Andhra Pradesh Journal of Psychological Medicine
(APJ Psychol Med) July-December 2015
Distinguished Past Editors
2010-2015
Rajshekhar Bipeta
2008-2010
Uday Kumar Kadiveti
2006-2008
Ashok K. Alimchandani
2004-2006
Vijay Gopal M
2002-2004
Prasad Rao G
2000-2002
NN Raju
1996-1998
Anand Bhogaraju
1988-1996
Karri Rama Reddy
THE PEER REVIEWERS
(in alphabetical order)
Anitha Rayirala, Assistant Professor of Psychiatry, Institute of Mental Health (IMH), Osmania Medical College (OMC),
Hyderabad, Telangana
Giridhar MNV, Consultant Psychiatrist, Lalitha Neuropsychiatry Centre, Tirupati, Andhra Pradesh.
Hareesh Angothu, Assistant Professor of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore.
Hemanta Dutta, Senior Resident in Psychiatry, LGBRIMH, Tezpur, Assam.
Nageswar Rao Nallapneni, Associate Professor of Psychiatry, Institute of Mental Health (IMH), Osmania Medical
College (OMC), Hyderabad, Telangana.
Naveen Dagudu, Associate Professor of Psychiatry, Santhiram Medical College, Nandyal, Andhra Pradesh.
Praveen Arathil, Assistant Professor of Psychiatry, Amrita Institute of Medical Sciences, Ponekkara P.O, Kochi, Kerala.
Ranjith Kumar, Assistant Professor of Psychiatry, Kurnool Medical College, Kurnool, Andhra Pradesh.
Rohith Verma, Assistant Professor of Psychiatry, All India Institute of Medical Sciences, New Delhi.
Shivanandh Budarapu, Assistant Professor of Psychiatry, Sri Venkateswara Institute of Medical Sciences, Tirupati,
Andhra Pradesh.
Siddarth Sarkar, Assistant Professor of Psychiatry, Department of Psychiatry and National Drug Dependence Treatment
Centre All India Institute of Medical Sciences, Ansari Nagar, New Delhi
Siva Kumar CH., Assistant Professor of Psychiatry, Institute of Mental Health (IMH), Osmania Medical College (OMC),
Hyderabad, Telangana.
Srinivas Kandrakonda, Physician Scientist-Medical Scientific Affairs and Consultant Psychiatrist, Raheja Mind Space,
Hyderabad, Telangana.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Andhra Pradesh Journal of Psychological Medicine
(APJ Psychol Med) July-December 2015
ISSN 2249 - 5851
Editorial Board
(Alphabetical order)
(details available on www.apjpm.org)
EDITOR
Lokeswara Reddy Pabbathi MBBS, MD
Assistant professor of Psychiatry, Department of Psychiatry, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh.
Consultant Psychiatrist,
Research interests: Forensic Psychiatry, Suicide, Adult psychiatry
[email protected]
NATIONAL EDITORIAL BOARD
Ahalya Raguram PhD
Chief advisor
Professor of Clinical Psychology, National Institute of Mental
T S Sathyanarayana Rao MBBS, MD
Health And Neurosciences (NIMHANS), Bangalore, India
Professor of Psychiatry, Head, Department of Psychiatry, JSS
University and Medical College Hospital, Mysore, India
Research interests: Psychosocial aspects of mental health;
Editor, Indian Journal of Psychiatry; Former Editor, Indian
Journal of Psychological Medicine. Chief advisor, Indian
Journal of Psychological Medicine, Indian Journal of Geriatric
Psychiatry. Chairman, Journal Committee, Indian Journal of
Social Psychiatry
Family, marital and individual therapies
[email protected]
Ajit Kumar Avasthi MBBS, MD
Professor of Psychiatry, Postgraduate Institute of Medical
Research interests: Sexual medicine; Adult psychiatry
Education and Research (PGIMER), Chandigarh, India
[email protected]
Regional Editor (South Asia), Asian Journal of Psychiatry;
Advisor
Former Associate Editor, Indian Journal of Social Psychiatry.
Rajshekhar Bipeta MBBS, DPM, DNB, Ex-CPI (ACRP/
APPI)
Editorial board member, Indian Journal of Psychiatry,
Advisor / Immediate Past Editor (2010-2015), Andhra Pradesh
Journal of Psychological Medicine (AP J Psychol Med)
(Indian Psychiatric Society, AP (IPS-AP): www.apjpm.org Human Behaviour, Practitioner Update, Current Medical
Deputy Editor, Indian Journal of Private
Psychiatry (Indian Association of Private Psychiatry)
Field Editor, Indian Journal of Psychiatry (Indian Psychiatric
Society)
Archives of Indian Psychiatry, Journal of Mental Health and
Journal, JK Science, IJM Today, Health and Disease.
Research interests: Schizophrenia; Anxiety and mood
disorders; Human sexuality and its dysfunctions;
Consultation-liaison psychiatry
[email protected]
Guest Associate Editor, Frontiers in Psychiatry, section
Addictive Disorders and Behavioral Dyscontrol
Anand Bhogaraju MBBS, DPM, DNB,
Editorial Board member, Academic Psychiatry (American
Association of Chairs of Departments of Psychiatry, American
Association of Directors of Psychiatric Residency Training,
Association for Academic Psychiatry, Association of Directors
of Medical Student Education in Psychiatry)
Retd. Professor of Psychiatry, Deputy Superintendent,
Associate Professor, Gandhi Medical College / Hospital
Research methodology; Neuropsychiatry, Theory of mind
[email protected]
[email protected]
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Department of Psychiatry, Institute of Mental Health (IMH),
Osmania Medical College (OMC), Hyderabad, India
Former Editor, AP J Psychol Med Research interests:
Anindya Kumar Ray MD, DPM (CIP, Ranchi)
Research interests: ECT; Psychopharmacology
Assistant Professor, Department of Psychiatry, Malda Medical
College, Govt of West Bengal
[email protected]
Research interests: Child psychiatry; ECT
[email protected]
Professor of Psychiatry, Program Director Advanced Yoga
Centre, NIMHANS, Bangalore, India
Anurag Srivastava MBBS, MD Professor of Psychiatry,
Department of Psychiatry, Mediciti Institute of Medical
Sciences, Hyderabad, India
Associate Editor, Acta Psychiatrica Scandinavica. Deputy
Editor, Asian Journal of Psychiatry. Journal committee
member, Indian Journal of Psychiatry
Research interests: Psychoanalytic psychotherapy; General
and social psychiatry
Research interests: Schizophrenia; ECT; Yoga
[email protected]
Indla Ramasubba Reddy MBBS, MD
Ashok Reddy Karredla MBBS, MD
Professor of Psychiatry, Department of Psychiatry, IMH/
OMC, Hyderabad, India
Director, Consultant Psychiatrist, Vijayawada Institute of
Mental Health And Neurological Sciences (VIMHANS),
Vijayawada, India
Editorial board member, Indian J Psychological Medicine
Editorial board member, Indian J Psychological Medicine
Research interests: Community mental health; Mental health
education; Psychopharmacology; ECT
[email protected]
[email protected]
Additional Professor of Psychiatry, Department of Child and
Adolescent Psychiatry, NIMHANS, Bangalore, India
Bhaskar Naidu MA, MPhil, PhD
Consultant Clinical Psychologist, Roshini Counseling Centre.
Professor, and Formerly, Head, Department of Clinical
Psychology, IMH/OMC, Hyderabad, India
Gangadhar BN MBBS, MD, DSc (Yoga)
[email protected]
John Vijay Sagar K MBBS, MD
Associate Editor, Frontiers in Child and Neurodevelopmental
Psychiatry
Research interests: Cognitive-behavioural therapy
Research interests: Autism; Specific learning disorders; Early
onset psychosis; Paediatric psychopharmacology
[email protected]
[email protected]
Chandersekar K MBBS, MD
Karri Rama Reddy MBBS, MD (Founding Editor)
Consultant Psychiatrist and Director, Department of Geriatric
Psychiatry, Asha Hospital, Hyderabad, India
Consultant Psychiatrist, Manasa Hospital, Rajahmundry, India
Research interests: Neuropsychiatry; Geriatric psychiatry,
especially dementia
Research interests: Clinical psychiatry
[email protected]
Chittaranjan Andrade MBBS, MD
Professor of Psychopharmacology, NIMHANS, Bangalore,
India
Editorial board member, Journal of Clinical Psychiatry,
Convulsive Therapy/The Journal of ECT, Bipolar Disorders,
Brain Stimulation: Basic, Translational and Clinical Research
in Neuromodulation, The Open Psychiatry Journal, Archives
of Indian Psychiatry, International Journal of BioSciences and
Technology and its associate journals, Mens Sana
Monographs. Indian Journal of Psychiatry, Section Editor,
Postgraduate CME. Field editor in Clinical Therapeutics
Former Editor, Indian J Psychological Medicine
[email protected]
Krishna Murthy Kavirayani MBBS, DPM, MD
Professor of Psychiatry, Head, Department of Psychiatry,
Narayana Medical College, Nellore, India
Research interests: Phenomenology; Social psychiatry;
Addiction disorders
[email protected]
MS Reddy MBBS, DPM, MD
Consultant Psychiatrist and Director, Asha Bipolar Clinic,
Asha Hospital, Hyderabad, India
Editor, Indian J Psychological Medicine
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Research interests: Bipolar disorder; Psychopharmacology
Roy Abraham Kallivayalil MBBS, DPM, MD
[email protected]
Professor of Psychiatry, Head, Department of Psychiatry,
Pushpagiri Institute of Medical Sciences, Kerala, India
NN Raju MBBS, MD
Professor of Psychiatry, Head, Department of Psychiatry, Vice
Principal, Andhra Medical College; Superintendent,
Government Hospital for Mental Care, Visakhapatnam, India
Former Associate Editor, Indian Journal of Psychiatry
Former Editor, AP J Psychol Med
[email protected]
Research interests: Clinical research; Drug development,
Anxiety disorders; Psychiatry training
Sadanandan Unni KE MBBS, DPM, DNB, DU (Infant
Psychiatry), AFSA (Child and Adolescent Psychiatry)
[email protected]
Professor of Psychiatry, Head, Department of Child
Psychiatry, General Psychiatry and Deaddiction Centre, Lady
Hardinge Medical College, New Delhi, India
Padma Sudhakar T MBBS, MD
Consultant Psychiatrist; Professor and Formerly, Head,
Department of Psychiatry, Sri Venkateswara Medical College,
Tirupati, India
Research interests: De-addiction, social, geriatric,
consultation-liaison and preventive psychiatry
Research interests: Child psychiatry
[email protected]
Editorial board member, Indian J Psychological Medicine
Sandeep Grover MBBS, MD
Research interests: Psychopharmacology; Biological
psychiatry
Assistant Professor of Psychiatry, PGIMER, Chandigarh,
India
[email protected]
Padmavati Ramachandran MBBS, DPM, MD
Joint Director, Schizophrenia Research Foundation (SCARF),
Consultant Psychiatrist, Chennai, India
Research interests: Schizophrenia; Community mental health;
Metabolic comorbidity and mental health
[email protected]
Prabhakar Korada MBBS, FCGP, DNB
Consultant Psychiatrist; Professor of psychiatry and Head,
Department of Psychiatry, Mallareddy Institute of Medical
Sciences, Hyderabad, India
Research interests: Thanatology; Effects of yoga, pranayam
and meditation on the mind; Alternative therapies for minor
psychiatric disorders
[email protected]
Prasad Rao G MBBS, DPM, MD
Director, Schizophrenia and Psychopharmacology division,
Asha Hospital; Consultant Psychiatrist, Hyderabad, India
Editor, Indian J Private Psychiatry. Former Editor, AP J
Psychol Med, Indian J Psychological Medicine. Deputy
Editor, Indian Journal of Psychiatry
Research interests: Schizophrenia; Psychopharmacology;
Neuro imaging in psychiatry
[email protected]
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Associate Editor, Indian Journal of Psychiatry, Indian Journal
of Social Psychiatry. Assistant Editor, Early Career
Psychiatrists Corner of Asian Journal of Psychiatry. Editorial
board member, Journal of Clinical Case Reports, World
Journal of Psychiatry
Research interests: Consultation-liaison psychiatry;
Caregivers of patients with severe mental disorders
drsandeepg2002@ yahoo.com
Soumitra S Datta MBBS, DPM, DNB, MD, , MRCPsych,
CCT in Child Psychiatry (UK)
* Consultant Psychiatrist, , Department of Palliative Care and
Psycho-Oncology, Tata Medical Centre, Kolkata, India.
Visiting Researcher, Institute of Psychiatry, Maudsley, Kings
College; Visiting Researcher, Institute of Women’s Studies,
University College London. Formerly, Consultant, Child and
Adolescent Psychiatry, Kings College Hospital, London
Research interests: Child and adolescent psychiatry; Evidence
based medicine; Consultation-liaison psychiatry
[email protected]
Suja Kurian MBBS, DPM, MD, CCST
Professor of Psychiatry, Christian Medical College, Vellore,
India
Research interests: Perinatal psychiatry
[email protected]
Uday Kumar K MBBS, MD (Past Editor)
Professor of Psychiatry, Narayana Medical College,
Consultant Psychiatrist, Nellore, India
Research interests: Alcohol and drug de-addiction;
Rehabilitation
[email protected]
Y C Janardhan Reddy MBBS, DPM, MD
Professor of Psychiatry; Consultant, OCD Clinic; NIMHANS,
Bangalore, India
Research interests: Obsessive-compulsive disorder; Bipolar
disorders; Clinical psychopharmacology
[email protected]
INTERNATIONAL EDITORIAL BOARD
Anoop Sankaranarayanan MBBS, DPM, MD, FRANZCP
Assistant Professor of Psychiatry, Weil Cornell Medical
College, Qatar. Consultant Psychiatrist, Lead Clinician for
Research and Director, Fellowship Training Program,
Department of Geriatrics, Rumailah Hospital, Hamad Medical
Corporation, Doha, Qatar. Formerly, Clinical Director, Hunter
Valley Mental Health Service, and Lecturer (Conjoint),
University of Newcastle, Centre for Brain and Mental Health
Research, Newcastle, NSW, Australia
David J Castle MBChB, MSc ((Epidemiology), GCUT,
DLSHTM, MD, FRCPsych, FRANZCP
Chair of Psychiatry, St. Vincent’s Hospital, Melbourne and
The University Of Melbourne. Consultant Psychiatrist, St.
Vincent’s Hospital, Melbourne. Clinical Professor, School of
Psychiatry and Neurosciences, University of Western
Australia
Deputy Editor, Australasian Psychiatry. Advisory board
member, International Journal of Social Psychiatry, Journal
of Mental Health. Editorial board member, Australasian
Psychiatry, African Journal of Psychiatry, Open Obesity
Journal, Stress and Health, Advances in Psychiatric Treatment,
World Journal of Psychiatry, Open Journal of Psychiatry,
ISRN Psychiatry, F1000 Research
Research interests: Epidemiology of schizophrenia; Gender
differences in the functional psychoses; Late onset
schizophrenia; Treatment strategies in schizophrenia; Physical
health problems in the mentally ill; Cannabis and mental
illness; Bipolar disorder; Behavioural/cognitive approaches
to the treatment of anxiety disorders; Nosology and treatment
of obsessive-compulsive spectrum disorders; Disorders of
body image; Teaching psychiatry to under- and post-graduates
[email protected]
Dhana Ratna Shakya MBBS, MD
Research interests: Suicide and self-harm; Psychosis;
Metabolic disorders in psychiatric illness; Smoking and
mental health; Cognitive disorders; Medical education
Associate Professor of Psychiatry, Consultant Psychiatrist,
BP Koirala Institute of Health Sciences (BPKIHS), Dharan,
Nepal
[email protected]
Research interests: Substance use disorder; Neuro-psychiatry;
Community psychiatry [email protected]
Cherrie Ann Galletly MBChB, DPM, FRANZCP, PhD
Professor of Psychiatry, School of Medicine, University of
Adelaide. Regional Director of Training, Northern Mental
Health, NALHN. Consultant Psychiatrist, Northern Mental
Health, Adelaide Health Service. Regional Director of
Training for Northern Mental Health
Editorial board member, Frontiers in Schizophrenia, Frontiers
in Psychiatry; International Advisory board, Mental Health
and Substance Use; Associate Editor, Australian And New
Zealand Journal of Psychiatry; Editorial Executive committee,
National Prescribing Service (Publishers of Australian
Prescriber); Editorial board member, World Journal of
Pharmacology
Research interests: Psychosis; Schizophrenia; Cardio
metabolic health; Neurostimulation; ECT; rTMS; Medical
education; Sleep disorders; Cognition
[email protected]
Dinesh Bhugra MBBS, FRCP, FRCPEdin, FRCPsych,
FFPH, MPhil, PhD, FRC Psych (Hon), FACP (Hon), FHKC
Psych (Hon), FAMS (Singapore), FIMSA (Hon), MAcad MEd
Professor of Mental Health and Cultural Diversity, Health
Service and Population Research Department, Institute of
Psychiatry (King’s College). Honorary Consultant, South
London and Maudsley NHS Trust, London. Formerly,
President and Dean, Royal College of Psychiatrists
Editor, International Review of Psychiatry, International
Journal of Social Psychiatry, International Journal of Culture
and Mental Health. Editorial board member, Archives of
Indian Psychiatry, Asian Journal of Psychiatry, British Journal
of Psychiatry, European Psychiatric Review, Global Mental
Health, Indian Journal of Psychiatry, Indian Journal of Social
Psychiatry, International Journal of Mental Health System
Development, Journal of Indian Association of Child and
Adolescent Mental Health, Mental Health, Religion and
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Culture, Psychiatry, Psychopathology, Sexual and
Relationship Therapy. Advisory board member, Australian
and New Zealand Journal of Psychiatry, Journal of Mental
Health Policy and Economics, International Journal of
Psychological Medicine, Psychiatria Danubina
Research interests: Cultural psychiatry; Public mental health;
Sexual variation and sexual dysfunction
[email protected]
Farooq Ahmed Khan MBBS, MD, MRCPsych
Consultant Psychiatrist, Birmingham & Solihull Mental
Health NHS Foundation Trust. Honorary Lecturer, Old Age
Psychiatry, Centre for Ageing and Mental Health,
Staffordshire University, England
Research interests: Geriatric psychiatry; Dementia;
Depression; Medical education
[email protected]
Goutham M Menon BA, MA, PhD
Professor and Director, School of Social Work, University of
Nevada, Reno, United States
Former Consultant Editor, Families in Society: The Journal
of Contemporary Social Services, Journal of Computer
Mediated Communication, Research on Social Work Practice.
Editorial board member, Journal of Technology in Human
Services, Social Development Issues, Journal of Social
Service Research
Research interests: Minority mental health; Schizophrenia;
International social work; Technology in health and human
services (E-health, E-therapy)
[email protected]
John Richard Newton MB ChB, MRCPsych, FRANZCP
Medical Director, Mental Health CSU Austin Health. Clinical
Director of BETRS (Body Image, Eating Disorders Treatment
and Recovery Service). Adjunct Clinical Associate Professor,
Department of Psychiatry and Psychology, Monash
University. Honorary Clinical Associate Professor,
Department of Psychiatry, University of Melbourne
Editorial board member, Journal of Eating Disorders
Research interests: Eating disorders; Cognitive Behaviour
Therapy; Psychosis; Health service evaluation
[email protected]
Matcheri S Keshavan MBBS, MNAMS, MD, FRCP ©,
FRCPsych
Stanley Cobb Professor of Psychiatry, Harvard Medical
School and Vice Chair, Department of Psychiatry, Beth Israel
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Deaconess Medical Centre, Boston; Attending Physician
Massachusetts Mental Health Centre. Visiting Professor,
NIMHANS, Bangalore, India
Chief Editor, Asian Journal of Psychiatry. Editorial board
member, Schizophrenia Research, Bipolar Disorders, Early
Intervention in Psychiatry, Acta Neuropsychiatrica,
Research interests Schizophrenia; Neuroimaging
[email protected]
Maureen Rubin BA (Sociology), MA, MSW, PhD
Assistant Professor, School of Social Work, Division of Health
Sciences, University of Nevada, Reno, United States; Adjunct
Assistant Professor, Department of Psychiatry, School of
Medicine, University of Texas Health Science Centre
(UTHSC), San Antonio
Research interests: Schizophrenia; Program evaluation;
Service-research; Children’s mental health; Integrated service
delivery
[email protected]
Mukesh Sanghadia MBBS,DPM,MD,MRCPsych,
Dip.ABPN, Dip.Psychosomatic Medicine, FAPA
Clinical Assistant Professor of Psychiatry, MSU-KCMS/
Western Michigan University School of Medicine Premier
Neuropsychiatry, Portage, MI 49002
Research interests: Brain modulation (TMS, ECT, etc);
Psychosomatic medicine; General psychiatry
[email protected]
Narsimha R Pinniniti MBBS, DPM, MD, Dip. ABPN
Chief Medical Officer, Twin Oaks Community Services,
Professor of Psychiatry, (UMDNJ-SOM), NJ, USA
Research interests: Cognitive therapy of serious mental
illnesses; Schizophrenia; Clinical services research; Building
and maintaining therapeutic relationships in psychiatry
[email protected]
Saeed Farooq PhD, MCPS (Psych), FCPS (Psych)
Visiting Professor, Staffordshire University, United Kingdom
and PGMI Lady Reading Hospital, Peshawar, Pakistan
Editor, Journal of Pakistan Psychiatric Society, Journal of
Postgraduate Medical Institute, Journal of Biomedical
Education. Associate Editor, BMC Health Service Research
Research interests: Treatment of severe mental illness in
developing countries; Use of digital technologies in mental
illness; Therapeutics in schizophrenia
[email protected]
Srinivasan Tirupati MBBS, MD, FRANZCP, FRCPsych
Conjoint Associate Professor, The University of Newcastle,
Senior Staff Specialist, Hunter Mental Health, NSW, Australia
Research interests: Schizophrenia; Psychosis in the young;
Rehabilitation; Community care; Trans-cultural mental health
[email protected]
Suman Kumar Sinha MBBS, MD, Certificate course in
Global Tobacco Control (USA), Postgraduate Overseas
Specialists Training (POST) Program Fellowship in
Community Psychiatry and Mental Health Research
(Australia)
Consultant Psychiatrist, Mental Health and Addiction
Services, Waikato Mental Health Services, Waikato Mail
Centre, Hamilton, New Zealand. Formerly, High-End
Consultant Psychiatrist, Directorate General of Health
Services, Government of India; Formerly, National
Consultant, Mental Health, WHO, New Delhi, India
Research interests: Tobacco control; Disaster psychiatry;
Community psychiatry; Public mental health
[email protected]
Tejam P MBBS, DD, MD
Consultant Psychiatrist, Shortely Bridge Hospital, Tees, Esk
and Wear Valleys NHS Foundation Trust, United Kingdom
Research interests: Bipolar disorder
[email protected]
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Andhra Pradesh Journal of Psychological Medicine
(APJ Psychol Med) July-December 2015
INDIAN PSYCHIATRIC SOCIETY - AP STATE BRANCH
Executive Council Members
Executive Council Members (Direct)
President
Murthy GVS, Visakhapatnam
Suresh Kumar G, Visakhapatnam
[email protected]
[email protected]
Rama Krishnam Raju R, Bhimavaram
[email protected]
Vice-President
Rosh Mallikarjun G, Srikakulam
Nagi Reddy K, Kurnool
[email protected]
[email protected]
Uma Jyothi N. Guntur
[email protected]
Hon. General Secretary
Vishal Reddy Indla, Vijayawada
Ramesh Babu B, Kurnool
[email protected]
[email protected]
Constitution committee members
Hon. Treasurer
Chandra Balaji N.R.P, Nellore
Ramasubba Reddy Indla, Vijayawada
[email protected]
[email protected]
Himakar P, Visakhapatnam
Hon. Editor
[email protected]
Lokeswara Reddy P, Tirupati
[email protected]
Task Force Committee Members
Narasimha Reddy K, Visakhapatnam
Immediate Past President
[email protected]
Prabhakar Korada, Hyderabad
[email protected]
Raju G.S.P, Visakhapatnam
Immediate Past Secretary
[email protected]
Laxmi Naresh Vadlamani, Hyderabad
[email protected]
Ramana Rao G.V, Bhimavaram
[email protected]
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Andhra Pradesh Journal of Psychological Medicine
(APJ Psychol Med) July-December 2015
Details available on www.apjpm.org
GENERAL INFORMATION
Disciplines/category
The society
Psychiatry; Psychology; Mental health; Behavioural medicine
/ sciences; Neuroscience; Medicine
Indian Psychiatric Society is registered under Society
Registration Act. Indian Psychiatric Society, AP branch (IPSAP), is the official state branch of the national body.
Aims and scope
The Andhra Pradesh Journal of Psychological Medicine (AP
J Psychol Med) is a strictly anonymous double-blind
interinstitutional externally peer-reviewed, open-access,
official scholarly journal of the Indian Psychiatric Society,
AP (IPS-AP). We invite papers from around the world. The
journal offers a platform for clinicians and researchers with
divergent concepts and perspectives. It publishes manuscripts
in the fields of psychiatry, psychology, psychiatric social work,
mental health nursing and all sciences related to mental health.
AP J Psychol Med aims to keep the field of mental health
vibrant and relevant by publishing the latest advances. In
accordance to this mission, the journal publishes basic and
clinical research from all disciplines and research areas related
to mental health. We consider original articles on all aspects
of the epidemiology, aetiopathogenesis, diagnosis,
management, prognosis and prevention of psychiatric
disorders. We also encourage and publish reviews, case
reports, editorials, commentaries and viewpoints that focus
on topics of current research and interest. The journal has
full editorial independence from the society, IPS-AP..
The journal started in the year 1988. It is published twice a
year and the manuscript acceptance rate is approximately
80%. We aim to provide the first decision within six to eight
weeks of submission. Accepted articles are published in print
in July and December of every year, and are also available
online.
Authors get several benefits such as free PDFs, a liberal
copyright policy, etc.
Type of articles
Editorial, commentaries, guest editorial, view points, review
articles, original articles, case reports, the stalwarts in the
field of mental health and letters to the editor.
Audience
We hope to reach a wide audience including psychiatrists,
psychologists, psychiatric nurses, psychiatric social workers,
other mental health professionals, and all professionals with
an interest in mental health.
Listings, database, directory, abstracting, indexing
AP J Psychol Med is a member of the Committee on
Publication Ethics (COPE), The World Association of
Medical Editors (WAME) and The European Association
of Science Editors (EASE). Unless otherwise specified, the
journal conforms to the guidelines set forth by the
International Committee of Medical Journal Editors
(ICMJE): Recommendations for the Conduct, Reporting,
Editing and Publication of Scholarly Work in Medical Journals
(2013), formerly the Uniform Requirements for Manuscripts
Submitted to Biomedical Journals: Writing and Editing for
Biomedical Publication, 2010.
The complete list is available on the journal website.
Year of first publication: Print: 1988, Electronic: 2010
Publication format: print, electronic
Journal website: www.apjpm.org
Editorial process
The manuscripts will be reviewed for possible publication
with the understanding that they are being submitted to one
journal at a time and have not been published, simultaneously
submitted, or already accepted for publication elsewhere.
Subscription information
This is an open-access journal. The online version is in public
domain. The print version of the journal is provided free of
cost to the members of IPS-AP branch.
Advertising policies
The journal accepts and displays classified advertising. The
appearance of advising or product information in the various
sections in the journal does not constitute an endorsement or
approval by the journal and/or the society of the quality or
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Andhra Pradesh Journal of Psychological Medicine
(APJ Psychol Med) July-December 2015
Details available on www.apjpm.org
value of the said product or of claims made for it by its
manufacturer.
Disclaimer
The information and opinions presented in the journal reflect
the views of the authors and not of the journal or the editor or
the society. Publication does not constitute endorsement by
the journal or the editor or the society. Neither the journal,
nor the editor, nor the society nor anyone else involved in
creating, producing or delivering the journal or the materials
contained therein, assumes any liability or responsibility for
the accuracy, completeness, or usefulness of any information
provided, nor shall they be liable for any direct, indirect,
incidental, special, consequential or punitive damages arising
out of the use of the journal. Neither the journal, nor any
other party involved in the preparation of material contained
in the journal represents or warrants that the information
contained herein is in every respect accurate or complete,
and they are not responsible for any errors or omissions or
for the results obtained from the use of such material. Readers
are encouraged to confirm the information contained herein
with other sources.
Copyright
Unrestricted use, distribution and reproduction of articles
published in AP J Psychol Med are allowed in any medium,
provided the original author and source are properly cited. In
doubt please contact the editor.
Addresses
Editorial office :
PUBLICATION ETHICS
Decisions
The editor of the AP J Psychol Med is elected by the members
of the society, i.e. IPS-AP. He is responsible for deciding
which of the submitted manuscripts need to be published. He
has editorial independence from the society; however, is
guided by the journal policy, editorial board, reviewers and
the society. He needs to be aware of issues like libel, copyright
infringement and plagiarism.
Conflict of interest (COI)
Definition: ‘COI exists when there is a divergence between
an individual’s private interests (competing interests) and his
or her responsibilities to scientific and publishing activities
such that a reasonable observer might wonder if the
individual’s behaviour or judgment was motivated by
considerations of his or her competing interests (WAME).’ It
is better to disclose completely. The disclosures should be
made in the ‘covering letter, author declaration form’ and the
same is published at the end of the manuscript.
Time criterion for declaration is ‘within the past 3 years and
for the foreseeable future’.
What constitutes COI: equity interests; corporate
relationships (e.g., employment); patent rights; consultancies
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Editorial
107
EDITORIAL
Mental Health care as part of Non Communicable Disease Health Care
Hareesh Angothu1, Lokeswara P Reddy2
1
Assistant professor of Psychiatry, Psychiatric Rehabilitation services, NIMHANS, Bangalore, Karnataka, India.
Assistantprofessor of Psychiatry, Department of Psychiatry, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh,
India.
2
INTRODUCTION:
Mental health treatment gap is broadly defined as the gap
between the number of people with mental illness who require
treatment and those who are getting effective mental health
care. Mental health gap is being increasingly used to denote
deficits in providing quality and effective mental health care
for those who are in need of. Computing the mental health
gap based on prevalence data of mental illnesses and using
as existing number of mental health professionals as
denominator can have certain limitations in calculating mental
health gap. World Health organization reports and reports
by others suggest this gap approximately from 32-78 percent
across different disorders and different regions. High
treatment gaps were observed in anxiety and substance related
disorders than psychotic and affective disorders.[1,2] To what
extent these statistics really represent the ground picture of
treatment gap is uncertain especially in countries like India,
as stigma and culturally accepted magic religious beliefs can
be significant barriers to mental health care access. One of
the proposed solutions among many others to reduce treatment
gap is to integrate mental health care with the care of Non
communicable Diseases (NCD) like Diabetes, Hypertension,
Respiratory Tract Diseases and Cancer at Primary Health care
level. First Mental Health Policy document prepared by the
Ministry of Health, Government of India has endorsed this
view stressing that this integrated care using the existing
primary Health Care approach should be one of the guiding
principle for our national mental health policy.[3]
Proposed advantages
Situation analysis and step wise plan making o integrate
mental health care as part of NCD care is yet to begin with
certain proposed advantages like patients getting raid attention
for their mental health problems at local level in primary health
care settings which could be less stigmatizing. Follow-up with
Address for correspondence: P. Lokeswara Reddy, Assistant
Professor of Psychiatry, SVRRGG Hospital, Tirupati.
Phone number :+91-9052066880
Email : [email protected]
How to cite this article: Hareesh A, Lokeswara PR.
Mental Health Care aspart of Non Communicable Disease
Heath Care. AP J Psychol Med 2015; 16(2):107-9
the local health worker could be better compared to follow
up at a regional psychiatric hospital. As early intervention
can happen in such proposed model prognosis can also be
better. Further if such model is successful it can reduce
significant load of common mental health problems at tertiary
care psychiatric hospitals, where such resources could be
utilized for piling of evidences in relation to India, better
research apart from management of complicated cases
referred by primary health care centers.
Proposed policy recommendation
One of the proposals is to improve the availability of
adequately trained mental health professionals to address the
needs of the community was to train larger number of people.
Others were to integrate mental health in training programs
of other allied fields, to offer an opportunity for skill up
gradation in Auxiliary Nursing Midwives in their mental
health skills, to create more posts at government sector so
that youngsters can get motivated to take up mental health
related course.[3] Evaluation of a similar systematic program
to train the trainers in Sri Lanka with a 40 hour curriculum
tailored for the needs of Sri Lankan primary health care
practitioners has showed higher post test score compared to
pre test scores in the core competencies in which they received
training.[4]
Reality in India
As there can be significant differences in the core
competencies in the general practitioners and Primary Health
care practitioners in their mental health disorder treatment
abilities, there would be a definite need for a situation analysis
in any area where such program is planned for integrating
mental health care with primary health care. Current
Undergraduate programs for medical students in India and
training provided in psychiatry as part of their internship is
very short leaving them less competent to deal mental illnesses
in their practice.[5] First of its kind a National Mental Health
Survey which is ongoing in India has few questions to elicit
information pertaining to access to mental health professionals
and access to psychotropic medications whose results are
awaited. District Mental Health program (DMHP) based on
Bellary model of providing mental health care at district level
as part of decentralizing mental health care has met with
several challenges in the districts in which it is being tried to
AP J Psychological Medicine Vol. 16 (2) July-December 2015
108
Editorial
implement. Like in Chhattisgarh, many DMHP centers don’t
have a program officer .i.e. a qualified psychiatrist, which in
our opinion is mainly because of less attractive salary.
What can improve and what can go wrong
The proposed model of including provision of mental health
care as part of providing care for non communicable diseases
can definitely have certain advantages in terms of reducing
the barriers in receiving mental health care. But significant
limitations can be there when one talks about providing quality
mental health care at Primary Health Care (PHC) level and
Cluster Health Center (CHC) level in India. Given the reality
of lack of qualified psychiatrists in the several DMHP, it would
be idiotic to expect that qualified mental health professions
would be willing to serve at Primary Health and CHC level
even on part time basis if not on a regular basis. There can be
several factors which could be behind their aversion to provide
their services at PHC, CHC level either in the government
sector or in the private sector whose discussion would be
beyond the scope of this article. If qualified mental health
professionals are not available and if they are not going to be
included in providing mental health care at PHC and CHC
level then the question needs to be answered is what or the
other ways to be considered or proposed to provide quality
mental health care at these subcenters so that primary
objective of integrating mental health care with Primary
Health care can get served. The only other alternate solution
available would be training the PHC and CHC staff members
in identifying the mental illnesses and providing training them
to deliver a quality mental health care for common mental
disorders and to train them when to refer.
Would it be a sustainable model of care delivery?
It depends upon the whether such support would be offered
to the PHC and CHC doctors on a continuum basis by the
tertiary care psychiatric team or not. As an example as of
now in the state of Andhra Pradesh among the 13 districts
harbouring about 4 crore population there are only 4 tertiary
psychiatric care facilities with post graduate training in the
state sector. There are 5 semi tertiary psychiatric facility
located at each district head quarter without Psychiatric post
graduate training facility. These centers ar struggling to
provide a comprehensive quality and effective mental health
care for all those who approach these centers given the scarcity
in the available e number of social workers, clinical
psychologists and psychiatrists whose posts at times would
be vacant.
Given this reality it would be unrealistic to expect the tertiary
care psychiatric mental health professionals to visit the
periphery based CHC and PHCs on a regular basis. Periodic
training of selected PHC and CHC medical staff in making
them confident of handling the common disorders can be
AP J Psychological Medicine Vol. 16 (2) July-December 2015
definitely a game changer. But it is a model which involves
steps and measure to handle challenges that can arise on a
continuous basis. For it to happen each district should be taken
as a unit and the district health administration should take up
the responsibility of arranging periodic and regular training
for PHC and CHC doctors on treatment of mental health
disorders and establishing and marinating the Tele care
services by which PHC and CHC doctors can be in touch
with the concerned nearby tertiary care psychiatric specialists
in case of unforeseen challenges or to liaise with referrals.
It would require lot of commitment and will from both the
Policy makers including district health officials , tertiary care
psychiatric special; sits who usually fall under the department
of Directorate of Medical education and the PHC and CHC
medical staff who will come under the department of Vaidya
Vidhana Parishad and Dirtectorate of Health respectively.
Interested tertiary care psychiatrists in liaison with the local
district collector if can demonstrate the results of this model
over a period few years then it can be a replicable model for
the rest of India. Biggest challenges that can arise are
resistance of PHC and CHC medical staff in getting training
to get expertise in mental health disorders, reluctance and
funds related issues in conducting these training centers or
camps at a regular basis both at distract administration level
and at tertiary specialist psychiatrist level. Reluctance of
tertiary care specialist psychiatrist to be available on phone
over 24 hours a day, especially where there is only one or
two psychiatrists at district level can be challenging for Tele
care on continuum basis. One more important and perhaps
ignored challenge can be erratic and or non supply of
Psychoiatropic medication at PHC and CHC level. In such
instances PHC and CHC doctors though are able to diagnose
cannot treat and are forced to refer to District Hospitals where
also at times supply of Psychotropic medication can be erratic.
Another challenge can be attrition of trained staff because of
transfers or study leave of PHC staff which could be taken
care if training camps are held at periodic and regular
intervals. Lesson learnt from failures in implementing DMHP
program should be considered along with the views of District
health Program managers before making any plan for
integrating mental health care with primary health care.
Otherwise soon it could be declared as failure model of mental
health care delivery not because of fault in the model but
because of problems in implementation
REFERENCES:
1.
Kohn R, Saxena S, Levav I, Saraceno B. The treatment
gap in mental health care. Bulletin of the World Health
Organization. 2004;82(11):858-866.
2.
Patel V, Xiao S, Chen H, Hanna F, Jotheeswaran AT,
Luo D, et al. The magnitude of and health system
Editorial
responses to the mental health treatment gap in adults
in India and China. Lancet (London, England) [Internet].
2016 May 17 [cited 2015 Dec 26]; Available from:htte:/
/www.ncbi.nlm.nih.gov/pubmed/27209149.
3.
Ministry of Health and Familr Welfare G of I. National
Mental Health Policy of India [Internet]. 2014 p. 1 –
29. Available from: http://www.nhp.gov.in/sites/dafault/
files/pdf/national mental health policy of india
2014.pdf
109
4.
Jenkins R, Mendis J, Cooray S, Cooray M. Integration
of mental health into primary care in Sri Lanka. Ment
Health Fam Med [Internet]. Radcliffe Publishing and
Wonca; 2012 Jan [cited 2015 Dec 27];9(1):15 – 24.
Available from; http://www.ncbi.nlm.nih.gov/pubmed/
232777794
5.
Thirunavukarasu M, Thirunavukarasu P. Training and
National deficit of psychiatrists in India – A critical
analysis. Indian J Psychiatry 2010;53, Suppl S3:83-8
AP J Psychological Medicine Vol. 16 (2) July-December 2015
110
Dr.D.S.RAJU MEMORIAL ORATION
Contemporary Parenting – Challenges.
Gowri Devi Mandadi1
1
Director, Child psychiatry department, Asha Hospital, Hyderabad, Telangana, India.
ABSTRACT
“Whoever touches the life of the child touches the most sensitive point of a whole, which has roots in the most distant past and
climb towards the infinite future.” The quote by Maria Montessori tells us how important childhood is in the life of an
individual. It also implies that children are not miniature adults but are ultimate products of a complex interaction between
genetic potential, biological capacities and the nurturing environment. It is no exaggeration that child with problem behaviours
needs to be understood in the context of his developmental strengths (competencies) the family, the society and the culture
(background) he belongs to. Similarly the problem behaviours can be helped through approaching the areas of need,
strengthening his competencies to adjust and adapt to the environment which includes family and society.
Three decades of experience in dealing with children of
various psychiatric problems gave me insights that
management is beyond diagnosis and treatment to
understanding the effect of changing society on the child and
parenting. Handling each child and its family is a new
experience and a challenge. Hence I chose the topic
“Contemporary Parenting – Challenges”. In my oration I try
to combine my observations about parenting in my clinical
practice with evidence from the literature about parenting.
Contemporary Society
When we look at the contemporary Indian society it is not
only facing acculturation by way of people migrating to
outside but also facing cultural invasion from outside. Thus
contemporary society seems to be complex, complicated and
confusing due to phenomena of globalisation where there is
fast movement of people, ideas and products between nations.
The stresses of migration from villages to towns or from towns
to cities or from one country to another country; are seriously
affecting the identity formation of children and their daily
activities. There is constant conflict and friction between the
parents who have influence of indigenous culture with the
children who try to adapt the new culture ignoring their
culture. A number of studies appeared in child psychiatry
journals on Asian, Chinese, South African and South American
population who migrated to North America about the adverse
effects of culture change on the behaviour and adjustment of
children and adolescents. Su Yeong Kim et al (2009) found
Address for correspondence: Dr.M.Gowri Devi, Director,
Child psychiatry department, Asha hospital, Banjara hills,
Hyderabad, Telangana, India
Phone number: +919652244901
Email: [email protected]
How to cite this article: Gowri DM. Contemporary
parenting-Challenges.AP J Psychol Med 2015;16(2):110-4
AP J Psychological Medicine Vol. 16 (2) July-December 2015
adjustment problems in adolescents of Chinese American
population due to great cultural discrepancy, divergence of
values between parents and children, affecting parent child
relationships. Study by Alderete (2000) in USA who studied
both Indian and Mexican immigrants in USA found that life
time prevalence of any psychiatric disorder was higher
(46.4%) in Indian immigrants compared to Mexican. Indians
had higher risk of affective disorder and drug dependence
due to negative effect of culture. However, study by Joe Ann
(2002) found positive outcome in the first generation of
adolescents of Asian Indian immigrants due to well adjusted
type of acculturation of both parents and children.
Psychological Problems-Contemporary Society
The cultural dissonance that the last decade witnessed
produced change in psychological behaviours of children
different from that of the usual child psychiatric disorders
seen in clinical practice. They vary in frequency and the way
of presentation. Children below five years, as young as two
years present with autistic features, getting glued to games
on cell phones, tablets, i pods, continuous TV watching, not
socializing, which doesn’t amount to autism spectrum
disorders. There are other group of brilliant children dropping
out of schools showing poor self esteem, self injurious
behaviour due to inability to face competition which again
doesn’t qualify for a psychiatric disorder. Another group of
adolescents present with precocious sexual behaviour
indulging in molestation and rapes, neglecting studies and
indulging in alcohol and other substances. The involvement
of a minor in the gruesome rape of Nirbhaya is an example of
criminality in minors in the contemporary society. Further
there are a group of children with mood dysregulation,
demanding behaviour, behavioural addiction, internet gaming,
texting with violence and road rage disrupting the family
atmosphere. This group again doesn’t qualify for any
psychiatric disorder.
Gowri DM: Contemporary parenting
In addition there are serious social problems pertaining to
child like neglect and abuse, child labour, child trafficking
and legal battles for child custody which affect the emotional
and psychological well being of the child. The issues of child
parenting seem to play important role in these situations.
Dynamics of Change
When we carefully evaluate the causes of such behaviours,
we find that familism and family cohesion is changed in these
families. Due to migration the joint and extended families
narrowed down to nuclear or single parent families with no
social support to raise children. Majority of the parents across
the economic strata are away from home, spending long hours
at work or indulging in frequent fights, arguments in front of
children when at home. Majority of the times the children are
left either at baby care centres or with old grandparents or
left to themselves to fend themselves. Parents compensate
their absence and love with expensive gifts or gadgets. They
hardly find time to monitor and guide children with their
studies and uncontrolled usage of computers, TV viewing,
chatting, internet, face book, and texting on smart phones.
Recent phenomena of legal battles of parents for divorce and
custody rights on the children are adding to the severe
emotional and behaviour problems of children.
It brings us to answering number questions about
contemporary parenting.
1.
What is parenting and its influence on the development
of children?
2.
How does parenting styles affect the mental health of
children?
3.
What did we learn about the effect of parenting from
the studies of child psychiatric disorders?
4.
What are the recent trends in parenting and their effects
on children?
5.
What are the parenting strategies in the contemporary
society?
Firstly let us understand what is parenting and its influence
on child development. “Parenting”, in simple terms is
described as taking care of the young in preparing them to
manage the tasks of life. It regulates the majority of child –
environmental interactions and finally shapes his adaptation.
Thus it contributes to the course and outcome of child
development and future mental health. When we date back
parenting to Vedas; it is taken as a routine affair of life like
birth and death. Interestingly, conceiving, giving birth to a
child and bringing up is taken as naturally as it treats the
highest thought of philosophy. Vedas emphasize the growth
and human behaviour on the basic premise of Dharma and
included Dharma chara, Dharma svagriha, Dharma
swadhyayana, Dharma sangha meaning following of moral
111
values, modelling at home, and self study at gurukul and
following a spiritual guru till end.
Subsequently, in all societies and cultures parenting involved
teaching children to behave in a respectful, responsible and
mannerly way in the society. Parents worked primarily to
protect their children from the damage of the world and
concern about basics like food, shelter, appearance and
behaviour of children. Success of parenting and the job they
did was measured on the outward behaviour of the child rather
than inner emotional world of the child and how it developed.
With the exploration of theories about child psychology and
development by John Bowlby (1958) and Ainsworth (1973)
the focus of parenting extended to the attachment and bonding
of parents to the children for their healthy development.
Margaret Mead (1935), the anthropologist studied the
relationship between the parenting styles and the origin of
aggression in illiterate, primitive tribes of Arapesh,
Mundugumor and Tchambuly.She brought out the existence
of strong association between different child rearing practices
and the later personality development. Interestingly James
Clark Molony (1949), psychiatrist, who studied the parenting
styles and adjustment of Okinawan people before and after
World War II concluded that breast feeding, close attachment
and gentle disciplining was the key to the well maintained
mental health of people in post war period. Alice Miller
researched the most popular parenting books in Germany and
concluded that the hidden cruelty due to authoritarian type of
child rearing practices in pre war Germany to be responsible
for the Holocaust in World War II under Hitler. All these
studies paved way to the development of” attachment
parenting” which has the core values of compassion, affection,
empathy and respectful treatment of children. This style of
parenting is described to be the hallmark of peace in the
families and societies around the world due to healthy
development and mental health of children.
Now it brings us to the second issue of general parenting
styles and factors that affect the mental health of children
and adolescents. Baumrind (1967) identified three groups of
children who had widely varying patterns of behaviour –
energetic friendly children, conflicted irritable children and
impulsive aggressive children. She interviewed the parents
of these children and described four parenting styles based
on two orthogonal dimensions of parenting – demandingness
(behavioural control, supervision, maturity demands) and
responsiveness (warmth, acceptance and involvement) which
are found to have great impact on child’s emotional
development. In authoritative type parents establish and
enforce firm rules for socially responsible behaviour,
constantly monitor behaviour and use firm, fair non punitive
disciplinary style. Their children seem to develop necessary
AP J Psychological Medicine Vol. 16 (2) July-December 2015
112
Gowri DM: Contemporary parenting
skills for self regulation, self direction and independent
thinking. In contrast authoritarian style, the parents are highly
demanding, and lack responsiveness to child’s need for
warmth. They expect the child to be obedient and submit
without discussion. This is the most common type of parenting
in our society, where the parents decide on type of school,
education, study hours, career and hobbies etc. with no
concern for child’s aptitude. The other type is permissive type
where parents are high in responsiveness with extreme
commitment, warmth to produce self competent, self reliant
and socially competent children with lack of demandingness
being more democratic. This is the second common type of
parenting in our society. Lastly, the neglectful parenting style,
where the parents neither demand nor respond to their
children. They are preoccupied with their own struggle to
achieve in their lives. This type of parenting is recently seen
where parents are self centred, career oriented, leaving
children in hostels or with grandparents considering them as
impediments to their career. Their children have no direction,
become selfish, and develop personality deviance, drug abuse
and externalising disorders.
Here I would like to quote a few studies that substantiate the
parenting practices in the development of child psychiatric
disorders.
Patterson (1982) and Rutter (1995) found that parental discord
which affects quality of parenting has negative effect on short
term coping and long term adjustment of children. They
described that inflexible, rigid disciplining, inconsistent
disciplining, parental over protection, mood dependent
discipline and irritable explosive discipline severely affect
the social adjustment and academic performance of children
and predispose them to develop emotional and conduct
disturbance. They also emphasised the importance of
improvement of behavioural disturbances by improving
parenting through parent training programmes.
Elizabeth and Karen (2000) from the University of Oregan
in a NIMH funded study examined the association between
parenting practices and child disruptive behaviours in 631
early elementary school children. They found that low levels
of warmth physically aggressive parenting was linked to the
oppositional and aggressive behaviour of both sex children
across ethnic groups of UK, USA, and South African
population.
Benzamin B Lahey et al (2008) who followed up
longitudinally the offspring of 1863 representative sample of
women and their parenting during the first year of their
children, came out with another interesting finding that early
parenting and especially parenting by temperamental
interaction of the child predict the risk of children developing
conduct disorders between 4 and 13 years of age.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Kathy Newman and Linda Harrison (2010) from the
University of Alabama reviewed studies published on
relationship between parenting styles and risk behaviours in
adolescents between 1996-2007. The six health risk
behaviours identified by Centre for Disease Control and
Prevention namely, behaviours that contribute to unintentional
injuries and violence, tobacco use, alcohol and other drug
use, sexual behaviour leading to unintended pregnancy and
STD, unhealthy dietary behaviours were studied. The results
indicated that adolescents of authoritative parents who had
positive parenting relationships, healthy open communication
reported less depressive symptoms and did not engage in
substance use, sexual risks and violent behaviours and they
were benefited by authoritative parenting practices across
numerous domains including five of the six focused on CDC
as critical issues threatening adolescent health.
In addition, in the contemporary society migration and change
in the environment also seem to be affecting the parenting
and parent child relationship resulting in serious behavioural
disturbances in children and adolescents. One interesting study
conducted in china by Yang Gao, Ping (2010) on impact of
migration on adolescent children is relevant to Indian context
where similar situation of parents migrating from rural to
urban areas leaving families behind is common. They found
that male children were at higher risk of skipping breakfast
with high levels of inactivity developing overweight, smoking,
internet addiction and suicidal ideation. They also noticed
girls getting used to sweetened beverages, watching TV
excessively, smoking occasionally, and binge drinking,
expressing unhappiness, suicidal ideation and leaving home.
We are also witnessing similar behaviour patterns in the
clinical practice in the recent past.
What are the changing trends in parenting in 21 century?
First and foremost is that parents are talking and trying to
learn about parenting. A horde of articles about parenting and
vociferous discussions in media and the research on various
aspects of parenting in the recent past is witness to the change
in attitudes of parents and society. Allessi (2000) talked about
concept of modern families and how they are developing
individually through family life cycle and perpetuating
parenting. The latest review article by Kristian Daneback and
others (2010) from Sweden where they analysed the various
web site articles on parenthood published between 1997-2002
indicated various user pattern, online support groups,
information sharing, and socialising and intervention
strategies by parents on parenting and special needs of
children.
Parents in all walks of life are indulging in giving better quality
of life in terms of material comforts, education and
entertainment. The families are shifting to places with better
amenities at the cost of their comfort. Madeline Holler (2004)
described the changing trends in parenting similar to changing
Gowri DM: Contemporary parenting
113
trends in academics. She felt that the contemporary parents
started thinking and feeling for the thoughts and emotional
needs of children and parenting accordingly.
children. Hence judicious use of modern technology and the
capacity of the child and a balanced parenting seem to be the
remedy for bringing better adult out of any child.
Thus we find parents bring their children to place of work
and make work place family friendly or work from home.
They are turning away from elaborate cooking and go for
fast foods. They even try to have week end holidaying or
entertainment with children. A minority of sophisticated
parents are going to the extreme of buying their babies some
smarts like tablets, educational videos, enrichment videos with
the idea of making their children smart and amused and
updated. Majority of children across different strata of society
are preferring to admit their children into kindergartens and
private costly schools instead of public schools, and working
hard to pay for the school fees. However there is a flip side to
this type of change in parenting as well. What is missing in
all their efforts is the active involvement of children in
exploring, learning and participating in achieving what their
heart and mind says. A few children and adolescents are
conditioned to the feelings of excitement, enjoyment and
dominance on computer games. They are spending many
hours of the day and night playing with video games and
getting addicted to internet gaming with multiple players.
Recent studies have indicated that 75% students use game
devices at home with 89% having nonstop experience of
playing games. They reported behaviour problems like
withdrawal, depression, anxiety, hostility, anger, aggressive
and rule breaking behaviour and at times night mares on
watching horror videos. There is increased incidence of these
behaviours more in children where mothers have been self
employed or with government jobs compared to at home
mothers. Similarly there are studies where children between
2 to 7 years of age from all economic strata are found to
watching TV, videos, DVDs for more than three hours a day
and manifesting aggressive behaviour, bullying and academic
difficulties.
What should be done?
It is obvious that providing highly motivating and exciting
amenities indiscreetly and inappropriately to children and not
prioritising the needs, monitoring and setting limits to
children’s behaviour is the cause of damage we see in the
society.
What did we learn?
Parenting is never easy, more so in the contemporary society.
There is no readymade recipe which guarantees a good night’s
sleep for parents or a perfect child. We understand culture
does have influence on societal norms, values which guide
the behaviour of children through parenting. We also learnt
that acculturation or culture invasion by a dominant culture
due to globalisation has brought complex, confusing parent
child’s acculturation discrepancy and adjustment problems
in the contemporary society. The newer trends of
contemporary parenting seem to be both a boon and bane to
The literature on parenting tells us that child rearing has to
be done keeping cultural, parental and child perspectives in
mind. The cultural perspective gives us the ideals and norms
of society and how they are instantiated. The parental
perspective defines the beliefs, attitudes and behaviour that
characterize the child care. The child perspective gives
insights on the impact of culture and care on the development
and adaptability of the child to any changes in life. In addition
we need to keep in mind that there is no stereotypy about
different cultural groups in the contemporary society where
the values are constantly changing over generations as a result
of changing social circumstances. The contemporary
parenting hence should be a “mindful parenting”, which is a
process by which parent child relationship will improve by
promoting moment to moment awareness of their parenting.
It can be brought through active listening with emotional
awareness and non judgemental acceptance to their parenting
interactions with their children. With this practice there will
be a shift in parent’s ability and willingness to be sincerely
present with constantly growing and changing nature of their
child. Further the parenting style should be more authoritative
with consensus and consistency between both the parents in
child rearing to avoid development of abnormal behaviours.
The following are my suggestions for proper parenting,
derived from my experience based on developmental
perspective and evidence on parenting research.
1. The prerequisite is that parents should be mentally
prepared to have a child and rear him up. The prospective
parents must be educated and prepared for pleasurable/
painful experiences of parenting; from preconception and
practice them patiently. It includes care during pregnancy,
child birth and care of neonate. Parents should have
updated knowledge on fast changing world and
technology to keep pace with and monitor the children
who learn new things fast.
2. During the process of parenting both parents should
consciously attempt to be good role models, with healthy
communication skills and unconditional love for their
children. They should impart the goals of life and values
that are traditional to their culture and society to give
strong foundation to connect with family.
3. First three years of life “being available” is essential in
parenting as the child is dependent on parents for his
physical and emotional security. Doing things for the baby
like bathing, dressing, and changing nappies gives sensory
motor stimulation and secure feeling. Holding close and
feeding the baby make him develop attachment and
AP J Psychological Medicine Vol. 16 (2) July-December 2015
114
Gowri DM: Contemporary parenting
bonding. Singing, talking and playing using bright
coloured and musical toys produce cognitive and social
stimulation. Best way of achievement is only by exposing
the child to human beings, nature and natural objects at
home. I strongly advise the parents against leaving the
babies in front of TV or with I pads as a means of
stimulation. With these simple measures I could see the
autistic behaviours in some children disappear and
healthy socializing behaviour develop.
4. Between three to five years, the child should be trained
to be independent in eating and toilet habits as a preschool
preparation with simple reinforcements. Making him eat
with children and family members in a group the child
develops the art of eating and etiquette through imitation
which gives him a sense of achievement. Toilet training
should be initiated taking the child’s physiological
responses following feeding so that child gets conditioned
automatically without phobia and shame. By assisting in
bathing and dressing he develops a sense of independence
and confidence. Child should be freely left to explore his
environment to develop self confidence as was explained
by Maria Montessori. Playing with siblings and other
children at home and outside makes him sociable and
cooperative. It is essential to expose them to culture
specific rhymes, poems and make believe stories in
addition to contemporary training in the kindergarten. The
child may be exposed to cartoons, educational material
on TV and other gadgets as brief incentives in a limited
controlled way to stimulate their curiosity.
5. Five to ten years of age is the best period to structure and
shape the behaviour in a socially approved way.
Structuring the routine from waking up to sleep with
personal activities, school, entertainment and hobbies by
coordinating with activities of parents make the child
develop interest, initiation to do activities without
procrastination. Giving quality time to the child while
eating or playing indoor games giving small household
chores makes him feel as a responsible member in the
family. At this stage parents need to keep their eyes open
to see for any subtle changes in mood and behaviour as
they are confronted with strangers outside home. It is
important for the parents to work on social skills as the
society expects smartness out of the individuals. This is
the best period to introduce the child to hobbies like art,
music, dance, reading etc as child is receptive and
obedient to the parents. Similarly parents should also
introduce the child to physical exercise like swimming,
games and yoga etc. They need to explain the basic rules
of conduct of not hurting others with words or acts but to
negotiate through communication. Further the child
should be encouraged not only to manage his personal
activities including studies but also take up small house
AP J Psychological Medicine Vol. 16 (2) July-December 2015
hold chores to feel competent. Parents, as part of
parenting need to have working relation with teachers to
find out the issues of child at school and also appraise
the teacher about the strengths and weaknesses of the
child for necessary help. At the end of this stage child
will develop independence, self regulation and enough
social skills to solve problems which are essential for
facing on coming turbulent adolescence.
6. When it comes to adolescence the adolescent has to go
into the “world of doing” to become “whole themselves”,
as they go away from “family focused life” to the “wider
social life”. It is important to parents to stay connected,
doing things together, and being vigilant and supportive
with their adolescents to know the happenings in his inner
and outer world as well. The parents while respecting his
independence and lateral thinking need to reason out
decisions in a democratic way through discussions.
Standing firm without hard and fast rules with regard to
limited usage of internet, face book, watching TV, chatting
and SMS will make adolescents responsible, transparent
and adherent to the family and social norms. Parents
through their subtle behaviour and role modelling should
teach children their gender specific roles and gender
sensitive behaviour towards opposite sex which would
develop them into more tolerant, understanding and
empathetic human being. I am sure over a period of time
we may witness more mature youth and decline in
violence against women and vulnerable. Parents need to
avoid coercion, suspicion or ridicule in dealing with
sensitive relationship and sexual behaviours of their
adolescents. They should also address the issues of drug
and substance abuse softly but firmly. Parents should not
limit or criticize their relationship with peers, who have
great influence on them but rather set limits to their
interaction under supervision. By this the parents can
identify the problems of depression, suicidal behaviour,
substance and alcohol abuse and serious relationship and
sexual problems early. Being available, understanding and
empathising with their children, parents can avert the
mishaps to their adolescents.
7. Finally I conclude that contemporary parenting is
challenging like walking on a tight rope. However being
mindful about the needs of the child in the changing
society and controlling their own emotions towards their
children, parents can still make their children competent,
self sufficient to face the challenges in their life. What is
important is being connected, with acceptance, empathy
and unconditional love towards child and faith in their
parenting.
ACKNOWLEDGEMENTS: Nil
Conflict of interest: None declared
Source(s) of support: Nil
115
PRESIDENTIAL ADDRESS
Living with schizophrenia.
Suresh Kumar G1
1
Assistant professor of Psychiatry, Department of psychiatry, Government hospital for mental care, Vishakhapatnam, Andhra
Pradesh, India.
It is with a great sense of gratitude that I stand before you this
morning for the honor bestowed and confidence you have
reposed in me for having elected me as president of this august
society. Looking forward to shouldering the responsibilities
to the best of my abilities with full confidence and your support
shall be my endeavor and strength to enable me to carry my
duties and reach to your expectations during the ensuing year.
The Indian psychiatric Society AP state branch is having its
35th annual conference this year. With all your valuable
suggestions and constructive effort that we can build up and
aid in the progress our society to reach new heights.
World federation for mental health proposed the theme for
the year 2014 is living with schizophrenia and more over I
am working in the Government mental hospital where more
than fifty percent of beds being occupied by the Schizophrenic
patients.
Who lives with schizophrenia? First of all, the people who
suffer from it. It does not matter whether it is an illness or a
disorder, whether you call it schizophrenia or integration
dysfunction, whether you refer to the people who suffer from
it as patients, service users or consumers. What matters is
that they suffer from it to an unbelievable degree and that the
rest of us who are lucky to have escaped from it have a moral
obligation to show solidarity and help.
We must not forget two things. First, that it is within our
philanthropic, advocacy, professional and social roles to do
that and, second, that no one is immune to mental illness
including ourselves and our families. By helping people with
schizophrenia and by promoting prevention, treatment and
research into this condition we help ourselves.
Schizophrenia is a disabling, chronic psychiatric disorder that
poses numerous challenges in its management and
consequences. Although schizophrenia is relatively rare, it is
Address for correspondence: Dr.G.Suresh Kumar, Assistant
professor of psychiatry, Government hospital for mental care,
Andhra Medical College, Vishakhapatnam, Andhra Pradesh,
India
Phone number: +919848608604
Email: [email protected]
How to cite this article: Suresh GK. Living with
schizophrenia. AP J Psychol Med 2015;16(2):115-7
also arguably the most severe mental disorder. In many
individuals, the disorder runs a chronic and relapsing course,
leading to progressively worsening disability, loss of
livelihoods and social networks, and increased risk of
discrimination and human rights abuse.
It extols a significant cost to the patient in terms of personal
suffering, on the caregiver as a result of the shift of burden of
care from hospital to families, and on society at large in terms
of significant direct and indirect costs that include frequent
hospitalizations and the need for long-term psychosocial and
economic support, as well as life-time lost productivity.
Care giver burden defined as a “psychological state produced
by the combination of physical work, emotional pressure,
social restrictions, and economic demands arising from taking
care for a patient as well”. Burden on relatives of patients
with schizophrenia has been found associated with an
important reduction in their quality of life (QOL), resulting
in caregiver’s physical and psychological wellbeing is
compromised.
Burden of care is more defined by its impacts and
consequences on caregivers. In addition to the emotional,
psychological, physical and economic impact, the concept of
‘burden of care’ involves subtle but distressing notions such
as shame, embarrassment, feelings of guilt and self-blame.
Fortunately, during the 1950s, modern psychopharmacology
developed novel effective medication and the community
mental health movement appeared. These two developments
increased the therapeutic potential and contributed immensely
to more humane treatment of patients. De-institutionalization
(chronic patients living in the community instead of
institutions) became possible and occupational rehabilitation
was implemented in a number of patients.
Today the treatment of people with schizophrenia is more
person-centered, more collaborative and more effective.
Acceptance and implementation of concepts like positive
mental health, recovery and resilience have had a decisive
influence on the mentality of professionals and the public. A
very positive development was that the patients have been
empowered and have developed a voice of their own and the
capacity to decide about their future in an autonomous way.
Autonomy is now a key word in the ethics guidelines of most
mental health professional ethics codes, and although there
AP J Psychological Medicine Vol. 16 (2) July-December 2015
116
Suresh G: Living with schizophrenia
are cultural differentiations the trend is towards the direction
of its universal acceptance.
Advocates and advocacy organizations like the World
Federation for Mental Health also live with schizophrenia, in
a sense. They try to identify with the patients, to feel their
needs, to side with them. The key word is EMPATHY.
Advocacy organizations have an important role to fulfill and
this role is to strive for improved patient care and defend the
patient’s rights. Collaborative community based care for
people and their families living with schizophrenia in India:
protocol for a randomized controlled trial has been conducted
by Thara et al., in COPSI study ( Community care for People
with Schizophrenia in India) with the primary objective being
in reducing the symptoms and disabilities of people with
schizophrenia and the secondary objectives were focused
mainly on the areas in improving the knowledge and attitude
of family members, Reducing the Impact on Caregiver burden,
Improving adherence to treatment, reducing experience of
stigma and Improve access to health care and disability
benefits. COPSI trail outcome indicator assessment done by
using appropriate scales. Intervention to be home based and
provided to patients by community health workers (CHWs)
each CHW were followed about fifteen cases and the
Interventions Split over three phase Intensive Engagement,
Stabilization and maintenance for a period of one year. Care
giver of patient also included in intervention process.
perspectives, caregivers have to be included in the care plan
and adequate information and support extended to the family
and caregivers. Access to better treatment for patients,
including medications, psychosocial interventions and
rehabilitation services, are important basic elements in easing
the burden on caregivers. Other measures such as availability
of crisis management, provision of legally mandated
community treatment to avert hospitalization, and well
informed and balanced advocacy are also important.
India’s scarce mental health resources, such as mental health
specialists, are largely concentrated in some states (mainly in
the south) and in urban areas and a large proportion are solely
in the private sector. Over half of all inpatient beds are located
in 40 odd mental hospitals, most of which were built before
Independence. It is not surprising, then, that the ‘treatment
gap’ for mental disorders is large all over the country, but
especially so in rural areas, northern states and amongst the
socially disadvantaged. Treatment gap in even Severe Mental
Disorders is approximately 50%. In case of Common Mental
Disorders it is over 90 %. And 6% of Kerala’s population has
mental disorders. 1 in a 5 has some sort of emotional and
behavioral problems.
Base line results of the COPSI trail are, most patients had
moderate to severe psychopathology on Positive and Negative
Syndrome Scale (PANSS) at baseline, Predominately
Negative symptoms most had duration of illness of greater
than 5 years, average age of patient was about 35 years most
were single (never married, divorced/ separated, widowed),
most were unemployed, most had completed primary school
education and belonged to lower socioeconomic class.
The mainstay of treatment for people with schizophrenia is
antipsychotic medication. There is now a greater choice of
medication for the treatment of the illness. The second
generation of antipsychotics, called the ‘atypical’, provides
more effective treatment options, with a reduction in
movement disorders. The aim is to optimize mental and
physical wellbeing, but some of these medications have an
increased risk of cardiovascular and metabolic problems
including coronary artery disease, weight gain, lipid
abnormalities and Type II Diabetes. People with schizophrenia
die 15-20 years earlier than the general population due to
co-existing physical illness and smoking.
Major Issues in living with Schizophrenia:
Suggestions:
Stigma, and the presence of competing and conflicting
explanatory models of mental illness (often based on “magicoreligious” beliefs), have also contributed to the non use of
the existing treatment facilities. A study that was conducted
at the Schizophrenia Research Foundation in Chennai found
that women with schizophrenia were more stigmatized than
men with schizophrenia, and that female caregivers were more
sensitive to stigma than male caregivers. Being single or
divorced compounded the problem of stigma even further
Stigma is an all-encompassing phenomenon and a profound
barrier to effective help seeking.
To improve awareness about the disorder and the service, the
Community mental health worker needs to establish close
networks with members of grass-root, health service, and
social welfare organizations. Next, the community mental
health worker must identify probable cases of schizophrenia.
Building individual and family capacity to cope with the
disorder (e.g., to support medication adherence) and ensuring
that the costs of long-term care are at least partly borne by an
equitable financing system, such as a voucher system,
insurance plan, or fixed monthly payments.
‘Burden of care’ as a complex construct certainly requires
the development of appropriate methodology for its costing.
In achieving a balance between the patients’ and caregivers’
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Provision of free drugs to these patients as a part of “DOTStype” program would help to share this burden in a small but
very significant way .Drug treatment for schizophrenia is
likely to be more effective if its administration is supervised.
Suresh G: Living with schizophrenia
About 60% of patients with schizophrenia may fail to adhere
to their treatment, in part because the disease itself leads to
impaired insight and cognitive functioning. Approaches that
are broadly similar to DOTS, entrusting the monitoring of
drug compliance to a relative, have been found to be effective
in improving treatment adherence for schizophrenia in
developing countries.
Community care in India is almost synonymous with family
care. There are no organized community-based programs for
people with chronic mental illness. The commonest site of
treatment is the mental hospital, many of which are large and
isolated, with little contact with the community they serve.
Efforts are under way to improve the conditions of many of
these hospitals. While the number of general hospital
psychiatry beds has increased in the last decade, the total
number is still grossly inadequate.
Non-governmental organizations (NGOs) have also played
a role in the growth of community care. Mental health NGOs
in India, Maldives, Nepal and Sri Lanka deal with numerous
mental health problems in the community. Common NGO
activities include advocacy, mental health promotion, and
prevention of mental disorders, rehabilitation, and direct
service provision.
Need for home based interventions mainly due to several
patients refuse to come to the treatment/rehab centre for
various reasons, including stigma, lack of insight. Access to
rehab centers is limited and not able to cater to their specific
needs Utilization of the family resources.
Advantages of home based intervention are training and
guidance provided by Rehab Team. Identification, honing and
development of available occupational skills of the patient
and the family. Integration of Patient with family in income
generating activities.
Advantages of telemedicine
Optimal utilization of scarce resources Maximum coverage
geographically with minimal travel More cost effective, since
travel, time and money are substantially reduced. Ensures
117
access to specialists’ services and thereby the quality of the
service. It enables people to articulate their needs and
participate in interactive sessions with experts.
Research and training
The SCARF studies on schizophrenia are the most widelycited research on the subject from any developing countries.
The film festival organized by SCARF called the “Frame of
Mind,” which features several films portraying mental illness
and an international competition for short films on mental
health and stigma, is a huge success and has had three editions
so far. Similar festivals have since been held in other cities
like Kolkata. Many NGOs use short films to spread awareness
among the public about their objectives. The world of most
MHNGOs is confined to a city or a few villages.
Conclusion
It is important to understand people’s perception of mental
health needs. Special programs are needed during and after
recovery and for the socially and economically marginalized,
such as poor women and children, especially in rural areas.
Awareness programs should be developed using local media
– print, audio (community radio) and visual (local TV
channels) – and organizing classes in schools, colleges and
other educational institutions. There is a need for promotional
and preventive components, for example referring to suicide
prevention, workplace stress management, school and college
counseling services. Mental health programs should be
integrated with other health programs, such as those for
women and children, or rural development., the people who
“live with schizophrenia” belong to various categories—
consumers, carers, professionals, advocates and society as a
whole. It is the dynamic collaboration and synergism between
these groups (“Working together for mental health”) that will
make “Living with Schizophrenia” worth living.
Acknowledgements: Nil
Conflict of interest: None declared
Source(s) of support: Nil
AP J Psychological Medicine Vol. 16 (2) July-December 2015
118
ORIGINAL ARTICLE
Study of insight in schizophrenia.
Aditi A Dagaonkar1, Bindoo S Jadhav2, Sunitha Shanker3, Bharat R Shah4, Hemangee S Dhavale5
Registrar in Psychiatry, 2Associate professor of Psychiatry, 3Clinical psychologist, 4Professor and Head of the department,
5
Professor of psychiatry, Department of Psychiatry, K.J. Somaiya Medical College, Hospital and Research Centre, Mumbai,
Maharashtra, India
ABSTRACT
Background: Unawareness of one’s own illness among people with schizophrenia has been a much documented
phenomenon. Insight into the illness and the level of functioning are known to be important in determining outcome in
schizophrenia.
Aims and objectives: 1.To assess the level of insight in patients with schizophrenia. 2.To study the correlation between
the global functioning and level of insight in the patient. 3.To assess the relationship between the level of insight in the
patient and the extent of disability in them.
Methods: Fifty patients with schizophrenia were selected. The level of insight, functioning and disability were evaluated
using the Birchwood Self Report Insight scale, Global assessment of functioning and Indian Disability Evaluation and
Assessment Scale respectively. Relationship between these parameters was studied.
Results: Seventy two percent of the patients had poor insight. Eighty four percent of the patients had a GAF score of less
than sixty. Sixteen percent were severely disabled. There was no significant relationship between the parameters studied.
Conclusions: Awareness of symptoms and mental illness is low even though perceived need for treatment is high. Level
of insight and disability & global functioning does not have a significant relationship.
Key message: There is no direct relationship between impaired insight and level of functioning and disability in patients
with schizophrenia. Need to study specific psycho-social and cultural factors also.
Keywords: Schizophrenia, Insight, Functioning, Disability.
Date of first submission: 25/7/15 Date of initial decision: 1/8/15 Date of acceptance: 16/10/15
INTRODUCTION:
Schizophrenia is one of the most debilitating mental illnesses.
It often strikes early in life and its impact on the employment,
social relationships and living status of patients are
devastating.
Despite the clinical heterogeneity within schizophrenia, it has
been widely acknowledged that lack of insight- one of the
‘core’ manifestations of psychosis, is one of the most prevalent
symptoms in the disorder. [1-4]
This has been thought to have a notable influence on the
adherence to treatment and clinical outcome.
However, insight is no longer regarded as an “all or none”
phenomenon. Some researchers have divided it into three
distinct dimensions: a general recognition of mental illness,
the capacity to correctly attribute symptoms to the pathology
of the illness, and the ability to recognize the benefits of (and
consequently cooperate with) the treatments.[5,6]
Research into the relationship between insight and functioning
in patients of schizophrenia has suggested that a patient’s
insight is significantly related to global and specific measures
of functional outcome. [7 - 9]
Address for correspondence: Dr Aditi A Dagaonkar, A 1203
Serenity Towers, Behind Oshiwara Police Station, Off. Link
Road, Oshiwara, Mumbai 400 104. Maharashtra, India.
Phone number: +91-9930047995
Email: [email protected]
One approach to the assessment of functioning in these
patients is the measure of global severity of psychiatric illness
by focusing on patient’s psychological, social and
occupational outcome. Another variable of measuring
functioning is disability, which is defined as the inability to
independently perform basic activities of daily living or other
tasks essential for independent living without assistance.
How to cite this article: Aditi AD, Bindoo SJ, Sunitha
S, Bharat RS, Hemangee SD. Study of insight in
schizophrenia. AP J Psychol Med 2015; 16(2): 118-22
With this model as the background, this study attempts to
address the relationship between insight, global functioning
and disability.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Aditi AD, et al: Insight in schizophrenia
119
AIMS AND OBJECTIVES:
Inclusion Criteria:
1.
To assess the level of insight in patients with
schizophrenia.
1.
Patients fulfilling DSM-IV TR diagnostic criteria for
schizophrenia.
2.
To study the relation between global functioning and
level of insight in the patient.
2.
Patients between 18-60 years of age.
3.
Duration of illness > 2 years.
3.
To assess the relationship between the level of insight
in the patient and the extent of disability in them.
4.
Presence of primary care giver attending the hospital.
Exclusion Criteria:
MATERIALS AND METHODS:
Materials:
·Diagnostic and Statistical Manual- IV Text Revision (DSMIV TR): The diagnostic manual was used to make a diagnosis
of schizophrenia as per the criteria required by the manual.
·Semi structured proforma: This tool was designed specifically
for the study and used to obtain various demographic
characteristics related to patient.
·Birchwood Self Report Insight Scale[10]: This is a rapid selfreport measure, consisting of eight items. The scale provides
three insight factors (re-labelling of symptoms, awareness of
illness and need for treatment) in addition to a total insight
score. A score of nine and above indicates good insight.
·Global Assessment of Functioning (GAF) Scale[11]: This is a
revision of the Global Assessment Scale: a procedure for
measuring overall severity of psychiatric disturbance.
·Indian Disability Evaluation and Assessment Scale
(IDEAS)[12]: This scale has four items – self care, interpersonal
activities, communication and understanding and work. Each
item is scored from 0 to 4 i.e. from no disability to profound
disability, using which the global disability is calculated.
1.
Diagnostic dilemma or psychotic illness other than
schizophrenia.
2.
Patients with mental retardation and/or co-morbid
organic disorders and/or substance abuse
3.
Non-availability of caregiver.
Methods:
Prior to the study, patients and their caregivers were informed
of the research objectives and assured of the confidentiality.
After taking Institutional Ethics Committee approval and
informed consent, fifty patients fulfilling inclusion and
exclusion criteria, attending Psychiatry outpatient department
of a General Teaching Hospital were selected.
The Pollack and Perlick method [13] was used to identify the
primary care giver. According to this method, a primary
caregiver is one who satisfied greatest number (=3) of the
following criteria:
Spouse, parent or spouse equivalent
a.
Most frequent contact with patient
b.
Support patient financially
Graph 1: Socio demographic variables of the sample
AP J Psychological Medicine Vol. 16 (2) July-December 2015
120
Aditi AD, et al: Insight in schizophrenia
Graph 2: Illness related variables
c.
Most frequent collateral participant in patient’s
treatment
d.
Is the person contacted in case of an emergency
After the participants were recruited, details of demographic
and illness related variables were collected using semi
structured proforma.The level of insight was determined using
Birchwood Self Report Insight Scale[10]. Global Assessment
of Functioning (GAF) Scale and Indian Disability Evaluation
and Assessment Scale (IDEAS) were used to assess
functioning and extent of disability respectively by
interviewing the caregiver.
awareness of having a mental illness was present in 28.6%
of the patients. However the perceived need for treatment in
these very patients was as high as 92.9%.
Table 2: Scores on the Global Assessment of
Functioning (GAF) Scale.
GAF Scores
No of patients
Percentage
71-80
8
8%
61-70
8
8%
51-60
10
20%
41-50
9
18%
The data was then pooled and statistical analysis was
conducted using SPSS software package.
31-40
14
28%
21-30
18
18%
RESULTS:
Total
100%
100%
A total of 50 patients were studied of which 24 were males
and 26 were females.
Table 1: Score distribution among the three dimensions
of insight in subjects with good insight
Dimensions of Insight
Percentage
Awareness of symptoms
14.3%
Awareness of mental illness
28.6%
Perceived need for treatment
92.9%
The evaluation of insight in the patients showed that 72% of
the patients had poor insight. On assessing the level of insight
along the different dimensions as described earlier, it was
found that even in patients with good overall insight, the
awareness of the symptoms was found in only 14.3% and
AP J Psychological Medicine Vol. 16 (2) July-December 2015
A GAF score of 51-60 indicates moderate symptoms and
difficulty. In our study, eighty four percent of the patients
had a GAF score less than 60, indicating a poor overall
functioning.
Table 3: Scores on the Indian Disability Evaluation and
Assessment Scale (IDEAS)
Extent of disability
No of patients
Percentage
No disability
3
6%
Mild disability
10
20%
Moderate disability
26
52%
Severe disability
8
16%
Profound disability
3
6%
Total
50
100%
Aditi AD, et al: Insight in schizophrenia
More than half the patients were moderately disabled. Sixteen
percent were having severe disability.
Table 4: Comparing patients with good and poor insight
on their scores on the GAF scale and IDEAS using one
way ANOVA
F score
P value
GAF
2.56
0.12
IDEAS
2.35
0.13
GAF – Global Assessment of FunctioningI
DEAS – Indian Disability Evaluation and Assessment Scale
ANOVA – Analysis of Variance
There was no statistically significant difference between
patients with good and poor insight with respect to their scores
on the Global Assessment of Functioning (GAF) Scale and
the Indian Disability Evaluation and Assessment Scale (Table
4)
DISCUSSION:
In our study, 72% of the patients had poor insight. Studies
done in the past [2-4,13-16] have also found poor insight to be a
distinguishing feature of schizophrenia.
On the sub-scales of insight, results similar to those in our
study, were seen in a study by Sevy S et al [15]in which the
percentage of patients having a lack of awareness was 58.2%
for symptoms, 32.7% for illness and 18.4% for treatment
response.
This can be explained by a number of reasons. Complex
symptoms, such as lack of insight, are significantly influenced
by the individual’s socio-cultural background and language,
as well as by the process of symptom formation itself.
Kim Y et al [17] found that awareness of the need for treatment
seems to improve, even in the absence of awareness of illness
or of psychotic experience, in outpatient settings. It was felt
that the effects of social interaction may be relevant to this.
The need for treatment will most likely be affected by the
level of disability experienced by the person. If the illness is
perceived as thwarting one’s daily functioning, then the person
is more likely to perceive the need for treatment so that he/
she is able to function and manage well. In our study, majority
of our sample was found to be significantly disabled.
Lele and Joglekar [18] have postulated that poor insight in
schizophrenia may be domain specific i.e. patient may have
selective awareness of some attributes of their illness, but
not others. Thus the different dimensions of insight could have
different etiologies just like the different symptom clusters in
schizophrenia.
Lastly, some theories suggest that denial and an avoidant
coping style may also play a role in the unawareness of
illness. [19]
121
It is well known that schizophrenia ranks among the top ten
causes of disability in developed countries worldwide. In this
study, 52% of the patients were moderately disabled and
sixteen percent experienced severe disability.
In our study, we found that those with good and poor insight
(two groups) did not have statistically significant scores on
Global Assessment of Functioning and Indian Disability
Evaluation and Assessment Scale.
Several studies done in the past [2,3,16,20] have found that less
awareness of several aspects of mental disorder was associated
with poorer psychosocial functioning in patients with
schizophrenia. However, Schwartz R.C. [21] found that degree
of insight was not related to global functioning.
In the Indian context family support plays a significant role
in the level of disability experienced by the person with
schizophrenia. Because of the support and help of the
immediate and extended family, the individual’s daily
functioning is not as affected as compared to cultures which
are more individualized.
This could also be explained using an alternative view on the
relation between these parameters.
A good global insight is not only a risk factor for hopelessness
about the future, [22] but is also known to be associated with
higher levels of depression. [8, 23] These factors, along with an
avoidant coping style may contribute to poor functioning and
greater disability in some patients with good insight.
On the other hand, patients with poor insight may be relatively
free from the serious psychological stress of hospitalization
and the stigma of being mentally ill. Infact, Mutsatsa et al [8]
found that patients with poor insight perceived themselves to
have a better level of independent performance at daily living
activities. Thus, despite the lack of awareness, there may be
better levels of functioning in some of these patients.
SALIENT FINDINGS:
1.
Seventy two percent of the patients had poor insight
2.
In patients with good insight:
- 14.3% had awareness of symptoms
- 28.6% had awareness of illness
- 92.9% had awareness of need for treatment
3.
Eighty four percent of the patients had a GAF score of
less than 60
4.
Fifty two percent were moderately and sixteen percent
were severely disabled
AP J Psychological Medicine Vol. 16 (2) July-December 2015
122
Aditi AD, et al: Insight in schizophrenia
STRENGTHS OF THE STUDY:
This study highlights the important fact that poor insight and
disability are the core features of schizophrenia.
LIMITATIONS:
Cross – sectional study.
Small sample size.
CONCLUSIONS:
This study shows that even though a person with schizophrenia
may not have awareness of his symptoms or that he is having
a mental illness; he does perceive a need for treatment. This
may highlight the need to be careful before we use and
understand the concept of insight in a generalized manner.
Perceived need for treatment is affected by various psychosocial factors and may need to be evaluated separately in each
person even if over-all insight seems apparently poor. This is
an important understanding because it has implications for
compliance with medication and rehabilitation services
provided.
REFERENCES:
1.
Carpenter, W.T., Bartko, J.J., Strauss, J.S., Hawk, A.B.
Signs and symptoms as predictors of outcome: a report
from the International Pilot Study of Schizophrenia.
1978 Am. J. Psychiatry 135, 940–944.
2.
Amador, X.F., Andreasen, N.C., Flaum, M., Strauss,
D.H., Yale, S.A., Clark, S. et al. Awareness of illness in
schizophrenia, schizoaffective and mood disorders.
Arch. Gen. Psychiatry 1994 51, 826– 836
3.
Pini, S., Cassano, G.B., Dell’Osso, L., Amador, X.F.
Insight into illness in schizophrenia, schizoaffective
disorder, and mood disorders with psychotic features.
Am. J. Psychiatry 2001 158, 122– 125.
4.
Wilson, W.H., Ban, T.A., Guy, W. Flexible system
criteria in chronic schizophrenia. Compr. Psychiatry
1986 27, 259– 265.
5.
Rickelman, B. L. Anosognosia in individuals with
schizophrenia: toward recovery of insight. Issues Ment
Health Nurs. 2004 25(3), 227-242.
6.
Kemp, R. A., Lambert, T. J. Insight in schizophrenia
and its relationship to psychopathology. Schizophr Res.
1995 18(1), 21-28.
7.
Schwartz RC, Cohen BN, Grubaugh A. Does insight
affect long-term impatient treatment outcome in chronic
schizophrenia? Compr Psychiatry. 1997 SepOct;38(5):283-8.
8.
Mutsatsa SH, Joyce EM, Hutton SB, Barnes TR.
Relationship between insight, cognitive function, social
function and symptomatology inschizophrenia : The
West London first episode study.Eur Arch Psychiatry
ClinNeurosci. 2006 Sep;256(6):356-363.
9.
Hasson-Ohayon I, Kravetz S, Roe D, David AS, Weiser
M: Insight into psychosis and quality of life. Compr.
Psychiatry. 2006 Jul-Aug; 47(4):265-9
AP J Psychological Medicine Vol. 16 (2) July-December 2015
10. Birchwood M, Smith J, Drury V, Healy J, Macmillan F,
Slade M. A self-report Insight Scale for psychosis:
reliability, validity and sensitivity to change.
ActaPsychiatr Scand. 1994 Jan;89(1):62-7.
11. Endicott J, Spitzer RL, Fleiss JL, Cohen I: Global
Assessment of Functioning (GAF) Scale Archives of
General Psychiatry 1976 33: 766-771.
12. IDEAS: A scale for measuring and quantifying in
disability in mental disorders, Indian Psychiatric Society
2002
13. Pollack CP, Perlick D. Sleep Problems and
institutionalization of the elderly. Journal of Geriatric
Psychiatry and Neurology, 1991 4:204-210
14. Fennig, S., Everett, E., Bromet, E. J., Jandorf, L., Fennig,
S. R., Tanenberg-Karant, M., et al. Insight in firstadmission psychotic patients. Schizophr Res, 1996
22(3), 257-263.
15. Sevy S, Nathanson K, Visweswaraiah H, Amador X.
The relationship between insight and symptoms in
schizophrenia Compr Psychiatry. 2004 JanFeb;45(1):16-9
16. Cernovsky ZZ, Landmark JA, Merskey H, Husni M:
Clinical correlates of insight in schizophrenia. Psychol
Rep. 2004 Dec;95(3 Pt 1):821-7.
17. Kim Y, Sakamoto K, Kamo T, Sakamura Y, Miyaoka
H. Insight and clinical correlates in schizophrenia.
Compr Psychiatry. 1997 Mar-Apr;38(2):117-23
18. Lele, M. V., Joglekar, A. S. Poor insight in
schizophrenia: neurocognitive basis. J Postgrad Med,
1998 44(2), 50-55.
19. Lysaker PH, Lancaster RS, Davis LW, Clements CA.
Patterns of neurocognitive deficits and unawareness of
illness in schizophrenia. NervMent Dis. 2003
Jan;191(1):38-44
20. David A, Van Os J, Jones P, Harvey I, Foerster A, Fahy
T: Insight and psychotic illness: cross-sectional and
longitudinal associations. Br J Psychiatry 1995;
167:621–628
21. Schwartz RC. Insight and illness in chronic
schizophrenia. Compr Psychiatry. 1998 SepOct;39(5):249-54.
22. Carroll A, Pantelis C, Harvey C. Insight and
hopelessness in forensic patients with schizophrenia.
Aust N Z J Psychiatry. 2004 Mar;38(3):169-73.
23. Smith TE, Hull JW, Israel LM, Willson DF Insight,
symptoms, and neurocognition in schizophrenia and
schizoaffective disorder. Schizophr Bull.
2000;26(1):193-200.
ACKNOWLEDGEMENTS: Nil
Conflict of interest: None declared
Source(s) of support: Nil
123
7
ORIGINAL ARTICLE
Prevalence and correlates for stress among students in a school of medicine in a university in Zambia
Naadira O Vally1, Seter Siziya2
1
Student in dental sciences, 5th year, Dental department. 2 Professor of medical statistics, Department of clinical sciences,
School of Medicine, Copperbelt University, Ndola, Copperbelt Province, Zambia.
ABSTRACT
Background: Stress can have serious consequences that can influence mental health status. Thus, using definition of health,
an individual suffering from stress is not a healthy person. No such studies have been conducted in Zambia.
Aims and objectives: To determine the prevalence of stress among undergraduate students and to determine factors associated
with stress.
Methods: This was a cross sectional study. Multivariate logistic regression analysis was conducted to determine independent
predictors of stress. Adjusted odds ratios (AOR) and their 95% confidence intervals (CI) are reported. The abstract has no
results on Pearson Chi-square and Fisher’s exact test.
Results: From a sample size of 360 students, 70.3% students responded of which 28.5% were found to be stressed. Second
year students were 2.29 (95% CI [1.21, 4.34]) and third year students were 2.69 (95% CI [1.44, 5.01]) times more likely to be
stressed than the fifth year students. Students who slept four hours or less were 1.58 (95% CI [1.15, 2.17]) times more likely
to be stressed compared to students who slept more than four hours. Students who felt that the cause of their stress was due
to tests were 80% (AOR= 1.80, 95% CI [1.19, 2.72]) more likely to be stressed compared to students who did not indicate as
such.
Conclusion: Relatively low prevalence of stress was observed among students at the school of medicine. This could be due
to strategies students could have been used to relieve stress.
Keywords: Stress, Medical university students, Zambia
Date of first submission: 9/10/15 Date of initial decision: 1/12/15 Date of acceptance: 16/12/15
INTRODUCTION:
Stress is a physical, mental, or emotional factor that causes
bodily or mental tension.[1]
Stress can cause anxiety, depression, phobia, fear, tension,
dizziness, fatigue, sleeplessness, gastrointestinal disturbance,
irritability and cynicism. [2] Thus from the definition of “health”
which states that: “Health is a state of complete physical,
mental, social and spiritual well-being and not merely the
absence of disease or infirmity”. [3] It follows from this
definition that a person suffering with stress is not at all a
healthy person even though he is physically fit but in reality
he is mentally, socially and spiritually not well.
Address for correspondence: Dr Naadira O Vally, P.O.Box:
32018, Lusaka, 10101, Lusaka Province, Zambia.
Phone number: +260 976-675811
Email: [email protected]
How to cite this article: Naadira OV, Seter S. Prevalence
and correlates for stress among students in a school of
medicine in a university in Zambia. AP J Psychol Med
2015; 16:123-8
Stress is common in university students world-wide but higher
in dental and medical students because medical and dental
schools have higher and more demanding learning
environments [4] such that there is excessive tests and
assignments, [5,6] lack of time management skills, pressure to
get good grades[6] and the medical curriculum is not simple
and trying to grasp it can be stressful.[7]
High prevalence rates of stress were observed in Universities
of Sheffield, Manchester and Leeds to be 31.2%, [8] 41.9% in
a Malaysian medical school [9] and 61.4% at the Faculty of
Medicine, Ramathibodi Hospital, Thailand. [10]
Stress reduction (relief) refers to various strategies that
counteract the stress response and produce a sense of
relaxation and tranquility.[11] To relief stress, students read
magazines or books, pray or engage in other spiritual
activities, meditate, listen to music or play a musical
instrument, shop, watch television, smoke, drink alcohol and
sleep. [1] No studies to our knowledge have been conducted
on stress among university students in Zambia.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
124
Naadira OV, et al: Stress in medical students
AIMS AND OBJECTIVES:
The objective of this study was (1) to determine the prevalence
of stress among students and (2) to determine factors
associated with stress.
MATERIALS AND METHODS:
The school of medicine of the Copperbelt University runs
for five years starting from year two going to year six while
the first year is in the school of natural sciences. The programs
are designed such that the preclinical students (second and
third years) take the same courses. The differentiation of the
programs starts in the clinical years. In the first clinical year,
dental students rotate through general internal medicine,
general surgery, paediatrics, obstetrics and gynaecology, oral
surgery, operative dentistry and basic sciences. Meanwhile,
first clinical year medical students rotate through general
internal medicine, general surgery, paediatrics, obstetrics and
gynaecology and basic sciences.
In second clinical year, dental students rotate through subspecialities of internal medicine and surgery, maxillofacial
and oral surgery, operative dentistry and endodontics,
prosthodontics and research project. Meanwhile, second
clinical year medical students rotate through sub-specialities
of internal medicine, surgery, paediatrics, obstetrics and
gynaecology and research projects.
During the time of the research, the sixth year did not exist
because the school of medicine had only been in existence
for the past four years.
A cross sectional study was carried out where questionnaires
were distributed to all 360 students of which 94 were dental
and 266 were medical students in the School of Medicine at
The Copperbelt University. Study participants were
undergraduate regular students from second year to fifth year.
The questionnaire was self-made but included parts from
generic stress questionnaire for students from Ministry of
Social Security, National Solidarity & Reform Institutions,
International Stress Management Association UK (ISMA) and
Sue Firth Ltd. The questionnaire comprised of social
demographic factors, behavioural factors, and other factors
(course-load, tests, exams, household work, family, job [if
any]).
There were thirty seven items asked to identify the level of
stress. The students were told to choose the best answer on
how each item affected them by either choosing strongly
disagree (0), disagree (1), not sure (2), agree (3) or strongly
Table 1: Social demographic factors associated with stress
Stress
Factors
Total
n (%)
p-value
Yes
n (%)
No
n (%)
153 (60.5)
60 (23.7)
40 (15.8)
55 (76.4)
8 (11.1)
9 (12.5)
98 (54.1)
52 (28.7)
31 (17.1)
81 (32.0)
172 (68.0)
24 (33.3)
48 (66.7)
57 (31.5)
124 (68.5)
0.777
215 (85.0)
38 (15.0)
64 (88.9)
8 (11.1)
151 (83.4)
30 (16.6)
0.272
213 (84.2)
40 (15.8)
62 (86.1)
10 (13.9)
151 (83.4)
30 (16.6)
0.597
65 (25.7)
188 (74.3)
20 (27.8)
52 (72.2)
45 (24.9)
136 (75.1)
0.632
101 (39.9)
85 (33.6)
20 (7.9)
47 (18.6)
36 (50.0)
32 (44.4)
2 (2.8)
2 (2.8)
65 (35.9)
53 (29.3)
18 (9.9)
45 (24.9)
<0.001
Age
≤ 24
25-29
≥ 30
0.003
Sex
Female
Male
Marital status
Not married
Married
Children
No
Yes
Program
BDS
MBChB
Year of Study
2
3
4
5
AP J Psychological Medicine Vol. 16 (2) July-December 2015
125
Naadira OV, et al: Stress in medical students
agree (4). After which each student was scored according to
how the item affected them. The cut-off point was taken as
seventy four (50%) of the overall score, considering to the
cut-off point of 0-25%; 26-50%; 51-75% and 76-100%
(citing) for stress. We combined 0-25% and 26-50% as not
stressed and 51-75% and 76-100% as stressed in running our
logistic regression analysis.
Data entry was carried-out via EpiData (version 3.1), while
data analysis was done through SPSS (version 16.0). The
Pearson Chi-Square test was used as well as the Fisher’s Exact
Test (2 sided) where the expected frequencies were less than
five in a two by two contingency tables. The Cut off point for
statistical significance was set at the 5% level. Multivariate
logistic regression analysis was conducted to determine
independent predictors of stress. All the factors that were
significant in bivariate analyses were considered in a
multivariate logistic regression. Variables were selected using
Backward LR method. Adjusted odds ratios (AOR) and their
95% confidence intervals (CI) are reported.
RESULTS:
From the overall of 360 students, 253 (70.3%) students (65
[25.7%] dental and 188 [74.3%] medical students) responded;
of these 81 (32.0%) were females. Majority (85.0%) of the
students were not married and 213 (84.2%) did not have any
children. From these 253 students, 72 students (28.5%) were
found to be stressed.
Table 1 shows social demographic factors associated with
stress from which only age (p= 0.003) and year of study
(p<0.001) were significantly associated with stress.
Table 2 shows behavioural factors associated with stress from
which only hours of sleep (p<0.001) and hours of study in a
week (p=0.007) were significantly associated with stress.
Table 4 shows independent factors associated with stress.
Students who were in second year were 2.29 (95% CI [1.21,
4.34]) times more likely to be stressed compared to students
in fifth year. Similarly, third year students were 2.69 (95% CI
[1.44, 5.01]) times more likely to be stressed. Students who
slept four hours or less were 1.58 (95% CI [1.15, 2.17]) times
more likely to be stressed compared to students who slept
more than four hours. Students who felt that the cause of
their stress was due to tests were 80% (AOR= 1.80, 95% CI
[1.19, 2.72]) more likely to be stressed compared to students
who did not indicate as such.
Table 1: Social demographic factors associated with stress
Stress
Factors
Total
n (%)
p-value
Yes
n (%)
No
n (%)
153 (60.5)
60 (23.7)
40 (15.8)
55 (76.4)
8 (11.1)
9 (12.5)
98 (54.1)
52 (28.7)
31 (17.1)
81 (32.0)
172 (68.0)
24 (33.3)
48 (66.7)
57 (31.5)
124 (68.5)
0.777
215 (85.0)
38 (15.0)
64 (88.9)
8 (11.1)
151 (83.4)
30 (16.6)
0.272
213 (84.2)
40 (15.8)
62 (86.1)
10 (13.9)
151 (83.4)
30 (16.6)
0.597
65 (25.7)
188 (74.3)
20 (27.8)
52 (72.2)
45 (24.9)
136 (75.1)
0.632
101 (39.9)
85 (33.6)
20 (7.9)
47 (18.6)
36 (50.0)
32 (44.4)
2 (2.8)
2 (2.8)
65 (35.9)
53 (29.3)
18 (9.9)
45 (24.9)
<0.001
Age
≤ 24
25-29
≥ 30
0.003
Sex
Female
Male
Marital status
Not married
Married
Children
No
Yes
Program
BDS
MBChB
Year of Study
2
3
4
5
AP J Psychological Medicine Vol. 16 (2) July-December 2015
126
Naadira OV, et al: Stress in medical students
Table 2: Behavioural factors associated with stress
Stress
Factors
Drinking Alcohol
Yes
No
Smoking
Yes
No
Drinking caffeinated drinks
Yes
No
Hours of sleep in a day
≤ 4
>4
Hours of study in a week
0-20
21-40
>40
Total
n (%)
Yes
n (%)
No
n (%)
69 (27.3)
184 (72.7)
16 (22.2)
56 (77.8)
53 (29.3)
128 (70.7)
0.255
10 (4.0)
243 (96.0)
0 (0.0)
72 (100.0)
10 (5.5)
171 (94.5)
0.067
173 (68.4)
80 (31.6)
51 (70.8)
21 (29.2)
122 (67.4)
59 (32.6)
0.597
90 (35.6)
163 (64.4)
38 (52.8)
34 (47.2)
52 (28.7)
129 (71.3)
<0.001
103 (40.7)
105 (41.5)
45 (17.8)
19 (26.4)
34 (47.2)
19 (26.4)
84 (46.4)
71 (39.2)
26 (14.4)
p- value
0.007
Table 3 shows other factors associated with stress. Only tests was significantly associated with stress (p=0.004).
Table 3: Other factors associated with stress
Stress
Factors
Course-load
Yes
No
Tests
Yes
No
Exams
Yes
No
Household work
Yes
No
Family
Yes
No
Job (if working)
Yes
No
Total
n (%)
Yes
n (%)
No
n (%)
p-value
220 (87.0)
33 (13.0)
67 (93.1)
5 (6.9)
153 (84.5)
28 (15.5)
0.069
190 (75.1)
63 (24.9)
63 (87.5)
9 (12.5)
127 (70.2)
54 (29.8)
0.004
205 (81.0)
48 (19.0)
61 (84.7)
11 (15.3)
144 (79.6)
37 (20.4)
0.345
30 (11.9)
223 (88.1)
11 (15.3)
61 (84.7)
19 (10.5)
162 (89.5)
0.289
41 (16.2)
212 (83.8)
12 (16.7)
60 (83.3)
29 (16.0)
152 (84.0)
0.900
26 (10.3)
227 (89.7)
8 (11.1)
64 (88.9)
18 (9.9)
163 (90.1)
0.783
DISCUSSION:
This is the first study on stress among medical and dental
students carried out in Zambia. The overall prevalence of
stress among students was found to be 28.5% with no gender
differences. The prevalence of stress in the current study is
lower than what has been reported in other countries. Previous
studies from medical schools in different countries have
reported varying levels of stress. [8,9,10,12,13,14] The overall
AP J Psychological Medicine Vol. 16 (2) July-December 2015
prevalence of stress was 31.2% in 3 British universities, [8]
41.9% in a Malaysian medical school, [9] and 61.4% in a Thai
medical school. [10]The difference in the prevalence of stress
could be due to the different settings of the medical school
and their curricula,[14] the use of different instruments to
measure stress [14]and different times of the academic year
when studies were conducted. Regarding gender difference
in the prevalence of stress, the current study did not find any
Naadira OV, et al: Stress in medical students
Table 4: Independent factors associated with stress
Factor
AOR (95% CI)
Year of study:
2
2.29 (1.21,4.34)
3
2.69 (1.44, 5.01)
4
0.60 (0.19, 1.96)
5
1
Hours of Sleep:
≤ 4
1.58 (1.15,2.17)
>4
1
Test
Yes
1.80 (1.19, 2.72)
No
1
significant difference. This finding is similar to a study carried
out in India.[15]
CONCLUSIONS:
Low prevalence of stress was observed relative to other
settings world-wide among students at the school of medicine
at the Copperbelt University. Since preclinical students had
higher levels of stress, interventions targeting them are
recommended to prevent burnouts. However further studies
such as longitudinal studies should be carried out to determine
the severely stressed students on which interventions may be
instituted considering factors identified in this study.
LIMITATIONS:
A low response rate was attained from clinical students which
might have introduced biasness to the results. Associations
observed did not indicate the causality due to the cross
sectional nature of the study.
ACKNOWLEDGEMENTS: Nil
The present study showed a significant association between
year of study and stress, where preclinical students were found
to be highly associated with stress compared to the clinical
students. This is partly due to their grade competition and
heavy workload. Competition to receive good grades for
freshman and sophomore students is generally focused on
the completion of preclinical laboratory projects in addition
to suc­cessful performance in demanding basic science
courses. [16] There is also competitiveness with fellow
classmates and trying to prove to lecturers that their class is
better than their senior classes.
REFERENCES:
Sleeping was associated with stress in the current study with
students sleeping four hours or less being at a higher risk of
being stressed. The lack of sleep could be due to students
spending more time studying, or the stress itself could be
leading to lack of sleep. Stress can cause anxiety, depression,
phobia, fear, tension, dizziness, fatigue, sleeplessness,
gastrointestinal disturbance, irritability and cynicism. [2]
In the current study, the other factor which is test was
significantly associated with stress. This may be due to the
frequency of tests that could be stressing them. In the second
and third year there are three terms and in each term there are
seven courses. Two tests are written for four courses and four
tests are written for three courses in each term: totalling to
twenty tests in a term. Thus students have to pass through a
lot of tests which they are unable to cope with. Previous
studies have identified the following factors associated with
stress among medical students: excessive homework, unclear
assignments, [5,6] lack of time management skills,
uncomfortable classrooms, weekly tests and assignments, the
pressure to earn good grades, and receiving a lower grade
than expected. [6]
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ravindranath.pdf
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Firth J. Levels and sources of stress in medical students.
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MohdSidik S, Rampal L, Kaneson N. Prevalence of
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Dahlin M, Joneborg N, Runeson B. Stress and
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Bramness JA, Fixdal TC, Vaglum P. Effect of medical
school stress on the mental health of medical students
in early and late clinical curriculum. Act a Psychiastr
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AP J Psychological Medicine Vol. 16 (2) July-December 2015
14. Shah M, Hasan S, Malik S, Sreeramareddy CT.
Perceived stress, sources and severity of stress among
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Conflict of interest: None declared
Source(s) of support: Nil
129
ORIGINAL ARTICLE
A study of phenomenology of delirium in patients with and without neuroimaging changes
Krishna P Mohan1, Sai P Kiran2, Madhavi K3
1
Associate Professor of Psychiatry, 3 Assistant professor of Psychiatry, Department of Psychiatry, Dr.Pinnamaneni Siddhartha
Institute of Medical Sciences, Gannavaram, Andhra Pradesh, India. 2 Senior Resident in Psychiatry, Department of Psychiatry,
Guntur Medical College, Guntur, Andhra Pradesh, India.
ABSTRACT
Background: Etiology of delirium is diverse and multi-factorial and 26% of the etiological factors for delirium are due to
Central nervous system lesions. The findings of major neuroanatomical changes among prolonged delirium patients suggest
the involvement of brain which could be better understood by neuroimaging. Limited data is available regarding neuroimaging
aspects of delirium.
Aims and objectives: To study and compare the phenomenology of delirium among the patients with and without neuroimaging
changes.
Methods: All the patients who are admitted in the Neuro ICU and diagnosed with delirium are included in the study. Confusion
assessment method (CAM) was used for screening altered mental status and the diagnosis of delirium was confirmed by ICD10. MRI (T1, T2, DWI) was done on the diagnosed patients and findings were noted. Patients were divided into two groups.
Fifteen patients identified consecutively with MRI changes were included in the first group and 15 patients identified
consecutively without MRI changes were included in the second group. Phenomenology of delirium is assessed in both the
groups using Delirium severity rating scale –revised 98 (DRS-R-98).
Conclusion: Our study concludes that in patients with Neuro-imaging changes, the phenomenology of delirium differs in
memory and motor activity among cognitive and non cognitive items respectively. Further research is needed for better
understanding of neuro- pathogenesis of delirium
Keywords: Delirium, Neuroimaging, Phenomenology.
Date of first submission: 25/9/15 Date of initial decision: 1/11/15 Date of acceptance: 16/11/15
INTRODUCTION:
Delirium is an acute emergency condition with a prevalence
of 14-24 % among the hospitalized patients. [1] Delirium is
the most frequent presentation in ICU patients which involves
the constellation of symptoms with acute onset and fluctuating
course. [2] The etiology of delirium is diverse and multifactorial and 26% of the etiological factors for delirium are
due to Central nervous system lesions. [3] The Pathophysiology
of delirium is poorly understood. [5] The findings of major
neuroanatomical changes among prolonged delirium patients
suggest the involvement of brain which could be better
Address for correspondence: Dr Krishna Mohan
Parvathaneni, Associate professor of Psychiatry, Department
of psychiatry, Dr.Pinnamaneni Siddhartha Institute of Medical
Sciences, Gannavaram, Andhra Pradesh, India.
Phone number: +919441584349
Email: [email protected]
How to cite this article: Krishna MP, Saikiran P,
Madhavi K. A study of phenomenology of delirium in
patients with and without neuroimaging changes. AP J
Psychol Med 2015; 16(2):129-32
understood by neuroimaging [6]. Delirium has a limited agenda
on teaching programs, research protocols, and therapeutic
strategies. There is a dearth of Indian studies both in
international and national scientific literature. [4]
AIMS AND OBJECTIVES:
To study and compare the phenomenology of delirium among
the patients with and without neuroimaging changes.
MATERIALS AND METHODS:
All the patients who are admitted in the Neuro ICU and
diagnosed with delirium are included in the study. Cases with
known cause of delirium like alcohol withdrawal delirium
and individuals with known cognitive deficits are not included
in the study. Glasgow coma scale was applied to know the
level of consciousness. Confusion assessment method (CAM)
was used for screening altered mental status and the diagnosis
of delirium was confirmed by ICD-10. The procedures and
rationale for the study were explained to patient caregivers,
as it was presumed that most of the patients were not capable
of giving informed written consent. MRI (T1, T2, DWI) was
done on the diagnosed patients and findings were noted.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
130
Krishna PM, et al: Delirium and neuroimaging
Patients were divided into two groups. Fifteen patients
identified consecutively with MRI changes were included in
the first group and fifteen patients identified consecutively
without MRI changes were included in the second group.
Phenomenology of delirium is assessed in both the groups
using Delirium severity rating scale –revised 98 (DRS-R-98).
The DRS–R98 is a 16-item scale with 13 severity items and
3 diagnostic items and it has high inter-rater reliability,
sensitivity and specificity for detecting delirium. It was
validated both as a total scale (16 items) and a severity scale
(13 items) for repeated measures. [7] Each item is rated 0
(absent/normal) to 3 (severe impairment), with descriptions
anchoring each severity level. Severity scale scores range from
0 to 39, with higher scores indicating more severe delirium.
Delirium typically involves scores above 15 points (severity
scale) or 18 points (total scale). Statistical analysis was done
using Epiinfo software 3.5 version and M.S.Excel software’s.
economic group. Regarding the occupation, majority of the
individuals were farmers (n=13).
Regarding the subtype of delirium, all the patients suffered
from hyperactive delirium. Total Severity mean values among
the individuals with and without imaging changes are 16.3
and 18.0 respectively which shows that severity of delirium
is more among the individuals without neuro imaging changes
(Figure 1).
RESULTS:
The current study comprises of two groups namely individuals
with and without neuroimaging changes respectively and each
group comprises fifteen patients. Mean age of all the
individuals is 48.6 years (48.6±13.2). Among the total
individuals (n=30), males constitutes twenty five and females
constitutes five in number which shows that males
outnumbered females. It was observed that seventeen
individuals were literates and thirteen individuals were
illiterates. Most of the individuals belong to low socio
economic group (n=20) rather than middle or high socio
Table 1 : Socio-demographic characteristics of study
population
Parameter
Group 1
Group 2
Sex
Male
12
13
Female
03
02
Education :
Literate
10
07
Illiterate
05
08
Socio economic status:
Low
11
09
Middle
02
03
High
02
03
Marital status :
Married
14
13
Unmarried
01
02
Occupation:
Farmer
07
06
Employed
03
04
Unemployed
02
02
Retired
01
01
House wife
02
02
Group 1 : Individuals with Neuro Imaging changes
Group 2 : Individuals without Neuro Imaging Changes
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Figure 1: Comparison of Total Mean Severity Values among
the two groups
Group 1 : Individuals with Neuro Imaging changes
Group 2 : Individuals without Neuro Imaging Changes
Among non cognitive disturbances, sleep wake cycle
disturbances has got highest severity mean values of 2.5 and
2.6 among individuals with and without neuro imaging
changes respectively. Similarly among cognitive
phenomenology, more severity was found for disorientation
with severity mean value of 1.9 and 1.93 among groups with
and without neuro imaging changes respectively (Table 2
and 3).
DISCUSSION:
Delirium is characterized by a disturbance of consciousness
with accompanying change in cognition. Delirium typically
manifests as a constellation of symptoms with an acute onset
and a fluctuating course. [8] The present study advances the
previous studies in comparing the phenomenology of delirium
among the patients with and without neuro imaging
abnormalities. Demographic details of the individuals reveal
that majority of the individuals are farmers and most of the
population belongs to low socio economic status. This could
be explained by the fact that sample recruited for the current
study is from rural population. Among the individuals with
neuro imaging changes, seven patients have white matter
hyper intensities. Earlier studies on delirium found that , most
Krishna PM, et al: Delirium and neuroimaging
131
Sleep disturbances
2.6 ± 0.53
2.5 ± 0.51
Perceptual
disturbances
1.93 ± 0.59
1.13 ± 0.91
Delusions
1.2 ± 0.77
0.3 ± 0.89
previous studies that noted the relation between atrophy and
delirium. [12] Past results on delirium found that delirium is
due to disruption of frontal networks. [13] In the current study,
one patient had Glioma at frontal region. Regarding the
phenomenology of delirium earlier studies found that sleep
wake cycle disturbances and inattention had high severe mean
values among non cognitive and cognitive disturbances
respectively. In our study it was observed that sleep wake
cycle disturbances and disorientation had high severe mean
values among non cognitive and cognitive disturbances
respectively.
Lability of affect
1.2 ± 0.70
1.06 ± 0.7
CONCLUSIONS:
Language
2.06 ± 0.59
1.73 ± 0.70
Thought process
0.7 ± 0.63
0.7 ± 0.79
Motor agitation
2.2 ± 0.67
1.5 ± 1.2
Motor retardation
0.06 ± 0.25
0.8 ± 1.18
Table 2 : Mean values of Neuro Psychiatric
Behavioural symptoms
Mean value
Mean value
among group 1 among group
Variable
(Mean ±
2 ( Mean ±
Standard
Standard
Deviation)
Deviation)
Group 1 : Individuals with Neuro Imaging changes
Group 2 : Individuals without Neuro Imaging Changes
Table 3 : Mean values of Cognitive symptoms
Our study concludes that Severity of delirium differs among
patients with Neuro-imaging changes when compared to
individuals without neuro imaging changes. On comparing
the phenomenology of delirium among the two groups,
individuals with neuroimaging changes had more severity
among all the parameters of the phenomenology of delirium
except memory and motor activity. These two parameters are
more severe among the individuals without imaging changes.
Further research is needed for better understanding of neuropathogenesis of delirium.
LIMITATIONS:
Current study sample is recruited from the single institute,
therefore results cannot be generalised to the entire population.
Mean values
among group 1
(Mean ±
Standard
Deviation)
Mean values
among
group 2
(Mean ±
Standard
Deviation)
Orientation
1.9 ± 0.6
1.93 ± 1.03
Delirium is influenced by co morbid medical conditions which
affects the course and severity of the phenomenology. To
overcome it we carefully screened for other co-morbid
conditions.
Attention
1.6 ± 0.72
1.53 ± 0.74
Small sample size.
Short term memory
0.2 ± 0.1
0.9 ± 0.7
Long term memory
0.33 ± 0.45
0.6 ± 0.81
Variable
Visuospatial ability
1.06 ± 0.56
ACKNOWLEDGEMENTS: Nil
REFERENCES:
1.
Tamara G. Fong, Samir R. Tulebaev, and Sharon K.
Inouye . Delirium in elderly adults:
diagnosis,
prevention and treatment., Nat Rev Neurol. 2009 April
; 5(4): 210–220. doi:10.1038/nrneurol.2009.24.
2.
Peter E. Spronk , Bea Riekerk ,Jose Hofhuis , Johannes
H. Rommes ., Occurrence of delirium is severely
underestimated in the ICU during daily care .,Intensive
Care Med (2009) 35:1276–1280., DOI 10.1007/
s00134-009-1466-8
3.
Pinto C . Indian research on acute organic brain
syndrome : Delirium . Indian Journal of Psychiatry .
2010 Jan ;52 ( suppl 1 ) : S 139-47 .doi 10.4103 / 0019
-5545.69226
1.2 ± 0.41
Group 1 : Individuals with Neuro Imaging changes
Group 2 : Individuals without Neuro Imaging Changes
of the patients diagnosed with delirium had white matter
hyper intensities and these white matter hyper intensities
predisposes the patient to delirium . [9-10] Three patients in our
study reported to have acute infarcts at right capsulo
ganglionic region on MRI which is in accordance with the
previous studies that the risk of finding a focal lesion on
neuroimaging of delirious patients was seven percent. [11] Our
study observed three patients with cerebral atrophy and one
patient with sub cortical atrophy which is in accordance with
AP J Psychological Medicine Vol. 16 (2) July-December 2015
132
Krishna PM, et al: Delirium and neuroimaging
4.
David j. Meagher et al., Phenomenology of delirium :
Assessment of 100 adult cases using standardized
measures., British journal of psychiatry doi : 10.1192 /
bjp . bp .106 . 023911.
5.
Jun Gwon Choi ., Delirium in the intensive care unit .,
Korean J Anesthesiol 2013 September 65(3): 195-202
.http://dx.doi.org/10.4097/kjae.2013.65.3.195
6.
7.
8.
Max L. Gunther, MS etal., Pathophysiology of Delirium
in the Intensive Care Unit., Crit Care Clin 24 (2008)
45–65.
Paula T. Trzepacz, M.D. etal.,Validation of the Delirium
Rating Scale-Revised-98:Comparison With the
Delirium Rating Scale and the Cognitive Test for
Delirium J Neuropsychiatry Clin Neurosci 13:2, 2001.,
Cavallazzi et al., Delirium in the ICU: an overview .,
Annals of Intensive Care 2012, 2:49
AP J Psychological Medicine Vol. 16 (2) July-December 2015
9.
Alessandro Morandi, MD etal., Neuroimaging in
delirious intensive care unit patients: A Preliminary Case
Series Report Psychiatry (Edgemont) 2010;7(9):28–33
10. Hatano Y etal., White-Matter Hyper intensities Predict
Delirium After Cardiac Surgery.,
Am J Geriatr
Psychiatry. 2012 Sep 21.
11.
Hufschmidt A, Shabarin V. Diagnostic yield of cerebral
imaging in patients with acute confusion . Acta Neurol.
Scand. 2008; 118:245–250. [PubMed: 18336626].
12. Roy L. Soizaa etal., Neuroimaging studies of delirium:
A systematic review., Journal of Psychosomatic
Research 65 (2008) 239–248.
13. Simon Fleminger , Remembering delirium., British
journal of Psychiatry .,2002.,180,4-5
Conflict of interest: None declared
Source(s) of support: Nil
133
ORIGINAL ARTICLE
Evaluation of factors associated with high risk behaviour with alcohol dependence syndrome – A hospital based
observational study
Suresh K Kumar1, Srikanth Lella2, Pavan V T Kumar3, Phani D Bhushan4.
1
Professor of Psychiatry, 3Associate professor of Psychiatry, Department of Psychiatry, NRI Medical College, Chinakakani,
Andhra Pradesh, 2Senior resident in psychiatry, Department of psychiatry, Siddhartha Medical College, Vijayawada,
Andhra Pradesh 4Professor and Head of the department, Department of Psychiatry, NRI Medical College,
Chinakakani, Andhra Pradesh, India.
ABSTRACT
Background: Alcohol is the world’s third largest risk factor for disease and disability. The mortality and morbidity associated
with alcoholism is compounded by the concept of risk taking. Heavy alcohol use is associated with varieties of high risk
behavior such as motor vehicle accidents, high risk sexual behavior, criminal acts and self injurious behavior.
Aims and objectives: To evaluate the association between severity of alcohol dependence and high risk taking behavior,
sociodemographic factors and personality variables in male patients with alcohol dependence syndrome attending a tertiary
care hospital in south India.
Methods: The study is an observational study conducted in the department of psychiatry in a tertiary care teaching hospital.
The severity of alcohol dependence was assessed using Severity of Alcohol Dependence Questionnaire and relationship of
high- risk behavior to alcohol use was determined by asking about that ‘critical incident’ to define the role of alcohol during
the incident.
Results: A total of 50 subjects were included in the final analysis out of which 28(56%) belonged to 20 to 40 years and the
remaining 22 (44%) belonged to 41 to 60 year age group. The high risk behavior was 66% (95% CI 51.2% to 78.8%) in the
study population. The association between severity of alcohol dependence and high risk behavior, the association between
sensation seeking score, impulsivity score and high risk behavior was statistically significant (p-value<0.001).
Conclusions: The proportion of high risk behavior is very high among alcoholics. Involvement in road traffic injuries, high
risk sexual practices, indulging in intentional self-harm and involving in conflict and violence were the common high risk
behaviors. There is Positive association between high sensation seeking scores and high risk behaviors among alcoholics.
Keywords: Alcohol Dependence Syndrome (ADS), High Risk Behavior, Road Traffic Accidents (RTA)
Date of first submission: 9/11/15 Date of initial decision: 1/12/15 Date of acceptance: 16/12/15
INTRODUCTION:
Alcohol is the world’s third largest risk factor for disease and
disability. Alcohol Dependence was defined as a maladaptive
pattern of drinking, leading to clinically significant
impairment or distress, as manifested by three or more of the
following occurring at any time in the same12-month period
Address for correspondence: Dr Kota Suresh Kumar,
Professor of Psychiatry, Department of psychiatry, NRI
Medical College, Chinakakani, Guntur, Andhra Pradesh,
India.
Phone number: +91-9848303169
Email: [email protected]
How to cite this article: Suresh KK, Srikanth L, Venkata
PKT, Phanibhushan D. Evaluation of factors associated
with high risk behaviour with alcohol dependence
syndrome – A hospital based observational study. AP J
Psychol Med 2015; 16(2):133-7
as per Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV).[1]
Alcohol dependency syndrome affects a wide spectrum of
patients that include all age groups and ethnicities. Four
percent of all deaths and 4.6 % of disability-adjusted lifeyears are attributed to alcohol. The Alcohol Use Disorders
Identification Test (AUDIT) is considered the most accurate
alcohol screening tool for identifying potential alcohol misuse,
including dependence. [2] The mortality and morbidity
associated with alcoholism is compounded by the concept of
“risk taking”.[3] Heavy alcohol use is associated with varieties
of high risk behaviour such as high risk sexual behaviour,
violent and criminal acts, self-injurious behaviour and fatal
injury including motor vehicle accidents.[4-8]
AIMS AND OBJECTIVES:
To evaluate the association between severity of alcohol
dependence and high risk taking behaviour, sociodemographic
AP J Psychological Medicine Vol. 16 (2) July-December 2015
134
Suresh KK, et al: High risk behaviour in alcohol dependence
factors and personality variables in male patients with alcohol
dependence syndrome attending a tertiary care hospital in
south India.

Sensation seeking was assessed by using Indian
adaptation of Sensation seeking scale, Form V.[12]

Impulsivity was assessed by Barratt’s Impulsiveness
Scale, Version 11.[13]

Mini Mental State Examination (MMSE)was used in
the present study to rule out cognitive impairment.[14]
MATERIALS AND METHODS:
Study design: The study is an observational study
Study setting: This study was conducted in Department of
Psychiatry in NRI Medical College & General Hospital,
Guntur, and Andhra Pradesh.
Study period: The data collection for the study was done
between January 2011 to June 2012 for a period of 18 months.
Sample size & sampling method: A total of 50 male patients
admitted in the study setting with a diagnosis of alcohol
dependence syndrome, who satisfied the inclusion and
exclusion criteria were included in the study consecutively,
hence no sampling was done
Inclusion Criteria: Males, aged between 21and 60 years,
who were diagnosed as Alcohol Dependence Syndrome
(ADS) by DSM-IV TR criteria by the American Psychiatric
Association. [1]
Exclusion Criteria: Patients, who were diagnosed with other
co-morbid Axis-I psychiatric condition, patients with clinical
evidence of organicity, persons with other substance use
except tobacco and persons with cognitive impairment were
excluded from the study.
Study tools: Severity of alcohol dependence was assessed
using Severity of Alcohol Dependence Questionnaire (SADQC).[9]
High risk behavior was defined as a behavior likely to result
in “likely to result in failure, harm, or injury”.[10] It was
assessed by Event- analysis method,[3] asking the participant,
whether he/she has indulged in any of the following high risk
behavioral events in last one month.The high risk behaviors
included a) Road traffic accidents, b) Crime and violence, c)
Self injurious behavior (defined as commission of deliberate
injury to one’s own body done without the aid of the other
person and is severe enough to cause tissue damage/
scarring)[11] and d) High risk sexual behavior. The relationship
of high- risk behavior to alcohol use was determined by asking
about, whether the participant was under the influence of
alcohol, while indulging in high risk behavior.
The questions included

Whether alcohol was consumed during or immediately
prior to the incident,

The quantity and the frequency of drinking,

Consequences of the risk behaviors.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Ethical considerations: Informed written consent was
obtained from all the study participants, after explaining the
risks and benefits involved in the study and voluntary nature
of their participation. Confidentiality of the study participants
was maintained throughout the study.
Study procedure: MMSE was done to rule out any cognitive
impairment. Patients who were deemed to be out of
withdrawal state and not having any cognitive impairment
were then assessed using the following standard operating
protocol.
After obtaining informed written consent from the participant,
they were interviewed to establish the diagnosis of Alcohol
Dependence Syndrome (ADS) based on DSM-IV TR
diagnostic criteria. Special proforma was used for collecting
the socio - demographic profile. Patients were interviewed
using the above mentioned study tools to measure the severity
of drinking, high risk behavior and personality traits.
Statistical methods:
Descriptive analysis of demographic, severity of alcohol
dependence and behavioral factors was done. Presence of high
risk behavior was considered as the primary outcome variable.
Categorical variables will be presented as frequencies and
percentages. Quantitative variables will be presented as mean
and standard deviation. The association between the
explanatory variables and the high risk behavior was assessed
by cross tabulation and comparing the percentage differences.
Chi square test was used to test the statistical association of
these differences. P value less than 0.05 was considered
statistically significant. IBM SPSS version 21 was used for
statistical analysis.
RESULTS:
A total of 50 subjects were included in the final analysis out
of which 28(56%) belonged to 20 to 40 years and the
remaining 22 (44%) belonged to 41 to 60 year age group.
The number of subjects hailing from rural area was 30 (60%).
Majority of the study subjects were married (80%). Majority
(60%) participants belonged to nuclear families. The number
of subjects from joint families and living single were 15(30%)
and 5 (10%) respectively. The educational status of majority
of the subjects was either primary or secondary schooling
(60%), followed by illiteracy (22%). Very few participants
135
Suresh KK, et al: High risk behaviour in alcohol dependence
completed graduation and beyond (18%). Farmers (32%),
unskilled labor (22%) and small scale businessmen (22%)
were the most common occupation groups in the study.
(Table 1)
Table 1: Socio-demographic profile of study population
Number
Sociodemograph
Percenof
ic parameter
tage
subjects
20-40 years
28
56%
Age group
41-60 years
22
44%
Area of
Rural
30
60%
residence
Urban
20
40%
Marital status
Married
40
80%
Single
04
08%
Separated
04
08%
Divorced
02
04%
Type of family
Nuclear
30
60%
Joint
15
30%
Alone
05
10%
Educational
Illiterate
11
22%
Status
Upto secondary
30
60%
Graduate
07
14%
Post graduate
02
04%
Occupation
Farmer
16
32%
Daily unskilled
11
22%
worker
Business
11
22%
Service
10
20%
Professional
02
04%
The reported incidence of high risk behavior was 66% (95%
CI 51.2% to 78.8%) in the study population. The most
common type of high risk behavior was Road traffic injury
seen in 34% (21.2% to 48.8%), followedby high risk sexual
behavior seen in 16% (7.2% to 29.1%) and Self injurious
behavior, seen in 10% (3.3% to 231.8%) participants. Three
(6%, 1.3% to 16.5%) participants reported that they were
involved in crime and violence. (Table 2)
Table 2: Presence and type of high risk behavior in study
Parameter
Freq- Perce
95% CI
uenc n-tage Lowe Higher
y
33
66%
51.2
78.8%
I. High risk
II. Type of high risk behavior
Road traffic injury
17
34%
21.2
48.8%
High risk sexual
08
16%
7.2%
29.1%
Self injurious
05
10%
3.3%
21.8%
behavior
Crime and
violence
03
6%
1.3%
16.5%
People in younger age group, living in urban locality, who
were not married, people who were hailing from nuclear
family and people with higher educational and professional
status had higher incidence of high risk behavior compared
to their counterparts. But there was no statistical significance
in association between any of these factors and high risk
behavior at a p-value of 0.05. (Table 3)
Table 3. Association between socio-demographic factors and high
risk behaviour in study population
High risk
Chibehaviour
square p-value
Parameter
value
Present Absent
Age group
20-40 years
21
07
2.297
0.129
41-60 years
12
10
Area of residence
Rural
17
13
1.85
0.174
Urban
16
04
Marital status
Married
27
13
0.02
0.87
Others
07
03
(Single/divorce/separated)
Type of family
Nuclear
11
19
0.535
0.765
Joint
04
11
Alone
02
03
Educational status
Illiterate
04
07
0.679
0.712
Upto secondary
09
21
Graduate and above
04
05
Occupation
Farmer
06
10
0.845
0.839
Business
03
08
Unskilled worker
03
08
Professional and service
05
07
People with higher digress of alcohol dependence had higher
incidence of high risk behavior. None of the participants with
severity score of 15-25 had high risk behavior. The proportion
was 69% and 100% in people with severity scores of 26 to
35 and 36 to 45 respectively. The association between severity
of alcohol dependence and high risk behavior was statistically
significant. (P-value<0.001)
Table 4. Association between severity of alcohol dependence
and high risk behavior in study population
Severity of
alcohol
dependence
15-25
26-35
36-45
High risk behaviour
Present
00
09
24
Absent
13
04
00
Chi-square
value
(Fisher’s
exact test)
37.7
p-value
<0.001
People with higher sensation seeking score and impulsivity
score had higher incidence of high risk behavior. Only 22.8%
of participants with sensation seeking score of 5-15 had high
risk behavior, where as this proportion was 100% in people
with sensation seeking score of 16 - 25. The proportion was
high risk behavior reported was only 7.2% in people with
impulsivity score of 55-65. This proportion has increased to
85.8% and 100% in people with impulsivity score of 66-75
and 76-85 respectively. The association between sensation
seeking score, impulsivity score and high risk behavior was
statistically significant (p-value<0.001).
AP J Psychological Medicine Vol. 16 (2) July-December 2015
136
Suresh KK, et al: High risk behaviour in alcohol dependence
Table5. Association between personality and high risk
behavior
in study population.
study population
Personality
scores
Sensation
seeking score
05 – 15
16 – 25
Impulsivity
score
55 – 65
66 – 75
76 – 85
High risk behaviour
Chi-square
value (Fisher’s
exact test)
p-value
Present
Absent
05
28
17
00
32.80
<0.001
01
24
08
13
04
00
30.58
<0.001
DISCUSSION:
Many studies in the past have documented the strong
association between heavy alcohol use varieties of high risk
behaviors, such as high risk sexual behavior,[15-18] violent and
criminal acts, self-injurious behavior [19-20] and fatal injury
including motor vehicle accidents. [4-8,19-25]
The current study has reported incidence of high risk behavior
was 66% (95% CI 51.2% to 78.8%). Like the current study
in the study of Barens et al [26] among the risk individuals
61.9% had alcohol use were associated high risk
comorbidities, 61.0% had high risk medication use and 64.3%
had high risk alcohol behaviors. People with higher digress
of alcohol dependence had higher incidence of high risk
behavior. None of the participants with severity score of 1525 had high risk behavior. The proportion was 69% and 100%
in people with severity scores of 26 to 35 and 36 to 45
respectively. Findings from the study by Mattoo et al [27] have
substantiated the current study findings. The authors have
documented high sensation seeking scores, higher proportion
of indulging in high risk behaviors with increasing severity
of alcohol use.
The most common type of high risk behavior was road traffic
injury seen in 34% (21.2% to 48.8%).studies by Myers, R.
A., et al. [23] Bradbury, A. et al [22], and Schmucker, U. et al [24]
in their studies have emphasized that alcohol plays a strong
role in causation of road traffic injuries. “Alcohol-related road
traffic injury and Global Burden of Disease” study also
emphasized that the road users under the influence of alcohol
not only puts themselves, but the other vulnerable road users
like pedestrians under high risk of RTI. [28]
High risk sexual behavior was reported by 16% of the study
participants. Studies by Chandra, P. S., et al.[15] Mbonye, M.,
et al[16] and Nash, S. D., et al [17] have documented unusual
sexual expectations and high proportion of high risk sexual
behavior among alcoholics. These studies have expressed a
deep concern over the enhanced risk of HIV and other STDs
among these subjects.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Self-injurious behavior was seen in 10% of participants.
Studies by Al-Sharqi, A. M., et al. [19] and Berman, M. E., et
al [20] have reported both acute and chronic alcohol use as a
strong risk factor for intentional self-harm, including suicides.
Three (6%) participants reported that they were involved in
crime and violence. Studies conducted by Barrens et al[26]
and Faller et al [29] were in strong agreement with the current
study. In their study, Faller et al [29] have reported 7.8% of
alcohol users to have antisocial personality.
As per the current study People with higher sensation seeking
score and impulsivity score had higher incidence of high risk
behavior, which were substantiated by studies from Chandra,
P. S., et al. [15] Mattoo, S. K., et al.[27]
CONCLUSIONS:
The proportion of high risk behavior is very high among
alcoholics
Involvement in road traffic injuries, high risk sexual practices,
indulging in intentional self-harm and involving in conflict
and violence were the common high risk behaviors
There is Positive association between high sensation seeking
scores and high risk behaviors among alcoholics.
ACKNOWLEDGEMENTS: Nil
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Conflict of interest: None declared
Source(s) of support: Nil
AP J Psychological Medicine Vol. 16 (2) July-December 2015
138
ORIGINAL ARTICLE
Evaluation of relation of personality, parenting, stress and depression in patients with secondary amenorrhoea.
Jayasankara K Reddy1, Chandril C Ghosh2,
1
Associate professor of Psychology, 2Postgrauate in psychology, Department of Psychology, Christ University, Bangalore,
Karnataka, India.
ABSTRACT
Background: Relatively few studies have assessed psychosocial correlates for secondary amenorrhea. Our study of the
Gynaecological condition concerning personality factor (on introversion-extroversion dimension), parenting (authoritarian
and authoritative) style, depression and perceived stress addresses this gap in the literature. The study inquires, whether
these variables are related.
Aims and objectives: To evaluate the relation of personality, parenting, stress and depression in patients with secondary
amenorrhoea.
Methods: Evaluation was done for forty-four young-adult female patients (with their fathers alive) affected by secondary
amenorrhea, requesting help for menstrual disorders. The Parental Authority Questionnaire administered on the parent of
patients, and Beck Depression Inventory, Perceived stress scale, Kundu Introversion-Extraversion Inventory on patients. In
addition to that sixty healthy participants were recruited. The 104 participants were divided into two groups according to
the presence (44 cases) or the absence (60 cases) of clinically diagnosed secondary amenorrhea.
Results: Appropriate use of correlation coefficient followed by a test of significance revealed significant correlations
between the variables which were hypothesised in accordance and hadbeen discussedregarding future research.
Conclusions: Secondary amenorrhea was found to be possibly associated with personality factors, stress, depression and
the kind of parenting individuals receive during their lifetime.
Keywords: Secondary amenorrhea, personality, depression, stress, parenting style
Date of first submission: 9/10/15 Date of initial decision: 1/11/15 Date of acceptance: 16/12/15
INTRODUCTION:
The present study aimed to determine the effect of
psychosocial correlates towards increasing the risk for
developing secondary amenorrhea. The intuition behind the
notion came from the possibility that psychogenic amenorrhea
is a consequence of the interaction of intra-psychic
susceptibility, external stress, and neuroendocrine disorders.[1]
On this line a study has found that a loss of self-esteem may
accompany the loss of menses among marathon runners.[2]
Since the role of parents’ behaviour on child development [3]
has been held so important by researchers, it might influence
Address for correspondence: Dr K Jayasankara Reddy,
Associate professor of Psychology, Department of
psychology, Christ university, Hosure road, Bangalore,
Karnataka, India.
Phone number: +91-9845120091
Email: [email protected]
How to cite this article: Jayasankara KR, Chandril CG.
Evaluation of relation of personality, parenting, stress and
depression in patients with secondary amenorrhoea. AP
J Psychol Med 2015; 16(2):138-45
AP J Psychological Medicine Vol. 16 (2) July-December 2015
the child’s health in future, thus forming one of the important
issues of investigation in this study. Watson [4] emphasised
parental control of the child’s behaviour while Freud [5]
emphasised parental nurturance of the child. Distinguishing
among Authoritarian, Authoritative, and Permissive parenting
styles, Baumrind [6] had arguably the most significant impact
to date on parenting theory. Baumrind’s parenting styles
differed in some attributes. Authoritative parents were
described as displaying high levels of parental control,
maturity demands, parent-child communications, and
nurturance with their children. The characteristics of
Permissive parents may be described as showing high rates
of communication and nurturance but low levels of maturity
demands and parental control. Finally, Authoritarian parents
were described as high in maturity demands and parental
control, while displaying low amounts of communication and
nurturance. Children resulting from this last type of parenting
may have the less social competence and are not very happy
and may suffer from depression and self-blame. [7] These could
give rise to higher perceived stress and encourage the
development of an introverted personality characteristicsanother issue of our investigation. The changes in brain
Jayasankara KR, et al: Psychosocial factors in secondary amenorrhoea
structure and chemical activity caused by child maltreatment
can have a broad range of effects on children’s behavioural,
communal, and expressive functioning. The persistent fear
response, hyperarousal, increased internalizing symptoms [8],
diminished executive functioning [9], delayed developmental
milestones. [10]
Toxic stress, resulting from child maltreatment, can have a
variety of adverse effects on children’s brains. Studies have
revealed that adults who were mistreated may have reduced
volume in the hippocampus, which is central to learning and
memory.[11-12]Toxic Stress can also reduce the hippocampus’s
capacity to bring cortisol levels back to normal after a stressful
event has occurred [13]. It can also have its effect on Corpus
callosum [11-12], cerebellum [11], prefrontal cortex [14], amygdala
[8, 13]
, cortisol levels. [14-15]
On the other hand, the tendency to be easily overwhelmed by
too much stimulation from social gatherings and engagement
may make experiences perceived as more stressful, and hence
has been investigated in this study. The hypothalamic–
pituitary–adrenal (HPA) axis, when activated by strain, wields
an inhibitory effect on the female reproductive system [16] and
hence stress could be related to amenorrhea. Depression [17]
is another associated condition with this Gynaecological
condition and were hence cross-checked on the present sample
under study. The relation between Personality factors and
health as was previously observed in a Japanese study which
stated neuroticism and extraversion scales as being associated
with health behaviours and BMI, this gave rise to the intuition
that extraversion may be related to the gynaecological issue
under consideration of this study.
Secondary amenorrhoea (menstruation cycles ceasing) is often
caused by hormonal disturbances from the hypothalamus and
the pituitary gland, from premature menopause or intrauterine
scar formation. It is defined as the absence of menses for
three months in a woman with previously normal menstruation
or nine months for women with a history of oligomenorrhoea.
[18]
The condition can be caused by inadequate eating and
excessive exercise, or it can be drug-induced. It can also have
lactational and physical reasons, and this usually happens to
women aged 40–55 and adolescent athletes. [19]Amenorrhea
may cause severe pain in the back near the pelvis and spine.
Personality, on the other hand, refers to “individual disparity
in a characteristic pattern of thinking, feeling and behaving”
as adapted from the Encyclopaedia of Psychology [20].
“Personality traits” likewise can be described as “enduring
personal characteristics that are revealed in a particular pattern
of behaviour in a variety of situations.” [21-22]and personality
differences have quite a lot of real life consequences.[21-22]
The trait of extroversion–introversion is a fundamental
dimension of human personality theories and was popularised
139
by Jung.[23]Although specific personality characteristics differ
among individuals, extroverts typically prefer to be in social
situations where they are busy and able to interact with others
rather than spending time alone. When interacting with other
people, extroverts seem more confident than those who are
introvert. Those who are extrovert, typically hanker after being
known by others, while those who are introvert do not view
recognition as significant. [24] An extroverted individual spends
more time each day interacting with people in social situations
as compared to an introverted person.[25]. Introverts are more
inclined towards keeping their feelings to themselves and
dealing with issues alone, although they are quite sympathetic
to the feelings of other people. Social relations for introverts,
begin with less fervour, than social relations developed with
more gregarious individuals. Introverts may give away the
impression that they do not seek interest in other persons [25],
nevertheless, it is worth noting that even though Introverts
prefer solitude to social activities, they are not necessarily
afraid of social encounters, unlike shy people.
Likewise, depression is “a persistent state of dispirited mood
and a distaste for activity that can affect a person’s thoughts,
behaviour, feelings and sense of well-being.”[26,27] People with
depressed mood can feel sad, anxious, empty, hopeless,
helpless, worthless, guilty, bad-tempered, mortified or restless.
They may feel disinterested in activities that were once
pleasurable, experience loss of appetite or overeating, have
trouble in concentrating, remembering details or making
decisions, and may contemplate, attempt or even commit
suicide. Insomnia, excessive sleeping, fatigue, aches, pains,
digestive disorders or reduced energy may also be present.
[28]
Similarly, stress is described as an experience of unrelenting
strain and pressure in psychology. Small amounts of stress
are healthy and positive, even desired, but extreme levels of
stress, however, could be very detrimental to health. External
environmental factors may be stressful [29], but stress may also
be synthesised by internal perceptions that may generate
negative emotions encircling a situation which they then
perceive stressful. Humans experience stress when they feel
the demands kept on them surpass their capacity to deal with;
and hence, they perceive stress.
It was predicted that there may be a relationship between
parenting style and the development of introverted personality.
We predict introversion (low extraversion) and the
Authoritarian parenting style to positively and significantly
correlate, such that greater the restrictive, punishment heavy
and unresponsive nature of parenting, more likely the
development of introverted characteristics in the resultant
child. It was also predicted that personality factor (on
introversion-extraversion dimension) is related to secondary
AP J Psychological Medicine Vol. 16 (2) July-December 2015
140
Jayasankara KR, et al: Psychosocial factors in secondary amenorrhoea
amenorrhea. Such that introverted personality is associated
with higher risk of developing the gynaecological problem.
Additionally, it was predicted that there would be a positive
and significant correlation between depression and perceived
stress with secondary amenorrhea.
any physical disorders (other than secondary amenorrhea),
deformities, those on medications (particularly contraceptive
drugs), low body weight or on excessive exercise were
excluded from the sample under study. Similarly, pregnant
and lactating mothers were not taken into consideration.
The previous research has mostly focused on the physiological
correlates of the gynaecological condition (secondary
amenorrhea). Relatively, few studies were made to assess
correlates for psychosocial factors concerning parenting and
personality factors, psychometrically. Our study of the role
of parenting style and personality factor on the development
of secondary amenorrhea tries to take our understanding
further on this issue.
After the study was explained in details, participants
completed the following inventories:
AIMS AND OBJECTIVES:
To study the role of psychosocial factors behind secondary
amenorrhea.
MATERIALS AND METHODS:
Participants were recruited from a middle socioeconomic
background and a minimum qualification of class ten with
knowledge of English language from Kolkata. Age categorised
participants into young adults (ages 18-35 years; n = 104),
middle-aged adults (ages 36-55 years), and older adults (aged
55 years or older than that). The participants belonging to the
young adult age group with their age ranging from 18 years
to 35 years old (average 42 years) were chosen for the study.
The participants were then grouped into two groups, one who
were suffering from secondary amenorrhea (without enough
organic clinical findings, as per the report of gynaecologist
in-charge) and those who were without any health-related
complaints (healthy group). The diagnosis for the secondary
amenorrhea was made by the gynaecologist in charge of
fertility clinic using standardised means. The sample of
participants chosen was currently not on any drugs and without
any history of the severe disease. Purposive sampling
collected one hundred four data from three private fertility
clinics with ethical permission and consent letters. Data of
younger children and middle -aged /older adults were not
taken into consideration becausewithin this age-range a
woman’s fertility remains at its peak relatively consistently.
The study shows that a woman’s fertility remains at its peaks
in the early and mid-20s, after which it starts to decline slowly,
with a more dramatic drop at around 35.[48] Below and above
this range, fertility seems to be inconsistent and reduced
chances of pregnancy, thus making secondary amenorrhoea
(menstruation cycles ceasing) relatively insignificant for these
groups. Moreover, age may alter factors associated with the
onset and maintenance of depression. [30] Additionally, a crosssectional study with the Big Five personality traits showed
Extraversion was negatively related to age.[31]Participants With
AP J Psychological Medicine Vol. 16 (2) July-December 2015
1. The Beck Depression Inventory–II [32] (BDI-II) is a 21question multiple-choice, self-report inventory, one of the
most widely used instruments for measuring the severity of
depression. It was designed for individuals aged 13 and over,
and is composed of items relating to symptoms of depression
such as hopelessness and irritability, cognitions such as guilt
or feelings of being punished, as well as physical symptoms
such as fatigue, weight loss, and lack of interest in sex [33].
BDI-II is positively correlated with the Hamilton Depression
Rating Scale with a Pearson r of 0.71, showing good
agreement. The test was also shown to have a high one-week
test–retest reliability (Pearson r =0.93), suggesting that it was
not overly sensitive to daily variations in mood [32]. The test
also has high internal consistency, á=.91[34].
2. Kundu Introversion-Extraversion Inventory (K.I.E.I) [35]
consists of 70 items with an uneven number of response
choices divided into five blocks. Block A consisted of items
like “Which one of the following four types of Cinema do
you like to enjoy most?, while block B had items like “
Always thinking about yourself.” Block C, D and E, on
the other hand, had items like “Do you prefer indoor games
to outdoor game?”, “Feeling difficult to start conversation
with stranger” and “Are you always conscientious in your
activities.” respectively. Block reliabilities, as well as total
test reliability, have been determined by split half method
applying the Spearman-Brown formula. In addition to that,
reliability has also been computed by Cronbach’s alpha is
calculated taking each block as a separate subtest. The
reliability coefficient (1st half vs. 2nd half) of the whole test is
0.82. [35] KIEI is validated against Introversion-Extraversion
score of Eysenck Personality Inventory (EPI). The present
study was conducted in Indian-context, and hence, this
inventory was chosen as a measure of the introversionextraversion dimension of adult behaviour in this study
because it was developed according to Indian Sociocultural
pattern. Non-Aggressive types of items were included to
minimise faking effect and to reduce the nature and number
of slanted responsesbeen included in the inventory.
3. Perceived stress scale [36]: It was used to assess the
degree to which situations in life are perceived as stressful.
[35, 36]
It measures the degree to which situation’s in one’s life
over the past month are appraised as stressful. Items were
141
Jayasankara KR, et al: Psychosocial factors in secondary amenorrhoea
designed to detect how unpredictable, uncontrollable and
overloaded respondents find their lives. It has general queries
about relatively current levels of stress experienced. Since
the questions are of a general natural and are not directed at
any particular sub-population group, using this abbreviated
version with a diverse population is predicted to yield equally
reliable results.
The PSS-10 items were introduced with “In the last month,
how often have you felt . . . ,” which was followed by such
items as nervous and stressed, that difficulties were piling up
so high that you could not overcome them, and that you could
not cope with all the things that you had to. Participants
responded on a 5-point scale ranging from 0 (never) to 4 (very
often). Of the ten items, four items were worded in a positive
direction, so they were reverse-scored. The responses to the
ten items were then summed to create a psychological stress
score, with higher scores indicating greater psychological
stress. Internal reliabilities (Cronbach’s as) for the PSS-10
were .78 in the Harris Poll sample, and .91 in both the 2006
and 2009 eNation samples.
4. The father of each participant was made to complete
the Parental authority questionnaire.[37] Parental Authority
Questionnaire (PAQ)-2is a questionnaire that was developed
for the purpose of measuring Baumrind’s [6] permissive,
authoritarian, and authoritative parental authority prototypes.
It consists of 30 items per parent and yields permissive,
authoritarian, and authoritative scores for both the mother
and the father; each of these scores is derived from the
phenomenological appraisals of the parents’ authority by their
son or daughter. The testing sessions over the two-week period
yielded the following Test-retest reliabilities (N = 61, mean
age = 19.2 years): r = .81 for mother’s permissiveness, r =
.86 for mother’s authoritarianism, r = .78 for mother’s
authoritativeness, r = .77 for father’s permissiveness, r = .85
for father’s authoritarianism, and r = .92 for father ’s
authoritativeness. These reliability coefficients are highly
respectable given the fact that there are only ten items per
scale.
The following Cronbach [38] coefficient alpha values of internal
consistency reliability were obtained for each of the six PAQ
scales: .75 for mother’s permissiveness, .85 for mother’s
authoritarianism, .82 for mother’s authoritativeness, .74 for
father’s permissiveness, .87 for father’s authoritarianism, and
.85 for father’s authoritativeness. Overall, seven studies were
conducted to test the PAQ’s reliability, internal consistency,
content-related validity, criterion-related validity,
discriminant-related validity, and its correlations with the
Marlowe-Crowne Social Desirability Scale. The results of
these studies showed the PAQ to have highly respectable
measures of reliability and validity.
The participants were asked to record their response on BDI–
II, K.I.E.I, and PSS inventories.
The participant’s father filled the PAQ inventory. Priority was
given to the father because according to research conducted
by Nielsen [39], “fathers have as much or more influence than
mothers on many aspects of their daughters’ lives. After
scoring the inventory, the parenting styles were ranked
according to the preference and the most preferred parenting
style was taken into account and the participants were grouped
accordingly.
Data gathered on the Indian sample revealed 26.41% were
subjected to Authoritative (responsive) parenting while a
majority (69.81%) were from the families with Authoritarian
(unresponsive) parenting, and only two (3.77%) reported
permissive parenting. Thus, the most preferred parenting style
is autocratic followed by democratic and negligibly
permissive style, this was what was expected from the sample
of Asian participants. [40] Since the proportion of participants
experiencing permissive parenting style is negligible in the
sample under study, it was not taken into consideration during
the subsequent analysis. Both democratic and autocratic
parenting style according to Maccoby and Martin [41] are
demanding but differ in their responsiveness. Authoritarian
parenting consists of unresponsive parenting style while
responsive parenting characterises democratic parenting.
The collected data were then assessed for each participant.
Statistical analyses were carried out by using suitable
correlation-the significance of which was then evaluated by
t-test. The following calculations were two-tailed.
RESULTS:
TABLE: 1:Correlations
gynaecological problem
Parenting style
Authoritative (n=26 )
Authoritarian (n=78 )
Note: *p<.05. n=104
between
Parenting
Secondary
Amenorrhoea
Present
6
38
style
and
phi
Χ2
-0.22
5.25*
Table 1 presents correlations between parenting style and the
gynaecological problem (secondary amenorrhea) and shows
that there is a significant relation between the variables. The
phi coefficient correlation was computed. Subsequently, chisquare was done to test the significance of the difference of
correlations computed. The fourfold contingency table
presented in Table 1 indicated that the phi coefficient is -0.22
and chi-square=5.25 with df as 1. It shows that the computed
Chi-square was higher than the critical × 2.05 (1); so, the
calculated PHI is significantly below the 0.05 level. Thus, a
AP J Psychological Medicine Vol. 16 (2) July-December 2015
142
Jayasankara KR, et al: Psychosocial factors in secondary amenorrhoea
low-to-moderate but significant negative correlation between
secondary amenorrhea and parenting style. Lesser the
parenting responsiveness, more the tendency to develop
secondary amenorrhea.
but significant positive correlation between perceived stress
and the Gynaecological condition was observed. Higher levels
of perceived stress were associated with greater tendency to
develop secondary amenorrhea.
Table: 2: Correlation between personality (on introversionextraversion dimension) and parenting style
Personality
N
Mean
rpb
Df
t-value
Authoritative
26
127.46
-0.23
102
-2.41*
Authoritarian
78
165.3
Note: *p<.05.
N=104
Table: 5: Correlation between depression and gynaecological
problem.
Secondary
N
Mean
rpb
Df
t-value
amenorrhoea
Present
44
20.18 +0.28 102
+2.91*
Absent
60
14.67
Note: *p<.01.
N=104
Table 2 provides information regarding correlation between
personalities (on introversion-extraversion dimension) and
parenting style. Point biserial correlation between the
variables indicated that rpb= -0.23, t= -2.41 with df=102. It
shows that the computed t-value was higher than the critical
×2.05 (102); so, the computed rpb is significantly below the 0.05
level. Thus, a low-to-moderate but significant negative
correlation between personality and the Gynaecological
condition was observed. More introverted characteristics,
more the tendency to develop secondary amenorrhea.
Table: 3: Correlation between perceived stress and
personality.
Variables
Mean
r
r2
Df
Personality 146.38 +0.24 .06
102
Stress
20.7
Note:*p<0.05. N=104
t-value
2.56*
Table 3 shows a correlation between perceived stress and
personality characteristics (on introversion-extraversion
dimension). Pearson product moment correlation coefficient
between the variables indicated that R= +0.24, t= 2.56 with
df=102. It shows that the computed t-value was higher than
the critical ×2.05 (102); so, the calculated r is significantly below
the 0.05 level. Thus, a low-to-moderate and significant
positive correlation between personality and perceived stress
was observed. More introverted characteristics, more the
tendency to experience perceived stress.
Table: 4: Correlation between perceived stress and
gynaecological problem
Stress
N
Mean
rpb
Df
Present
44
22.27
+0.38
102
Absent
60
19.13
Note: *p<0.01. N=104
t-value
+4.09*
Table 4 shows a correlation between perceived stress and the
gynaecological problem (secondary amenorrhea). Point
biserial correlation between the variables indicated that rpb=
+0.38, t= +4.09 with df=102. It shows that the computed tvalue was higher than the critical ×2.01 (102); so, the computed
rpb is significantly below the 0.01 level. Thus, a moderate
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Table 5 indicates a correlation between depression and the
gynaecological problem (secondary amenorrhea). Point
biserial correlation between the variables indicated that rpb=
+0.28, t= +2.91 with df=102. It shows that the computed tvalue was higher than the critical ×2.01 (102); so, the computed
rpb is significantly below the 0.01 level. Thus, a low-tomoderate but significant positive correlation between
depression and the Gynaecological condition was observed.
Higher levels of depression were associated with a higher
tendency to develop secondary amenorrhea.
Table: 6: Correlation between stress and parenting style.
Perceived Stress
N
Mean
rpb
Df
t-value
Authoritative
26
18.73 -0.2 102
-2.06*
Authoritarian
78
22.67
Note: *p<0.05. N=104
Table 6 points towards a correlation between perceived stress
and parenting style. Point biserial correlation between the
variables indicated that rpb= -0.2, t= -2.06 with df=102. It
shows that the computed t-value was higher than the critical
×2.05 (102); so, the computed rpb is significantly below the 0.05
level. Thus, a moderate but significant negative correlation
between perceived stress and parenting style was observed.
Higher the Authoritarian nature of parenting, more are the
levels of perceived stress.
Table: 7: Correlation between personality (on introversionextraversion dimension) and gynaecological problem.
Personality
N
Mean
rpb
df
t-value
Present
44 163.0909 +0.38 102
+4.18*
Absent
60 129.6667
Note. *p<.01.
N=104
Table 7 discusses correlation between personality (on
introversion-extraversion dimension) and the gynaecological
problem (secondary amenorrhea). Point biserial correlation
between the variables indicated that rpb= +0.38, t= +4.18
with df=102. It shows that the computed t-value was higher
than the critical ×2.01 (102); so, the computed rpb is significantly
Jayasankara KR, et al: Psychosocial factors in secondary amenorrhoea
below the 0.01 level. Thus, a significant positive correlation
of moderate strength between personality and the
gynaecological problem was observed. Higher levels of
introverted characteristics were associated with a higher
tendency to develop secondary amenorrhea.
In summary, we had four primary goals in the analyses to be
reported. First, we tested whether there was a significant
relation between parenting style and the gynaecological
problem (secondary amenorrhea).
Second, we sought to determine, the correlational significance
between secondary amenorrhea with other variables
(personality, depression and stress). Third, a significant
relation between perceived stress and parenting style was
observed. Fourth, a significant relation between personality
and perceived stress was determined.
DISCUSSION:
Altogether, our results confirmed that Authoritarian parenting
is linked with the development of introverted personality,
which the child carries into the adulthood. Introverts, under
high-stress situations, would have low overall coping scores
because they will employ more passive coping skills [42].
Hence, introversion is associated with higher perceived stress
as we observed in the present study. Frequent experience of
such intense mental stress can disrupt the normal process of
the hypothalamus, which is responsible for controlling the
functions of the pituitary gland and menstruation. If the
hypothalamus malfunctions, the pituitary gland decreases the
production of hormones, affecting the process to promote
ovulation in the ovaries, this causes the ovaries to stop sending
eggs through the fallopian tubes into the uterus, and
menstruation stops resulting in Amenorrhea.
We found that subjection to Authoritarian parenting might
lead to higher perceived stress in the individual. The finding
can be explained by the past study stating that a child with
such parental exposure experienced toxic stress which in turn,
can reduce the hippocampus’s capacity to bring cortisol levels
back to normal after a stressful event has occurred [13] thus
prolonging the effect of stress. The Gynaecological condition
also has been associated with depression in the present study
which is from the previously reported studies [43].
Responsiveness which differentiates between authoritative
and authoritarian parenting styles refers to actions which
intentionally foster individuality, self-regulation, and selfassertion by being attuned, supportive and acquiescent to the
child’s particular needs and demands can be an important
determinant of a child’s personality. Unresponsive
Authoritarian parenting thus gives rise to personalities that
may have less social competence (feeling awkward when they
are the centre of social attention and are indifferent to social
activities), tend to be quite (are less lively), and not very
143
happy. [12] It may lead a child to suffer from depression
(considering selves unpopular, feeling less optimistic and the
like) and self-blame [12]. Thus, resulting in the development
of introverted personality characteristics.
The previous study on a sample of school teachers has shown
significant negative correlation emerged between stress and
extroversion [44]. Hence, substantiating our finding which states
that with introversion comes the higher level of perceived
stress in other words introverts have a harder time coping
with stress than extroverts. The result canbe explained by the
fact that they lack social support (due to inadequate social
competency), lesser adjustment due to lack of sociability [45]
and the finding that they are chronically over-aroused and
jittery [46] may explain the issue.
The observed relation between perceived stress and
Amenorrhea can be attributed to the fact that stress, as
evidenced by an increase in cortisol secretion, suppresses
hypothalamic gonadotropin-releasing hormone (GnRH) input
to the pituitary-ovarian axis. If the decrement in GnRH drive
is chronic, anovulation results. The more complete the
suppression of GnRH, the more likely is the reproductive
compromise to be clinically recognisable. Profound and
persistent loss of GnRH input manifests as amenorrhea. [47]
However, the present design is insufficient to find a
relationship between adverse childhood experiences and
amenorrhoea since there are many possibilities of confounders
which are not accounted for, affecting the relation. Hence,
specifically, it is to be noted that those with secondary
amenorrhoea were more likely to have authoritative parenting
as per self-report of the fathers.
LIMITATIONS:
This study was primarily limited by its sample size and the
context. Moreover, a large sample with the distinct cultural
background would have benefitted our results.
Clinical, instrumental and neuroendocrine examinations could
have been done, including plasma oestrogens, luteinizing
hormone (LH) pulsatility study, thyrotropin releasing hormone
(TRH) test to distinguish between those whose endocrine
evaluation did not show evidence of certain pathological
changes from those who did.
FUTURE DIRECTIONS:
Further research in resolving the relative importance of nature
versus environment in determining the level of extraversion
and Amenorrhea is required to gain a more meaningful insight.
A great depth of information may have been obtained by
studying the participants over a fair period, and this could
have added significant data and greater insight into
participants’ experiences. Another possible modification to
AP J Psychological Medicine Vol. 16 (2) July-December 2015
144
Jayasankara KR, et al: Psychosocial factors in secondary amenorrhoea
the study could have been taking into consideration parenting
style of both the parents and the result of the disparity between
them. The following result could, in turn, have given us an
insight into how the discrepancies between parenting styles
interact with their personality of mother and father to affect
the probability of developing the Gynaecological condition.
The significance of effects of adverse childhood
experiences [49] on the risk of various health problems
(unaffected by social or secular changes) cannot be
overlooked since they can serve as etiological factors of
various adulthood health issues, and which with proper
interventions can be prevented to a great extent. Moreover,
stress management programme can be arranged in addition
to the conventional administration of a short course of
progesterone to trigger menstrual bleeding to relieve the pain.
ACKNOWLEDGEMENTS: Nil
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Conflict of interest: None declared
Source(s) of support: Nil
AP J Psychological Medicine Vol. 16 (2) July-December 2015
146
CASE REPORT
Persistent Hysterical Hiccups: A Possible Pathophysiological Mechanism.
Hemendra Singh1, Mamta S Chhabria2, Meenakshi P Giri2
1
Assistant professor of Psychiatry, 2,3Intern in Psychiatry, Department of Psychiatry, M.S.Ramaiah Medical College, Bengaluru,
Karnataka, India.
ABSTRACT
Background: Persistent hysterical hiccups are not a usual presentation in medicine. Both, the rational of choosing a
specific modality of intervention and the possible biological mechanism behind hysterical hiccups are often ambiguous.
Case description: A 37-year old married female with history of hiccups since the past two weeks was referred to the
Department of Psychiatry for further management. She was extensively evaluated for other medical causes for hiccups
and later diagnosed as a case of persistent hysterical hiccups. She improved with chlorpromazine which is an
antidopaminergic drug.
Discussion: This case responded well with antidopaminergic medication. The case suggests the possible role of dopamine
in the biological mechanism of a specific clinical category of persistent hysterical hiccups.
Conclusion: Our case demonstrates the use of chlorpromazine to effectively treat hiccups of psychogenic origin.
Keywords: Persistent hiccups, hysterical hiccups, dopamine
Date of first submission: 30/9/15 Date of initial decision: 8/10/15 Date of acceptance: 14/12/15
INTRODUCTION:
Hiccups are classified as persistent when the episodes last
for more than 48 hours. When hiccups last beyond one month
they are classified as intractable. [1] An episode of hiccups is
generally self limiting and does not require any intervention.
However, intractable hiccups might require medical
intervention after a thorough investigation for their cause. In
the prevailing literature on the subject, the occurrence of
intractable hiccups is attributed to a vast number of factors,
including structural, metabolic, drugs and psychogenic [2].
Hysterical or psychogenic hiccups are best described as a
conversion reaction to internal conflicts or acute stressors
and may present as persistent hiccups. An extensive
investigation is necessary to rule out numerous other
etiological factors, before arriving at the diagnosis of
hysterical hiccups.
The biological mechanism of persistent hiccups remains
poorly understood. However, dopamine and gammaAddress for correspondence: Dr Hemendra Singh. #46,
Pratosh, 2nd Cross, Panduranga Nagar, Bannerghatta Road,
Bangalore- 560076, Karnataka, India
Phone number: +918971220731
Email: [email protected]
How to cite this article: Hemendra S, Mamta SC,
Meenakshi PG. Persistent Hysterical Hiccups: A Possible
Pathophysiological Mechanism. AP J Psychol Med 2015;
16(1):146-7
AP J Psychological Medicine Vol. 16 (2) July-December 2015
aminobutyric acid (GABA) have been reported to mediate
neurotransmission in the complex reflex arc which is
implicated in the etiology of hiccups. [3] Several treatment
options ranging from conventional remedies, alternative
medicine to emerging therapies might be used to treat hiccups.
But even today, there remains a dearth of widely accepted
protocols or consensus statements addressing the management
of hiccups.[4] Here we report an unusual case of persistent
hysterical hiccups that was successfully treated with
chlorpromazine.
CASE HISTORY:
A 37-year old married female, presented to the medical
emergency ward of our hospital with complaints of 10-12
episodes of hiccups, followed by laughing, shouting, or crying,
but with no loss of consciousness, since two weeks. She also
reported disturbed sleep since the past one month. Each
episode of hiccups lasted 5-10 minutes. During a hiccups
episode, she was unable to communicate with anybody despite
trying to do so. She also complained of an inability to move
her legs during an episode. At the time of examination, she
was oriented and had a pulse of 78 beats/min, blood pressure
of 120/70 mmHg, respiratory rate of 24 cycles/min, and a
normal body temperature. She was referred to the Psychiatry
Outpatient Department because of abnormal behavior during
episodes of intractable hiccups. In the previous year, she had
3 to 4 episodes of persistent hiccups, which lasted for 2 to 3
months. She had no past or family history of any other
psychiatric illnesses, nor did she possess a premorbid
Hemendra, et al: Hysterical hiccups: Pathophysiological mechanism
personality. However, she expressed dissatisfaction with the
fact that her 22 year old son had eloped with a girl she
disapproved of. She was also apprehensive about her
relationship with her son in future. She denied any history of
head trauma or any seizure disorder. Other physical and
systemic examinations, including that of the central nervous
system, were normal.
Neurology and gastroenterology reviews were done, and
investigations were done to rule out organic causes of hiccups
so as to confirm the diagnosis. Her haemoglobin was 10 g/dl.
Random blood sugar, complete blood count, erythrocyte
sedimentation rate, liver function test, renal function tests,
including serum electrolytes, abdominal ultrasound, chest Xray, upper gastrointestinal endoscopy, and computed
tomography scan of the brain were found to be normal. HBsAg
and HIV serological tests were negative. Hence the patient
was diagnosed to have hysterical hiccups. She was treated
with oral chlorpromazine 50mg 1-0-1 and with oral iron
supplements. Hiccups completely stopped on the following
day and there was no reoccurrence during the remainder of
the patient’s hospital stay, which was of one week. The patient
was discharged after a week and prescribed oral
chlorpromazine 50mg 1-0-1 and iron supplements.
Chlorpromazine was tapered and stopped over three weeks.
No further episodes of unusual hiccups were reported during
follow ups for two months.
DISCUSSION:
Our case demonstrates the use of chlorpromazine to
effectively treat hiccups of psychogenic origin. Since
chlorpromazine or metaclopromide has antidopaminergic
properties, the role of dopamine as a causative factor in
intractable hiccups has been suggested by some studies. [5-6]
However, refuting this, there are case reports that report the
occurrence of severe hiccups in association with
administration of perphenazine, a dopamine antagonist. [7]
Furthermore, there are other studies which suggest that lack
of dopamine is implicated in the aetiology of hiccups due to
the fact that dopamine agonists, such as pramipexole and
amantadine, have been effectively used to treat cases of
intractable hiccups. [8-9] A few case reports also postulate both
hypo and hyperdopaminergic states, along with serotonergic
modulation in the pathogenesis of hiccups. [10-11] In this case
report, we postulate the possible categories of psychogenic
hiccups based on aetiopathogenesis. In the first category we
postulate that these hiccups are possibly due to the
hyperdopaminergic state, which might respond to
antidopaminergic agents. In the second category we postulate
that they could possibly be due to the hypodopaminergic state,
which responds to dopamine agonists. And, in the third
category we postulate that these hiccups could possibly be
147
due to unspecified pathophysiology, and would thus require
various types of interventions. This clinical categorization
suggests treatment options that could improve the
management of psychogenic hiccups.
CONCLUSIONS:
This case suggests the possible role of dopamine in the
biological mechanism of intractable hysterical hiccups. There
is lack of controlled studies to test the hypothesis that
hysterical hiccups might have a pathophysiological substrate
in common with other psychiatric disorders, which respond
well to antidopaminergic drugs. There is hence a need for
longitudinal controlled studies to test this hypothesis.
ACKNOWLEDGEMENTS: Nil
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Amantadine: to treat hiccups. J Pain Symptom Manage
2009;38:460-5.
10. Ray P, Zia Ul Haq M, Nizamie SH. Aripiprazoleinduced hiccups: a case report. Gen Hosp Psychiatry
2009;31:382-4.
11.
Kani AS, Öcek T, Aksoy-Poyraz C, Turan S, Duran A.
Aripirazole induced acute hiccups: a case report. J
Neuropsychiatry Clin Neurosci 2015;27(1): e60.
Conflict of interest: None declared
Source(s) of support: Nil
AP J Psychological Medicine Vol. 16 (2) July-December 2015
148
CASE REPORT
Aripiprazole induced priapism: a case report
Satya K Trivedi1, Ajish G Mangot2, Siddhartha Sinha3
1
Senior Resident in psychiatry, 2Assistant professor of Psychiatry, Department of Psychiatry, People’s College of Medical
Sciences and Research Centre, Bhanpur, Bhopal, Madhya Pradesh, India, 3Senior Resident in psychiatry, Department of
psychiatry, Ranchi Institute of Neuro-Psychiatry and Allied Health Sciences (RINPAS), Kanke, Ranchi, Jharkhand, India
ABSTRACT
Background: Priapism is a urologic emergency representing a true disorder of penile erection that persists beyond or is
unrelated to sexual interest or stimulation. Variety of drugs is known to produce priapism, including psychotropics.
Case description: We report a case of an adolescent young male with psychosis who developed priapism after taking a
single oral dose of 10mg aripiprazole.
Discussion: Virtually all antipsychotics have been known to be rarely associated with priapism. The potential of
antipsychotics to cause priapism is believed to be dependent on their affinity to block alpha-1 adrenergic receptors.
Aripiprazole has the least affinity to adrenergic receptors among all atypical antipsychotics. This makes it an extremely
rare occurrence all around the world.
Conclusion: Polymorphism of alpha-2A adrenergic receptor gene in schizophrenia patients is known to be associated
with sialorrhoea while on clozapine treatment. Probably similar polymorphism of alpha-1 adrenergic receptor gene could
contribute to its altered sensitivity and resultant priapism.
Key Message: Future pharmacogenomics based approach may help in personalizing the treatment and effectively prevent
the emergence of such side effects.
Keywords: Aripiprazole, priapism, adverse event, adrenergic
Date of first submission: 22/8/15 Date of initial decision: 6/9/15 Date of acceptance: 14/11/15
INTRODUCTION:
Priapism is a pathologic condition representing a true disorder
of penile erection that persists beyond or is unrelated to sexual
interest or stimulation. It is a urologic emergency and if left
untreated could lead to permanent erectile dysfunction. [1] Out
of the three known types of priapism, the most common is
the ischemic type. Numerous putative causative factors for
ischemic type of priapism have been described, with
psychotropic drugs being one among them. [2]
Hereby we report a case of aripiprazole induced priapism in
an adolescent young male suffering from schizophrenia.
Written informed consent was taken from the patient and his
Address for correspondence: Dr Satya K Trivedi, Senior
Resident, Department of Psychiatry, People’s College of
Medical Sciences and Research Centre, Bhanpur, Bhopal,
Madhya Pradesh, India - 462037.
Phone number: +91-8719838605
Email: [email protected]
How to cite this article: Satya KT, Ajish GM, Siddhartha
S. Aripiprazole induced priapism: a case report. AP J
Psychol Med 2015; 16:148-50
AP J Psychological Medicine Vol. 16 (2) July-December 2015
parents for this case report, a copy of which is available for
review with the principal author.
CASE HISTORY:
An adolescent single male belonging to middle socioeconomic status studying in class XII had presented to our
out-patient services with 2 months history of acute onset
continuous course of illness characterized by third person
auditory hallucination – commentary type, delusion of
reference, delusion of persecution, poor self care, insomnia
and irritability leading to significant socio-occupational
dysfunction. There was no history of alcohol/drug
consumption with insignificant past medical/surgical history.
He had a family history of psychosis in his father. Detailed
general physical and systemic evaluation was normal. Routine
biochemical parameters were within normal limits. Brain
imaging also did not reveal any abnormality. He was
diagnosed to have paranoid schizophrenia as per WHO ICD10 criteria and was prescribed aripiprazole 10 mg/day and
lorazepam 2mg. Within 7 hours he presented to the emergency
services with complaints of continuous penile erection and
pain of 1 hour duration. He was examined by the urologist on
duty who diagnosed him as having priapism. Initial
conservative management with ice packs was in vain
Satya KT, et al: Aripiprazole induced priapism.
following which blood aspiration with saline irrigation was
performed. Two milliliters injection adrenaline was
administered in each cavernosal body with which he achieved
satisfactory detumescence. His vital parameters were
continuously monitored during the entire procedure. No repeat
injections or aspiration-irrigation procedure were needed.
Except for the single dose of aripiprazole, he had not taken
any other medication which was confirmed by the family
members. He had no previous history of similar incident. No
recent alcohol or substance consumption was suspected
clinically, which was later confirmed by his urine analysis
report. There was no history of any perineal trauma either.
Patient was observed in emergency services for further 24
hours. On discharge, patient was started on tablet amisulpiride
400 mg in divided doses with lorazepam 2mg for sleep. On
follow-up a week later, patient was tolerating amisulpiride
well with no untoward incidents reported in the intervening
period.
DISCUSSION:
The potential of antipsychotics to cause priapism is believed
to be dependent on their affinity to block alpha-1 adrenergic
receptors. [3] Among the older typical antipsychotics,
chlorpromazine and thioridazone have the maximum
propensity to block alpha-1 adrenergic receptors. While
among the newer atypical antipsychotics, clozapine,
quetiapine, and risperidone have maximum affinity. [4] And
as such, virtually all antipsychotic medications have been
reported to rarely cause priapism. [5] But aripiprazole displays
the lowest affinity to alpha-1 adrenergic receptors among all
the atypical antipsychotics. [6] Yet there have been reports of
aripiprazole induced priapism. Two reports suggest an
association between dose of aripiprazole and priapism. [7,8]
Report by Mago et al., 2006 discusses about a case of recurrent
priapism with aripiprazole administration. [9] Priapism has also
been reported when aripiprazole was used in combination
with oxcarbazepine and lithium. [10] Interestingly a case similar
to ours was presented by Togul et al., 2012. [11] They report
priapism with 10 mg aripiprazole within 8 hours of its first
administration to a patient with schizophrenia. But they shifted
their patient to olanzapine, which itself has alpha-1
adrenoreceptor antagonistic action and has been associated
with priapism. [4,5] In our case too, patient developed priapism
within few hours of taking the single oral dose of 10mg
aripiprazole, presumably after attaining peak plasma levels.
Patient had no history of any alcohol/substance use, confirmed
by his urine analysis report. No other drug consumption was
confirmed. With the available evidence, we can conclude that
aripiprazole led to priapism in this case. He was duly evaluated
by the urologist on duty and managed as per accepted
guidelines. [2] Adrenaline was used in our case as it was
149
immediately available in the emergency tray and its
effectiveness with regards to relieving priapism has been
documented earlier. [12] Our choice of amisulpiride was based
on the fact that sulpiride does not have any alpha receptor
affinity making it a safe drug with regards to priapism. All
the other popularly used antipsychotics have at least low
affinity to alpha-1 receptors. [4]
CONCLUSIONS:
In our case the emergence of priapism doesn’t seem to be
related to dose contrary to previous reports. [7,8] But why only
certain individuals develop priapism requires further
elucidation. It could be an idiosyncratic reaction or related to
altered sensitivity of adrenergic receptors in this patient.
Polymorphism in alpha-2A adrenergic receptor gene has been
associated with sialorrhea in schizophrenia patients on
clozapine treatment. [13] Similarly could alpha-1 adrenergic
receptor gene polymorphism in schizophrenia patients be
responsible for increased vulnerability to develop priapism?
Future pharmacogenomics based approach could help in
personalizing the treatment of various mental disorders and
hopefully help in avoiding the emergence of such side effects.
ACKNOWLEDGEMENTS: Nil
REFERENCES:
1.
Montague DK, Jarow J, Broderick GA, Dmochowski
RR, Heaton JP, Lue TF, et al. American Urological
Association guideline on the management of priapism.
J Urol 2003;170:1318–24.
2.
Salonia A, Eardley I, Giuliano F, Hatzichristou D,
Moncada I, Vardi Y, et al. European Association of
Urology Guidelines on Priapism. Eur Urol
2014;65(2):480-9.
3.
Andersohn F, Schmedt N, Weinmann S, Willich SN,
Garbe E. Priapism associated with antipsychotics: role
of alpha1 adrenoceptor affinity. J Clin Psychopharmacol
2010;30(1):68-71
4.
Lidow MS. “General Overview of Contemporary
Antipsychotic Medications.” Neurotransmitter
Receptors in Actions of Antipsychotic Medications.
Boca Raton: CRC, 2000. 27. Print.
5.
Compton MT, Miller AH. Priapism associated with
conventional and atypical antipsychotic medications: a
review. J Clin Psychiatry 2001 May;62(5):362-6.
6.
Goodnick PJ, Jerry JM. Aripiprazole: profile on efficacy
and safety. Expert Opin Pharmaco 2002
Dec;3(12):1773-81.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
150
Satya KT, et al: Aripiprazole induced priapism.
7.
Hsu WY, Chiu NY, Wang CH, Lin CY. High dosage of
aripiprazole induced priapism: a case report. CNS
Spectr 2011 Aug;16(8):177.
11.
8.
Aguilar-Shea AL, Palomero-Juan I, Sierra Santos L,
Gallardo-Mayo C. [Aripiprazole and priapism]. Aten
Primaria 2009 Apr;41(4):228-9.
12. Keskin D, Cal C, Delibas M, Ozyurt C, Gunaydin G,
Nazli O, et al. Intracavernosal adrenalin injection in
priapism. Int J Impot Res 2000 Dec;12(6):312-4.
9.
Mago R, Anolik R, Johnson RA, Kunkel EJ. Recurrent
priapism associated with use of aripiprazole. J Clin
Psychiatry 2006 Sep;67(9):1471-2.
10.
Negin B, Murphy TK. Priapism associated with
oxcarbazepine, aripiprazole, and lithium. J Am Acad
Child Adolesc Psychiatry 2005 Dec;44(12):1223-4.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Toðul H, Budaklý AA, Algül A, Balibey H , Ebrinç S.
Aripiprazole Induced Priapism. Bulletin of Clinical
Psychopharmacology 2012;22(Suppl. 1):S149
13. Solismaa A, Kampman O, Seppala N, Viikki M, Makela
KM, Mononen N, et al. Polymorphism in alpha 2A
adrenergic receptor gene is associated with sialorrhea
in schizophrenia patients on clozapine treatment. Hum
Psychopharmacol 2014 Jul;29(4):336-41.
Conflict of interest: None declared
Source(s) of support: Nil
151
STALWART
Albert Bandura
Rufus Ephraim1
1
Postgraduate Resident in Psychiatry, Department of Psychiatry, Sri Venkateswara Medical College, Tirupati, Andhra Pradesh,
India.
ABSTRACT
Background: Albert Bandura is a renowned psychologist and has contributed a lot to the field of psychology. He is famous
for social learning theory and the theoretical construct of self-efficacy the influential Bobo Doll experiment. Bandura supported
a style of psychology which was based on investigating psychological phenomena through repeatable, experimental testing.
In his wide spanning career he published many books and was honoured with many awards. He started his life in Canada and
finally settled in America.
Keywords: Albert Bandura, Social learning theory, Bobo Doll experiment
Date of first submission: 9/9/15 Date of initial decision: 25/11/15 Date of acceptance: 29/11/15
INTRODUCTION:
Albert Bandura was born on December 4, 1925 in Mundare,
in Alberta, a small town of roughly four hundred inhabitants,
as the youngest child, and only son, in a family of six. He
went to a small high school with only 20 students and 2
teachers. The limitations of education in a remote town such
as this caused Bandura to become independent and selfmotivated in terms of learning, and these primarily developed
traits proved very helpful in his lengthy career. Bandura
arrived in the US in 1949 and was naturalized in 1956. He
married Virginia Varns (1921–2011) in 1952, and they raised
two daughters, Carol and Mary.
Education and academic career
Bandura’s introduction to academic psychology came about
by a fluke; as a student with little to do in the early mornings,
he took a psychology course to pass the time, and became
enamored of the subject. Bandura graduated in three years,
in 1949, with a B.A. from the University of British Columbia,
winning the Bolocan Award in psychology, and then moved
to the then-epicenter of theoretical psychology, the University
of Iowa, from where he obtained his M.A. in 1951 and Ph.D.
in 1952. Arthur Benton was his academic adviser at
Iowa, giving Bandura a direct academic descent from William
James, while Clark Hull and Kenneth Spence were influential
Address for correspondence: Dr. Rufus Ephraim, Resident
in psychiatry, Department of psychiatry, Sri Venkateswara
Medical College, Tirupati, Andhra Pradesh, India.
Phone number: +91-7207631555
Email: [email protected]
How to cite this article: Rufus E. Albert Bandura. AP J
Psychol Med 2015; 16(2):151-3
collaborators. There he came to support a style of psychology
which sought to investigate psychological phenomena through
repeatable, experimental testing. His inclusion of such mental
phenomena as imagery and representation, and his concept
of reciprocal determinism, which postulated a relationship of
mutual influence between an agent and its environment,
marked a radical departure from the dominant behaviourism
of the time. He completed his postdoctoral internship at the
Wichita Guidance Center. The following year, 1953, he
accepted a teaching position at Stanford University. In 1974,
he was elected president of the American Psychological
Association (APA), which is the world’s largest association
of psychologists.
RESEARCH
Social learning theory
Social learning theory posits that there are three regulatory
systems that control behavior. First, the antecedent
inducements greatly influence the time and response of
behavior. The stimulus that occurs before the behavioural
response must be appropriate in relationship to social context
and performers. Second, response feedback influences also
serve an important function. Following a response, the
reinforcements, by experience or observation, will greatly
impact the occurrence of the behaviour in the future. Third,
the importance of cognitive functions in social learning.
Aggression
Bandura believed modifiers of reward and punishment
in classical and operant conditioning were inadequate as a
framework, and that many human behaviors were learned from
other humans. Bandura began to analyze means of treating
unduly aggressive children by identifying sources of violence
in their lives.
AP J Psychological Medicine Vol. 16 (2) July-December 2015
152
Rufus E: Albert Bandura
In 1961 Bandura conducted a controversial experiment known
as the Bobo doll experiment, designed to show that similar
behaviors were learned by individuals shaping their own
behaviour after the actions of models. The Bobo doll
experiment emphasized how young individuals are influenced
by the acts of adults. When the adults were praised for their
aggressive behaviour, the children were more likely to keep
on hitting the doll. However, when the adults were punished,
they consequently stopped hitting the doll as well. The
experiment is among the most lauded and celebrated of
psychological experiments.
Social cognitive theory
By the mid-1980s, Bandura’s research had taken a more
holistic bent, and his analyses tended towards giving a more
comprehensive overview of human cognition in the context
of social learning. The theory he expanded from social
learning theory soon became known as social cognitive theory.
Social foundations of thought and action
In 1986, Bandura published Social Foundations of Thought
and Action: A Social Cognitive Theory , in which he re­
conceptualized individuals as self-organizing, proactive, selfreflecting, and self-regulating, in opposition to the orthodox
conception of humans as governed by external forces. He
advanced concepts of triadic reciprocality, which determined
the connections between human behaviour, environmental
factors, and personal factors such as cognitive, affective, and
biological events, and of reciprocal determinism, governing
the causal relations between such factors.
Moral agency
Bandura applied his human agentic view via social cognitive
theory for the personal and social aspects of control
over moral values and conduct. In particular, he states that in
the social cognitive theory of the moral self, moral
reasoning is linked to moral action through affective self­
regulatory mechanisms by which moral agency is exercised.
However these self-regulatory mechanisms have to be
activated psychosocially. First, all people are capable of
two morally agentic abilities, to act humanely and to not act
inhumanely. Selective moral disengagement occurs when a
person actively disengages their self-regulating efficacy for
moral conduct.
Awards
Bandura has received more than sixteen honorary degrees
from various universities around the world. He was elected a
Fellow of the American Academy of Arts and Sciences in
1980.
He received the Award for Distinguished Scientific
Contributions from the American Psychological
AP J Psychological Medicine Vol. 16 (2) July-December 2015
Association in 1980 for pioneering the research in the field
of self­regulated learning.
In 1999 he received the Thorndike Award for Distinguished
Contributions of Psychology to Education from the American
Psychological Association.
In 2001, he received the Lifetime Achievement Award from
the Association for the Advancement of Behaviour Therapy.
He is the recipient of the Outstanding Lifetime Contribution
to Psychology Award from the American Psychological
Association and the Lifetime Achievement Award from
the Western Psychological Association, the James McKeen
Cattell Award from the American Psychological Society, and
the Gold Medal Award for Distinguished Lifetime
Contribution to Psychological Science from the American
Psychological Foundation.
In 2008, he received the University of Louisville Grawemeyer
Award for contributions to psychology.
Books: He has many books to his credit

Bandura, A. (1997). Self-efficacy: the exercise of
control. New York: W.H. Freeman.

Bandura, A. (1986). Social Foundations of Thought and
Action: A Social Cognitive Theory. Englewood Cliffs,
N.J.: Prentice-Hall.

Bandura, A., & Walters, R.H. (1959). Adolescent
Aggression. Ronald Press: New York.

Bandura, A. (1962). Social Learning through Imitation.
University of Nebraska Press: Lincoln, NE.

Bandura, A. (1969). Principles of behavior
modification. New York: Holt, Rinehart and Winston.

Bandura, A. (1971). Psychological modeling:
conflicting theories. Chicago: Aldine·Atherton.

Bandura, A. (1973). Aggression: a social learning
analysis. Englewood Cliffs, N.J.: Prentice-Hall.

Bandura, A. (1975). Social Learning & Personality
Development. Holt, Rinehart & Winston, INC: NJ.

Bandura, A., & Ribes-Inesta, Emilio. (1976). Analysis
of Delinquency and Aggression. Lawrence Erlbaum
Associates, INC: NJ.

Bandura, A. (1977). Social Learning Theory.
Englewood Cliffs, NJ: Prentice Hall.

Bandura, A. (1997). Self-Efficacy: The Exercise of
Control. NY: W. H. Freeman and Company.
CONCLUSION:
Albert Bandura has had an enormous impact on personality
theory and therapy. His straightforward, behaviourist-like
Rufus E: Albert Bandura
style makes good sense to most people. His action-oriented,
problem-solving approach likewise appeals to those who want
to get things done, rather than philosophize about ids,
archetypes, actualization, freedom, and all the many other
mentalistic constructs personologists tend to dwell on.
aggressive models. Journal of Abnormal and Social
Psychology, 63, 575-582
4.
Bandura, A. (2006). Autobiography. M. G. Lindzey &
W. M. Runyan (Eds.) A history of psychology in
autobiography (Vol. IX). Washington, D.C.: American
Psychological Association.
5.
Bandura, A. (1965) Influence of models’ reinforcement
contingencies on the acquisition of imitative
response. Journal of Personality and Social
Psychology, 1, 589­595.
6.
Bandura, A. (1977) Social Learning Theory. New York:
General Learning Press.
REFERENCES:
1.
Bandura, A. (1986). Social foundations of thought and
action: A social cognitive theory. Prentice-Hall, Inc.
2.
Bandura, A. (1977). Social learning theory. Englewood
Cliffs, NJ: Prentice Hall.
3.
Bandura, A. Ross, D., & Ross, S. A. (1961).
Transmission of aggression through the imitation of
153
Conflict of interest: None declared Source(s) of support: Nil
AP J Psychological Medicine Vol. 16 (2) July-December 2015
154
Andhra Pradesh Journal of Psychological Medicine
(APJ Psychol Med) January-June 2015
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