain relationships, as people avoiding people, hallucinations, delu- with regular contact with everyone in
need to set healthy boundaries with sions, and also disorganized thoughts the community. Therefore, the partici-
PWS. and speech. This leads to a complete pants rely greatly on the spiritual lead-
“There is a need to enhance the feeling change in the nature of their relation- ers for ideas useful in decision-making.
of being safe in our presence. Hence, we ships, and PWS are also challenged by Inhabitants of the rural area associated
should learn and try to cope effectively the stigma and discrimination attributed the treatment of mental illness with the
and help them go through the illness…. to severe mental illness. In addition, the nature of the illness itself as well as with
It is really difficult. However, certain study participants viewed PWS as dan- other traumatic events.6 In addition,
boundaries and safe distance ought to gerous people to be feared. This perceived a combination of traditional healing
be maintained, and it is also important stigma is common amongst individuals practices and modern medicines is con-
to enhance the feeling of comfort….” in less dominant groups with low educa- sidered effective in managing psychotic
(Participant 1) tional achievements and less income.17 symptoms. These include the mixing of

Lestari et al.
complementary and alternative thera- that the participants had with PWS in 2. Ministry of Health Republic of Indonesia.
pies with medical treatment. Converse- this study was only three hours/week, Basic health resources 2018. Jakarta: Badan
ly, mindfulness, acupuncture, yoga, light so this might be a very short period of in- Penelitian dan Pengembangan Keseha-
tan, 2018.
therapy, and herbal medicines have also teraction compared to living with PWS.
3. Lu Y. Mental health and risk behaviours
been adopted in the maintenance and Further study is recommended to inter-
of rural-urban migrants: Longitudinal ev-
improvement of mental health, while view families living with PWS to under- idence from Indonesia. Popul Stud Camb
occupational therapy is used to facilitate stand their experiences, views, thoughts, 2010; 64(2): 147–163.
better social interactions.27–29 and feelings, to help us understand how 4. Dharmayanti I, Tjandrarini DH, Hi-
Use of humor is one way to reduce ten- to deal with PWS appropriately. dayangsih PS, and Nainggolan O. The
sion during interactions with PWS. This The members of the society possess- impact of environmental health and so-
valuable strategy is frequently adopted ing negative experiences and engaging cio-economic condition on mental health
to promote coping with stressful life in less frequent interactions with PWS in Indonesia. Indonesian J Health Ecol
events, and also to enhance interperson- 2018; 17: 64–74.
perhaps experience a range of emotions,
al relationships, grow communication 5. Christiani Y, Byles J, Tavener M, and Dug-
including anger, frustration, and secu-
dale P. Socioeconomic related inequality
skills, manage conflicts, and improve rity-related issues. Meanwhile, individ- in depression among young and mid-
coping strategies. Furthermore, there uals with positive experiences tend to dle-adult women in Indonesia’s major
is also a possibility of adopting humor have had longer interactions and have cities. J Affect Disord 2015; 182: 76–81.
in maintaining social relationships and also been more willing to communicate 6. Abbay AG, Mulatu AT, and Azadi H.
building social bonds between PWS and personal experiences. Community knowledge, perceived
other society members.30,31 beliefs and associated factors of mental
Participants agreed that a huge amount Conclusions distress: A case study from Northern
of time is required to build relationships Ethiopia. Int J Environ Res Public Health
Societal adaptation to PWS focuses on 2018; 15: 1–22.
with PWS. Avoiding arguments with
understanding the means to deal with 7. Shankar J, Liu L, Nicholas D, et al.
PWS was quite common in the culture,
the uncertainty and complexity, along- Employers’ perspectives on hiring and
and it made PWS feel comfortable during
side creating environments that support accommodating workers with mental
interactions. In addition, a disposition
mental health and wellbeing. There- illness. SAGE Open, 2014; 4:1–13.
of indifference was recognized as a com- 8. Zippay A and Lee SK. Neighbors’ percep-
fore, communities are recommended
mon way to deal with difficult situations, tions of community-based psychiatric
to improve the strategies adopted in
despite the fact that they still helping housing. Soc Serv Rev 2008; 82(3): 395–417.
addressing care for PWS, which ought
PWS with daily activities.32 9. Balaji M, Chatterjee S, Brennan B, Ran-
to be supported by integrated mental
Studying the techniques the society gaswamy T, Thornicroft G, and Patel V.
health system, stakeholders, and the Outcomes that matter: A qualitative study
uses to adapt with PWS would reveal
entire healthcare system. This study with persons with schizophrenia and
possible ways to overcome social barriers
examined the adaptive experiences of their primary caregivers in India. Asian J
in community treatment. Furthermore,
societies within a limited geographical Psychiatr 2012; 5(3): 258–265.
it is possible to achieve better results
area, hence the suggestion that future 10. Smith JA. Participants and researchers
from mental health programs by work-
research include samples from families searching for meaning: Conceptual devel-
ing together with the society to create a opments for interpretative phenomeno-
supportive environment and reduce the living with PWS in this area to gain the
logical analysis. Qual Res Psychol 2019;
stigma.33 Also, an adaptive society is char- most relevant insights. Accordingly, fu-
16(2): 166–181.
acterized by five essential components, ture studies can address the same topic
11. Korstjens I and Moser A. Series: Practical
including community safety, social bond- in different settings, location, and/or cul- guidance to qualitative research. Part 4:
ing, justice, identities and functions, as ture of a wider region or be expanded to Trustworthiness and publishing. Eur J
well as purpose in life.34 There is a like- a multi-state analysis. Gen Pract 2018; 24(1): 120–124.
lihood of improving these outcomes by 12. Rodham K, Fox F, and Doran N. Explor-
Declaration of Conflicting Interests ing analytical trustworthiness and the
collaborations with health care institu-
The authors declare that there are no conflicts of process of reaching consensus in interpre-
tions, stakeholders, and policymakers.
interests regarding this study. tative phenomenological analysis: Lost
in transcription. Int J Soc Res Methodol
Limitations of the Study Funding 2015; 18(1): 59–71.
The results of the study were very posi- The authors received no financial support for the 13. Peat G, Rodriguez A, and Smith J.
tive. However, due to the limited scope research, authorship, and/or publication of this Interpretive phenomenological analysis
article. applied to healthcare research. Evid Based
of observation in a local area, there is a
Nurs 2019; 22(1): 7–9.
possibility that these findings are not
translatable to other societies with a References 14. Francis J, Giles-Corti B, Wood L, and
Knuiman M. Neighbourhood influences
higher level of social capital to support 1. World Health Organization. Schizophre- on mental health in master planned
PWS. However, the results can possibly nia. Geneva: WHO, 2019. Available from: estates: A qualitative study of resident
be helpful for PWS worldwide. Addition- https://www.who.int/news-room/fact- perspectives. Health Promot J Austr 2014;
ally, the maximum length of interaction sheets/detail/schizophrenia. 25(3): 186–192.

Original Article
15. Tropp LR. Adaptation to diversity: Indi- wards mental illness among residents of disorders. Med Clin North Am 2017;
vidual and societal processes. Proc Natl Gimbi town, Western Ethiopia. Psychiatry 101(5): 847–864.
Acad Sci U S A 2019; 116(25): 12131–12133. J 2016; 2016: 6740346. 28. Thirthalli J, Zhou L, Kumar K, et al. Tra-
16. Phelan JC and Link BG. Fear of people 22. Bennett M, Lucksted A, and Blanchard J. ditional, complementary, and alternative
with mental illnesses: The role of person- 18.3 improving community engagement medicine approaches to mental health
al and impersonal contact and exposure in veterans with schizophrenia: Qual- care and psychological wellbeing in India
to threat or harm. J Health Soc Behav itative data analysis from an Ongoing and China. Lancet Psychiatry 2016; 3(7):
2004; 45(1): 68–80. Treatment Trial. Schizophr Bull 2019; 660–672.
17. Bromley E, Gabrielian S, Brekke B, et al. 45(Supplement_2): S118. 29. Shimada T, Nishi A, Yoshida T, Tanaka
Experiencing community: Perspectives of 23. Granerud A and Severinsson E. The new S, and Kobayashi M. Development of an
individuals diagnosed as having serious neighbor: Experiences of living next individualized occupational therapy pro-
mental illness. Psychiatr Serv 2013; 64(7): door to people suffering from long-term gramme and its effects on the neurocogni-
672–679. mental illness. Int J Ment Health Nurs tion, symptoms and social functioning of
18. Cadge C, Connor C, and Greenfield S. 2003; 12(1): 3–10. patients with schizophrenia. Occup Ther
University students’ understanding and 24. Högberg T, Magnusson A, and Lützén Int 2016; 23(4): 425–435.
perceptions of schizophrenia in the UK: K. To be a nurse or a neighbour? a moral 30. Gelkopf M. The use of humor in serious
A qualitative study. BMJ Open 2019; 9(4): concern for psychiatric nurses living next mental illness: A review. Evid Based Com-
e025813. door to individuals with a mental illness. plement Alternat Med 2011; 2011: 342837.
19. Hickling FW, Robertson-Hickling H, and Nurs Eth 2005; 12(5): 468–478. 31. Yim J. Therapeutic benefits of laughter
Paisley V. Deinstitutionalization and at- 25. Jahandar P, Tafreshi MZ, Rassouli M, in mental health: A theoretical review.
titudes toward mental illness in Jamaica: Atashzadeh-Shoorideh F, and Kavousi A. Tohoku J Exp Med 2016; 239(3): 243–249.
A qualitative study. Rev Panam Salud Nurses’ perspective on spiritual leader- 32. Bell D. The indifferent. Qual Res Psychol.
Publica 2011; 29(3): 169–176. ship: A qualitative study based on Fry’s 2018;15(2-3):140–155.
20. Rossetto A, Robinson EJ, Reavley NJ, and spiritual leadership model. Electron Phys 33. Schnell T. Existential indifference: Anoth-
Henderson C. Perceptions of positive 2017; 9(11): 5721–5731. er quality of meaning in life. J Humanist
treatment and discrimination towards 26. Wang M, Guo T, Ni Y, Shang S, and Tang Psychol 2010; 50(3): 351–373.
people with mental health problems: Z. The effect of spiritual leadership on 34. Silove D. The ADAPT model. Intervention
Findings from the 2017 Attitudes to Men- employee effectiveness: An intrinsic 2013; 11(3): 237–248.
tal Illness survey. Psychiatry Res 2019; 273: motivation perspective. Front Psychol
141–148. 2018; 9: 2627.
21. Benti M, Ebrahim J, Awoke T, Yohannis Z, 27. Asher GN, Gerkin J, and Gaynes BN. Com-
and Bedaso A. Community perception to- plementary therapies for mental health

Original Article
Quantifying and Categorizing aDRs
in Psychiatric Residential long-Stay
Patients Utilizing UKU-SeRS Scale
Joelin Mathew1, Amruta Varghese1, Manjusha Sajith1
ABSTRACT weight gain, constipation, and tremors. The ADRs are still prevalent and have become
majority of ADRs were “mild” and had a a subject of great concern.
Background: Psychotropic drugs are “possible” causality relationship. The ADRs can be monitored using
essential but not devoid of adverse drug
reactions (ADRs), which lead to non- Conclusion: The study demonstrated a high different scales. But most scales do not
compliance and further failure of therapy, incidence of ADRs, which was primarily cover all the parameters associated with
hampering the patient’s quality of life. managed either by reduction of dose or ADRs of psychotropics. Rating scales that
continued drug use with the treatment of are currently available, mostly evaluate
Methods: A cross-sectional, observational side effects.
study was carried out in a residential a single side effect such as extrapyrami-
nursing home in Pune, India, from October Keywords: Psychotropic drugs, adverse drug dal symptoms (EPS), sedation, weight
2018 to March 2019. Psychiatric inpatients reactions, UKU-SERS gain, or sexual dysfunction. There have
of both genders and all ages receiving Key Messages: Adequate monitoring of been few studies using scales that assess
psychotropic drugs for at least one month patients who are on psychotropic medications multiple side effects. However, the use
were enrolled. Patients who were not will help in the early detection of ADRs. In our of one scale instead of several separate
alert or oriented enough to give a detailed sample, the commonest ADRs were weight scales can have advantages and might
history and response to a questionnaire, gain, constipation, and tremors. provide a better insight into the overall
P
including dementia patients, and those who
were not willing to give informed consent sychiatric medications are not de- side effect profile.3 The Udvalg for Klini-
were excluded. The ADRs were categorized, void of side effects.1 Guidelines ske Undersogelser (UKU) side effect rat-
and their management was documented suggest that medications for psy- ing scale is a comprehensive rating scale
using the Udvalg for Kliniske Unders gelser chiatric patients should be continued for designed to categorize and measure a
(UKU) side effect rating scale. ADRs were broad range of ADRs caused by psycho-
several months or years because of the
assessed for causality and severity using
chronic and relapsing nature of psychi- tropic drugs.4 Studies done till date have
the WHO-Uppsala Monitoring Centre
(WHO-UMC) causality assessment scale atric disorders. This may, however, lead scrutinized ADRs, their profile, and their
and the Modified Hartwig and Siegel scale. to an increased risk of adverse drug reac- management aspects; however, they did
tions (ADRs) in such patients.2 Socio-de- not use a scale that categorized psychi-
Results: In our study, 115 patients (76.6%)
experienced 273 adverse drug events. mographic factors, polypharmacy, and atric ADRs. There is paucity of Indian
Atypical antipsychotics accounted for multiple comorbidities can also contrib- literature on the use of a single scale for
the maximum number of ADRs (54.94%; ute to ADRs. Despite the advancements identifying and classifying ADRs owing
n = 150). The most common ADRs were in psychopharmacological treatment, to psychotropic drugs. Available studies
1
Dept. of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to Be) University, Pune, Maharashtra, India.
HOW TO CITe THIS aRTICle: Mathew J, Varghese A, Sajith M. Quantifying and categorizing ADRs in psychiatric residential long-
stay patients utilizing UKU-SERS scale. Indian J Psychol Med. 2021;43(1):38–44.
Address for correspondence: Manjusha Sajith, Dept. of Clinical Pharmacy, Poona Submitted: 26 Nov. 2019
College of Pharmacy, Bharati Vidyapeeth (Deemed to Be) University, Pune, Accepted: 25 apr. 2020
Maharashtra, India. E-mail: manjusaji1@yahoo.com Published Online: 20 aug. 2020

Original Article
that utilized the UKU scale are limited to commenced after the informed consent implies the discontinuation of the drug
a specific psychiatric diagnosis like bipo- and assent forms were signed by the pa- or change to another preparation.
lar affective disorder or a specific domain tients, their caretakers, and counselors. The documented ADRs were assessed
like outpatient settings.5, 6 Against such a For patients with mental retardation, for causality and severity. Causality as-
background, this study is not limited to the informed consent and assent forms sessment, which determines the caus-
a particular diagnosis or a specific cate- were obtained with the help of close rel- al relationship of a suspected drug to
gory of drugs but focuses on the applica- atives, counselors, and the nursing staff. the ADR in question, was done using
tion of the UKU scale. The objectives of Details such as socio-demographic infor- the WHO-Uppsala Monitoring Cen-
our study are to identify and categorize mation, medical and medication history, tre (WHO-UMC) causality assessment
ADRs in psychiatric patients receiving the reason for hospitalization, drugs pre- scale.7 ADRs were also correlated with
psychotropic drugs, to assess the causali- scribed (general and psychotropic med- the drug/drugs with the aid of the lit-
ty and severity of the documented ADRs, ications), dose, dosage form, frequency, erature product monograph, software,
and to analyze ADRs according to the and the duration of treatment were not- and Micromedex. The WHO-UMC scale
demographics and predisposing factors. ed in a predesigned pro forma. The dai- divides the causality of an ADR into six
ly analysis reports of the patients were categories: “certain,” “probable,” “possi-
Materials and Methods keenly observed and documented. The ble,” “unlikely,” “conditional/unclassi-
A cross-sectional observational study patients’ weight and blood pressure were fied,” and “unassessable/unclassifiable.”
was carried out in a residential psychiat- noted regularly. The medication chart The Modified Hartwig and Siegel scale
ric hospital in Pune, India, from October was reviewed after an ADR had occurred, was used for assessing the severity.8 This
2018 to March 2019. It was a 225-bed hos- and the ADR was analyzed for three days scale consists of seven questions which
pital that provides acute as well as long- as per the UKU scale. We observed the on answering classifies the severity of
term care facilities for patients suffering patients for about 2–3 months for certain ADR as “mild,” “moderate,” and “severe.”
from various psychiatric disorders such late-onset ADRs such as weight gain. Individual scales were utilized for each
as schizophrenia, mood disorders, per- For determining ADRs, all the psy- patient.
sonality disorders, and substance-related chotropic medications were considered. Confidentiality of the patients was pre-
disorders. The study protocol was ap- ADRs were identified by the assessment served throughout the study. The collect-
proved by the Institutional Ethics Com- of the symptoms using a semistructured ed data were summated and entered into
mittee of Bharati Vidyapeeth (Deemed interview with the patients and supple- a Microsoft Excel sheet and analyzed us-
to be University) Medical College. Psy- mented by clinical observation and in- ing the Statistical Package for the Social
chiatric inpatients of both genders and formation obtained from the ward staff Sciences (SPSS) version 18.0. The data are
all ages, with or without comorbidities, and the case records. The interview was presented in the form of mean, frequen-
diagnosed with psychiatric illness, and conducted by the clinical pharmacist, cy, and percentage. A chi-square test was
receiving psychotropic drugs for at least and the opinions of the clinicians and performed to find out the association
one month, were enrolled in the study. the counselors were also considered to between ADRs and psychotropic drugs
Patients who were not alert or oriented confirm the feedback obtained from the and scales utilized for causality and se-
enough to give a detailed history and re- patients. verity assessment (WHO-Uppsala scale,
sponse to a questionnaire, including de- The UKU side effect rating scale was Hartwig severity scale). The level of sig-
mentia patients, and those who were not used for documenting ADRs.4 This scale nificance was considered to be <0.05.
willing to give informed consent were ex- requires to be used for a duration of
cluded. Patients’ informed consent was three days. The UKU scale includes 48 Results
taken for the study, and the counselors items. Each item is scored on a 4-point A total of 150 patients were recruited for
approved the consent. A total of 180 pa- scale (0–1–2–3). ADRs were documented the study. The demographic and clinical
tients were initially screened, of which based on the feedback obtained by the profiles of the patients are shown in
150 were recruited. Out of the 30 patients patients on each of the parameters listed Tables 1 and 2, respectively.
excluded, 5 patients were discharged, 15 on the UKU scale. The methods suggest- Maximum patients enrolled were di-
patients were not willing to take part in ed for the management of the observed agnosed with schizophrenia (63.33%; n =
the study, and 10 patients did not cooper- ADRs were documented as per the conse- 95), followed by bipolar affective disorder
ate as the study proceeded. quence parameter of the UKU scale. The (10.66%; n = 16). The prescription pat-
The subject information sheet was consequence parameter is categorized tern of psychotropic drugs in this study
provided to the counselors, caretakers, into four degrees (0, 1, 2, 3) wherein de- revealed that the majority of the drugs
and patients. It included information gree 0 implies no action, degree 1 implies were atypical antipsychotics (83.33%; n
on the detailed procedure, objectives of a more frequent assessment of the pa- = 125), followed by typical antipsychot-
the study, and advantages of the study. tient but no reduction of the dose and/or ics (65.33%; n = 98), benzodiazepines
Patients’ informed consent forms, assent occasional drug treatment of side effects, (50.66%; n = 76), and mood stabilizers
forms, and subject information sheets degree 2 implies a reduction of the dose (49.33%; n = 74). On average, patients re-
were made available in English and and/or continuing the drug with the ceived approximately three drugs per
the local language (Marathi). The study treatment of side effects, and degree 3 prescription.

Mathew et al.
Table 1. Table 2.
whereas no significant association was
observed between the gender and ADR
Socio-demographic Variables Clinical Characteristics of (Table 6).
of Psychiatry inpatients Psychiatry Patients The clinical characteristics of patients
Number of patients Number of patients (%) who developed ADRs showed that 68
Variables (%) (n = 150) Variables (n = 150) patients (59.13%) were diagnosed with
Gender No. of psychiatric medications schizophrenia, the same number of pa-
Male 83 (55.33) ≤2 13 (08.66)
tients received more than five psycho-
tropic drugs, 58 patients (50.43%) were
Female 67 (44.66) 3–4 63 (42.00)
under psychotropic drug therapy for less
Age (in years) ≥5 74 (49.33)
than six months, 47 patients (40.86%)
< 20 15 (10.00) Duration of psychotropic therapy had comorbidities, and 8 patients (6.95%)
20–39 77 (51.33) ≤6 months 82 (54.66) had a family history of psychiatric illness
40–59 38 (25.33) 7–12 months 31 (20.66) (Table 7).
60–79 19 (12.66) > 1 year 37 (24.66) The consequence of ADRs according
≥80 01(06.66) to UKU scale showed that maximum pa-
Comorbidity
tients developed ADRs of Type 2 degree
Educational status Yes 55 (36.66)
(n=67; 58.26%) that required reduction
Primary 13 (08.66) No 95 (63.33) of dose and/or continuing the drug with
Secondary 31 (24.00) Family history of psychiatric disorders the treatment of ADR, followed by Type
Higher secondary 35 (23.33) Yes 08 (05.33) 1 degree 23 (20.00%) requiring more fre-
Graduate 59 (39.33) No 142 (94.66) quent assessment of the patient, but
Postgraduate 12 (08.00) no reduction of dose, and/or occasional
Length of stay
Employment status drug treatment of side effects (Table 8).
≤6 months 82 (54.66)
Employed 57(38.00)
7–12 months 31 (20.66) Discussion
Unemployed 88 (58.66)
> 1 year 37 (24.66)
Self-employed 02 (01.33) In different parts of the world, the inci-
Note: The highest values in each category have dence rate of ADRs in psychiatric inpa-
Retired 03 (02.00) been highlighted.
tients varies from 43.5% to 94.6%.9 The
Marital status
incidence of ADRs in our patients was
Married 44 (29.33) of the ADR categories as per the UKU
76.6% (n = 115), and the number of events
scale, that is, psychic, neurologic, auto-
Unmarried 99 (66.00) was 273.
nomic, and others.
Divorced 05 (03.33) A total of 45 drugs were prescribed
According to the WHO-UMC causality
Widow 02 (01.33) in our study (which included 4 typical
assessment scale, the maximum num-
Note: The highest values in each category antipsychotics, 8 atypical antipsychotics,
ber of events was classified as “possible”
have been highlighted. 14 antidepressants, 3 mood stabilizers,
(59.7%; n = 163) and 87 (31.86%) of possi-
7 sedative-hypnotics and benzodiaze-
ble events were associated with antipsy- pines, 6 anticonvulsants, and 3 central
Out of 150 patients monitored, 115 chotics. The correlation of ADRs with the nervous system [CNS] stimulants). Near-
(76.66%) experienced ADR, and the num- WHO category (possible) was not signifi- ly half of the patients received more than
ber of events was 273. Among the psy- cant, and the P value was 0.057 (Table 4). five psychotropic drugs and, on average,
chotropic drugs, atypical antipsychotics The severity of ADRs was assessed the patients received approximately
(54.94%; n = 150) were observed to have by the Hartwig scale. Most of the ADRs three drugs per prescription, which is
the maximum number of ADRs followed were mild (45.05; n = 123). The correlation similar to the findings of Sharma et al.10
by mood stabilizers (17.21%; n = 47) and of ADRs and Hartwig’s scale was not sig- Most patients were prescribed antipsy-
antidepressants (10.25%; n = 28). nificant (Table 5). chotics. This is in contrast to the findings
Among 273 events, 31 (11.35%) of psy- The participants had a female prepon- of Gurung et al as prescription pattern
chic ADRs, 60 (21.97%) of autonomic derance (53.11%; n = 145) as compared to may vary within different hospital set-
ADRs, and 54 (19.78%) of other ADRs males 128 (46.88%), and the maximum tings.11 Other classes of psychotropic
were associated with antipsychotics, number of events was reported in the drugs prescribed were mood stabilizers,
whereas 17 (6.22%) of neurological ADRs age group of 20–39 years (45.05%; n = antidepressants, anticonvulsants, ben-
were associated with mood stabilizers, 123), graduate (41.02%; n = 112), unem- zodiazepines, other sedative-hypnotics,
and this was statistically significant (Ta- ployed (52.38%; n = 143), and unmarried and CNS stimulants. None of the pa-
ble 3). Sedation (10.98%; n = 30), tremor (71.42%; n = 195). On the chi-square test, a tients received depot psychotropic drugs.
(12.82%; n = 35), constipation (15.38%; n = significant association was found between The highest number of events was ob-
42), and weight gain (16.48%; n = 45) have the age group, educational status, employ- served in association with antipsychot-
been observed to be the highest in each ment status, marital status, and ADR, ics, especially atypical antipsychotics

Original Article
Table 3.
Summary of Adverse Drug Reactions According to UKU-SERS

Number of events (N= 273)
Antipsychotics Antidepressants Mood Stabilizers Benzodiazepines Hypnotic-Sedatives Anticonvulsants
Type of ADR n (%ADR) n (%ADR) n (%ADR) n (%ADR) n(%ADR) n (%ADR)
Psychic ADR 31(11.35) 09 (3.29) 14 (5.12) 20 (7.32) 00 04 (1.46)
Neurologic ADR 13 (04.76) 07 (2.56) 17 (6.22) 00 00 04 (1.46)
Autonomic ADR 60 ( 21.97) 07 (2.56) 09 (3.29) 03 (1.09) 00 04 (1.46)
Others 54 (19.78) 05(1.83) 07 (2.56) 01(0.36) 00 04 (1.46)
UKU-SERS: Undersogelser side effect rating scale
Table 4.
Causality Assessment of Suspected Adverse Drug Reactions in Relation to Psychotropic Drug Class
Number of events n(%ADR) (N= 273)
WHO Probability Mood
Assessment Antipsychotics Antidepressants Stabilizers Benzodiazepines Anticonvulsants Total
Probable 45 (16.48) 07 (2.56) 03 (1.09) 03 (1.09) 03 (1.09) 61 (22.34)
Possible 87 (31.86) 14 (5.12) 37 (13.55) 16 (5.86) 09 (3.29) 163 (59.70)
Unlikely 26 (9.52) 07 (2.56) 07 (2.56) 05 (1.83) 04 (1.46) 49 (17.94)
Table 5.
Severity Assessment of Suspected Adverse Drug Reactions in Relation to Psychotropic Drug Class
Number of events n(%ADR) (N= 273)
Mood
Severity Assessment Antipsychotics Antidepressants Stabilizers Benzodiazepines Anticonvulsants Total
Mild 123 (45.05) 21 (7.69) 36 (13.18) 22 (8.05) 15 (5.49) 217 (79.48)
Moderate 35 (12.82) 07 (2.56) 11 (4.02) 02 (0.73) 01 (0.36) 56 (20.51)
(54.94%; n = 150), followed by mood stabi- go undiscovered and reporting may be and psychic ADRs (11.35%; n = 31), where-
lizers (17.21%; n = 47). Several studies also biased. Participants are more likely to re- as mood stabilizers were associated
indicate the same.11–14 In our study popu- port unusual, interesting, or particularly mostly with neurological ADRs (6.22%;
lation, maximum ADRs were observed dangerous events. Trigger tools, if used, n = 17). There are not many studies con-
because of atypical antipsychotics. The often need training for better outcomes.16 ducted using the UKU scale, which gives
prescription pattern also revealed that UKU-SERS includes a list of ADRs likely deficient information on the same. The
the majority of patients received antipsy- to be encountered in patients receiving overall ADRs observed were weight gain
chotics across all diagnostic categories. In psychotropics. This scale is designed in (16.48%; n = 45), followed by constipation
contrast, a study by Shah et al15 showed such a manner that it allows interaction (15.38%; n = 42), tremors (12.82%; n = 35),
that antidepressants caused maximum with the patient, which is an add-on for and sedation (10.98%; n = 30), and this
ADRs (41.86%; n = 114). Therefore, the confirming ADRs. UKU-SERS is a com- coincides with the findings of a number
association of antipsychotics and occur- prehensive rating scale that helps assess of studies.5, 10, 12, 14, 15 A high incidence of
rence of ADRs found in our sample may multidomain side effects.3 weight gain was seen owing to more pre-
have been influenced by the prescription ADRs were assessed using the UKU scription of atypical antipsychotics, espe-
pattern of psychotropic drugs. scale after a few days of psychotropic drug cially long-term therapy with them, as 131
Patients may experience multiple administration. The scale categorizes patients (48%) had received psychotropic
ADRs during treatment with psychotro- ADRs into psychic, neurologic, autonom- medications for more than six months.
pic drugs. Traditional methods that are ic, and other ADRs. A total of 83 (30.40%) Similar results were reported by Farhat
commonly used in healthcare settings ADRs were found in the autonomic cate- et al.17 and Sengupta et al.18 The exact
to identify ADRs include a detailed re- gory, which is comparable with the find- mechanism of antipsychotic-induced
view of the medical record, incident ings of Shah et al.5 Autonomic ADRs were weight gain is unclear. Still, studies sug-
reporting systems, and trigger tools. followed by psychic, others, and neuro- gest that it is possibly because of several
These methods undoubtedly enable us logic ADRs. Antipsychotics were associat- genetic polymorphisms, the antagonism,
to identify, assess, and document ADRs ed mostly with autonomic ADRs (21.97%; or inverse agonism of atypical antipsy-
and events. However, many events may n = 60) followed by other (19.78%; n = 54) chotics such as olanzapine and clozapine

Mathew et al.
Table 6.
levels.21 Fluoxetine, an selective sero-
tonin reuptake inhibitor, was observed
Correlation of ADRs and Socio-demographic Factors to exhibit nausea as an ADR in several pa-
Variables No. of events (% ADR) Chi-square P value tients. Nausea with fluoxetine may be me-
(n = 273) value diated centrally through the stimulation
Gender 1.05 0.303 of certain serotonin receptors (5-HT3C)
Male 128 (46.88) that activate the chemoreceptor trigger
Female 145 (53.11) zone.22 In patients with nausea, antiemet-
Age (in years) 217.82 a
< 0.001
ic drugs such as ondansetron were given.
Antipsychotics such as clozapine have a
< 20 24 (8.79)
high affinity for muscarinic cholinergic
20–39 123 (45.05)
receptors, which results in gastrointes-
40–59 103 (37.72) tinal hypomotility and reduces bowel
60–79 22 (8.05) movements, which contribute to consti-
> 80 1(0.36) pation.23 Patients with moderate to severe
Educational status 123.79 a
< 0.001 constipation were recommended to add
Primary 23 (8.42)
laxatives such as lactulose and bisacodyl.
Divalproex was most commonly observed
Secondary 41 (15.01)
to induce tremor in most of the patients.
Higher secondary 65 (23.80)
Valproic acid has multiple mechanisms
Graduate 112 (41.02) of action, including reduction of the
Postgraduate 28 (10.25) high-frequency neuronal firing of sodi-
Uneducated 04 (1.46) um-dependent action potentials, as well
Employment status 228.43 a
< 0.001 as increasing GABAergic neurotransmis-
Employed 117 (42.85) sion.24 Amantadine or propranolol were
prescribed to these patients to provide
Unemployed 143 (52.38)
relief from tremors. In contrast to these
Self-employed 06 (2.19)
findings, a study conducted by Gurung
Retired 07 (2.56) et al.11 observed EPS as the most common
Marital status 358.72 a
< 0.001 ADR followed by sedation. This difference
Married 71 (26.00) in the findings could be due to the differ-
Unmarried 195 (71.42) ence in the prescribing pattern of psycho-
Divorced 07 (2.56) tropic medications.14
Certain ADRs such as hyperglycemia,
Widow 0
endocrine problems, joint pain, and mus-
ADRs: adverse drug reactions. Note: The highest values in each category have been highlighted. aThe result is
significant. cular pain were observed in patients,
especially the elderly and patients with
co-morbidities, but could not be catego-
at the serotonin 2C receptor (5-HT2C), may persist for the first few months and
rized as UKU scale does not have a provi-
and the antagonism at the histamine H1 usually wears off.12 Analyzing the risk and
sion to categorize these ADRs. Therefore,
receptor, which can disrupt the normal benefit of psychotropic drugs, medication
these ADRs were only observed and doc-
hormonal regulation of the system.19 Pa- causing sedation was recommended to be umented. The management of ADRs by
tients with weight gain were preferred administered at night so that it does not utilizing the consequence parameter of
for lifestyle modifications, and in those interfere with the patient’s daily activi- the UKU scale exhibited maximum pa-
who are susceptible or with diabetes and ties. Among the antidepressants, patients tients to be categorized as degree 2, which
cardiovascular disease were recommend- who were receiving paroxetine were ob- is the reduction of dose and/or continu-
ed change of therapy to aripiprazole. In served to have sedation and sexual dys- ous drug with treatment of side effects.
certain diabetic patients, a change of an- function. The biochemical mechanisms The occurrence of ADRs in psychiatric
ti-diabetic drugs was also suggested. associated with sexual dysfunction were patients may differ according to their
Sedation/somnolence is known to increased serotonin release, resulting in age, gender, drugs prescribed, and the
occur as the psychotropic medications agonism at inhibitory 5-HT2 receptors, underlying disease condition. In our
act on the CNS. Benzodiazepines and selectively decreased dopamine in both study, ADRs were commonly observed
atypical antipsychotics were associated the limbic and frontal areas, selectively in females and the younger population.
with sedation. Benzodiazepines enhance decreased norepinephrine, antagonism Similar results have been observed in
GABA at the GABAA receptor. Different at cholinergic receptors and α1 adrenergic different studies.12, 25 The explanation
antipsychotics block histamine H1 re- receptors, inhibition of nitric oxide for a higher risk in females may be that
ceptors, resulting in sedation.20 Sedation synthetase and elevation of prolactin the ADRs are multi-causal, including

Original Article
Table 7.
Among the 55 patients having co-
morbidities, 47 experienced ADRs. The
Correlation of ADRs and the Clinical Characteristics of the Study underlying physical condition may in-
Subjects fluence the pattern of prescription of psy-
Variables Number of Number of Chi-square P value chotropic drugs and enhance the precip-
patients without patients with ADR value itation of ADRs. Patients receiving more
ADR (%) (n = 150) (%) (n = 115) than five psychotropics experienced
Diagnosis maximum ADRs. Studies show growing
Schizophrenia 82 (54.66) 68 (59.13) 118.17 ‡
< 0.001 evidence regarding the increased ADRs
Bipolar affective disorder 137 (91.33) 13 (11.30) due to polypharmacy. Concerns with
Depression 149 (99.33) 01 (0.86)
polypharmacy include not only possibili-
ties of cumulative toxicity and increased
substance induced psy- 137 (91.33) 13 (11.30)
chosis vulnerability to adverse events26 but also
adherence issues that emerge with in-
Mild MR 141(94.00) 09 (7.82)
creasing regimen complexity.
OCD 147 (98.00) 03 (2.60)
The causality assessment of an ADR
Others 142 (94.66) 08 (6.95) with the psychotropic drug can be car-
No. of psychiatric medications ried out using Naranjo and WHO-UMC
≤2 143 (95.33) 07 (6.08) 48.62 ‡
< 0.001 scale. However, constraints in carrying
3–4 110 (73.33) 40 (34.78) out certain factors included in the Naran-
≥5 82 (54.66) 68 (59.13) jo scale, namely the placebo administra-
tion, rechallenge process in patients, lack
Duration of psychotropic therapy
of tests performed to obtain the serum
≤6 months 92 (61.33) 58 (50.43) 16.18 ‡
0.001
drug concentration, and clarification
6–12 months 117 (78.00) 33 (28.69) through objective measurement, restrict-
≥1 year 126 (84.00)) 24 (20.86) ed the use of the Naranjo scale in our
Comorbidity study. Causality assessment was done by
Yes 103 (68.66) 47 (40.86) 3.84 0.050 using the WHO-UMC scale,7 which clas-
No 82 (54.66) 68 (59.13) sified maximum ADRs to have a possible
relationship with psychotropic drugs
Family history of psychiatric disorders
(59.70%; n = 163), followed by probable
Yes 142 (94.66) 08 (6.95) 85.23 ‡
< 0.001
(22.34%; n = 61) and unlikely (17.94%; n =
No 43 (28.66) 107 (93.04) 49). Also, there was no sufficient informa-
ADRs: adverse drug reactions. Note: The highest values in each category have been highlighted. ‡The result is tion on drug withdrawal, which restricts
significant.
the likeliness of ADRs to be categorized
as certain or probable. This observation
Table 8.
has been found in multiple studies.10, 14, 15
Consequence of ADR According to UKU Scale This is in contrast to the studies by Shah
Degree of ADR Consequence Number of patients (%) et al.5 and Pahari et al.27 No cases could
0 No action 18 (15.65%)
be labeled “certain,” as rechallenge was
not attempted once the drug was with-
1 More frequent assessment of the patient, but 23 (20.00%)
no reduction of dose, and/or occasional drug drawn. The severity was assessed using
treatment of side effects Hartwig’s severity assessment scale,
2 Reduction of dose and/or continuous drug with 67 (58.26%) which categorized maximum ADRs to
the treatment of side effects be mild (45.05%, n = 123), which showed
3 Discontinuation of drug or change to another 10 (08.69%) resemblance to the findings of numerous
preparation studies.14, 28 No cases were categorized as
ADR: adverse drug reaction. severe in our study, as there were no ep-
isodes of fatal or life-threatening ADRs.
gender-related differences in pharmaco- might be objective physiological differ-
kinetics, pharmacodynamics, pharmaco- ences in response to psychotropics.13 Also,
Limitations
genetics, immunological, and hormonal the psychiatrists may have considered Although the UKU scale categorizes ADRs
factors, as well as diversity in the use of the special requirements of the elderly into specific groups, it does not categorize
medications (contraceptives) by women patients and may have prescribed lower certain ADRs, such as endocrine, metabol-
compared with men.25 The reason for dosages and avoided high-risk drugs and ic, muscular, and bone-related ADRs. Also,
more ADRs being experienced in the dangerous combinations, thus reducing it does not have a category for correlating
younger population may be that there the risk of ADRs in elderly patients.25 the laboratory values with the ADRs.

Mathew et al.
The study was conducted for a short antipsychotic medication: A systematic reactions at psychiatry out-patient-depart-
duration in a single center. This limited review. J Psychopharmacol 2015 Aug; 29(8): ment in our tertiary care teaching hospi-
the data collection and overall findings. 857–866. tal, Surendranagar. J Drug Deliv Ther 2014
4. Lindstrom E and Lewander T. UKU-SERS- Jan 8; 4(1): 49–52.
We did not compare the ADRs in long-
Pat: The UKU side effect self-rating scale. 2002. 16. Michel P. Strengths and weaknesses of avail-
term patients and in those who were new-
{online} Research Gate. Available at: able methods for assessing the nature and scale
ly prescribed psychotropic drugs. Future https://www.researchgate.net/publica- of harm caused by the health system: Literature
studies may address these limitations and tion/247241175_UKU-SERS-Pat_-_the_ review. Geneva: World Health Organiza-
also perform a comparison of the pattern UKU_side_effect_self-rating_scale tion, 2003.
of ADRs in the residential nursing home (accessed January 19 2020). 17. Farhat S, Ahmad A, Parveen S, et al.
and outpatient healthcare setting. 5. Shah A, Yadav PP, Chaudhari M, et al. Adverse drug reaction monitoring to
A prospective study of adverse drug anti-psychotic drugs in out-patient de-
Conclusion reactions in patients with bipolar disorder partment of a psychiatry hospital. World J
in psychiatry outpatient department of Pharm Pharm Sci 2015; 5: 608–617
Our study demonstrates a representative a tertiary care hospital. J Clin Diagn Res: 18. Sengupta G, Bhowmick S, Hazra A, et
profile of ADRs experienced in different JCDR 2017 May; 11(5): FC24. al. Adverse drug reaction monitoring in
age groups, with a variation in their psy- 6. Gummadi T, Harave VS, Aiyar LN, et al. psychiatry out-patient department of an
chiatric disorders and the pattern of psy- Adverse drug reaction monitoring in a ter- Indian teaching hospital. Indian J Pharma-
chotropic prescription in the residential tiary care psychiatry setting: A comparative col 2011 Feb; 43(1): 36.
nursing home. Most of the psychiatric study between inpatients and outpatients. 19. Cooper SJ, Reynolds GP, with expert
Indian J Psychol Med 2017 May; 39(3): 306. co-authors (in alphabetical order): Barnes
inpatients receiving psychotropic drugs
7. World Health Organization. The use of TR, England E, Haddad PM, et al. BAP
experienced ADRs. Females, patients in
the WHO-UMC system for standardized case guidelines on the management of weight
the age group of 20–39 years, and those re- causality assessment. Geneva: World Health gain, metabolic disturbances and cardio-
ceiving more than five psychotropic drugs Organization; 2015. vascular risk associated with psychosis
experienced more ADRs. ADRs observed 8. Hartwig SC, Siegel J, and Schneider PJ. and antipsychotic drug treatment. J Psy-
were weight gain, sedation, constipation, Preventability and severity assessment chopharmacol 2016 Aug; 30(8): 717–748.
and tremors caused majorly by atypical in reporting adverse drug reactions. Am J 20. Miller DD. Atypical antipsychotics: sleep,
antipsychotics and mood stabilizers. Hosp Pharm 1992; 49(9): 2229–2232. sedation, and efficacy. Prim Care Companion
ADRs cannot be eradicated but should 9. Aburamadan H A, Sridhar S B, and Tadross J Clin Psychiatry 2004; 6(Suppl 2): 3.
T M. Intensive monitoring of adverse drug 21. Nevels RM, Gontkovsky ST, and Williams
be managed to enhance compliance with
reactions to antipsychotic medications in BE. Paroxetine—the antidepressant from
the drug. Pharmacovigilance of psycho-
the inpatient psychiatry department of a hell? Probably not, but caution required.
tropic medications is essential to improve Psychopharmacol Bull 2016 Mar 1; 46(1): 77.
secondary care hospital of UAE. Int J Phar-
patient care. Constant vigil in detecting maceutical Investig 2018; 8(3): 151–156. 22. Koda-Kimble M. Applied therapeutics. 9th
ADRs and subsequent dose adjustments 10. Sharma T, Vishwakarma K, Dhasmana ed. Philadelphia, PA: Lippincott Williams
can make therapy with psychotropic DC, et al. Adverse drug reactionmoni- & Wil, 2003.
drugs safer and more effective.8 Pharma- toringinpsychiatryoutpatientdepartmen- 23. Every-Palmer S, Newton-Howes G, and
cists, doctors, and caregivers should work tofatertiarycareteachinghospital. JK Sci Clarke MJ. Pharmacological treatment for
in collaboration for the betterment of the 2014 Oct 1; 16(4): 156. antipsychotic-related constipation. Cochrane
11. Gurung A, Jaju JB, Pawar GR, et al. Study Database Syst Rev 2017; 2017(1): CD011128.
patient’s health status and quality of life.
of drug utilization pattern and adverse 24. Morgan JC, Kurek JA, Davis JL, et al.
drug reactions of psychotropic drugs in Insights into pathophysiology from
Declaration of Conflicting Interests
psychiatric inpatient department of tertia- medication-induced tremor. Tremor Other
The authors declare that there are no conflicts of Hyperkinet Movements 2017; 7: 442.
ry care hospital. Int J Basic Clin Pharmacol
interests regarding this study.
2018 Feb; 7(2): 259. 25. Lucca JM, Ramesh M, Parthasarathi G, et
12. Singh H, Yacob M, and Sabu L. Adverse al. A prospective surveillance of pharma-
Funding covigilance of psychotropic medicines in
drug reactions monitoring of psychotropic
The authors received no financial support for the a developing country. Psychopharmacol
drugs: A tertiary care centre study. Open J
research, authorship, and/or publication of this Bull 2016 Mar 1; 46(1): 54.
Psychiatry Allied Sci 2017; 8(2): 136–140.
article.
13. Lucca JM, Ramesh M, and Ram D. 26. Kukreja S, Kalra G, Shah N, et al. Poly-
pharmacy in psychiatry: A review. Mens
References Gender differences in the occurrences
and pattern of adverse drug reactions Sana Monogr 2013 Jan; 11(1): 82.
1. Lucca JM, Varghese NA, Ramesh M, et al. in psychiatric patients: A prospective 27. Pahari NI, Tripathi SK, Maity TA, et al.
Economic impact and severity of adverse observational study. Trop J Med Res 2017 Evaluation and analysis of adverse drug
drug reactions in patients with mental Jan 1; 20(1): 84. reactions of second generation antipsy-
illness: A prospective observational study. 14. Sridhar SB, Al-Thamer SS, and Jabbar R. chotics in a psychiatry outpatient depart-
Int J Health Allied Sci 2017 Apr 1; 6(2): 93. Monitoring of adverse drug reactions in ment. Int J Pharm Pharm Sci 2012; 4: 158–162.
2. Rajkumar RP and Melvin G. Pharmaco psychiatry outpatient department of a Sec- 28. Munoli S and Patil SB. Adverse drug reac-
vigilance for psychiatrists: An introduction. ondary Care Hospital of Ras Al Khaimah, tion monitoring of antipsychotic drugs and
Indian J Psychiatry 2014 Apr; 56(2): 176. UAE. J Basic Clin Pharm 2016 Jun; 7(3): 8. mood stabilizers in a teaching hospital. Int J
3. VanStrien AM, Keijsers CJ, Derijks HJ, et 15. Shah VM and Mehta DS. A longitudi- Pharmacol and Clin Sci 2016; 5(4): 118–121.
al. Rating scales to measure side effects of nal study of monitoring adverse drug

Original Article
effect of a Video-assisted Teaching
Program about eCT on Knowledge and
attitude of Caregivers of Patients with
Major Mental Illness
Padmavathi Nagarajan1, Gomathi Balachandar1, Vikas Menon2, Balachandar Saravanan3
ABSTRACT (30%) and a moderate level of knowledge intervention improves the knowledge and
on the remaining 28 (70%) of the study acceptance of ECT among them.
E
Background: Electroconvulsive therapy subjects. The attitude scores revealed
(ECT) is a widely used treatment modality lectroconvulsive therapy (ECT) is
a neutral attitude among 47.5% and a
for mental disorders such as major conservative attitude among 10% of an essential treatment modality
depression, bipolar affective disorder the subjects toward ECT. There was a in Psychiatry that involves the
(BPAD) and catatonia. However, it is significant improvement in both mean application of electric current to the hu-
considered as one of the most controversial (±SD) knowledge (13.4 ± 4.7 vs 25.6 ± 2.9) man brain for alleviating the symptoms
and misunderstood procedures, especially and attitude (10.7 ± 3.5 vs 14.6 ± 3.9) scores of several mental disorders such as bipo-
among caregivers. following intervention with video-assisted lar disorders, schizophrenia, and major
Methods: An experimental pre-test, teaching. depression.1,2 Despite its clinical effica-
post-test design was adopted. Forty Conclusion: A single session involving cy, it is considered to be one of the most
caregivers of persons with schizophrenia video-assisted teaching improves the controversial and misunderstood pro-
(n = 12), depression (n = 13), BPAD with knowledge and attitude toward ECT among cedures.3–5 The hindrances for pursuing
mania (n = 8), and BPAD with depression caregivers by removing the myths and the treatment are predominantly due to
(n = 7) were selected using convenience misconceptions about ECT.
sampling. The caregiver’s knowledge and the pervasive fear of ECT and inaccurate
Keywords: ECT, knowledge, attitude, video- portrayals by the media.6 Thus, the stig-
attitude toward ECT were assessed before
assisted teaching ma attached to ECT is counterintuitive to
and after the intervention with a single
session video-assisted teaching on ECT. CTRI reference number its improved outcome, despite its clinical
The data collection tool used to assess the REF/2016/11/012581 efficacy and safety. This had warranted
caregiver’s knowledge and attitude was several investigations focusing on the
Key Messages: Caregivers of patients with
based on a pre-validated questionnaire. knowledge, attitude, and the experience
mental illnesses have a lack of knowledge
Results: The pre-test evaluation and ambivalent attitudes toward ECT. of the clinicians, patients, and their care-
demonstrated poor knowledge among 12 Single session video-assisted teaching givers. There are numerous reports of
1
Dept. of Psychiatric Nursing, Nursing College, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. 2Dept. of Psychiatry,
Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. 3Dept. of Anaesthesiology, Jawaharlal Institute of Postgraduate
Medical Education and Research, Puducherry, India.
HOW TO CITe THIS aRTICle: Nagarajan P, Balachandar G, Menon V, Saravanan B. Effect of a video-assisted teaching program about
ECT on knowledge and attitude of caregivers of patients with major mental illness. Indian J Psychol Med. 2021;43(1):45–50.
Address for correspondence: Padmavathi Nagarajan, Dept. of Psychiatric Nursing,
Submitted: 30 Dec. 2019
Nursing College, Jawaharlal Institute of Postgraduate Medical Education and
Accepted: 9 Jun. 2020
Research, JIPMER Campus Rd, Gorimedu, Dhanvantari Nagar, Puducherry 605006,
Published Online: 11 aug. 2020
India. E-mail: padmavathi2002@gmail.com

Nagarajan et al.
negative perspectives about ECT, espe- English or Tamil, were recruited by conve- followed by discussion. The total dura-
cially among patients and caregivers.7–9 nience sampling. In this study, the “care- tion of the video session was 20 minutes.
This suggested poor standards in the con- giver” refers to a person/family member The quality check of the video was done
duct of the procedure, involving dissatis- who assumes the responsibility of taking by two experts (qualified psychiatrists)
faction in the ethical aspects such as ob- care of the patient without any wages (un- from the Dept. of Psychiatry, JIPMER.
taining informed consent and provision paid) and has been living with the patient Handouts were distributed to reinforce
of practical and emotional support. By for at least one year. Caregivers of clients the knowledge at the end of the session.
adhering to these standards of care, the with acute medical illness, those who had The video-assisted teaching covered of
perception about ECT among patients a mental illness and those who had re- the following aspects of ECT: myths and
and caregivers can be improved to ensure ceived a similar type of ECT educational misconceptions, informed consent, indi-
better treatment outcomes. This can be program in the past were excluded. cations, pre-, intra-, and post-procedural
achieved by providing educational efforts The research proposal was approved care, and the side effects. A post-test was
such as educational videos and pam- by the institutional ethics committee conducted one week after the interven-
phlets. Such educational interventions (IEC) for human studies. The study was tion with the same questionnaire used
provide individuals with a resource of prospectively registered under the Clin- for the pre-test.
information about ECT, thereby allowing ical Trials Registry-India (CTRI) with the
them to take an individual decision about reference number: REF/2016/11/012581. Data Analysis
the course of treatment and its need in Data collection was done from October
The number of study participants and
the future.10 However, the efficacy of such 2016 to November 2016. After explain-
the number of responses were men-
an intervention has not been evaluated in ing the study details, informed consent
tioned as frequency (percentage). The
detail among the Indian population. The was signed by the participants. The out-
knowledge and attitude scores were
present study aimed to assess the knowl- come measure used was a standardized
mentioned as mean ± SD. The number
edge and attitude of patients with major tool that has been used in many previous
of responses for each knowledge ques-
psychiatric illness and their caregivers studies in the Indian population.7,12–14
tionnaire item was analyzed using the
toward ECT and to assess the effect of a The knowledge assessment question-
video-assisted educational program on McNemar test with Bonferroni correc-
naire had 29 items and the scores ranged
their knowledge and attitude toward tion, and the number of responses for
from 0 to 29. A score of one was given
ECT among caregivers of patients with each attitude questionnaire item was
for every correct answer and the wrong
major psychiatric illness. analyzed using the Wilcoxon signed-
response was scored as zero. The knowl-
rank test with Bonferroni correction. The
edge scores were categorized into three
Materials and Methods groups: those with scores 0–11 (less than
paired t-test was used for comparing the
pre-test and post-test knowledge and at-
An experimental, one group, pre-test, 40% of total score) were considered as
titude scores. Chi-square test was used
post-test design was used. The study was having poor knowledge; 12–20 (40%–
to assess the association of knowledge
carried out in the Dept. of Psychiatry, 70% of total sore) as moderate; and 21–29
scores with demographic variables. Data
Jawaharlal Institute of Post Graduate (more than 70% of total score) as good.
analysis was done using Statistical Pack-
Medical Education and Research (JIP- The attitude assessment questionnaire
age for the Social Sciences (SPSS 16.0). P
MER), Puducherry, Southern India. The consisted of 16 items: 9 items were neg-
< 0.05 was considered statistically sig-
study population comprised of caregiv- atively phrased and 7 were positively
nificant for all comparisons except for
ers of patients with major mental illness phrased. The total score ranges from 16 to
the item-wise analysis of knowledge and
attending the inpatient and outpatient 48. A higher score represents a positive at-
attitude scales between groups, where
units of the Dept. of Psychiatry who titude. Scores were categorized into three
Bonferroni correction was applied for
were undergoing ECT. The sample size groups—positive attitude: 39–48, neu-
multiple comparisons. Accordingly, P <
was informed by the previous study con- tral: 28–38, and negative attitude: 16–27.
0.0017 was considered statistically sig-
ducted by Kheiri et al.11 In that study, the After the pre-test, on the same day, a
nificant for knowledge analysis and, P <
authors had observed a mean difference video-assisted teaching session was ad-
0.0031 was considered statistically signif-
of 7.0 units, whereas we collectively de- ministered to a group of 3–5 caregivers.
icant for attitude analysis.
cided that a mean difference of 2.5 units After an extensive literature review and
is clinically significant. We estimated consultation with the experts, a video
that a sample size of 40 would have 90% was prepared regarding the procedure
Results
power to detect this difference with an and information about ECT. The video A total of 40 caregivers participated.
alpha error of 5%. was prepared in an actual clinical setting. The distribution of their demographic
Forty caregivers of patients with schizo- The main purpose of this video was to variables is shown in Table 1. Males 31
phrenia (n = 12), depression (n = 13), bipolar understand and see the real clinical sce- (77.5%) outnumbered females 9 (22.5%);
affective disorder (BPAD) with mania (n = nario of ECT administration to a subject. the mean age was 34.5 ± 8.9 years. In
8), and BPAD with depression (n = 7), of We made the video like a film enacted total, 25 (62.5%) subjects were married,
both sexes, aged above 18 years and who by simulated patients. Simultaneously, a 33 (82.5%) were employed, 31 (77.5%)
can read, speak, and understand either narration of the contents was provided, belonged to nuclear family, 23 (57.5%)

Original Article
subjects were residing in rural area: 16 mental illness. Even today, a mental ill- mental illness regarding ECT through
(40%) were parents, 12 (30%) were chil- ness that is non-responsive to drugs can video-assisted teaching.
dren, 10 (25%) were siblings, and 2 (5%) respond to ECT, and it is mostly indicat- Previous studies that employed dif-
were spouses. ed in catatonia, and pre- and post-partum ferent methods of educational inter-
The clinical profile of patients suggest- affective and psychotic states. ECT may ventions are summarized in Table S1.
ed that among 40 patients, 52.5% were even be lifesaving in these patients.15 Pamphlets, lecture cum discussion, and
aged 31–45 years, 30% were 18–30 years, The negative media portrayal of ECT videos were shown to be effective in im-
and 17.5% were aged ≥45 years. The main and the use of the word “electricity” may proving both the knowledge and atti-
reason for ECT administration was sui- have contributed to its negative public tude of the patients, the general public
cidal risk in half of the patients, inade- perceptions. This negative attitude may and also the medical students.22,24 An
quate treatment response/resistance and lead to the fear and avoidance of ECT, ECT education training program that
refusal to take food in 22.5%, and cata- which acts as an obstacle to psychiatric combined a lecture, videotape, familiar-
tonia in 5%. Duration of illness was less patients’ right to an effective treatment. ization with the ECT equipment, and
than one year for 45% of the patients and Hence, the authors made an effort to observation of an ECT treatment was
more than two years in 17.5%; 80% of the educate the caregivers of patients with found to be effective among student
patients had been hospitalized 2–5 times
Table 1.
and have had 2–5 episodes of illness,
while 10%, each had ≥ 5 episodes and Knowledge Assessment Before and After the Intervention
≤ 2 past episodes. P Value
Before the intervention, the mean Before Intervention After Intervention (McNemar Test)
knowledge score was 13.4 ± 4.7 and n = 40 n = 40 (Correct Bonferroni Cor-
the mean attitude score was 10.7 ± 3.0. Knowledge Questionnaire (Correct Response) Response) rection P = 0.0017
1. During ECT anesthetic/other 22 (55%) 39 (97.5%) <0.001
Twelve (30%) subjects had poor knowl-
medications are used
edge, 28 (70%) had a moderate level of
2. How often is ECT given per 08 (20%) 34 (85%) <0.001
knowledge, and none of the subjects had week?
adequate knowledge. Attitude scores 3. How many ECTs do most 06 (15%) 33 (82.5%) <0.001
suggested that 17 (42.5%) had a positive patients require in one
attitude, 19 (47.5%) had a neutral attitude, course?
and 4 (10%) had a negative attitude to- 4. Where is the current 28 (70%) 40 (100%) <0.001
applied?
ward ECT.
5. Who can administer ECT? 38 (95%) 40 (100%) 0.5
The effect of video-assisted teaching
was analyzed using the paired t-test. 6. What is ECT? 20 (50%) 37 (92.5%) <0.001
After the intervention, the mean knowl- 7. Certain investigations are 34 (85%) 40 (100%) 0.03
needed before ECT
edge score increased to 25.3 ± 2.9 from
8. How long is the current 07 (17.5%) 39 (97.5%) <0.001
the baseline score of 13.4 ± 4.7. Similar-
applied?
ly, the attitude score increased to 14.6 ± 9. How is ECT given? 21 (52.5%) 40 (100%) <0.001
1.43 from the baseline score of 10.7 ± 3.05
10. Is written permission of 34 (85%) 39 (97.5%) 0.06
and both were found to be statistically the patient or his/her family
significant (P < 0.001). Chi-square test member always necessary?
revealed that none of the demographic 11. ECT can be given against 29 (72.5%) 38 (95%) <0.004
variables were associated with knowl- the wishes of patients and
edge or attitude scores at baseline. the family
12. ECT is given only to those 23 (57.5) 28 (70%) 0.063
Each questionnaire items of pre- and
patients who have little
post-test knowledge and attitude score chance of improvement
assessment are listed in Tables 1 and
13. ECT can also be given to 10 (25%) 36 (90%) <0.001
2, respectively. Except for a few items, older persons (60–65 years)
there was a significant difference in the 14. ECT is given only to 09 (22.5%) 17 (42.5%) 0.008
knowledge score after the intervention inpatients
and similarly, attitudinal changes were 15. Pregnant women can also 0 (0%) 36 (90%) <0.001
also visible. receive ECT
16. ECT is useful in treating 30 (75%) 40 (100%) 0.002
Discussion psychiatric disorders
17. Compare to medications 13 (32.5%) 35 (87.5%) <0.001
ECT is the oldest and most controversial how useful is ECT?
treatment in the field of psychiatry.15 It 18. ECT often worsen the 25 (62.5%) 40 (100%) <0.001
has been used for nearly 80 years and psychiatric illness
has been demonstrated to produce tre- 19. How does ECT work? 22 (55%) 33 (82.5%) 0.001
mendous improvements in patients with

Nagarajan et al.
anesthesia, brain damage, and memo-

P Value
ry loss and the stigma associated with
Before Intervention After Intervention (McNemar Test)
n = 40 n = 40 (Correct Bonferroni Cor- the treatment were reported by other
Knowledge Questionnaire (Correct Response) Response) rection P = 0.0017 researchers as the main issues raised by
20. Effects of ECT last only for 12 (30%) 24 (60%) <0.001 the patients and caregivers.8,9 In contra-
a short while diction, Chavan et al. highlighted that
21. Scientific evidence favors 22 (55%) 31 (77.5%) 0.004 most of the patients and their relatives
the usefulness of ECT
were well informed about ECT, and its
22. Does ECT results in a 05 (12.5%) 26 (65%) <0.001
permanent cure? effects and drawbacks. However, major-
23. Headache is a common 10 (25%) 36 (90%) <0.001 ity of them did not consider ECT as a
side effect of ECT safe treatment during pregnancy or old
24. ECT results in permanent 27 (67%) 40 (100%) 0.004 age.29 The findings of the current study
damage to the brain were almost similar and are supported
25. Use of ECT leads to 12 (30%) 30 (75%) <0.001 by other studies, which revealed that the
temporary impairment in
caregivers had lack of knowledge regard-
memory
ing ECT and that a substantial number
26. Use of ECT leads to per- 24 (60%) 40 (100%) <0.001
manent loss of memory of subjects had positive attitude toward
27. During ECT chances of 15 (37.5%) 40 (100%) <0.001 ECT.7,12,24
death are very high Virit et al.30 assessed the attitude of
28. Most of patients receiving 07 (17.5%) 38 (95%) <0.001 BPAD patients and their caregivers to-
ECT develop epilepsy later ward ECT, and they concluded that pa-
29. ECT can damage other 27 (67.5%) 40 (100%) 0.004
tients and relatives were satisfied with
body parts permanently
the treatment, found it beneficial, and
Statistically significant at P = 0.0017.
maintained a positive attitude toward
nurses in improving their knowledge of Table 2.

ECT procedure. 25 In view of the stigma
associated with ECT, counseling ses-
Attitude Score Before and After the Intervention
sions have also been conducted to the Attitude Pre-test Post-test
caregivers, and it was effective in reduc- Question-
Positive Ambiva- Neg- Positive Ambiva- Negative P Value
naire
ing the stigma and thereby improving Atti- lent ative Attitude lent Attitude (Wilcoxon
their acceptance of ECT as a safe thera- tude Atti- Signed-Rank
tude Test)
peutic strategy.12 Bonferroni
In addition, Shamsaei et al. demon- Correction P
strated that the family pre-ECT teaching = 0.0031
intervention and counseling decreased 1. ECT is 30 08 02 40 0 0 0.003
the depression, anxiety, and stress lev- dangerous (75%) (20%) (5%) (100%)
and should
el of family caregivers of patients with
not be used
mental disorders receiving ECT. Their
results suggested that even a short-term 2. ECT is 29 08 03 39 0 1 (2.5%) 0.003
inhuman (72.5%) (20%) (7.5%) (97.5%)
educational intervention for family
treatment
members can improve the emotional
outcomes of treatment in the family.13 3. I will ad- 32 01 07 38 0 2 0.02
Drawing from this available literature, vise a close (80%) (2.5%) (17.5%) (95%) (5%)
relative to
we designed a simulated video with a receive ECT
voice-over providing the narration and a if recom-
subsequent short discussion that aimed mended
to address the frequently asked ques-
4. ECT is 31 04 05 40 0 0 0.006
tions regarding the procedure. often given (77.5%) (10%) (12.5%) (100%)
Many researchers from India had ex- to people
plored the knowledge and views of pa- who do not
tients and their relatives toward ECT need it
and found that the knowledge and ac- 5. ECT is 27 04 09 40 0 0 0.001
ceptance of ECT were poor.26–28 often given (67.5%) (10%) (22.5%) (100%)
The pre-assessment knowledge scores as a pun-
ishment to
of the present study indicated that many violent/an-
subjects were unaware of the ECT pro- gry patients
cedure and the related facts. The fear of

Original Article
its use. Mccall et al. 31 found that among

Attitude Pre-test Post-test patients with major depression, the pa-
Question-
Positive Ambiva- Neg- Positive Ambiva- Negative P Value tient’s quality of life and function im-
naire
Atti- lent ative Attitude lent Attitude (Wilcoxon
proved as early as two weeks after the
tude Atti- Signed-Rank
tude Test) completion of ECT. Although ECT was
Bonferroni generally viewed as beneficial, effective,
Correction P and safe, memory impairment was its
= 0.0031
most commonly reported adverse ef-
6. Following 14 17 09 25 0 15 0.225 fect.14,32
discovery (35%) (42.5%) (22.5%) (62.5%) (37.5%)
of new medi-
The present study showed a significant
cines, treat- difference in knowledge and attitude
ment with scores after video-assisted teaching pro-
ECT is never gram (P < 0.001). These findings are cor-
required
roborated by several other studies that
7. If ECT fails 14 20 06 32 03 05 0.001 assessed the effect of educational inter-
in a patient, (35%) (50%) (15%) (80%) (7.5%) (12.5%)
vention using the video among various
then no oth-
er treatment groups such as caregivers, health care
will succeed professionals, and the general public.11,31,14
Review of literature suggested that
8. ECT is at 29 08 03 39 0 1 0.003
times life (72.5%) (20%) (7.5%) (97.5%) (2.5%) educational videos and pamphlets in-
saving creased the knowledge and promoted
a favorable and neutral attitude toward
9. Treatment 35 03 02 40 0 0 0.038
with ECT is (87.5%) (7.5%) (5%) (100%) ECT.18 The present study also got similar
cruel findings by using video-assisted teach-
10. Treat- 23 11 06 38 0 02 0.001 ing combined with handouts.
ment with (57.5%) (27.5%) (15%) (95%) (5%) Our results indicated that the in-
ECT is tervention was effective in improving
outdated
knowledge and attitudes. Therefore,
11. Treatment 34 03 03 40 0 0 0.024 the intervention may be useful in those
of ECT is (85%) (7.5%) (7.5%) (100%) with moderate as well as poorer levels of
unlawful
knowledge about ECT.
12. Once a 14 20 06 28 04 08 0.003
person is
given ECT,
(35%) (50%) (15%) (70%) (10%) (20%) Limitations
in future Non-probability sampling technique,
whenever
tertiary care setting, limited sample size,
he becomes
ill ECT is non-randomized design, and the absence
the only of a control group are the major limitations.
treatment Long-term effect of the intervention was
option
not assessed. Therefore, the persistence of
13. ECT gets 23 10 07 38 0 02 0.001 educational effect on knowledge and atti-
you better (57.5%) (25%) (17.5%) (95%) (5%)
quicker than
tude scores of the caregivers after a certain
medications time could not be commented on.
14. I am glad
that my rela-
25
(62.5%)
05
(12.5%)
10
(25%)
31
(77.5%)
01
(2.5%)
08
(20%)
0.011 Conclusion
tive received The knowledge possessed by caregivers
ECT
was moderate and most of the caregivers
15. ECT is 29 05 06 38 0 02 0.006 had a neutral attitude toward ECT. Vid-
given dis- (72.5%) (12.5%) (15%) (95%) (5%)
eo-assisted teaching helps in increasing
criminately
to people knowledge and attitude toward ECT. Our
findings may indirectly indicate better ac-
16. ECT is 36 04 0 40 0 0 0.046
the worst (90%) (10%) (100%) ceptance of ECT as a lifesaving intervention
treatment among caregivers of patients with major
option under mental illness following the intervention.
any circum-
stances
More educational interventions are need-
ed to reduce the stigma associated with
Statistically significant at P = 0.0031.
ECT and to improve the acceptance of ECT

Nagarajan et al.
among the general public, patients, health 10. Gass JP. The knowledge and attitudes module” on the knowledge and atti-
professionals, and significant others. of mental health nurses to electro- tudes of medical students towards ECT
convulsive therapy. J Adv Nurs 1998; 27: in India. Ann Med Health Sci Res 2012;
Declaration of Conflicting Interests 83–90. 2: 140–145.
11. Kheiri M, Sahebalzamani M, and Jahanti- 22. Solomon S, Simiyon M, and Vedachalam
The authors declared no potential conflicts of
gh M. The study of the effect on knowl- A. Effectiveness of an educational inter-
interest with respect to the research, authorship,
and/or publication of this article. edge of, and attitudes towards electro- vention on medical students’ knowledge
convulsive therapy among Iranian nurses about and attitude towards electrocon-
and patients’ relatives in a psychiatric vulsive therapy. Acad Psychiatry 2016; 40:
Funding
hospital, 2009–2010. Procedia—Soc Behav 295–298.
The authors received no financial support for the
Sci 2011; 30: 256–260. 23. Paul C, Jose TT, Paul B. Effectiveness of
12. Sadeghian E, Rostami P, Shamsaei F, et video assisted teaching on electro convul-
article.
al. The effect of counseling on stigma in sive therapy in improving the knowledge
psychiatric patients receiving electrocon- and attitude of the public. Int J Nur Res
Supplemental Material
vulsive therapy: A clinical study. Neuro- 2018; 4: 139–143.
Supplemental material for this article is available 24. Hoffman GA, McLellan J, Hoogendoorn V,
psychiatr Dis Treat 2019; 15: 3419–3427.
online.
13. Shamsaei F, Kazemian H, Cheragh F, et al. Electroconvulsive therapy: Impact of
et al. The effect of family teaching on a brief educational intervention on public
References depression, anxiety and stress in caregiv- knowledge and attitudes. Int Q Commu-
ers of patients received electroconvulsive nity Health Educ 2018; 38: 129–136.
1. Townsend MC. Essentials of psychiatric
therapy. J Ment Health Train Educ Pract 25. Karen O, Lange RT, Willan S, et al. Effects
mental health nursing: concepts of care in
2019; 14: 289–296. of an education training program on
evidence-based practice. 5th ed. Philadelphia:
14. Zhang QE, Zhou FC, Zhang L, et al. attitudes to electroconvulsive therapy. J
F.A. Davis Company, 2011.
Knowledge and attitudes of older psychi- ECT 2007; 23: 82–88.
2. Gangadhar BN, Shyam Sundar A, Thir-
atric patients and their caregivers towards 26. Grover S, Chakrabarti S, Rajagopal R,
thalli J, et al. ECT administration manual.
electroconvulsive therapy. Psychogeriat- et al. Does the experience of electrocon-
2nd ed. NIMHANS Publication: Banga- vulsive therapy improve awareness and
lore, 2013. rics 2018; 18: 343–350.
15. Gazdag G and Ungvari GS. Electrocon- perceptions of treatment among relatives
3. Carney S and Geddes J. Electroconvulsive of patients? J ECT 2011; 27: 67–72.
therapy. BMJ 2003; 21(326):1343–1344. vulsive therapy: 80 years old and still
27. Kuruvilla T, Fenwick CD, Haque MS, et al.
4. Goodman JA, Krahn LE, Smith GE, et al. going strong. World J Psychiatry 2019;
Elderly depressed patients: What are their
9: 1–6.
Patient satisfaction with electroconvulsive views on treatment option. Aging Ment
16. Battersby M, Ben-Tovim D, and Eden J.
therapy. Mayo Clin Proc 1999; 74: 967–971. Health 2006; 10: 204–206.
Electroconvulsive therapy: A study of atti-
5. Dowman J, Patel A, and Rajput K. 28. Dan A, Grover S, and Chakrabarti S.
tudes and attitude change after seeing an
Electroconvulsive therapy: attitudes and Knowledge and attitude of patients with
educational video. Aust N Z J Psychiatry
misconceptions. J ECT 2005; 21: 84–87. psychiatric disorders and their relatives
1993; 27: 613–619.
6. Stuart H. Media portrayal of mental ill- toward electroconvulsive therapy. Indian
17. Jenaway A. Educating patients and rela-
ness and its treatments: what effect does J Psychol Med 2014; 36: 264–269.
tives about electroconvulsive therapy: The
it have on people with mental illness? 29. Chavan BS, Kumar S, Arun P, et al. ECT:
use of an information leaflet. Psychiatr
CNS Drugs 2006; 20: 99–106. Knowledge and attitude among patients
Bull 1993; 17: 10–12.
7. Chakrabarti S, Grover S, and Rajagopal and their relatives. Indian J Psychiatry
18. Andrews M and Hasking P. Effect of two
R. Perceptions and awareness of electro- 2006; 48: 34–38.
educational interventions on knowledge
convulsive therapy among patients and 30. Virit O, Ayar D, Savas HA, et al. Patients’
and attitudes towards electroconvulsive
their families: a review of the research and their relatives’ attitude towards elec-
therapy. J ECT 2004; 20: 230–236.
from developing countries. J ECT 2010; troconvulsive therapy in bipolar disorder.
19. Warnell RL, Duk AD, Christison GW, et
26: 317–322. J ECT 2007; 23: 255–259.
al. Teaching electroconvulsive therapy to
8. Rajkumar AP, Saravanan B, and Jacob 31. Mccall WV, Dunn A, and Rosenquist PB.
medical students: effects of instructional Quality of life and function after electro-
KS. Perspectives of patients and relatives
method on knowledge and attitudes. convulsive therapy. Br J Psychiatry 2004;
about electroconvulsive therapy: a qual- Acad Psychiatry 2005; 29: 433–436.
itative study from Vellore, India. J ECT 185: 105–109.
20. Oldewening K, Lange RT, Willan S, et al. 32. Tang WK, Ungvari GS, and Chan GWL.
2006; 22: 253–258. Effects of an education training program Patients and their relative’s knowledge of,
9. Harikrishna GL, Manoranjitham S, on attitudes to electroconvulsive therapy. experience with, attitude toward, and sat-
and Kuruvila A. Stigma associated with J ECT. 2007; 23: 82–88. isfaction with electroconvulsive therapy in
electroconvulsive therapy among primary 21. Balhara Y, Yadav T, Mathur S, et al. Hong Kong, China. J ECT 2002; 18: 207–212.
care givers of patients who received ECT. The impact of a “brief ECT orientation
Int J Psychiatr Nurs 2016; 2: 56.

Original Article
Identifying emotional Facial expressions
in Practice: a Study on Medical Students
Alapan Bandyopadhyay1, Sarbari Sarkar1, Abhijit Mukherjee1, Sharmistha Bhattacherjee1,
Soumya Basu2
ABSTRACT respect to sex of the observers. However, der the conscious control of a person to
it was seen that participants could identify a much lesser extent than their verbal
Background: Successful identification emotions better from male faces than counterparts.1,2 This attribute makes
of emotional expression in patients is of those from female faces, a finding that was facial expressions an excellent guide to
considerable importance in the diagnosis statistically significant. Negative emotions
of diseases and while developing rapport a human’s “true” emotional state even
were identified more accurately from
between physicians and patients. when he/she is trying to hide it.
male faces, while positive emotions were
Despite the importance of such skills, identified better from female ones. The identification and correct interpre-
this aspect remains grossly overlooked in tation of facial expressions play an im-
conventional medical training in India. This Conclusions: Male participants identified portant role in fruitful social interactions,
study aims to explore the extent to which emotions better from male faces, while as this can help the observers to formu-
medical students can identify emotions females identified positive emotions better
late and regulate their own behavior in
by observing photographs of male and from female faces and negative ones from
response to the emotions expressed by
female subjects expressing different facial male faces.
others (expresser)3 and, thus, helps build
expressions. Keywords: Emotional facial expressions, rapport between people. For example,
Methods: A total of 106 medical students medical students, universal facial correctly identifying the emotion of anger
aged 18–25, without any diagnosed expressions, static images
may lead to a psychological as well as phys-
mental illnesses, were shown images Key Messages: Misidentification of iological state of “fight or flight” in the ob-
of the six universal facial expressions emotions, especially negative emotions, server. Therefore the lack of this quality
(anger, sadness, fear, happiness, disgust, from static facial expressions was common can prove to be quite debilitating to the so-
and surprise) at 100% intensity with an in medical students of both sexes, which is cial and emotional health of a person and
exposure time of 2 seconds for each image. an aspect that needs to be addressed during
The participants marked their responses can frequently lead to interpersonal con-
the training of medical students in India.
flicts. This is evidenced by the widely stud-
E
after each image was shown. Collected data
were analyzed using Statistical Package for motional facial expressions (EFEs) ied association of the inability to identify
the Social Sciences. are one of the most important and express emotions with psychological
parts of the non-verbal communi- and physical abuse.4 People suffering from
Results: Participants could identify 76.54%
cation array that humans possess. This chronic illnesses have also been shown to
of the emotions on average, with higher
accuracy for positive emotions (95.6% makes EFEs a crucial component of all have difficulties in expressing EFEs.5
for happiness) and lower for negative interpersonal interactions between two Being an evolutionary remnant of
emotions (46% for fear). There were no or more members of the species. Like non-verbal communication, the ability
significant variations in identification with other non-verbal cues, they too are un- of humans to identify and interpret EFEs
Dept. of Community Medicine, North Bengal Medical College, Siliguri, West Bengal, India. 2Dept. of Psychiatry, Monash University, Melbourne, Victoria, Australia.
1
HOW TO CITe THIS aRTICle: Bandyopadhyay A, Sarkar S, Mukherjee A, Bhattacherjee S, Basu S. Identifying emotional facial
expressions in practice: a study on medical students. Indian J Psychol Med. 2021;43(1):51–57.
Address for correspondence: Abhijit Mukherjee, 34, SN Banerjee Road, New Submitted: 9 aug. 2019
Barrackpore, Kolkata 131, West Bengal, India. E-mail: drabhijit71@gmail.com Accepted: 31 Mar. 2020
Published Online: 30 Jul. 2020

Bandyopadhyay et al.
shows surprising consistency across geo- While all doctors are expected to be current ongoing psychiatric illnesses
graphical and ethnic boundaries, albe- leaders and good communicators, this using the Primary Care Evaluation of
it with slight cultural modifications.6,7 aspect of training is grossly overlooked in Mental Disorders Patient Health Ques-
Studies have provided evidence to estab- the medical curriculum, especially in the tionnaire (PRIME-MD PHQ) self-admin-
lish the “universality” of a cluster of such Indian context. This study will help to istered questionnaire.16 They were also
facial expressions, namely anger, sadness, address this gap by trying to determine screened for any recent history of head
fear, surprise, happiness, and disgust. It how medical students fare in the identifi- trauma and for diagnosis of any neuro-
has also been shown that this process of cation and interpretation of human EFE logical anomalies or diseases that would
EFE recognition is highly optimized in in an idealized setting, with static images grossly affect their cognitive or behav-
humans, as the identification of certain showing the six universal facial expres- ioral functions. Of the 113 volunteers,
facial expressions can occur even when sions at 100% intensity, and, thus, gener- seven (four males and three females)
the said expression is presented outside ate data on this particular subject. were excluded as they had attended lec-
of the conscious awareness of a person.8 tures or seminars that discussed facial
It must also be noted, however, that even Objectives expressions and their role in non-verbal
with the inter-cultural consistency, the The current study was conducted with communication in the last one year, so as
accuracy of identification of emotions the following objectives: to avoid introducing any selection bias.
varies between individuals based on the 1. To find the proportion of students Subsequently, the total number of the
content of the emotions expressed, their who can correctly identify the six uni- participants was 106, with 53 males and
intensity, as well as the characteristics of versal EFEs from static pictures. 53 females. An attending physician ver-
the observer.9,10 Research on this partic- 2. To compare the differences in the ified that none of them were under the
ular subject has also provided evidence identification rates of emotions influence of any psychotropic substance
regarding the sharp decrease in accuracy based on the sex of the observers and at the time of the undertaking of the ex-
among observers when they were shown expressers. periment.
a large number of EFEs in a particular ex-
perimental setting.11 Research Hypothesis Study Tools
Creating rapport with patients and
A large proportion of medical students To measure the ability of the participants
caregivers is of utmost importance to
are unable to identify and interpret one to recognize EFE, four image sets from
doctors. They should be very adept at
or more universal facial expressions cor- the Karolinska Directed Emotional Faces
identifying as well as interpreting EFEs
rectly and there are significant differenc- (KDEF)17 were used, which is a directory
of their patients and carers to the best ex-
es between males and females in their of 4,900 human facial expressions. Each
tent possible. This is important as it can
ability to identify and interpret universal of these sets contained seven images,
help to establish a relationship of trust
facial expressions. each corresponding to a facial expression
between them and the people they are
at 100% intensity, namely anger, disgust,
treating, which has been shown to lead
to better clinical outcomes.12 Physicians Materials and Methods fear, happiness, sadness, surprise, and
neutral, in front profile. Each of the four
are also expected to act as leaders while at The study was an analytical cross-sec- sets corresponded to the facial features
the same time be considerate and closely tional one conducted in a tertiary care
engaged with their patients to motivate of a single person, with two sets showing
health center cum teaching institute emotions of females (KDEF nos 01, 02)
them for treatment.13 The act of recog- of eastern India. It was conducted over
nizing and responding to the patients’ and the rest showing emotions of males
a period of four months from June to (KDEF nos 35, 14). In addition to these
as well as their caregivers’ non-verbal September 2018. Relevant ethical per-
signals can also help the doctor under- four sets of images, four extra images
missions were obtained from the Institu- were also selected from the KDEF, to be
stand the deviations from the normal fa-
tional Ethics Committee. used for demonstration purposes: two
cial expression spectrum that are present
were of a male expressor (KDEF no 09)
in their patients, especially those who Study Population showing happiness and neutral expres-
suffer from chronic ailments or physical
or emotional pain. This not only helps Medical students aged 18–24 years, hail- sions and two were of a female (KDEF no
in the management of the psychological ing from different parts of India and 07) showing anger and neutral expres-
symptoms of the disease but also gener- varied backgrounds, and pursuing Bach- sions, all at 100% intensity. Of the 32 total
ate positive response from the patients elor of Medicine, Bachelor of Surgery images, 24 (the remaining eight were the
and the caregivers who are likely to be (MBBS) in a tertiary care teaching insti- four demonstration images and four neu-
under distress too.14 There is increasing tute of eastern India volunteered as par- tral images) were selected and shuffled to
evidence that doctors’ awareness of and ticipants. Written consent was obtained. form a set of randomly arranged images.
ability to respond to emotions in them- After screening for any history of neuro- The participants were shown this image
selves and other people influence their psychiatric or developmental disorders set and had to mark what he/she thought
ability to deliver safe and compassionate as per their medical examination records the emotion in the picture was, in the an-
health care, a particularly pertinent issue at the time of admission to the medical swer sheet provided to them, which con-
in the current health care climate.15 course, they were also screened for any tained six options for each corresponding

Original Article
image (anger, disgust, sadness, surprise, participant was scored out of 24, with each respectively were identified. When bro-
happiness, and fear). correctly identified emotion assigned a ken down with respect to the sex of the
The answers were marked as right or score of 1, and each incorrectly identified observers, it was observed that the male
wrong, with the correct answers being emotion assigned a score of 0. The data and female participants had similar ac-
marked with the score of 1 and the incorrect thus collected by the researchers were curacy of identifying EFEs (76.9% and
responses as 0. The wrong responses were compiled using MS Excel (Microsoft Inc) 76.1%, respectively). The mean score
further classified according to the chosen and analyzed using the principles of de- (95% CI) of the male participants (18.47;
response and documented. The more faces scriptive and analytical statistics using the [18.02, 18.93]) was marginally better than
a participant correctly identified, the high- Statistical Package for the Social Sciences that of their female counterparts (18.26;
er was the score given to him/her. (Version 20, IBM Corp). Statistical signifi- [17.71, 18.82]) but was not statistically
cance was considered at P values <0.05. significant (P = 0.56). When considering
Study Technique identification of EFEs from male and fe-
Results male faces, because each participant was
Before the start of the experiment, the
Analysis of the collected data showed shown 12 images each of male and fe-
participants were clearly explained
that the mean (±SD) age of the partici- male faces, the total score on which they
about the procedure. It was ensured that
pants (n = 106) was 21.72±1.83 years. A were marked was 12 for each of the male
the environment in which the experi-
majority of the study participants were and female faces. The participants iden-
ment was conducted was isolated from
unmarried (103, 97.2%) and were from tified EFEs in male faces (mean = 9.47;
potentially distracting stimuli (e.g., loud
nuclear families (74, 69.8%). The partic- 95% CI = 9.21, 9.72) better than in female
noises, bright lights, etc.). Two demon-
ipants were distributed almost equally faces (mean = 8.9; 95% CI = 8.66, 9.15), a
stration images were used to explain
among different years of MBBS study, difference that was found to be statisti-
and demonstrate the whole experiment
from 26 participants (27.6%) studying cally significant (P = 0.002) (Table 3).
to the participants through a 2-second
in the first year (first professional) to 23 While the female participants had sim-
image exposure,18 followed by response
(21.7%) enrolled in the final year (third ilar scores while identifying emotions
marking. The remaining four images of
professional part II, Table 1). from male and female faces (mean 9.03
neutral faces of the four expressors were
The participants had a mean score of and 9.23, respectively), the male partic-
also shown to the participants in order to
18.37±1.84 out of 24, or 76.54%, where ipants correctly identified male faces
do away with any confusion arising from
each correctly identified emotion was (mean = 9.7) better than female ones
unfamiliarity with their faces. (mean = 8.78) (Table 3).
scored 1 and incorrectly identified emo-
Each participant was shown the afore- Both the male and female participants
tion was scored 0. Overall, the accuracy
mentioned set of randomly arranged im- did similarly while identifying differ-
of correctly identifying emotions was
ages on a computer screen with 1208 × 768 ent emotions (Table 4). For example,
higher in the case of positive emotions
resolution, 60 Hz refresh rate. Each image the identification of anger was equally
(95.6%) than that of negative emotions
was presented to the participant for two (Table 2). Participants fared especial- poor among both males (53.3%) and fe-
seconds, after which it was replaced by a ly poorly in the identification of emo- males (54.7%), while it was better for
blank screen. The participants identified tions such as anger and fear, of which emotions like surprise (male = 95.3%,
the facial expression demonstrated on only 54% (n = 424) and 46% (n = 424), females = 92.5%). The male participants
the on-screen images and then chose and
marked the identified emotion in the list Table 1.
of the emotions on the answer sheet pro- Sociodemographic Characteristics of the Participants (n = 106)
vided to them. Care was taken to ensure
Parameters Frequency Percentage (%)
that the participant looked at the photo-
Male 53 50
graph for the full two seconds and marked Sex
their answers only after the image had Female 53 50
been replaced with the blank slide. After a Married 3 2.8
Marital status
response was marked for a particular im- Unmarried 103 97.2
age, the next image was shown, and the Nuclear 74 69.8
process repeated for the full set. There was Type of family
Joint 32 30.2
no option of more than one response or
Current place of Hostel 94 88.7
the repetition of the images to each partic- stay Own residence 12 11.3
ipant. The collected responses were com-
First professional 26 27.6
piled, compared, and analyzed.
Current Second professional 27 25.4
Data Analysis professional year Third professional part I 30 31.8
Participants were shown 24 images, Third professional part II (final year) 23 21.7
each image corresponding to an EFE. Of a total 113 volunteers, seven were excluded as they had previously attended lectures or seminars discussing
facial expressions and their role in non-verbal communication in the last one year.
After their responses were collected, each

Table 2. Discussion
The Proportion of Interpreted EFEs by Study Population (n = 424) In line with the “happy face advantage”
Emotions Interpreted hypothesis,19 the emotion the study par-
by Participants (%) ticipants most accurately identified was
happiness (97.4%), followed by surprise
(93.9%). These findings are consistent
Happi- Sad- with the theory proposed by Smith and
Actual Emotions ness Surprise Fear Anger ness Disgust
Schyns which states that since these
Depicted in the Images (n) (%) (%) (%) (%) (%) (%)
“positive” emotions are associated with
Happiness (424) 97.4 2.6 0 0 0 0
“catastrophic” transformations of the
Surprise (424) 2.4 93.9 1.9 0 0.9 0.9
mouth region (the mouth opens, reveal-
Fear (424) 0.5 36.8 45.7 0.5 7.3 9.2 ing the teeth, which are otherwise not
Anger (424) 0 4.4 1.2 54 8.3 32.1 visible in the neutral face), they can be
Sadness (424) 0.9 1.4 4.6 0.9 81.8 10.4 identified with more accuracy than other
Disgust (424) 0.2 0.9 1.9 4.3 6.4 86.3 expressions.20 The highest accuracy for
Positive emotionsa (848) 95.6b the identification of happiness, which
Negative emotionsc (1696) 66.98b
was represented by a smiling face, can
also be explained from an evolutionary
Each of the 106 participants identified four sets of EFEs, each set containing one image for each of the six EFEs.
Therefore, each participant marked four images of each EFE (24 images in total), leading to a total of 424 depicted perspective. In primates, clenched bared
images for each of the EFEs. aHappiness and surprise. bCorrectly identified proportions of emotions. cAnger, fear, teeth displays (thought to have evolved
sadness, and disgust. EFEs: emotional facial expressions.
into smiles in humans) and open mouth
correctly identified happiness in all the Table 3.
emotional images shown to them (100%),
while the female participants did slightly
Sex-Based Variations in Mean Scores While Identifying EFEs from
poorly (94.8%) in this regard (P = 0.001). Images of Male/Female Faces (Total Score = 12)
There were significant differences be- Mean Identification
tween the accuracy of identification from Scores
male and female faces (Table 5). Fear was Participants (n) Male Faces Female Faces t-Test P value
identified in male faces (53.8%) much bet-
Male (53) 9.70 ± 1.19 8.77 ± 1.01 4.32 0.000036*
ter than it was in female faces (37.7%; P
Female (53) 9.23 ± 1.42 9.04 ± 1.45 0.68 0.501045
= 0.001). Similarly, sadness too was iden-
tified in male faces (85.9%) better than 9.46 ± 1.33 8.91 ± 1.25 3.14 0.001924*
Total (106)
female ones (77.8%; P = 0.030). On the 18.37 ± 1.84a
contrary, female happiness (100%) was Each participant identified four sets (two male faces and two female faces) of six EFEs each. Therefore, each par-
correctly identified better than its male ticipant marked (and were scored on) 12 EFEs expressed by male faces and 12 EFEs expressed by female faces (24
images in total). aScore out of 24 total EFEs marked by each participant. *Statistically significant. EFEs: emotional
counterpart (94.8%; P = 0.001). facial expressions.
Further analysis of sex variations
during identification of EFEs showed
Table 4.
that the female participants could iden-
tify negative emotions like fear (53.8%, Proportions of Emotional Facial Expressions (EFEs) Identified
P = 0.04) and sadness better from male Correctly by Study Participants (n = 212)
faces (88.7%, P = 0.09) than from faces EFEs Identified Correctly
of their own sex (Table 6). On the other by Participants
hand, they identified positive emotions
better from female faces than they did EFEs Depicted Female Chi-Squared
from male ones. Interestingly, male par- (n = 212 [100%]) Participants Male Participants Test P Value
ticipants also scored better when iden- Anger 116 (54.7%) 113 (53.3%) 0.09 0.77
tifying emotions from male faces (9.70 Disgust 177 (83.5%) 189 (89.2%) 2.88 0.09
± 0.327) than they did from female ones
Fear 99 (46.7%) 95 (44.8%) 0.15 0.69
(8.77 ± 0.280) (Table 3). This was most
Happiness 201 (94.8%) 212 (100%) 11.29 0.001*
pronounced in the cases of negative emo-
tions such as anger (male face = 61.3%; Sadness 179 (84.4%) 168 (79.3%) 1.92 0.17
female face = 45.3%; P = 0.02), fear Surprise 196 (92.5%) 202 (95.3%) 1.48 0.23
(male face = 53.8%; female face = 35.9%; Each of the 106 participants identified four sets of EFEs (each containing six EFEs). Each participant marked four
P = 0.01) and to a lesser extent in the case images of each EFE (24 images in total). Therefore, 53 female participants marked a total of 212 images for each
EFE. Same for male participants. *Statistically significant.
of sadness and disgust.

Original Article
Table 5.
respectively, the vice versa was not ob-
served. The shared visual cues between
Differences in the Identification of EFEs from Male/Female Faces these emotions (expression of anger and
(n = 212) disgust share a brow-lowering compo-
EFEs Identified nent; while surprise and fear share simul-
Correctly from taneously raised eyebrows, flared nostrils,
Faces
and open mouth)26 could have led to their
EFEs Depicted Chi-Squared misidentifications. Other, more intense
(n = 212 [100%]) Female Faces Male Faces N Test P Value visual cues probably led to the preven-
Anger 106 (50%) 123 (58%) 2.73 0.10 tion of similar mistakes when emotions
Disgust 181 (85.4%) 185 (87.3%) 0.32 0.57 like disgust or surprise were shown. The
Fear 80 (37.7%) 114 (53.8%) 11.07 0.001* increased confusion between fear and
Happiness 212 (100%) 201 (94.8%) 11.32 0.001*
surprise (which share several visual char-
acteristic cues) as compared to anger and
Sadness 165 (77.8%) 182 (85.9%) 4.68 0.030*
disgust also favors this assumption.
Surprise 200 (94.3%) 198 (93.4%) 0.15 0.70
In line with prior research,27 our find-
Each participant identified four sets (two male faces and two female faces) of six EFEs each. Therefore, a total of ings reiterate the lack of differences be-
106 study participants marked 212 images of EFEs expressed by male faces and 212 images of EFEs expressed by
female faces. *Statistically significant. EFEs: emotional facial expressions. tween the overall accuracy of the male
and female participants in the identi-
displays (laughter) have been seen to (females correctly identified 84.4% of fication of EFEs, except for a slight ad-
represent appeasement and playfulness, sadness versus male participant who vantage noticed for male participants in
respectively. Both functions play an im- could correctly identify 79.3% of images identifying happiness.
portant role in the de-escalation of con- depicting sadness). Another important finding of the
flicts, an aspect that is preserved in the Of the misidentified emotions, though study was the significant differences
social functions of human smiles and anger and fear were misidentified most in the accuracy observed between male
laughter.21 Because the correct identifi- commonly as disgust and surprise, and female faces. It was observed that
cation and interpretation of these emo-
tions reduce conflicts as well as improve Table 6.
survival in populations, expressions of Proportions of EFEs Identified from Female and Male Faces by
positive emotions like happiness might Participants (n = 106)
have evolved in humans to be more high-
EFEs Identified by
ly recognizable across sexes. Participants
Participants were the least accurate in from Faces
identifying negative emotions such as Sex of Chi-
fear or anger—only 45.8% and 54%, re- Partici- EFEs Depicted Female Squared
pants (n) (n = 106 [100%]) Faces Male Faces Test P Value
spectively of these emotions were iden-
tified correctly. These emotions do not Anger 58 (54.7%) 58 (54.7%) 0.0 1
appear to have social connotations; their Disgust 88 (83%) 89 (84%) 0.4 0.84
primary purpose seems to be respond- Fear 42 (39.6%) 57 (53.8%) 4.29 0.04*
ing to emotional experience.22 Despite 95
Female Happiness 106 (100%) 11.63 0.001*
being a negative emotion, the compara- (53) (89.6%)
tively higher accuracy in the identifica- 94
Sadness 85 (80.2%) 2.92 0.09
tion of disgust might be due to the more (88.7%)
pronounced features associated with 96
Surprise 100 (94.3%) 1.04 0.31
it (wrinkled nose, lowered eyebrows, (90.6%)
squinting eyes, and a gaping mouth).23 Anger 48 (45.3%) 65 (61.3%) 5.45 0.02*
The higher identification accuracy 96
Disgust 93 (87.7%) 0.46 0.50
noticed in the case of sadness can be ex- (90.6%)
plained by the fact that we as humans Fear 38 (35.9%) 57 (53.8%) 6.87 0.01*
are hardwired to identify and recognize Male (53) 106
Happiness 106 (100%) – 0
emotions associated with crying. It has (100%)
has been well documented that the cry Sadness 80 (75.5%) 88 (83%) 1.81 0.18
of an infant represents an honest need 102
Surprise 100 (94.3%) 0.42 0.52
for attention.24,25 Based on this theory, fe- (96.2%)
male participants were expected to score Each participant identified four sets (two male faces and two female faces) of six EFEs each. Therefore, a total
better than males in identifying sadness, of 53 female participants identified a total of 106 images of EFEs from female faces and a total of 106 images of
EFEs from male faces. Same for male participants. *Statistically significant. EFEs: emotional facial expressions.
which was validated by the current study

emotions such as disgust, fear, and sad- static images at 100% intensity of EFEs. 7. Elfenbein HA and Ambady N. On the
ness were identified better (with fear and These represent an ideal situation, and in universality and cultural specificity of
sadness having statistically significant real-world scenarios, most emotions are emotion recognition: a meta-analysis. Psy-
expressed at lower than 100% intensity chol Bull 2002 Mar; 128(2): 203.
findings) in male faces than female ones
8. Morris JS, Öhman A, and Dolan RJ.
by both male and female participants, along with other body language cues.
Conscious and unconscious emotional
and that of happiness and surprise were
generally better identified in female fac- Future Directions learning in the human amygdala. Nature
1998 Jun; 393(6684): 467.
es overall (although male participants Further research into the topic needs to 9. Kirouac G and Doré FY. Accuracy and
identified surprise marginally better be done, using more dynamic scenarios latency of judgment of facial expressions
from male faces than female ones). These as well as using combinations of EFEs of emotions. Percept Mot Skills 1983 Dec;
observations reinforce findings recorded and other verbal and non-verbal cues to 57(3): 683–686.
in existing research.10,28 They might have 10. Hess U, Blairy S, and Kleck RE. The
emulate real-world situations and gen-
intensity of emotional facial expressions
evolutionary roots, as males have histor- erate more data on this topic. Also, the
and decoding accuracy. J Nonverbal Behav
ically been more physically involved in evolution of EFEs themselves and their 1997 Dec 1; 21(4): 241–257.
disputes and conflicts than their female social functions need to be explored in 11. Calvo MG and Lundqvist D. Facial
counterparts. As such, humans have further studies. expressions of emotion (KDEF): identifi-
evolved to identify negative emotions cation under different display-duration
more from the male members of the spe- Conclusion conditions. Behav Res Methods 2008 Feb
cies. Females, being primarily in caregiv- 1; 40(1): 109–115.
Indian medical students could identify
er positions, might have evolved to have 12. Weng HC, Chen HC, Chen HJ, et al.
positive EFEs much better than negative
Doctors’ emotional intelligence and the
more easily identifiable positive EFEs. ones. For most expressions, the accuracy patient–doctor relationship. Med Educ
However, the extent to which these evo- of identifications showed significant vari- 2008 Jul; 42(7): 703–711.
lutionary links exist needs further re- ations with respect to the sex of the ex- 13. Lown BA, McIntosh S, Gaines ME, et al.
search. pressors, but not to the sex of the observer. Integrating compassionate, collaborative
In clinical practice, where the expres- care (the “Triple C”) into health profes-
sion of negative emotions from the Declaration of Conflicting Interests sional education to advance the triple aim
patients as well as their caregivers is The authors declared no potential conflicts of of health care. Acad Med 2016 Mar 1; 91(3):
expected to be more frequent than the interest with respect to the research, authorship, 310–316.
and/or publication of this article. 14. Scheepers RA, Lombarts KM, Van Aken
expression of positive emotions, this in-
MA, et al. Personality traits affect teach-
ability of the future physicians to correct-
Funding ing performance of attending physicians:
ly identify negative EFEs is an interest-
The authors received no financial support for the results of a multi-center observational
ing finding of this study that needs to be research, authorship, and/or publication of this study. PLoS One 2014 May 20; 9(5):
replicated by further research. Medical article. e98107.
curriculum, especially in India, does not 15. Lewis NJ, Rees CE, Hudson JN, et al. Emo-
fully address the training of communica- References tional intelligence in medical education:
tion skills in medical students. This study measuring the immeasurable? Adv Health
1. Troisi A. Ethological research in clinical
brings forth a troubling fact that future Sci Educ 2005 Nov 1; 10(4): 339–355.
psychiatry: the study of nonverbal behav-
16. Spitzer RL, Kroenke K, and Williams
doctors might have potential difficulty ior during interviews. Neurosci Biobehav
JBW. Validation and utility of a self-report
in picking up subtle non-verbal cues that Rev 1999 Nov 1; 23(7): 905–913.
version of PRIME-MD: The PHQ primary
are so important in a doctor–patient re- 2. Grant EC. An ethological description of
care study. JAMA 1999; 282: 1737–1744.
lationship and communication with the non-verbal behaviour during interviews.
17. Lundqvist D, Flykt A, and Öhman A. The
family members. This study suggests the Br J Med Psychol 1968 Jun; 41(2): 177–184.
Karolinska Directed Emotional Faces—KDEF
3. Isaacowitz DM, Löckenhoff CE, Lane
need to address this aspect of training by (CD ROM). Stockholm: Karolinska In-
RD, et al. Age differences in recognition
introducing suitable changes in the ex- stitute, Department of Clinical Neuro-
of emotion in lexical stimuli and facial
isting medical curriculum. science, Psychology Section, 1998. ISBN
expressions. Psychol Aging 2007 Mar;
91-630-7164-9.
22(1): 147.
Limitations 4. Avdibegovic E, Brkic M, and Sinanovic O.
18. Palermo R and Coltheart M. Photographs
of facial expression: accuracy, response
The major limitation is that this study Emotional profile of women victims of times, and ratings of intensity. Behav Res
was done among the medical students of domestic violence. Materia Sociomed 2017 Methods, Instrum Comput 2004 Nov 1;
a single tertiary medical center of India, Jun; 29(2): 109. 36(4): 634–638.
5. Kline JA, Neumann D, Haug MA, et al. 19. Kirita T and Endo M. Happy face advan-
and the sample is therefore not represen-
Decreased facial expression variability in tage in recognizing facial expressions.
tative of all medical students. Another
patients with serious cardiopulmonary Acta Psychol 1995; 89: 149–163.
important limitation is that the KDEF, disease in the emergency care setting. 20. Smith FW and Schyns PG. Smile through
from which the images used in this study Emerg Med J 2015 Jan 1; 32(1): 3–8. your fear and sadness transmitting and
were obtained, was not specifically vali- 6. Ekman P and Friesen WV. Constants identifying facial expression signals over
dated for the Indian population. Also, across cultures in the face and emotion. J a range of viewing distances. Psycholo Sci
the current study was performed using Personal Soc Psychol 1971 Feb; 17(2): 124. 2009; 20(10): 202–208.

Original Article
21. Preuschoft S. “Laughter” and “smile” in 24. Fridlund AJ. The new ethology of human 27. Hall JK, Hutton SB, and Morgan MJ. Sex
Barbary macaques (Macaca Sylvanus). facial expressions. In: Russell J and differences in scanning faces: does atten-
Ethology 1992 Jan 12; 91(3): 220–236. Fernandez-Dols JM, eds. The psychology tion to the eyes explain female superiority
22. Susskind JM, Lee DH, Cusi A, et al. Ex- of facial expression. New York: Cambridge in facial expression recognition? Cognit
pressing fear enhances sensory acquisition. University Press, 1997: 103–129. Emot 2010; 24: 629–637.
Nature Neurosci 2008 Jul 1; 11(7): 843–850. 25. Hauser MD. The evolution of communication. 28. Becker D, Kenrick D, Neuberg S, et al. The
23. Rottman J. Evolution, develop- Cambridge, MA: MIT Press, 1996. confounded nature of angry men and
ment, and the emergence of dis- 26. Susskind JM and Anderson AK. Facial happy women. J Pers Soc Psychol 2007;
gust. Evol Psychol 2014 Apr 1; 12(2): expression form and function. Commun 92(2): 179–190.
DOI:10.1177/147470491401200209 Integr Biol 2008 Oct 1; 1(2): 148–149.

Original Article
Mental-Illness-Related Stigma in Health
Care in South India: Mixed-Methods Study
Thenral Munisami1, Rajesh Kannan Namasivayam2, Arunkumar Annamalai3
ABSTRACT interpersonal, and personal—anti-stigma help seeking behavior of the health care
measures also need to be systematically providers.4 This creates an overall nega-
Background: Stigma related to mental designed. Qualitative studies give more tive impact on health care settings.5
illness is a reality among health care insight regarding the nature of stigma in
providers. This study is an attempt to Mental-health-related stigma is a seri-
medical practitioners toward mental illness
understand the attitudes of doctors from ous public health issue6 and affects the
different specialties toward mental illness Keywords: Mental health, stigma, health quality of life of the patient.7 Undertreat-
and the stigma related to it. care, mixed-methods, South India ment is another issue related to this stig-
Key Messages: Stigma reduction initiatives ma.8 Social marginalization is also prev-
Methods: We used a concurrent nested
mixed-methods approach to understand targeting the healthcare professionals alent in clinical settings.9 In the medical
and identify the various factors of need to be structured covering cognitive, community, health care professionals
mental-illness-related stigma in medical emotional and behavioral aspects. It should face mental health stigma (when affect-
practitioners. Between November 2018 be continuous for sustained changes and ed) and also stigmatize others within the
and March 2019, 100 medical practitioners contact based collaborative program to be community (when another medical pro-
from South India were administered a corrective learning experience.
fessional is affected).10 These covert neg-
A
a self-reporting OMS-HC (Opening ccess to mental health treatment ative attitudes may be due to the lack of
Minds Scale for Health Care Providers), is affected by several barriers, knowledge among doctors during their
followed by in-depth interviews among
of which mental-illness-related medical school training.11,12
25 of the 100 participants selected using
stigma is identified as paramount.1 It Few studies had addressed stigma re-
purposive sampling. Quantitative surveys
were analyzed using SPSSv23. In-depth can be in the form of stereotyping, loss lated to mental illness among medical
interviews were transcribed as extended of status, separation, labeling, discrim- practitioners. Especially, studies among
notes, translated, and initially explored ination using power, or all of the above Indian medical practitioners are lacking.
using focused coding and the constant in various forms and combinations.2 This suggests a need to systematically
comparative method. The stigma related to mental illness and accurately measure the attitudes of
Results: Though findings from quantitative among health care providers is a reality the medical practitioners. To understand
analysis show low to moderate stigma in the existing health care system, which the true nature of this stigma, it is neces-
(Mean = 53.52, SD = 7.61), the qualitative is less studied and affects the general sary to do an exploratory study to identify
study revealed unintended and covert health-seeking behavior of the patients various factors of mental-illness-related
negative attitude toward mental illness. as well.3 This stigma not only affects the stigma in medical practitioners.
Conclusion: As stigma occurs at various patients seeking mental-health-related In this study, we used a concurrent
levels—structural, institutional, help but also affects the mental health nested mixed-methods approach to
Shri Sathya Sai Medical College and Research Institute, Ammapettai, Kanchipuram, Tamil Nadu, India. 2Government Institute of Psychiatric Medicine, Research
1
and Rehabilitation, Government Theni Medical College & Hospital, Theni, Tamil Nadu, India. 3LAMED, Center for Interdisciplinary Research on Language
Acquisition and Allied Sciences, Chennai, Tamil Nadu, India.
HOW TO CITe THIS aRTICle: Munisami T, Namasivayam RK, Annamalai A. Mental-illness-related stigma in health care in South
India: Mixed-methods study. Indian J Psychol Med. 2021;43(1):58–64.
Address for correspondence: Thenral Munisami, 179, First Floor, 14th Cross Street, Submitted: 9 Oct. 2019
Defence Officer’s Colony, Ekkattuthangal, Chennai, Tamil Nadu 600032, India. Accepted: 8 apr. 2020
E-mail: drthenralmd@gmail.com Published Online: 20 Jul. 2020

Original Article
understand and identify the various correlate with higher stigma. The scale members’/relatives’ mental health is-
factors of mental-illness-related stigma has Cronbach’s α of 0.77.13 sues? (Issues addressed in questions 1
in medical practitioners. The study was The participants were followed up for and 2.)
designed to understand the attitudes their responses. The responses were ob- 4. As an administrator, what are the
of doctors from different specialties to- tained as a separate Word document at- aspects you would consider in the
ward mental illness and to deconstruct tached in the mail. Reminders were given placement of a person whose mental
and analyze the various components of after a couple of weeks. No personal identi- illness has improved? (Nature of job,
stigma related to it. fiers were collected from the respondents. disclosure, timings.)
Out of the 225 doctors, 67 did not re- 5. How interested are you in commu-
Materials and Methods spond to the email. Out of the 158 respons- nicating with a psychiatrist and how
This was a mixed-methods study. It was es received, only 100 cleared the checks often do you interact with the psy-
approved by the Institutional Ethical for completeness and consistency. Out chiatrist in your workplace in dis-
Committee. The quantitative compo- of these 100 doctors with complete re- cussing about patients? (Referral, fol-
nent used random sampling, while the sponses, 25 were purposively chosen for low-ups, doubts and clarifications,
qualitative component used purposive in-depth interviewing. The choice of doc- liaison issues.)
sampling. Between November 2018 and tors was done based on representativeness Quantitative survey was analyzed us-
March 2019, 100 medical practitioners, from the five cities and also the specialties ing SPSSv23. The in-depth interviews
across various specialties, working at dif- that were approached for the quantita- were transcribed as extended notes,
ferent health care levels in South India tive survey. After procuring permission, translated, and initially explored us-
were randomly chosen using the lottery AK met them in person at their places of ing focused coding and constant com-
method. The methodology for choosing work and interviewed them. The findings parative method.14,15 A few emergent
the participants is as follows. were taken as field notes. The author who codes and categories were identified
Five states of South India and their re- conducted the interview in person (AK) is from the text and added to the existing
spective capitals were chosen, namely a trained qualitative researcher with over codes gained from observational stud-
1. Tamil Nadu, Chennai ten years of experience in qualitative re- ies. Axial coding was done to develop
2. Andhra Pradesh, Vijayawada search. The following interview guide was connections between the categories
3. Karnataka, Bangalore used for the in-depth interviewing: derived from all the data. Themes were
4. Kerala, Trivandrum 1. As a doctor, what are the challenges identified by looking for similarities,
5. Telangana, Hyderabad you face in dealing with mentally ill differences, and relationships between
Premier tertiary care centers from patients? (In diagnosing, treating, ex- categories.16
these cities were chosen. Five doctors plaining, referring, and other issues.)
from each of the following specialties 2. In case of your own mental health is- Results
sues, what aspects would you consid-
were randomly chosen to be contact-
er in seeking help? (Modality of treat- Participant Characteristics
ed for the study: pediatrics, obstetrics,
general surgery, general medicine, der- ment, place, timing, trials, disclosure.) Table 1 shows the sociodemographic
matology, anesthesiology, ENT, and oph- 3. How do you deal with your family characteristics of the participants. Table 2
thalmology. Five general practitioners Table 1.
belonging to the same geographic loca-
tion too were randomly chosen using
Sociodemographic Characteristics of the Participants
online directories. Overall, 225 doctors Sociodemographic Characteristics Quantitative (N = 100) Qualitative
were contacted through phone initial- Age Mean: 35.12 years Mean: 34.57 years
ly and explained about the study, and (SD = 2.37) (SD = 1.18)
their email addresses were obtained. A Males n = 40 n = 10
Gender
questionnaire about sociodemographic Females n = 60 n = 15
details (age, gender, specialization, and General practi- 29 5
years of practice) and OMS-HC (Opening tioners
Minds Scale for Health Care Providers) Pediatricians 13 3
was emailed to them. Obstetricians 16 3
The OMS-HC is a 20-item self-report General surgeons 12 2
Specialization
questionnaire on a 5-point scale, orga- Physicians 11 3
nized under three major sub-headings: Dermatologist 5 4
Attitudes of health care providers toward Anesthesiologist 4 2
people with mental illness; disclosure/ ENT specialist 5 2
help-seeking; and social distance. Seven Ophthalmologist 5 1
items (3, 8, 9, 10, 11, 15, and 19) are reverse Number of years of practice Mean: 10.19 years Mean: 11.54 years
coded. The minimum score is 20, and the (SD = 2.13) (SD = 2.94)
maximum score is 100. Higher scores

Munisami et al.
shows the responses of the participants Table 2.

on the OMS-HC. The overall score for
mental-illness-related stigma in medical
Responses to the Opening Minds Scale for Health Care Providers
practitioners in South India show low to (OMS-HC)
moderate stigma (OMS-HC score Mean Neither
= 53.52, SD = 7.614). Agree
Strongly nor Dis- Strongly
Findings from the 1
Questions
I am more comfortable helping a
Disagree
11
Disagree
24
agree
22
Agree
35
Agree
8
Qualitative Research person who has a physical illness
than I am helping a person who
The qualitative analysis using grounded has a mental illness.
theory approach revealed various nodes 2 If a person with a mental illness 12 44 15 25 4
complain of physical symptoms
that were organized into themes, and (e.g., nausea, back pain, or head-
relevant illustrative quotes were selected. ache), I would likely attribute this
Table 3 shows the findings from qualita- to their mental illness.
tive research. They can be broadly classi- 3 If a colleague with whom I work 1 13 13 51 22
told me they had a managed
fied as personal and interpersonal factors. mental illness, I would be just as
willing to work with him/her.
Personal Factors 4 If I were under treatment for a 4 20 22 34 20
mental illness, I would not dis-
Lack of awareness about mental illness
close this to any of my colleagues.
and the resultant unconscious biases 5 I would be more inclined to seek 8 9 13 50 20
are the major reasons why doctors ex- help for a mental illness if my
press stigma-related behavior toward a treating health care provider was
not associated with my workplace.
patient. This lack of awareness, coupled
6 I would see myself as weak if I had 12 19 19 36 14
with a lack of adequate training and a mental illness and could not fix
skills, leads to a failure to recognize and it myself.
diagnose mental health problems. Even 7 I would be reluctant to seek help if 28 42 7 18 5
if identified, doctors felt that it was diffi- I had a mental illness.
8 Employers should hire a person 2 3 8 48 39
cult to explain, treat, and refer patients
with a managed mental illness
to a psychiatrist when the patients them- if he/she is the best person for
selves did not feel a need to do so. All this the job.
affects the patient–provider interactions 9 I would still go to a physician if I 2 20 20 41 17
and the quality of the care. knew that the physician had been
treated for mental illness.
The acceptance of mental illness in sig-
10 If I had a mental illness, I would 10 16 28 33 13
nificant others is debatable and differs tell my friends.
from doctor to doctor though treating 11 It is the responsibility of health 2 3 2 28 65
the illness has always been emphasized. care providers to inspire hope in
When the doctors themselves are affect- people with mental illness.
12 Despite my professional beliefs, 43 36 12 7 2
ed, they prefer nonjudgmental psychi-
I have negative reactions toward
atrists and preferred disclosure to men- people who have a mental illness.
tal health professionals who are mostly 13 There is little I can do to help 16 27 13 33 11
unknown to them. However, they felt people with mental illness.
no discomfort in taking treatment for 14 More than half of people with 5 14 23 43 15
mental illness do not try hard
their mental illness. When it comes to
enough to get better.
the workplace culture, the doctors re- 15 People with mental illness seldom 8 33 26 26 7
spected the privacy of the patients. They pose a risk to the public.
invariably stated that they prefer nondis- 16 The best treatment for mental 19 24 23 20 14
closure policies and felt that mentally ill illness is medication.
patients have the right to pursue their 17 I would not want a person with 14 34 18 30 4
a mental illness, even if it were
vocation, provided the illness does not
appropriately managed, to work
interfere with productivity. with children.
18 Health care providers do not need 18 29 27 24 2
Interpersonal Factors
to be advocates for people with
Doctors, when faced with challenges in mental illness.
identifying/diagnosing mental health is- 19 I would not mind if a person with 1 11 10 48 30
mental illness lived next door to me.
sues, felt that liaising with mental health
20 I struggle to feel compassion for a 18 38 15 13 16
experts is an issue to be addressed. person with mental illness.
Also, there are difficulties in referrals,

Original Article
follow-ups, doubts, and clarifications, Table 3.

which affect holistic patient care.
Findings from Qualitative Research
Discussion Themes Nodes Frequency Findings Illustrative Quotes
Stigma is a combination of several in- Challenges Diagnosing 15 Most of the par- “Taking a history and
faced in ticipants reported making a provision-
dependent and interrelated factors.2
dealing with difficulty in diagnos- al diagnosis is very
Studies have reported a commixture of mentally ill ing mental health challenging when it
emotional, behavioral, and cognitive patients problems comes to mental illness
components leading to a cascade of label- … specially when the
symptoms and signs
ing, othering, devaluation, and discrim-
are not clear” (General
ination.17 The process of stigmatization practitioner, 12 years’
and its consequences happen in tandem experience)
at various levels: personal, interpersonal,
Treating, 10 Some of them stated “Explaining the need
and structural.18 Stigma fosters fear, ap- explaining, that it was difficult to to meet a psychiatrist
prehension, and distorted views of men- and explain to the patients is very difficult… They
tal illness and psychiatry.19 referral about the mental become very defensive
Though OMS-HC indicated low to illness, treat them, or when we ask them to
refer to a psychiatrist, visit a psychiatrist…
moderate stigma and a positive attitude when the patients They keep asking why
and approach to mental illness among themselves do not feel they should meet them
doctors, the interviews revealed many a need to do so. (mental health ex-
unintentional discriminatory behaviors, pert)…” (Physician, ten
years’ experience)
which they were unaware of. This reflect-
ed a tendency to “see the illness ahead Mental health The expecta- 13 Most of them expected “When I face any
of the person” and could contribute to help-seeking tion from the the psychiatrist to be mental health issue…
dismissive behaviors such as addressing behavior doctor nonjudgmental I would like to visit a
psychiatrist only if they
mentally ill persons as “difficult” and
are nonjudgmental…
“manipulative.” Also, they held pessimis- Otherwise, I might think
tic views about the course of illness, treat- twice before taking any
ment duration, and treatment outcome, professional help…”
(Obstetrician, eight
which may affect the mental health seek-
ing behavior of the doctors. This reso-
nates with previous studies that mention Modality of 21 Most of them stated “If I have any mental ill-
mental-illness-related stigma in health treatment that they did not have ness… I will not hesitate
any issues with taking to take medications…
care as a barrier to access and care.20
medications. (Dermatologist, nine
In the present study, the challenges years’ experience)
doctors face in dealing with mentally ill
patients fell under “what and how to say “If taking medicines is
the only option, I will
and do” categories of problems. Though
take them” (General
many had little or no difficulty in identi- surgeon, 11 years’ expe-
fying psychiatric issues in their patients, rience)
they felt that they are ill-equipped to
Disclosure 11 Some of them said that “I would prefer to keep
persuade the patient for a psychiatric
they would prefer to my mental illness
referral. Similar studies have shown that disclose their mental private… I would reveal
there is a long-standing difference of health issues to some- my mental illness
opinion among the nonpsychiatric doc- one unknown to them. to any doctor who is
unknown to me or my
tors about the appropriateness of psy-
social circle…” (General
chiatric referrals.21 The doctors, during practitioner, 14 years’
the in-depth interviews, were more con- experience)
cerned about the side-effects of psycho-
tropics and the duration of treatment. Dealing Taking expert 20 Bringing insight to the “When my friends or
with mental help patient was of prime relatives suffer from
Studies from Swedish primary care also
health issues importance to most of any mental issues, I will
reported similar findings of skepticism among signif- the participants. explain the nature of the
related to medications.22 Some practi- icant others illness and encourage
tioners, in our study, reported that they them to take psychiatric
opinion…” (Pediatrician,
start a few patients on benzodiazepines
10.5 years’ experience)
as sedatives and anti-anxiety agents, al-
beit for a short term, without consulting

Munisami et al.
other doctors remain very low, and many

Themes Nodes Frequency Findings Illustrative Quotes private super-specialty hospitals and
Acceptance 6 Some of them reported “Accepting mental tertiary care centers function without
difficulties in accepting illness in spouse or
a psychiatry department.25 Psychiatry
mental illness in signif- kids is not easy… It
icant others. takes time… And also, has been alienated, ostracized, and side-
the process of seeking lined from the mainstream medicine and
professional help is not has been rightly called the “Cinderella”
easy… I would wonder
of medicine.26 It has always been a direct
how the people around
us would respond, etc…” consultation by the patient or relatives
(General practitioner, when the reasons are obvious and, at
eight years’ experience) times, by doctors when the behavioral
Being an ad- Recruiting 23 Most of them stated “I don’t think I would disturbances are unmanageable. Many a
ministrator people that they would not ever reject any suitable time, referrals are made only when they
reject a person because candidate just because
of mental illness. he/she has mental are sought for.27,28
illness…” (General Previous studies showed that in the
practitioner, Hospital case of their (doctors) illness, perceived
Administrative Head, stigma was higher than self-stigma, and
nine years’ experience)
also they were not sure about adherence
Disclosure 25 All of them stated that “Revealing the news to
to medication.29 When it comes to the
they would not disclose the patient’s relatives
without the consent of would require the matter of mental illness among their sig-
the patient. consent of the patient… nificant others, doctors were more con-
Without consent, it is vinced of the need for treatment in the
unethical…” (General
elderly but found it difficult to persuade
surgeon, 11 years’ expe-
rience) them for treatment.30 On the contrary,
Interaction Referral, 22 Most of the respon- “Calling up a psychia-
for their own children, they were not
with psychi- follow-ups, dents stated that trist to clarify doubts very convinced for taking any psychiatric
atrist doubts and there are difficulties in or refer the patients to consultation for stress-related issues and
clarifications giving referrals, doing them is not easy… Most were highly skeptical about starting psy-
follow-ups, clearing of the times, there is not
doubts, and getting much communication chotropics.31 Even in this present study,
clarifications regarding between the mental in-depth interviews reflected this skep-
the mental illness health experts and us, tical attitude of nonpsychiatric doctors
especially in private toward psychiatric medications.
practice…” (Anesthe-
siologist, 12 years’ Doctors in the study felt that the spec-
experience) trum of mental illness is vast and could
Liaison issues 4 A few of them reported “Working in collabo- not be categorized under an umbrella
issues in liaising with ration with a mental term “psychiatric disorders.” In-depth in-
mental health experts health professional in terviews revealed that they saw common
treating a patient is
psychiatric illnesses differently from
still a distant reality…
The system is just not serious mental health disorders. Also,
there to enable smooth the attitudes of the respondents toward
liaison…” (Physician, 14 mental illness varied widely between
manageable mental illnesses that are
common and severe psychiatric illnesses
a psychiatrist. The reasons cited were dif- symptoms, and discussing the treatment
that required hospitalization.
ficulty in convincing the patients to con- with the patient. The majority accept so-
The in-depth interviews revealed that
sult a psychiatrist, the perceived stigma cial distancing and attribute it to the na- doctors had a better understanding of
of mental illness, and poor communica- ture of the mental illness. Many expect- psychotic and neurotic illnesses than
tion and rapport the doctors had with the ed the psychiatrist to play an active role substance use and personality disorders.
psychiatrist. Similar problems of lack of in sensitizing the fellow doctors and to They were not much convinced about the
rapport between nonpsychiatric doctors participate actively in general case con- need for referral and the reliability of per-
and psychiatrists have been reported in ferences and academic meets. Academic sons with substance use disorders in case
the literature, and this has been known literature cites similar suggestions from of employment. They were not convinced
to affect the delivery of quality care.23 nonpsychiatric doctors who stated the about referring a patient for psychiatric
On the other hand, when dealing with need for sensitization by psychiatrists.24 treatment (even when there were symp-
psychiatric patients referred to them, the Consultation-Liaison Psychiatry (C-L toms suggestive of underlying mental
nonpsychiatric doctors find difficulty Psychiatry) is almost nonexistent in In- illness), an attitude that is commonly en-
in eliciting the history, delineating the dia. Studies show that referral rates from countered in regular clinical practice.27,28

Original Article
Alienating, segregating, and ostraciz- of the findings. The concurrent mixed- 11. Kallivayalil R. The importance of psychi-
ing psychiatry continues, and though method design was chosen to offset the atry in undergraduate medical education
public awareness about mental health weakness due to <50% responses in the in India. Indian J Psychiatry 2012 Jul;
54(3): 208. http://www.ncbi.nlm.nih.gov/
has improved, health care professionals quantitative survey and single inter-
pubmed/23226842. Cited October 28, 2019.
need to “unlearn” many erroneous con- viewer bias in qualitative research. The
12. Chawla JM, Balhara YPS, Sagar R, et al.
cepts about psychiatric issues. But for a study was self-funded, which affected Undergraduate medical students’ attitude
few conditions, it has been reported that the scale of research. Hence, a limited toward psychiatry: a cross-sectional study.
they hold a nihilistic attitude about re- number of respondents were chosen, Indian J Psychiatry 2012 Jan; 54(1): 37–40.
covery from the illness.32 and the study was limited to South India. 13. Modgill G, Patten SB, Knaak S, et al.
As stigma occurs at various levels Future research focusing on rigorous Opening Minds Stigma Scale for Health
(structural, institutional, interpersonal, evaluation and standardization of an- Care providers (OMS-HC): examination of
and personal), anti-stigma measures also psychometric properties and responsive-
ti-stigma measures and testing the de-
ness. BMC Psychiatry 2014 Dec 23; 14(1):
need to target the same. The strategies signed intervention methods for effective-
120. http://bmcpsychiatry.biomedcentral.
to be implemented should be integrated ness could guide us in the right direction. com/articles/10.1186/1471-244X-14-120.
both vertically and horizontally.33 Cited October 29, 2019.
The structural level includes insurance Declaration of Conflicting Interests 14. Charmaz K. Constructing grounded theory:
coverage, budget allocation, legislation, The authors declared no potential conflicts of a practical guide through qualitative analysis.
and policies, especially encouraging interest with respect to the research, authorship, London, UK: SAGE Publications, 2006:
mental health-seeking behavior among 223 p.
health care providers. Institutional, 15. Glaser BG, Strauss AL, and Strauss AL. The
Funding discovery of grounded theory. UK: Routledge,
interpersonal, and personal level are
The authors received no financial support for the 2017. https://www.taylorfrancis.com/
closely knit, and “catching them young,” research, authorship, and/or publication of this books/9781351522168. Cited October 28, 2019.
and training medical students, interns, article.
16. Gibson WJ and Brown A. Working with
postgraduates, and resident doctors qualitative data. London, UK: SAGE, 2009:
with more emphasis on treating men- References 222 p.
tal illness within the same ontological 1. Abbey S, Charbonneau M, Tranulis C, 17. Goffman E. Stigma: notes on the management
realm as other illnesses is a key step in et al. Stigma and discrimination. Can J of spoiled identity. New York: Simon &
achieving “conceptual parity” and inte- Psychiatry 2011 Oct; 56(10): 1–9. Schuster, 1963: 147 p.
gration of psychiatry into mainstream 2. Link BG and Phelan JC. Conceptualizing 18. Livingston JD. Mental Illness-Related
stigma. Annu Rev Sociol 2001 Aug 28; Structural Stigma | Mental Health Com-
medicine.33
27(1): 363–385. mission of Canada, 2013. https://www.
Sensitizing the nonpsychiatrists about
3. Henderson C, Noblett J, Parke H, et al. mentalhealthcommission.ca/English/
the magnitude of mental health issues, media/3477. Cited October 30, 2019.
Mental health-related stigma in health
the heterogeneity of the presenting com- 19. Ungar T, Knaak S, and Szeto AC. Theoret-
care and mental health-care settings. Lan-
plaints, the impact of psychiatric treat- ical and practical considerations for com-
cet Psychiatry 2014 Nov; 1(6): 467–482.
ment on the overall improvement and 4. Ross CA and Goldner EM. Stigma, bating mental illness stigma in health
well-being of the patient, and also the negative attitudes and discrimination care. Community Ment Health J 2016 Apr
increased gratification for themselves for towards mental illness within the nursing 15; 52(3): 262–271.
being “holistic” is an important strategy profession: a review of the literature. J 20. Knaak S, Mantler E, and Szeto A. Mental
illness-related stigma in healthcare: barri-
in combating stigma. Positive role mod- Psychiatr Ment Health Nurs 2009 Aug;
16(6): 558–567. ers to access and care and evidence-based
els can bring about a change in organiza-
5. Wallace JE. Mental health and stigma in solutions. Healthc Manage Forum 2017
tional cultures.33 Mar; 30(2): 111–116.
the medical profession. Health (London)
Stigma reduction programs should be 21. Hull J. Psychiatric referrals in general
2012 Jan 25; 16(1): 3–18.
an ongoing and continuous process fo- practice. Arch Gen Psychiatry 1979 Apr
6. Corrigan P. How stigma interferes with
cusing on pre-service and in-service train- mental health care. Am Psychol 2004 Oct;
1; 36(4): 406. http://archpsyc.jamanet-
ing of all cadres of health professionals. work.com/article.aspx?doi=10.1001/
59(7): 614–625.
archpsyc.1979.01780040048005. Cited
De-stigmatizing mental illness should 7. Smith M. Stigma. Adv Psychiatr Treat
October 30, 2019.
be done through an emphasis on incor- 2002 Sep 2; 8(5): 317–323.
22. Svensson SA, Hedenrud TM, and
porating elements designed to increase 8. Oliver MI, Pearson N, Coe N, et al. Wallerstedt SM. Attitudes and behaviour
knowledge, develop skills, and change Help-seeking behaviour in men and wom- towards psychotropic drug prescribing
the attitude toward mental illness. The en with common mental health problems: in Swedish primary care: a questionnaire
programs should target the uninten- cross-sectional study. Br J Psychiatry 2005 study. BMC Fam Pract 2019 Dec 5; 20(1): 4.
Apr 2; 186(4): 297–301. https://bmcfampract.biomedcentral.com/
tional, unconscious bias toward mental
9. Thornicroft G. Stigma and discrimination articles/10.1186/s12875-018-0885-4. Cited
illness and be a truly myth-bursting and
limit access to mental health care. Epide- October 30, 2019.
transformative learning experience.33 miol Psichiatr Soc 2008; 17(1): 14–19. 23. Shrivastava A, Johnston M, and Bureau
The study has the following limitations: 10. Sayce L. Stigma, discrimination and social Y. Stigma of mental illness-1: clinical
lower response rate from the respon- exclusion: what’s in a word? J Ment Heal reflections. Mens Sana Monogr 2012 Jan;
dents, which affects the generalizability 1998 Jan 6; 7(4): 331–343. 10(1): 70–84.

Munisami et al.
24. Ahmedani BK. Mental health stigma: 28. Grover S, Sahoo S, Aggarwal S, et al. Rea- issues: a meta-synthesis. Neuropsychiatr
society, individuals, and the profession. J sons for referral and diagnostic concor- Dis Treat 2016; 12: 2807–2818.
Soc Work Values Ethics 2011; 8(2): 41–416. dance between physicians/surgeons and 32. Drake RE and Whitley R. Recovery and
25. Grover S. State of consultation-liaison the consultation-liaison psychiatry team: severe mental illness: description and
psychiatry in India: current status and an exploratory study from a tertiary care analysis. Can J Psychiatry 2014 May; 59(5):
vision for future. Indian J Psychiatry 2011 hospital in India. Indian J Psychiatry 236–242.
Jul; 53(3): 202. http://www.ncbi.nlm.nih. 2017; 59(2): 170. http://www.ncbi.nlm. 33. Committee on the Science of Changing
gov/pubmed/22135437. Cited October 28, nih.gov/pubmed/28827863. Cited Octo- Behavioral Health Social Norms; Board on
2019. ber 30, 2019. Behavioral, Cognitive, and Sensory Scienc-
26. Arena E. Oxford handbook of psychiatry. 29. Kamaradova D, Latalova K, Prasko J, et al. es; Division of Behavioral and Social Sci-
3rd ed.pdf. https://www.academia. Connection between self-stigma, adher- ences and Education; National Academies
edu/35843898/Oxford_Handbook_of_ ence to treatment, and discontinuation of Sciences, Engineering, and Medicine.
Psychiatry_3rd_Ed.pdf. Cited October 30, of medication. Patient Prefer Adherence Approaches to reducing stigma. In: Ending
2019. 2016; 10: 1289–1298. discrimination against people with mental and
27. Keertish N, Sathyanarayana MT, Kumar 30. Kua EH. Psychiatric referrals of elderly substance use disorders. Washington, DC:
BGH, et al. Pattern of psychiatric referrals patients in a general hospital. Ann Acad National Academies Press, 2016 Aug 3.
in a tertiary care teaching hospital in Med Singapore 1987 Jan; 16(1): 115–117. https://www.ncbi.nlm.nih.gov/books/
southern India. J Clin Diagn Res 2013 31. Choudhry FR, Mani V, Ming LC, et al. Be- NBK384914/. Cited October 30, 2019.
Aug; 7(8): 1689–1691. liefs and perception about mental health

Original Article
exploratory Factor analysis of Young’s internet
addiction Test among Professionals from india:
an Online Survey
Mamidipalli Sai Spoorthy1, Lokesh Kumar Singh2, Sai Krishna Tikka2, Suchandra Hari Hara3
ABSTRACT two factors that explained 49% of the of behavior addiction, and its compo-
variance (Kaiser–Meyer–Olkin measure of nents, like that of substance use, include
Background: Internet use has spread sampling adequacy: 0.95, Bartlett’s test of salience, tolerance, withdrawal, conflict,
across the world due to easy accessibility sphericity: P = 0.000). They were “mood relapse, and mood modification. Young
and affordability. However, it has been and relationship issues” and “duration
creating many problems at several took the first initiative for the measure-
and productivity.” Cronbach’s α was 0.92,
levels. So, there is a need to identify the ment of the existence of this entity. She
which indicates a high level of internal
suitability of psychometric properties and adapted the DSM-IV criteria for patho-
consistency.
the factor structure of the widely used logical gambling and designed a scale
Internet Addiction Test (IAT) in the Indian Conclusion: In Indian settings, IAT can that can detect and classify IA.1,2
settings. Our objective was to perform an be understood based on the two-factor Prevalence of IA based on a worldwide
exploratory factor analysis on the IAT and structure. The scale has excellent reliability.
review had shown that the rates range
to test the reliability of the scale. Further studies are needed to replicate
from 1.5% to 8.2%.3 Another survey from
these results, by using confirmatory factor
Methods: It was a cross-sectional study 11 European countries, reported an over-
analysis and validity testing.
that included various professional groups. all prevalence rate of 4.4% (mean age of
We used an online questionnaire that Keywords: Factor analysis, internet included students: 14 years).4 Consider-
included sociodemographic details and addiction, professionals, reliability, validity ing the diverse rates of IA from different
Young’s IAT. Exploratory factor analysis Key Messages: Internet Addiction Test can studies, it is important to understand
was used to identify the factor structure of
be explained based on a two-factor model the influence of culture, education, so-
Young’s IAT in the Indian setup.
among professionals in India—mood cio-economic background, and belief
Results: The mean age of the sample (N and interpersonal issues, and duration systems on these rates. The previous de-
= 1,782) was 27.7 years (SD = 8.74) with and productivity. The two factors overall cade has also seen a rise in the interest of
a predominantly male population 1040 explained 49% of the variance. The tool had
researchers on IA not only in the Western
(58.4%). In total, 1.0% (17) of the sample a high internal consistency in this sample.
world but also in countries like India. A
I
had significant problems with internet
usage, whereas 13% (232) were in the nternet addiction (IA) or pathologic review of Indian studies that assessed
range of frequent/occasional problems, internet use is on the rise due to the IA showed varying rates of severe/prob-
and the mean score on IAT was 32 (SD = increasing access and affordability of lematic addiction, ranging from 0.3% to
16.42). Exploratory factor analysis revealed the services. It is supposed to be a subset 18.8%.5–7 The studies included had used
1Dept. of Psychiatry, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India. 2Dept. of Psychiatry, All India Institute of Medical Sciences, Raipur,
Chhattisgarh, India. 3Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India.
HOW TO CiTe THiS arTiCle: Spoorthy MS, Singh LK, Tikka SK, Suchandra HH. Exploratory factor analysis of young’s internet
addiction test among professionals from India: An online survey. Indian J Psychol Med. 2021;43(1):65–69.
Address for correspondence: Suchandra Hari Hara, Dept. of Psychiatry, National Submitted: 22 aug. 2019
Institute of Mental Health and Neurosciences, Bangalore, Karnataka 560029, Accepted: 11 apr. 2020
India. E-mail: suchikhhr02@gmail.com Published Online: 20 Jul. 2020
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative aCCeSS THiS arTiCle ONliNe

Spoorthy et al.
different cutoff values for the Internet Considering the lack of validation of the It was an open and voluntary survey
Addiction Test (IAT) and different types IAT in Indian settings, identification of as the participants had the freedom to
of assessment.5 the psychometric properties of this tool decide at the first instance to fill or not
Most of the studies only focused on as- in professional groups is of importance to fill the responses. They were not pro-
sessing the prevalence and severity of IA, as they are more prone to develop IA, vided any incentives for participation
whereas a few assessed co-morbidities considering the access they have to the in the survey. Participants were able to
with IA.5 The majority of these studies internet both at the workplace and the check the completeness of their respons-
focused on assessing IA in school chil- home environment.9 es after filling the questions. They were
dren and adolescents; only a couple of The objective of our study was to car- able to review and change their answers
them tried to study the severity among ry out an exploratory factor analysis of through a review option. No responses
professionals and professional students. Young’s IAT, to assess the reliability of were excluded for the reason of a varia-
However, the sample size of those who the scale among professionals from In- tion in the time taken to fill the survey,
studied the severity in professional dia, and thus, to establish psychomet- unless the responses were incomplete.
groups was less; it ranged between 104 ric properties of Young’s IAT in Indian Participants could only fill the survey
and 846.7–9 Most of the studies done from settings. once through a device, that is, the users
India were pro forma based, except a few8 with the same IP address were not able to
that included web-based assessment. An Materials and Methods access the survey twice, thus preventing
online mode of assessment assessment a duplication of responses. Those who
would probably be a better way of iden- Sample Collection and did not fill the survey initially were sent
tifying IA than the former techniques Study Design one reminder to complete the survey.
because it would identify people who are We used the English version of the IAT
This was a cross-sectional web-based
more vulnerable to develop IA. for this study. It includes 20 items that
(www.surveymonkey.com) survey done
According to the non-Indian studies are rated on a Likert scale ranging from
over two months (January–February
that performed a factor analysis of the 0 to 5: does not apply, rarely, occasional-
2018) through a predesigned online ques-
IAT, the number of factors that can ex- ly, frequently, often, and always. Based
tionnaire, using convenience sampling.
plain the tool had ranged from one to on the scores generated, the participants
The included sample was 18–65 years of
six. The single factor that explained all are classified into four categories by the
age, of either gender, and comprised of
the 20 items was dependence, and the cutoff values as indicated by Young: <20:
students (nursing and MBBS), nurses,
components of the six-factor model were below average users; 20–49: average us-
and doctors (professionals). The study
salience, excessive use, anticipation, dy- ers; 50–79: occasional/frequent problems
was conducted in the Psychiatry and Psy-
scontrol, impairment of work, and social with internet use; and 80–100: signifi-
chology departments of five colleges in
life. The difference is probably due to the cant problems with internet use.13 It is
India (Hi Tech Medical College and Hos-
varied sample size and degree of hetero- a subjective assessment by the partici-
pital, Bhubaneshwar, Odisha; Pt. J.N.M
geneity.10,11 The other most important pants. IAT takes an average of 5–10 min-
Medical College, Raipur, Chhattisgarh;
reasons behind the difference in factor utes for completion.
Amity University, Ranchi, Jharkhand;
structure are the language of the IAT and
the cultural context in which the study
Central Institute of Psychiatry, Ranchi, Analysis
Jharkhand). The primary center for data
was done.10 The responses collected were manually
collection was All India Institute of Med-
However, studies from India that as- entered into an SPSS database, and the
ical Sciences, Raipur. Approval was taken
sessed the psychometric properties of results were analyzed. A total of 2,015
from the institutional ethics committee.
the IAT are rare. To our knowledge, only The questionnaire included an assess- responses were received; 233 were exclud-
one study was done from India that per- ment of sociodemographic details and ed as they were incomplete. So, the final
formed factor analysis and validation scores on the IAT. The survey was pre- sample size was 1,782. The appropriate-
of IAT. It was performed on 1,914 junior tested in All India Institute of Medical ness of the current sample for perform-
and senior high school students from Sciences, Raipur before the actual study ing factor analysis was assessed using the
India and both exploratory and confir- was done, and the questions were mod- Kaiser–Meyer–Olkin measure of sample
matory factor analyses were carried out ified based on the feedback received. adequacy and Bartlett’s test of spherici-
to assess psychometric properties of IAT. The questionnaire was circulated using ty.14 For sampling adequacy, values >0.80
Unlike the developed countries, in In- emails, WhatsApp, and Facebook to the and 0.90 are considered excellent, values
dia, there might be certain cultural and contacts of the investigators. They were between 0.50 and 0.60 marginally ac-
familial factors such as constant urge provided details of the time taken to ceptable, and values <0.50 unacceptable.
for companionship, struggle with au- complete the survey and information The cutoff for loading of items was cho-
tonomy, and freedom-related issues that that filling in the survey implies the pro- sen as 0.4; items with values <0.4 were
might affect IA differently, particularly in vision of informed consent by the partic- excluded from the final analysis.
young adults.12 However, we do not yet ipants. No personal identification details The criteria set for retainment of fac-
know how the pattern of IA is different like name, place of work, or designation tors are as follows: Eigenvalues >1 and
in a wider group, such as professionals. were collected as a part of the survey. the point of inflexion in the scree plot.15

Original Article
Table 1.
findings and the cutoff of 0.4 for retain-
ing of items based on previous studies,
Sociodemographic Characteristics of the Study Sample the analysis was run again after re-
Variables Frequency (%)/Mean (SD) moving items 3, 4, and 5 from the scale
Age (in years) 27.76(8.74) (Table 2). Exploratory factor analysis
Female 742(41.6) generated two factors with eigenval-
Gender ues >1, and the scree plot also showed
Male 1,040(58.4)
inflexion at two factors (Figure 1). The
Doctor 489(27.4)
first factor was named “mood and rela-
Occupation Nursing professionals 611(34.3) tionship issues.” It had an eigenvalue of
Students 682(38.3) 7.2 and explained 42.4% of the variance.
Alone 102(5.7) The second factor was named “duration
Home 876(49.2) and productivity.” Its eigenvalue was
Residence 1.11 and it explained 6.6% of the vari-
Hostel 545(30.6)
ance (Cumulative: 49% of variance). Ten
Private accommodation 259(14.5)
items from the scale loaded on-to the
Gadget most commonly used Desktop/laptop 171(9.6)
first factor, followed by seven items on
to access the internet Mobile phone 1,611(90.4) the second factor.
Results 7.8, followed by 1.13 and 1.02 for the sec- Mean Scores and
ond and third factors, respectively. They Correlation analyses
Sociodemographic Details were extracted after varimax rotation
The mean score on items that loaded
with Kaiser’s standardization. These
of the Sample three factors explained 50% of the vari- onto factor 1 was 14.62 (SD = 9.05), out
Fifty-eight percent of the sample were ance. However, the inflexion in the scree of a maximum score of 50. On factor 2, it
males, and the mean age was 27.7 years plot suggested the presence of only two was 13.94 (SD = 6.79) out of a maximum
(SD = 8.74). In total, 27.4% were doctors factors (Figure 1). score of 35. Both factors were significant-
(Post MBBS, Postgraduates), 38.3% were Thirteen items loaded onto the first ly positively correlated with each other.
students, and 34.3% were nurses (Table 1). factor—mood and relationship issues, Pearson’s product correlation value was
Almost half of the participants were liv- followed by five items onto the factor 0.74 (P = 0.000).
ing in their home, and mobile phone was duration spent, and two items onto im-
the most common gadget used to access paired productivity.
Test of Reliability
the internet. As only two items loaded on the third Cronbach’s α measures internal con-
factor and because of the scree plot sistency and construct reliability. The
Scores on IA Test and the
Results of Factor Analysis Figure 1.
The mean score of participants on IAT Scree Plot Showing Two Factors
was 32, i.e., within the average user range
(SD = 16.42). One percent of the sample
had severe IA causing significant prob-
lems, whereas 13% had mild–moderate se-
verity with frequent/occasional problems.
In total, 63% were average internet users.
Before performing the exploratory fac-
tor analysis, we computed Bartlett’s test
of sphericity (χ2 = 13145.42; P = 0.000)
and Kaiser–Meyer–Olkin measure of
sampling adequacy (0.957: cutoff >0.50).
The determinant value was 0.001,
which suggests that a factor analytic
solution can be met (cutoff>0.0001). The
findings suggest that our sample met the
requirement for generation of distinct
and reliable factors. Exploratory factor
analysis,16 with the 20 items of IAT, re-
sulted in three factors with eigenvalues
>1. The first factor had an eigenvalue of
Spoorthy et al.
by the results of this meta-analysis,

Table 2.
which had shown that the total variance
Factor Loadings on Different Items of IA Test explained by the factors ranged from
Factors 34.1% to 91%.17 Among the factors stud-
Serial
Number Items of the IA test 1 2 ied, time spent was the commonest, fol-
Item 1 How often do you find that you stay online longer than you 0.57
lowed by impairment of social relations
intended? and work.17 We found that mood and
Item 2 How often do you neglect household chores to spend 0.58 relationship issues is the factor with the
more time online? highest loading, followed by duration
Item 6 How often do your grades or schoolwork suffer because of 0.60 spent and impaired productivity. This
the amount of time you spend online? might be partly due to the inclusion of a
Item 7 How often do you check your email/WhatsApp/Facebook/ 0.50 higher age group and the professionals.
YouTube, etc., before something else that you need to do? Replication of the psychometric prop-
Item 8 How often does your job performance or productivity 0.57 erties of this diagnostic tool is of special
suffer because of the internet? importance because the disorder has not
Item 9 How often do you become defensive or secretive when 0.46 gained its place in the nosological sys-
anyone asks you what you do online? tems yet.18 However, the applicability
Item 10 How often do you block out disturbing thoughts about 0.45 of the scale in the settings of different
your life with soothing/calming thoughts of the internet? countries needs to be further assessed.
Item 11 How often do you find yourself anticipating when you will 0.49 It needs special mention that this me-
go online (check Facebook/WhatsApp, etc.) again?
ta-analysis had no study from India.17
Item 12 How often do you fear that life without the internet would 0.53 Based on studies from different coun-
be boring, empty, and joyless?
tries like Spain, Italy, Bangladesh and
Item 13 How often do you snap, yell, or act annoyed if someone 0.58 Turkey, Cronbach’s α of IAT ranged
bothers you while you are online?
0.83–0.91, suggesting good–excellent
Item 14 How often do you lose sleep due to late-night logins? 0.50
reliability of the scale across different
Item 15 How often do you feel preoccupied with the internet when 0.65 settings.19–21 Our study also found that
off-line, or fantasize about being online?
IAT has excellent reliability among pro-
Item 16 How often do you find yourself saying “just a few more 0.58 fessionals in Indian settings. This is in
minutes” when online?
line with the previous Indian study that
Item 17 How often do you try to cut down the amount of time you 0.55
performed factor analysis.12
spend online and fail?
That previous Indian study had
Item 18 How often do you try to hide how long you have been 0.58
online?
shown that IAT can be explained based
on a one-factor model.12 In contrast, we
Item 19 How often do you choose to spend more time online over 0.57
going out with others? found a two-factor solution. This might
be due to the inclusion of participants
Item 20 How often do you feel depressed, moody, or nervous 0.69
when you are off-line, which goes away once you are back with a mean age of 27 years compared to
online? the mean age of 14 years in the previous
Extraction method: principal axis factoring; rotation method: varimax with Kaiser’s normalization. IA: internet study.12 As per the age, the area affected
addiction. by IA can vary, in adults the main effect
of IA would be on mood and relation-
reliability statistics table (Table 3) pro- tional online survey. Our study adds to ship issues compared to duration and
vides the actual value of Cronbach’s α (α = the existing literature about the factor productivity, which might be affected
0.92). This indicates a high level of inter- structure of the IAT. across ages.
nal consistency for the IAT in our sample. A recent systematic review and me- However, the previous study had cer-
ta-analysis tested the validity, internal tain drawbacks: it included solely the ad-
Discussion consistency, and reliability of IAT.17 A olescent population and was geograph-
We tried to replicate the factor analysis total of 25 studies conducted between ically restricted to North India. So, the
of IAT in Indian settings by a cross-sec- 2011 and 2018 were included. It conclud- generalization of the study to the entire
ed that the IAT has acceptable internal country is not possible. Our study tried
Table 3. consistency, test–retest reliability, and to overcome this limitation through the
Reliability Statistics convergent validity in specific groups. online mode of the survey and the in-
Our findings showed that the IAT can be clusion of a heterogeneous population.
Cronbach’s α
Cron- Based on Stan- No. of subdivided into two factors—mood and The inclusion of a heterogeneous sam-
bach’s α dardized Items Items relationship issues, and duration and ple is better than a homogenous sample
0.92 0.92 20 productivity issues and that they explain as heterogeneous samples do not lower
49% of the variance. This is supported the variance and factor loadings.22 For

Original Article
a valid factor analysis, the recommend- 11. Widyanto L and Griffiths M. Internet
Funding addiction: A critical review. J Ment Health
ed sample size is at least 300 or a ratio
The authors received no financial support for the Addict 2006; 4: 31–51.
of 10:1 for respondents to variables. An-
research, authorship, and/or publication of this 12. Dhir A, Chen S, and Nieminen M. Psycho-
other positive thing about our study is article.
metric validation of Internet Addiction
the inclusion of relatively large sample
Test with Indian adolescents. J Educ
size, because exploratory factor analysis References Comput Res 2015; 53: 15–31.
works better with larger samples.23 13. Young K. Internet addiction: Diagnosis
1. Young K. Internet addiction: The emer-
The difference in the number of factors gence of a new clinical disorder. CyberPsy- and treatment considerations. Contemp
obtained depends on many factors like chol Behav 1996; 3: 237–244. Psychother 2009; 39: 241–246
the sample size, the number of variables 2. Young K. Caught in the net: How to recognize 14. 14. Kaiser HF. The application of elec-
in the instrument, the type of factor anal- signs of internet addiction and a winning strate- tronic computers to factor analysis. Educ
ysis used (principal component analysis, gy for recovery. New York, NY: Wiley, 1998. Psychol Meas 1960; 20: 141–151.
exploratory factor analysis, or confirma- 3. Durkee T, Kaess M, Carli V, et al. P-598— 15. Cattell RB. The scientific use of factor analysis
prevalence of pathological internet in behavioral and life sciences. New York, NY:
tory factor analysis), the method used
use among adolescents in Europe: Plenum Press, 1978.
in retaining the number of factors, and
Demographic and health-related risk 16. Yong AG and Pearce S. A beginner’s guide
whether the rotation technique was used
factors. Eur Psychiatry 2012; 27(suppl 1). to factor analysis: Focusing on explorato-
or not. The setting in which the study was ry factor analysis. Tutor Quant Methods
DOI:10.1016/S0924-9338(12)74765-X.
done and the population upon which the 4. Petersen KU, Weymann N, Schelb Y, et al. Psychol 2013; 9: 79–94.
scale was applied have large effects.23,24 [Pathological internet use—epidemiol- 17. Moon SJ, Hwang JS, Kim JY, et al.
Our study has certain limitations. Be- ogy, diagnostics, co-occurring disorders Psychometric properties of the Internet
ing a web-based survey, the results might and treatment]. Fortschr Neurol Psychiatr Addiction Test: A systematic review and
have been affected to some extent by the 2009; 77: 263–271. meta-analysis. Cyberpsychol Behav Soc
volunteer effect and a low response rate. 5. Suchandra KHH, Singh LK, and Mamidi- Netw 2018; 21: 473–484.
palli SS. An overview of internet addiction 18. Grant JE and Chamberlain SR. Expanding
We conducted only the exploratory fac-
in India. Ori Jou of Psy 2018; 26: 6–10. the definition of addiction: DSM-5 vs.
tor analysis and did not perform confir-
6. Yadav P, Banwari G, Parmar C, et al. In- ICD-11. CNS Spectr 2016; 21: 300–303.
matory factor analysis. We also did not
ternet addiction and its correlates among 19. Fernández-Villa T, Molina AJ, García-
test for test–retest reliability or concur- high school students: A preliminary study Martín M, et al. Validation and psycho-
rent validity. Further studies need to be from Ahmedabad, India. Asian J Psychia- metric analysis of the Internet Addiction
conducted considering these aspects in try 2013; 6: 500–505. Test in Spanish among college students.
their methodology. 7. Sharma A, Sahu R, Kasar PK, et al. Inter- BMC Public Health 2015; 15: 953.
net addiction among professional courses 20. Faraci P, Craparo G, Messina R, et al.
Conclusions students: A study from Central India. Int J Internet Addiction Test (IAT): Which is
Med Sci Public Health 2014; 3: 1069–1073. the best factorial solution? J Med Internet
IAT has good internal consistency and 8. 8. Grover S, Chakraborty K, and Basu D. Res 2013; 15: e225.
can be understood based on a two-fac- Pattern of internet use among profession- 21. Rezaul Karim AK and Nigar N. The Inter-
tor structure in various professionals’ als in India: Critical look at a surprising net Addiction Test: Assessing its psycho-
groups and students in Indian settings. survey result. Ind Psychiatry J 2010; 19: metric properties in Bangladeshi culture.
More well-designed studies need to be 94–100. Asian J Psychiatr 2014; 10: 75–83.
undertaken, targeting a varied group of 9. Gedam SR, Shivji IA, Goyal A, et al. Com- 22. Kline P. An easy guide to factor analysis. New
subjects. This would help in understand- parison of internet addiction, pattern and York, NY: Routledge, 1994.
ing the reliability and validity of IA in a psychopathology between medical and 23. Field A. Discovering statistics using SPSS for
dental students. Asian J Psychiatr 2016; Windows. New Delhi: SAGE Publications,
better way.
22: 105–110. 2000.
10. Cho H, Kwon M, Choi JH, et al. Develop- 24. Preacher KJ, Zhang G, Kim C, et al.
ment of the internet addiction scale based Choosing the optimal number of factors
The authors declared no potential conflicts of
on the internet gaming disorder criteria in exploratory factor analysis: A model
interest with respect to the research, authorship,
suggested in DSM-5. Addict Behav 2014; selection perspective. Multivar Behav Res
39: 1361–1366. 2013; 48: 28–56.

Viewpoint
Grief in the COVID-19 times: Are we looking at
complicated grief in the future?
Prateek Varshney1, Guru Prasad2, Prabha S. Chandra1, Geetha Desai1
Grief is the price we pay for love. considered a consequence of “bad air and are associated with multiplicity of losses,
—Colin Murray Parkes1 bad emotions,” which compounded the which are different from losses occurring
G
rief is a universal phenomenon stigma in diagnosis and resulted in due to cancer or other illnesses. A review
and a normal response to loss unwarranted ostracization even while on the experiences of grief during previ-
and bereavement.2 It is temporal- grieving. The Spanish Flu (1918) did see ous pandemics, with lessons for the
ly preceded by a loss ranging from per- some discussion on scientific understand- COVID-19 times, highlighted the possibil-
sonal to societal. Grief reactions range ing of the illness; nevertheless, prevalent ity of risk of complicated grief.5
from being a normal phenomenon to socioreligious etiological models
diagnosable psychiatric conditions. This What Is Complicated Grief?
elucidates the importance of discussing Periods of loss and grief can translate
this concept of grief, which is identified into positive consequences of
as an intense yearning for what is lost, as readjustment and healing responses,
a pathognomonic feature, along with ac- resulting in resilience and post-traumatic
companying emotional, cognitive, physi- growth.6,7 However, in some individuals,
cal, and behavioral manifestations.2,3 grief reactions can differ from the normal
The seed of grief may sprout from the resolution, either in intensity or duration.
soil of the psyche, nurtured by bereave- This is considered as complicated grief,
ment or non-bereavement-related losses. which is described as “an intense and
The shade of grief may provide respite prolonged, impairing form of grief
to cope with the harsh loss and leads to wherein an individual gets indefinitely
recuperation of the individual from the perpetuated fear about sexual routes of stuck in the incapacity to process the loss
loss. The process of mourning is an im- transmission and impaled the dignity in and move on in life, with a persistent
portant protective factor against patho- dying and the bereaving. In the more yearning.” A systematic review of risk
logical grief.4 recent pandemics of Severe Acute factors for complicated grief identified
Respiratory Syndrome (SARS), Middle factors present prior to death such as
Pandemics and Grief East Respiratory Syndrome (MERS), insecure and disorganized attachment
It is imperative to acquaint oneself with Ebola, Nipah, and Zika viruses, though styles, adverse childhood experiences,
the sequential pandemics that have the models of transmission have been elu- traumatic experiences in the past, and
molded our understanding of grief’s cidated, the social understandings of the past history of psychiatric illness. Risk
dynamic interactions with pandemics. shadow pandemic of grief is still far from factors identified with death included
The bubonic plague (13th century) was being completely understood. Pandemics bad or violent death, sudden unexpected
National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India. 2Bowring Hospital, Bengaluru, Karnataka, India.
1
HOW TO CITE THIS ARTICLE: Varshney P, Prasad G, Chandra PS, Desai G. Grief in the COVID-19 times: Are we looking at complicated
grief in the future?. Indian J Psychol Med. 2021;43(1): 70–73.
Address for correspondence: Prateek Varshney, Dept. of Psychiatry, National Submitted: 26 Oct. 2020
Institute of Mental Health and Neurosciences, Bengaluru, Karnataka 560029, Accepted: 2 Dec. 2020
India. E-mail: iampprraatteeeekk@gmail.com Published Online: 10 Jan. 2021
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCESS THIS ARTICLE ONLINE

Viewpoint
death, lack of adequate caregiving, and a system, despite best intentions, may not of each member’s bereavement experi-
difficult dying experience.4 Perceived be able to cater to the psychological needs ence. Death of chronically ill, especially
social support, secure attachment, and of the impoverished. The COVID-19 may the older adults, may be overlooked or
self-disclosures are potential protective not have precipitated healthcare defi- minimized by the society. Such pent-up
factors in developing complicated grief. cits, rather may have highlighted the emotions may not be adequately tended
unpreparedness of the healthcare system to in the absence of adequate resources
How Are COVID Times in handling a pandemic. and financial constraints following the
Deaths occurring due to COVID-19
Potentially Contributing to invariably have been labeled as “bad
pandemic. The above factors may result
in “disenfranchised grief ” and interfere
Complicated Grief? deaths” as they include physical and in adequate coping.11
psychological suffering, with physical
The spread of COVID-19 has been rapid, The interdynamics of various predis-
separation from family members, lack
and at present, it has been detected in posing factors such as age, gender, past
of preparation, being treated without
almost every country. Globally, there history of psychiatric illness, social sup-
respect, unwanted medical interventions
have been 62,363,527 confirmed cases port systems, loss of livelihood, and the
or inability to access medical interven-
of COVID-19, including 1456,687 deaths, financial burden of treatment that can be
tions due to financial restraints,10 sudden
as reported by the World Health supportive and indefinite may culminate
progression, and unexpected demise.2
Organization (WHO).8 COVID-19-related into the final outcome of complicated
The suddenness of these outcomes may
deaths can strike anyone, the risk grief. A possibility of prolonged grief dis-
result in the absences of wills and ad-
increasing dramatically with age.3 There vance directives, and there could be mul- order in the wake of COVID-19 has been
is delay in identifying cases due to tiple losses within the family, also called published.14
asymptomatic carriers and subsyndromal “bereavement overload.”11
symptomatology which may often overlap Family members who are survivors
How to Mitigate
with similar viral infections. Patients with could also experience bereavement guilt, the Development of
COVID-19 are often admitted in isolation described as “remorseful emotional reac-
wards in designated COVID-19 hospitals, tion in grieving with the recognition of
Complicated Grief?
with minimal face-to-face contact with having failed to live up to one’s own stan- Identifying and discerning the various
family members, and may progress to dards and expectations in relationship forms of loss and consequent grief may
complications within a few days. Death to the deceased and or the death.” The facilitate the requisite prevention and
may ensue in an isolated setting. Most of grief may be exacerbated with the guilt treatment strategies. The loss of a close
the time, health care professionals may be of having survived the illness, unlike the one is in itself considered a primary loss
by the side of the dying. They too often are deceased, resulting in “survivor guilt.” and the consequences of this primary loss
wearing personal protective equipment, The risk of infection may necessitate such as loss of companionship, sexual
which may inadvertently mitigate their the disposal of the body without the intimacy, and changes in family roles
ability to reciprocate and/or gauge the family members being able to see the are conceptualized as “secondary.” The
patient’s emotions. deceased’s face and body and not be- mentioned problems, compounded by
The deaths and consequent grief arising able to perform cremation and final multiple losses in a single family and
ing from the ongoing pandemic possi- rites. Mourning and performing the fi- the often-prevalent ambiguity around
bly shares features with grief related to nal rites is a cultural defense12 that is not
such losses, make closures hard. This
natural disasters and after intensive care done during the ongoing pandemic and
could bolster frustration, helplessness,
unit (ICU) treatment.9 In situations of results in lack of these ceremonies, like
and disempowerment,15 especially in
pandemics and natural disasters, along face-to-face mourning and consequent
vulnerable and marginalized communities
with the loss of loved ones, there is the closure, potentially leading to guilt in
such as daily wage earners and migrant
closure of facilities, stopping of produc- survivors.13 “Physical distancing” has in-
populations. Furthermore, the loss of jobs
tive activities, reduction in services/sup- variably resulted in “social distancing”;
and lack of financial resources during the
plies, strictly controlled visits, and quick the isolation and quarantine results in
pandemic might add burden to the
descent to deterioration in health.9 “touch starvation.” The travel restric-
ongoing grief. The progression of grief
The healthcare system is overwhelmed tions and forced separations imposed by
into complicated grief is a possibility that
in the ongoing pandemic, and many the government can compound the ex-
can be prevented and mitigated.
may not find access to adequate health pression of grief. The possibility of both
care, which may result in unnecessary over- and underestimation of COVID-
suffering and prolonged turmoil. Even related deaths to avoid fear in public
Communication
when admitted, the consequent inten- may leave one either being overwhelmed Communication between patients,
sive treatment and uncertainty of the du- with impending loss or leave them bliss- family members, and health care workers
ration of hospital stay may surpass the fully unaware regarding the severity of is the key. About COVID-19, one especially
families’ paying capacity, further adding the situation. needs to communicate the need for
financial issues as a source of imped- The multitude of deaths in a family isolation and its resulting separation
ance in grieving. The mental health care may culminate in a lack of recognition from family; a rough estimate of the

Varshney et al.
number of days helps in psychological involved in the treatment, D—dead body smartphones. To circumvent the problem
preparedness for the individual and transportation and cremation has to be of ambiguous loss, the use of digitized
family alike. The family needs to be told done as per protocol and the same should photos of the deceased’s face as an
about the restrictions regarding visits be clearly informed to the family members evidence of death is a viable alternative to
and face-to-face interactions lest they at the end of communicating about the an in-person embrace. Virtual memorial
be left distraught and misinformed. death of a loved one.17 services and performance of final rites
The possibility of unexpected deaths, A space or specific area for grieving may provide short -term support for
asymptomatic carriers, and risk of may help in easier expression of emo- survivors of COVID-19 deaths. The use of
transmission of infection needs to be tions without hesitation and facilitate such services may provide participation
explained in simple language. healthier acceptance of death. of family members and friends who
would have otherwise been devoid of the
The Dignity of the Dying Validation opportunities to offer their condolences
The nearest one can come to his/her near due to travel restrictions, financial
Counseling via telepsychiatry and/or
and dear ones is through the use of video constraints, work commitments, and
telephone by mental health professionals,
calls and virtual images. They provide people who are at high risk for contrac-
with people who have suffered similar
respite, albeit temporary, from the physical ting the infection and developing
losses may act as healthy expressive
and psychological turmoil, while fostering complications.20
modalities and provide comforting
a sense of belonging and social support. In the Indian scenario, the multitude
validation of their distress.
Given the rapid progression and sud- of faiths, religions, and customs makes
The COVID-specific HEALING pro-
den death, planning in terms of the will, it challenging to follow their faith-relat-
cess and DERAILERS in therapy17 which
advance directives, and treatment choic- ed practices of final rites. While trying
highlight the elements that facilitate
es might not be available, more so in the to maintain the safety of those who are
healing and the barriers in the resolu-
Indian setting. Hence, they need to be mourning and bereaving, health care
tion of grief can be adapted in the Indian
proactively sought out for. professionals need to be sensitive to the
context but would probably need more
cultural practices of the deceased.
focus on meaning-making. The inabil-
Opportunities and Space to ity to verbalize emotions and the social Stigma
Grieve acknowledgment of these feelings often
lead to substituted physical complaints Stigma could be a potential barrier to
Breaking bad news has to be done
that may need to be identified. Facilitat- family members of the deceased patients
sensitively and cautiously lest it may
ing psychological and social aspects of of COVID-19 in disclosing their distress
precipitate an emotional turmoil.
grieving becomes imperative. A collectiv- and participating in any rituals related to
Facilitation of acceptance of loss is aided
istic society may act as a buffer for losses the death.21
by adequate social support and expressive
as familial support may be available. At
writings in essays and letters. The sharing
the same time, those away from family Grief Among Health
of positive memories helps in the
upliftment and “continuing bonds.”16 The
may find it difficult to deal with such Workers
losses, due to the unusual circumstanc-
current invisible and physical barriers, Health care professionals who are front-
es of current travel restrictions. Turning
such as healthcare workers garbing line workers have been documented to
to spirituality or religion may also foster
protective equipment, the paucity of time, undergo significant psychological distress
faster acceptance.
and multiplicity of losses necessitate the during this COVID-19 pandemic.13 They
“Grief therapy,”19 which facilitates
need to modify the previous models witness not only their patients but also
grief management, may act as a template
used and the need for innovative, professionals from their own field dying
for developing a specific intervention for
nevertheless feasible, modifications. One due to COVID-19. It is important to
complicated grief. Complicated grief psy-
novel approach conceptualized is the address the grief symptoms among them
chotherapy (CGT) is the best-studied in-
“COVID” practical recommendations, and provide psychological support.
tervention for prolonged and recalcitrant
which entail C—custom-made cubicles to Vicarious trauma is an interesting
grief disorders. It facilitates progression
minimize the risk of transmission whilst concept that holds much relevance in
donning minimal protective gear, O—on through stages of mourning and checks
the current scenario. The unprecedented
admission, briefing about the result, for any derailments. It has been found to
and sudden deaths, with a forced isola-
diagnosis, treatment, prognosis, and be more effective than interpersonal psy-
tion to contain the spread of infection,
expected duration of stay, V—video chotherapy and antidepressants.18
behoove the health care workers to be
chatting between the critical patient and more integrated with the grieving pro-
family should be facilitated and
Ritual Substitutes cess. The concept of “vicarious grief ”
encouraged, I—information regarding In current times, a virtual funeral as a thus becomes more important as the suc-
the demise should be communicated at substitute method of grieving is relevant cessive witnessing of traumatic events,
the earliest and should be done by a person and also accessible, given the technological while being short-staffed due to an
with training or expertise who was advances and universal availability of acute imbalance in demand and supply,

Viewpoint
predisposes health care personnel, espe- 2. Bryant RA. Grief as a psychiatric grief. Dialogues Clin Neurosci [Inter-
cially frontline workers,to internalization disorder. Br J Psychiatry 2012; net] 2012 Jun [cited 2020 Aug 31]; 14(2):
of loss and burnout. This may manifest 201(1): 9–10. 119–128. http://www.ncbi.nlm.nih.gov/
3. Carr D, Boerner K, and Moorman S. pubmed/22754284 (December
as loss of appetite and sleep, irritability,
Bereavement in the time of coronavirus: 16, 2020).
inattention, numbness, fear, and despair,
Unprecedented challenges demand novel 13. Dhadphale M. The living will, cultural
thus increasing the risk of impaired psy- interventions. J Aging Soc Policy [Inter- aspects of death, and mourning rituals.
chological well-being and diminished net] 2020; 32(4–5): 425–431. Ann Indian Psychiatry 2018;
psychological resilience, predisposing to 4. Nakajima S. Complicated grief: Recent 2(1): 47.
grief and its complications. developments in diagnostic criteria and 14. Eisma MC, Boelen PA, and Lenferink
Thus, COVID and its interface with treatment. Philos Trans R Soc B Biol Sci LIM. Prolonged grief disorder following
psychiatric manifestations, especially 2018; 373(1754): 20170273. the Coronavirus (COVID-19) pandemic.
grief, is a potent public health concern. 5. Mayland CR, Harding AJE, Preston N, Psychiatry Res [Internet] 2020 [cited 2020
and Payne S. Supporting adults bereaved Sep 9]; 288: 113031, http://www.ncbi.nlm.
The need for acceptable and affordable
through COVID-19: A rapid review of nih.gov/pubmed/32360895 (December 16,
psychotherapeutic and psychopharma-
the impact of previous pandemics on 2020).
cological interventions in the Indian
grief and bereavement. J Pain Symptom 15. Zhai Y and Du X. Loss and grief amidst
context needs to be looked into. Manage [Internet]. 2020 Aug [cited 2020 COVID-19: A path to adaptation and
Nov 28]; 60(2): e33–e39, http://www.ncbi. resilience. Brain Behav Immun [Internet]
What Does the Future nlm.nih.gov/pubmed/32416233 (2020, 2020 Jul 1 [cited 2020 Nov 22]; 87: 80–81,
Entail? December 16, 2020). https://www.sciencedirect.com/science/
6. Bonanno GA. Loss, trauma, and human article/pii/S0889159120306322?via%3Di-
Grief is a universal phenomenon; however, resilience: Have we underestimated hub (December 16, 2020).
pandemics like COVID-19 might make the human capacity to thrive after 16. Klass D, Silverman PR, Nickman S, Silver-
the grieving process challenging and extremely aversive events? Am Psychol man PR, and Nickman S. Continuing bonds
potentially act as a gateway to complicated [Internet] 2004 [cited 2020 Aug 24]; 59(1): [Internet]. Taylor & Francis, 2014 [cited
grief. We have predominantly focused on 20–28. 2020 Aug 24], https://www.taylorfrancis.
grief in adults; but it is important to 7. Tedeschi RG. Trauma and transformation: com/books/9781315800790 (December 16,
Growing in the aftermath of suffering. 2020).
address grief among children and other
Sage Publications, 1995, 163 p. 17. Tikka SK, Garg S, and Dubey M. How to
special populations (pregnant women,
8. WHO. Coronavirus disease (COVID-19) effectively break bad news: The COVID-19
military personnel, migrant workers, etc.). Situation Report-194 [Internet]. [cited etiquettes. Indian J Psychol Med [Inter-
Although evidence for psychological 2020 Aug 2], https://www.who.int/docs/ net] 2020 Sep 23 [cited 2020 Nov 22];
interventions for grief is available across default-source/coronaviruse/situation-re- 42(5): 491–493.
other countries, the same from India is ports/20200801-covid-19-sitrep-194. 18. Goveas JS and Shear MK. Grief and the
lacking. It is important to consider the pdf?sfvrsn=401287f3_2 (2020, December COVID-19 pandemic in older adults. Am
cultural aspects in the manifestation as 16, 2020). J Geriatr Psychiatry 2020; 28(10):
well as the treatment of grief. A focused 9. Gesi C, Carmassi C, Cerveri G, Carpita B, 1119–1125.
training in providing support for people and Cremone IM, Dell’Osso L. Com- 19. Neimeyer RA. Techniques of grief therapy:
plicated grief: What to expect after the Creative practices for counseling the bereaved
in grief as an aftermath of COVID-19-
coronavirus pandemic. Front Psychiatry [Internet]. Routledge, 2012 [cited 2020
related deaths may help in mitigating the
[Internet] 2020 [cited 2020 Aug 20]; Nov 26], 388 p, https://books.google.co.in/
woes of the grieving. 11: 489, http://www.ncbi.nlm.nih.gov/ books/about/Techniques_of_Grief_Ther-
pubmed/32574243 (December apy.html?id=q82pyGrilkEC&redir_esc=y
Declaration of Conflicting Interests 16, 2020). (December 16, 2020).
The authors declared no potential conflicts of 10. Krikorian A, Maldonado C, and Pastrana 20. Muturi I, Freeman S, and Banner D.
interest with respect to the research, authorship, T. Patient’s perspectives on the notion COMMENTSVirtual funerals: A feasible
of a good death: A systematic review of and safer option during the COVID-19
the literature. J Pain Symptom Manage pandemic. J Am Geriatr Soc [Internet]
Funding 2020 Nov 14 [cited 2020 Nov 26]; 68(11):
[Internet] 2020 [cited 2020 Dec 1]; 59(1):
The authors received no financial support for the 152–164. 2472–2473, https://onlinelibrary.wiley.
research, authorship, and/or publication of this com/doi/10.1111/jgs.16774 (December 16,
11. Kokou-Kpolou CK, Fernández-Alcántara
article.
M, and Cénat JM. Prolonged grief related 2020).
to COVID-19 deaths: Do we have to fear 21. Bagcchi S. Stigma during the COVID-19
References a steep rise in traumatic and disenfran- pandemic. Lancet Infect Dis [Inter-
1. Oxford Essential Quotations. Oxford chised griefs? Psychol Trauma 2020; 12(c): net] 2020 [cited 2020 Sep 9]; 20(7):
University Press, 2015. Epub ahead of 94–95. 782, http://www.ncbi.nlm.nih.gov/
print January 1, 2015. DOI: 10.1093/ 12. Shear MK. Grief and mourning gone pubmed/32592670 (December
acref/9780191804144.001.0001. awry: pathway and course of complicated 16, 2020).

Viewpoint
Mental Illness in Indian Hindi Cinema:
Production, Representation, and Reception
before and After Media Convergence
Abhijit Pathak1, Ramakrishna Biswal1
M
edia is a collective term for vari- Due to the omnipresence of media, people Cinema is a powerful medium of
ous means of mass communica- absorb the received information and some- building a public belief system, and
tion with the primary function of times critically examine the received mes- when it comes to mental illness, cin-
disseminating and receiving information. sages, using information received through ema has always played and will keep
Television, radio, cinema, print, and internet multiple other sources. In short, the media playing a crucial role in disseminating
knowledge and forming beliefs and at-
titude towards mental illness.3–6 Like
international cinema, Hindi cinema also
has an old relationship with mental ill-
ness. However, the depiction of mental
illness in Hindi cinema has undergone
several changes. During the 20th centu-
ry, mental illness was misrepresented in
the Hindi cinema.7–9 With the advent of
media convergence, that is, the amalga-
mation of audiovisual and print media
on digital platforms,10 Hindi cinema
gradually portrayed a much more real-
istic picture of mental illness, but not
wholly. Assuming the 20th century as
a pre-media convergence period and fo-
cusing on the role of cinema in building
the attitude and belief on the issue of
mental illness, we analyze the portrayal
of the same in Hindi cinema through the
are the sources through which people come constructs the belief, opinion, and attitude lens of production and representation in
to know what is happening around them. which facilitate social change.1, 2 the pre-media convergence and post-me-
Dept. of Humanities and Social Sciences, National Institute of Technology Rourkela, Rourkela, Odisha, India.
1
HOW TO CITE THIS ARTIClE: Pathak A, Biswal R. Mental illness in Indian Hindi cinema: Production, representation, and reception
before and after media convergence. Indian J Psychol Med. 2021;43(1):74–80.
Address for correspondence: Abhijit Pathak, Dept. of Humanities and Social Submitted: 3 Dec. 2019
Sciences, National Institute of Technology Rourkela, Rourkela, Odisha 769008, Accepted: 31 Mar. 2020
India. E-mail: abhijitpathak29@gmail.com Published Online: 13 Jul. 2020
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCESS THIS ARTIClE ONlINE

Viewpoint
dia convergence eras. Subsequently, the influence on media and how these media incurable nature and miracle through
article looks into the building up of the houses serve their interests. religious rituals, in front of a receptive
wrong conception in the mind of the au- “Representation” works with analysis audience. This led to misunderstand-
dience regarding mental illness through and understanding of messages con- ing and common opinion on mental
the Hindi cinema. Further, it also tries veyed by the different forms of media. It illness.27 Further, cinema makers auda-
to explore the factors responsible for the tries to pick up the extent of subjectivity ciously generalized a single symptom as
differences in the depiction of mental and forceful imposition of themes and to an entire mental illness. The symptom
illnesses in pre- and post-media conver- trace the formation and consequence of “retrograde amnesia” was used in the
gence periods. themes. With regard to mental health, movies over three decades.28–30
studies on representation analyze the The protagonist in such movies made
Methodology concerning actors such as medical pro- during this period suffered from a men-
fessionals and patients with mental ill- tal disorder, and the story revolved
The authors have collected articles from
ness and the portrayal of treatment in around him or her. The person with
websites such as ResearchGate and Goo-
cinemas and soap operas.11 mental illness is characterized as naive,
gle Scholar by using keywords such as
“Reception” primarily deals with the careless, forgetful, destructive, childish,
“Indian Hindi Cinema,” “production,”
nature of the involvement of the audi- life-threatening, and incompetent. Sever-
“representation,” and “reception,” along
ence with the media. Theories give the al movies across the world have depicted
with terms “health” and “mental ill-
foundation to reception and divide the the same symptoms of mental illness.31–36
ness.” Along with these, the authors
view of the audience into passive and ac- Several studies across the world on mov-
have gone through different Hindi cin-
tive. An article titled “media effect theo- ies have the same depiction of the suffer-
emas that used the mental illness con-
ry” has divided the media audience theo- ers.{30–35} Along with this, Indian Hindi
cept. We selected such movies in which
ries into four phases, starting with strong Cinema relies a lot on the magicoreli-
the protagonist is a sufferer or mental
to mild influence on the audience.12 gious belief prevalent in our society as
illness is used as a central theme, and we
Among those theories, Lasswell’s “Mag- the cause and cure of mental illness.37, 38
avoided the movies in which such char-
ic Bullet Theory” labelled “audience” Most of the movies relate mental illness
acters were used as fillers or for making
to be passive and receptive to whatever with paranormal elements and depict
a comic scene.
is thrown at them.13 “Individual Differ- mental health professionals as eccentric,
ence/Attitude Change Theory” claimed
An Introduction to the audience to be active.14 Lowery gave
weird, unprofessional, apathetic, hold-
ing grudges against the patient, and sha-
Production, Representation, insights on the gradual shift from blind man in a white apron.37, 38
and Reception faith to subjectivity and individuality In movies, psychiatric treatments were
in interpreting messages.15 This process shown as modes of punishment, elec-
Cinema involves three major process- envelops the stakeholders of the society troconvulsive therapy (ECT) has been
es starting from bringing the concept who themselves are producers and repre- presented as “electric shock” and a tool
into reality to making of attitude, belief, sentatives of the media. The “reception” of torture, and psychotropic drugs have
and knowledge around it among peo- process studies the layman’s response to been portrayed with lots of dramatiza-
ple. These three processes, that is, pro- health messages received through differ- tion and inaccuracy. Scientifically, ECT
duction, representation, and reception, ent media organs, their usage of those is one of the best measures of treatment
help us to understand the purpose and messages, and the impact it creates on and acts as a lender of the last resort for
content and facilitate interpretation. their decisions regarding their health.
While the first two are essential from severe mental illness.39 However, it has
been prominently used as a tool for cre-
the producer’s point of view, the last one Production and ating insanity in movies.40–42 ECT in the
delves into the audience’s point of view.
How these three processes interplay in
Representation of Mental films has been used by a negative char-
the context of media convergence is dis- Illness by Hindi Cinema in acter to erase memories or to bolster the
cussed further. insanity of the protagonist or supporting
“Production” refers to building, creat-
Pre-media Convergence Era actor.43
ing, and executing the content through The pre-media convergence era is a Lobotomy (which is hardly in use as a
audio or audiovisual format. Clive11 ex- long period. One should not forget the treatment method for mental illness) has
tended and gave a more profound mean- varied pre-existing beliefs on mental been depicted as a standard weapon for a
ing to the word “production” and stated illness causation, treatment, and out- psychiatrist to fulfill his/her grudge. Like
that it is the process of studying and come that were existing in the mid-20th in the movie Kyon Ki where the female
observing the behavior of a producer of century.16–26 The period marked dramat- protagonist’s father played the negative
a media house. This process of media ic advancement in Hindi cinema and character of a psychiatrist and performed
studies tries to learn the commercial en- pharmacotherapy for mental illness par- a lobotomy on the male protagonist as a
vironment of any media institution. Fur- allelly. Therefore, producers of the films punishment for loving his daughter, the
ther, it peeps into the nature of the gov- captured and presented all popular ideas female lead. Thus, the Indian Hindi cine-
ernment’s and other corporate houses’ and beliefs on mental illness, such as ma in the late 20th century and early 21st

Pathak and Biswal
century minted money by solidifying the Indian Hindi Cinema in the pre-media entertainment, it strengthened the exist-
existing beliefs on mental illness.38 convergence era happened to sustain the ing belief on mental illness by showing
interest of the audience. that it has relations with black magic
Why Such Representations? As depicted in Figure 1, a template on and ghosts, which had led to ignoring of
A study on reality television brought out mental illness was formulated, compris- a medical condition by people and also
the concept of people seeking entertain- ing the “concept,” “creating and exploit- they often mistreated and still mistreat
ment out of “dramatized contrast,” such ing opposition,” “reversal,” and “dramat- persons with mental illness. Studies
as people’s indulgence in movies that ic contrast.” The template was then sent have reported sufferers as being the vic-
create anxiety and fear rather than secu- to the production segment to represent tim of inhumane behavior by the general
rity and pleasure. Therefore, portraying a mental illness through the Hindi cine- population and by family members.53–55
person with mental illness as naive and ma, followed by the positive receptivity Further, they are labelled as life-threat-
violent sustains the dramatic effect.44 of the audience, leading to the continua- ening, criminal, aggressive, and violent,
The overall impression over the au- tion of a model for production. which is an act of boosting the prejudic-
dience through such a concept creates es, resulting in fear, anxiety, and stigma.
a “template.” The “template” is not a
Consequences of A study reported that compared to peo-
readymade construct applied by the the Unrealistic ple receiving information through print
producer. It is an existing notion about media, those who are frequently exposed
"Representations" to mental health issues through tele-
any object or subject among the viewers
which is tested by program and film pro- Over the years, mental illness has sup- vision and cinema are more intolerant
ducers. If they get a favorable response plied the Hindi cinema with engaging towards a person with mental illness.56
from the viewers, they get encouraged to content. The sole motive was to amuse As previously discussed, movies relate
repeat them.45,44 The movies are also fond and surprise the viewers, but that result- supernatural elements and magicore-
of exploiting the possibilities of mental ed in the formation of wrong concepts ligious beliefs with mental illness and
illness juxtaposed with the idea of “cre- on mental illness. As a result, the resent- spread stigma.57 Such depictions boost
ating and exploiting opposition” such as ment of clinicians and academicians unscientific explanations and fear and
good and evil, disaster and restoration, over the superficial content on mental provide people an additional excuse to
life and death, etc.46,47 Especially in the illness grew gradually. The discourses alienate patients with mental illness from
case of life and death, a doctor is seen as among the clinicians and academicians the community.58 Movies with such plot
a figure of paramount importance since were more concerned with the sufferers hamper and delay the treatment process
he is the savior and possibly can also be and their caregivers. Cinema gave very as caregivers and patients themselves get
Satan who can sabotage the lifeline. Such little insight on the sufferers and their pessimistic and perceive psychiatric treat-
alteration of attributes associated with caregivers and held the taboo associated ment as a waste of time and attribute the
the character is the result of “reversal” with mental illness high. A taboo or for- causes of mental illness to paranormal
applied by the production crew with the midable concept in society eventually re- phenomena.59 Hindi cinemas, by using
intention of unexpected representation sults in stigma. Stigma, according to the the concept of “creating and exploiting
of a psychiatrist as the villain to sustain Cambridge Dictionary, is “a strong sense opposition,” showed mental health pro-
the interest of the viewers.48 The psy- of detachment or disapproval on some- fessionals as “conspirators” and psychi-
chiatrists shown in the intense hospital thing, which brings disgrace or shame.”49 atric treatment as a “conspiracy” to erase
scene in most of the cinemas are placed Stigma persists because the family of the memory or to make people insane
with such a concept to get the desired the patient assumes that revealing the and, in the process, deepened fears and
effect of drama to meet the expectation mental condition of their family mem- prevented the public from approaching
of the audience. Hence, the unrealistic ber will harm their reputation in soci- mental health professionals. Thus, men-
representation of mental illness in the ety.50–52 Though cinema took the topic for tal health professionals are the victim of
utopian concepts presented in the mov-
Figure 1.
ies. Further, people believe that mental
Production and Representation of Mental Illness by Indian Hindi illness has a connection with paranormal
cinema in Pre-Media Convergence Era elements and has no cure.
Production and
Representation of Mental
Illness by Hindi Cinema in
Post-Media Convergence
Period
The post-media convergence period
marked a gradual shift in Hindi cinema

Viewpoint
from entertainment to infotainment. Scientists, health professionals, and edu- of the new “template” for Hindi cine-
Popular movies gained the attention of cators are well aware of this fact.65 ma. So, the current template projects
not only the viewers but also the care- The cyberconnectivity led media con- mental health professionals as devoted
givers of people with mental illness.59–62 vergence to make all organs of media to humanity and the protagonist from
These movies have substantially por- portable, making information available an ordinary background as successfully
trayed different facets of mental illness through multiple sources. Therefore, re- combatting life adversities and overcom-
such as dyslexia, Asperger’s syndrome, iterating the “unrealistic representation” ing their disabilities.62, 63 This template is
depression, and Tourette syndrome. will lead to monotony and gradual aloof- now successfully catering to the needs of
Dear Zindagi63 the story of an urban ness, which might hinder the minting the Hindi cinema. The overall discourse
middle-class female suffering from de- of money by the producers. Because the has been based on media-mental health
pression, carefully brings scenes one producers are well aware of this, they from the psychosocial point of view. It is
by one where lifestyle adversities and have retired the existing “template” and to be noted that Hindi cinema somehow
flashback of childhood isolation put the applied the “twitch.”45,48 managed to operate the same portrayal
protagonist into depression. The movie “Twitch” is meant to sustain the un- of a person with mental illness in the
then advances by breaking stereotypi- predictability and the viewers’ interest.48 pre-media convergence era, which gives
cal thoughts prevalent about patients Kitzinger stressed to retire templates at a hint of the dominant presence of the
with mental illness and the therapists. regular intervals to combat the predicting “Magic Bullet Theory” on the viewers.13
The movie is the first of its kind, which ability of the viewers and predictability However, the post-media convergence
has correctly shown the therapeutic re- of the plots. 45 Today, the producers in era is witnessing the change in the tem-
lationship between the mental health Hindi cinema are focusing on the hard- plate of the Hindi cinema. Thus, this
professional and the patient. A therapist, ship of sufferers and their caregivers. With transformation suggests the existence of
as a facilitator of the therapeutic process, this change, they have now entered the the “Attitude Change Theory.”14
comforts the client in a nondirective way niche segment of sufferers and caregivers. Due to the advent of various digital mul-
than by giving advice or instructions. A few movies have shown the patients’ timedia platforms, the audience is well
On the other hand, title of the movie and their caregivers’ feelings such as ag- informed prior to the release of a movie.
Judgementall Hai Kya was earlier Mental ony, pain, and suffering and done well Hence, the ongoing production through
Hai Kya.64 That title was derogatory and at the box office. This successful experi- the existing template on mental illness
invited widespread criticism from the mentation has led to the establishment is now unwelcomed by the audience
professionals and public, which led to the
change in the title. The movie, however, Figure 2.
became an exception to the post-media Production and Representation of Mental Illness by Hindi Cinema
convergence period and depicted the use in Post-media Convergence Period
of ECT without anesthesia, which is rare-
ly done nowadays. Though the wrong
diagnosis has been shown in Judgementall
Hai Kya, the movie focused on psychotic
symptoms and the protagonist beauti-
fully executed those symptoms through
her act. But the inaccurate representa-
tion of the symptoms suggests that the
filmmakers have to do more thorough
research on mental illness. Nevertheless,
a hidden message that the film gave was
that though a patient who has a chronic
mental illness can make a family feel he
or she is troublesome, bothersome, and
a burden to them, the person can also be
a helping hand in a few and important
occasions. The protagonist’s uncle’s con-
cern over regular intake of medication
and frequent prompting also gives a pos-
itive message of family support system
and adequate management of illness.
Despite all the pros and cons, it has to be
understood that producers solely do not
make cinema to educate or to make peo-
ple aware by serving accurate information.

Pathak and Biswal
(see Figure 2). Thus, the producers tend Table 1.

to retire the current template, and inclu-
sion of the new template with a com-
Representation of Psychiatry in Hindi Cinema
bination of “twitch” leads to the new Representation of psychiatry in pre-media convergence era
model for representing mental illness in Themes Movies Year Identified characteristics
Hindi Cinema. In short, the producers
Portrayal of patient Khilona 1970 Childish, naive, violent,
are trying their hands on realistic repre- Sadma 1983 destructive, ignorant, reckless,
sentation of mental illness and need to Dilwale 1994 etc.
be well informed and educated on the Portrayal of mental Damini 1993 Apathetic, unprofessional, un-
types of mental illness. health professional Dilwale 1994 scientific, used as comic fillers
(mainly psychiatrist) Kyon Ki 2005 and boundary violators.
Guidelines for Movie Portrayal of psychiatric Khamoshi 1970 Erasing of memories, tools of
Making Concerning treatment
(mainly psychotropic
Damini
Raja
1993
1995
punishment.
Psychiatric Issues medicine, electro

convulsive therapy and
Kyon Ki 2005
• Sufficient exposure to signs and lobotomy)

symptoms of any particular disorder Representation of psychiatry in post-media convergence period
seems necessary for scriptwriters and Portrayal of patient Taare Zameen Par 2007 Empowered, contributor to the
director before conceptualizing and My Name Is Khan 2010 community.
finalizing the script. Dear Zindagi 2017
Hichki 2018
• Script finalizing in the presence of
chosen representatives of different Portrayal of mental Taare Zameen Par 2007 Empathetic, polite, sensitive,
health professional Kartik Calling Kartik 2010 committed to help.
stakeholders, that is, caregivers, pa-
My Name Is Khan 2010
tients, and mental health profession- Dear Zindagi 2017
als seems desirable. Incorporation of
Treatment method Taare Zameen Par 2007 Focused on one to one
multiple opinions in the script will Dear Zindagi 2017 intervention, inclusion of
make it more sensible. other stakeholders like family,
• Though recent movies have particu- community, workplace, etc.
larly portrayed the hardships of the
urban middle class, the struggle of performing lobotomy, which is no longer think. In this way, they sustain the percep-
the rural families and patients from the treatment of a patient with severe tion and earn out of it. However, cinema
lower strata is still absent from the sil- mental illness, has been shown in the producers should also understand their
ver screen. Therefore, filmmakers can movie Kyon Ki. A wrong depiction of ECT fundamental duties prescribed in Article
utilize the opportunity to take up the has also created a widespread stigma 51A(h) of the Indian Constitution to de-
issue of rural India and the rural peo- among the community. velop the scientific temper among the cit-
ple’s perspectives on mental illness. On the other hand, though a handful, izens. Though contemporary cinema has
• Movies must not be made with an aim shown some progressive gestures in this
there have been movies in the post-media
to label people with different kinds of direction, it will be more appreciable if
convergence period that beautifully de-
mental illness. Instead, they should the momentum of scientific temper could
picted a patient’s struggle with self and
aim at informing and developing be maintained by serving the right infor-
also with society in which he or she lives
empathy. We need more social inte-
and their accomplishments. The thera- mation, especially on mental health and
gration of people with mental illness,
pist is represented more sensibly, with at- illness, without losing the entertainment
and movies are one of the important
tributes such as sensitivity, empathy, and quotient of the content.
vehicles to do that.
concern for the patient’s well-being. The
Table 1 talks about the representation Declaration of Conflicting Interests
depiction of an overt and covert message
of psychiatry in pre- and post-media con- The authors declared no potential conflicts of
that the family is important in the pa-
vergence periods. During the pre-media interest with respect to the research, authorship
tient’s path of recovery is a great leap the
convergence era, the patient has been and/or publication of this article.
Hindi cinema has taken in recent times.
shown as troublesome, a burden to the
family. The depiction of the psychiatrist Funding
as Mr Evil, unprofessional, insensitive,
Conclusion The authors received no financial support for the re-
The representation of mental illness is not search, authorship and/or publication of this article.
apathetic, and comic filler was prevalent
in the pre-media convergence era. When as simple as it seems. As discussed earlier,
it comes to treatment methods, psycho- through the production process of media References
tropic medicines were shown as ineffec- studies, producers try to find out the per- 1. Philo G. Active audiences and the con-
tive, mostly harming the patient, or as ception of the viewers on any subject and struction of public knowledge. Journal
a tool for erasing memory. Psychiatrist represent what the majority of viewers Stud 2008; 9(4): 535–544.

Viewpoint
2. Happer C and Philo G. The role of the Jamaica: patients’ conceptions and prac- third-person effect. J Community Psychol
media in the construction of public belief titioners’ attitudes. Afr J Tradit Comple- 2007; 35: 181–195.
and social change. J Soc Polit Psychol ment Altern Med 2011; 9(1): 94–104. 34. Olstead R. Contesting the text: Canadian
2013; 1(1): 321–336. 18. Joel D, Sathyaseelam M, Jayakaran R, et al. media depictions of the conflation of
3. Kimmerle J and Cress U. The effect of tv Explanatory models of psychosis among mental illness and criminality. Sociol
and film exposure on knowledge about community health workers in South India. Health ill 2002; 24: 621–643.
and attitude towards mental disorder. J Acta Psychiat Scand 2003; 108(1): 66–69. 35. Signorielli N. The stigma of mental illness
Community Psychol 2013; 41(8): 931–943. 19. Kleinman A, Eisenberg L, and Good B. on television. J Broadcast Electron 1989;
4. Diefenbach DL. The portrayal of mental Culture, illness and care: clinical lessons 33: 325–331.
illness on prime-time television. J Com- from anthropologic and cross-cultural 36. Wahl OF and Roth R. Television images of
munity Psychol 1997; 25: 289–02. research. Ann Intern Med 1978; 88: mental illness: results of a metropolitan
5. Gabbard GO and Gabbard K. Psychiatry 251–258. Washington media watch. J Broadcast
and the cinema. Washington, DC: American 20. Kulhara P, Avasthi A, and Sharma A. Mag- 1982; 26: 599–605.
Psychiatric Press, 1999. ical-religious beliefs in schizophrenia: a 37. Ragini MMS 2. Directed by B. Patel [film].
6. Orchowski LM, Spickard BA, and Mc- study from North India. Psychopathology Mumbai: Balaji Motion Pictures, 2014
Namara JR. Cinema and the valuing of 2000; 33(2): 62–68. 38. Kyon Ki. Directed by Priyadarshan [film].
psychotherapy: implications for clinical 21. Nambi SK, Prasad J, Singh D, et al. Mumbai: Orion Pictures, 2005
practice. Prof Psychol-Res Pr 2006; 37: Explanatory models and common mental 39. Pagnin D, de Queiroz V, Pini S, et al. Effi-
506–514. disorders among patients with unex- cacy of ECT in depression: a meta-analytic
7. Chandramouleeshwaram S, Edwin NC, plained somatic symptoms attending a review. J ECT 2004; 20: 13–20.
and Rajaleelan W. Indie insanity—mis- primary care facility in Tamil Nadu. Natl 40. Damini. Directed by R. Santoshi [film].
representation of psychiatric illness in Med J India 2002; 15(6): 331–335. Mumbai: Red Chillies Entertainment, 1994.
mainstream Indian cinema. Indian J Med 22. Poreddi V, Blrudu R, Thimmaiah R, et al. 41. Raja. Directed by I. Kumar [film]. Mumbai:
Ethics 2016; 1(1): 1–2. Mental health literacy among caregivers Maruti International, 1995.
8. Padhy SK, Khatana S, and Sarkar S. Media of persons with mental illness: a descrip- 42. Khamoshi. Directed by A. Sen [film]. Mum-
and mental illness: relevance to India. tive survey. J Neurosci Rural Pract 2015; bai: Geetanjali, 1970.
J Postgrad Med [serial online]. 2014; 60: 6(3): 355–360. 43. Swaminath G and Bhide A. “Cinemad-
163–170. 23. Sangeeta SJ and Mathew KJ. Community ness”: In search of sanity in films. Indian J
9. Swaminath G and Bhide A. “Cinemad- perception of mental illness in Jharkhand, Psychiatry 2019; 51: 244–246.
ness”: in search of sanity in films. Indian India. East Asian Arch Psychiatry 2017; 44. Hill A. Fearful and safe: audience re-
J Psychiatry [serial online]. 2009; 51: 27(3): 97–105. sponse to British reality programming.
244–246. 24. Schoonover J, Lipkin S, Javid M, et al. Per- Telev New Media 2000; 1(2): 193–113.
10. Chakaveh S and Bogen M. Media conver- ceptions of traditional healing for mental 45. Kitzinger J. Media templates: patterns of
gence: an introduction. In: Jacko JA, ed. illness in rural Gujarat. Ann Glob Health association and the (re)construction of
Human-computer interaction, HCI intel- 2014; 80(2): 96–102. meaning over time. Media Cult Soc 2000;
ligent multimodal interaction environ- 25. Scolari CA. Media evolution: emergence, 22(1): 61–84.
ments. Berlin: Springer, 2007: 811–814. dominance, survival and extinction in 46. Labov W. Language in the inner city:
11. Seale C. Health and media: an overview. the media ecology. Int J Commun 2013; studies in the Black English Vernacular.
Sociol Health ill 2003; 25(6): 513–531. 7: 24. Philadelphia: University of Pennysylvania
12. Borah P. Media effects theory. In: Barn- 26. Sorsdahl KR, Flisher AJ, Wilson Z, et al. Press, 1973.
hurst KG, Ikeda KI, Maia RC, et al., eds. Explanatory models of mental disorders 47. Propp VI. Morphology of the folktale.
The international encyclopedia of political and treatment practices among tradition- Austen: University of Texas Press, 1968.
communication. 1st ed. London: John Wiley al healers in Mpumalanga, South Africa. 48. Langer J. Tabloid television: popular
& Sons, 2016. Afr J Psychiatry (Johannesbg) 2010; 13(4): journalism and the “other news.” Oxon:
13. Lasswell HD. Propaganda technique in the 284–290. Routledge, 1998.
world war. London: K. Paul, Trench, Trub- 27. Anderson CA and Communities, I. Reflec- 49. Cambridge Dictionary [homepage on
ner & co. Ltd, 1927. tions on the origin and spread of national- the internet]. Cambridge: Stigma, n.d.
14. Chan, L. Applying an attitude change the- ism. 2nd ed. London: Verso, 1991. https://dictionary.cambridge.org/dictio-
ory and a western media education instru- 28. Khilona. Directed by C. Vohra [film]. Mum- nary/english/stigma. Accessed November
ment in the eastern setting. Med Psy Rev bai: Prasad Production Pvt Ltd, 1970 28, 2019.
[n.a.]. 2008; 1(1): 15p. http://mprcenter.org/ 29. Sadma. Directed by B. Mahendra [film]. 50. Magaña SM, Ramirez Garcia JI, Hernán-
review/chanattitude-change/. Accessed Mumbai: R.S. Entertainment, 1983 dez MG, et al. Psychological distress
November 26, 2019. 30. Dilwale. Directed by H. Baweja [film]. among Latino family caregivers of adults
15. Lowery SA and DeFleur ML. Milestones in Mumbai: S.P. Creations, 1994 with schizophrenia: the roles of burden
mass communication research: media effects. 31. Anderson CA and Bushman BJ. Psychol- and stigma. Psychiat Serv 2007; 58(3):
New York: Longman, 1983. ogy: the effects of media violence on 378–384.
16. Das S, Saravanan B, Karunakaran, KP, et society. Science 2002; 295: 2377–2379. 51. Venkatesh BT, Andrews T, Mayya SS, et al.
al. The effect of a structured educational 32. Cutcliffe JR and Hannigan B. Mass media, Perception of stigma toward mental ill-
intervention on explanatory models of ‘monsters’ and mental health clients: the ness in South India. J Fam Med Prim Care
relatives of patients with schizophrenia: a need for increased lobbying. J Psy Ment 2015; 4(3): 449.
parallelly controlled trial. Br J Psychiatry Health Nurs 2001; 8: 15–21. 52. Weiss MG, Ramakrishna J, and Somma
2006; 188: 286–287. 33. Diefenbach DL and West MD. Television D. Health-related stigma: rethinking con-
17. James CC and Peltzer K. Traditional and and attitudes toward mental health cepts and interventions. Psychol Health
alternative therapy for mental illness in issues: cultivation analysis and the Med 2006; 11(3): 277–287.

Pathak and Biswal
53. Choe JY, Teplin LA, and Abram, KM. Per- with the National Crime Victimization for orthodox psychiatric practice. J Med
petration of violence, violent victimiza- Survey. Arch Gen Psychiatry 2005; 62(8): Ethics 2004; 30: 23–26.
tion, and severe mental illness: balancing 911–921. 60. Taare Zameen Par. Directed by A. Khan [film].
public health concerns. Psy Serv 2008; 59: 56. Granello DH, Pauley PS, and Carmichael Mumbai: Amir Khan Productions, 2007.
153–164. A. Relationship of the media to attitudes 61. My Name Is Khan. Directed by K. Johar [film].
54. Kamperman AM, Henrichs J, Bogaerts S, et toward people with mental illness. J Hu- Mumbai:Dharma Productions, 2007.
al. Criminal victimisation in people with manist Couns Educ Dev 1999; 38: 98–110. 62. Hichki. Directed by S.P. Malhotra [film].
severe mental illness: a multi-site preva- 57. Das S, Doval N, Mohammed S, et al. Mumbai: Yash Raj Films, 2018.
lence and incidence survey in the Nether- Psychiatry and cinema: what can we learn 63. Dear Zindagi. Directed by G. Shinde [film].
lands. Plos One March 2014; 9(3): e91029, from the magical screen? Shanghai Arch Mumbai: Red Chillies Entertainment, 2017.
13p. https://journals.plos.org/plosone/ Psychiatry October 2017; 29(5): 310–313. 64. Judgementall Hai Kya. Directed by P. Kove-
article?id=10.1371/journal.pone.0091029. 58. Anderson M. “One flew over the psychi- lamudi [film]. Mumbai: Balaji Motion
Accessed November 26, 2019. atric unit”: Mental illness and the media. Pictures, 2019.
55. Teplin LA, McClelland GM, Abram J Psy Ment Health Nurs 2003; 10: 297–306. 65. Naidoo J and Wills J. Health promotion:
KM, et al. Crime victimization in adults 59. Aina OF. Mental illness and cultural foundations for practice. London:Balliere
with severe mental illness: comparison issues in West African films: implication Tindall, 2000.

Practical Psychotherapy
behavior Therapy for the Treatment of
Tourette’s Disorder in India: a Patient
Series from an Indian General Hospital
Psychiatric Unit
Natarajan Varadharajan1, Subho Chakrabarti1, Swapnajeet Sahoo1, Srinivas Balachander1
ABSTRACT treatments along with medications led to been estimated to be around 1% (range
a 75% reduction in the severity of tics and 0.4%–3.8%).2 Although data from Asian
Reports on behavioral interventions for reduction in comorbid symptoms. Patients countries is scarce, prevalence rates of
the treatment of Tourette’s disorder (TD) and caregivers also reported similar rates
from India are limited. This patient series 0.4%–0.56% have been reported.2,3 This
of improvement as well as reductions in
describes the usefulness and feasibility of suggests that TD is not rare, even among
subjective distress and caregiver burden.
conducting behavioral interventions for Five patients have been followed up for Asian populations.
patients with TD from an Indian general seven months to seven years; apart from Several behavioral treatments have
hospital psychiatric unit. Behavioral one patient, all others have had only been tried for the management of TD.
treatments in these seven consecutively minor exacerbations of tics during this These include habit reversal treatment
treated adult/adolescent patients with period. This limited experience suggests (HRT), comprehensive behavioral inter-
TD included all components of habit that behavior therapies for TD can be vention for tics (CBIT), exposure with
reversal treatment, comprehensive successfully implemented in low-resource, response prevention (ERP), massed neg-
behavioral intervention for tics, and non-specialized Indian settings. They are
exposure with response prevention ative practice, self-monitoring, contin-
effective, and gains from such treatment
in some patients. Patients were gency management, relaxation training,
are usually enduring.
predominantly male, with adolescent- cognitive behavioral treatment, biofeed-
onset severe TD, typical features and Keywords: Tourette’s disorder, behavior back, and assertiveness training. How-
psychiatric comorbidities, and poor therapy, India ever, the only ones with proven efficacy
T
response to multiple medications prior ourette’s disorder (TD) is a child- are HRT, CBIT, and ERP.4–8 Therefore, the
to the institution of behavior therapy. In current consensus on management of
hood-onset complex neurode-
addition to long delays in diagnosis, none
velopmental disorder charac- TD recommends psychoeducation when
of the patients or their caregivers had
been informed by the doctors they had terized by multiple motor and vocal tics are transient or mild, behavioral in-
consulted earlier about TD or the need for tics, frequently accompanied by comor- terventions for tics of moderate severity,
behavioral treatments before attending bid psychiatric disorders.1 The overall and combined treatment with medica-
our center. Institution of behavioral international prevalence of TD has tions (alpha-2 agonists or antipsychotics)
Dept. of Psychiatry, Postgraduate Institution of Medical Education and Research (PGIMER), Chandigarh, India.
1
HOW TO CITe THIS aRTICle: Varadharajan N, Chakrabarti S, Sahoo S, Balachander S. Behavior therapy for the treatment of
Tourette’s disorder in India: A patient series from an Indian general hospital psychiatric unit. Indian J Psychol Med. 2021;43(1):81–85.
Address for correspondence: Subho Chakrabarti, Dept. of Psychiatry, Submitted: 28 Feb. 2020
Postgraduate Institution of Medical Education and Research (PGIMER), Accepted: 15 apr. 2020
Chandigarh 160012, India. E-mail: subhochd@yahoo.com Published Online: 13 Jul. 2020

Varadharajan et al.
and HRT, CBIT, or ERP when the tics are of TD and the consultant psychiatrist. enhance the patient’s motivation for
severe.4–6 Interventions were based on principles treatment and coping with the emotion-
The principal components of HRT of HRT, CBIT, and ERP. A standardized al consequences of tics. A typical behav-
are awareness training (self-detection of treatment protocol was followed for ioral treatment session lasted about 45
premonitory urges and tics), competing each patient. To begin with, TD was di- minutes. Response to behavioral inter-
response training (learning voluntary agnosed according to the Diagnostic and ventions was monitored regularly by the
behaviors physically incompatible with Statistical Manual of Mental Disorders trainees, the patients, and the caregivers;
tics), and caregiver support (enhancing (DSM-IV-TR or DSM-5) criteria. All pos- changes to the treatment plan were made
the patients’ awareness and encour- sible alternative conditions were ruled based on the patients’ needs. Both during
agement by caregivers). CBIT utilizes out by careful history-taking, physical the inpatient and follow-up phases, the
these core HRT components along with examination, and carrying out the nec- generalization of the response was en-
relaxation training, psychoeducation, essary investigations. After establishing sured by teaching the patients to manage
and functional intervention (identifying the diagnosis, a comprehensive clinical, tics triggered by events in the daily life.
events that worsen tic severity and devel- behavioral, and psychosocial assessment Caregivers were involved at each stage of
oping strategies to manage them in daily of TD and comorbidities was carried the treatment. They were trained to gen-
life). ERP involves exposure to premoni- out. Behavioral assessments followed tly point out the occurrence of tics to the
tory urges while refraining from indulg- the standard “A-B-C” approach, in which patients, thereby enhancing their aware-
ing in tics. the types of tics, their antecedents, and ness of the tics. They assisted patients
Existing Indian literature on TD con- consequences, including the associated in practicing competing responses and
sists of one case series9 and about a doz- subjective distress, environmental and provided encouragement and support.
en case reports. Most patients appear to other contextual factors influencing the Caregivers were particularly encouraged
have been treated with medications, with occurrence of tics, and the motivation to conduct sessions of their own so that
the administration of repetitive tran- for treatment, were evaluated. Psychoso- they could become effective cotherapists
scranial magnetic stimulation (rTMS) or cial assessments included (unstructured) once the patients went home. Addition-
deep brain stimulation in patients resis- evaluation of both patients and their ally, their emotional and practical diffi-
tant to medications.10,11 Although HRT is caregivers about their knowledge regard- culties in caring for the patient were ad-
mentioned in some instances,12,13 there is ing TD, emotional problems, disability dressed by providing ongoing support.
virtually no information on the behavior- caused by tics, social impact of tics, and In one patient who had obvious triggers
al management of TD. Therefore, there is caregiver burden. The Yale Global Tic Se- for tics, ERP was carried out in addition
a need to examine whether behavioral verity Scale (YGTSS) was used to rate tic to HRT and CBIT. ERP for OC symptoms
treatments are equally effective for TD in severity. The Yale-Brown Obsessive Com- was also conducted in all four patients
routine clinical settings in India. pulsive Scale (Y-BOCS) was used to rate with OCD.
This patient series describes seven con- the severity of obsessive compulsive dis- Two patients responded well to cloni-
secutive patients from our center who order (OCD), and the Revised Connor’s dine and did not require antipsychotics,
were treated with a combination of be- Parent Rating Scale was used to rate the which are usually second-line options for
havioral techniques and medications. severity of attention-deficit hyperactivity the pharmacological treatment of TD.
This report, representing our experience disorder (ADHD). Both patients and care- Other patients received either clonidine
of behavior therapy for TD, is presented givers were educated about rating the and/or antipsychotics for tics. All patients
to demonstrate that behavioral interven- progress of the treatment themselves. received medications for the treatment of
tions are feasible and effective even in Assessments were followed by the ed- comorbid conditions. Three patients re-
low-resource, non-specialized settings ucation of patients and caregivers about quired changes in the medications while
such as general hospital psychiatric units both TD and the behavioral treatments undertaking behavior therapy. Patients’
in India. to be implemented. Relaxation training written informed consent was obtained.
was undertaken next, as it forms a part of Patient anonymity has been preserved.
Methods CBIT. Either autogenic training or Jacob-
This patient series describes behavior son’s progressive muscular techniques
Results
therapy carried out in seven consecutive- for relaxation were taught. Awareness Table 1 depicts the details of clinical fea-
ly treated adult/adolescent patients with training, consisting of self-monitoring tures and behavioral interventions.
TD attending the general hospital psy- by the patients with the caregivers’ help, Six of the seven patients were hospi-
chiatric unit of a multispecialty hospital to enable early detection of premonitory talized for behavioral treatment after
in North India. The CARE guidelines for urges and tics, was instituted after that. inadequate response to initial pharma-
consensus-based clinical case reporting Competing responses were decided upon cotherapy. All but one were male. They
have been followed for this report. after discussions with patients and care- were all educated and mostly students.
Behavioral treatments were conducted givers and then practiced in the presence The mean age at presentation (+SD) was
by different trainee psychiatrists under of the trainees and caregivers. Individ- 24.42 (+6.35) years. The mean age of on-
the supervision of senior residents well ual support consisted of conventional set of tics was 13.86 (+ 4.88) years, but a
versed in the behavioral management supportive and expressive techniques to proper diagnosis of TD was made only

Table 1.
Details of Behavioral Interventions for Tourette’s Disorder

YGTSS Patients’ Caregivers’
Global severity score reports overall
(maximum 100) of reduc- estimate
Age of tion in of the
Age onset Psychiatric Symptom Daily doses No. of distress response Post-in-
(years)/ (years) comorbidity profile* of medica- Pre-treat- Post-treat- BI ses- due to to behavior tervention
sex tions ment ment sions tics therapy follow-up
1. 30 male 16 Schizophre- Motor tics† Clonidine 90 24 120 60% 55% Duration 3.5
nia Phonic tics 0.5 mg years—major
OCD (throat Clozapine relapse once;
clearing, 125 mg responded
unintelligible Sertraline to rTMS and
sounds), 150 mg change in
self-injury medications
2. 17 male 12 ADHD Motor tics† Clonidine 73 24 40 70% 75% Dropped out
OCD Phonic tics 0.4 mg
(throat Methyl-
clearing, phenidate
unintelligible 15 mg
sounds)
3. 20 12 Dissociative Motor tics† Clonidine 66 8 40 80% 80% Dropped out
female disorder Phonic tics 0.3 mg
(throat
clearing)
4. 22 male 13 OCD Motor tics† Haloperidol 77 23 55 70% 75% Duration 7
Phonic tics 0.75 mg years—no
(unintelligi- Cloimip- relapses;
ble sounds) ramine 75 improved
mg functioning
5. 32 male 14 Generalized Motor tics† Clonidine 80 10 40 90% 90% Duration 7
anxiety Phonic tics 0.3 mg years—minor
disorder and (throat Fluoxetine exacerba-
social phobia clearing) 20 mg tions when
stressed;
anxiety
symptoms
persist
6. 31 male 23 Major de- Motor tics † Risperi- 73 10 60 90% 80% Duration 2
pression Phonic tics done 2mg years—minor
(throat Escitalo- exacerba-
clearing), pram 20 tions when
self-injury mg non-adherent
7. 19 male 7 OCD Motor tics† Haloperidol 80 36 40 70% 80% Duration 7
Phonic tics 1.25 mg months—
(throat Escitalo- minor
clearing) pram 20 stress-relat-
mg ed exacerba-
tions
ADHD = attention-deficit hyperactivity disorder, BI = behavioral intervention, ERP = exposure and response prevention, OCD = obsessive compulsive disorder, rTMS = repetitive
transcranial magnetic stimulation,YGTSS = Yale Global Tic Severity Score. *Other features included waxing and waning course, stress-related exacerbation of symptoms, ability
to partially suppress tics voluntarily, premonitory urges, “just right” phenomenon. †Motor tics included shoulder, movements of limbs, head/neck, mouth, face and abdomen, eye
blinking, repeated tapping, bowing, and touching.
by a mean age of 22.15 (+ 5.25) years. In of TD was quite characteristic, with of medication treatment among the pa-
addition to the long delay in diagnosis, typical and common motor and pho- tients had been poor. Accordingly, the tics
none of the patients and their caregivers nic tics, premonitory urges, “just right” were of moderate to severe intensity be-
had been informed about TD or the need phenomenon, and the ability to partially fore starting behavior therapy. Mean pre-
for behavioral treatments by the doctors suppress tics voluntarily. Other features treatment YGTSS scores was 77±7.53, and
they had consulted earlier. All patients included worsening with stress and asso- all patients had a severe psychosocial im-
had at least one comorbid psychiatric ciated problems such as self-injury. pairment. According to their subjective
diagnosis; the most common one was Before starting the behavioral treat- estimates, there was considerable dis-
OCD, in four patients. The clinical profile ments, the response to multiple trials tress and burden among the caregivers.

Varadharajan et al.
Only one patient required 120 ses- The booster sessions included all compo- treatment, helping them deal with the
sions of behavioral treatment. Manag- nents of HRT and CBIT. emotional and social consequences of
ing his TD proved particularly difficult, the illnesses, and enhancing their mo-
because not only did he suffer from co- Discussion tivation for treatment. Based on the
morbid schizophrenia and OCD, but his All the seven patients of this study had a YGTSS scores, about a 75% decrement in
pretreatment YGTSS score was also the fairly typical picture of TD. The slightly the tics was observed. Patients and care-
highest (90). The rest of the patients re- later age of onset was in keeping with givers also reported about 76% improve-
quired an average of about 46 sessions Indian reports9,12 and within the range ment in tics. There was a considerable
(45.83+9.17; range: 40–60) to achieve a of 4–15 years reported in cross-cultur- improvement in the comorbidities such
reasonable response. al studies among Asian populations.3 as OCD as well. Additionally, improve-
Treatment response was defined as However, it appeared that minor tics ments in functioning and satisfaction
a global severity score of 40 or less on such as eye blinking at younger ages with behavioral interventions, as well
the YGTSS, which corresponded with had been missed in some patients be- as reductions in associated distress and
the presence of minimal/mild severity cause of the lack of awareness among burden, were observed among patients
of tics and minimal/mild psychosocial the parents. The overwhelming male and caregivers. Long-term effectiveness
impairment.14 According to this cutoff, a preponderance found in this report has of the behavioral treatments was also ev-
response was achieved in all the patients. been noted in cross-cultural studies ident from the fact that during follow-up
Average YGTSS scores fell to 19.28±10.31 but could also reflect the gender differ- ranging from several months to years,
following treatment. The change in ences in health-seeking behavior in the only one patient suffered a major relapse
YGTSS scores (58/77) represented a 75% Asian countries.2,3 The symptom profile, of the symptoms. Thus, the combination
decrement in the symptom severity. In including the types of tics, the waxing of medications and behavioral treat-
the four patients with OCD, Y-BOCS and waning course, the high rates of as- ments proved to be more effective than
scores also decreased by about 64% from sociated comorbidities, and problems medications when used alone.
pretreatment scores of 28.0+7.0 to the such as self-injury, was very similar to HRT and CBIT are considered high-
posttreatment scores of 10.0+4.1. Symp- the existing literature on TD. This also ly effective treatments for TD, with re-
toms of ADHD reduced by about 30% in endorsed the findings of cross-cultur- sponse rates of 33%–50%, while ERP is
the single patient with this co-morbidity. al studies that have concluded that the rated as “probably effective” because of
Patients reported an average reduction profile of TD is largely similar across fewer ERP trials.4,6,19,20 However, ERP is
of 76% (range 60%–90%) in subjective cultures.2,3,15 Despite this typical presen- recommended as a first-line treatment
distress due to the tics. Caregivers also tation of TD, there was a delay in the for comorbid OCD.1,5 The symptoms of
reported an overall reduction of 76% in diagnosis of about eight years. Other comorbid conditions such as OCD often
symptom severity. Additionally, the care- studies have also found that the mean cause greater distress and functional im-
givers felt that the educative and sup- lag between the onset of the symptoms pairment in TD than the tics themselves.
portive sessions had helped in reducing and the diagnosis ranges 6–8 years.15–18 They can hinder the response to behav-
their psychological distress and burden As in these studies, the principal cause ior therapy. Therefore, they require addi-
of care. Thus, it was evident that all these of the delayed diagnosis among our tional treatment.5 Though medications
patients who had responded poorly to patients was unawareness about TD and behavioral management are found
initial medication treatment showed among families as well as medical pro- to be equally effective, our patients had
much better responses after the addition fessionals. Later onset, prominence severe TD where the combination of two
of behavioral treatments to their medica- of comorbid OCD, and the ability to treatments is more useful and is usually
tion regimes. partially suppress the tics are some of recommended.4 Available data also sug-
Prospective follow-up was carried the other factors, noted in the earlier gests that gains obtained with behavior-
out for all the patients. However, two reports16–18 that could have delayed the al interventions are maintained over sev-
patients dropped out in the first few diagnosis in our patients. eral months.4,6,19 Therefore, the results of
months after the completion of treat- The findings regarding behavioral in- behavioral interventions among our pa-
ment. Five patients have remained on terventions in this report are of greater tients were remarkably similar to prior
active follow-up for durations ranging significance because of the scarcity of Western reports4–6 in terms of effective-
from about seven months to seven years. data on this aspect from India. Behavior- ness, response rates, long-term outcome,
Only one has suffered a major relapse, al interventions were carried out using and other benefits for both the patients
that is, a complete return of symptoms a structured protocol, which included and the caregivers.
to the pretreatment levels. However, he all the usual components of HRT and HRT may help suppress tics through
responded well to rTMS and a change of CBIT.4,19 Additional ERP was used in one several different mechanisms.19,20 Since
medications. The rest have had minor ex- patient for control of tics and in four environmental factors influence the oc-
acerbations (i.e., the reappearance of 1–2 patients for the treatment of OCD. Sup- currence of tics, individualized HRT treat-
tics of milder intensity), which have re- portive sessions were carried out with ment mitigating their adverse impacts
sponded to booster sessions of behavior both the patients and the caregivers for may reduce the frequency and severity
therapy during outpatient follow-ups. improving their understanding of the of the tics. Premonitory urges are often

experienced as aversive events, generat- of treatment for TD. Finally, public and 8. Fründt O, Woods D, and Ganos C. Behav-
ing anxiety that is only relieved by indulg- especially professional awareness re- ioral therapy for Tourette syndrome and
ing in tics. During HRT, the patients learn garding TD and its treatment, includ- chronic tic disorders. Neurol Clin Pract
2017; 7: 148–156.
to refrain from indulging in tics upon ing the role of behavioral interventions,
9. Gurtoo A, Anand KS, Garg S, et al. Gilles
experiencing premonitory urges. This needs to be improved.
De La Tourette’s syndrome: a case series
breaks the negative reinforcement cycle of 14 patients from India. Ann Indian
that maintains tics. The mechanisms of Declaration of Conflicting Interests Acad Neurol 2005; 8: 49–52.
change in ERP may involve habituation The authors declared no potential conflicts of 10. Dwarakanath S, Hegde A, Ketan J, et al.
or inhibitory learning, which reduces the interest with respect to the research, authorship, “I swear, I can’t stop it!”—a case of severe
need to resort to tics in response to the Tourette’s syndrome treated with deep brain
premonitory urges.20 Improvement with stimulation of anteromedial globus pallidus
Funding interna. Neurol India 2017; 65: 99–102.
behavioral treatments may also be me-
The authors received no financial support for the re- 11. Singh S, Kumar S, Kumar N, et al. Low-fre-
diated by biological mechanisms such as search, authorship, and/or publication of this article. quency repetitive transcranial magnetic
enhancement of frontal lobe activity that
stimulation for treatment of Tourette syn-
suppresses the basal-ganglia-mediated
activation of tics.
References drome: a naturalistic study with 3 months
of follow-up. Indian J Psychol Med 2018;
1. Robertson WC Jr. Tourette syndrome and 40: 482–486.
Conclusions other tic disorders treatment & manage- 12. Das S, Kartha A, and Purushothaman ST.
ment. Medscape Neurology [Internet]. De- Long-term follow-up of a case of Gilles de
Given that our findings represent un- partments of Neurology, Paediatrics, and la Tourette’s syndrome. Indian J Psychol
controlled data from a very small num- Family Practice, Clinical Title Series, Uni- Med 2016; 38: 263–265.
ber of patients, only a few tentative con- versity of Kentucky College of Medicine 13. Prakash J, Singh P, Bhat PS, et al. A case
clusions can be made. To begin with, our [updated May 30, 2019]. https://emedicine. of Gilles de la Tourette’s syndrome. Ind
experience has shown that it is feasible medscape.com/article/1182258-treatment Psychiatry J 2015; 24: 192–194.
to conduct behavior therapies for TD in 2. Robertson MM, Eapen V, and Cavanna AE. 14. Storch EA, De Nadai AS, Lewin AB, et al.
general hospital psychiatric settings in The international prevalence, epidemiol- Defining treatment response in pediatric
ogy, and clinical phenomenology of To- tic disorders: a signal detection analysis of
India, despite the comparative lack of
urette syndrome: a cross-cultural perspec- the Yale Global Tic Severity Scale. J Child
resources and specialized skills for treat-
tive. J Psychosom Res 2009; 67: 475–483. Adolesc Psychopharmacol 2011; 21: 621–627.
ment. When behavioral treatments are 3. Staley D, Wand R, and Shady G. Tourette 15. Freeman RD, Fast DK, Burd L, et al. An
carried out, results appear to be prom- disorder: a cross-cultural review. Compr international perspective on Tourette
ising, particularly among those with Psychiatry 1997; 38: 6–16. syndrome: selected findings from 3,500
severe TD with inadequate response to 4. Essoe JK, Grados MA, Harvey S, et al. individuals in 22 countries. Dev Med
medications. Delays in diagnosis and Evidence-based treatment of Tourette’s Child Neurol 2000; 42: 436–447.
initiation of adequate treatment, lack of disorder and chronic tic disorders. Expert 16. Wand R, Shady G, Broder R, et al. Tourette
awareness about TD, and limited access Rev Neurother 2019; 19: 1103–1115. syndrome: issues in diagnosis. Neurosci
to behavioral treatment are common 5. Jankovic J. Tourette syndrome. UpToDate Biobehav Rev 1992; 16: 449–451.
[Internet]. Department of Neurology, 17. Shilon Y, Pollak Y, Benarroch F, et al.
even in the West.4,19,20 That these may
Baylor College of Medicine [updated May Factors influencing diagnosis delay in
be far bigger problems in India is evi-
21, 2019]. https://www.uptodate.com/ children with Tourette syndrome. Eur J
dent from the lack of Indian studies on contents/tourette-syndrome-pathogene- Paediatr Neurol 2008; 12: 398–400.
this aspect. Moreover, our patient series sis-clinical-features-and-diagnosis 18. MolDebes NM, Hjalgrim H, and Skov L.
also demonstrated that medical practi- 6. Steeves T, McKinlay BD, Gorman D, Limited knowledge of Tourette syndrome
tioners lack awareness about TD and its et al. Canadian guidelines for the evi- causes delay in diagnosis. Neuropediat-
treatment. Consequently, they often fail dence-based treatment of tic disorders: rics 2008; 39: 101–105.
to inform patients and caregivers about behavioural therapy, deep brain stimula- 19. McGuire JF, Ricketts EJ, Piacentini J, et al.
these aspects. Therefore, firstly there is tion, and transcranial magnetic stimula- Behavior therapy for tic disorders: an ev-
tion. Can J Psychiatry 2012; 57: 144–151. idenced-based review and new directions
an urgent need to conduct proper effi-
7. Verdellen C, van de Griendt J, Hartmann for treatment research. Curr Dev Disord
cacy trials of behavioral interventions
A, et al. European clinical guidelines for Rep 2015; 2: 309–317.
for TD in India. Skills for delivering Tourette syndrome and other tic disor- 20. Capriotti MR, Himle MB, and Woods DW.
these treatments from general hospital ders. Part III: behavioural and psycho- Behavioral treatments for Tourette syn-
settings also have to be developed to in- social interventions. Eur Child Adolesc drome. J Obsessive Compuls Relat Disord
crease the access to these effective forms Psychiatry 2011; 20: 197–207. 2014; 3: 415–442.

Learning Curve
The Inconvenient Truth About Convenience and
Purposive Samples
Chittaranjan Andrade1
ABSTRACT MDD, all over the world. In practice,

however, if the study is conducted on
Most research is conducted on convenience and purposive samples that may be randomly
outpatients with MDD in a private
or nonrandomly drawn. A convenience sample is the one that is drawn from a source
that is conveniently accessible to the researcher. A purposive sample is the one whose hospital in India, the population
characteristics are defined for a purpose that is relevant to the study. The findings of a shrinks to all outpatients with MDD in
study based on convenience and purposive sampling can only be generalized to the (sub) similar private hospitals in India. This
population from which the sample is drawn and not to the entire population. This article population is effectively a subpopu-
explains the concepts involved with the help of examples of both good and bad sampling lation of “everybody with MDD, all
practice. Database studies and studies with enriched designs are cited as special examples over the world.” The concept is further
of convenience and purposive sampling. Issues related to the internal and external validity explained in the rest of this article.
of convenience and purposive samples are explained. The importance of good sampling
techniques in the design and interpretation of research is understated; this must change.
Unfortunately, it is rarely possible to
Keywords: Convenience sampling, purposive sampling, internal validity, external validity, draw a random sample from the pop-
enriched samples, database studies
ulation. For our antidepressant study,
W
for example, it would be impossible to
e wish to study whether a and future. However, this is possible
list every person on the planet who has
new antidepressant drug only if our sample is representative of
MDD, and to draw a random sample
is superior to placebo in the population; a sample is likely to be
from this list; of course, it would be
patients with major depressive disorder representative of the population only if it
impossible to sample persons with MDD
(MDD). Our unstated desire is to draw is randomly drawn from the population.
who have not yet been born. Research,
conclusions about the efficacy of this
As a side note, “population,” here and therefore, is almost always conducted on
drug in all patients with MDD, all over
the world, now, and in the future, as well. in the rest of this article, is used in its convenience samples.
This is because it is meaningless to do a statistical sense to refer to the entire
study whose findings apply only to the group of persons with the character-
Convenience Samples
sample that we recruit and to nobody istics of interest. So, in a study of the A convenience sample is one that is
else, anywhere else, anytime else. safety and efficacy of escitalopram drawn from a source that is conveniently
In research, we therefore implicitly in MDD, the sample is the group of accessible to us. This sample, however,
seek to generalize the findings from our patients in the study, and the popu- may not be representative of the pop-
sample to the entire population, present lation, in principle, is everybody with ulation at large. Thus, for example, a
Dept. of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India.
1
HOW TO CITE THIS ARTICLE: Andrade C. The Inconvenient Truth About Convenience and Purposive Samples. Indian J Psychol Med.
2021;43(1): 86–88.
Address for correspondence: Chittaranjan Andrade, Dept. of Clinical Submitted: 6 Nov. 2020
Psychopharmacology and Neurotoxicology, National Institute of Mental Health Accepted: 7 Nov. 2020
and Neurosciences, Bangalore, Karnataka 560029, India. E-mail: andradec@gmail. Published Online: 17 Dec. 2020
com
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCESS THIS ARTICLE ONLINE

Learning Curve
convenience sample of patients may be compromised; yet, samples are perhaps subjects. That is, there may be unmea-
drawn from a hospital; but these patients often recruited in this manner. sured and inadequately unmeasured
may not be representative of all patients, Here is a particularly egregious confounds. For example, in a database
such as patients in the community. Also, example of a nonrandomly drawn con- study of the influence of lifestyle behav-
a convenience sample of students may venience sample. In a hypothetical study iors on the risk of dementia, databases
be drawn from a nearby medical college; of blood micronutrient levels in patients may record whether or not a subject is
but these students may not be represen- with schizophrenia, a healthy control a smoker, but not how many cigarettes
tative of all students, such as students in sample was formed from friends and are smoked in a day, or whether the cig-
other professional and nonprofessional colleagues who volunteered to donate arettes are low or high in tar content; so
colleges. blood. Micronutrient levels were found to smoking is an inadequately measured
Research that is conducted on conve- be lower in patients than in controls. The confound. The database may not contain
nience samples can only be generalized only generalized interpretation possible any information about dietary habits, so
to the population that was conveniently is that the population of schizophrenia diet is an unmeasured confound.
accessible, from which the sample was patients who attend the researcher’s It is not common to cover the entire
drawn. As an example, a study on learn- hospital have lower blood micronutrient country for healthcare or insurance data-
ing disabilities is conducted on a random levels than the population of friends and bases. However, in database studies,
sample of students drawn from a govern- colleagues of the researcher. Research an example of exceptions could be
ment school in a rural part of Karnataka, of such nature is therefore unhelpful to national register-based studies in Scan-
India. This is a convenience sample, and the cause of science. Readers may also dinavian countries, where everybody in
note that when such a control sample the country is recorded in registers and
the findings from the study can only be
is nonrandomly drawn, the researcher where different registers can be cross-
generalized to the students of that school,
can “help” prove the study hypothesis linked. The external validity of these
and possibly to students of other govern-
by deliberately selecting controls who studies comes closest to the ideal.
ment schools in that region. It would be
have a balanced diet and lead a healthy
imprudent to generalize the findings to
lifestyle. Purposive Samples
city schools, private schools, and schools
in other parts of India or the world. Research is also almost always conducted
Population-Based on purposive samples. A purposive
A study conducted on a convenience
sample can have high internal validity if Convenience Studies sample is the one whose characteristics
the findings are trustworthy. This is pos- are defined for a purpose that is relevant
Some studies, such as those that extract
sible if the study was methodologically to the study. For example, a study may
data from healthcare or insurance data-
sound and if the data were properly ana- purposely examine the antidepressant
bases in a state or country, claim to be
lyzed. However, a study conducted on a benefits of fluoxetine in children and
population-based studies. Here, “popu-
adolescents because we do not know
convenience sample will have limited lation” does not mean “from the entire
whether the drug will work as well in
external validity. This is because the country” let alone from all over the
children and adolescents as in adults.
findings cannot easily be generalized world; “population” means that there is Also, a study may purposely examine
to populations with characteristics that no sampling, and that the whole popula- smoking quit rates with varenicline in
differ from the population that was con- tion of eligible subjects in that database persons who have been smoking more
veniently accessible, and from which the is studied. There is, therefore, no need to than ten cigarettes a day for at least the
sample was drawn.1 generalize from the sample to the popu- past 1 year because patients with lower
Here is a further important limita- lation when the population is itself the levels of smoking may be able to quit
tion. Generalization from a convenience subject of study. However, this is still a on their own (so drug may be no better
sample to its population is possible only form of convenience sampling because than placebo in such patients). Also, a
if the sample was randomly drawn from the database was conveniently available study may purposely examine attitudes
that population. So, if a study on hos- and only the subjects eligible to belong toward ECT in depressed patients who
pitalized alcohol-dependent patients in that database were studied. So, the have never received ECT because it is
in a deaddiction center recruited only findings do not necessarily generalize important to know what these patients
those patients occupying beds assigned to people in other databases, or to other think about a treatment that might
to the research student, or only on days people in that country, let alone to others sometimes be recommended to them.
on which the student was on duty, or in the rest of the world. Thus, even these The greater the number of inclusion
only from the clinical unit in which the population-based studies are a form and exclusion sample selection criteria
student was working, the sample may be of convenience sampling with limited set, each for a necessary purpose, the
biased in known or unknown ways and external validity. more purposive the sample becomes.
may not represent even the population of Internal validity in database studies Advantages of purposive samples are
patients that attend the specific deaddic- may not be high because the databases many. For example, they study only the
tion center, let alone alcohol-dependent may not contain all the information population that is of specific interest,
patients hospitalized elsewhere. This that is necessary for the study and the or they make the sample homogeneous
further compromises the external valid- recorded information may not necessar- (when between subjects variance is
ity of the study. Research of this nature is ily have been accurately obtained from reduced, statistical significance is more
Andrade
easily obtained), or they exclude subjects representative the sample is of the popu- drawn from their subpopulation can
who are at risk of serious adverse events. lation, and the less is the external validity indeed be probability samples if the
The disadvantage of purposive samples of the findings of the study. findings are generalized only to the
is the same as that of convenience Almost all research, including most subpopulations from which they were
samples: the more purposive the sample research that claims to be population- drawn. They are nonprobability samples
is, the more limited the external validity based, is conducted on samples that are only if the results are sought to be gener-
will be. both convenience samples and purposive alized to the entire population.
Random sampling is possible with samples. The results of such research can Readers may find that convenience and
purposive samples just as it is with con- only be generalized to the subpopulations purposive samples are defined in differ-
venience samples. However, even with with the characteristics that define and ent ways in different reference sources.
random sampling, when the sample is limit the convenience and purposive Usually, this is because research methods
purposive, generalization is only possible samples. As an additional concern, if such differ in different research disciplines.
to the population defined by the sample samples are not drawn at random from
selection criteria. So, the findings of a ran- their respective subpopulations, then the Take-Home Message
domized controlled trial (RCT) that was research cannot be validly generalized to If a study conducted on a convenience
conducted in adults cannot be general- even the subpopulations, let alone to the and purposive sample was method-
ized to children with the same diagnosis; entire population of interest. ologically sound, the internal validity
or the safety profile of an antidepressant
would be good; but because the sample
in an RCT that recruited nonsuicidal Need for Convenience and was both a convenience and purposive
depressed patients cannot be generalized
to depressed patients who are suicidal.
Purposive Samples sample, the external validity would be
limited by the restrictions defined by the
Research based on convenience and pur-
Enriched Samples Are posive samples can be important and
convenience and purposive nature of the
sample (generalization is possible only
Purposive Samples necessary, such as when sociocultural
to the population from which the sample
and other factors are expected to influ-
Many acute phase RCTs use a placebo was drawn, and to those in the popula-
ence outcomes. Through convenience
run-in phase as part of the design; tion who have the characteristics of the
and especially purposive sampling, the
patients who improve during this period sample studied; the findings cannot be
findings relevant for subpopulations
are not randomized. Many maintenance generalized to everybody).
can be identified. In other words, there
phase RCTs use a maintenance treat-
is nothing wrong with convenience and
ment stabilization phase as part of the Declaration of Conflicting Interests
purposive sampling as long as readers
research design; patients who drop out The author declared no potential conflicts of in-
are aware of the (sub)population to terest with respect to the research, authorship,
or relapse during this period are not ran-
which the findings are relevant. In this and/or publication of this article.
domized. Such enriched samples are also
context, readers may note that stress,
examples of purposive samples; internal
support, nutrition, drug compliance, and Funding
validity may be high, but external valid-
a host of confounding variables could The author received no financial support for the
ity is low because of poor generalizability research, authorship, and/or publication of this
to patients in everyday practice.2 differ between different convenience
article.
and purposive samples, and could even
Recapitulation influence response rates in psychophar- References
macology studies, making such samples
Research is conducted on samples 1. Andrade C. Internal, external, and ecolog-
necessary, but making generalization
because it is rarely feasible or even nec- ical validity in research design, conduct,
across subpopulations problematic.1
essary to study the entire population. and evaluation. Indian J Psychol Med
2018; 40(5): 498–499.
However, because we want to draw con- Parting Notes 2. Andrade C. Examination of participant
clusions about the population, and not
Convenience and purposive samples flow in the CONSORT diagram can
just about the sample, the sample must
improve the understanding of the gener-
be truly representative of the popula- are described as examples of nonprob-
alizability of study results. J
tion. This is only possible if the sample ability sampling.3 A probability sample
Clin Psychiatry 2015; 76(11):
is randomly drawn from the population. is one where the probability of selec- e1469–e1471.
In a random sample, every member of tion of every member of the population 3. Battaglia MP. Nonprobability sam-
the population has an equal chance of is nonzero and is known in advance. pling. In: Lavrakas PJ (ed) Encyclopedia
being selected. The greater the extent to So, strictly speaking, convenience and of survey research methods. London: SAGE
which this criterion is violated, the less purposive samples that were randomly Publications, 2008, pp. 535–526.

Letters to the Editor
Safeguarding the Frontier An overburdened and crumbled of being ostracized. Among the environ-
healthcare system cannot manage an mental factors, poor working conditions,
Covidians During the expanding pandemic if HCPs fall sick or patient overload, lack of supplies, and
COVID-19 Pandemic: Scuffles surrender to moral injury. We propose a unsafe conditions jeopardize an already
model to depict threats to HCPs during strained HCP.
and Proposed Strategies COVID-19 pandemic and the strategies Strategically, the approach to compact
Respected Editor, threats can be four-pronged (Figure 1,
O
to deal with it. The model emphasizes
n November 10, 2020, India’s a delicate interplay between various right wheel). At the governmental level,
COVID-19 cases crossed 8.6 mil- factors that determine the efficiency of an the prime focus should be on enacting,
lion, of which approximately HCP in COVID times. The model further implementing, and putting in place a
127,500 people succumbed.1 The burden depicts the factors threatening the effi- system with zero tolerance on attack
of multiple stressors, such as scarcity of ciency of HCP (Figure 1, left wheel). against the healthcare workforce. It is
personal protective equipment (PPE), Threats can be broadly grouped as in the government’s capacity to ensure
undue work demands, pessimistic public physical, psychological, social, and envi- a smooth supply of equipment and
attitudes, and physical attacks, instigate ronmental. Physical stressors, such as well-validated protocols to ensure trans-
lasting moral injury on healthcare pro- excessive physical exertion due to long parency. These can be done by increasing
fessionals (HCPs).2,3 Governmental and working hours in PPE, staff constraints, investments in the healthcare sector and
institutional strategies to address psy- physical attacks, and inadequate rest and contingency funding. Incentivizing and
chosocial well-being and mitigate these sleep, cause bodily damage to the worker. insuring HCPs can boost morale and zeal
negative gestures from society are sub- Psychological threats include existing low in the workforce.
optimal in our country with diverse so- morale, stress, anxiety induced by sub- Society has a pivotal role to play by
cio-cultural and regional disparities. We optimal working conditions, and the fear being responsible and empathetic to the
thoroughly searched the literature and of infecting self, family, and community. HCPs. There should be mutual trust and
official websites to shed light on various confidence-building measures to enhance
The arduous task of triaging and ensur-
problems faced by HCPs during this pan- cooperation and respect. Institutions
ing equitable distribution of care to all
demic and put forward a strategic model have impactful roles in providing job
the deserving patients is very stress induc-
to overcome these tussles. security and staff protection by ensur-
ing, as it may come in direct conflict with
With a huge population of 1.36 billion ethical, moral, and religious principles of ing optimal working conditions and
in the country, every doctor and nurse in HCPs. Among social factors, stigma exhib- making the working environment as
India caters to 1457 and 483 people, respec- ited by the very society they chose to serve, flexible as possible by diverting priority
tively, with an estimated shortage of evictions, stone pelting, and the mounting attention and resources to COVID care,
600,000 doctors and 2 million nurses.4,5 number of HCPs infected induce a state without compromising attention to other
In addition to corona virus, HCPs in India
are fighting another insidious threat— Figure 1.
stigma. Incidents of eviction, ostracism,
and mental harassment toward HCPs
Strategic Model for Healthcare Professionals
are repeatedly reported.6 There have been
incidents of mob attack, rape threats,
verbal spats, and exhibitionism toward
HCPs, due to the fear that they are vectors
of coronavirus.7 The petrifying phenome-
non is that HCPs have been perceived as
“an impending risk, as opposed to being
a solution” to COVID-19.
HCPs are at high risk of having moral
injury and mental-health problems
while dealing with the challenges of
COVID-19.8 Apart from these challenges,
HCPs are vulnerable to burnout, mental
trauma, and depression. Hectic working
hours, lack of protective gear, and separa-
tion from family have emerged as major
factors contributing toward disturbed
mental health.8

emergency cases. Proper staff training, 3. The Lancet. COVID-19: Protecting health-
ORCID iD
open communication, and ensuring ade- care workers. Lancet 2020; 395: 922.
Alwin Issac https://orcid.org/0000-0002- 4. WHO. Wanted: 2.4 million nurses, and
quate supplies and facilities can make staff
4528-8787
in an institution feel part of the system. that’s just in India, https://www.who.
Testing times like these call for a lot of int/bulletin/volumes/88/5/10-020510/en/
Vijay VR1, Nadiya Krishnan1, Alwin Issac1,
(2010, accessed September 18, 2020).
effort at a personal level from the HCPs. Jaison Jacob1, Shine Stephen1, Rakesh VR1,
5. Stephen S and Vijay VR. Metamorphosis
These may include stress adaptation and Harmeet Kaur Kang2, Manju Dhandapani3
of nursing profession: An Indian perspec-
change management strategies, open- College of Nursing, All India Institute of Medical
1
Sciences, Bhubaneswar, Odisha, India. 2Chitkara tive. J Glob Health; 9. Epub ahead of print
ness to learn and contribute, and a high
School of Health Sciences, Chitkara University, 2019. doi: 10.7189/jogh.09.020314.
state of accountability and responsibility. 6. Times of India. Covid-19: Health min-
Patiala, Punjab, India. 3Post Graduate Institute of
This would also require moving out of Medical Education & Research, Chandigarh, India. ister says “deeply anguished” at reports
routines and comfort zones and moving of doctors facing eviction from land-
into an unknown, uncertain realm. Address for correspondence: lords | India News—Times of India,
In summary, humankind is capable of Alwin Issac, College of Nursing, All India Institute https://timesofindia.indiatimes.com/
amazing resilience, and healthcare is not of Medical Sciences, Bhubaneswar, Odisha, India.
india/covid-19-health-minister-says-
E-mail: aimalwinissac@gmail.com
an exception to it, albeit with support deeply-anguished-at-reports-of-doc-
from the governmental, institutional, and Submitted: 12 Oct. 2020 tors-facing-eviction-from-landlords/
societal systems. None of the strategies Accepted: 12 Nov. 2020 articleshow/74797873.cms (2002, accessed
can exist in isolation; each one must turn Published Online: 19 Dec. 2020 September 18, 2020).
to be the “Cape of Good Hope” through 7. Ravi R. Abused, attacked, beaten:
collaboration by giving priority to society. References Frontline workers are risking their lives
1. MoHFW | Home, https://www.mohfw. everyday in India, https://thelogicalin-
gov.in/index1.php (accessed November dian.com/news/covid-19-healthcare-
10, 2020). workers-attacked-20665 (2020, accessed
The authors declared no potential conflicts of in-
2. Coronavirus in India: Lack of equipment September 18, 2020).
terest with respect to the research, authorship,
and/or publication of this article. forces doctors to fight Covid-19 with 8. Greenberg N, Docherty M,
raincoats, helmets—India News, https:// Gnanapragasam S, et al. Managing
Funding www.indiatoday.in/india/story/coronavi- mental health challenges faced by health-
rus-in-india-doctors-face-equipment-sho- care workers during covid-19 pandemic.
The authors received no financial support for the
research, authorship, and/or publication of this tages-1661773-2020-03-31 (2020, accessed BMJ; 368. Epub ahead of print March 26,
article. September 18, 2020). 2020. doi: 10.1136/bmj.m1211.
HOW TO CITe THIS ArTICLe: Vijay VR, Krishnan N, Issac A, Jacob J, Stephen S, Rakesh VR, Kang HK, Dhandapani M. Safeguarding the
Frontier Covidians During the COVID-19 Pandemic: Scuffles and Proposed Strategies. Indian J Psychol Med. 2021;43(1): 89–90.
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative ACCeSS THIS ArTICLe ONLINe
provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub. DOI: 10.1177/0253717620978586
COVID-19 and right to Die To compound matters, the stigma the scarce evidence for transmission
surrounding COVID deaths has meant of COVID-19 from dead bodies of con-
With Dignity: Time to re- that families often have to prune or even firmed or suspected cases, both national4
evaluate Policies Over the forego death-related rituals; instead, and international5 guidelines have advo-
in several nations, the state has had to cated including the family members in
Practice of Last rites? take over the responsibilities of con- the last rites of patients, albeit minus the
Sir, ducting the last rites of the deceased. traditional rituals of hugging, touching,
T
he ongoing COVID-19 pandem- However, with the rising number of case and kissing the bodies. However, these
ic is not just an unprecedented fatalities, one must legitimately worry if are the very rituals that provide a sense
healthcare crisis; it is also rapidly the state has the resources to deal with of closure to the family members, and
becoming a social, economic, humanitar- this issue effectively. Global reports about depriving them of a final opportunity to
ian, and human rights crisis. Healthcare mass burials and dead bodies being touch their loved ones may distort the
for dying patients has been distorted thrown cursorily into burial pits support process of grief and increase the risk of
in several ways; these include extreme these concerns.1,2 The right to a dignified a range of psychiatric morbidities, such
restrictions in visitation policies and burial extends from the right to a digni- as depression, anxiety, suicidal risks, and
practices that deny dying patients a fi- fied death.3 post-traumatic stress disorders.6 In the
nal opportunity to physically meet their To avoid these infractions of the funda- long run, feelings of guilt and shame
loved ones and bid goodbye. mental right to die with dignity and given may ensue and the society may also
criticize them; this compromises their protocols, such as wearing protective city/puducherry/puducherry-
right to live with dignity. gear and observing post-rites quarantine; inappropriate-dumping-of-covid-
Furthermore, there have been instances this information should be disseminated positive-mans-body-into-pit-causes-
furore/articleshow/76241424.cms
where family members have refused to and emphasized at the community level
(2020, accessed December 18, 2020).
take the body and perform the last rites using various media platforms. 3. Correspondent. Supreme Court urged to
or burial. This may be due to two reasons: To sum up, policies over performing protect patients’ right to dignified death,
first, the family members may fear con- the last rites of the deceased during the burial [Internet]. The Hindu [cited 2020
tracting the infection and the consequent pandemic merit a revaluation. Optimal Nov 11], https://www.thehindu.com/
stigma and ostracization; second, there family involvement in decision making news/national/supreme-court-urged-to-
may be practical difficulties in follow- on funeral rites and adequate pre-funeral protect-patients-right-to-dignified-death-
ing the recommendations on dead-body counseling for the bereaved can help in burial/article31799742.ece (2020, accessed
December 18, 2020).
management, such as the requirement this regard.
4. Directorate General of Health Services
of a grave of a specific depth7 or a lack of (EMR Division). COVID-19: Guidelines
adequate land parcels to bury the on dead body management [Internet].
Vikas Menon1, Jigyansa Ipsita Pattnaik2,
deceased, in view of overflowing ceme- Susanta Kumar Padhy3 [cited 2020 Aug 30], https://www.
teries. The latter has led to measures such 1
Dept. of Psychiatry, Jawaharlal Institute of Post- mohfw.gov.in/pdf/1584423700568_
as cremation of all dead bodies irrespec- graduate Medical Education and Research, COVID19GuidelinesonDead
tive of the religion or community of the Puducherry, India. 2Fellow in Child Psychiatry, bodymanagement.pdf (2020, accessed
deceased, which has hurt religious sen- Dept. of Psychiatry, St John's National Academy December 18, 2020).
of Health Sciences, Bengaluru, Karnataka, India. 5. World Health Organization. Infection
timents.8 This points to a gap between 3
Dept. of Psychiatry, All India Institute of Medical prevention and control for the safe man-
policy and implementation. Sciences, Bangalore, Bangalore, Karnataka, India. agement of a dead body in the context of
COVID-19: Interim guidance [Internet].
Address for correspondence: https://apps.who.int/iris/bitstream/
Vikas Menon, Dept. of Psychiatry, Jawaharlal In- handle/10665/331538/WHO-COVID-
stitute of Postgraduate Medical Education and 19-lPC_DBMgmt-2020.1-eng.pdf?se-
Research, Dhanvantri Nagar, Puducherry, Pondi- quence=1&isAllowed=y (2020, accessed
cherry 605006, India. E-mail: drvmenon@gmail. December 18, 2020).
com 6. Chochinov HM, Bolton J, and Sareen J.
Death, dying, and dignity in the time of
Submitted: 22 Oct. 2020
the COVID-19 pandemic. J Palliat Med
Accepted: 18 Nov. 2020
[Internet] [cited 2020 Aug 21], https://www.
Published Online: 21 Dec. 2020
liebertpub.com/doi/10.1089/jpm.2020.0406
(2020, accessed December 18, 2020).
References 7. Municipal Administration and Urban
These issues highlight the need for Development (General) Department.
1. Al-Arshani S. Photos of mass graves
adequate pre-funeral counseling for the Operational guidelines for disposal of
in Brazil show the stark toll of the
family members that is geared toward suspected/confirmed cases of COVID-
coronavirus, as experts predict that it
19 dead bodies [Internet], http://www.
dispelling myths and misconceptions will surpass 125,000 deaths by August
manupatrafast.in/covid_19/Telangana/
around handling bodies of victims; this [Internet]. Business Insider. [cited 2020 Govt/Operational%20Guidelines%20
will facilitate an informed decision about Aug 22], https://www.businessinsider. Monitoring%20Disposal%20
their participation in funeral rites. In in/international/news/photos-of-mass- Confirmed%20Dead%20Bodies.pdf
turn, this will allow for healthier griev- graves-in-brazil-show-the-stark-toll-of- (2020, accessed December 18, 2020).
ing and reduce adverse psychological the-coronavirus-as-experts-predict-that- 8. Akshatha M. Burial of coronavirus victims
it-will-surpass-125000-deaths-by-august/ turns a logistical challenge for Bengaluru’s
fallouts among those bereaved. During
slidelist/76057209.cms (2020, accessed BBMP [Internet]. Economic Times 2020
this counseling, the family members
December 18, 2020). [cited 2020 Nov 11], https://economictimes.
can be given the option to exercise their 2. Dominique B. Puducherry: indiatimes.com/news/politics-and-nation/
right to conduct the funeral rites of the Inappropriate dumping of COVID burial-of-coronavirus-victims-turns-a-
deceased. If they decide to proceed, they positive man’s body into pit causes logistical-challenge-for-bengalurus-bbmp/
can be asked to carry out the funeral furore [Internet]. [cited 2020 Aug 22], articleshow/77234209.cms (2020, accessed
rites following all the necessary safety https://timesofindia.indiatimes.com/ December 18, 2020).
HOW TO CITe THIS ArTICLe: Menon V, Pattnaik JI, Padhy SK. COVID-19 and Right to Die With Dignity: Time to Re-Evaluate Policies
Over the Practice of Last Rites?. Indian J Psychol Med. 2021;43(1): 90–91.

Escalating Suicide Rates and support. Being at home during the behaviors among them.3 On the other
lockdown is a stressful and demanding hand, parental engagement or responsive
Among School Children situation for several children. The lock- and supportive family, social connected-
During COVID-19 Pandemic down and school closure also mean that ness, having intimate friends, sense of
children do not have school as an avenue impulse control, help-seeking behavior,
and Lockdown Period: An to escape from difficult homes anymore. and various other resilience factors are
Alarming Psychosocial Importantly, many children are experi- recognized to be very crucial and decisive
Issue encing emotional trauma due to various protective factors among children.13,14
psychosocial stressors such as prolonged The mounting rate of suicidal behav-
Dear Sir,
G
confinement in a hostile home envi- iors among children is a very serious
lobally, suicide among children ronment, poor communication, lack of psychosocial issue that requires an
is a significant preventable pub- interaction (in-person) with friends and imperative concern in its prevention
lic health problem, and it is the teachers, study-related pressure, appre- during and after the COVID-19 era.
second leading cause of death among hensions about attending online classes, It calls for the collective efforts of all
younger people aged 10–24 years.1 In In- lack of appropriate facility to attend stakeholders in the society, to intervene
dia, a student dies by suicide every hour, online classes, financial crisis at family, effectively at the individual, family,
and 28 such loss of life occurs every day.2 and community levels to address the
During this COVID-19 pandemic and suicidal behaviors among children. In
lockdown, the suicidal tendency among this context, the detection and under-
school children is significantly ris- standing of warning signs, risks, and
ing.3,4 Since the beginning of lockdown protective factors are very crucial, not
(March–October), in Kerala, 173 chil- only for health care professionals but
dren, aged 10–18 years, died by suicide.5 also for the public, including parents,
Similar reports from other parts of the teachers, student population, and other
world have also shown a significant key personnel in different sectors, to
increase in the deaths of children due identify and link the students to appro-
to suicide during the lockdown period priate services and support.11,13,14 Hence,
than the prelockdown period, claiming a parents and teachers play a significant
9.3%–33% rise in the number of children role in suicide prevention among school
presenting with self-harm injuries as children, especially during the home
well.6,7 Moreover, this is often underre- confinement period, and parenting skills
ported and neglected from other corners, become more decisive while handling
though it is a grave psychosocial and pre- children at risk.3,14 Children from fami-
ventable issue that needs to be addressed lies with secure parent–child attachment
promptly. overuse of social media, and fears of showed enhanced social and coping
Though response measures to combat contagion, and these can have traumatic skills, lesser mental health problems, and
the virus are vital, the prolonged school and enduring detrimental effects on chil- lesser involvement in high-risk behav-
closure and home confinement might dren.9–11 Additionally, the lockdown has iors, including suicidal behavior.11,13,14
have a detrimental impact on children.3 aggravated underlying problems such as As the rate of suicidal behavior among
This pandemic and its response measures parental pressure, scolding from parents, children has shown a significant rise,
have led to the complete nationwide discord in the household, domestic vio- there is an urgent need for crisis hotlines
closure of educational institutions in lence, and substance abuse, which harm to provide mental health services and
many parts of the world, including India, children and drive them to take these resources to all children without any
affecting about 900 million students extreme steps.11 All these disrupt their barriers. Government of Kerala, for
worldwide.3,8 The pandemic has caused healthcare activities, sleep patterns, diet, example, has taken the initiative for a
significant psychosocial sufferings, outdoor activities, and social life, affect- teleconsultation facility for children
leading to the development or exacerba- ing their wellbeing destructively.11 who are facing stress (for instance, Ottak-
tion of fear, distress, anxiety, depression, Stressful life events, mental health kalla Oppamundu—you are not alone,
and other psychiatric disorders, includ- conditions, and family environments we are with you, “CHIRI”—a tele-coun-
ing extreme suicidal thoughts among are major risk factors for suicidal seling service, etc.) as part of ORC (our
school children.3,9 Nonetheless, the behavior among children.12 The higher responsibility to children)—a planned
mental health effects of this crisis on risk of being exposed to neglect; phys- community intervention that connects
children are an issue often neglected by ical, emotional, and sexual abuse and people.4 Teleconsultation services have
families and society, leading to severe violence; and economic crisis at home been effective in providing mental
setbacks.3 caused by this pandemic, might have led health services to children, including
Notably, it is not the figures alone, to the increased suicide rates among chil- addressing their suicidal behaviors, and
as mentioned above, but the fact of dren.3,10,12 Moreover, loneliness and poor providing help to vulnerable families
imperative mental health concerns of social support and social relationships also during the previous epidemics.3
young people and their cry for help are well-recognized correlates of suicidal The public’s basic knowledge on “how
to intervene or support children who over school closures. The Guardian
ORCID iD [Internet]. [cited 2020 Nov 17], http://
are at risk” is crucial at this phase of the
Bibin V. Philip https://orcid.org/0000-0002- www.theguardian.com/education/2020/
pandemic. “Childline” services or similar
0505-7941 jul/13/deaths-special-needs-children-kent-
kinds of mental health and legal services
raise-concerns-over-school-closures (2020,
need to be strengthened and should Submitted: 22 Oct. 2020
Accepted: 1 Dec. 2020 December 16, 2020).
be “child-friendly” to address various
Published Online: 8 Jan. 2021 7. The Independent. Coronavirus lockdown
kinds of traumatic experiences of
may have led to increased child sui-
children such as abuses, neglect, and cides, new report warns. The Independent
exploitation. Peer-led initiatives also References [Internet]. [cited 2020 Nov 17], https://
would help. Primarily, one would need 1. AACAP. Suicide in children and teens www.independent.co.uk/news/health/
to work with children to create mean- [Internet]. Academy of Child and coronavirus-uk-child-suicide-men-
ingful change, rather than enforcing Adolescent Psychiatry. [cited 2020 Aug tal-health-nhs-a9617671.html (2020,
measures on them, addressing their 28]., https://www.aacap.org/AACAP/ December 16, 2020).
emotional, psychosocial, physical, and Families_and_Youth/Facts_for_Families/ 8. UNESCO. Education: From disruption
FFF-Guide/Teen-Suicide-010.aspx (2018, to recovery [Internet]. https://plus.
economic needs. Moreover, the focus
December 16, 2020). google.com/+UNESCO. [cited 2020
should be on the strengths and resilience
2. The Hindu. Student suicides rising, 28 lives Aug 25], https://en.unesco.org/covid19/
of the children. All the interventions lost every day. The Hindu [Internet]. [cited educationresponse (2020, December 16,
to address suicidal behavior among 2020 Aug 27], https://www.thehindu.com/ 2020).
children, during and after the COVID-19 news/national/student-suicides-rising-28-
9. Guessoum SB, Lachal J, Radjack R, et al.
crisis, should ultimately aim to bring out lives-lost-every-day/article30685085.ece
Adolescent psychiatric disorders during
“overall well-being of all children” and (2020, December 16, 2020).
the COVID-19 pandemic and lockdown.
become a national health priority. 3. Hou T, Mao X, Dong W, Cai W, and Deng
Psychiatry Res 2020; 291: 113264.
G. Prevalence of and factors associated
10. Lee J. Mental health effects of school
with mental health problems and suicid-
Acknowledgments closures during COVID-19. Lancet Child
ality among senior high school students
The author would like to thank Jaisy Bibin for her Adolesc Health 2020; 4(6): 421.
in rural China during the COVID-19 out-
helps in proof reading and editing the article. 11. Wang G, Zhang Y, Zhao J, Zhang J, and
break. Asian J Psychiatry 2020; 54: 102305.
4. The Times of India. Increasing suicidal Jiang F. Mitigate the effects of home con-
Declaration of Conflicting Interests finement on children during the COVID-
tendency among children during lock-
The author declared no potential conflicts of in- down in Kerala; Over 60 end lives since 19 outbreak. Lancet 2020; 395(10228):
terest with respect to the research, authorship, 945–947.
March 25—Times of India. The Times of
India [Internet]. Thiruvananthapuram. 12. Carballo JJ, Llorente C, Kehrmann L,
[cited 2020 Sep 14], https://timesofin- et al. Psychosocial risk factors for suicidal-
Funding ity in children and adolescents. Eur Child
dia.indiatimes.com/home/education/
The author received no financial support for the Adolesc Psychiatry 2020; 29(6): 759–776.
news/increasing-suicidal-tendency-
among-children-during-lockdown-in- 13. Dema T, Tripathy JP, Thinley S, et al.
article.
ker-over-60-end-lives-since-march-25/ Suicidal ideation and attempt among
articleshow/76924011.cms (2020, school going adolescents in Bhutan—a
Bibin V. Philip1
December 16, 2020). secondary analysis of a global school-
Dept. of Psychiatry, Institute of Integrated
1
5. Manorama Online. 173 child suicides in based student health survey in Bhutan
Medical Sciences (Government Medical College)
Palakkad, Kerala, India. Kerala since lockdown, stress forced most. 2016. BMC Public Health [Internet] 2019;
OnManorama [Internet]. [cited 2020 Nov 19(1), https://bmcpublichealth.biomed-
16], https://www.onmanorama.com/ central.com/articles/10.1186/s12889-019-
Address for correspondence:
news/kerala/2020/10/26/children-death- 7791-0 (December 16, 2020).
Bibin V. Philip, Dept. of Psychiatry, Institute
by-suicide-on-the-rise-in-kerala.html 14. Liu JJ, Bao Y, Huang X, Shi J, and Lu L.
of Integrated Medical Sciences (Government
Medical College) Palakkad, Kerala 678013, (2020, December 16, 2020). Mental health considerations for children
India. E-mails: bvengathanam@gmail.com, 6. The Guardian. Deaths of children with quarantined because of COVID-19. Lancet
bibinphilip2016@gmail.com special needs in Kent raise concerns Child Adolesc Health 2020; 4(5): 347–349.
HOW TO CITe THIS ArTICLe: Philip BV. Escalating Suicide Rates Among School Children During COVID-19 Pandemic and Lockdown
Period: An Alarming Psychosocial Issue. Indian J Psychol Med. 2021;43(1): 92–93.

List of Reviewers 2020
We gratefully acknowledge the contribution of the following reviewers who assessed papers for Indian Journal of Psychological
Medicine in 2020:
• Akash Vishwakarma • K Vidya • Sagar Karia

• Amit Singh • Karthick Subramanian • Samrat Bhandari
• Anil Kakunje • Krishna Prasad Muliyala • Sanju George
• Anil Kumar TV • Kurian Jose • Santanu Nath
• Aniruddha Mukherjee • Laxmi Vadlamani Naresh • Satyam Sharma
• Anirudh Kala • Lekhansh Shukla • Seshadri Chatterjee
• Anju Mathew • M Rao • Shabeesh Balan
• Anu Mital • Manik Bhise • Shaji KS
• Arghya Pal • Manoj Eradath • Shilpa Sadanand
• Arunkumar Annamalai • Manushree Gupta • Shivanand Kattimani
• Aseem Mehra • Meena Hariharan • Shweta Rai
• Ashok Mysore • Migita D’cruz • Shweta Singh
• Ashwin Mohan • Nandheesha Hanumanthappa • Shwetha TS
• Avinash De Sousa • Naresh Nebhinani • Shyam Arumugham
• Balasubrahmanya KR • Natarajan Varadharajan • Shyamanta Das
• Barikar C Malathesh • Neena Sawant • Sivakumar Thanapal
• Bheemsain Tekkalaki • Neeti Rustagi • Sivapriya Vaidyanathan
• Bichitra Nanda Patra • Nilamadhab Kar • Smita Deshpande
• Bikram Dutta • Nilesh Shah • Smitha CA
• Chandra Sekhar K • Nileswar Das • Smitha Ramadas
• Chonnakarn Jatchavala • Nitasha Sharma • Snehil Gupta
• Christina George • Nivedhitha Selvakumar • Soumya Basu
• Dan Pothiyil • Padmaja G • Srinagesh Mannekote Thippaiah
• Dayal Narayan • Palanimuthu Thangaraju Sivakumar • Sudhir Kumar CT
• Debashish Basu • Parthasarathy Ramamurthy • Suhas Satish
• Deepak Ghadigaonkar • Paulomi Sudhir • Sujita Kar
• Deepanjali Deshmukh • Pragya Sharma • Sundernag Ganjekar
• Devavrat Harshe • Preethy Kathiresan • Suravi Patra
• Dheeraj Kattula • Preeti Kandasamy • Susanta Padhy
• Dinakaran Damodharan • Priya Sreedaran • Swapnajeet Sahoo
• Manjula Simiyon • Rajakumari Reddy • Tarun Verma
• Naveen Kumar • Rajeev Ranjan • Tess Rajan
• Gagandeep Makkar • Rajesh Kumar • TS Jaisoorya
• Gitanjali Narayanan • Rajiv Radhakrishnan • TV Asokan
• Harish M Tharayil • Rajkumari Reddy • Vandana Choudhary
• Harish Thippeswamy • Ramdas Ransing • Varsha Vidyadharan
• Harshini Manohar • Ravi Rajkumar • Varun Mehta
• Harsimarpreet Kaur • Ravish H • Venkataram Shivakumar
• Hrishikesh Nachane • Raviteja Innamuri • Vidhu Karunakaran
• Jaspreet Brar • Reema Samuel • Vidhya Malyam
• Jay Ranjan • Rishab Gupta • Vijaya Raghavan
• Jayaprakash Russell Ravan • Rohit Verma • Vijaykumar Harbishettar
• Jayaprakashan KP • Roshan Sutar • Vikas Gaur
• Joel Philip • Sachin Nagendrappa • Vishal Dhiman
• John Vijay Sagar Kommu • Sadhana Singh • Vivek Agarwal

Szja 43 1

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Szja 43 1

Uploaded by

Copyright:

Available Formats

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 i

ii Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Volume 43 | Issue 1 | January 2021 | www. journals.sagepub.com/home/szj

EDITOR-IN-CHIEF Psychopharmacology Roy Abraham Kallivayalil EXECUTIVE COMMITTEE OF INDIAN PSYCHIATRIC

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 iii

MANAGED BY JOURNAL OF PSYCHOLOGICAL MEDICINE AND RESEARCH

RNI No. MAHENG/2011/38799 Editor: Dr. Shahul Ameen

iv Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

with Executive Dysfunction in Mental-Illness-Related Stigma

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 v

Practical Psychotherapy Letters to the Editor Escalating Suicide Rates

vi Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Weightage for Various

Copyright © 2020 Indian Psychiatric Society - South Zonal Branch

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 1

4 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

ABSTRACT such as antipsychotics, antiemetics, or obsessive ideas may also accompany

Copyright © 2020 Indian Psychiatric Society - South Zonal Branch

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 5

6 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 7

program. J Clin Psychopharmacol 2015;

8 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 9

Department of Clinical Psychology, NIMHANS, Bengaluru, Karnataka, India.

Copyright © 2020 Indian Psychiatric Society - South Zonal Branch

10 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Sociodemographic Profile of Participants

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 11

12 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 13

14 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 15

Copyright © 2020 Indian Psychiatric Society - South Zonal Branch

16 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Relationship Between Controlled Oral Word Association Test

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 17

to read the words from the time taken to Table 1.

18 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 19

20 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 21

Conclusion paranoid schizophrenia. Ind Psychiatry J

22 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 23

ABSTRACT associated with focused attention, behavior. Classic descriptions of schizo‑

Copyright © 2020 Indian Psychiatric Society - South Zonal Branch

24 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 25

26 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

i.e., SG and HCG. The two groups were Table 1.

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 27

age, duration of illness, and education. Table 4.

erished responses. Total peculiar scores Visual working memory

28 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 29

30 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Copyright © 2020 Indian Psychiatric Society - South Zonal Branch

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 31

32 Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021

Indian Journal of Psychological Medicine | Volume 43 | Issue 1 | January 2021 33

Themes, Sub-themes, and Categories

Feeling powerless Living next to PWS makes them feel: