Psychiatry and Mental health, Psychiatry and Mental health, Neurology, Neuroscience
10
Scopus Publications
Scopus Publications
Klingsor Syndrome-A rare case report from Andaman and Nicobar Islands Pooja Govind, Anand Lingeswaran Indian Journal of Psychiatry, 2024 Klingsor syndrome or genital self-mutation (GSM) is a rare clinical entity,[1] seen in psychiatric disorders such as depression, under command hallucinations, religious preoccupations, and substance abuse.[2] Self-injury behavior as a mode of suicide goes unreported, and 6% of adults have self-injurious behavior and 0.5 to 1.8% die by suicide.[3] Most episodes of GSM tend to occur in the context of psychosis or delusional coercion.[4] Phallicide is GSM with motive to die in depression or bipolarity.[5] This case report describes Klingsor syndrome associated with commanding hallucinations in a 45-year-old male at a tertiary care hospital in Andaman. He was brought to the emergency after partially amputating his penis, reporting he acted in response to commanding hallucinations. There was 6-month history of low mood, anhedonia, delusional guilt, and auditory hallucinations but did not seek treatment. He consumed alcohol daily to mute hallucinations and was abstinent 1 week before admission, with poor social or occupational functioning for 6 months. On examination, he was alert but uncooperative, with poor eye contact and decreased speech. Initially guarded and psychotic, he became more cooperative after 24 hours. His speech was relevant and coherent, with dull affect, delusions of guilt, and self-harming hallucinations. Cognitive functions were satisfactory, with no alcohol withdrawal signs. Admitted in a surgery ward, he underwent suprapubic catheterization. Due to persistent suicidal ideations, he was transferred to a psychiatry ward for comprehensive management. Columbia-suicide severity rating Scale (C-SSRS) assessed the severity of suicidal thoughts, and high risk was present as he still had commanding AH, which were distressful (Ideation intensity score 23). History revealed poor psychosocial support and a year-long marital separation with psychiatric admissions for alcohol use disorder 4 years ago, without complicated withdrawal, and past suicidal gestures under intoxication, though details were unavailable, and no treatment sought. Premorbid assessment was not possible due to the absence of reliable attendant and no relevant family history. Based on the Diagnostic and Statistical Manual for Mental Disorders - 5th edition (DSM-5), the diagnosis of Major Depressive Disorder-Severe Depression with Psychotic symptoms with Alcohol Use Disorder-Severe was made. Acute suicide risk was noted, and a high-risk protocol was followed in the ward setting. ECT was suggested, but family members denied. He underwent comprehensive physical and neurological workup, which was normal. Pharmacotherapy with Mirtazapine 45 mg and Olanzapine 20 mg with clonazepam for sleep disturbance yielded significant improvement reflected in Hamilton Rating Scale for Depression score as 32 (at admission); 12 (at discharge) and Brief psychiatric rating scale score as 48 (at admission); 22 (at discharge). Admitted for one and half months, he showed good improvement and underwent supportive counseling. His mood and psychotic symptoms improved, and reassessment on C-SSRS revealed no active ideas. Written informed consent was obtained from the patient and caregiver. He was referred to higher centers for urologist intervention. GSM is the highest in the schizophrenia spectrum (49.0%) and substance users (18.5%) and less common in depression (8.9%) and bipolar disorder (1.3%).[3] Case reports of suicide by GSM under depression are present; however, we could not find any such lethal act secondary to commanding hallucinations. It is one the first reports from Andaman and Nicobar Islands. Suicide rates are the highest in Andaman in India.[6] The literature on GSM is sparse, needing more studies to identify social characteristics and risk factors. This rare case report from the Andaman Island highlights GSM in a psychiatric patient with commanding hallucinations. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
A rare presentation of psychotic depression with suicidality in a case of papillon-lefèvre syndrome Anand Lingeswaran, S. Devakumari Gopal Indian Journal of Psychological Medicine, 2018 Papillon–Lefèvre syndrome (PLS) is an autosomal recessive disorder that presents with palmoplantar hyperkeratosis and childhood-onset progressive loss of all dentition. Mental retardation is the only neurodevelopmental disorder reported with this condition till date. We report the first ever case in the literature of PLS presenting with psychotic depression and suicidal intention. A 40-year-old, never married, unemployed woman presented for psychiatric consultation and was given an International Classification of Diseases version 10 diagnosis of severe depression with psychotic symptoms. Physical examination warranted dermatological and dental evaluation before electroconvulsive therapy (ECT) could be administered. She was diagnosed with PLS and pseudoainhum by the skin and dental specialists. Karyotyping study was normal, and histopathology of the palmar tissue showed hyperkeratinization. She was treated with ECT, duloxetine and olanzapine, and she achieved full remission of her depression. She was prescribed oral retinoids and emollients for the skin disorder, and there was a good improvement. The dental prosthesis was fixed, and she was able to eat and feel better than before. Early diagnosis of this condition and rehabilitation would be important in improving wellbeing.
Profile of young suicide attempt survivors in a tertiary care hospital in Puducherry Anand Lingeswaran Indian Journal of Psychological Medicine, 2016 Context: Puducherry has the highest suicide prevalence rate in India by 2014, predominantly among the 14–30 years age group. Aims: The aim of the present study is to study the characteristics of adolescent and youth suicide attempters in Puducherry and measure the suicide intent. Settings and Design: An observational study of 6 months duration was conducted in the Department of Psychiatry, at Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India. Materials and Methods: Modified version of World Health Organizations SUicide PREvention Multisite Intervention Study on Suicidal questionnaire was used to collect sociodemographic data and Beck's suicide intent scale was used to measure the suicide intent scores. International Classification of Diseases-10 was used for diagnosis. Statistical Analysis: Statistical Package for the Social Sciences version 13 was used for descriptive analysis and correlation statistics. P value was set as <0.05. Results: Of 56 eligible participants, 40 formed the sample, their mean age was 18. 13 (±2.50), more females (1.1:1), rural, literate, lower socioeconomic status (67.5%), mostly single (90%), living in nuclear (95%), and Hindu (87.5%). One hundred percent had psychosocial stressors before suicide attempt. Acute stress disorder/adjustment disorder was the most common diagnosis. Emotionally unstable and anankastic personality traits were seen in 12%. Pesticide ingestion (45%) was the most common suicide method. Sixty percent attempted suicide within <30 min of suicidal contemplation. Statistical associations were found between the alleged purpose, seriousness, attitude toward living/dying, conception about medical rescuability, and the overall suicide intent. Conclusions: Adolescent and youth suicide attempts occur due to psychosocial stressors rather than due to the past or on-going mental health disorders with above personality traits suggest poor coping skills and resilience taken to deal with stressful situations by younger people.
Antiretroviral treatment induced catatonia in 16-year-old boy Anand Lingeswaran Journal of Pediatric Neurosciences, 2014 We present a 16-year-old boy, who had presented to us with catatonic features of mutism, withdrawal, passive negativism, grimacing, gesturing, echopraxia, and excitement of 5 days duration while taking antiretroviral therapy (ART) for a period of 2 years. He had history of birth asphyxia and acquired HIV infection from his father when the same syringe and needle was used on both of them in a medical setting where the father and son had consulted for treatment of pyrexia of unknown origin. He was the eldest of a three children family in which the biologic father had acquired HIV through extramarital sexual contact with HIV-infected sex workers but was unaware of his HIV positive status till our patient, the 16-year-old was admitted and treated for pulmonary tuberculosis at 14 years of age. The boy's mother had only acquired HIV after having three children with the HIV-positive husband, thus leaving the other two children HIV negative. The catatonia completely resolved within 2 days after the ART was withheld, and risperidone 1 mg twice a day was prescribed. This case highlights the risks of ART and breach of universal precautions.
Suicide in Puducherry, India: A public health burden Anand Lingeswaran Indian Journal of Psychological Medicine, 2012 404 Indian Journal of Psychological Medicine | Oct Dec 2012 | Vol 34 | Issue 4 External Control Psychology is an attempt to control others to act in a way they do not want to.[6] This ideology of a person who uses external control does not permit individuals outside the self to formulate preference about individual freedom, and advocates that other individuals should be punished to modify their behavior to attain the controllers’ needs.[6] The “Deadly Habits” demolishes individual freedom of the oppressed individual and therefore acts to disconnect relationships, as freedom has been identified as one of the basic human needs.[6]
Depression associated with dysembryoblastic neuroepithelial tumor Anand Lingeswaran, Deepak Barathi Indian Journal of Psychological Medicine, 2012 Dysembryoblastic neuroepithelial tumor (DNET), a benign, rare tumor of the brain, commonly presents with generalized or partial epilepsy, post-epilepsy sequelae of psychotic, depressive or anxiety symptoms or disorders, or is usually asymptomatic. We report the first case in scientific literature of temporal lobe DNET presenting with only major depressive disorder, without epilepsy. A 24-year-old single male, presented with pervasive sadness, easy fatigability, loss of interest in his daily activities, decreasing appetite associated with poor of quality sleep, poor attention and concentration, pessimism about the future, and headaches. He was diagnosed with severe depression, without psychotic symptoms. Magnetic resonance imaging of the brain showed a lobulated hyperintense temporal lobe mass of 2.7 × 2.2 mm in the hippocampus region suggestive of a DNET. Electroencephalography, thyroid function tests, blood sugar, and electrocardiogram were normal. The depression responded well to tablet Escitalopram 10 mg once daily initially, with no adverse effects reported.
Repetitive transcranial magnetic stimulation in the treatment of depression: A randomized, double-blind, placebo-controlled trial Anand Lingeswaran Indian Journal of Psychological Medicine, 2011 Background: The efficacy of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression has never been reported as yet in the Indian literature. Aims: To study the efficacy of rTMS in the treatment of depression and to evaluate its safety and tolerability. Settings and Design: A randomized, double-blind, sham-controlled trial was conducted at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore. Materials and Methods: 23 patients with depression were randomized to receive either active (n=9) or sham (n=14) treatment with rTMS. Treatment consisted of six sessions of rTMS for 2 weeks (10 trains of pulses, intensity equal to motor threshold, 10 Hz frequency, train duration of 5 seconds, 1 minute inter-train duration). Response was assessed using Hamilton Depression Rating Scale (HDRS), Montgomery Åsberg Depression Rating Scale (MADRS) and Clinical Global Index (CGI). The safety and tolerability was assessed with side-effect checklist for electroconvulsive therapy. 50% reduction in HDRS scores from baseline was defined as treatment response. Outcome measures were analyzed by repeated measures analysis of variance. Chi-square test was used to analyze the categorical variables. Results: No statistical significance was seen on the baseline socio-demographic and illness characteristics (Pearson's Chi-square=0.5). Although HDRS (sham 22.0-12.4; active 22.8-12.7) and MADRS (sham 30.7-17.3; active 31.8-16.7) scores reduced by the end of 2 weeks treatment, it was not statistically significant. One patient developed manic symptoms early in the treatment. Conclusions: Treatment with rTMS did not show improvement at the end of 2 weeks. More studies with larger sample size and with higher rTMS dosages need to be done.
Pharmacovigilance on olanzapine Anand Lingeswaran, Harsha Shetty, Kigshuk Lahon, Amit Paramel, Gyaneshwar Sharma Indian Journal of Pharmacology, 2010 Sir, Pharmacovigilance, the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other drug-related problems, is highly essential in India, where there is a lack of adequate efficacy and safety-related data, limited efforts made on adverse drug reaction (ADR) monitoring by the manufacturers, lack of ADR data for traditional medicines and absence of structural and policy changes within the drug regulatory authorities. Olanzapine has adverse effects such as dystonic reactions, akathisia, tardive dyskinesia, tremors, hyperprolactinemia, weight gain, neuroleptic malignant syndrome and metabolic syndrome. In a busy tertiary care hospital setting, it is not unusual for psychiatrists to prescribe olanzapine without checking for the presence of multiple medical illnesses comorbid with major mental illness. Olanzapine can cause life-threatening adverse drug to drug interactions. In this respect, ADR reporting within the hospital is highly imperative. We designed a retrospective chart review to study the method of ADR monitoring in olanzapine-treated patients. The study was conducted at the Department of Pharmacology and Psychiatry at Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pondicherry, India, from 1st January 2006 to 31st December 2006. All cases that had been started on oral olanzapine treatment and followed-up for more than 8 weeks were recruited for the study. Using a semi-structured proforma, the personal and clinical data such as age, sex, body weight in kilograms and clinical diagnoses (ICD 10), name of medication, dosage and its titration in the 1-year period were recorded. Documentation of adverse effects and laboratory investigation details were also recorded. The Naranjo’s scale (WHO) was used for studying the causal relation between olanzapine and the observed adverse event. Statsdirect, statistical software, Version 2.7.2 was used for analysis. The sample comprised of 71 cases, all with the diagnosis of schizophrenia of various subtypes (ICD-10), 28 (39.4%) cases had documented at least one ADR. Mean age of the patients was 28.3 years and mean duration of schizophrenic illness was 2.2 years. Of the 71 cases, 13 cases (18.3%) (six males and seven females) had documented weight gain. The mean age of all 13 cases was 29.84 years (SD, 11.95). The mean dose of olanzapine in the 13 cases was 6.7 mg/day, lower when compared with evidence from clinical trials that show 10–20 mg/day as the most effective dose. The overall weight difference (mean of differences -4.53; t -4.91; P < 0.001) of the 13 cases was highly significant statistically and clinically [Figure 1]. The ladder plot depicts the individual sex differences of weight gain [Figure [Figure2a2a and andb].b]. The Shapiro-Wilk W test showed no evidence of non-normality (W = 0.89; P = 0.123), which makes the findings of this study generalizable. Figure 1 Mean weight at baseline and at 8 weeks Figure 2a Weight gain in males over 8 weeks Figure 2b Weight gain in females over 8 weeks Five cases (7.0%) developed tremors only and five (7.0%) developed increased appetite. Of the 71 cases, three (4.2%) cases had developed laboratory-determined hyperglycaemia. On the Naranjo’s scale, the results were weight gain (score 2–5; possible to probable), tremors (6–7; probable), increased appetite (2–3; possible) and hyperglycaemia (6–7; probable). As per the Australian Adverse Drug Research Council report[1] on suspected adverse reactions with olanzapine, the two most frequent adverse reactions in clinical trials were somnolence and weight gain. Our results were different probably because of the long duration of schizophrenia itself, making the patient vulnerable to extrapyramidal side-effects (EPS) and weight gain. However, weight gain is a commonly reported ADR due to olanzapine. There is enough evidence to state that olanzapine is 10-times more likely to produce weight gain, seen in 8 weeks, than placebo in the treatment of schizophrenia.[2,3] Surprisingly, the low mean dose of 6.7 mg/day in our study had produced similar weight gain in contrast to studies that report that a mean daily dose of 15 mg (SD, 2.5) of olanzapine increased the body weight by 11.8 kg in 1 year.[4] The low incidence of EPS with olanzapine can be explained on the basis of its greater affinity for 5-HT2 receptors than for D2 receptors hence causing fewer EPS in contrast with classical antipsychotics (e.g., haloperidol). Olanzapine is well known to cause weight gain and presumably increased appetite as an initial symptom in the course of treatment. A large number of case reports have demonstrated the link between hyperglycaemia during olanzapine treatment.[5] The differences in findings observed in other countries and those reported in this study highlight the need for developing our own local and national-level ADR database. India seems to rate below 1% in ADR reporting, as against the world rate of 5%. A national regulatory body should be established to implement the system of reporting adverse events of drugs introduced in the Indian market by pharmaceutical companies. Similarly, ADR audits will prove useful in hospitals too. Finally, the government has to play an effective regulatory role in ensuring the availability of safe medicines to the consumers.
Dandy-Walker variant associated with bipolar affective disorder Anand Lingeswaran, Deepak Barathi, Gyaneswahr Sharma Journal of Pediatric Neurosciences, 2009 The Dandy-Walker malformation is a congenital brain malformation, typically involving the fourth ventricle and the cerebellum. To date, the Dandy-Walker syndrome has not been described in association with bipolar disorder type I mania, and therefore we briefly report the case of a Dandy-Walker variant associated with acute mania. A 10-year-old boy was brought by his mother to the outpatient clinic of the Department of Psychiatry of a tertiary care hospital, with symptoms of mania. The MRI brain of the patient showed a posterior fossa cystic lesion, a giant cisterna magna communicating with the fourth ventricle and mild hypoplasia of the cerebellar vermis, with the rest of the structures being normal and no signs of hydrocephalus. These findings showed that the patient had a Dandy-Walker variant. He responded partially to valproate and olanzepine, which controlled the acute manic symptoms in the ward.
