ABSTRACTS FOR E-POSTERS

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H. M. Yusra, W. J. Alexander Gnanadurai, A. Balaji Department of Psychiatry, Government Kilpauk Medical College Hospital, Chennai, Tamil Nadu, India Background: Rett syndrome is a rare, X-linked dominant neurodevelopmental disorder that primarily affects females. It is characterized by a period of apparently normal early development followed by a progressive loss of acquired motor and communication skills, typically beginning between 6 and 18 months of age. The syndrome is caused by de novo mutations in the MECP2 gene, which plays a critical role in transcriptional regulation and chromatin remodeling. Patient Profile: 3 year old male child presented with speech delay difficulty in walking and frequent rubbing of eyes. Child was apparently normal till 5 months of age. He did not attain head control. He started to babble at 8 months of age and spoke bisyllable words around 1 year for age currently he does not speak. Family history of autism and intellectual disability present in sister and maternal cousin. On examination child is not responding to oral commands. Microcephaly, poor head control present, stereotypical movement of hands noted.Genetic studies showed mutation of MECP2. Discussion: The MECP2 gene, located on Xq28, encodes a protein essential for synaptic maturation and maintenance. Mutations in this gene disrupt neuronal gene expression and synaptic function, leading to widespread neurological dysfunction. The near complete absence of males with classic RETT postulated a lethal effect of the MECP2 mutation in males Contrary to this MECP2 mutations have been reported and documented in male patients that displayed a wide assortment of presentations including but not limited to severe neurodevelopmental disabilities and congenital encephalopathy.

An

Samant Singh, Sarah Afzal 1 , Richa Tripathi, Rashid Alam All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, 1 Max Superspeciality Hospital, Shalimar Bagh, Delhi, India A case of severe, chronic depressive disorder and headache temporally aligned with profound vision loss, secondary to complex inflammatory ocular pathology, further complicated by an acquired circadian rhythm disorder and underlying endocrine comorbidities.This complex presentation highlights multiple interacting pathologies. The chronic headache and MDE( Major depressive episode) are strongly linked to the devastating visual impairment and the underlying chronic intraocular inflammation (uveitis), with CSR( Central serous retinopathy) and iridocyclitis.This case represents a severe medically complex depressive episode secondary to chronic, sight-threatening ocular inflammation and subsequent blindness-induced circadian rhythm disruption. It emphasizes the need for thorough investigation of physical causes, including inflammatory and infectious markers like CMV(cytomegalovirus), in patients presenting with new-onset, complex psychiatric and neurological symptoms, particularly when compounded by endocrine disease.

Is

L. R. Jayasri, T. Siva Ilango Karpaga Vinayaga Medical Science and Research Centre, Chengalpattu, Tamil Nadu, India Introduction: Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a congenital disorder characterized by agenesis of the uterus and upper vagina in phenotypically normal females with normal ovarian function and secondary sexual characteristics. While MRKH is associated with psychological distress, severe psychiatric comorbidities such as schizophrenia are rarely reported. The coexistence of these two distinct conditions highlights the possible interaction between genetic, neurodevelopmental, and psychosocial factors. Objectives: To present a rare case of MRKH syndrome associated with schizophrenia. To explore the genetic and psychosocial links underlying this comorbidity. To emphasize the importance of multidisciplinary management in such complex presentations. Case: A detailed case study of a 26-year-old female with MRKH syndrome was conducted, supported by a literature review of previously published case reports and studies exploring psychiatric manifestations in MRKH. Results: The patient presented with primary amenorrhea, short stature, and psychotic symptoms including auditory hallucinations and prominent negative features, diagnosed as schizophrenia. She was treated with risperidone 8 mg nightly with partial improvement. Psychosocial stigma posed major barriers her mother initially attributed the illness to occult causes due to cultural stigma, delaying psychiatric care. The stress of MRKH during adolescence, combined with family rejection and emotional trauma, may have acted as a precipitating factor for psychosis. This case illustrates the need for integrated multidisciplinary management of MRKH, encompassing gynecological care, psychiatric treatment, and psychosocial support. Early recognition, reduction of stigma, and family counselling are crucial to ensuring holistic care and improving long-term outcomes for affected women.

To

Nahida Mohd, Rakesh Banal GMC, Jammu, Jammu and Kashmir, India Background: Precipitated opioid withdrawal occurs when an opioid antagonist, such as naltrexone, displaces an opioid agonist or partial agonist(eg; buprenorphine) from receptors, leading to an abrupt onset of withdrawal .Although it typically presents with autonomic and somatic symptoms, delirium is a rare but clinically significant complication. Aims: To describe a case of mixed -type delirium resulting from precipitated opioid withdrawal successfully managed with low- dose haloperidol. Methods: A 38-year old male with one year history of opioid dependence had remained abstinent for 2 months and had intermittently taken buprenorphine. During psychiatric evaluation, he underwent a naloxone challenge test and was initiated on tab naltrexone 25mg subsequently increased to 50mg daily. while on naltrexone for 6 days, he ingested buprenorphine obtained from a friend. soon after he developed severe body aches, rhinorrhea, altered sensorium, visual hallucinations and psychomotor agitation. He was brought to psychiatry hospital, referred to emergency department to exclude alternative causes of delirium, there was no history of head trauma, seizure disorder, medical illness or surgical intervention. NCCT head and baseline investigations were normal, UDS was negative. MSE revealed disorientation and irrelevant speech, symptoms consistent with mixed-type delirium. Results: The patient received haloperidol 2.5mg IM, followed by oral haloperidol 0.5mg twice daily. Over 2 days, he regained orientation, and behavioral disturbances resolved. He was discharged in a stable condition. Conclusion: This case underscores that precipitated opioid withdrawal can, in rare instances, present with mixed-type delirium. Early recognition, appropriate detoxification protocols and timely intervention can ensure favorable outcomes.

Can

Anamika Das, Disha Maity 1 , Imon Paul 1 , V. V. Gantait 1 IQ City Medical College and Hospital, 1 Department of Psychiatry, IQ City Medical College and Hospital, Durgapur, West Bengal, India A 11 year old male child hailing from an urban area of South Bengal educated upto class 6, fully immunised as per age with no history of developmental delay presented to us with repetitive shoulder shrugging and eye blinking for 5 years, spending excessive time organising his things for 5 years and repetitive throat clearing for last 1 year 6 months. The onset was acute,course fluctuating, with waxing and waning pattern. The episodes precipitated on stressful situation and in episodes of sore throat. Started with motor movements (hand movement,eye blinking) followed by vocal involvement -sounds like ‘phoooo’, ‘aaaa’. He would also repeat obscene words. He had an episode of sore throat with fever around 3 years back after which the symptoms worsened. There was difficulty in day to day activities with impairment in scholastics. Multiple psychiatrists consulted with a waxing waning course. Patient presented with worsening of symptoms since last 20 days after an episode of sore throat. A diagnosis of Tourette Disorder was made and a diagnosis of PANDAS was considered. The patient was started on Risperidone and Clonazepam and baseline blood investigations with ASO titer and Anti DNAse B was prescribed. ASO tItre was 408.7 IU/ml. paediatrician advised for short course steroids and antibiotics . improvement was present in all domains of symptoms and further planned for Habit Reversal Therapy.

Ect

Sushan Pokharel, Jyotika Kanwar 1 , Raj Laxmi 1 , Swapnajeet Sahoo 1 Postgraduate Institute of Medical Education and Research, 1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India Background: Cardiac complications are rare (with 0.9% incidence), but still are the most common comorbidity due to ECT, particularly in elderly. Despite the lack of significant controlled trials, the literature suggests that ECT can be given safely in patients with pacemakers, after pretreatment stabilization. Aim: To present a case of ECT in an elderly patient with cardiac issues with a pacemaker. Case Presentation: A 78-year-old male with hypertension, BPH, and a severe psychotic episode of major depression treated with medications, presented with another severe non-psychotic episode with treatment resistance. After 4 index ECTs, further ECTs were stopped due to recurrent VPCs. He also had symptomatic bradycardia, irregular rhythm, pauses on holter, and RBBB. A multidisciplinary team then planned to resume ECT after placing a pacemaker. A permanent synchronous (DDD) pacemaker was placed, followed by a new cycle of 7 ECTs with improvement noted clinically and on HDRS and BDI scales. He was discharged and continued on weekly ECTs. Conclusion: This case-report is evidence that ECT need not be the last resort in severe mental illnesses, even in elderly patients with pacemakers. ECT, as in this case, has not been associated with serious pacemaker dysfunction. Studies recommend synchronous pacing over asynchronous one during ECT, as done in our patient, while some contradict. Depolarizing muscle relaxants such as succinylcholine and suxamethonium, which have been reported to cause pacemaker failure and cardiac arrest, should be used with caution. A periodic examination of the pacemaker may be necessary.

Low

Kavin Guleria, A. K. Pandey Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India Background: Auditory hallucinations are a common and disabling symptom in schizophrenia spectrum disorders. A substantial proportion of patients continue to experience hallucinations despite adequate antipsychotic pharmacotherapy. Repetitive transcranial magnetic stimulation (rTMS) has emerged as a potential non ‘invasive neuromodulation intervention for treatment ‘resistant hallucinations that may be used as an adjunctive strategy alongside conventional medications. Aim: This case series aimed to evaluate the effect of low ‘frequency rTMS as an augmenting treatment in three adult patients with schizophrenia spectrum disorders who had persistent auditory hallucinations despite adequate antipsychotic therapy. Methods: Three patients with persistent auditory hallucinations (one with schizoaffective disorder and two with schizophrenia) on adequate antipsychotic treatment were treated with adjunctive low ‘frequency rTMS . Each patient received 10 daily sessions of 1 Hz,900 pulses per day for approximately 15 minutes on left temporoparietal region. Auditory hallucinations were assessed using the Psychotic Symptom Rating Scales (PSYRATS-AH) auditory hallucination subscale before and after treatment. Results: All three patients had significant reductions in PSYRATS-AH scores following rTMS. Case 1 (33 ‘year ‘old female) showed a reduction from 55 to 36 (34.5% improvement). Case 2 (36 ‘year ‘old male) showed a reduction from 67 to 49 (26.9% improvement). Case 3 (20 ‘year ‘old female) showed the greatest reduction. Conclusion: Low ‘frequency rTMS can be an effective adjunctive treatment for persistent auditory hallucinations in schizophrenia spectrum disorders resistant to pharmacotherapy. The consistent reduction in symptom severity across all three patients supports the need for larger controlled trials to establish optimal rTMS parameters and identify predictors for treatment response.

Mgt

Sanjay Kumar, Soniya Vats 1 , Lakshmi S. Kumar 1 Army Medical Corps, 1 National Forensic Sciences University, Ganghinagar, Gujarat, India Introduction: Borderline Personality Disorder (BPD): chronic emotion dysregulation, impulsivity, unstable relationships, frequent self-harm and suicidal behaviors. Prevalence: 0.7-2.7% in general population; much higher in clinical settings (up to 22% of inpatients); female:male ratio 3:1. Patient: Ms. K.B., 25-year-old female, presenting with low mood, anger outbursts, suicidal threats, sleep/appetite disturbance, triggered by job search stress and family criticism. Diagnosed with Emotionally Unstable Personality Disorder, Impulsive Type (ICD-10). Intervention: Dialectical Behaviour Therapy (DBT), evidence- based for BPD, developed by Linehan. 18 weekly individual sessions (40-90 min each). DBT Modules: Mindfulness, Distress Tolerance, Emotion Regulation, Interpersonal Effectiveness. Key Techniques: Distress Tolerance: STOP skills for managing painful emotions/suicidal urges. Interpersonal Effectiveness: DEARMAN skills for expressing needs and maintaining relationships. Mindfulness: teaching wise mindand present- moment awareness to reduce overwhelm. Emotion Regulation: cognitive restructuring, opposite action, sleep hygiene to overcome vulnerabilities. Results: Significant reduction in impulsivity and self- harm incidents. Improved ability to set boundaries, communicate feelings, and challenge suspicious thoughts. Enhanced self-esteem, confidence, and interpersonal relationships.

Sin

Prerna, Panna Sharma 1 AIIMS, New Delhi, 1 Anvaya Healthcare, Delhi, India Background: Genital somatic symptoms often cause distress and repeated medical consultations among men, particularly in the context of guilt, health anxiety and sexually transmitted infections. Distinguishing organic pathology from somatoform presentations at the dermatology-psychiatry interface poses diagnostic and management challenges. Aim: To describe the phenomenology and management of a patient presenting with distressing genital sensations in the context of past high-risk sexual behaviour and herpes simplex virus (HSV) infection. Case Description: A 43-year-old married male labourer presented with a 10-month history of pain, tingling and insect-crawling sensations over the penis, with ghabrahat, palpitations, health-related worries and disturbed sleep, causing occupational and interpersonal dysfunction. Symptoms began after disclosure of high-risk sexual behaviour to his wife, accompanied by intense guilt. Initial urological and general medical evaluations were unremarkable. Dermatology review showed healed vesicular lesions and seropositivity for HSV-1 and HSV-2; however, the sensations were not explained by the infection. He was subsequently referred to psychiatry. Methods: A detailed psychiatric evaluation was conducted, including clinical interviews and review of dermatology and urology records. Physical and neurological examinations, laboratory tests and dermatological assessment were used to rule out active organic pathology. Pharmacological treatment and psychoeducation were initiated. Results: Escitalopram (5-20 mg/day) produced minimal benefit; subsequent Duloxetine (20-40 mg/day) and Olanzapine 5 mg/day led to approximately 50% reduction in genital sensations and associated anxiety. Conclusions: This case highlights how guilt related to high-risk sexual behaviour, health anxiety and somatic preoccupation can converge to produce persistent genital somatoform symptoms, underscoring the importance of integrated dermatology-psychiatry collaboration.

The

Anshuman Vasudev, Priya Ranjan Avinash 1 , Robin Victor 1 , Praveen Rikhari 1 , Simrat Kaur 1 Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, 1 Department of Psychiatry, Himalayan institute of medical sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India Background: Delusional Disorder is characterized by the presence of persistent, systematized delusions lasting at least 1 month, typically in the absence of prominent mood symptoms, formal thought disorder, or negative symptoms. While auditory hallucinations are commonly described in psychotic disorders, olfactory hallucinations are relatively rare in primary psychiatric conditions and are more often associated with organic aetiologies. In the Indian sociocultural context, sensory experiences are frequently interpreted through culturally sanctioned beliefs such as black magic or contamination with Vibhuti (sacred ash). Case Details: Here we report a case of 32-year-old married female from a rural, lower-middle socioeconomic background presenting with suspiciousness, sleep disturbance, and odd behaviour of 3.5 months duration. Detailed clinical interview, collateral history, mental status examination, and diagnostic evaluation using DSM-5-TR was undertaken. She was diagnosed with delusional disorder persecutory type first episode currently in acute episode. The patient exhibited complex, systematized delusions of persecution and sexual assault involving family members. She reported persistent foul odours resembling dirty socks or faeces, attributed to Vibhuti allegedly used to harm her. Safety behaviours included food restriction, burning clothes, sealing doors, and increased religiosity. Mental status examination revealed dysphoric affect, intact cognition except impaired abstraction and judgment, and poor insight (1/5). Treatment with haloperidol resulted in partial improvement in sleep but persistent delusional beliefs. Conclusion: This case illustrates how olfactory hallucinations can act as sensory confirmation of persecutory delusions within a cultural framework. Careful phenomenological assessment is essential to differentiate Delusional Disorder from schizophrenia and to guide appropriate management.

Too

Ayushi Goyal, Kunal Kumar, Abhinit Kumar, Nikhil Nayar School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India Dissociative disorders in children often present as striking motor symptoms in response to overwhelming psychological stress. We report the case of a 7-year-old male child who developed recurrent dissociative episodes characterized by abnormal body movements, generalized stiffness, and transient loss of voluntary motor functions. These episodes were consistently precipitated by school-related situations, particularly when the child was asked to attend school. There were no features suggestive of epilepsy, including loss of consciousness, incontinence, tongue biting, or post-ictal confusion. Neurological examination and investigations were within normal limits, ruling out an organic etiology. Psychosocial assessment revealed significant stressors in the form of persistent bullying by teachers and peers, resulting in marked fear and school avoidance. A diagnosis of dissociative disorder was established. Management involved psychoeducation, supportive psychotherapy, stressor identification and modification, and liaison with school authorities. The child showed significant improvement with a reduction in dissociative episodes. This case highlights the impact of school-based bullying on child mental health and emphasizes early recognition of dissociative disorders in pediatric populations.

Use

Kartik Chaudhary, Sudipta Kumar Das, Udit Kumar Panda, Shikha Adil Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India Background: Withdrawal and craving management in Alcohol Dependence Syndrome (ADS) with chronic liver disease (CLD) is challenging. Gabapentin, which is excreted via renal route without hepatic involvement, has demonstrated efficacy in reducing craving and withdrawal symptoms in ADS. Evidence is limited for it’s use in comorbid ADS and CLD. Aims: To evaluate clinical outcomes and safety of extended-release gabapentin in patients with ADS and compensated CLD. Methods: Prospective case series of 12 patients with ADS and compensated CLD (Child-Pugh A) (mean age 48.3±7.2 years; all males) who were prescribed Gabapentin ER. The dose was titrated to 600-1200 mg/day based on response and tolerability. Assessments at baseline and 8 weeks included drinking patterns, sleep quality, neuropathic symptoms, liver function, VASC and HAM-A scores. Results: All 12 patients completed 8-week follow-up. Three patients (25%) achieved abstinence; nine (75%) demonstrated >70% reduction in average number of standard drinks. Mean VASC decreased from 7.8±1.4 to 3.2±1.8. Five patients (42%) reported anxiety improvement; six (50%) had better sleep quality. Among three patients with baseline neuropathy, two (67%) experienced subjective symptom relief. Benzodiazepine co-prescription (n=5) was tapered successfully in four patients. No hepatic decompensation occurred and liver parameters remained stable. Side effects included mild dizziness (25%) and daytime somnolence (17%). Conclusion: Gabapentin ER showed hepatic safety and moderate improvements in craving and drinking outcomes in ADS with compensated CLD. The once-daily formulation may enhance adherence as compared to immediate-release preparations. With baclofen and acamprosate showing limited efficacy, gabapentin’s renal metabolism supports further investigation as therapeutic alternative.

Bdnf

Nikhita Shettar, Raghavendra B. Nayak, Vijay Yenagi Dharwad Institute of Mental Health and Neurosciences, Dharwad, Karnataka, India Background: The brain-derived neurotrophic factor (BDNF) gene on chromosome 11p13 has several SNPs linked to bipolar disorder. Patients show reduced BDNF levels, making it a potential biomarker. The rs6265 (Val66Met) polymorphism involves a Val†’Met substitution at codon 66, impairing BDNF secretion and activity. Another BDNF variant, rs1048218, has been associated with depressive disorders, further highlighting BDNF’s role in mood pathology. Objective: To study BDNF gene SNPs in bipolar disorder. Methods: Study was conducted in tertiary level psychiatric teaching institute, single centre study. 31 adults (aged 18-45 years) with bipolar disorder diagnosed as per ICD-11 criteria, irrespective of sex, were genotyped using sanger sequencing for two BDNF single-nucleotide polymorphisms (rs1048218 and rs6265) :5 ml blood sample was collected for genetic analysis. Scales used for assessment: Hamilton Depression Rating Scale, Young Mania Rating Scale. Results: In the final data comprising 31 samples, sequence analysis revealed that rs6265 exhibited a C†’A substitution in 5 (16%) individuals and a C†’T substitution in another 5 (16%) individuals. At the rs1048218 locus, 3 (10%) individuals showed a C†’G nucleotide change. Collectively, 13 of the 31 samples (42%) demonstrated SNP variations across the two loci analysed. Conclusions: More than 2/3rd had BDNF gene polymorphism, suggesting potential contributory factors in bipolar disorder. As this was a pilot study, the findings highlight the need for further research focusing on BDNF-related genetic variants.

Case

Bhagyashri Ravindra More, Aneesh Bhat MIMER Medical College and BSTR Hospital, Pune, Maharashtra, India Background: Mephentermine, chemically known as N,2-dimethyl-1-phenylpropan-2-amine, is a sympathomimetic amine structurally related to amphetamine and methamphetamine. It acts as an alpha-adrenergic receptor agonist, exerting both direct and indirect effects on noradrenergic receptors by promoting norepinephrine release. Mephentermine has been used to enhance performance in competitive sports and bodybuilding. However, there is limited literature regarding its abuse and dependence. Here, we present a case of mephentermine dependence in a young Indian adult male. Case Report: A 26-year old male gym instructor initially abused injectable mephentermine as a performance enhancer. However, after two years of abuse and dependence on the drug, he began experiencing its negative effects and a decline in performance. Detailed psychiatric evaluation revealed no other psychiatric disorders. He met the diagnostic criteria for substance dependence as described in the ICD-10. The patient was managed on an outpatient basis, with psychoeducation provided to him and his family regarding the risks of mephentermine use and strategies for discontinuation. Conclusion: This case highlights that mephentermine, a commonly used vasopressor, can be abused and lead to dependence in certain individuals, potentially resulting in significant physical and psychiatric manifestations. Awareness about the risks of mephentermine abuse is limited. Efforts are needed to educate the public and healthcare professionals on the potential for mephentermine dependence and effective management strategies. Key words: Competitive sports, dependence, mephentermine, performance enhancer

Deep

Sayon Mandal, Akansha Bhardwaj, Nand Kumar All India Institute of Medical Sciences, New Delhi, India Background: Obsessive-Compulsive Disorder (OCD) is a disabling psychiatric condition marked by recurrent obsessions and compulsive behaviours. Although pharmacotherapy and cognitive-behavioral therapy (CBT) remain standard treatments, a substantial subset of patients exhibit treatment resistance. Deep Transcranial Magnetic Stimulation(dTMS), has gained attention as a novel intervention targeting core neurocircuitry implicated in OCD. However, recent reports indicate that dTMS may, in some instances, exacerbate depressive symptoms or precipitate suicidal ideation, an effect that warrants further investigation. Aims and Methods: We report the case of a 39-year-old man with OCD and comorbid depressive symptoms who, after previously demonstrating favorable responses to medication and CBT, experienced a rapid intensification of depression and the onset of suicidal ideation following 28 sessions of dTMS administered with the H7 coil. Results: dTMS was discontinued, and the patient was hospitalized for Modified Electroconvulsive Therapy (mECT) with concurrent medication optimization. Post treatment, his depressive symptoms improved significantly, and suicidal ideations resolved. Treatment response for obsessive-compulsive symptoms was subsequently achieved through pharmacotherapy and psychotherapy. Discussion: This case highlights a rare yet clinically significant adverse reaction to dTMS in OCD. Although dTMS holds promise in modulating dysfunctional cortico-striatal-thalamo-cortical circuits, inadvertent engagement of mood-regulatory networks may, in susceptible individuals, precipitate destabilizing affective responses. Neuroanatomical variability or maladaptive downstream effects of stimulation may contribute to this paradoxical reaction, though underlying mechanisms remain unclear. Systematic exploration of the downstream network effects of dTMS is needed to elucidate the neurobiological basis of such adverse outcomes and to guide the development of safer, precision-oriented stimulation protocols.

Dose

Archana Chauhan, Prateek Yadav, Vinay Singh Chauhan, Shilpa Mandal Armed Forces Medical College, Pune, Maharashtra, India Background: Depression is a prevalent mental health disorder affecting 3.8% of the global population, with higher rates in women and older individuals. The World Health Organization projects depression will become the second-leading cause of global disease burden by 2030. Antidepressant medications, such as sertraline, mirtazapine and venlafaxine have a variable efficacy and play a vital role in managing moderate to severe depression. This study aims to evaluate the dose-response association of these drugs over 8 weeks. Methods: This observational study included 100 drug-naive patients diagnosed with depression according to ICD-10 criteria at a tertiary care hospital. Patients were started on sertraline or mirtazapine or venlafaxine based on clinical judgment. The Hamilton Rating Scale for Depression (HAM-D) was used to assess depression severity at baseline, 4 weeks and 8 weeks. Doses were adjusted based on clinical response and the response was analyzed. Results: At baseline, 73% of patients had moderate depression, and 27% had severe depression. The dose of antidepressants was up-titrated to mean dose of 122.9mg of Sertraline, 23.6mg of Mirtazapine and 119.4mg of Venlafaxine which resulted in the highest reduction in HAM-D scores (61%) in cases on sertraline, followed by mirtazapine (58%) and venlafaxine (43%). No significant association between sociodemographic variables and treatment response was found. Conclusion: Sertraline, mirtazapine, and venlafaxine all showed significant improvements in HAM-D scores over 8 weeks, with a positive dose-response association up to 150 mg, 45 mg, and 187.5 mg, respectively, not influenced by socio-demographic factors. Key words: Dose-response, mirtazapine, sertraline, venlafaxine

Dual

Satya Rama Vikramaditya Tennety, Bheemsain Tekkalaki Jawaharlal Nehru Medical College, Belgaum, Karnataka, India Introduction: Psychosis in the context of structural brain disease is diagnostically and therapeutically challenging. Brain arteriovenous malformations (AVMs) can cause neuropsychiatric sequelae via hemorrhage, ischemia, or postoperative changes. Chronic alcohol dependence further complicates the clinical picture by contributing to cognitive impairment, mood disturbance, and psychotic symptoms. This case highlights psychosis arising at the intersection of a treated brain AVM and long-standing alcohol dependence. Case Report: A 44-year-old man, presented with a 10-year history of schizophrenia-like psychosis with secondary depressive symptoms. His illness began after his first seizure, which led to the diagnosis of a brain AVM. He had a 7-year history of alcohol dependence prior to this, suggesting the seizure may have been alcohol-withdrawal related. Following decompressive craniotomy, psychotic symptoms delusions of infidelity, persecutory and referential delusions, second-person auditory hallucinations, and thought disorganization emerged and progressed. Functionally, he had unemployment, anhedonia, crying spells, death wishes, and two episodes of deliberate self-harm. Symptoms persisted despite sustained abstinence from alcohol. Pharmacological trials with trifluoperazine caused extrapyramidal symptoms, while olanzapine and depot flupentixol offered partial benefit. ECT, administered as eight sessions across two admissions, produced significant improvement. Clinical course remained complicated by alcohol use, poor adherence, and inconsistent follow-up. Discussion and Conclusion: This case illustrates psychosis driven by converging structural and substance-related factors. AVM-related neurovascular disruption likely contributed to persistent symptoms, compounded by long-standing alcohol dependence. Pharmacological resistance and robust ECT response emphasize the role of neuro-modulatory interventions. Early neuropsychiatric evaluation, integrated alcohol management, and multidisciplinary follow-up are critical for optimizing outcomes in such cases.

Fear

Cheepati Vineela Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Violence associated with untreated psychosis is uncommon but clinically significant, particularly when driven by persecutory and referential delusions. Misinterpretation of threat may lead to extreme defensive behaviors. Aim: To describe a case of delusion-driven homicide and highlight psychopathology, diagnostic considerations, and preventive implications. Results/Discussion: A 30-year-old male killed his mother and brother under the belief that they were devils capable of reading his thoughts and intending to kill him. Even after the act, he maintained that they might return to harm him. Psychopathology revealed persecutory delusions, delusion of thought broadcasting, and impaired reality testing, consistent with schizophrenia. There was no evidence of misidentification syndromes such as Fregoli syndrome. The act represented fear-driven violence secondary to untreated psychosis. Conclusion: This case underscores the lethal potential of untreated delusions. Early diagnosis, strict treatment adherence, and regular psychiatric follow-up are crucial in preventing violence and improving long-term outcomes in Schizophrenia.

From

Swarna Neetu Deepthi, Nekkanti Nimeesha Guntur Medical College, Guntur, Andhra Pradesh, India Background: Darier’s disease, a rare autosomal dominant keratinization disorder caused by ATP2A2 mutations, presents with keratotic papules, plaques and nail changes and is increasingly linked to psychiatric symptoms, including mood disturbances and psychosis, likely due to shared neuronal calcium regulation abnormalities. Aim: To highlight the mind-skin link in Darier’s disease with psychosis and stress the need for early multidisciplinary care, as stress can worsen skin symptoms and trigger psychosis. Methods: A 47-year-old woman with Darier’s disease who presented with a 2-month history of symptoms that had intensified over the past week, including irritability, anger outburts, poor self-care, reduced sleep and appetite, talking and laughing to self, wandering behaviour, hallucinations, and delusions, was precipitated by a trigger, with a similar complaints reported 3 months earlier and a positive psychiatric family history. A detailed clinical, dermatological, and psychiatric evaluation was performed. Routine laboratory tests, CT brain, neuroimaging, skin biopsy were conducted, confirming Darier’s disease with no neurological abnormalities. Results: The patient showed marked improvement with antipsychotic and dermatological treatment during inpatient care and remained stable on follow-up. Conclusion: This case emphasizes link between Darier’s disease and psychosis, often triggered by stress, and underscores the importance of early recognition and coordinated dermatology-psychiatry care for optimal outcomes.

Harm

Himanshu Sahu, Subhendu Datta, Supartha Barua, Nitu Mallik Medical College Kolkata, Kolkata, West Bengal, India Background: Obsessive-compulsive disorder (OCD) is a heterogeneous psychiatric illness characterized by intrusive thoughts and repetitive behaviors performed to reduce anxiety. Harm-related obsessions form a recognized subtype, however, presentations involving repetitive biting behavior directed toward others are rare and diagnostically challenging. Aims: To describe a rare presentation of harm-related obsessive-compulsive disorder in a middle-aged female presenting with obsessive biting behavior toward her spouse. Case: A 54-year-old married female presented to the psychiatry outpatient department with a one-year history of recurrent, intrusive urges to bite her husband, associated with severe anxiety and distress. The patient experienced transient relief after biting, followed by guilt and fear of causing harm. She attempted to resist the urges by restraining herself and avoiding close contact. There was no history of psychosis, mood disorder, substance use, or neurological illness. Mental status examination revealed anxious affect, preserved insight, and intact reality testing. Routine laboratory investigations and imaging were within normal limits. A diagnosis of harm-related obsessive-compulsive disorder was made. Results: The patient was treated with a tab Fluoxetine started with 20 mg then increased to 40 mg and cognitive-behavioral therapy. There was marked reduction in obsessive urges, anxiety, and biting behavior, with improvement in interpersonal functioning. Conclusion: This case highlights an unusual phenomenological variant of harm OCD. Early identification and appropriate treatment can reduce morbidity and prevent interpersonal harm.

High

Manshi Kakrania, Rashi Agarwal, Tarun Pal Lala Lajpat Rai Medical College, Meerut, Uttar Pradesh, India Background: With the rapid expansion of online trading platforms, an increasing number of individuals are engaging in high-frequency stock, forex, and cryptocurrency trading. Although often perceived as a legitimate and socially acceptable activity, excessive trading shares several behavioural and psychological features with gambling, potentially predisposing individuals to significant mental health problems. Aim: To examine how problematic trading behaviours contribute to psychological distress, functional impairment, and psychiatric morbidity. Methods: A cross-sectional, observational study design was adopted to assess impulsive trading behaviours and their association with psychiatric comorbidities among adults engaged in active financial trading. HAM-A, HAM-D, BIS-11 and G-SAS were used to analyse comorbid mood, anxiety, and substance-use disorders associated with impulsive nature to trade. Results: It is noticed that traders exhibit loss of control, preoccupation with market activity, chasing losses, and withdrawal-like symptoms when unable to trade, leading to elevated stress, sleep disturbances, irritability, depressive symptoms, and social/occupational dysfunction. High-risk groups include individuals with baseline impulsivity, emotional dysregulation, financial insecurity, or prior gambling behaviour. Neurobiological parallels with gambling disorder particularly dopaminergic reward anticipation highlight the addictive potential of trading. Conclusion: Problematic trading is an emerging behavioural addiction with significant mental health implications. Early identification, clinician awareness, and development of screening tools specific to trading-related harms are urgently needed. Integrating behavioural addiction frameworks into routine psychiatric assessment may help mitigate long-term psychological and socioeconomic consequences.

Hima

NRI Academy of Sciences, Guntur, Andhra Pradesh, India Background: Caregiving for individuals with schizophrenia is a huge burden, and resilience is a key protective factor. Brief resilience scale (BRS) assesses resilience, and has been translated and validated in various languages and has good psychometric properties. There is a dearth of validated scales to assess caregiver burden and its related psychological factors like resilience in Telugu states. Aim: To validate the Telugu version of BRS. Methods: The six item English BRS scale was translated based on World Health Organization guidelines for translation and adaptation of rating scales. Translated scale was rated by 124 Telugu speaking caregivers of schizophrenia patients across three centers over a period of one year. R language was used to perform Exploratory Factor Analysis (EFA) with oblimin rotation and Cronbach’s alpha was calculated to assess internal consistency. Results: Assumptions for the EFA were analyzed using the Kaiser-Meyer-Olkin (KMO) test (for sampling adequacy), Bartlett’s test of sphericity (for inter-item correlation significance), and the communality assessment (for the strength of factor extraction). EFA revealed that the items of BRS scale were significantly loaded onto two factors with eigenvalues of 1.99, and 1.81, and one is explained by method factor, which together explain 63% of the total variance. Cronbach’s alpha for the scale was 0.84, indicating good internal consistency. Conclusion: Telugu translated BRS demonstrated a reliable two-factor structure with good psychometric properties, confirming its validity for assessing resilience. Key words: Adaptation, brief resilience scale, rating scales, reliability, resilience, South India, validity

Lost

Deepa Gupta, Shipra Singh, Rishi Biswanath IHBAS, Delhi, India Abstract People with untreated schizophrenia may become lost within legal and social systems, especially when they lack documentation or identifiable contacts. Their disorganized behaviour may be misinterpreted as criminal intent, leading to police involvement rather than healthcare referral. Effective treatment, however, can restore functioning and allow for identification, rehabilitation, and reintegration. The following cases illustrate this trajectory. Case 1: A’ 42-year old unidentified man was found attempting to set fire to a vehicle. Police perceived him as dangerous, but assessment revealed he was burning garbage reflecting his impaired judgment. Antipsychotic improved coherence and insight, enabling him to share accurate personal details and return home with police assistance. Case 2: V’ 32-year-old male, engineer in Canada, was found wandering streets and he was discovered sitting on a stranger’s porch, leading to police involvement and subsequent deportation to India due to inability to verify identity. Evaluation revealed psychotic symptoms and impaired reality testing. With treatment, he showed marked improvement. He was eventually discharged in the care of his father. Case 3: A’ 35-year-old unidentified man was brought from a forest area where a corpse was found nearby. He exhibited marked withdrawal and negative symptoms. With rtreatment, his symptoms subsided, he eventually provided his father’s contact number. With police assistance, he was reunited with his family after clinical stabilization. Discussion These three cases emphasize how untreated psychosis can leave individuals vulnerable - misidentified as criminals, separated from family, or displaced across regions or countries.

Love

Akanksha Ghoshal Central Institute of Psychiatry, Kanke, Jharkhand, India Background: Psychotic disorders often arise from the interaction of psychosocial stressors with individual vulnerabilities. Romantic rejection is a stressor that undermines self-esteem and precipitates psychiatric decompensation. This vulnerability is relevant in young adults, for whom romantic relationships determine identity formation. Young professionals like engineers may succeed scholastically yet remain underprepared for emotional challenges. Limited interpersonal skills and restricted support systems heighten stress responses, manifesting as psychotic symptoms. Objectives: To describe four cases of young engineers developing psychosis following romantic rejection, highlighting the role of poor coping, limited social interactions, and maladaptive personality traits in symptom onset and persistence. Methods: Four consecutive cases were evaluated in a tertiary-care institute. Sociodemographic, clinical, and psychosocial information was gathered through interviews and collateral reports, with focus on coping patterns, social functioning, and treatment course. Results: All four patients were young male engineers, academically successful and professionally established, without prior psychiatric or substance-use history. Each developed acute psychotic symptoms such as persecutory delusions, ideas of reference, and disorganized behavior, within days of romantic rejection. Similarities included restricted peer networks, minimal romantic experience, and reliance on academic/professional success for self-worth. Traits of rigidity, perfectionism, and poor emotional regulation impeded adaptation. Improvement on antipsychotic medication was partial, suggesting unresolved stress and inherent vulnerability causing symptom persistence. Conclusion: This case series underscores that intellectual competence doesn’t ensure emotional resilience. Romantic rejection, with inadequate coping, limited social support, and personal vulnerabilities, acted as a stressor precipitating psychosis. A comprehensive biopsychosocial approach including psychotherapy, SST and family psychoeducation is essential.

Post

Rubina Khan, Dipanwita Biswas 1 , Iftekhar Anzoom 1 Calcutta National Medical College and Hospital, 1 Calcutta National Medical College, Kolkata, West Bengal, India Background: Fahr’s syndrome is a rare neurodegenerative disorder marked by idiopathic bilateral intracranial calcifications, most commonly affecting the basal ganglia, and is associated with a spectrum of neuropsychiatric manifestations. Postpartum psychosis, presenting acutely in the early puerperal period, is a psychiatric emergency with dominating affective and psychotic symptoms. The co-occurrence of these two conditions is exceptionally rare and diagnostically challenging. Aims: To highlight the importance of organic screening in postpartum psychosis and to underscore neuroimaging’s role in uncovering secondary causes. Methods: A 20-year-old primiparous woman presented two weeks after delivery with acute-onset restlessness, mood lability, persecutory delusions, and insomnia. There was no prior psychiatric or relevant family history. Neurological examination revealed mild extrapyramidal features. Routine laboratory evaluation, metabolic work-up including calcium and parathyroid hormone, and CT imaging were conducted. Results: Neuroimaging revealed symmetrical calcifications in bilateral basal ganglia and cerebellar dentate nuclei. The patient was diagnosed with postpartum psychosis secondary to Fahr’s syndrome. Multidisciplinary management included low-dose antipsychotic and mood-stabilizer therapy. Conclusion: This case highlights the value of comprehensive evaluation, including neuroimaging, in cases of new-onset or atypical postpartum psychosis. Early identification and management of underlying organic pathology like Fahr’s syndrome can be lifesaving and improve long-term outcomes in such rare co-occurrences.

Pres

Mimansa Maheshbhai Vaghela, Naren Amin, Reema Vasani 1 C U Shah Medical College and Hospital, 1 Department of Psychiatry, C. U. Shah Medical College and Hospital, Surendranagar, Gujarat, India Email: [email protected] Background: Posterior reversible encephalopathy syndrome (PRES) is a neurological condition characterized by headache, seizures, altered sensorium, visual disturbances, with radiological evidence of vasogenic edema. While commonly associated with hypertension, toxic exposures, autoimmune conditions, its occurrence in patients with psychotic spectrum disorders receiving multiple antipsychotics is rare and challenging, especially when extrapyramidal symptoms overlap clinically. Case Report: A 39 year-old female with a 5 month history of psychiatric illness receiving HALOPERIDOL 10MG, LORAZEPAM 2MG, TRIFLUOPERAZINE 15MG, CHLORPROMAZINE 150MG, and TRIHEXYPHENIDYL 6MG presented with staring look,decreased communication,irrelevant speech,fearfulness, suspiciousness,persecutory delusion,and auditory hallucinations. Following suspected ingestion of an unknown compound, she developed severe extrapyramidal symptoms including rigidity, mutism and subsequently became non-responsive, warranting ICU admission. Neuroimaging findings were suggestive of PRES. Antipsychotics were withheld and supportive ICU management was initiated, resulting in gradual clinical improvement. With regular follow-ups, the patient is currently well maintained on medications. Discussion: This case emphasizes the need to recognize PRES as a possible neurological complication in patients with psychotic disorders on multiple antipsychotics, particularly when extrapyramidal features mimic or mask neuroleptic adverse events. Early identification, removal of potentially offending medications, blood pressure optimization, intensive supportive care are essential for reversibility and favorable outcomes. Key words: PRES syndrome; extrapyramidal symptoms; psychotic spectrum disorder, multiple antipsychotic medications; ICU management; case report.

Role

Shweta Kiran, Priyam Sharma 1 , Shipra Singh 2 , Om Prakash 2 , R. K. Dhamija 2 Tele-MANAS, 1 Mentoring Institute, Tele-MANAS, IHBAS, 2 IHBAS, Delhi, India Background: Suicide is a major contribution for various Mental illnesses. It is a complex phenomenon with no single etiology.(1) . Each year ~727000 lives are lost to death by suicide worldwide.(2)Across India a total of 1 lakh people die by suicide, while a major chunk of the population attempted to end their lives, hence requiring a pressing need for help and intervention. In the wake of the COVID-19 pandemic, the GOI (MoHFW) came up with Tele-MANAS (Tele mental health Assistance and Networking across States) which serves as a digital arm of the NMHP, which offers 24/7, free mental health support via telephone services, ensuring callers to reach out in the hour of crisis by dialing a toll free number 14416. (3) Aim: to assess the contribution of Tele-MANAS in preventing Suicide. Methodology: This case series includes 5 callers who presented with active self-harm thoughts to Tele-MANAS Delhi. The cases were obtained from the records maintained at the State Cell. Results: All the callers presented with high-risk behavior in the form of active ideation associated with recent stressors. Tele-MANAS counsellors approached the callers using crisis interventions and further involvement of Mental Health Professionals who de-escalated the distressed callers and ultimately made that the callers reached the nearest MHE with the help of care giver or the Police. Conclusion: This case series highlights the vital role of Tele-MANAS in responding to impending self-harm through telephonic crisis intervention and strengthening the outreach facilities.

Ssri

Jesmin Sobnam, Sumedha Roy 1 Institute of Psychiatry, IPGME and R and SSKM Hospital, 1 Institute of Psychiatry, Kolkata, West Bengal, India A 48 years old male patient presented with complaints of disturbed sleep at night. His mother reported that he slept with her and at night he would suddenly start kicking his legs, throwing his hands and legs and would often shout. He often changed postures in sleep and also fell down from bed on few occasions. His mother had often been kicked by him and hurt herself. These events were occurring for last 1 year, and for last 6 months has increased in frequency occurring almost every night. It occurs mostly after around 2-3 hours of falling asleep. On enquiry regarding his medications, he said that he was on Tablet Fluoxetine 20mg for last 1 year as he was having symptoms of anxiety and some repeated thoughts of checking if the door was unlocked.He reports that his symptoms did begin after sometime of starting the medicine. But his anxiety symptoms and checking had greatly improved with the medicine. Treatment started with stopping T.Fluoxetine and T.clonazepam (0.5mg) was added at bedtime and the Behavioural therapy was initiated for his anxiety. On follow up after 2 weeks he reported sleeping well and no abnormal acitivites in sleep.The patient’s history is compatible with REM sleep behaviour disorder and as the patient showed improvement after stopping Fluoxetine,it is possibly Serotonin reuptake inhibitors(SSRI) Induced.Thus it suggesting a role of the serotonergic system in the pathogenesis of REM Sleep Behaviour Disorder.

Uric

Mohd Nahid Irshad, Om Prakash, Rachna Agarwal, Suman S. Kushwaha, Amit Khanna Institute of Human Behaviour and Allied Sciences, Delhi, India Background: Depression and Dementia is thought to be the result of genetic predisposition combined with environmental interactions, and the oxidative stress may be one of its pathogenesis. Oxidative stress can lead to decreased brain neurogenesis and increased neuronal apoptosis and it can affect the activity of 5-HT neurotransmitters and the metabolic pathways of monoamine neurotransmitters. Serum Uric acid is a strong antioxidant that provides more than 60% antioxidant activity in plasma. Aim: This study aims to ascertain difference in uric acid level in LOD and Alzheimer’s dementia in comparison to normal elderly. Methods: The study included 42 LOD cases and 41 Alzheimer’s dementia cases in comparison with 41 normal elderly individuals diagnosed in accordance with ICD-10 recruited at IHBAS (tertiary care hospital).. The Serum uric acid (SUA) value was derived from fasting plasma samples analysis. The level of SUA of all the participants was quantified using automatic biochemical analyzer. Data were analyzed by SPSS using Shapiro wilk test and Kruskal wallis test. Results: Uric acid levels did not differ significantly between late onset depression, dementia, and normal elderly groups (Kruskal-Wallis H = 0.435, p = 0.804), suggesting no association between uric acid and diagnostic category in the study population. Uric Acid Profiles Across Normal Elderly, Alzheimer’s Dementia, and Late-Onset Depression: A Cross-Sectional Study Overall, the absence of significant group differences suggests that serum uric acid does not independently differentiate late-life depression, dementia, and healthy aging, likely due to its non-specific nature and large physiological variability but warrants further investigation in larger samples. Key words: Alzheimer’s dementia, biomarker, late-onset depression, uric acid

When

Yendluri Chidvilas, Sindhuja Omkaram, Rokkam Kishore Kumar Santhiram Medical College and General Hospital, Nandyala, Andhra Pradesh, India Introduction: Tolosa-Hunt Syndrome (THS) is a rare, idiopathic granulomatous inflammatory disorder of the cavernous sinus and orbital apex that may initially mimic primary headache syndromes or psychiatric conditions. Hemicranial pain, sleep disturbance, and mood symptoms arising during periods of emotional stress can obscure early neurological signs, delaying diagnosis. Summary: The patient reported a year-long history of left-sided hemicranial pain and recent onset of low mood, worrying thoughts, and fragmented sleep following her husband’s death. Subtle but significant neurological findings including ptosis and pain-limited ocular movements prompted MRI evaluation. Imaging revealed T2 hypointense, enhancing soft tissue thickening involving the orbital apex, superior orbital fissure, and cavernous sinus, with inflammatory narrowing of the internal carotid artery. Extensive exclusion workup ruled out IgG4-related disease, myasthenia gravis, thyroid ophthalmopathy, and vascular stenosis. High-dose corticosteroids led to rapid improvement in pain and ocular symptoms, while sertraline and short-term sleep support addressed her psychiatric symptoms. This case describes a 55-year-old woman who first presented to psychiatry with depressive features and insomnia before characteristic imaging findings confirmed THS. Conclusion: This case underscores the importance of maintaining suspicion for organic etiologies in patients presenting with unilateral headaches and mood symptoms. Early identification of cranial nerve involvement, appropriate imaging, and integrated neurology-psychiatry management are essential for timely diagnosis and optimal outcomes in Tolosa-Hunt Syndrome. Key words: Cavernous sinus inflammation, cranial neuropathy, hemicranial pain, MRI, psychiatric presentation, tolosa-hunt syndrome

Acute

Pragati Suryakant Karande, Roshan Phillip Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India Background: Severe hypothyroidism may rarely manifest with prominent psychiatric symptoms, including psychosis, paranoid delusions, hallucinations, and behavioral disturbances, collectively termed myxedema psychosis. These presentations are frequently misidentified as primary psychotic disorders, leading to delayed diagnosis and treatment. Aims: To present a case of acute psychosis secondary to severe hypothyroidism and the importance of routine thyroid evaluation in individuals presenting with psychosis. Methods: A 50-year-old male with a known history of hypothyroidism, non-adherent to medication for five years, presented with a six to seven month history of irritability, disturbed sleep, persistent suspiciousness, muttering behavior, and physical aggression.There was no past or family history of mental illness.clinical assessment and relevant biochemical investigations were undertaken. Results: Thyroid function tests revealed severe hypothyroidism, with markedly reduced FT3 and FT4 levels and a TSH level exceeding 100 mIU/L. Thyroid ultrasonography showed an atrophied right lobe and a TIRADS IV nodule in the left lobe. A diagnosis of psychosis secondary to severe hypothyroidism was established after excluding schizophrenia, delusional disorder, and substance-induced psychosis. The patient was initiated on olanzapine, lorazepam as required, and levothyroxine 50 µg daily, along with supportive care. Over the subsequent days, he demonstrated significant improvement in irritability, suspiciousness, sleep, appetite, and a marked reduction in hallucinations and aggression. Conclusion: Myxedema psychosis is an uncommon but reversible cause of acute psychosis. Early recognition and timely thyroid hormone replacement, supplemented with short-term antipsychotic therapy, lead to rapid clinical recovery.

Basal

Aabid Parvaiz, Abdul Majid SKIMS MCH, Srinagar, Jammu and Kashmir, India Background: Panic disorder is a common anxiety disorder that typically responds to pharmacological and psychotherapeutic interventions. In cases where symptoms are resistant to treatment, it is essential to reassess the diagnosis and evaluate for underlying medical or organic causes that may contribute to psychiatric manifestations. Case Description: A 45-year-old male smoker, normo-tensive, non-diabetic, and euthyroid, presented with a two-year history of recurrent panic attacks. Despite adequate trials of standard psychotropic medications, the patient showed no significant clinical improvement. Laboratory evaluation revealed elevated hemoglobin levels (17 g/dL), for which therapeutic phlebotomy was performed considering secondary polycythemia. However, this intervention did not alleviate his panic symptoms. During physical examination, a lesion was noted on the dorsum of the nose. A skin punch biopsy of the lesion confirmed basal cell carcinoma. The patient underwent wide local excision of the lesion. Outcome: Following surgical excision, the patient exhibited a drastic and immediate improvement in panic attacks, with marked reduction in both frequency and severity. Conclusion: This case highlights a possible association between basal cell carcinoma and treatment-resistant panic disorder, with complete resolution of symptoms following tumor excision. It underscores the importance of evaluating underlying medical conditions in refractory psychiatric presentations.

Belly

Pariniti Khillan, Porimita C. Gogoi PGIMER, Chandigarh, India Background: Dystonia is a syndrome of sustained, often painful muscular spasms, producing repetitive, twisting movements, or abnormal postures, that develop following exposure to antipsychotic medication. Acute Dystonia develops within 5 days following antipsychotic exposure and responds rapidly to medication whereas the tardive form develops within weeks to months of antipsychotic exposure. Truncal dystonia is characterized by involuntary contractions and postures of the paraspinal, abdominal, and chest muscles, sometimes referred to as belly dancer syndrome. Aim To describe the case of a 40 year, old male with bipolar type one disorder since 15 years, presenting with involuntary truncal and abdominal movements since 2 months and discuss challenges in management. Methods: Patient presented to the outpatient department of a tertiary care hospital. Clinical assessment, relevant investigations, and standardized rating scales were used. Results: Despite chronic progressive dystonic posturing at baseline, the patient showed gradual improvement over 8 weeks following initiation of GABA analogues and anticholinergic medications. Mood stabiliser and antipsychotic were continued to prevent recurrence of mania. Dystonia resolved gradually over 8 weeks and a manic relapse at 10 weeks required cautious uptitration of antipsychotics under anticholinergic cover, with sustained remission of both manic and extrapyramidal symptoms over 4-5 months. Conclusions: Identification of and appropriate management of abnormal involuntary movements with judicious antipsychotic use and anticholinergic protection allowed safe control of mania with reduction in disabling dystonic movements.

Brain

Vasuda Gupta, Fiona Mahapatro, Sanjiv Kale DY Patil University School of Medicine, Navi Mumbai, Maharashtra, India Background: Brain granulomas can be associated with psychiatric manifestations. Patients may experience symptoms such as hallucinations, delusions, personality changes, cognitive impairment, mood disorders, and behavioral disturbances. They can provoke epileptiform activity on EEGs, which is linked to psychiatric symptoms including psychosis and mood disturbances. They may present with seizures, headaches, or psychiatric symptoms. Materials and Methods: The study is a cross sectional and observational study, conducted at a tertiary care centre. Patients of granuloma referred for psychiatric evaluation over 9 months were assessed. Detailed psychiatric evaluation including MSE was done, and diagnosis (if any) was made as per DSM 5. There were 7 patients in all, 6 patients had unconventional presentation. Results: Interesting findings emerged. Out of the 7 patients who had granulomas, 5 (71.43%) had seizure activity, 2 (28.57%) had comorbid depression-anxiety, 1 (14.29%) had schizophrenia, 1 (14.29%) had hyperactivity,1 (14.29%) had delirium. Conclusion: Since granulomas, seizure and psychiatric illnesses coexist, one has to be vigilant about the diagnosis. Consultation- Liaison by the treating physician and psychiatrist would entail a better prognosis. Key words: Granuloma, psychiatric symptoms, seizures

Brief

Pitta Samagnya, K. B. Ravi Kumar 1 Government Hospital for Mental Care, Andhra Medical College, 1 Department of Psychiatry,Government Hospital for Mental Care,Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Reactive obsessions are short-duration, stress-triggered intrusive thoughts that arise in response to identifiable external stimuli. They differ from spontaneous (autogenous) obsessions in Obsessive-Compulsive Disorder (OCD), which occur without clear triggers and follow a persistent, chronic course. Early differentiation is essential to prevent misdiagnosis and unnecessary pharmacological intervention. Aim: To report a case of brief reactive obsessions and clarify its differentiation from OCD. Methods (Case Summary): An 18-year-old female medical undergraduate with no past neuropsychiatric illness, no family history, and a premorbid personality without obsessive traits had no history of contamination fears, doubt obsessions, blasphemous thoughts, other sexual obsessions, and no compulsions. She presented with recurrent intrusive thoughts of male and female genital organs occurring continuously for two weeks, following one week of surgery postings in which she examined male and female sexual organs during physical examination. She experienced these thoughts in a continuous, recurrent pattern, which are unwanted, distressing, and ego-dystonic, with intact insight. There were no avoidance behaviours, mood symptoms, or functional impairment. Y-BOCS checklist and severity scores were within normal limits. Complete blood picture and thyroid function tests were normal. Results/Discussion: The presentation is consistent with brief reactive obsessions, characterised by sudden onset following a clear situational trigger, realistic content, preserved insight, absence of compulsions,spontaneous improvement . In contrast, autogenous obsessions in OCD tend to be trigger-independent, persistent, and often require treatment. Conclusion: The patient was managed with psycho education,reassurance,stress-management using a watchful waiting approach. Recognising reactive obsessions helps avoid unnecessary treatment and reduces distress.

Early

Ritwick Tripathi King George’s Medical University, Lucknow, Uttar Pradesh, India Background: Anorexia nervosa with comorbid depression is difficult to treat and places patients at high medical and psychiatric risk. Medication options are limited, and cognitive-behavioural therapy (CBT) may be less effective when depression is severe. These challenges have led to interest in neuromodulation approaches such as repetitive transcranial magnetic stimulation (rTMS), with early evidence suggesting benefit. Aims: To describe the role of early augmentation with bilateral rTMS alongside standard treatment in a patient with anorexia nervosa and comorbid depression. Methods: A 22-year-old woman with anorexia nervosa (body mass index [BMI] 14.7 kg/m²) and severe depression received multimodal treatment that included early rTMS augmentation of ongoing CBT and fluoxetine 60 mg/day. rTMS was initiated early to accelerate therapeutic response to standard treatment, an approach previously used in obsessive-compulsive disorder and major depression. Baseline assessments included the Hamilton Depression Rating Scale (HAM-D), Eating Disorder Examination-Questionnaire (EDE-Q) and BMI. She underwent accelerated bilateral dorsolateral prefrontal cortex (DLPFC) theta-burst stimulation (TBS; two sessions per day; left DLPFC intermittent TBS, 600 pulses/session; right DLPFC continuous TBS, 900 pulses/session) for a total of 40 sessions. Results: Both depressive and eating-disorder symptoms improved (HAM-D: 29±17; EDE-Q: 5.52±3.62), accompanied by better mood, sleep and eating behaviour. BMI increased to 16.9 kg/m² at discharge. The intervention was well tolerated, with no reported adverse effects. Conclusion: This multimodal approach, including early augmentation with accelerated bilateral rTMS, was well tolerated and associated with clinical improvement in a difficult-to-treat case. Larger controlled studies are needed to validate these findings.

False

Hillol Das, Ria Sen Calcutta National Medical College, Kolkata, West Bengal, India Background: Delusional parasitosis involves the false conviction of being infested by insects or parasites. Although commonly linked with primary psychiatric conditions, it can also occur secondary to medical and neurological disorders. In older adults with cognitive decline, potentially reversible contributors such as vitamin B12 deficiency may present with behavioral or psychotic symptoms that overlap with dementia, leading to diagnostic delay. Aims: To present a case where delusional parasitosis emerged in a patient with dementia and was subsequently found to be associated with significant vitamin B12 deficiency, and to highlight the need for metabolic screening in late-life neuropsychiatric presentations. Methods: Comprehensive assessment included clinical history, mental status examination, cognitive evaluation, dermatological inspection, and relevant laboratory tests. Serum vitamin B12 levels were measured, and neuroimaging was done. Management involved vitamin B12 supplementation along with supportive psychiatric care. Results: The patient exhibited persistent sensations and visual misperceptions of insects, leading to marked distress and self-injury from scratching. Cognitive symptoms appeared worsened during this period. Investigations showed low vitamin B12 levels, with no dermatological or infectious pathology. After initiating parenteral B12 therapy, there was a steady reduction in the delusional belief and associated behaviors, accompanied by improved alertness and engagement. Sustained improvement was observed during follow-up. Conclusion: This case underscores that delusional parasitosis in individuals with dementia may reflect an underlying, reversible vitamin B12 deficiency. Routine metabolic workup in atypical psychotic or behavioral symptoms in older adults is essential, as timely identification and treatment can lead to meaningful clinical recovery. Validation of Telugu version of brief resilience scale in caregivers of patients with schizophrenia: An exploratory factor analysis

Folie

Nikita Anand, M. Raghuram Varun Arjun Medical College, Banthra, Uttar Pradesh, India Introduction: Folie à deux, also known as shared psychotic disorder, is an uncommon psychiatric phenomenon in which a dominant individual with psychosis influences a closely connected partner to adopt identical delusional beliefs. Most often observed in relationships marked by emotional dependence and social isolation. Conjugal cases are rare and frequently overlooked, leading to delays in diagnosis. This case report describes a married couple who developed shared persecutory delusions, emphasizing clinical characteristics and therapeutic implications. Materials and Methods This descriptive case report was prepared using comprehensive psychiatric interviews, mental-status examinations, collateral information from family members, and review of available medical records. Diagnostic impressions were formed using ICD-11 and DSM-5 guidelines. Standard physical and neurological evaluations were conducted along with routine laboratory tests to exclude organic etiologies. Clinical progress was assessed during an inpatient admission where the couple was temporarily separated and treated individually. Results The husband, later identified as the primary patient, had longstanding untreated psychotic symptoms characterized by persecutory delusions involving neighbours and relatives. Over time, his wife who had no past psychiatric illness began sharing the same delusional system. The couple had minimal social contact outside their household, and the wife exhibited marked emotional dependence on her husband. During hospitalization, separation of the pair resulted in a rapid decline in the wife’s delusional conviction, accompanied by improved insight with supportive psychotherapy. The husband required antipsychotic medication, which produced partial symptom relief. No significant medical or neurological abnormalities were detected in either individual.

Ghost

Vikas Dhruwa, Siva Teja Reddy, S. Gopi 1 Andhra Medical College, 1 Department of Neurology, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Progressive Supranuclear Palsy is a neurodegenerative disorder characterized by early postural instability,vertical gaze palsy,axial rigidity, and cognitive deficits.Visual hallucinations are distinctly uncommon in PSP.When hallucinations do occur,they are typically linked to advanced disease,frontal lobe dysfunction,or medication effects.Evidence for antipsychotic treatment in PSP is limited,and most agents risk worsening motor symptoms. Aim: The aims is to highlight the rare occurrence of visual hallucinations in PSP and to examine the clinical rationale for using low-dose quetiapine to reduce hallucinations. The objective is to support clinical recognition of this unusual presentation and outline that quetiapine may be more beneficial than other agents. Methods: A 67 years old male came with complaints of sudden falls,slowness of activities since 2 years,on examination was having bradykinesia,vertical gaze palsy and tendency to fall back,upon history,clinical evaluation,imaging studies was diagnosed as PSP.Upon serial MSE was noted to have Visual hallucinations for which T.QUETIAPINE 50mg was started,and increased gradually to 300 mg/d. Results: The introduction of quetiapine 300 mg/day was associated with marked reduction in hallucinations,improved behavioral regulation.Compared to other antipsychotics,quetiapine demonstrated superior tolerability and adequate symptomatic control. Conclusion: Visual hallucinations in PSP represent an uncommon neuropsychiatric manifestation,often posing diagnostic and therapeutic challenges.This case report suggest that low-dose quetiapine may provide clinical reduction in hallucinations while maintaining motor stability, offering practical advantages over alternatives.

Mania

Prakrati Ratiya, Abhinav Agrawal Government Medical College and Hospital, Chandigarh, India Background: Organic (secondary) mania refers to manic symptoms that arise due to an identifiable medical or neurological condition .Abrupt onset of symptoms following head injury, seizure disorder, metabolic disturbance,etc, often provides diagnostic clues. Mr VM., 22/M, currently pursuing BBA, unmarried, unemployed, belongs to Christian Nuclear family of Upper Middle socio-economic status, Resident of Harare, Zimbabwe, presented with total duration of illness of 4 days, abrupt in onset, continuous course with precipitating factor not known characterized by irritability, over religiosity, increased energy, verbal and physical aggression, decreased need for sleep, grandiosity, increased energy,hearing voice not apparent to others with alleged history of fall 1 day ago associated with loss of consciousness,ENT bleed. Aims: 1. To Present a case of organic mania 2. To ensure medical stabilization and evaluate possible contribution of seizure disorder to current presentation. Methods: Setting: Inpatient psychiatric care. Assessment: Routine blood investigations, EEG, Surgery and medicine clearance. Intervention: Initiate T. Risperidone at 2 mg per day, with adequate benzodiazepine cover (T. Clonazepam 0.25 mg 1-1-1/1sos) along with anti epileptic, T Divalproex sodium 500mg (1-x-2) Neurology consult in view of abnormal awake EEG ?post ictal Results Within the inpatient stay, the patient showed rapid reduction in symptoms within 3-4 days of hospital stay. Conclusion: The abrupt onset of manic symptoms after head injury and a past seizure history indicated organic mania rather than primary bipolar disorder. The patient improved with antiepileptics, antipsychotics, and behavioural monitoring.

Manic

Ritika Deshmukh, Nagalakshmi Institute of Mental Health, Hyderabad, Telangana, India Background: Limbic encephalitis (LE) manifests with subacute neuropsychiatric symptoms, including mania, often mimicking primary psychiatric disorders. Misdiagnosis delays immunotherapy and worsens prognosis. Aims: Describe atypical manic onset of autoimmune LE in a 45-year-old male, highlight diagnostic features, and advocate early neuroimaging in new-onset mania with seizures. Methods: Case report of a 45-year-old male with abrupt manic symptoms: pressured speech, excessive spending, grandiosity, elevated self-esteem, reduced sleep need, racing thoughts, and distractibility. After 2-3 months, generalized seizures led to hospitalization. Investigations comprised MRI (bilateral medial temporal T2/FLAIR hyperintensities), cerebrospinal fluid analysis (lymphocytic pleocytosis), electroencephalography (temporal epileptiform discharges), and serum autoantibodies (anti-LGI1 positive). Results: Confirmed autoimmune LE without neoplasm. Immunotherapy with intravenous methylprednisolone, intravenous immunoglobulin, and rituximab controlled seizures and resolved mania within weeks. Partial memory recovery noted at 6 months; follow-up MRI showed hippocampal atrophy. Conclusion: Rule out LE in atypical mania via MRI, electroencephalography, and cerebrospinal fluid in progressive cases. Timely immunotherapy prevents chronic deficits and refines diagnostic practice.

Motor

Srujan Agravat Smt. NHLMMC, Ahmedabad, Gujarat, India Background: Tremors and gait disturbances in geriatric psychiatric patients can have multiple etiologies including psychotropics, mood-state-related motor slowing and neurodegenerative changes. These can resemble Parkinsonism and lead to unnecessary dopaminergic therapy. Distinguishing between these overlapping etiologies is essential yet challenging. Case Presentation: A 70-year-old woman with long-standing Bipolar 1 Disorder developed tremors, gait ataxia and psychomotor slowing while being stable on multiple psychotropics including Valproate, Escitalopram and atypical antipsychotics. Valproate was omitted for possible parkinsonism and was referred to neurology for the same, where she was trialed on dopaminergic therapy. She later developed increased anxiety and paranoid suspiciousness without improvement in motor symptoms, MRI Parkinson protocol and F-DOPA PET scan did not show evidence of dopaminergic degeneration. Suspecting medication induced motor symptoms, offending agents - Valproate, Escitalopram, and dopaminergic therapy were withdrawn. Her motor symptoms improved without the addition of new medications. Conclusion: This case illustrates the diagnostic complexity of evaluating motor symptoms in older adults with bipolar mood disorder. Addition of Escitalopram corresponded with the onset of tremors. Valproate is known to cause gait ataxia and can exacerbate parkinsonism in susceptible patients. Bipolar Depression can contribute to slowness. Such overlapping etiologies can mimic Parkinsonism. Such patients are sensitive to dopaminergic fluctuations - from both dopamine-blocking and dopamine-enhancing medications. Hence a broad differential, careful medication review, and confirmatory imaging are crucial before initiating dopaminergic therapy to save time, money and healthcare resources. Just rationalizing medications may be sufficient for symptom improvement.

Opiod

Neelima Majhi, Snigdha Awasthi, Sourav Khanra, Sanjay Kumar Munda Central Institute of Psychiatry, Ranchi, Jharkhand, India Background: Here we present a case of 34 year male who presented with compulsive eating and showed good response on naltrexone augmentation. Aim: To examine neurobiological link between OCD and compulsive eating and its possible treatment with naltrexone Methods: A 34 yr old male was admitted with complaints of low mood,feeling uncomfortable,spending excessive time and money on novel food items and eating,irritability and anger outbursts since 12 years.patient had a long history of being treated with different SSRIs,mood stabilizers and amisulpride upto 300mg with minimal response. An initial diagnosis of dysthymia and eating disorder unspecified was made. Serial MSEs revealed depressive ruminations,just right phenomena,death wishes and referential ideas.Body image issues and food addiction were ruled out. Diagnosis was revised to other OCD and tab Fluoxetine was started. History and psychometric tests were suggestive of impulse disturbance,sadistic tendencies,feelings of rejection,inferiority and depression. Subsequently the eating and shopping behaviour was conceptualised as a form of disordered impulse control and Tab Naltrexone was started. Results: Patient’s compulsive behaviour and mood improved by 30-40% and was discharged on above medicine The adjunctive treatment helped in reduction of compulsive eating and guardians reported reduction in demanding behaviour in subsequent follow ups. Conclusion: This case highlights intersection of impulsivity and compulsivity and how naltrexone can be used as a possible treatment option.

Pilot

Vaishali Miglani, Kanika Sukoon Health, India Background: Higher Education Institutes (HIEs) in India lack standardized, legally aligned frameworks for campus mental health crisis triage and emergency response. Effective systems must operate within the rights-based provisions of the MHCA 2017, emphasizing risk-stratified, functional-based care model. Aim To report the pilot implementation and feasibility of a risk-stratified, functional-based mental health triage and emergency management model, designed to be age, population & setting appropriate. Methods: A mandatory Foundational Assessment Protocol (FAP) and a three-tier triage framework Routine Support (Level 1), At-Risk (Level 2), and High Risk (Level 3) were implemented at O.P. Jindal Global University. The model was applied to 688 emergency mental health presentations over six months (June-November 2025). The FAP included detailed clinical history, Mental Status Examination, comprehensive risk assessment (C-SSRS/BSS), and functional impairment assessment (WHODAS/SOFAS). Level 3 cases triggered immediate stabilization, continuous observation, Health Centre transfer, parental supervision and MHCA emergency disclosures. Results Of 688 emergencies, 68.7% (n=473) were Level 1, 23.7% (n=163) Level 2, and 7.6% (n=52) Level 3. Health Centre transfer was required in 10.3% (n=71) of cases. The framework addressed 34 cases of suicidal ideation/attempt and 6 cases of acute psychosis. University Mandated Presence (UMP) was initiated in 4.2% (n=29) of students with persistent risk. Conclusion: This pilot demonstrates the feasibility and clinical utility of a risk-stratified, functional-based MHCA-aligned triage framework suitable for university settings. The Sukoon On Campus model offers a scalable and legally defensible template for emergency mental health care across Indian HEIs.

Serum

Priyanka, Nishtha Chawla 1 , Rizwana Quraishi 1 , Raman Deep 1 All India Institute of Medical Sciences, 1 Department of Psychiatry, All India nstitute of Medical Sciences, New Delhi, India Background: Purinergic system dysregulation has been implicated in the pathophysiology of bipolar disorder, with elevated serum uric acid (UA) levels reported particularly during the manic episodes. However, evidence from Indian clinical settings remains sparse. Aim: To assess and compare serum UA levels in patients with bipolar I disorder during a manic episode and healthy controls, and to examine its association with baseline clinical characteristics. Methods: This observational case-control study included 100 participants recruited from a tertiary care hospital. The case group comprised 50 patients aged 18-45 years with DSM-5-diagnosed bipolar I disorder, current episode mania (YMRS >12). Fifty healthy controls with no known illness were enrolled from the same setting. Baseline assessments included socio-demographic and clinical data, Young Mania Rating Scale (YMRS), Clinical Global Impression-Bipolar Version (CGI-BP), and Global Assessment of Functioning (GAF). Serum uric acid and relevant biochemical parameters were estimated. Results: Mean age was comparable between cases (28.72 ± 7.46 years) and controls (30.20 ± 6.11 years). Patients with mania had significantly higher baseline serum UA levels compared to healthy controls (6.57 ± 1.44 mg/dL vs 5.32 ± 1.51 mg/dL; p < 0.001). The diagnostic group effect remained significant after adjustment for sex, body mass index, and serum creatinine. Serum UA levels did not show a significant correlation with baseline YMRS, BVC, or GAF scores. Conclusion: Serum UA levels are significantly elevated during manic episode.

Seven

Pandit Devjyoti Sharma Mann Urja Clinic, Bhuj, Gujarat, India Background: Seven steps of yoga psychotherapy methods can be used at any time for relieving distress of the person suffering from negative affectivity. Aims: Seven steps of yoga psychotherapy are used for relieving distress and improving functioning & QOL by improving the ability to manage and control one’s- emotions to adapt to situations. Methods: Seven steps of yoga psychotherapy methods have been developed by combining eastern yoga philosophy with the western evidence based psychotherapies. Participants start practicing these seven steps sequentially by: 1. Relaxing body through movement meditation or Asana (postures) 2. Calming mind through deep breathing or pranayama (breath control) 3. Observing non-judgmentally that what is happening with thoughts, feelings and experiences without labelling them as good or bad, right or wrong, which reflects acknowledging experiences as they are without automatically reacting 4. Accepting emotions as they are and developing awareness that emotions are not permanent and tolerating such temporary emotions gracefully and allowing emotions to pass out calmly without reacting them 5. Practicing Loving-kindness instead of criticizing Self and consciously responding to situations more thoughtfully 6. Analysing the emotions to find out their origin by identifying contributing factors that develop and maintain those emotions 7. Modifying distressing emotions provides a sense of control by modifying the intensity and duration of an emotion. Results: Participants adaptively manage negative feelings and regulate their emotions effectively. Conclusion: Above seven steps involve moment meditation, control breathing, mindfulness attention, loving kindness and develops self awareness for emotional regulation.

Sleep

Ashish Yadav, Deepti M. Bhatt, Vishal Damani, Parnavi Singh 1 Gujarat Institute of Mental Health, Ahmedabad, Gujarat, 1 ESIC Medical College and Hospital, India Background: Over-the-Top (OTT) streaming platforms have revolutionized media consumption, promoting binge- watching behaviors that significantly impact sleep patterns among young adults, particularly undergraduate medical students. This study examines the correlation between binge-watching on OTT platforms and bedtime/sleep procrastination among medical students. Objectives: To assess the correlation between binge-watching and bedtime procrastination among undergraduate medical students, compare severity across different demographic factors, and evaluate associated behavioral patterns. Methods: A cross-sectional observational study was conducted among 506 undergraduate medical students in Ahmedabad, Gujarat. Data were collected using validated questionnaires: Binge-Watching Questionnaire (BWQ), Bedtime Procrastination Scale (BPS), and socio-demographic assessments. Statistical analysis included Pearson correlation coefficients and ANOVA. Results: Among 506 students, 65.6% (n=332) reported binge-watching behavior. A significant positive correlation was found between binge-watching and bedtime procrastination (r = 0.366, p < 0.001). Binge-watchers had significantly higher BPS scores (28.18± 5.60) compared to non-binge-watchers (24.93± 6.97). First-year students and higher-income groups showed significantly higher binge-watching rates. Mobile devices were the most common platform for binge-watching (41.0%). Conclusion: Binge-watching on OTT platforms is significantly correlated with bedtime procrastination among medical students, potentially compromising sleep quality and academic performance. Targeted interventions addressing media consumption habits are essential for promoting healthy sleep patterns in medical education. Key words: Bedtime procrastination, binge-watching, medical students, over-the-top platforms, sleep behavior

Smart

Shweta Mittal, Ann Panjikkaran, Aman Sardana 1 Nottinghamshire Healthcare NHS Foundation Trust, 1 Sussex Partnership NHS Foundation Trust, Nottingham, UK Aims: The aim of this project was to evaluate the effectiveness of handovers within The Mid and North Notts Crisis and Home Treatment team (CRHT) by identifying structural and communication gaps in the MDT and suggesting targeted improvements to promote safe, high-quality patient care. Background: Clinical handovers are vital in the delivery of safe and effective patient care. Sub-optimal handovers can occur due to a variety of reasons including unclear policies, high workloads and poor communication. The community based CRHT handovers are conducted daily, with duties shared among different consultants on a rotating basis. Methods: CRHT patients are allocated by night staff to nurses for morning handover and MDT. At times, clinicians presented patients they were unfamiliar with, leading to brief or insufficient introductions and potentially affecting handover quality. To formally identify gaps in the current CRHT handover, a Microsoft Forms questionnaire was developed, combining Likert scale questions on patient safety and structure with free-text fields for suggestions. A follow-up questionnaire will assess staff feedback on the new format. Outcomes: 17 responses were received following the pre-intervention questionnaire. 4 out of 17 staff members strongly agreed that the current handover process ensures patient safety and a further 12 agreed. Conclusion: This quality improvement project identified potential gaps within the current CRHT handover. Staff feedback highlighted key areas for improvement, including the ability to present patients they are familiar with and ensuring greater consistency in the plans made by different consultants.

Smoke

Pooja Meena, Harmanpreet, Om Prakash IHBAS, New Delhi, India Introduction: Visual hallucinations in elderly individuals can arise from ocular pathology, sensory deprivation, or primary psychotic disorders. In patients with significantly reduced visual acuity, distinguishing Charles Bonnet-like hallucinosis from psychotic disorders is essential for appropriate management. Case Summary: Krishna, a 73-year-old widowed female from a lower-middle socioeconomic Hindu family in rural Uttar Pradesh, not formally educated and with no past psychiatric or substance history, presented with continuous visual hallucinations since April 2025. Her visual acuity was markedly impaired at 3/60 bilaterally, with a history of bilateral cataractsurgery 11 months earlier. From April to September 2025, she persistently saw insects crawling out of her eyes. From September onward, she reported visual hallucinations of smoke emerging from both feet, leading to sleep disturbance and nighttime attempts to shrug offthe smoke. Despite these symptoms, she exhibited no fear, irritability, confusion, or wandering, though her participation in daily household chores declined. Routine investigations and NCCT head were within normal limits. Management: She received Risperidone 4 mg with partial improvement. On admission on 18/11/2025, the dose was increased to 6 mg/day, resulting in complete resolution of symptoms within one week. Discussion: Although reduced visual acuity initially suggested sensory-deprivation hallucinosis, the continuous symptom pattern, fixed conviction, and robust antipsychotic response were more consistent with Psychosis Not Otherwise Specified (Psychosis NOS), presenting predominantly with visual hallucinations in late life. Implications: This case highlights the importance of integrating ophthalmological and psychiatric evaluation when assessing visual hallucinations in older adults, ensuring timely differentiation between ocular causes and psychosis.

Stuck

Jaivardhan, Akshay Jadhav Pravara Institute of Medical Sciences, Loni, Maharashtra, India Background: Chronic mania has long been noted in psychiatric literature but lacks the formal status given to chronic depression. It is classically defined by persistent manic symptoms for over two years without remission. When standard treatments (a mood stabilizer plus an antipsychotic) fail typically after a three week trial the condition is termed treatment resistant mania. Aim: To discuss the clinical recognition, diagnostic challenges, and treatment implications of chronic mania and treatment-resistant mania. Case Vignette: A 32-year-old married male from lower SES presents with history of decreased sleep, overtalkativeness, increased energy, overfamiliarity, hyperreligiosity, and grandiose delusions increased since 5 days with a 12-year history of continuous psychiatric illness with seven prior exacerbations requiring hospital admissions and multiple ECTs, followed by mood stabilizers and antipsychotics, leading to partial remission with residual symptoms with no family psychiatric history or medical comorbidities. On examination, he is less cooperative, shows increased psychomotor activity, attention aroused but not sustained, and easy rapport establishment with affect elated with speech increased in volume and tone with decreased reaction time with thought content shows grandiosity and flight of ideas with judgment is impaired and insight absent. Conclusion: This case poignantly illustrates the burden of chronic, treatment resistant mania, where even intensive therapy fails to achieve full remission. It highlights the pressing need for better diagnostic frameworks, more precise criteria, and tailored treatment strategies to improve long-term outcomes and recognition of this under appreciated clinical entity.

Study

Ayush Agrawal, Manoj Kumar Sahu Pt. JNM Medical College, Raipur, Chhattisgarh, India Background: Delirium is a common neuropsychiatric complication among critically ill adults and is associated with increased morbidity, prolonged hospitalization, and poorer clinical outcomes. Early recognition of contributing factors is essential for guiding prevention and targeted management strategies in intensive care units. Aim: To determine the incidence of delirium in adult ICU patients and to identify the predisposing and precipitating risk factors. Methods: This prospective longitudinal study included adult patients consecutively admitted to a critical care unit. Participants were assessed regularly using CAM-ICU. Demographic characteristics, baseline comorbidities, clinical precipitants, and hospital stay were recorded. Descriptive statistics were generated, and Chi-square tests were used to compare categorical risk factors. Results: Of the 101 enrolled patients, 99 were eligible for CAM-ICU evaluation. Incidence of delirium was 43.4% (95% CI 33.7-53.2). Most cases of Delirium emerged within the first four days of ICU admission (Mean- 3.6 ± 1.8). Predisposing factors such as alcohol use, smoking, diabetes, hypertension, and anaemia were frequently observed but did not differ significantly between groups. Among precipitating factors, mechanical ventilation was strongly associated with delirium (51.2% vs 8.9%; p < 0.001), while sepsis demonstrated a borderline association (p < 0.05). Patients with delirium had a longer hospital stay compared to those without delirium. Conclusion: Delirium occurred in a substantial proportion of ICU patients and tended to develop early during critical care. Mechanical ventilation emerged as the most significant associated factor, highlighting the importance of consistent delirium monitoring and preventive care strategies in ICU settings.

Taalu

Bonjeet Nath, Raj K. R. Seal 1 Gauhati Medical College and Hospital, 1 Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam, India Background: Culture-bound syndromes (CBS) represent culturally shaped patterns of distress that may not align with biomedical categories. While syndromes such as Dhat and Koro are well described, many local idioms of distress in Northeast India remain undocumented. Taalu Sunno is one such culturally recognized condition reported in Mayong village, Assam, characterized by palatal and head-related sensations following febrile illness. Aim: To document and describe the phenomenology, cultural explanatory model, and clinical relevance of Taalu Sunno through a case encountered in psychiatric practice. Methods: A detailed clinical evaluation, medical work-up, and cultural formulation interview were conducted for a male patient in his early thirties presenting with persistent palatal and cephalic sensations. Local cultural beliefs and traditional healing practices were explored to contextualize the illness experience. Results: The patient described sensations of pulling,tearing,and splittingin the palate, along with head heaviness, reduced appetite, and anxiety, emerging after a prolonged febrile episode. No medical or neurological abnormalities were identified. The condition is widely recognized in the community, with traditional herbal remedies typically used, especially in infants. Psychiatric consultation was sought only when symptoms exceeded culturally expected recovery timelines. Conclusion: Taalu Sunno illustrates how cultural beliefs shape symptom expression, illness attribution, and help-seeking behavior. Documenting such idioms is essential for culturally sensitive psychiatric assessment. This case expands the understanding of CBS in India and underscores the need for integrating cultural narratives within clinical practice.

Think

Ankit Raghuwanshi, Rajvardhan Bhanwar 1 , Ramghulam Razdan 1 Index Medical College, Hospital and Research Centre, 1 Department of Psychiatry, Index Medical College, Hospital and Research Centre, Indore, Madhya Pradesh, India Introduction: Catatonia is a complex psychomotor syndrome often associated with psychiatric disorders, but it can also occur secondary to medical conditions, including infections. Tuberculosis (TB), though primarily a pulmonary disease, can present atypically in endemic areas. We report a rare case of pulmonary TB manifesting as catatonia in the psychiatry outpatient setting. Case Description: A 22-year-old female presented with acute onset mutism, posturing, refusal to eat, and negativism for 7 days. There were no clear mood or psychotic symptoms. History revealed constitutional symptoms suggestive of TB. Physical examination showed reduced breath sounds in the right upper lung zone. Mental status examination confirmed catatonia (BFCRS score: 18). Chest X-ray showed right upper lobe cavitation. CBNAAT was positive for Mycobacterium tuberculosis (rifampicin-sensitive). CT brain was normal. Results: A lorazepam challenge test produced partial improvement. The patient was started on lorazepam and anti-tubercular therapy (HRZE). Over 10 days, there was significant improvement in catatonic symptoms, and he was discharged in stable condition. Discussion: Catatonia secondary to pulmonary TB is rare but important, especially in endemic regions. Immune and metabolic effects of TB may disrupt CNS function even without direct involvement. Conclusion: Medical causes must be ruled out in catatonia. TB should be considered in atypical psychiatric presentations in high-prevalence areas.

Autism

Shweta Banerjee, Nishant Goyal 1 , K. S. Parvathy 2 Central Institute of Psychiatry, Departments of 1 Psychiatry and 2 Clinical Psychology, Central Institute of Psychiatry, Ranchi, Jharkhand, India This paper has been presented at Eastern zone PG-CME(Regional conference) Background: The average age of diagnosis was 3.1 years for children with autistic disorder, 3.9 years for pervasive developmental disorder not otherwise specified, and 7.2 years for Asperger’s disorder. A 16-year-old boy in class 11 presented to the child and adolescent OPD with his parents, reporting poor interaction, concentration, and academic performance, noted by his parents since age 2-3 years. One episode of seizure reported at the age of 14 years. Aims: Diagnosis, Assessment and Management. Methods: History taking, Developmental assessment, Mental status examination/ Behavioural observation, Psychological testing. Results: 1. Vineland Social Maturity Scale: average level of socio-adaptive functioning 2. Developmental Screening Test: average level of developmental functioning 3. Malin’s Intelligence Scale For Indian Children: Above average level of verbal intelligence, Average level of performance intelligence, Average level of intellectual functioning 4. Gilliam Asperger’s Disorder Scale: Borderline level of probability of Asperger’s disorder 5. Strength And Difficulty Questionnaire: Very High peer problems and internalizing difficulties, Very Low prosocial behaviour 6. Sensory Integration Scale: Auditory hypersensitivity. Conclusion: Provisional diagnosis kept as: Pervasive developmental disorders- Asperger’s syndrome (F84.5)+ Epilepsy syndromes undetermined whether focal or generalized. Management: Psychoeducation of guardians regarding Asperger’s syndromes, Skills training, Occupational training.

Beyond

Yagyani Bali, Delnaz Palsetia, Alka Subramanyam, Neena Sawant TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India Background: Acute-onset behavioural disturbances, psychosis and catatonia in adolescents following a febrile prodrome may represent autoimmune or post-infectious encephalitis, conditions that can present predominantly with psychiatric symptoms. Routine MRI, EEG and CSF studies may remain normal in early stages, and antipsychotic sensitivity or intolerance can serve as an important diagnostic clue. Early identification is crucial to avoid complications and initiate appropriate interventions. Cases: We report two adolescent males. Case 1, a 17-year-old, developed withdrawn behaviour, sleep disturbance and repetitive speech after a febrile event. Following haloperidol administration for behavioural management, he developed fever, rigidity and altered sensorium, diagnosed as neuroleptic malignant syndrome. He later showed psychosis and catatonia. Routine investigations were unremarkable, but FDG-PET demonstrated fronto-occipital metabolic abnormalities suggestive of autoimmune encephalitis despite a negative autoimmune panel. He showed significant improvement with lorazepam, cautious antipsychotic titration and memantine. Case 2, a 13-year-old with developmental delay, microcephaly and consanguineous parentage, developed agitation, repetition of phrases and behavioural disturbance following high-grade fever. MRI, EEG and CSF were normal, but CPK was elevated during initial evaluation. He achieved full recovery with memantine alone, without requiring antipsychotics. Discussion: Both cases highlight adolescent-onset behavioural syndromes with febrile triggers, neuroleptic intolerance or vulnerability and normal routine investigations. The favourable response to memantine in both patients suggests a possible role for NMDA-modulating agents in managing behavioural or catatonic symptoms linked to autoimmune or post-infectious encephalitic processes, particularly when antipsychotic use is limited by adverse effects.

Bodily

Rupam Kumari, Preeti Dalal, Ankita Chattopadhyay, Manoj Kumar Institute of Human Behaviour and Allied Sciences, New Delhi, India Background: Bodily Distress Disorder involves persistent physical symptoms without adequate medical explanation, often coexisting with high health anxiety. Aims and Methods: We hereby aim to demonstrate the unique presentation of a 36 years male with persistent somatic preoccupation, who resorted to prolonged and unsupervised intake of multiple medications, gradually leading to dependence and creating management challenges. Results: The patient presented with a five-year history of body aches, weakness, and tingling sensations. Despite reassurance from multiple doctors and normal investigations, he remained unconvinced and preoccupied with health-related issues, seeking repeated consultations for the same. He began self-medicating with Alprazolam and progressively increased his intake to 6-8 tablets of 0.5 mg daily. Attempts to reduce Alprazolam resulted in withdrawal, leading to further dose escalation and functional decline. He also would complaint of epigastric discomfort with poor appetite for which he was prescribed medications like Mefenamic Acid, Ofloxacin, and Ranitidine by a doctor. After initial improvement, he started taking these on his own about 2-3 tablets of each daily to feel relaxed and fresh. He was diagnosed as 6C20 Bodily distress disorder, 6C44.2 Sedative, hypnotic or anxiolytic dependence and 6C4H Disorders due to use of non-psychoactive substances. Inpatient treatment with a chlordiazepoxide-assisted taper, psychoeducation, CBT, relaxation training, and family counselling led to significant improvement. Conclusion: This case demonstrates how health anxiety and somatic preoccupation can reinforce excessive medication use, eventually leading to dependence and inappropriate usage of non-psychoactive medications, highlighting the need for early identification, integrated biopsychosocial management, and responsible prescribing practices.

Broken

M. Sridharan, Ravi Kiran, Nagesh Government Medical College, Kadapa, Andhra Pradesh, India Background: Takotsubo cardiomyopathy is an acute, transient cardiac condition characterized by regional systolic dysfunction, typically affecting the mid and apical segments of the left ventricle with preserved or hypercontractile basal function. It is often triggered by intense emotional or physical stress and predominantly affects postmenopausal women. There are reported cases following electroconvulsive therapy (ECT), particularly in patients with depression and schizophrenia. In this report, we describe a case of Takotsubo cardiomyopathy following ECT in a patient with schizophrenia, detailing its clinical presentation, diagnosis, and management. Case Presentation: A 50-year-old postmenopausal female with schizophrenia developed delayed recovery, hypotension, desaturation, and atrial fibrillation immediately after ECT. Cardiac evaluation revealed severe left ventricular dysfunction, mid-cavity hypo- to akinesis, and apical ballooning consistent with Takotsubo cardiomyopathy. The patient was managed with supportive care and made a full recovery within 48 hours. Discussion: This case highlights a rare but serious cardiovascular complication of ECT. While Takotsubo cardiomyopathy is typically reversible with timely intervention, its occurrence post-ECT underscores the need for careful cardiac monitoring in high-risk patients. Awareness of this potential complication can aid in early diagnosis and improve outcomes. Key words: Cardiac complications, electroconvulsive therapy, postmenopausal, schizophrenia, stress-induced cardiomyopathy, takotsubo cardiomyopathy

Caught

Sumana Kole Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Consumer health wearables provide real-time physiological data, but constant monitoring can heighten bodily vigilance. In susceptible individuals, minor fluctuations may be catastrophically misinterpreted, giving rise to technology-amplified health anxiety and panic symptoms. Case Report: A 30-year-old woman with no prior psychiatric history began experiencing sudden episodes of intense fear, palpitations, tremors, and a sense of impending collapse. These episodes appeared shortly after she started using a smartwatch to track heart rate and sleep. She repeatedly checked her device up to 70 times per day and became distressed by transient increases in heart rate during routine activities. She interpreted values above 110 bpm as signs of serious cardiac illness, despite normal cardiology workup. Panic attacks began occurring in anticipation of abnormal readings.Mental status examination showed anxious affect, heightened health preoccupation, and device-checking compulsivity. A diagnosis of panic disorder was made. Cognitive-behavioural therapy focused on interoceptive exposure, cognitive restructuring around physiological variability, and gradual reduction of device reliance. Significant improvement was noted within six weeks. Discussion: This case illustrates how digital health tools, while beneficial, can become anxiety amplifiers. Continuous biometric feedback may reinforce hypervigilance and catastrophic interpretation of normal physiological changes. Women often balancing high stress and societal health-conscious expectations may be particularly vulnerable to such presentations. Conclusion: Clinicians should inquire about wearable technology use when assessing new-onset panic or health anxiety. Understanding technology-mediated symptom pathways enables targeted psychoeducation and balanced digital-health practices. This case underscores the evolving interface between mental health and personal health technology.

Course

Hemant Choudhary, Vaibhav Patil, Mamta Sood All India Institute of Medical Sciences, New Delhi, India Background: Schizophrenia has been considered a chronic illness with poor long-term outcomes in its early conceptions. Substantial literature has emerged over the years, highlighting that around half of the patients with schizophrenia have a favorable long-term outcome. Despite these advances, the available research on the long-term course and outcome of schizophrenia is mired with limitations. Aims: To evaluate the methodological limitations of the existing studies on the long-term course and outcome of schizophrenia. Methodology: We searched the literature from Medline and Google Scholar from inception till September 2025. We included studies related to the course and outcome of schizophrenia and other psychotic disorders (excluding mood disorders). The data were summarized in a narrative review. Results: Major limitations included high heterogeneity in the study methodology and the underlying illness construct, high attrition rates in follow-up, lack of studies evaluating the long-term impact of interventions (especially psychosocial interventions), and limited data on the influence of individual factors on the course and outcome of schizophrenia. Some attempts have been made in recent years to address these limitations, but international collaborative studies have been scarce. We have proposed an approach for future research to address several of these limitations. Conclusion: Schizophrenia is a heterogeneous group with a variable course and outcome. The outcome of schizophrenia is not inevitably poor, unlike previous descriptions. Several methodological limitations are seen in existing studies, with possible directions for future research. Key words: Course, outcome, psychotic disorders, schizophrenia

Double

Isha Kanwal, Rajeev Ranjan, Pankaj Kumar AIIMS, Patna, Bihar, India Introduction: Gaming disorder is new entity recognised under behavioral addictions in ICD-11. There is emerging evidence that has shown its clinical overlap with Obsessive Compulsive Disorder, and that OCD may itself act as a risk facor for the development of Gaming Disorder.The underlying similarities and differences in neurobiological correlates is still a work in progress. Case Summary: This is a case of a 15 year old boy, a student with no prior significant psychiatric, medical or family history. He presented with a total duration of illness of 4 years of progressively worsening symptoms characterised by repetitive,intrusive,ego-dystonic, anxiety provoking doubts/thoughts regarding contamination followed by handwashing/cleaning rituals and counting. He also manifested symptoms of excessive gaming behaviour marked by preoccupation, impaired control,neglect of other interests, and continued gaming despite negative consequences including academic decline, sleep disturbances,and poor self care. These behaviours resulted in marked impairment across personal,social,family and academic domains. No abnormalities detected on general physical examination. Mental status examination revealed preoccupation with gaming,obsessive thoughts/doubts,precontemplation stage of motivation regarding gaming. Assessed and monitored by Y-BOCS and Gaming Disorder and Hazardous Gaming Scale (GDHGS). Management and Outcome: The patient was managed using a combination of pharmacotherapy (SSRI) ande psychotherapy, targeting both OCD and gaming disorder. Conclusion: The case highlights the potential comorbidity between OCD and Gaming disorder,particularly in adolescent population. This emphasizes the need for earlyy recognition and integrated management strategies.

Echoes

Muskan Goyal, S. Kiran Kumar Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Misophonia is an emerging clinical entity characterized by disproportionate emotional reactions such as irritation, anxiety, or distress to specific sounds. It is not yet formally classified in major diagnostic systems like ICD-11 or DSM-5, and evidence regarding effective pharmacological management remains limited. Aim: To describe the clinical presentation and early treatment response in a patient with misophonia managed in an outpatient psychiatric setting. Methods: A 28 years old male patient presented to the psychiatry OPD with complaints of irritation, anxiousness on hearing specific sounds(chewing,sniffing,ticking etc). Symptoms had been present for several years and were associated with significant distress and impairment in daily activities. There was no history of psychiatric illness, substance use, seizures, or major medical comorbidities. Mental status examination was unremarkable except for marked emotional reactivity when describing exposure to trigger sounds. No obsessive thoughts or compulsive behaviors were reported. Routine blood investigations were within normal limits, and MRI brain showed no structural abnormalities. Results: The patient was started on fluoxetine along with short-term clonazepam. At the first follow-up, after 2 weeks, the patient reported 20-30% improvement in distress. Sleep and baseline anxiety also showed improvement, and no adverse effects were noted. Conclusion: This case illustrates the clinical presentation of misophonia in an outpatient setting and demonstrates a modest early response to fluoxetine. Although evidence-based pharmacological treatments for misophonia remain scarce, selective serotonin reuptake inhibitors may provide benefit in reducing associated emotional distress. Further research is needed to develop standardised guidelines.

Effect

D. K. Deepak, D. K. Deepak 1 Military Hospital, Dehradun, Uttarakhand, 1 CIP, Kanke, Jharkhand, India Background: Current first-line treatment strategies for OCD include SSRI/TCAs and/or CBT. However, even with this, the majority only show partial improvement. Therefore, novel treatments for OCD are of considerable interest, one of which is TDCS. Aims and Objectives: To assess the effect of TDCS to (cathodal) SMA and (anodal) DLPFC in OCD as compared to sham stimulation. Materials and Methods: This is a prospective hospital-based randomised double blind, sham-controlled study where the sample size is 30 OCD patients (15 tDCS and 15 sham). Patients were ignorant whether they had received tDCS or sham stimulation. Ratings were done by a colleague who was also unaware of who had received tDCS and who had received sham stimulation. Results and Discussion: The findings of the study revealed that out of 30 patients who were included in the study (15 tDCS and 15 sham), the active and sham groups were comparable in terms of age, sex, marital status, religion, education, occupation and class of drug status. No side effects were reported in either group. There was a significant reduction. There was considerable improvement in obsession and compulsion over time in both groups, but there was no significant improvement between the Active and Sham groups over time. There was a significant improvement in the scores of CGI-S over time.

Facial

Seena Shylanathan, Anoop Vincent Sree Narayana Institute of Medical Sciences, Ernakulam, Kerala, India Background: Lithium is a first line mood stabilizer in Bipolar Disorder. Although, several cutaneous adverse effects such as Acne, Psoriasis, Alopecia are recognized, facial hyperpigmentation is a rare and under-reported reaction. Such visible adverse effects can significantly impact treatment adherence and quality of life. Aim: To report two cases of Lithium induced facial hyperpigmentation in patients with Bipolar Disorder and highlight it’s clinical relevance to long-term psychiatric management. Methods: Two female patients diagnosed with Bipolar Disorder and receiving long-term Lithium therapy presented with progressive facial hyperpigmentation. Detailed psychiatric evaluation, and medication histories were obtained. Dermatological assessment was conducted, including skin biopsy in one case to confirm drug induced hyperpigmentation. Causality assessment was performed by WHO-UMC scale, and severity was graded using Modified Hartwig and Seigel scale. Patients were followed up after Lithium discontinuation. Results: Both patients developed gradual facial hyperpigmentation after 4-5 years of Lithium use at a dose of 400mg/day. The adverse reaction was assessed as probable on the WHO-UMC causality scale and graded as moderate (level 3) in severity. Following Lithium discontinuation and alternative psychiatric management, facial pigmentation showed gradual improvement and complete resolution within one year. Conclusion: Facial hyperpigmentation is a rare but reversible adverse effect of prolonged Lithium therapy. Psychiatrists should remain vigilant for under recognised cutaneous reactions, as timely identification and interventions can improve adherence and treatment outcomes.

Facing

Jyoti Kapoor Manasthali - Mental Health and Wellness Services, Gurugram, Haryana, India India’s contemporary mental-health landscape is shaped by rapid socio-digital transitions, rising stress burdens, and widespread emotional dysregulation conditions that often exceed the scope of conventional biomedical management alone. At the same time, India is home to a rich heritage of scientific and philosophical wisdom embedded in Ayurveda, Yoga, contemplative practices, and mind-body healing traditions. This symposium brings these streams together, presenting an evidence-based integrative framework that strengthens psychiatric practice while remaining culturally grounded and clinically pragmatic. Drawing upon meta-analyses, RCTs, and systematic reviews published between 2015 and 2025, we evaluate the efficacy, safety, accessibility, and implementation potential of key integrative modalities. Strong evidence supports yoga for depression (SMD=0.37-0.73) and anxiety; mindfulness-based cognitive therapy for relapse prevention (RR=0.69); omega-3 EPA for major depressive disorder (SMD=0.61); structured exercise with antidepressant-comparable effect sizes; and music therapy for depression (SMD=-0.66). Moderate but promising evidence exists for Ashwagandha (stress/anxiety), acupuncture, and lavender aromatherapy. Ayurvedic formulations show emerging potential, warranting more rigorous trials. Chromotherapy remains scientifically unsupported. Cost analyses suggest high feasibility within Indian settings: yoga and exercise remain low-cost interventions, nutritional supplementation is moderately priced, and digital mindfulness tools offer accessible self-care pathways. Safety profiles across modalities demonstrate minimal adverse effects. By integrating ancient Indian knowledge systems with contemporary neuroscience and psychiatric evidence, this symposium outlines a unified model for enhancing resilience, emotional regulation, and clinical outcomes. India is uniquely positioned to lead the global movement toward culturally aligned, evidence-based integrative psychiatry. Key words: Ayurveda, India, integrative psychiatry, mindfulness, nutritional psychiatry, yoga therapy

Family

Sagar Sondhi, Shivangi Government Medical College and Hospital, Chandigarh, India Background: Depression in adolescents often presents with irritability, behavioural disturbances, somatic complaints, and academic decline. Delayed help-seeking, family conflict, and reliance on faith-healing may worsen the illness trajectory and disrupt treatment. Aim: To describe the assessment and multimodal management of a 13-year-old girl with single-episode depressive disorder with psychotic symptoms and catatonia, emphasising diagnostic complexity and family-related perpetuating factors. Methods / Case Summary: The patient presented with a 1.5-year fluctuating illness following exposure to a neighbourhood suicide. Symptoms included persistent fearfulness, irritability, low mood, crying spells, anorexia, anhedonia, second-person auditory hallucinations, delusion of reference, socio-academic decline, hostility, two suicide attempts, and catatonic features (staring, mutism, posturing, ambitendency). Previous treatment interruptions due to faith-healing contributed to relapses. She was admitted under MHCA-2017 Section 87. Assessment included serial Mental State Examinations, psychometry, the Brief Psychiatric Rating Scale, the Hamilton Depression Rating Scale, and laboratory investigations. Management involved olanzapine 10 mg, intravenous lorazepam 4 mg for catatonia, a trial of risperidone (stopped for hyperprolactinemia), cross-taper to aripiprazole 5 mg, and escitalopram 10 mg. Psychosocial interventions included rapport-building, psychoeducation, and structured family counselling. Results / Discussion: Longitudinal evaluation revealed predominant affective symptoms, resulting in a revised diagnosis of psychotic depression with catatonia. Multidisciplinary treatment improved mood, interaction, behaviour, psychotic symptoms, and functioning. High expressed emotion and stigma significantly affected illness course. Conclusion: Early recognition, systematic evaluation of catatonia, judicious pharmacotherapy, and intensive psychoeducation particularly addressing family-system factors are essential for sustained recovery.

Gender

Neerja Gidwani, G. Prasad Rao, Chytanya Deepak, Amit Awasthi, Sahil Doshi Asha Hospital, Hyderabad, Telangana, India Aim: To compare the prevalence of Hikikomori in male and female adolescents in India. Background: Hikikomori refers to a pattern of severe and prolonged social withdrawal, in which individuals confine themselves to their homes and disengage from education, employment, and social interaction. Although originally identified in Japan, this phenomenon is now recognized across diverse cultural contexts and age groups. Recent shifts in lifestyle, increasing reliance on digital communication, and evolving family dynamics have been linked to heightened vulnerability to such withdrawal, particularly among adolescents and young adults. However, emerging evidence suggests that gender-related differences may also influence how social withdrawal is experienced and reported. Methods: A sample size of 220 adolescents out of which 129 were males 91 were females aged 15 to 19 years from urban and semi-urban educational institutions in Hyderabad. They were assessed using HQ-25 which is a 25-item self-report questionnaire. Results: Among 129 males, 45.7% met criteria for hikikomori, compared with 56.0% of 91 females. Hikikomori prevalence was higher in females in this sample. Conclusion: This study is probably one of the firsts on Hikikomori to be conducted in India. Hikikomori has been historically found to be more prevalent in males, but this trend might be changing.

Heroin

Shreya Purvey, Akash Kumar 1 , Shruti Sinha 1 , Harsha Singh 1 All India Institute of Medical Sciences, 1 Department of Psychiatry, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India Background: Opioid dependence remains a major global health challenge. Although withdrawal commonly manifests with autonomic, gastrointestinal and psychological symptoms, the occurrence of psychosis during opioid withdrawal is rare. Such presentations may mimic primary psychotic disorders, complicating detoxification and increasing the risk of misdiagnosis or delayed intervention. Aims: To describe a case of transient psychotic episodes occurring in close temporal association with heroin withdrawal. To highlight the importance of identifying atypical psychiatric symptoms during opioid detoxification. Methods: A 39 ‘year ‘old male with a 3 ‘year history of heroin use and long ‘standing tobacco dependence presented with typical Opioid Withdrawal Syndrome-anxiety, restlessness and limb pain after 7 days of abstinence. He had no past or family history of psychiatric illness. Three months earlier, he experienced a brief episode of irrelevant speech, aggression, fearfulness, suspiciousness and confusion after 7-8 days of abstinence, resolving spontaneously within 1-2 hours. During the current admission, he developed two similar episodes on days 10 and 11 of abstinence, each requiring prompt management with injectable antipsychotics. Results: The case illustrates acute, recurrent and short ‘lasting psychotic episodes temporally linked to heroin withdrawal, resolving rapidly with antipsychotic treatment. Conclusion: Psychosis during opioid withdrawal is uncommon but clinically important. With evidence limited to isolated case reports, continued documentation is essential. Clinicians should remain alert to atypical psychiatric symptoms during detoxification to ensure patient safety and improve outcomes.

Hidden

Sneha Sahitya Bhrugubanda, Nekkanti Nimeesha Guntur Medical College, Guntur, Andhra Pradesh, India Background: Substance use among adolescent females is often overlooked, yet it carries profound psychiatric and social consequences. Early initiation is frequently linked with adverse childhood experiences, trauma, and weak social support systems. We present three cases that highlight the intersection of substance use, psychiatric morbidity, and social adversity in young women. Case Presentation: Case 1: A 13-year-old girl from a broken family, exposed to street life, developed depressive symptoms, ruminations, deliberate self-harm, and substance use. She improved with antidepressant therapy and cognitive behavioral therapy. Case 2: A 14-year-old girl with parental loss and sexual abuse developed heavy alcohol dependence, post-traumatic stress disorder with psychotic symptoms, and self-harm. Treatment with fluoxetine, risperidone, thiamine supplementation, and cognitive behavioral therapy led to improvement. Case 3: A 15-year-old girl with parental loss and neglect presented with alcohol, nicotine, and inhalant dependence, alongside obsessive sexual thoughts and compulsive sexual behaviors. She improved with fluoxetine, risperidone, baclofen, and cognitive behavioral therapy. Conclusion: These cases underscore the urgent need for early psychiatric identification of substance use and comorbid psychiatric conditions in adolescent girls. Beyond clinical treatment, strengthening shelter homes, implementing trauma-informed care, and developing community-based psychosocial interventions are crucial. A multidisciplinary approach is essential to reduce long-term morbidity, prevent social consequences of addiction, and increase resilience among vulnerable adolescent girls.

Mental

Virendra Vikram Singh Base Hospital Barrackpore, West Bengal, India War affects a population many ways. Mostly while discussing war, issues related to military comes to our mind, however the civilian population is also deeply affected. Mental health during war is severely affected because of multiple challenges. Wars too have changed over period of time in terms of presentation and participation. The ongoing conflict between Russia and Ukraine is much different from traditional wars. It has affected both civil and military, people staying put or internally displaced. The service delivery setup is largely disrupted, and it is overburdened wherever functional. Newer strategies including use of digital technology are being used to address the issues. This poster aims to present Mental health challenges for civilian population during this war from the published literature and draw conclusion and comments for own population in India.

Middle

K. H. Rajesh, M. Anupama JJM Medical College, Davangere, Karnataka, India Background: Diabetes currently affects 352 million people worldwide, with projections of 486 million by 2045. The global incidence rate was 10.5% in 2021, with 8.8% in Southeast Asia and 9.6% in India, and rates are expected to rise. Beyond vascular complications, diabetes can also impair cognitive functions, particularly influenced by blood pressure. The study focuses on middle-aged Indians (44-59 years) and aims to explore how their diverse lifestyles and health perceptions impact cognitive outcomes for targeted management. Methodology: This prospective cross-sectional study (Aug-Oct 2025) recruits middle-aged (44-59 years) type 2 diabetes patients without hypertension from non-psychiatric OPDs at J.J.M Medical College hospitals, Davangere, using convenient sampling. English and Kannada speakers of both genders are included; exclusions cover non-consenters, complications, or psychiatric/neurodegenerative conditions. Results: Among 50 adults with type 2 diabetes, most were women, from rural, lower socio economic, nuclear families, with high rates of family history of diabetes. Glycaemic control improved from predominantly high initial RBS to normal current levels. Global cognition on HMSE is largely intact, but detailed testing reveals subtle deficits. Verbal and visual memory scores show mild reductions in long ‘term retention, and prolonged Digit Vigilance and high Stroop effect scores indicate slowed processing speed and executive inefficiency in a subset. Conclusions: Type 2 diabetes in this mid ‘life, predominantly rural, low socio ‘economic cohort shows good short ‘term glycaemic control with largely preserved global cognition but subtle domain ‘specific inefficiencies, underscoring the need for routine cognitive screening and longitudinal evaluation in diabetic care.

Noonan

Pranjal Tripathi, N. Prasanna Kumar Government Hospital for Mental Care, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Noonan syndrome is a genetic condition present at birth that impacts development across multiple body systems. It is characterized by a range of physical issues, including distinctive facial features, short stature, and various heart defects. The severity of the disorder varies greatly among individuals, and treatment focuses on managing the specific symptoms experienced by each person. Although present from birth, it is often diagnosed later when the characteristic symptoms become more pronounced. Aims: to describe a case of Noonan Syndrome presenting with behavioural issues Methods - A 14 year old male was brought to OPD of Department of Child and Adolescent Psychiatry, Government Hospital for Mental Care, Andhra Medical College, Vizag with complaints of delayed developmental milestones since birth, poor scholastic performance, irritability, anger outbursts, being verbally abusive since last 2 years. Results: Routine blood examination, general physical and systemic examination was done, along with evaluation of dysmorphic features which revealed large palpebral fissures, low set ears, long face, high arched eyebrows, triangular facies, winged scapula, pectus excavatum and pulmonary stenosis. He had mild intellectual disability on IQ evaluation, while CT brain was normal. Conclusion: Comprehensive physical examination is of paramount importance to evaluate underlying syndromic traits in order to arrive at an optimal diagnosis which can pave the way for better management and prognostication.

Online

Isha Goel, A. V. Saboo Dr Panjabrao Deshmukh Memorial Medical College, Amravati, Maharashtra, India Background: Online gambling has emerged as a significant behavioural addiction among young adults, facilitated by easy smartphone accessibility and reward-based gaming interfaces. Individuals under 25 years are especially vulnerable due to ongoing maturation of the prefrontal cortex involved in decision-making and impulse regulation. Aims and Objectives: To present a case of online poker addiction in a medical student, examine psychosocial consequences, and highlight neurodevelopmental factors that may increase susceptibility in young adults. Materials and Methods: A 21-year-old male MBBS student developed escalating online poker use over 12 months. Symptoms included craving, failed attempts to control playing, irritability when restricted, academic decline, sleep disturbance, and financial losses of approximately ‚¹5 lakhs. There was no past psychiatric or substance-use history. Management involved psychoeducation, motivational interviewing, family involvement, stimulus control, and activity scheduling. Pharmacotherapy included fluoxetine 20 mg/day (titrated to 40 mg/day) for anxiety and dysphoria, and naltrexone 50 mg/day to reduce gambling urges. Results: The patient demonstrated reduced craving, improved impulse control, and restoration of academic functioning within 8 weeks. Supportive psychotherapy and family engagement contributed significantly to behavioural improvement. Conclusion: This case underscores the heightened vulnerability of young adults to online gambling, partly due to immature executive control networks. Early psychiatric intervention, behavioural strategies, and regulated access to online gambling platforms for individuals below 25 years may help prevent addiction and reduce related harm

Poison

Aditya Guru, Ram Ghulam Razdan, Harman Singh Bhatia Index Medical College Hospital and Research Centre, Indore, Madhya Pradesh, India Background and Aims: Repetitive self-mutilation is termed the van Gogh syndrome after Vincent van Gogh a renowned Dutch painter of late 19th century, who during a bout of psychosis deliberately mutilated his ear. A rare case of a 28-year-old Indian male is discussed here who experienced command auditory hallucinations which told him to amputate his own foot. The patient was diagnosed with paranoid schizophrenia. On mental status examination, the patient there was delusions of control, delusions of persecution and commanding hallucinations. Methods: Brief Psychiatric Rating Scale score was used to indicate severity of psychosis. Positive and Negative Syndrome Scale score to assess schizophrenia. Hamilton Depression Rating Scale & Young Mania Rating Scale pointing against the differentials of bipolar affective disorder or Unipolar depression. Conclusion: A provisional diagnosis of paranoid schizophrenia was made using the International Classification of Diseases-10. Injectable haloperidol and promethazine given intramuscularly for the first 7 days, then shifted to oral medications. Management of the wound was done. Response to the initial dose of anti-psychotic was good. The patient was kept on haloperidol and clonazepam tablets. On continuing the regimen for 6 weeks, the symptoms remitted and mutilation wounds were healed. Key words: Paranoid schizophrenia, self-mutilation, Van Gogh syndrome

Prader

Rachit Sharma Military Hospital, Meerut, Uttar Pradesh, India Two girls (aged 7 & 14 years) were brought to paediatrics OPD by parents with c/o obesity, insatiable appetite, increased irritability, stubbornness and poor scholastic performance subsequently referred to psychiatry OPD for evaluation. On evaluation, short stature, central obesity with small hyperflexible hands and feet with unusually fair skin and light-colored hairs were noted. Facial dysmorphisms in the form of narrow forehead, almond-shaped eyes, fish like mouth were also noted. In course of the treatment they were diagnosed with Prader Willi syndrome by FISH. IQ assessment showed mild to moderate level of retardation of intellectual disability along with behavioural manifestations in the form of temper tantrums, poor frustration tolerance and frequent anger outbrusts.

Seeing

Shreya Rastogi, Shipra Singh, Deepak Kumar Institute of Human Behaviour and Allied Sciences, New Delhi, India Background: Prader-Willi syndrome (PWS) is a rare genetic disorder characterised by distinctive physical traits, behavioural challenges, and a unique cognitive profile. School performance is often below expectations based on IQ, with difficulties in memory, processing speed, phonological awareness, and executive functioning commonly affecting reading, writing, and math skills. Research on specific learning disorders (SLD) highlights persistent weaknesses in these cognitive areas that are open to targeted interventions. Aims: To present the case of a 13-year-old child with genetically confirmed PWS who experienced academic challenges disproportionate to a normal IQ, and to demonstrate how identifying typical SLD-related cognitive deficits led to a diagnosis using the NIMHANS battery. Methods: The child underwent clinical evaluation including developmental history, standardised IQ testing confirming average intelligence, and focused academic assessment using the NIMHANS SLD battery covering reading, spelling, written expression, and mathematics, supplemented by teacher reports. Results: Despite an average IQ, the child exhibited significant impairments in decoding, spelling, written expression, and numeracy that reflected underlying phonological, working memory, and executive function deficits typical of SLD. Performance on the NIMHANS battery was markedly below age-appropriate norms, confirming SLD across academic domains distinct from the broader cognitive profile in PWS. Conclusion: This case emphasises that academic difficulties in PWS should not be solely attributed to the syndrome. Proactive screening for SLD in children with PWS can open doors to tailored educational support, protect self esteem and foster individual strengths beyond the diagnosis.

Sexual

Poulomi Ghosh Prasad institute of medical science and Hospital, Lucknow, Uttar Pradesh, India Neuropsychiatric disturbances are common in chronic kidney disease, including depression, delirium, and cognitive decline, but obsessive-compulsive symptoms are rarely described. The interaction between uremic biochemical derangements and psychiatric manifestations involves alterations in neurotransmitter balance, cortical excitability, and fronto-striatal functioning. Sexual obsessions in older adults, especially when fluctuating with hemodialysis cycles, represent a particularly unusual phenomenon. A 65-year-old woman with end-stage renal disease on maintenance hemodialysis developed recurrent, ego-dystonic intrusive sexual thoughts accompanied by distressing urges for intercourse. These symptoms caused marked functional impairment. Laboratory tests showed significantly elevated urea (186 mg/dL). A clear cyclical pattern emerged: obsessive symptoms worsened as urea accumulated between dialysis sessions and diminished briefly after dialysis. Mental status examination revealed preserved orientation and cognition, with prominent sexual obsessions. She was treated with sertraline, initiated at 25 mg/day and increased to 75 mg/day, achieving partial improvement. However, symptom variability continued to parallel biochemical changes, indicating that metabolic factors contributed substantially to her presentation. This case illustrates the potential role of uremia-induced cortical hyperexcitability in generating OCD-like symptoms, particularly intrusive sexual cognitions. Uremic toxins such as guanidinosuccinic acid and indoxyl sulfate may disrupt serotonergic, dopaminergic, glutamatergic, and GABAergic pathways, contributing to dysfunction of the cortico-striatothalamo-cortical circuitry implicated in OCD. Transient improvement following dialysis supports the role of toxin clearance in restoring neurochemical balance, while the partial response to SSRIs underscores the relevance of serotonergic modulation. Recognition of atypical obsessive-compulsive phenomena in ESRD may enhance understanding of renal-brain interactions and guide integrated management strategies. Key words: Intrusive thoughts, neurotoxicity, uremia

Shadow

Suchanshu Vats Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India Introduction: Obsessive-Compulsive Disorder with harm-related fears can present with highly specific and bizarre obsessions. Although selective serotonin reuptake inhibitors are first-line pharmacotherapy and effectively reduce comorbid anxiety symptoms, a substantial proportion of patients experience persistent obsessions and compulsions, necessitating augmentation with evidence-based psychotherapy. Objective: To describe a case of refractory OCD characterized by persistent snake-bite fears and compulsive checking behaviors despite adequate SSRI treatment, and to illustrate the rapid efficacy of Exposure and Response Prevention as an augmentation strategy. Methods: Single case report. A 32-year-old male with a two-year history of OCD presented with predominant obsessions of being bitten by snakes, leading to compulsive checking. He experienced marked autonomic arousal Triggered by these obsessions. The patient had been on fluoxetine 40 mg/day for 2 months with good control of anxiety symptoms but no meaningful reduction in obsessive thoughts or checking compulsions (Y-BOCS score remained 28/40). He was then initiated on manualized ERP delivered in an intensive format. Results: After only 3 weeks (10 sessions) of ERP, the patient achieved complete remission of snake-bite obsessions and checking compulsions. Post-treatment Y-BOCS score was 4/40 (subclinical range), compared to 21/40 before initiation of ERP. Conclusions: This case highlights that even highly specific and seemingly bizarre OCD presentations respond rapidly to properly implemented ERP, even when SSRI monotherapy provides only partial benefit. Early incorporation of ERP in partially responsive patients can dramatically shorten illness duration and prevent chronic disability.

Shared

Md. Niyaz, S. P. Panda Armed Forces Medical College, Pune, Maharashtra, India Background: Alcohol Use Disorder (AUD) and Gambling Disorder frequently co-occur and share phenomenological similarities with substance addictions. Overlapping neurobiological substrates involve reward processing, impulsivity and impaired inhibitory control. Understanding shared mechanisms is essential to explain mutual reinforcement of addictive behaviors and to guide integrated treatment strategies. The case illustrates how behavioral and substance addictions interact through common neural pathways. Aims: To explore shared neurobiological mechanisms underlying AUD and Gambling Disorder through a detailed case-based review, with emphasis on temporal relationship, personality traits, and reward-circuit dysfunction. Methods: A case-based descriptive review was conducted involving a 35-year-old male with co-occurring Gambling Disorder and Alcohol Dependence Syndrome. Clinical history focused on onset, progression, temporal sequencing of addictive behaviors, personality traits, psychosocial stressors and relapse patterns. Neurobiological mechanisms were interpreted in light of existing addiction models. Results: Gambling behavior preceded regular alcohol use, supporting a gateway and coping hypothesis, wherein alcohol was initially used to manage gambling-related stress and losses. Over time, alcohol use escalated to dependence, with gambling relapses precipitating alcohol binges. The case demonstrated shared reward-circuit dysfunction involving mesolimbic dopamine pathways, ventral striatum, and nucleus accumbens, along with impaired prefrontal inhibitory control. High impulsivity, sensation-seeking traits, cognitive distortions, and poor distress tolerance further contributed to mutual reinforcement of addictions. Conclusion: This case highlights the shared neurobiological and psychological mechanisms linking Alcohol and Gambling Disorders. Dysfunctional reward processing, impaired executive control, and maladaptive coping form a common pathway sustaining comorbidity. Recognition of these shared mechanisms underscores the need for integrated, mechanism-based treatment approaches.

Shorts

Zinedine Zidane, Sukriti Mukherjee, Sukanto Sarkar, Sucharita Mandal All India Institute of Medical Sciences, Kalyani, West Bengal, India Background: Obsessive-Compulsive Disorder is a chronic and often disabling condition, with 40-60% of patients showing inadequate response to standard pharmacotherapy and CBT. Dysregulation of cortico-striato-thalamo-cortical circuitry, particularly involving the supplementary motor area, contributes to persistent symptoms. Continuous Theta Burst stimulation, a patterned form of Repetitive Transcranial Magnetic Stimulation with short duration and strong inhibitory neuroplastic effects, has emerged as a possible neuromodulatory intervention for OCD. Aims: To describe clinical outcomes following long-term SMA-targeted cTBS across three patients of OCD. Methods: Three patients with OCD received cTBS delivered over the SMA. Patients underwent consecutive sessions, followed by maintenance. YBOCS were recorded at baseline, and during follow-up to assess clinical change. Results: Case 1, a 36-year-old female, improved from a Y-BOCS score of 11 to 3 and maintained remission for one year with weekly maintenance sessions. Case 2, a 28-year-old male with poor insight, showed partial improvement from 32 to 24 following repeated courses, with sustained benefit during ongoing weekly sessions. Case 3, a 28-year-old male with OCD and Hoarding Disorder, improved from 28 to 20 with each treatment course, requiring consecutive sessions every 3-4 months. Conclusion: SMA-targeted cTBS produced meaningful symptom reduction in all three cases. Patients achieved sustained remission through periodic maintenance stimulation. These observations support the potential clinical utility of cTBS as a safe and practical adjunctive treatment, though controlled studies with standardized protocols are required to establish efficacy.

Silent

Prerana Narayanan Adichunchanagiri Institute of Medical Sciences, B.G Nagara, Karnataka, India Introduction: Hypothyroidism is a frequently overlooked medical cause of psychiatric symptoms. While low mood, fatigue, and cognitive slowing are common, myxedema psychosis can present dramatically yet be misinterpreted as a primary psychiatric illness. Patients may appear resistant to antidepressants, leading to misdiagnosis and delayed treatment. Case Description: A 42-year-old woman presented with a six-month history of pervasive low mood, apathy, hypersomnia, and slowed speech, for which multiple antidepressants were trialled without improvement. Over the past month, she developed paranoid ideas that neighbours were watching her, alongside marked slowing, puffiness, and a hoarse voice. Tests (TSH > 80 µIU/mL, low T3/T4)confirmed severe hypothyroidism with sinus bradycardia, leading to a diagnosis of hypothyroidism-induced psychosis masquerading treatment-resistant depression. She was started on levothyroxine ( 75mcg ) with low-dose antipsychotics, and within four weeks her paranoia, mood, and psychomotor slowing all resolved, allowing antipsychotics to be tapered as she improved solely on thyroid hormone replacement. Discussion: This case underscores how medical illnesses can quietly mimic psychiatric disorders, especially when mood and cognitive symptoms predominate. Hypothyroidism disrupts brain metabolism and neurochemical balance, leading to secondary psychosis that often resolves once thyroid function is corrected. Conclusion: Hypothyroidism-induced psychosis is rare but treatable. This case emphasises the importance of holistic assessment and avoiding diagnostic anchoring. Key words: Hypothyroidism, myxedema psychosis, treatment-resistant depression

Social

Shweta Singh, Kriti Sapra 1 , Anil Nischal 1 , Amit Singh 1 King George’s Medical University, 1 Department of Psychiatry, KGMU, Lucknow, Uttar Pradesh, India Background: Social Media (SM) increasingly exposes adolescents and adults to extensive, emotionally relevant information, elevating the risk of information overload (In0Ov). However, evidence specifically addressing platform-specific overload and underlying psychological mechanisms remains limited. Objective: This scoping review aims to map and synthesise existing literature on the MH impact of SM In-Ov among adolescents and adults, with a focus on key psychological mechanisms and differences across major platforms. Methods: The review is being conducted following the PRISMA-ScR guidelines. Searches across electronic databases including PubMed, PsycINFO, Scopus, and Web of Science are underway. Studies assessing SM InOv (general or across specific platforms) in adolescents and/or adults in relation to MH outcomes are being included. Data are being charted and synthesised narratively. Preliminary Observations: Preliminary screening of literature suggests predominance of cross-sectional quantitative studies, with limited longitudinal or experimental research. Prevalent underlying psychological mechanisms focus on cognitive overload and fatigue, social comparison, rumination and FOMO, reduced sustained attention, and sleep disruption, linking In-Ov to common MH problems and reduced well-being. SM platforms have varying affordances, but research generally treats SM as a homogenous concept, limiting understanding of platform-specific In-Ov and MH impact. Conclusions: This scoping review is expected to provide a comprehensive overview of how SM In-Ov contributes to MH impact among adolescents and adults, highlight key psychological pathways involved, and understand the need for platform-specific studies in SM In-Ov. The findings can support early identification of digital risk factors and preventive MH strategies relevant to adolescents and adults.

Sudden

Swetha Gadda, G. Bindu 1 Andhra Medical College/Government Hospital for Mental Care, 1 Government Hospital for Mental Care, Visakhapatnam, Andhra Pradesh, India Background: Dissociative neurological symptom disorder (previously conversion disorder) involves involuntary disruptions in motor, sensory, or cognitive functions without an identifiable neurological cause. Symptoms can include speech disturbances like dysphonia, aphonia, or dysarthria, which cannot be explained by neurological diseases, substance effects, or other mental disorders. Psychosocial stressors often precede symptom onset. Aim: To diagnose and manage a case of dissociative neurological symptom disorder presenting as sudden speech loss in a woman following familial conflict and suspicion of theft involving her son, and to evaluate symptomatic improvement after initial psychotherapy. Methods: Detailed clinical history focusing on the onset and psychosocial context of symptoms. Physical examinations including video laryngoscopy to exclude organic causes. MSE to assess psychiatric condition. Differential diagnosis excluding neurological, substance-related, and other mental disorders. Psychological intervention and patient reassurance. Follow-up evaluation after one week to monitor symptom progression. Results: After psychotherapy and reassurance, partial improvement in speech occurred at one-week review, with patient able to use some words though unable to form full sentences. Conclusion: This case illustrates dissociative neurological symptom disorder triggered by acute psychosocial stress, manifesting as sudden speech loss without organic pathology. Thorough exclusion of neurological and medical causes is critical. Psychotherapy and reassurance are effective initial treatments, with early signs of recovery observed. Ongoing follow-up is essential for further functional restoration.

Adapted

Ronak Wahal All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India Background: Psychiatric assessment of people presenting with congenital hearing loss and mutism presents many difficulties because of communication gap, low literacy and lack of tailored scales and assessment tools for such populations. These hinderances cause late diagnosis, confusing symptoms and ineffective treatment adherence. Dissociative disorders, due to its various presentations, presents a major challenge in diagnosing and treating because of this communication gap. Case Description: A 24 year old woman, with congenital hearing impairment and mutism, little schooling experience, and unable to read and write except her name, had history of episodes of loss of responsiveness, tightening of limbs, gait disturbances, and easy annoyance. The symptoms started with her miscarriage which occurred at 3rd month of gestation. She had irritability after the episodes accompanied by gait and sleep disturbances. Neurological examination and MRI, EEG showed no significant abnormality. Adaptive interview techniques incorporating the family members along with ward behavior observation revealed that the patient was alert, cooperative and able to follow simple gestural commands. Assessment of thought and perceptual abnormalities was not established due to communication barrier. The episodes were triggered by high expressed emotions by family and her desire for a child. Sertraline was started and increased to 100mg/day along with short course of benzodiazepenes resulting in clinical improvement. Conclusion: The case highlights the importance of adapted assessment approach, psychoeducation and family involvement in management of patients where communication, which is the cornerstone of psychiatric assessment, is a barrier.

Bipolar

V. Archana Mohan, Mounika Tejaswini, D. Vijayalekshmi Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Introduction: Bipolar I disorder (BPAD) with rapid cycling becomes especially challenging when combined with alcohol dependence and acute multiorgan dysfunction. Coordinated care is required when mood episodes coexist with kidney, liver, and metabolic derangements. Aim: To highlight the complexity and management challenges of BPAD type 1 with rapid cycling and multiple medical comorbidities. Objective: To present a 46-year-old male with BPAD type 1, rapid cycling, sarcoidosis,acute kidney injury, acute hepatitis, diabetes mellitus type 2, and alcohol dependence, emphasizing integrated care. Methods/Case: A 46-year-old male with longstanding alcohol dependence and BPAD type 1 presented with mood instability, reduced sleep, irritability, and functional decline, along with deranged renal and liver function and poorly controlled diabetes. Mental status examination suggested rapid cycling without psychosis. CT brain was normal, while ultrasound and laboratory evaluation showed acute kidney injury with pathology indicating alcohol-associated liver disease with steatohepatitis and fibrosis and whole body PET-CT indicating Sarcoidosis . Treatment included T.Oxcarbazepine 300mg/day,T.Risperidone 6 mg/day, T.Trihexiphenidyl 2mg/day, insulin, and organ-directed supportive therapy, planned jointly with nephrology, hepatology, and endocrinology. Results: Alcohol abstinence, psychotropic optimization to account for organ dysfunction, and titration of insulin and supportive measures led to stabilization of mood, improved sleep and functioning, and partial reversal of biochemical evidence of renal and hepatic injury. Glycaemic control improved and no further affective episodes occurred during follow-up. Conclusion: This case illustrates the need for early detection of alcohol-related multiorgan involvement and sarcoidosis in BPAD with rapid cycling and effective treatment, functional recovery.

Calming

Manas Rajeshkumar Upadhyay, Kenil Jagani Pandit Deendayal Upadhyay Medical College, Rajkot, Gujarat, India Background: Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental condition characterized by inattention, hyperactivity, and impulsivity. Standard management includes behavioural therapy and pharmacotherapy with stimulants such as methylphenidate or non-stimulants like atomoxetine, guanfacine, and clonidine. However, a subset of patients exhibit poor or partial response, posing therapeutic challenges. This case describes a child with treatment-resistant ADHD who showed remarkable improvement following sodium valproate initiation, highlighting its potential role as an adjunct in refractory cases. Case History: A 9-year-old girl with ADHD presented with hyperactivity, aggression, excessive crying, sleep disturbances, and demanding behaviour. Her father’s permissive approach reinforced maladaptive behaviours. Symptoms worsened over six months without identifiable stressors, warranting admission. Episodes of staringand non-responsivenesswere noted, and EEG on admission revealed generalized epileptiform discharges. Management and Outcome: Despite multiple medications including methylphenidate 40mg, atomoxetine 10mg, aripiprazole 10mg, quetiapine 75mg, clonidine 100mcg, carbamazepine 200mg, clonazepam 1.5mg, and zolpidem 5mg, there was minimal improvement. Considering the EEG findings suggestive of subclinical seizures, sodium valproate (1000 mg/day) was introduced, leading to dramatic improvement in behavioural symptoms and sleep. Conclusion: This case underscores the need for thorough neurophysiological evaluation in ADHD patients with poor treatment response and behavioural dysregulation. The presence of epileptiform discharges suggested a neurobiological contribution to symptoms. Marked improvement with valproate highlights its potential as a mood-stabilizing antiepileptic adjunct in selected ADHD cases with subclinical epileptiform activity and behavioural instability, and considering EEG assessment in atypical or treatment-resistant ADHD presentations.

Changes

K. Rashmi KVG Medical College Hospital, Sullia, Karnataka, India Changes in behavior should never be underestimated, as they can represent hidden manifestations of cerebrovascular compromise. Psychiatrists play a vital role in detecting these red flags and initiating timely referrals for neuroimaging and neurological assessment. Integrating psychiatric evaluation into stroke care pathways promotes early diagnosis, targeted therapy, and holistic recovery. Greater awareness, careful clinical observation, and collaboration between psychiatry, neurology, and medicine are key to bridging this diagnostic gap and improving patient outcomes.Here we have a triad of geriatric neuropsychiatric cases that collectively challenge the differential diagnosis of cognitive and behavioral impairment in the elderly.Each of our three patients presented to psychiatry OPD with psychiatric manifestations-ranging from behavioral disturbances and depression to cognitive deficits, masking an underlying organic pathology.

Chronic

Samiya Ahmed, Samiya Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India Background: Cerebrovascular accidents (CVA) and head injuries are major causes of long-term disability, often resulting in persistent neuropsychiatric disturbances. These sequelae frequently remain under-recognized and complicate recovery. Aims: To evaluate characteristics of chronic neuropsychiatric sequelae following CVA and head injury, and to emphasize the importance of early identification and multidisciplinary management. Methods: A case This case of a 54 year old male demonstrates gross changes in personality and behaviour following head injury in RTA. Prior to the accident, he was a social,well adjusted normal functioning individual with good frustration tolerance but after that he was unmanageable at home with frequent bouts of unprovoked aggression, irritability, wandering and disinhibited behaviour. radiological investigations were done. Chronic infarct and gliosis right parietooccipital region and dilatation of body and occipital horn of lateral ventical were seen,, he was started on tablet olanzapine and tablet valproate, and the patient showed significant improvement in the behavourial complaints, during subsequent follow up. Results: Findings- cognitive impairments- executive dysfunction, attention deficits, and memory problems are common. Emotional disturbances including depression, anxiety, and emotional lability are prevalent, while behavioral issues such as agitation, apathy, and impulsivity contribute significantly to caregiver burden. Early neurorehabilitation and integrated psychiatric follow-up were associated with improved long-term outcomes. Conclusion: Chronic neuropsychiatric sequelae after CVA and head injury impact functional recovery. Early detection and a coordinated multidisciplinary approach are essential for optimizing patient outcomes and enhancing quality of life.

Command

Simran Gill, Palak Patel VMMC and safdarjung hospital, New Delhi, India Background: Alcohol-induced psychotic disorder with hallucinations (ICD-11) is an uncommon but clinically significant complication of chronic alcohol use, characterized by prominent hallucinations occurring during or shortly after alcohol intoxication or withdrawal, with preservation of consciousness. Presentation with command auditory hallucinations leading to self-harm is rare and poses diagnostic challenges. Aims: To describe the clinical presentation, diagnostic considerations, and treatment outcome of a young adult with alcohol-induced psychotic disorder presenting with command auditory hallucinations and self-harm. Methods: A comprehensive clinical assessment including detailed alcohol use history, mental status examination, physical and neurological evaluation, and relevant laboratory investigations was conducted to characterize psychotic symptoms and exclude delirium and other medical causes. Diagnosis was established based on ICD-11 criteria and temporal association with alcohol use. Results: A 30-year-old male with a 20-year history of alcohol use in a dependence pattern, consuming approximately one bottle per day, presented with suspiciousness, markedly reduced sleep, and command auditory hallucinations. Under the influence of the hallucinations, he had amputated his tongue using a knife on 02/11/2025. His last alcohol intake was on 30/11/2025. The patient remained conscious and oriented, with intact attention and memory, and without fluctuating sensorium or significant autonomic instability. A diagnosis of alcohol-induced psychotic disorder with hallucinations was made. Treatment with benzodiazepines, thiamine supplementation, and antipsychotic medication led to marked improvement in hallucinations and sleep. Conclusion: This case highlights alcohol-induced psychotic disorder as a distinct clinical entity that may present with severe psychopathology, including command hallucinations and self-harm, despite preserved sensorium.

Damsels

Kalindi Kamble, Parijat Roy, Shilpa Adarkar Department of Psychiatry, Seth G S Medical College and K E M Hospital, Mumbai, Maharashtra, India Introduction: Millions of Women worldwide struggle with Substance Use Disorder (SUD). Almost three quarters of women with SUD struggle with alcohol use. Cannabis followed by Opioids are the most commonly used drugs among women. Women typically begin substance use later than men, however their rates of consumption increase more rapidly than men, a phenomenon known as telescoping. Use of substances as coping strategies to face mental health issues is more common in women. Owing to differences in first pass metabolism and other physiological factors, the medical complications are often more severe in women than men. Childhood adversities, poverty, homeless status, social exclusion, partner substance use, intimate partner violence and mental illness are some of the common risk factors. Unfortunately, there exists a huge treatment gap and women face many barriers in accessing treatment than their male counterpart, with some studies claiming over 90% of women having SUD do not receive adequate treatment. Cases: The first case is of Alcohol Dependence in a 25y old Girl, highlighting the importance of Genetics in development of SUD. The second case is of Sedative Hypnotic Dependence in a 35y old Woman, facing intimate partner violence. The final case in our series is of a 27y old Girl, having injectable Opioid Dependence, with a history of multiple childhood adversities. Discussion: In the above cases, we have tried looking at various risk factors which ultimately culminated in the development of SUD, with a focus on various treatment modalities that were used.

Digital

Shivam Tyagi, Ravjot Kaur, Neal Kasbe 1 , Anusha Garg 2 GMCH, Chandigarh, 1 SMC, Meerut, Uttar Pradesh, 2 IHBAS, Delhi, India Background: Cybercrime is rising rapidly worldwide and in India, exposing different age groups to distinct digital threats. In India, cybercrimes increased by about 63.5% from 2018 to 2019, and reached 50,035 reported cases in 2020. Globally, cyberbullying affects a substantial proportion of teens, and many report long-term mental-health harm. Despite increasing digital integration, psychiatric and forensic responses to these age-stratified risks remain underdeveloped. Aims: To explore age-stratified epidemiology of cybercrime, profile associated psychiatric risks, describe forensic and clinical implications, and propose prevention and rehabilitation strategies. Methods: Narrative synthesis combining peer-reviewed studies, government data, global surveys, and clinical-forensic practice literature. Results: Among adolescents, a recent 2025 meta-analysis estimated a pooled prevalence of 19% for cyberbullying in Indian youth, with grooming and algorithm-driven self-harm contagion, leading to depressive or anxiety symptoms, self-harm, or suicidality. In adult population, a large share of cybercrime involves financial fraud, cyberstalking, and identity theft; victims often present with acute stress, trauma, guilt, and trust deficits. Geriatric population though under-studied, is increasingly targeted by scams exploiting cognitive vulnerability and fear of authority i.e. digital arrest, result in severe financial and psychological harm, including anxiety, depression, and in extreme cases suicide. Conclusion: Incorporating empirical data underscores the urgency. Psychiatrists should routinely screen for cyber-victimization and screen for digital exposures, apply age-adapted therapeutic strategies, and active medico-legal documentation, and forensic liaison. Forensic systems should factor in age and cognitive vulnerability; and policy must combine digital literacy, protective regulations, and targeted interventions across the lifespan with reforms in digital policies.

Healing

Mohit Raj, Preeti Dalal, Ankita Chattopadhyay, Manoj Kumar Institute of Human Behaviour and Allied Sciences, New Delhi, India Background: Post-traumatic stress disorder (PTSD) and alcohol dependence syndrome (ADS) frequently coexist, with alcohol often used as a maladaptive tool to manage intrusive memories and emotional turmoil. Understanding when alcohol use is secondary to untreated trauma is essential for targeted intervention. Aim and Methods: To present a case demonstrating remission of alcohol dependence following targeted PTSD treatment, highlighting the pivotal role of trauma-focused care in dual diagnosis. The patient underwent comprehensive neuro-psychological evaluation, was diagnosed using standard clinical criteria, and received pharmacological and trauma-focused psychotherapeutic interventions. Results: A 48-year-old man presenting with alcohol dependence syndrome was found to be suffering from severe PTSD after a tragic incident in which he accidentally hurt a 4 yrs old girl child during a crossfire with an accused. He reported intense flashbacks, pervasive guilt, avoidance, sleep disturbance and hyperarousal, followed by increased use of alcohol as coping tool, subsequently leading to alcohol dependence. With targeted trauma-focused treatment, the patient exhibited marked improvement in PTSD symptoms most notably the disappearance of intrusive memories and emotional dysregulation. Remarkably, as PTSD symptoms subsided, alcohol craving and consumption declined in parallel, culminating in sustained abstinence. Conclusion: This case underscores the potent influence of untreated trauma on the development and maintenance of alcohol dependence. It highlights that addressing the primary psychological injury PTSD can independently catalyse remission from secondary substance use disorders. Trauma-focused evaluation should therefore be considered essential in patients presenting with alcohol dependence.

Incubus

Annanya Ray, Shruti Garg, Shreyashi Koner Institute of Human Behaviour and Allied Sciences, Delhi, India Aim: To describe the clinical phenomenology of incubus experiences in female patients with schizophrenia and other primary psychotic disorder and to explore the therapeutic outcomes following integrated psychopharmacological and psychosocial interventions. Methods: This case series was conducted by recruiting three patients admitted to female Psychiatry ward of a tertiary neuropsychiatric hospital through the Psychiatry OPD/emergency services. Diagnosis was made using ICD-11 diagnostic criteria. Positive and Negative Syndrome Scale and other case-relevant instruments were used to assess the psychopathology and its improvement. Patients received individualized treatment involving optimization of antipsychotic, mood-stabilizer, modified Electro-convulsive therapy (ECT) along with supportive and insight-oriented psychotherapy. Follow-up assessments were conducted in the OPD. Results: All patients with incubus experiences had schizophrenia and other primary psychotic disorder. Age, duration of psychosis, marital and menopause status varied in these patients. Multiple interview sessions were required to elicit the detailed history of incubus experiences. Notable symptomatic improvement and resolution of these experiences were observed with appropriate psychopharmacological management (including modified ECT when indicated) combined with structured psychotherapeutic interventions. Follow-up assessments revealed persistent remission of incubus phenomena, along with enhanced psychotic symptom control, improved psychosocial adjustment, and resolution of incubus-related guilt. Conclusion: Patients experiencing incubus phenomena often feel embarrassed to disclose these experiences, even to mental-health professionals, which may contribute to underreporting. Incubus syndrome can appear at any age, irrespective of the duration of psychosis, marital and menopause status. Integrated treatment combining pharmacotherapy with psychosocial interventions can lead to symptomatic & functional recovery and reduce distress associated with incubus phenomena.

Insight

Arish Khan 1 , Seshan 1 , Hina 2 1 IHBAS, 2 AIIMS, New Delhi, India Background: Insight in obsessive-compulsive disorder (OCD) varies widely and influences symptom severity, functional impairment, and treatment response. Poor insight is associated with greater conviction in obsessive beliefs, more severe compulsions, and reduced global functioning. Understanding this relationship in Indian patients is essential for improving clinical assessment and management strategies. Aims: To assess the relationship between insight and symptom severity in OCD, and to evaluate associations with symptom dimensions and global functioning. Methods: A cross-sectional study was conducted on 92 adults meeting ICD-10 criteria for OCD at a tertiary care centre in North India. Insight was assessed using the Brown Assessment of Beliefs Scale (BABS) and symptom severity with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Standard statistical tests and Pearson’s correlation were applied. Results: Contamination was the most frequent symptom dimension (65.2%). Poor insight was present in 34.8% of patients. Mean Y-BOCS scores increased progressively across insight groups (excellent to poor: 8.7, 14.6, 17.3, 29.0; p<0.001). Insight showed a strong positive correlation with Y-BOCS severity (r=0.78). Harm/aggression and sexual/religious dimensions were significantly associated with better insight. Poor insight was strongly associated with severe functional impairment on GAF. Conclusion: Poorer insight was common and strongly correlated with higher OCD severity and lower functioning. Insight also showed specific associations with certain symptom dimensions. Routine assessment of insight using structured tools may improve prognostication and allow more targeted treatment planning in clinical OCD management.

Lessons

Madhurima Chakraborty, Harshavardhan Sampath, Sanjiba Dutta Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India Background: Disulfiram, an aversive agent widely used for relapse prevention in alcohol dependence, is known to cause psychiatric side effects such as psychosis. However, severe depression and suicidality are rarely documented. The risk may be amplified when disulfiram is administered covertly without patient consent or psychiatric supervision delaying recognition and timely management of adverse reactions. Case Report: A 57-year-old man with alcohol dependence syndrome was brought to the psychiatry outpatient department with severe depressive symptoms, irritability, insomnia, and suicidal ideation. Symptoms emerged 10 days after cessation of alcohol, during a two-week period in which his family surreptitiously administered disulfiram. He had no personal or family history of mood or psychotic disorders, and showed no signs of alcohol withdrawal or psychosis. He was admitted to the acute psychiatry unit, and disulfiram was discontinued. Laboratory investigations were normal, excluding metabolic causes of mood disturbance. A Naranjo score of 7 indicated probable disulfiram-induced depression. His symptoms resolved within one week without antidepressants. He received supportive care, family psychoeducation, and was commenced on acamprosate for relapse prevention. Discussion: Disulfiram inhibits dopamine β-hydroxylase, reducing norepinephrine and increasing dopamine, thereby disrupting catecholamine balance and potentially triggering depressive states. Although disulfiram-induced psychosis is well documented, severe depression with suicidality remains uncommon yet clinically significant. Conclusion: Disulfiram-induced depression can closely resemble a primary mood disorder but typically resolves upon discontinuation. Covert administration, despite good intentions, may cause unintended harm. Informed consent, careful monitoring, and evidence-based alternatives are essential in relapse prevention. Submitted in MIDCIPS 2025.

Musical

Hafija Khatun College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India Background: Musical obsessions, also called musical intrusive thoughts, are a rare form of obsessive-compulsive disorder (OCD) symptoms. These obsessions involve persistent and repetitive musical fragments that are experienced as unwanted and uncontrollable, causing significant distress and functional impairment. They are ego-dystonic, meaning they conflict with the individual’s sense of self, and are often mistaken for auditory hallucinations. Correctly distinguishing musical obsessions from psychotic hallucinations is crucial for accurate diagnosis and treatment. Case Description: This report presents a 37-year-old married Muslim male mason with a 5-year history of Bipolar I Disorder on medication. Over the past two years, he experienced intrusive and repetitive thoughts of musical phrases like “Sandesh aate hai” and other familiar songs. He recognized these thoughts as internally generated but unable to suppress them despite conscious effort. To cope, he engaged in multiple daily masturbations, which caused him shame. These symptoms led to marked distress and impaired his daily functioning, prompting psychiatric consultation. Management: A thorough clinical assessment confirmed the intrusive musical thoughts as obsessions rather than hallucinations. The patient began treatment with a selective serotonin reuptake inhibitor (SSRI) targeting the predominant obsessive-compulsive symptoms, while his bipolar mood symptoms were closely monitored. Over time, he showed significant improvement, with reductions in the intensity of musical obsessions and enhanced daily functioning. Conclusion: This case highlights the clinical importance of differentiating musical obsessions from psychotic symptoms, especially in patients with comorbid mood disorders. Early diagnosis and SSRI treatment can effectively reduce symptoms and improve quality of life.

Ominous

Mehak Mittal, Tarun Pal, Rashi Agarwal, Rameez Ul Islam, Nikita Maan Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India Background: Opioid abuse is an escalating public health concern in Meerut, driven by easy accessibility of prescription opioids and malpractice by healthcare professionals and unqualified practitioners. During just one month, seven patients presented to our tertiary psychiatry unit with opioid use disorder, indicating the severity of problem. Notably, three were females, suggesting a significant rise in opioid misuse among women. This study highlights clinical patterns, psychiatric comorbidities, and systemic contributors to opioid dependence. Aims: To describe the demographic and clinical profile of opioid-dependent patients in Meerut; assess withdrawal, anxiety, and depressive symptoms using COWS, HAM-A, and HAM-D; and examine the role of prescription practices, accessibility, and personality traits in development of dependence. Methodology: A cross-sectional descriptive study was conducted on seven consecutive patients meeting ICD-11 criteria for opioid use disorder. Sociodemographic data, initiation, pattern of opioid use, and progression to dependence were recorded. COWS, HAM-A, and HAM-D were used to assess withdrawal and comorbid symptoms. Relevant literature was reviewed to contextualize findings. Results: Six of seven patients initiated opioid use through prescribed analgesics, later developing dependence; only one sought illicit opioids directly. Easy availability through pharmacies, liberal prescribing, and quack practices were key contributors. Most patients exhibited moderate to severe withdrawal with anxiety and depressive symptoms. Personality features like impulsivity, emotional instability, low frustration tolerance were frequently observed. Conclusion: The clustering of cases within one month reflects an urgent opioid misuse problem in Meerut. Predominantly prescription-origin dependence highlights the need for stricter prescribing, regulation of malpractice, and early psychiatric intervention.

Organic

Aanchal Gupta NSCB Medical College and Hospital, Jabalpur, Madhya Pradesh, India Background: Frontal lobe lesions may present with prominent disturbances in affect, speech, and behavior, often resembling primary psychiatric disorders. Right frontal lobe infarcts are particularly associated with apathy, reduced verbal output, impaired initiation, and mood changes. Recognizing such neuropsychiatric presentations is important for timely differentiation between organic and functional psychiatric conditions. Case Description: A 55-year-old male with poorly controlled diabetes mellitus presented with an abrupt episode of unawareness of his surroundings 15 days prior to evaluation. This was followed by persistent behavioral changes, including markedly decreased speech, low mood, reduced social interaction, diminished appetite, and prolonged periods of mutism. There was no previous psychiatric history. Mental status examination revealed apathy, blunted affect, psychomotor slowing, and deficits on frontal lobe tests such as impaired verbal fluency and difficulty in abstract thinking, while no focal motor deficits were observed. MRI brain demonstrated a subacute-on-chronic right frontal lobe infarct, consistent with his clinical presentation. Stroke management was initiated with antiplatelet therapy, statins, and glycemic optimization. A low-dose antidepressant was introduced along with psychoeducation. Gradual improvement in speech initiation and affective symptoms was noted on follow-up. Conclusion: This case underscores the importance of considering frontal lobe pathology in patients presenting with sudden-onset mutism, apathy, and depressive symptoms, particularly among individuals with vascular risk factors. Neuroimaging plays a crucial role in distinguishing organic neuropsychiatric syndromes from primary psychiatric disorders, enabling timely and appropriate management.

Othello

Dev Himanshubhai Desai, Madhura Ghate, Shalmali Kulkarni Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India Background: Normal Pressure Hydrocephalus(NPH) is characterised by disproportionate ventricular enlargement with normal cerebrospinal fluid pressure and presents with gait disturbance, urinary incontinence, and cognitive impairment. While cognitive and motor symptoms are well recognised, prominent psychiatric manifestations are uncommon and often mistaken for primary psychiatric illness. Misdiagnosis may delay neurosurgical intervention. Rarely, NPH may manifest with Othello syndrome, a delusional belief of spousal infidelity. Aim: To describe a rare presentation of NPH manifesting as Othello syndrome and highlight the need for neuroimaging in elderly patients presenting with late-onset psychosis. Methodology: A detailed clinical assessment, mental status examination, ophthalmological evaluation, cognitive testing using MOCA-Blind, and MRI brain imaging were conducted for a 65-year-old male presenting with behavioural disturbances, psychosis, gait impairment, and urinary incontinence. Symptom evolution, treatment adjustments, and behavioural response were documented across follow-ups. Results: The patient exhibited irritability, aggression, urinary incontinence, shuffling gait, visual impairment, and a fixed delusion of infidelity. MRI revealed ventriculomegaly with an Evans Index of 0.37 and periventricular changes consistent with NPH. Fundus examination showed papilledema. Cognitive screening(MOCA-Blind=16/22) ruled out dementia. Initial treatment with risperidone showed limited improvement; subsequent switching to quetiapine resulted in reduced irritability and improved sleep. Over follow-ups, behavioural symptoms stabilised, and family members reported improved manageability. Conclusion: Psychotic presentations of NPH can closely mimic primary psychiatric disorders. This case underscores the necessity of comprehensive neurological examination and neuroimaging in elderly patients presenting with late-onset psychosis, particularly when accompanied by gait disturbance or urinary symptoms, to prevent misdiagnosis and enable timely intervention.

Pattern

Safoorabi, Shijoy P. Kunjumon Travancore Medical College, Kollam, Kerala, India Introduction: Adolescence is a vulnerable period for initiation of psychoactive substance use. In tertiary psychiatry outpatient settings, adolescents presenting with substance use represent a distinct clinical subgroup with important psychosocial and treatment implications. However, data describing their patterns of use in Indian clinical settings are limited. Aim: To study the socio-demographic and clinical profile and substance use pattern among adolescents attending Psychiatry OPD with substance use. Methods: This cross-sectional case series included 20 consecutive adolescents (aged 12-18 years) presenting with substance use to the Psychiatry OPD between January 2025 and June 2025. Sociodemographic and clinical details were collected using a structured proforma. Substance use characteristics (type, mode, frequency, and age at onset) were recorded. Screening was done using the CRAFFT tool. Descriptive statistics are presented. Results: The sample comprised 20 adolescents (mean age 16.2 ± 1.4 years), with 16 males (80%) and 4 females (20%). Tobacco was the most common substance, reported in 16 adolescents (80%), including both smoked forms (cigarettes/bidis) and chewable/sublingual preparations. Alcohol use was reported in 6 (30%), and cannabis in 2 (10%). Multiple-substance use (mainly tobacco + alcohol) was observed in 8 adolescents (40%). The median age of initiation was 15 years. Most adolescents reported academic decline (55%), poor peer relationships (40%), and family history of substance use (30%). CRAFFT scores indicated high-risk use in 12 out of 20 adolescents (60%). Conclusion: Adolescents presenting to psychiatry OPD with substance use predominantly reported tobacco, followed by alcohol, with cannabis being relatively less frequent.

Profile

Isha Sandip Tawde, Darpan Kaur, Rakesh Ghildiyal Department of Psychiatry, Mahatma Gandhi Missions Medical College and Hospital, Navi Mumbai, Maharashtra, India Introduction: The neuropsychiatric aspects of acute intraparenchymal haemorrhage are significantly under-explored, reflecting a major gap in the existing clinical literature. Aims and Objectives: To present an interesting case series on post stroke delirium in Hypertensive patients with acute intraparenchymal haemorrhage admitted at a Tertiary care Hospital. Methods: Case 1: Mr ABC 65 year old female under evaluation and treatment for stroke was referred in view of disorientation. Case 2: Mr DEF a 52 year old male under evaluation and treatment for stroke was referred in view of confusion. Case 3: Mr GHI a year old male under evaluation and treatment for stroke was referred in view of irritability with agitation. Results: All three patients had Hypertension as a common medical comorbidity and were diagnosed with Delirium. Case 1: MRI Brain Report indicated right cerebellar bleed with blood attenuation in right cerebellar hemisphere suggestive of acute intraparenchymal haemorrhage, with mild compression of 4th ventricle. Patient was advised Tab Quetiapine 25mg. Case 2: MRI Brain report stated acute intraparenchymal haemorrhage involving right corona radiata and right parietal lobe and midline shift, investigations showed deranged LFTs. Patient was advised Tab Haloperidol 0.5mg. Case 3: MRI Brain report mentioned acute intraparenchymal haemorrhage involving the right thalamocapsular region extending to the basal ganglia, compression of the adjacent right lateral ventricle and midline shift to the left. Patient was advised T. Haloperidol 0.5mg. Conclusion: Neuropsychiatric liaison is recommended in Post stroke Hypertensive patients with acute intraparenchymal bleed for early identification and treatment of Delirium.

Quality

Shubha Joshi, Sujita Kumar Kar, Shrikant Srivastava, Akanksha Sonal King George Medical University, Lucknow, Uttar Pradesh, India Background: Late-life depression is known to significantly impair quality of life in older adults. Symptoms such as anhedonia, apathy, and reduced motivation limit social engagement, autonomy, and overall functioning. Importantly, even after symptomatic remission, many individuals continue to experience deficits in psychosocial and functional domains, leading to a persistently reduced QoL. Understanding these long-term impacts is essential for clinicians to plan interventions that target not only symptom relief but also functional recovery. Identifying the specific areas of life affected can help guide comprehensive management in geriatric depression. Aim: To compare the quality of life between currently depressed elderly individuals and those in remission. Methods: This was a cross-sectional study conducted with 50 participants aged 60 years and above, comprising 25 individuals with current depression and 25 individuals in remission. Socio-demographic and clinical details were recorded. Quality of life was assessed using the WHOQOL-BREF instrument across its four domains. Results: Participants in the remission group demonstrated significantly higher quality-of-life scores across domains compared to those with current depression. The differences between the groups were statistically significant, indicating better perceived well-being among remitted individuals. Conclusion: Quality of life was better in the remitted group, indicating that remission contributes to improved well-being in elderly individuals with depression. Key words: Depression, elderly, late-life depression, quality of life

Raising

Pote Shweta Prakash, P. Sai Kiran, N. Unajyothi Guntur Medical College, Guntur, Andhra Pradesh, India Background and Aims: Idiopathic intracranial hypertension (IIH) is characterised by persistently elevated intracranial pressure without an identifiable structural or secondary cause. It predominantly affects obese women of reproductive age and commonly presents with headache, visual disturbances, and the potential risk of vision loss. Beyond its established neurological profile, emerging literature highlights that psychiatric manifestations particularly anxiety and depressive symptoms are highly prevalent in IIH and significantly impair functioning, though they often remain underrecognised. Materials and Methods: A retrospective case series of individuals diagnosed with IIH who initially presented with prominent mood or anxiety symptoms. Case Reports: Case 1: A 12-year-old girl (BMI >25) presented with a 2-week history of headache and declining scholastic performance. She also developed low mood, reduced sleep, which improved with melatonin and anhedonia for 4 weeks, leading to a diagnosis of depression and initiation of antidepressants. Headache and visual complaints persisted, prompting ophthalmologic examination that revealed papilledema. Lumbar puncture confirmed raised intracranial pressure, and her symptoms improved post-procedure. Case 2: A 50-year-old woman with no psychiatric history presented with acute anxiety, palpitations, headache, and insomnia, with relief from zolpidem. A recent psychosocial stressor contributed to distress. Recurrent headaches and visual disturbances prompted ophthalmologic referral, which led to the identification of papilledema and elevated intraocular pressure. Neurological evaluation and lumbar puncture confirmed IIH/pseudotumour cerebri. Discussion and Conclusion: These cases demonstrate that IIH may present predominantly with psychiatric symptoms such as depression, anxiety, or insomnia, overshadowing underlying neurological pathology. Awareness of IIH-related mood symptoms is essential to avoid misdiagnosis.

Section

Arnab Biswas Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India Background: Systemic corticosteroids are frequently used for their anti-inflammatory and immunomodulatory benefits but are associated with neuropsychiatric adverse effects in 5-20% of patients. Common manifestations include mood changes, anxiety, insomnia, and psychosis. Obsessive-compulsive symptoms (OCS) or de novo Obsessive-Compulsive Disorder (OCD) are rarely reported, particularly in paediatric populations, where developmental neurobiological vulnerability may heighten risk. Case History: A 14-year-old previously healthy girl, diagnosed with Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH), was started on systemic corticosteroids. Five days later, she developed intrusive, ego-dystonic thoughts that harm might befall her family unless she performed certain rituals. This progressed to compulsions including hand-washing, checking, symmetry behaviours, and counting, resulting in significant functional impairment. There was no past or family psychiatric history. Medical and neurological workups were unremarkable. The strong temporal association with corticosteroid initiation suggested steroid-induced de novo OCD. Discussion: The case aligns with limited literature describing corticosteroid-associated obsessive-compulsive phenomena. Proposed mechanisms include HPA axis dysregulation, altered serotonergic signalling, disruption of the cortico-striato-thalamo-cortical circuit, and possible glutamatergic imbalance. Adolescents may be particularly susceptible due to ongoing maturation of neural networks regulating anxiety and cognitive control. Management involved gradual steroid taper alongside fluoxetine (10-20 mg/day) and supportive counselling, leading to progressive improvement and complete remission by six weeks. This case underscores that corticosteroids can precipitate reversible de novo OCD even in individuals without psychiatric vulnerability. Early recognition, timely dose adjustment, and SSRI treatment are crucial for full recovery. Greater clinical vigilance is warranted, especially in paediatric settings, to prevent misdiagnosis and reduce morbidity.

Seizure

Aditi Patni, Karishma Rupani, Ajita Nayak Seth GS Medical College, KEM Hospital, Mumbai, Maharashtra, India Background: Behavioural changes and scholastic decline in adolescent patients of epilepsy may be misinterpreted as primary psychiatric illnesses, especially in those who are seizure-free. Interictal epileptiform discharges (IEDs) can contribute to behavioural dysregulation and cognitive deterioration, leading to challenges in diagnosis and untimely treatment. Case Description: A 13.5-year-old boy was referred for behavioural problems and declining scholastic performance despite having a superior IQ a year earlier. History suggested oppositional defiant disorder with hyperactivity. Past history included episodes of seizures, for which he had been on antiseizure medications (ASMs), which were then discontinued, and the child remained seizure-free for four years after stopping ASMs. ENT and ophthalmology evaluations were normal. Occupational therapy indicated poor attention, comprehension, and task completion. Anti-psychotics were added in the optimum doses. Behaviour didn’t improve, and his academic performance continued to decline; repeated IQ testing showed borderline intelligence. Lack of response to antipsychotic drugs, cognitive decline with history of seizures, prompted a repeat EEG, which showed inter-ictal discharges in the form of generalised bursts of epileptiform complexes. His ASMs were restarted, after which behaviour gradually improved and school complaints ceased, with modest academic improvement. Discussion: This case depicts that inter-ictal epileptiform discharges contribute to behavioural disturbances and may be associated with cognitive decline even in the absence of epilepsy. While the reintroduction of anti-seizure medications improved behavioural symptoms, cognitive deficits persisted, highlighting the potential long-term impact of untreated interictal epileptic activity.

Shadows

Niranjan Singh Bhayal, Kenil Jagani PDU Medical College, Rajkot, Gujarat, India Background: Personality pathology, particularly dependent and borderline traits, can significantly influence the onset, course, and treatment outcome of depressive disorders. Such individuals display heightened sensitivity to rejection, poor autonomy, and emotional instability, increasing vulnerability to recurrent depression. Case Presentation: A 25-year-old male with a four-year history of recurrent depressive episodes presented with low mood, anhedonia, fatigue, and social withdrawal. Episodes were precipitated by interpersonal stress, especially criticism from authority figures and family. During acute phases, he would experience dissociative episodes involving disorientation, language switching, and transient psychotic-like experiences for which he was diagnosed as Major Depressive Disorder with psychotic features in previous admission. On further detailed evaluation we found premorbidly, he demonstrated dependent and borderline personality traits, including excessive reassurance seeking, unstable self-image, affective instability, and fear of abandonment. Management and Outcome: With Desvenlafaxine 100 mg, Fluoxetine 60 mg and Olanzapine 7.5 mg, no improvement was perceived. A revised regimen of Fluoxetine 40 mg and Alprazolam 0.75 mg with gradual withdrawal of Desvenlafaxine and Olanzapine, combined with assertiveness and vocational therapy and parental psychoeducation focusing on communication and reducing overprotection, led to marked improvement- approximately 70% reduction in depressive symptoms and full remission of dissociative episodes. Conclusion: This case highlights how personality pathology can perpetuate depressive illness through maladaptive coping and emotional instability. An integrated, individualized approach combining pharmacotherapy with targeted psychotherapeutic strategies can effectively break this cycle, fostering long-term remission, autonomy, and improved psychosocial functioning.

Tardive

Shubha Joshi, Porimita Chutia 1 , Shailendra Mohan Tripathi 2 King George Medical University, Lucknow, Uttar Pradesh, 1 Post Graduate Institute of Medical Education and Research, Chandigarh, India, 2 Institute of Medical Sciences, University of Aberdeen, United Kingdom and Betsy Cadwaladr University Health Board, Wales, UK Background: Tardive dyskinesia is a distressing, often persistent movement disorder associated with prolonged exposure to antipsychotics. Early identification of risk factors, including older age, medical comorbidities, and neurological vulnerabilities, is essential to prevent progression and tailor management effectively. This case series highlights TD management with baclofen and the role of vascular risk factors. Cases: This case series discusses three patients aged 62-77 years who developed tardive dyskinesia at low antipsychotic doses during treatment for schizophrenia or mood symptoms. All cases involved peri-oral dyskinesias. Aripiprazole showed a dual clinical role: in one patient, it precipitated TD, whereas in two others, switching to low-dose aripiprazole improved dyskinetic symptoms. Oral baclofen (20 mg/day) was added in all cases, resulting in significant reductions in AIMS scores within days to weeks. Importantly, no adverse effects or tolerance to baclofen were observed. Neuroimaging and medical histories revealed vascular comorbidities in these patients, emphasising the need to identify such factors when choosing antipsychotic regimens. Results: All three patients showed meaningful improvement in TD severity following the introduction of baclofen, either alongside or after dose adjustment of antipsychotics. Aripiprazole demonstrated both TD-inducing and TD-ameliorating properties depending on individual vulnerability. Conclusion: TD can emerge even at low antipsychotic doses in older adults, highlighting the importance of early recognition and individualised management. Baclofen may be a useful treatment for TD, with rapid benefit and good tolerability. Key word: Baclofen, elderly, older adults, risk factors, tardive dyskinesia

Typhoid

Samiksha Sahu, K. M. Sarita Gandhi Medical College, Bhopal, Madhya Pradesh, India Background: Typhoid fever, caused by Salmonella typhi, rarely leads to post-infectious neuropsychiatric sequelae, including catatonia. This case series reports four patients (aged 16-25 years, from typhoid-endemic regions in India) who developed catatonia following confirmed enteric fever. All presented with prolonged fever (7-14 days), positive blood cultures for S. typhi, and received antibiotics (ceftriaxone or cefuroxime), achieving defervescence within 48-72 hours. However, 5-10 days post-resolution, they exhibited catatonic features: mutism, stupor, posturing, waxy flexibility, and rigidity (Bush-Francis Catatonia Rating Scale scores 15-22), without primary psychiatric history or ongoing infection. Aims: To describe the clinical course of post-typhoid catatonia in four cases, evaluate response to lorazepam and ECT, and highlight typhoid toxin’s role in neuropsychiatric complications. Methods: Initial management involved lorazepam (4-8 mg/day) for 3-5 days. Persistent symptoms prompted bilateral ECT (6-12 sessions, 2-3 times weekly) under anaesthesia, targeting presumed basal ganglia dysfunction from typhoid endotoxins disrupting dopaminergic-cholinergic balance. Adjunct olanzapine (5-10 mg) addressed residual negativism. Follow-up spanned 6 months. Results: Lorazepam yielded partial response, but ECT produced dramatic improvement: catatonia scores dropped to <5 by session 4-6, achieving full remission (normal speech, mobility, cognition) within 2-4 weeks. No adverse effects or relapse noted at 6-month follow-up. Conclusion: pathophysiologically, typhoid toxin induces blood-brain barrier breach, neuroinflammation, and parkinsonism-catatonia overlap, as evidenced in recent models. These findings affirm ECT’s efficacy in organic catatonia refractory to benzodiazepines, urging typhoid serology in acute catatonic states from endemic areas. Early intervention prevents prolonged morbidity.

Unusual

Shweta Ohariya, Nimisha Mishra, Sunil Ku. Ahuja Shyam Shah Medical College, Rewa, Madhya Pradesh, India Background / Objectives: Obsessive-Compulsive Disorder (OCD) is a chronic mental health condition characterized by intrusive, repetitive thoughts (obsessions) and ritualistic behaviors (compulsions). While OCD typically manifests as checking or cleaning rituals, atypical and self-harming presentations are rare. This report aims to describe a unique case of OCD presenting with self-inflicted pin insertions into the abdominal wall, emphasizing the importance of identifying such atypical forms for timely intervention. Methods: A 17-year-old female presented to the emergency department with abdominal pain and discomfort. Clinical and radiological evaluations revealed multiple metallic pins inserted superficially into the subcutaneous tissue of the abdominal wall. A detailed psychiatric assessment and collateral history from family were obtained. Results: The patient reported inserting pins as a means to reduce anxiety triggered by academic pressure and family conflicts. Over time, this behavior evolved into a compulsive ritual driven by obsessional distress. She was diagnosed with Obsessive-Compulsive Disorder (DSM-5 criteria) and treated with Selective Serotonin Reuptake Inhibitors (SSRIs) along with Cognitive Behavioral Therapy (CBT). Significant improvement was observed over subsequent follow-ups. Conclusion: This case highlights that OCD can present with self-harming and medically serious compulsions. Awareness of such atypical presentations is crucial for early diagnosis and effective management, preventing further self-injury and improving patient quality of life.

Urinary

T. Prama Basaveshwara Medical College And Hospital, Chitradurga, Karnataka, India Background: Risperidone is widely used in the management of schizophrenia and is generally well tolerated. However, rare adverse effects including urinary incontinence may significantly impact quality of life and treatment adherence. We report a case of new-onset urinary incontinence in a patient receiving high-dose risperidone for treatment-resistant schizophrenia. Case: A 48-year-old man with a 15-year history of treatment-resistant schizophrenia who had previously been treated with olanzapine, aripiprazole, and clozapine but discontinued these medications due to adverse effects. He was subsequently started on risperidone, which was well tolerated and resulted in symptom improvement at a dosage of 8 mg/day. He remained on this regimen for one year,after which he developed new-onset urinary incontinence.Comprehensive urological, neurological, and metabolic evaluation revealed no identifiable cause.The incontinence appeared temporally related to risperidone use. Intervention and Outcome: The risperidone dose was gradually tapered from 8 mg to 4 mg, then to 2 mg daily, resulting in notable improvement. Complete resolution of urinary symptoms was observed after full discontinuation of risperidone.Risperidone was cross tapered with haloperidol. Conclusion: This case highlights urinary incontinence as a potential but under-recognized adverse effect of risperidone, particularly at higher doses. It emphasizes the importance of prolonged monitoring of side effects to ensure better tolerability, adherence, and overall patient outcomes.

Vitamin

Jahanvi Zandawala, Vinayak Koparde Jawaharlal Nehru Medical College, Belgaum, Karnataka, India Background: Vitamin B12 deficiency can present with psychiatric symptoms, including acute psychosis, even before anemia or neurological signs appear. Recent pediatric reports show that sudden-onset or atypical psychosis may be directly related to B12 deficiency and often improves rapidly after supplementation. Early recognition helps prevent misdiagnosis and unnecessary long-term antipsychotic treatment. Case Presentation: A 16-year-old girl was admitted for limb weakness and pain. Within the first days of admission, she developed acute fearfulness, second-person auditory hallucinations, persecutory delusions, food refusal due to mistrust, and one episode of disinhibited undressing driven by a belief of being recorded. Mental Status Examination and TAT findings indicated a psychotic spectrum disorder with depressive features. Investigations showed Hb 9.8 g/dL, MCV 97.1 fL, reticulocyte count 5.1%, and a critically low vitamin B12 level of 32 pg/mL. She received IV methylcobalamin 1000 mcg twice daily for 7 days, along with Risperidone 6 mg/day (3 mg BD), Trihexyphenidyl, escitalopram 10 mg, and clonazepam. Within one week, her BPRS score improved from 60 to 24, with complete remission of psychotic symptoms and significant improvement in depressive symptoms. Discussion: Her clinical course closely aligns with published pediatric reports describing B12 deficiency induced acute psychosis that improves rapidly with supplementation, even when antipsychotics alone yield limited response. Conclusion: Vitamin B12 deficiency should be routinely screened in sudden-onset adolescent psychosis, especially when presentations are rapid, atypical, or show slower-than-expected antipsychotic response. Early testing is affordable, treatment is safe, and timely correction enables full and sustained recovery.

Atypical

A. P. Sathishkumar, Ritwik Mishra 1 Armed Forces Medical College, 1 Command Hospital, Pune, Maharashtra, India Cutaneous adverse drug reactions are well-recognised complications of antipsychotic therapy, accounting for a significant proportion of psychotropic-induced dermatological reactions. While olanzapine is generally considered a well-tolerated atypical antipsychotic, rare severe cutaneous reactions have been reported. Acute Localised Exanthematous Pustulosis (ALEP) is an uncommon variant of acute generalised exanthematous pustulosis, characterised by the sudden onset of sterile, non-follicular pustules on an erythematous base, typically confined to localised regions. We report the case of a 28-year-old male with metastatic carcinoma of the rectum receiving adjuvant chemotherapy who developed ALEP following initiation of olanzapine for psychotic symptoms. The patient had a prior history of psychotic illness and was diagnosed with Other Non-Organic Psychotic Disorder after exclusion of organic causes. Olanzapine was initiated at a low dose with planned titration. On the fourth day of treatment, the patient developed multiple pustular lesions localised to the facial region. Dermatological evaluation confirmed the diagnosis of ALEP. Olanzapine was promptly discontinued, leading to the rapid resolution of skin lesions within three days. Subsequent management with haloperidol resulted in satisfactory psychiatric stabilisation without recurrence of dermatological symptoms. This case highlights a rare but clinically significant adverse reaction to olanzapine, particularly in medically complex patients. Early recognition and timely withdrawal of the offending agent are crucial to prevent morbidity. Clinicians should maintain a high index of suspicion for atypical cutaneous reactions when initiating antipsychotics, especially in patients receiving concurrent chemotherapy.

Bridging

Akansha Bhardwaj, Gunjan Chadha 1 Department of Psychiatry, Institute of Liver and Biliary Sciences, 1 Department of Psychiatry, Atal Bihari Vajpayee Institute of Medical Sciences and RML Hospital, New Delhi, India Psycho-dermatology, an interdisciplinary field that bridges dermatology and psychiatry, addresses the intricate connection between skin disorders and mental health. Skin conditions can significantly impact an individual’s emotional well-being, while psychological stress can exacerbate or trigger dermatological issues. This paper aims to illustrate the complex interplay between dermatological and psychiatric conditions through a series of case studies, highlighting the importance of an integrated treatment approach. Three case studies are presented, each demonstrating a distinct psychosomatic dermatological condition. Detailed evaluations were conducted to identify the underlying psychological factors contributing to the dermatological symptoms. Case 1: A 41 years old female diagnosed with delusional disorder (Ekbom syndrome) exhibited improvement in symptoms with antipsychotic treatment. Case 2: A 23-year-old female with body dysmorphic disorder showed progress with a combination of pharmacotherapy and cognitive- behavioural therapy. Case 3: A 16-year-old female with trichotillomania reported significant improvement through a combination of medication and behavioural therapy. The case series underscores the critical importance of a multidisciplinary approach in treating psychosomatic dermatological conditions. Integrating dermatological and psychiatric interventions can enhance patient outcomes by addressing both physical and psychological aspects. Future research should focus on developing standardized protocols for managing these complex conditions and exploring the long-term benefits of integrated treatment strategies.

Clinical

Nabanita Sengupta, Deepak Gupta, Riya Sharma, Sanjana Abrol Center For Child and Adolescent Well Being, New Delhi, India Background: Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition with limited pharmacological options targeting core symptoms. Abnormalities in folate metabolism, including cerebral folate deficiency, have been linked to ASD pathophysiology. Leucovorin (folinic acid), a reduced form of folate, has shown potential in improving communication and cognition n in children with ASD. On September 22, 2025, the FDA recognized Leucovorin as a promising molecule for managing ASD symptoms. However, clinical data from Indian settings remain limited. Aim: To evaluate the clinical outcomes of Leucovorin supplementation in children with ASD based on parental reports and clinical observation. Methods: Ninety six children diagnosed with ASD were observed over a 13 month period (July 2024 to August 2025) in a clinical setup. Leucovorin was administered orally, titrated from 7.5 mg to 45 mg daily based on clinical response. Data were obtained through parental feedback and clinician observations, without the use of standardized assessment tools, making this an exploratory observational study. Results: Out of 96 children, 47(48.95%)showed improvements in speech and communication, 43(44.79%)improvement in comprehension and cognitive engagement, 18(18.75%) improvement in behavioral regulation, 20(20.83%) showed improved eye contact, while 21(21.87%) experienced worsening of sensory symptoms. Conclusion: Leucovorin shows promising benefits in speech, comprehension, and behavior in children with ASD. Despite limitations due to the absence of standardized assessment tools, these preliminary findings support the need for larger, controlled studies in Indian clinical settings.

Cyclical

Gouthami Ganagalla, Sandhya Government Hospital for Mental Care, Vishakapatnam, Andhra Pradesh, India Background: Cyclical vomiting syndrome (CVS) consists of recurrent, sudden, and stereotypical episodes of severe nausea and vomiting separated by symptom free periods. Associated with high incidence of psychiatric comorbidities. Psychosocial factors also play a role in triggering this condition Aim: To report and discuss a case of cyclical vomiting syndrome. Case Summary: a 16 year old female child with father refered to psychiatry department with complaints of recurrent vomiting and fearfulness . Vomiting episodes started when She was 7 years of age. Vomiting had started after child cheeks pinched by unknown lady. She had 5-6 times of vomiting per day and continued.stopped by itself without any medication after 3 years. Then, the child started to have similar episodes of vomiting since last 6 months and feeling fearful of that same lady. The symptom-free interval between two episodes of vomiting is of 7 years.during this interval, no physical complaint and was regular in her daily activities . currently stopped studying. The child had significant psychosocial stressors, father staying away from Child for last 5 years and alcoholic and emotionally closed off and interacts less with the child. Results: As on evaluation for the recurrent vomiting by genereal medicine no abnormality detected .The child was treated on amitriptyline 25 mg at night. The child improved with the medication. The child is on regular follow-up, and his vomiting episodes have reduced. Conclusion: Antidepressants like TCA can used to treat CVS. Psychiatrists play active role for better outcome.

Delusion

Vidhi Kaushik, Deepak Krishna Ghormode, Neetika Jha Shri Shankaracharya Institute of Medical Sciences, Durg, Chhattisgarh, India Background: Delusional misidentification syndrome is a group of psychopathological phenomena characterized by a belief that a person, place, object, or event has been duplicated, reformed, or replaced. Inter-metamorphosis is one of its presentations defined as the belief that people, usually familiar, are swapping identities although maintaining appearance. However, Reverse inter-metamorphosis is rare, described as belief that one has changed identities with others while maintaining physical appearance. Here we present a case with Schizophrenia and phenomenon of reverse inter-metamorphosis. Case Presentation: A 41 years, unmarried male, postgraduate, unemployed, from a Hindu nuclear family of lower socio-economic status and rural background presented with insidious onset and continuous illness since 5 years characterized by delusion of grandiosity and persecution, thought insertion, thought broadcast and auditory hallucination (commenting and commanding type). He also believed that he gets changed into the other person whomsoever he talks or sees. He would describe that his face gets changed as that of the other’s and hence it appeared that the same two persons are talking to themselves and patient would be firm on it despite contradictory evidence suggestive of reverse inter-metamorphosis. He also had disturbed sleep and appetite with poor selfcare leading to marked socio occupational dysfunction. All routine investigations and MRI brain showed no significant abnormality. Diagnosis of Schizophrenia was considered and treated with Quetiapine 350 mg/day for 8 weeks and tab clonazepam 0.5mg HS, showed no significant improvement hence changed to Risperidone 2mg-4mg/day.

Disaster

C. S. Bharath Armed Forces Medical Services Introduction: Disasters are sudden, large-scale events leading to significant mortality, physical injury, displacement, and psychological trauma. With global increases in disasters due to climate change and population expansion, mental-health consequences have become a critical public-health concern. The 2011 Sikkim earthquake exemplified these effects, causing over 111 deaths, hundreds of injuries, and widespread psychological distress across India, Nepal, Bhutan, Bangladesh, and Tibet. Morbidity: Psychiatric morbidity following disasters is extensive. Psychological distress commonly emerges immediately and may persist, affecting functioning, social support, and recovery processes. Up to 13-19% of individuals may experience disaster exposure in their lifetime, with many developing acute and chronic emotional and behavioral responses. Epidemiology: Disasters include natural events such as earthquakes and floods, and human-made events including technological accidents and acts of violence. The rising frequency and intensity of disasters has resulted in substantial global mental-health burden. Psychiatric Sequelae: Common psychiatric sequelae include post-traumatic stress disorder, acute stress disorder, major depressive disorder, anxiety disorders, adjustment disorders, brief psychotic episodes, and substance-use disorders. Assessment: Effective assessment requires rapid triage, clinical evaluation, and use of screening tools. It is essential to exclude medical conditions such as head injury, toxic exposure, delirium, dehydration, and medication interruption. Community surveillance aids early identification of at-risk individuals. Disaster Response: Evidence-based interventions include Psychological First Aid, crisis counseling, and early supportive care guided by principles of proximity, immediacy, expectancy, and simplicity. Conclusion: Disasters result in significant psychiatric consequences. Early identification, structured triage, and timely psychological support are essential to reduce long-term morbidity and enhance community.

Dopamine

Chaitanya Sharma, Shalini Naik, Chahat Jamwal PGIMER, Chandigarh, India Aim: To illustrate gambler’s fallacy as a cognitive distortion perpetuating online gambling disorder in a patient with episodic psychosis. Methodology: A 33-year-old unmarried male from Chandigarh presented with a 13-year history of psychosis since 2012, featuring paranoid delusions and disturbed sleep responsive to aripiprazole. Medication discontinuation in 2014-15 led to negative symptoms that resolved upon restarting. Online gambling emerged in 2020 during COVID-19 lockdown, escalating to daily preoccupation, tolerance, and losses over 1 crore from family accounts. This was driven by the gambler’s fallacy believing losses could be recovered via strategies from online tutorials, despite recognizing randomness. Assessments included MSEs, medical records, family interviews, and neuropsychological assessment revealing severe deficits in attention, response inhibition, planning, verbal & visual memory, and visuospatial skills. Differentials encompassed persistent delusional disorder, schizophrenia spectrum, and gambling disorder. Results: No active psychotic symptoms were present; partial insight and preparation for change were noted. Comorbidities included hypertension, diabetes, dyslipidemia, and paternal bipolar history. Treatment comprised naltrexone 50 mg/day, continued aripiprazole, metabolic agents, CBT, psychoeducation, and lifestyle modifications, yielding improved functioning and 2 months’ gambling abstinence. Conclusions: This case highlights challenges in distinguishing primary psychotic disorders from gambling-related cognitive distortions. It supports the primary addiction hypothesis, which proposes that dopamine network dysregulation resulting from hippocampal-prefrontal dysfunction disrupts nucleus accumbens integration of dopamine and glutamate signals. This disruption promotes reinforcement of addictive behaviors and loss of inhibitory control, making addiction vulnerability a core feature of schizophrenia independent of self-medication.

Efficacy

Sharath Hiremath Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India Background: Antidepressants are widely used for anxiety and depressive disorders, yet most evidence derives from therapeutic dose trials. The effectiveness of low dose regimens remains unclear. Aims: To compare clinical effectiveness of low dose antidepressants (escitalopram, sertraline) in anxiety disorders versus depressive disorders. Methods: We conducted a retrospective chart review at Basaveshwara Hospital (Jan-Dec 2024). Patients were grouped as anxiety disorders (n = 78; completers with outcome data n = 30) or depressive disorders (n = 84; completers n = 32). Symptom severity was measured with HAM A and HAM D. Response was defined as >50% reduction from baseline and assessed at 4-6, 6-8, and 8-12 weeks. Anxiety patients received escitalopram 5-15 mg or sertraline 25-75 mg. Depressive disorder patients initiated escitalopram 5-10 mg with titration at week 4-6 to escitalopram 15-20 mg or sertraline 150-200 mg if inadequate response. Results: In anxiety (baseline HAM A = 26), low dose antidepressants (escitalopram 5-15 mg; sertraline 25-75 mg) yielded response rates of 39%, 54%, and 69% at 4-6, 6-8, and 8-12 weeks, respectively. In depressive disorders (baseline HAM D = 23), initial low dose treatment produced minimal response; after titration at week 4-6, response rates improved to 44%, 60%, and 72% at corresponding timepoints. Conclusion: Low dose escitalopram and sertraline were effective for anxiety disorders. Depressive disorders typically required dose escalation for meaningful response, supporting diagnosis specific dosing and prospective studies to define optimal low dose and titration protocols.

Emerging

Subalakshmi, Sai Kiran Padupala 1 Guntur Medical College, 1 Guntur Medical Institute, Guntur, Andhra Pradesh, India Introduction: Genetic mutations play a critical role in neurodevelopmental and behavioural disorders. ADGRL1 variants are linked to DEDBANP (Developmental Delay, Behavioural Abnormalities, Neuropsychiatric Disorder); SETD1A mutations underlie NEDSID (Neurodevelopmental Disorder with Speech Impairment and Dysmorphic Facies); and NRXN1 deletions/mutations are associated with a range of conditions including autism spectrum disorder, intellectual disability, and language impairment. Early genetic evaluation enhances diagnostic clarity and guides individualized management. Case Report 1: An 11-year-old boy presented with global developmental delay, severe speech impairment, hypotonia, altered gait, dysmorphic facies (long nose, thick lips, sandal gap, wide-spaced nipples), mild hearing loss, microcephaly, and mild intellectual disability (IQ 56), with a positive family history. MRI brain findings were normal. Genetic testing identified a heterozygous ADGRL1 variant, confirming DEDBANP. Case Report 2: A 5-year-old boy showed impaired social communication, regressive and non-spontaneous speech, tantrums, and early scholastic difficulties despite initially normal milestones. Genetic analysis revealed a heterozygous SETD1A mutation, supporting a diagnosis of NEDSID. Case Report 3: A 7-year-old boy exhibited expressive language delay, attention difficulties, repetitive behaviours, and borderline intellectual functioning, without dysmorphism. Chromosomal microarray detected a pathogenic NRXN1 deletion, consistent with NRXN1-related neurodevelopmental disorder. Discussion and Conclusion: ADGRL1, SETD1A, and NRXN1 are essential genes involved in synaptic organisation, chromatin regulation, and neuronal connectivity. This rare case series highlights the phenotypic variability of single-gene neurodevelopmental disorders and emphasises the importance of early genomic evaluation. Prompt identification enables accurate diagnosis, targeted neurodevelopmental rehabilitation strategies, and gene-informed clinical management, ultimately improving developmental outcomes.

Gambling

Bhanu Kiran Hirwani, Nitin P. Patil Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Sangli, Maharashtra, India Background: Gambling disorder is a behavioural addiction characterized by persistent, recurrent gambling and significant psychosocial impairment. The rise of online gambling platforms has exacerbated the condition, highlighting the importance of early diagnosis and effective treatment. This report presents a case diagnosed by DSM-5 criteria and evaluates clinical response to naltrexone. Case Presentation: Clinical Findings: A 37-year-old male presented with a 5 year history of escalating online gambling, excessive phone use, irritability, abusive behaviour, and occupational dysfunction. He exhibited key gambling disorder criteria as per DSM-5, including needing increasing amounts for excitement, irritability when attempting to cut down, persistent preoccupation, gambling to escape distress, and repeated “chasing” of losses. Clinical Assessment: Clinical information was obtained through detailed interviews and mental status examination. Diagnosis was based on DSM-5 criteria. Treatment Plan: Naltrexone 50 mg/day was initiated following normal baseline liver function tests and was well tolerated. Concurrently, CBT sessions targeting impulse control, cognitive distortions, and relapse prevention were implemented. Treatment response was monitored during regular outpatient follow-up. Health Outcome: Over follow-ups, the patient showed marked reduction in urges, improved impulse control, sustained abstinence, and better interpersonal functioning along with daily routine engagement (including social and occupational recovery). Discussion/Conclusion: This case highlights the increasing clinical burden of online gambling disorder and supports the combined efficacy of naltrexone and CBT in managing cravings and behavioural regulation. Early diagnosis and structured monitoring alongside pharmacotherapy can lead to significant functional recovery even in chronic cases, emphasizing the need for awareness and intervention frameworks.

Gripping

Pratibha, D. Arogyanadhudu Andhra Medical College / Government Hospital For Mental Care, Visakhapatnam, Andhra Pradesh, India Background: Dissociative amnesia is a psychiatric disorder presenting with memory impairment and inability to recall autobiographical information that is inconsistent with normal forgetting. The hallmarks of borderline personality are pervasive and excessive instability of affects, self image and interpersonal relationships as well as marked impulsivity. Aim: To understand atypical presentation of dissociative amnesia. Though caused by traumatic event followed by minor head injury, the amnesia has extending beyond the traumatic period, but was generalised for un related period, not limiting to person, place or experience with preserved identity. Methods: Patient presented with amnesia for 1 day, the amnestic period was for 2 years, along with apprehension, tremors, sweating, inability to sleep. Reportedly, the symptoms started when her live-in partner asking her to take a break and go home for a while, followed by a minor head injury in an auto. Results: History revealed severe, cumulative trauma including attachment issue, temperament issues, lifelong physical abuse and relationship issues resulting in fear of abandonment, fear of loneliness pointing towards borderline personality. The apprehension and inability to maintain concentration, was secondary to amnestic period following November 2023. On neurological examination, the results were normal, confirming the dissociative etiology. Conclusion: This case demonstrates that dissociative amnesia can represent a decompensation following prolonged, severe psychosocial stress. The diagnosis hinges on a comprehensive assessment to exclude neurological conditions. Management must be rooted in a psychotherapeutic approach focused on safely processing traumatic material and building resilience, underscoring the condition’s psychogenic origins and the limited role of pharmacotherapy.

Inhalant

Kavin Guleria, Mona Srivastava Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India Background: Inhalant use disorders in adolescents are often under-recognized, with topical agents such as Vicks VapoRub rarely reported as substances of misuse. Co-occurrence with conduct disorder can worsen clinical outcomes. Case Presentation: A 17-year-old male with a four-year history of aggression, lying, stealing, fire-setting, and cruelty towards animals presented with six months of daily Vicks VapoRub inhalation. He placed the ointment in a polythene bag and inhaled it for 20-30 minutes, two to three times per day, leading to light-headedness and behavioral deterioration. The patient met criteria for conduct disorder with inhalant use disorder . Examination revealed irritability, impaired judgment, and pre contemplation stage of motivation . No medical comorbidities were identified. Management: A multimodal approach was undertaken, including pharmacotherapy with endoxifen, aripiprazole, propranolol, and clonazepam (tapered). Psychoeducation focused on identifying maladaptive behaviors, risk awareness, and developing alternatives to substance use. Family counseling emphasized communication improvement and environmental control. At two-week follow-up, aggression had reduced and abstinence from Vicks inhalation was reported. Conclusion: This case highlights a rare presentation of Vicks VapoRub inhalant abuse in an adolescent with conduct disorder. Readily available topical preparations may be overlooked for their abuse potential. Early identification, comprehensive assessment, and integrated pharmacological and psychosocial interventions are essential to prevent chronic complications associated with inhalant misuse. Clinicians should remain vigilant for unconventional inhalants in adolescents presenting with behavioral disturbances.

Internet

Ganesh Kumar Meena, Preethy Kathiresan AIIMS, New Delhi, India Background: Internet use among the elderly has increased substantially due to greater accessibility of smartphones, social media, online entertainment, informational needs. Excessive or maladaptive use may lead to internet addiction, an emerging but under-recognized behavioural concern in the elderly population. Existing literature has largely focused on adolescents and young adults, leaving gaps in understanding the prevalence, risk factors, and consequences of internet addiction among older adults. AIM: To understand correlates of internet addiction in elderly. Materials and Methods: This narrative review synthesizes existing literature on internet addiction in the elderly. Electronic databases including PubMed, and Google Scholar were searched for English-language articles published in the recent years. A total of 19 studies were reviewed. Results: Reported risk factors for internet addiction in elderly include loneliness, social isolation, depression, digital literacy and sensation seeking. Family and social support, positive exercise experience are reported as protective factors. Internet addiction in older adults has been linked to sleep disturbances, worsening mood symptoms, neglect of physical activity, and impaired social functioning. Literature suggests bidirectional relationship between internet addiction and depressive and anxiety symptoms. Conclusion: Internet addiction in the elderly is an emerging mental health concern with significant psychosocial implications. Greater awareness, standardized assessment methods, and geriatric-focused research are needed to distinguish adaptive from maladaptive internet use and to guide early identification and targeted interventions in this vulnerable population. Key words: Elderly, internet addiction, mobile addiction, older adults

Low Dose

Aditya Aithal, Santosh Ramdurg Shri B.M. Patil Medical College, Hospital, and Research Centre, BLDE University, Vijayapura, Karnataka, India Background: Quetiapine is a second-generation antipsychotic widely used in schizophrenia, mood, and anxiety disorders. It is generally considered to have low extrapyramidal symptom (EPS) risk due to low D2 receptor occupancy and high 5-HT2A antagonism. However, rare cases of acute dystonia have been reported even at low doses, particularly in susceptible patients on concomitant serotonergic medications. Aims: To report a rare case of acute oromandibular dystonia induced by low-dose quetiapine (25 mg) in a patient on an SSRI, and to discuss underlying pharmacological factors and clinical implications. Methods: We describe a single case involving a 32-year-old male with somatoform disorder who had been stable for one year on escitalopram (20 mg/day) and clonazepam (0.5 mg/day). Low-dose quetiapine (25 mg at bedtime) was added for agitation and insomnia. Results: Three days after quetiapine initiation, he developed acute oromandibular dystonia characterised by sudden tongue deviation and dysarthria. Examination revealed sustained tongue contractions with no other neurological deficits. Quetiapine was discontinued, and intravenous promethazine (50 mg) was administered, resulting in complete symptom resolution within two hours. The patient remained asymptomatic at one week, implicating quetiapine as the likely cause. Conclusion: Even low-dose quetiapine can precipitate acute dystonia, likely via transient D2 blockade exacerbated by SSRI-induced serotonergic modulation. Pharmacokinetic interactions (e.g., CYP3A4/CYP2C19 metabolism) may further elevate quetiapine levels, compounding this risk. Clinicians should remain vigilant when initiating quetiapine in patients on SSRIs, especially during early titration and polypharmacy. Early recognition and prompt anticholinergic treatment ensure complete recovery.

Mind Gut

Bhavin Surani, Priya Ranjan Avinash 1 , Robin Victor 1 , Praveen Rikhari 1 , Simrat Kaur 1 Himalayan Institute of medical sciences, Swami Rama Himalayan University, 1 Department of Psychiatry, Himalayan institute of medical sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India Introduction: Trichotillomania (TTM), also known as hair-pulling disorder, is a psychiatric condition classified under obsessive–compulsive and related disorders, commonly associated with anxiety. Repeated hair pulling may lead to trichophagia, which can result in trichobezoar formation. Trichobezoar is the second most common type of bezoar and consists predominantly of ingested hair accumulated within the gastrointestinal tract. It can cause serious complications such as intestinal obstruction, ulceration, perforation, and intussusception. Due to vague and nonspecific symptoms, early diagnosis is often challenging, necessitating a high index of clinical suspicion. Case Report: A 10-year-old female presented with upper abdominal pain and progressive abdominal distension for 15 days. She had been evaluated by multiple practitioners and managed symptomatically without sustained relief. With worsening symptoms, she presented to our center with features of acute abdomen. Abdominal examination revealed distension and tenderness. An erect abdominal X-ray showed fecal matter and gas-filled bowel loops. Upper gastrointestinal endoscopy revealed a large trichobezoar extending from the gastroesophageal junction into the duodenum. Endoscopic removal was attempted but unsuccessful. A past history of trichotillomania was elicited, dating back five years. Discussion: The patient underwent exploratory laparotomy, during which a large gastric trichobezoar was removed, followed by primary repair of the gastric wall. Postoperatively, psychiatric evaluation was initiated, and she received psychological therapy along with antidepressant medication for trichotillomania. This combined surgical and psychiatric approach resulted in significant clinical improvement, habit reduction, and stabilization of her overall condition. This case highlights the importance of multidisciplinary management and early consideration of trichobezoar in children presenting with unexplained abdominal symptoms.

Modified

Ishani Pal Dr Panjabrao Deshmukh Medical College, Amravati, Maharashtra, India Background: Organophosphate self ‘poisoning is a common method of deliberate self ‘harm in India and can reduce serum cholinesterase, increasing sensitivity to succinylcholine used during modified electroconvulsive therapy (ECT). Aims: To report a case of prolonged apnea after ECT in a young man with brief psychotic disorder and recent organophosphate ingestion, and to highlight peri ‘anaesthetic precautions. Methods: A 26 ‘year ‘old man presented with 5 days of irrelevant talk, disturbed sleep and behavioural changes following interpersonal stress, and later attempted self ‘harm by ingesting an organophosphate insecticide. He was diagnosed with brief psychotic disorder and organophosphate toxicity, medically stabilised and started on psychotropics, but showed inadequate improvement, so modified ECT under general anaesthesia with succinylcholine was planned. Results: After the first ECT, he failed to resume spontaneous respiration and required intubation, ventilatory support and medical ICU care. Serum cholinesterase level was markedly reduced, and a diagnosis of succinylcholine ‘related prolonged apnea in the context of organophosphate poisoning was made. ECT and succinylcholine were discontinued; with supportive management his respiratory status and cholinesterase levels normalised, and psychotic symptoms remitted gradually on pharmacotherapy alone. Conclusion: Recent or suspected organophosphate exposure warrants pre ‘anaesthetic cholinesterase estimation and avoidance of succinylcholine for ECT, with close liaison between psychiatry, anaesthesia and medicine to balance psychiatric benefits against toxicological and anaesthetic risks.

Parental

K. Sathiyakala AIIMS, Patna, Bihar, India Background of the Study: Parents are universally recognised as the primary caregivers and play a profound role in shaping their children’s behaviour, emotional regulation, and overall development. The influence of parents extends far beyond basic caregiving, impacting the psychological and social path of their children from infancy through adolescence. Recent research underscores that both parenting behaviour and parenting styles are critical determinants of child outcomes, especially in the context of behavioural disorders. Parenting styles are often conceptualised as enduring characteristics or approaches adopted by parents, relatively independent of the child’s individual traits. These styles authoritative, authoritarian, permissive, and neglectful are thought to reflect the parent’s attitudes and values about child-rearing. Aim: The primary aim of this study was to assess the pattern of parental handling of children with behavioural disorders among parents attending selected Outpatient Departments (OPDs) of tertiary care centres. Methods: This study utilized a quantitative approach and employed a cross-sectional research design. A convenience sampling method was used to select 135 participants who met the inclusion criteria for this study. Results: Out of 135 samples, 55 (45%) parents had authoritative type of parenting styles, 47 (35%) parents exhibits permissive parenting styles, 19 (14%) parents shows authoritarian type of the parenting styles and 14 (10%) parents shows neglecting parenting pattern. Conclusion: The analysis of parenting styles provides valuable insights into how parents manage children with behavioural disorders and informs effective strategies to support both the children and their families.

Partners

Neelam, Sanjay Gehlot S. N. Medical College, Jodhpur, Rajasthan, India Background: Shared Delusional Disorder (SDD), or folie à deux (ICD-11 6A24), is a rare psychiatric condition where a delusion is transmitted from one individual (the inducer) to another (the recipient) within a close relationship. It is often associated with social isolation and stress. Aim: This case report aims to illustrate the clinical presentation, diagnostic challenges, and management difficulties inherent in SDD, especially when the individual causing the condition resists psychiatric intervention. Methods: We present the case of a 42-year-old male admitted with aggression, paranoia, and disturbed sleep. A detailed clinical interview was conducted with the patient and, separately, with his wife to assess the nature and shared belief of their delusional system. Results: The patient developed persecutory delusions post-marriage, believing colleagues were stealing data and uploading his wife’s photos online. His wife not only confirmed these beliefs but also elaborated on them, claiming she was also being blackmailed. She was identified as the primary inducer, with a history of similar pre-marital beliefs. Despite treatment initiation with risperidone and lorazepam for the patient, his wife insisted he was a victim of a conspiracy and took him home against medical advice, leading to premature discharge and treatment discontinuation. Conclusion: This case highlights the critical importance of assessing both individuals in a dyad when SDD is suspected. It underscores a significant therapeutic challenge: successful treatment is often hindered if the inducing individual maintains the delusional system and rejects medical advice, potentially leading to poor outcomes and relapse.

Patterns

Nithin David Department of Forensic Medicine And Toxicology, AJ Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India Email: [email protected] Background: Suicidal poisoning is a significant public health problem in India, largely influenced by the easy availability of toxic substances. Identifying patterns of poisoning is essential for effective clinical management, medico-legal interpretation, and suicide prevention. Objectives: To study the demographic profile, types of poisons used, and medico-legal outcomes in cases of suicidal poisoning from a forensic perspective. Materials and Methods: A retrospective analysis of alleged suicidal poisoning cases referred for medico-legal evaluation and autopsy at a tertiary care center was conducted. Data regarding age, sex, type of poison, source of access, survival period, and cause of death were analyzed using hospital records, police inquest reports, and forensic toxicology findings. Results: Young adults constituted the majority of cases, with a male predominance. Agricultural pesticides, particularly organophosphates and aluminum phosphide, were the most commonly used agents, followed by pharmaceutical drugs. Higher mortality was associated with highly toxic compounds and delayed medical intervention. Conclusion: Readily accessible pesticides remain the predominant agents in suicidal poisoning. Regulatory control, early intervention, and mental health support are vital, with forensic evaluation playing a key role in prevention strategies. Key words: Forensic toxicology, medico-legal analysis, pesticides, suicidal poisoning

Phantoms

Debopama Datta College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India Background: Psycho-dermatological conditions such as delusional infestation manifest as fixed false beliefs regarding insects or abnormal sensations on or beneath the skin. These disorders frequently precipitate repetitive scratching, excoriations, and significant functional impairment. Early identification is crucial to prevent morbidity and improve outcomes, particularly when encountered in dermatology settings prior to psychiatric evaluation. Aims: This case report aims to highlight the presentation and management of delusional infestation occurring within the context of bipolar I disorder, emphasizing the importance of integrated dermatology-psychiatry collaboration in recognition and treatment. Case Description: A 41-year-old euthyroid, non-diabetic male with a 5-year history of Bipolar I Disorder on maintenance treatment presented with a 2-month history of persistent crawling and stinging sensations, reportedly accompanied by sticky discharge from skin and ears. Dermatological examination revealed no primary lesions despite numerous excoriation marks from vigorous scratching. Psychiatric evaluation was subsequently undertaken. Results: Detailed assessment confirmed delusional infestation within bipolar disorder context. Antipsychotic therapy was optimized alongside psychoeducation, behavioral strategies to reduce scratching, and adjunctive dermatological care. Regular follow-up sessions monitored treatment adherence, mood stability, and progressive restructuring of fixed beliefs, resulting in gradual symptom improvement. Conclusion: This case underscores the necessity of recognizing delusional infestation in patients presenting with unexplained dermatological complaints, particularly those with pre-existing mood disorders. Collaborative dermatology-psychiatry management facilitates timely diagnosis, minimizes skin damage, and enhances clinical outcomes.

Piercing

R. Raghunandan, K. P. Lakshmi Amrita Institute of Medical Science and Research Institute, Kochi, Kerala, India Background: Deliberate self-harm (DSH) in Emotionally Unstable Personality Disorder (EUPD) usually involves superficial injuries. Deep-tissue foreign body insertions, especially into anatomically high-risk areas, are rare and poses significant diagnostic and management challenges. Case Presentation: A 25-year-old male with EUPD traits, dissociative symptoms presented with repeated needle insertion into his thighs, scrotum, chest wall, and supraclavicular region without suicidal intent and were often occurring during states of dissociation or limited awareness. Two major surgical procedures were performed under spinal anaesthesia. Subsequent imaging revealed retained metallic foreign bodies adjacent to critical vascular structures. Despite intermittent periods of stability, the patient continued with self-harm behaviours. Management included high-dose quetiapine, mirtazapine, Endoxifen, trauma-focused psychotherapy, and close interdisciplinary coordination. Discussion: Foreign body insertion as a form of DSH is rarely reported in EUPD and it represents a psychiatric-surgical-ethical intersection. Dissociation, trauma recall, and poor distress tolerance are key roles. Endoxifen, a protein kinase C inhibitor, shows emerging anti-impulsive and mood-stabilizing effects in recent trials for bipolar type II disorder and borderline personality features. In this case, it provided add on benefit in reducing affective lability and behavioural dyscontrol alongside standard psychotropics. Conclusion: This case illustrates a rare and medically severe presentation of Non Suicidal Self Injury in EUPD, complicated by dissociative phenomena and fluctuating insight. It highlights the importance of early multidisciplinary engagement, risk stratification, and trauma-informed psychiatric care. Deep self-injury without suicidal intent in personality disorders remains underrepresented in the literature and warrants further clinical and ethical exploration.

Prenatal

Ankita Garg, Deepak Gupta Sir Ganga Ram Hospital, New Delhi, India Background: Autism Spectrum Disorder (ASD) is influenced by genetic, prenatal and perinatal factors. Indian studies presenting large clinical cohorts integrating these risk factors are limited. Aim: To describe the frequency and distribution of prenatal, perinatal and familial risk factors in children diagnosed with ASD at a tertiary-care centre. Methods: A retrospective chart review was conducted for children diagnosed with ASD attending a Child and Adolescent Psychiatry Clinic in Delhi (January-November 2025). Data on prenatal (parental age, maternal health, emotional wellbeing), perinatal (gestation, delivery, birth weight, birth asphyxia, NICU stay), early feeding variables and family history were extracted. Descriptive statistics were used. Results: The study included 283 children (mean age 5.47 years; 81.6% male). Advanced paternal age (>40 years) was seen in 14.1%, advanced maternal age (>35 years) in 18%. Maternal complications were present in 35.69% hypothyroidism being most common and emotional distress in 9.5%. Preterm birth occurred in 15.9%; 77% were born by caesarean section. Low birth weight was noted in 18.3%. Birth asphyxia occurred in 0.4%, and 16.6% required NICU admission. 17% were never breastfed; among those breastfed, 17.88% received breastfeeding for <1 month and 75.3% for <6 months. Family history of neurodevelopmental disorders was present in 15.2%, psychiatric disorders in 4.6%, thyroid disorders in 32.9%, and metabolic disorders in 15.2%. Conclusion: This large ASD cohort contributes important Indian data on prenatal, perinatal and familial risk factors. The findings highlight modifiable and non-modifiable contributors and underscore the need for improved antenatal care, high-risk infant surveillance and early intervention.

Striving

K. Pradhyumna, Sharanabasappa Sapthagiri Institute of Medical Sciences, Bengaluru, Karnataka, India Background: Academic achievement in India is often tied to family pride and social status. Adolescents are particularly vulnerable to these pressures, as they navigate both external expectations and internal self-demands. While quantitative studies highlight the prevalence of stress and anxiety, fewer studies have explored adolescents’ lived experiences of academic expectations and failure. Aim: To explore how academic expectations and perceived failureshape adolescents’ mental health and identity, and to identify themes of interpretation and internalization. Methods: Using community-based purposive sampling through word of mouth, adolescents who were currently studying were recruited. Data collection involved digitally recorded in-depth interviews, guided by a semi-structured questionnaire, and continued until thematic saturation was reached. All interviews were transcribed verbatim and analysed using Braun and Clarke’s six-step framework for thematic analysis. Results: A total of 11 adolescents shared their narratives. Seven overarching themes were identified: (1) The Weight of Expectations (self vs others), (2) A Double-Edged Sword: Pressure and Motivation, (3) Coping in the Shadows, (4) When Pressure Turns Inward: Mental Health Costs, (5) Becoming Someone Else: Identity under Pressure, (6) Dreaming of Another Life, and (7) The Unseen Adolescent: Need for Recognition Beyond Marks. Experiences reflected both adaptive resilience and maladaptive coping, with clear links to mood, sleep, confidence, and self-concept. Conclusions: Academic expectations profoundly shape adolescents’ mental health and identity. While some pressures can motivate, unmet expectations often trigger distress, unhealthy coping, and erosion of self-worth. Interventions must shift from score-centric evaluation to holistic recognition of adolescents’ individuality.

Wellness

Rajiv Kumar Saini Military Hospital, Devlali Maharashtra, India Background: Wellness is a core construct in psychiatric practice, emphasizing the integration of physical, psychological, and lifestyle determinants of health. Military personnel experience unique occupational stresses, increasing vulnerability to metabolic, behavioral, and sleep-related morbidities. Early identification of such risk factors can significantly enhance prevention and operational fitness. Aim: To design and implement a structured Wellness Card with a numerical Wellness Quotient Score for soldiers, and to assess its utility in detecting modifiable health risks requiring targeted intervention. Methods: A wellness questionnaire covering eight domains BMI, lipid profile, blood pressure and vitals, blood sugar, sleep quality, subjective mental wellness, smoking, and alcohol use was administered to 130 soldiers. Each parameter was scored 0-3, yielding a maximum score of 30. Scores <26 triggered lifestyle counselling or specific interventions, including metabolic evaluation, ECG screening, dietary advice, or psychological services. Results: Screening identified several previously undiagnosed conditions: Hyperlipidemia: 8 cases Diabetes: 6 cases Hypertension: 4 cases Alcohol-related issues: 3 cases Insomnia / sleep issues: 5 cases All affected individuals received targeted management. The wellness screening had high acceptability, with active participation and positive feedback from soldiers. Conclusion: The Wellness Quotient system is an effective and useful method which can easily be filled during routine follow up of a special population at risk for occupational life style diseases. The findings give a scope for Clientele education and early intervention.

“Snake

V. R. Venugopal, Suranjita Mazumdar Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tejpur, Assam, India Background: Somatic delusions are prevalent in schizophrenia, yet Delusional Zoopathy the conviction that macroscopic animals (e.g., reptiles or mammals) inhabit the body represents a rare and bizarre phenotype distinct from classic Delusional Infestation (Ekbom syndrome), which typically involves microscopic organisms. This case illustrates the complex phenomenology and treatment challenges of zoopathy within the schizophrenia spectrum. Case Presentation: A 35-year-old married female from Assam, educated up to 10th standard, housewife, with comorbid hypothyroidism and no significant family psychiatric history, presented with an 11-year total duration of illness. She initially developed persecutory delusions toward neighbors and family members, accompanied by third-person auditory hallucinations, self-talking, and inappropriate smiling. Four months prior to presentation, she developed the fixed belief that a snake had entered through her mouth and was residing in her stomach. She reported severe abdominal pain, restlessness, and distinct writhing sensations attributed to the snake’s movements. The patient persistently demanded ultrasound abdomen examination to “detect the snake” and refused to accept reassurance despite repeated explanations. She showed no response to adequate trials of Aripiprazole and Olanzapine but achieved significant improvement with Clozapine 200mg daily, with reduction in somatic complaints and partial insight into the impossibility of her belief. Conclusion: Unlike monosymptomatic delusional infestation or substance-induced cases previously reported, this case demonstrates that bizarre zoopathic delusions can emerge within chronic schizophrenia, often requiring clozapine for treatment-resistant presentations. The presence of cenesthopathic hallucinations (writhing sensations) likely reinforced the delusional conviction, highlighting the importance of targeting both positive symptoms and somatic experiences in management.

Alcoholic

Inge Chaitanya Sudhir, B. Sairam Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Psychotic symptoms during alcohol withdrawal are clinically significant but inconsistently documented in routine hospital settings. Contemporary prevalence data from Indian tertiary-care centres remain sparse. Objective: To determine the point prevalence, subtypes, and clinical correlates of hallucinations and delusions among patients admitted for alcohol withdrawal. Methods: A retrospective chart review was conducted at the Department of Psychiatry, Andhra Medical College, from July 2025 to August 2025. Records of adults diagnosed with alcohol dependence and admitted for withdrawal management were examined. Results: Among 131 patients, hallucinations occurred in 40 (30.5%) and delusions in 35 (26.7%). Auditory hallucinations predominated: Second Person Auditory (n=26), Third Person Auditory Hallucination (n=15), and Elementary Hallucination (n=5). Multiple hallucination types were documented in six cases. Most psychotic symptoms occurred in the absence of Delirium Tremens (39/40 hallucination cases; 34/35 delusion cases). Patients demonstrated wide variability in alcohol-use duration and daily consumption. Logistic models indicated limited stable predictors, partly due to convergence issues, although delirium, longer duration of daily drinking, and higher consumption displayed trends toward association. Conclusion: Psychotic symptoms, particularly auditory hallucinations, were common among patients admitted for alcohol withdrawal and typically occurred without delirium. These findings underscore the need for routine psychosis assessment during withdrawal and further prospective studies to clarify risk factors.

Attitudes

Unmesh Bhosale, Surbhi Dubey Pt. JNM Medical College, Raipur, Chhattisgarh, India Background: Psychiatric services in India are delivered through both government and private sectors. Satisfaction with mental health services depends on multiple factors, including infrastructure, interpersonal skills, reliability, and responsiveness. Rural and urban populations often differ in access, expectations, and satisfaction levels. Aim: To compare attitudes and satisfaction levels of attendants of psychiatric patients attending government versus private hospital services, along with assessing rural-urban differences. Materials and Methods: A one-time cross-sectional interview study was conducted at the Psychiatry OPD of Dr. BRAM Hospital (government) and a private psychiatric clinic in Raipur. A total of 100 attendants were included (50 from each setting). The sample consisted of 60% urban and 40% rural attendants across both hospitals. A self-designed semi-structured questionnaire assessed appearance, reliability, responsiveness, assurance, and rural-urban variations in satisfaction. Results: Appearance satisfaction: Private 82% vs Government 46% Reliability: Private 76% vs Government 52% Responsiveness: Private 80% vs Government 48% Overall satisfaction: Private 84% vs Government 58% Rural vs Urban: Urban attendants showed higher satisfaction across all domains compared to rural attendants, particularly in appearance and responsiveness scores. Conclusion: Attendants reported higher satisfaction in private hospitals across appearance, reliability,responsiveness, and assurance domains. Urban attendants were more satisfied than rural attendants, likely due to better prior exposure to structured healthcare services. Government hospitals require improvements in infrastructure and individualized care, particularly to meet the expectations of rural populations.

Autoscopy

G. Preethi, Malaiappan 1 , Anne Sangeetha 1 Institute of Mental Health, Madras Medical College, 1 Institute of Mental Health, Chennai, Tamil Nadu, India Background: Obsessive-compulsive symptoms (OCS) and psychotic features may coexist, creating diagnostic and therapeutic challenges. Phenomena such as intrusive sexual thoughts, religious-cultural delusions, and autoscopy are rare, and their overlap blurs the boundaries between obsessive-compulsive disorder (OCD) and schizophrenia spectrum disorders. Aims: To present a diagnostically complex case of a young woman with intrusive obsessions, autoscopy, and religious delusions, highlighting the overlap between OCD and psychosis and discussing management implications. Methods: A 24-year-old unmarried female with five years of illness was evaluated at a tertiary psychiatric institute. Detailed history, mental status examination, and psychometric assessments (BPRS, HAM-D, Y-BOCS) were conducted. Course of illness, treatment response, and phenomenology were analyzed. Results: The patient exhibited persistent intrusive sexual thoughts, blasphemous imagery, autoscopy and elaborate religious delusions involving Krishna and an alien world. Symptoms led to marked distress, impaired self-care, functional decline, and repeated suicidal ideation. BPRS score was 64 (severe), HAM-D 22 (severe depression), and Y-BOCS obsession subscale 15 (moderate). Treatment with antipsychotics and SSRIs yielded partial improvement, though intrusive thoughts persisted. The case posed significant diagnostic ambiguity between schizophrenia and OCD with poor insight, compounded by cultural and religious themes. Conclusion: This case illustrates the complex phenomenological overlap between OCD and psychotic disorders, emphasizing the importance of systematic assessment, use of rating scales, and cultural formulation in clinical practice. Recognition of such presentations is crucial for accurate diagnosis and individualized management.

Behaviour

Sindhuja Omkaram, Y. Chidvilas Santhiram Medical College and General Hospital, Nandyal, Andhra Pradesh, India Background: Organic Personality Disorder (Frontal Lobe Syndrome) arises from structural impairment of the frontal lobes, producing profound changes in behaviour, impulse regulation, and executive functioning. Such presentations often appear psychiatric, delaying recognition of the underlying neurological pathology. Case Report: Mrs. R, a 61-year-old woman, living with epilepsy for 15 years and irregular medication adherence, presented with a 5-year history of progressive behavioural disturbances. She developed severe disinhibition, including urinating and defecating inside the house, attempting to drink urine, spilling urine into food containers, and undressing inappropriately. Her symptoms escalated to aggression, shouting at neighbours, nighttime wandering, irritability, and significant forgetfulness with frequent misplacement of objects. She reacted angrily when confronted, indicating impaired judgment and declining executive functioning. Given the progressive and dramatic nature of symptoms, MRI brain imaging was advised. Neuroimaging revealed marked frontal lobe pathology gliosis, lacunar infarcts, chronic microbleeds, and ischemic changes correlating strongly with her disinhibition, impulsivity, and cognitive decline. Based on the clinical and radiological findings, a diagnosis of Organic Personality Disorder (Frontal Lobe Syndrome) was made. Conclusion: This case highlights the importance of considering organic brain pathology in patients presenting with striking behavioural dysregulation. Frontal lobe lesions can mimic primary psychiatric disorders, and neuroimaging plays a vital role in revealing the underlying cause. Early recognition ensures appropriate psychiatric, neurological, and caregiver-directed interventions. Key words: Behavioural disinhibition, cognitive decline, epilepsy, frontal lobe syndrome, MRI, organic personality disorder

Catatonia

Sanjana Sharma, Ritwik Mishra, Rajneesh Bharat 1 Armed Forces Medical College, 1 Command Hospital, Southern Command, Pune, Maharashtra, India Catatonia is recognized as a neuropsychiatric syndrome associated most frequently with mood disorders, and is highly responsive to GABA ‘ergic agents, particularly lorazepam. Disruption of fronto ‘striato ‘limbic circuits with GABA ‘A hypoactivity and relative NMDA hyperactivity has been proposed as a pathophysiological mechanism, explaining the lorazepam challenge response seen across diverse catatonic presentations. Case series and consensus guidelines emphasize that early identification and prompt benzodiazepine treatment substantially reduce morbidity and mortality, reserving electroconvulsive therapy for lorazepam non ‘responsive cases. Catatonia presents unique diagnostic and therapeutic challenges for clinicians. Beyond the underlying psychiatric illness, physicians must also manage complications arising from the catatonic state itself. Although catatonia may manifest as motoric overactivity or immobility, it is relatively uncommon and often difficult to diagnose, particularly in patients with undifferentiated psychiatric illness on multiple psychotropics. We present a 36 ‘year ‘old woman with seizure disorder, prior endometriosis surgery, and chronic interpersonal stress presented with acute confusion, irrelevant speech, self ‘neglect, and a generalized tonic-clonic seizure in background of irregular, self ‘directed use of olanzapine, zolpidem, venlafaxine and benzodiazepines. She was diagnosed as a case of catatonia and started on intravenous lorazepam producing a rapid and marked improvement within hours. She was later diagnosed as a case of moderate depressive episode. This report adds to emerging evidence that abrupt changes or unsupervised withdrawal in chronic benzodiazepine or psychotropic use can precipitate catatonia. It highlights risks of indiscriminate psychotropic use, importance of early recognition, timely intervention, and multidisciplinary rehabilitation in a case of catatonia.

Childhood

Amin Krishna Rajeshkumar, Rakesh Gandhi 1 Medical College Baroda, 1 Department of Psychiatry, Medical College Baroda and SSG Hospital, Vadodara, Gujarat, India Background: Childhood-onset schizophrenia (COS) is rare and characterized by onset of psychotic symptoms before the age of 13 years. It presents with hallucinations, delusions, disorganized thinking, social withdrawal, cognitive decline, and significant impairment in academic and social functioning. Erotomanic or jealous delusions are even rarer before adulthood. Their occurrence raises diagnostic and developmental considerations. Case: A 12-year-old girl presented with an 8-month history of persistent belief that her male school teacher was in love with her, coupled with jealousy toward female classmates whom she believed were trying to win his affection which lead to frequent fights with female classmates. She also experienced running commentary auditory hallucinations describing her daily actions such as combing her hair or applying skin cream. Behavioural changes included increased grooming and heightened attraction toward the opposite gender. There was no substance use or mood disturbance. Investigations were unremarkable. A diagnosis of early-onset schizophrenia (DSM-5) was made. She was started on tablet risperidone and its dose was increased on follow up, alongside family psychoeducation. The patient showed partial improvement in her symptoms. Conclusion: This case highlights erotomanic and jealous delusions in childhood-onset schizophrenia and emphasizes the need for sensitive assessment of psychotic content involving emerging sexuality in adolescents.

Clonidine

Krishna Kumar Carpenter, Ankur Nayan VKSGMC, Neemuch, Madhya Pradesh, India Background: Clonidine, an alpha-2 adrenergic agonist, is widely used for hypertension, anxiety disorders, and withdrawal states due to its sympatholytic effects. It is generally considered to have low abuse potential. However, prolonged and unsupervised use may rarely lead to dependence and withdrawal symptoms. Literature on clonidine dependence is limited in psychiatric practice. Aims: To evaluate a rare case of clonidine dependence and highlight its successful management. Methods: A 45-year-old male presented at a tertiary health care centre in Neemuch, Madhya Pradesh, with a history of self-medication with clonidine 0.1 mg tablets, consuming up to 30 tablets/day. Following detailed psychiatric evaluation, a provisional diagnosis of clonidine dependence was made. Patient was given psychoeducation and a supervised detoxification plan was initiated. Clonidine was gradually tapered by reducing the dose by 5 tablets/week to minimize withdrawal symptoms. Concurrently, tablet lorazepam was started at 6 mg/day to manage the withdrawal phase. After successful clonidine discontinuation, lorazepam was gradually tapered at a rate of 1 mg/week. The patient was closely monitored throughout the tapering process for withdrawal symptoms, adverse effects, and clinical stability. Results: Lorazepam effectively managed transient anxiety state during the withdrawal phase. Both medications were successfully discontinued. On follow-up, the patient remained asymptomatic, maintained good psychosocial functioning, and did not require any ongoing pharmacological treatment. Conclusion: Clonidine dependence, though uncommon, but can occur with prolonged use. Gradual tapering with benzodiazepine support is an effective and safe management approach. Clinicians should remain vigilant while prescribing clonidine and ensure regular monitoring to prevent dependence.

Clozapine

Chandresh Choudhary, Sanjay Gehlot Dr SN Medical College, Jodhpur, Rajasthan, India Clozapine is an effective drug for treatment resistant schizophrenia. Clozapine mainly causes agranulocytosis but rarely it causes parotitis. Here we report a case of a 30-year-old male who developed painful parotid swelling on the 8th day of clozapine initiation. Imaging done to rule out sialolithiasis or infection. The temporal association and a Naranjo score of 5 supported the diagnosis of clozapine-induced parotitis. Symptoms resolved within six days of discontinuation of clozapine. The rechallenge was not attempted. Clozapine-induced parotitis is an uncommon but important adverse effect, possibly related to immune or anticholinergic mechanisms. Awareness of such rare reactions can aid early identification and improve treatment adherence.

Cognitive

Arun Kumar Dwivedi, Ranveer Singh 1 Military Hospital, Jodhpur, Rajasthan, 1 Command Hospital (SC), Pune, Maharashtra, India Background: Cognitive deficits are a core feature of many psychiatric disorders. Since psychiatric diagnoses are largely syndromal, there is substantial variation in functional impairment within the same category. Objective tools like the PGI Battery of Brain Dysfunction (PGI-BBD) are valuable in quantifying these deficits, particularly in the military setting where cognitive functioning is critical to operational readiness and rehabilitation. Methods: The study was conducted at a tertiary care Armed Forces hospital and included 200 male inpatients diagnosed with Alcohol Dependence Syndrome (ADS), Anxiety Disorders, Depressive Disorders, Bipolar Affective Disorder (BPAD), or Schizophrenia. These diagnostic groups were selected due to their high prevalence in psychiatric caseloads. After obtaining informed consent, cognitive function was assessed using PGI-BBD. Data were analyzed using SPSS version 20.0. Comparisons across groups were performed using ANOVA and Tukey’s post hoc tests. Results: ADS patients showed impairments in remote memory, visual retention and recognition, verbal and performance quotients, and perceptuo-motor functioning. Anxiety Disorders were associated with deficits in attention, concentration, and verbal memory. Depressive Disorders revealed impairments in attention, immediate and delayed recall, verbal memory, comprehension, and perceptuo-motor functioning. BPAD patients had deficits in attention, concentration, and visual memory. Schizophrenia was associated with deficits in verbal and visual memory and performance-based tasks. Conclusion: Cognitive impairments were present in all diagnostic groups even during remission. These deficits may contribute to occupational dysfunction in military personnel, highlighting the need for cognitive retraining as part of psychiatric rehabilitation.

Delirious

Shalini Indora, Minakshi Parikh 1 BJMC,Civil Hospital, 1 BJ Medical College, Ahamdabd, Gujarat, India Introduction: Delirious mania (DM) is a severe, acute-onset neuropsychiatric syndrome combining delirium and mania, posing a diagnostic challenge, especially in unidentified patients. Early identification is crucial for life-saving intervention. Case Presentation: An unidentified 36-year-old male presented with severe agitation, incoherent speech, poor hygiene, fever, and altered consciousness (delirium). Initial investigations showed markedly elevated CPK (>2000) and WBC (14 times 10^9), pointing to a medical cause. His delirium resolved within 48 hours with fluids and Quetiapine 50mg. Collateral history, obtained after contacting his brother, revealed a 3-year episodic illness, recent psychosocial stressors, and a family history of psychotic illness. Following delirium resolution and on serial MSE,the patient continued to exhibit core manic features, including excitement, pressured speech, grandiosity, and formal thought disorder, confirming the suspicion of Delirious Mania. Management: Management was initiated with a combination of mood stabilizers and antipsychotics: Valproate 1500 mg/day, Olanzapine 10 mg/day, Haloperidol 10 mg/day, and Risperidone 4 mg/day, resulting in gradual improvement. Conclusion: This case emphasizes the necessity of continuous diagnostic re-evaluation for agitated patients, particularly those lacking an initial history. Clinicians must maintain a high index of suspicion for DM, even when a clear medical cause for the initial delirium exists, to ensure timely and essential psychiatric intervention.

Depiction

Gurveen Kaur, Deepali Negi, Yesh Chandra Singh 1 , Vinit Patel 2 All India Institute of Medical Sciences, New Delhi, 1 Venkateshwara Institute of Medical Sciences, Amroha, Uttar Pradesh, 2 All India Institute of Medical Sciences, Raipur, Chhattisgarh, India Background: Music is a powerful sociocultural force shaping attitudes toward substance use. While Western studies report 23-33% substance references in songs, no systematic analysis exists for Indian music. Considering India’s rising burden of substance use, analysing substance portrayals in popular music is essential for public health understanding. Aims: To quantify and characterize substance-related content in top Indian songs of 2024 and thematic analysis of these references. Methods: A content analysis of 198 songs from Billboard India, Apple Music, Spotify, and JioSaavn charts was conducted. Two trained coders independently reviewed all lyrics. Mentions were classified as explicit, implicit-identifiable, or implicit-ambiguous, and categorized by substance type using ICD-11. Reference frequency and density were calculated. Thematic analysis grouped subthemes into six domains: Love/Relationships, Lifestyle/Status, Risk/Problematic Use, Coping/Emotion, Celebration/Enjoyment, and Identity/Spirituality. Coding disagreements were resolved through consensus. Results: Substance references appeared in 19.7% of songs, substantially lower than western estimates. Alcohol accounted for 71.8% of mentions. Explicit references (41%) were more common than implicit forms. Songs contained an average of 2 substance mentions, with a density of 0.7 per minute. Thematically, Love/Relationships (43.6%) and Lifestyle/Status (41%) dominated, suggesting culturally distinct representations in which substances serve metaphorical purposes, rather than behavioural indicator. Depictions of risk, harm, or coping were minimal, ranging from 1-10% in these categories. Conclusion: Indian popular music features relatively low but predominantly positive or symbolic substance portrayals. Minimal representation of risk or problematic use raises concerns about subtle normalization underscoring the need for culturally grounded media-literacy and prevention strategies.

Endoxifen

Gunjan Miniyar, Shilpa Adarkar 1 , Parijat Roy 1 , Maitrayee Patil 1 Seth GS Medical College and KEM Hospital, 1 Department of Psychiatry, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India Introduction: Gambling disorder previously known as Pathological Gambling, is classified as a behavioral addiction and includes symptoms such as needing to gamble with increasing amounts of money, restlessness or irritability when trying to stop, unsuccessful efforts to quit, preoccupation with gambling etc. Common forms of Gambling include lottery, scratch tickets, sports betting, casino table games, slot machines and the recent online games. With an estimated prevalence of 1.2-1.4%, the consequences are often not limited to the individual but their families as well. No medication is approved for its treatment, however, drugs like Naltrexone, Antidepressants and Mood Stabilizers are often used along with psychotherapies for management. Here, we have used Endoxifen, a novel Selective Estrogen Receptor Modulator (SERM) with Protein Kinase-c inhibition for successful treatment of gambling disorder. Case: A 43y male, chartered accountant, with no past history of any psychiatric disorder, had come to our OPD with history of incurring losses of 3-3.5crores in the last 1y playing online rummy. With minimal improvement on Naltrexone 100mg in the past, we decided to start Endoxifen 8mg, up titrated to 16mg within a week along with psychotherapy. The patient perceived significant reduction in craving on 16mg, and has been maintained on it since the last 5 months, without any lapses/ relapses. Discussion: Endoxifen shows promise in treating addiction, as it reduces craving and impulsivity. Our case is one of the few cases, which highlights the potential use of Endoxifen in treating Gambling Disorder and similar behavioural. Key words: Behavioural addiction, endoxifen, gambling disorder

Enhancing

Partik Kaur, Mamta Singla Christian Medical College, Ludhiana, Punjab, India Introduction: Traditional clinical teaching often relies on passive observation, limiting students’ opportunities for meaningful engagement and skill development. The Doctor-Learner (DL) method promotes active student participation in real clinical environments under supervision. This study evaluated the effectiveness of the DL method in enhancing the clinical diagnostic skills of medical interns in psychiatry. Methods: A prospective interventional study was conducted in the Department of Psychiatry after ethical approval. Thirteen medical interns were selected through convenience sampling. Four psychiatry faculty members and one biostatistician participated. Interns were trained in the DL method and followed a structured checklist covering history-taking, differential diagnosis, treatment planning, obtaining consent, ordering investigations, maintaining notes, administering scales, counseling, and preparing discharge summaries under supervision. Learning outcomes were assessed using pre- and post-tests (MCQs and viva voce). Data were analyzed using SPSS version 29.0. Feedback from interns and faculty was collected via a validated questionnaire. Results: Post-test scores showed a statistically significant improvement in diagnostic skills (p < 0.001). Over 90% of interns found the method feasible and enriching, citing improved understanding of psychiatric conditions and diagnostic confidence. Faculty reported enhanced teaching quality, student engagement, and motivation. Both groups supported integrating the DL method into routine clinical teaching. Conclusion: The Doctor-Learner method is a feasible and effective approach to clinical education in psychiatry, bridging theory and practice while enhancing diagnostic and communication skills. Larger, multi-centric studies are recommended to validate and standardize this method.

Exploring

Raghav KVG Medical College and Hospital, Sullia, Karnataka, India Background: Alexithymia, characterized by difficulty in identifying and expressing emotions, is frequently observed in individuals with alcohol dependence. Emotional dysregulation may contribute to poor coping, relapse, and treatment resistance. Tobacco use, highly prevalent among alcohol-dependent individuals, may further exacerbate alexithymia; however, this association remains underexplored in Indian populations. Objectives: To assess the prevalence and severity of alexithymia in alcohol-dependent patients compared to healthy controls, and to examine the influence of concurrent tobacco use and alcohol withdrawal severity on alexithymia. Methods: A comparative cross-sectional study was conducted at the Department of Psychiatry, KVG Medical College, Sullia, including 112 male participants 56 with Alcohol Dependence Syndrome (ADS) and 56 healthy controls. Assessments included sociodemographic and clinical details, history of alcohol/tobacco use, Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-AR), and the Toronto Alexithymia Scale-20 (TAS-20). Data were analyzed using SPSS v21. Independent t-test/Mann-Whitney U test and Chi-square test were applied, with p < 0.05 considered significant. Results: ADS patients had significantly higher TAS-20 scores than controls (60.3 ± 13.9 vs. 49.7 ± 9.3; p < 0.001). True alexithymia was present in 41.1% of ADS patients versus 3.6% of controls. Tobacco use was more frequent among ADS patients (83.9% vs. 26.8%; p < 0.001) but its duration or type did not influence TAS-20 scores. A history of complicated withdrawal (64.3%) correlated with greater alexithymia severity. Conclusion: Alexithymia is highly prevalent in alcohol dependence and is aggravated by severe withdrawal, underscoring the need to address emotional regulation in de-addiction programs.

Goldenhar

Sridevi Pradeep Yenepoya Medical College, Ullal, Karnataka, India Background: Goldenhar Syndrome (oculo-auriculo-vertebral spectrum) is a congenital disorder with craniofacial and vertebral anomalies, and occasionally subtle neurodevelopmental vulnerabilities. These structural susceptibilities may reduce neurological resilience, allowing postpartum hypoxic events to mimic or be misattributed to affective symptoms. Case Report: Mrs K, a woman aged 27 years, with features of Goldenhar Syndrome and no psychiatric history, underwent an emergency caesarean section for twin delivery. Postoperatively, she developed acute respiratory distress and unresponsiveness which required 1 month ICU care. After recovering, her family observed significant behavioural and cognitive changes that progressively worsened over four years. She had diminished social interaction, apathy, poor initiative, and exhibited marked forgetfulness, loss of previously mastered skills. MRI showed neuroparenchymal atrophy, and EEG demonstrated beta activity. She was diagnosed with Dementia in other diseases classified elsewhere (F02.8) secondary to postpartum hypoxic brain injury. She was started on Tab Sertraline 50 mg-optimised to 100mg; Tab Donepezil 5mg, Memantine mg and cerebroprotein hydrolase. Discussion: The coexistence of Goldenhar Syndrome may have heightened susceptibility to hypoxic damage, accelerating cognitive decline. Overlapping behavioural symptoms with postpartum depression contributed to delayed diagnosis. Conclusion: This case underscores the importance of considering underlying neurodevelopmental conditions when evaluating atypical or progressive postpartum behavioural changes. Key words: Dementia, goldenhar syndrome, post partum depression

High Dose

Sahil Jamal, A. K. Mishra, Prashant Choudhary UPUMS, Saifai, Uttar Pradesh, India Background: Fentanyl dependence represents a rising challenge in India, characterized by high opioid tolerance, severe withdrawal symptoms, and inadequate response to standard buprenorphine doses. The presence of chronic pain disorders such as sickle cell disease (SCD) further complicates treatment because opioid analgesia is clinically required during vaso-occlusive crises. Aims: To present the clinical course and therapeutic response of a patient with fentanyl dependence and co-morbid SCD managed with high-dose buprenorphine in a rural tertiary care centre. Methods: A 24-year-old male with daily fentanyl use and a history of recurrent SCD pain crises underwent supervised induction of buprenorphine-naloxone. The dose was escalated based on withdrawal severity, craving intensity, and functional improvement. Pain crises were collaboratively managed with the hematology team using supervised rescue opioids. Psychosocial interventions, including motivational interviewing, family counselling, and psychoeducation, were provided throughout treatment. Follow-up was conducted over a period of three months. Results: Escalation to a high maintenance dose of 24 mg/day of buprenorphine in divided doses was required to achieve adequate control of withdrawal and craving, as standard doses (up to 12 mg/day) proved insufficient. After three months of follow-up, the patient remained abstinent from illicit fentanyl, reported improved daily functioning, and required only one hospitalization for SCD crises, compared to three admissions during the previous similar duration. No major adverse effects occurred, except mild constipation and transient sedation. Conclusion: High-dose buprenorphine may be a safe and effective therapeutic option for fentanyl dependence when standard doses fail, even in the presence of complex comorbidities.

Immersive

Nishtha Budhiraja Wundrsight Health, Bengaluru, Karnataka, India Addiction psychiatry is entering a new era where immersive technologies are reshaping assessment and intervention. Virtual Reality (VR) enables safe and controlled simulation of high-risk environments, offering unique opportunities to address craving and relapse mechanisms. This symposium presents translational work from the National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi, focusing on the development and clinical testing of VR-based cue exposure therapy for alcohol dependence. The centerpiece study is a single-blind pilot feasibility trial (n = 16) comparing two immersive interventions: ReliefXR, a relaxation-based module providing calming, non-alcohol environments, and ReviveXR, a cue-exposure module combining ReliefXR with controlled alcohol-related simulations for coping and resistance training. Preliminary findings indicate that the combined approach (Relief + ReviveXR) was well tolerated and showed greater reductions in craving and improved adherence compared to ReliefXR alone. Additional presentations will discuss the neurobiological rationale for immersive therapy, the design of culturally valid virtual environments, and ethical and regulatory considerations in deploying digital therapeutics for addiction care in India. Together, these sessions aim to highlight the scientific, clinical, and implementation pathways for integrating immersive technologies into psychiatric treatment frameworks. Key words: Alcohol dependence, cue exposure therapy, digital therapeutics, ReliefXR, ReviveXR, virtual reality

Improving

Neelima Liz John, Susmitha Martha John 1 Kent and Medway Mental Health NHS Trust, Gillingham, England, 1 Believers Church Medical College Hospital, Thiruvalla, Kerala, India Background: Systematic monitoring of antipsychotic side effects is essential for medication adherence and relapse prevention. Local Trust and NICE guidelines recommend use of validated rating scales such as the Glasgow Antipsychotic Side-Effect Scale (GASS), with completion at one month after initiating depot antipsychotics and at least every six months thereafter. A first audit cycle (2024) identified suboptimal adherence to these standards. Aim: To re-audit compliance with recommended GASS monitoring for patients receiving depot antipsychotic injections in a community mental health team (CMHT) and assess changes following service adjustments. Methods: Using a retrospective review, 20 randomly selected CMHT patients receiving depot antipsychotics were assessed. Electronic notes (Rio) and uploaded specialist assessment forms were examined to determine whether GASS assessments were completed at the minimum six-monthly interval. Initial one-month post-initiation GASS assessments were excluded as most service users had commenced treatment prior to the first audit cycle. Results: In the first audit cycle, only 5% (1/20) of service users had GASS assessments completed at the recommended six-monthly interval. Following staffing improvements and increased awareness of guidelines, the re-audit demonstrated substantial improvement: 75% (15/20) of service users received GASS assessments every six months. Reasons for missed assessments were often undocumented. Conclusions: Implementation of consistent processes and increased staffing led to marked improvement in compliance with GASS monitoring. Despite progress, documentation gaps and occasional patient refusal indicate further opportunities to strengthen adherence to Trust guidelines. Improved structured monitoring may positively influence medication adherence and clinical outcomes. A repeat audit is recommended in 12 months.

Influence

Ankur Nayan, Pooja Dhurvey 1 VKSGMC, Neemuch, 1 CIMS, Chhindwara, Madhya Pradesh, India Background: “Life events” are any significant changes in one’s personal circumstances that have consequences in the personal and social domain, affecting physical and mental health. It has been proposed that patients with psychotic illness are more likely to experience stressful life events prior to the first and recurrent episodes. Aims: To estimate and compare the prevalence and type of of pre-onset stressful life events (SLEs) in patients with bipolar disorder and schizophrenia. Methods: A cross-sectional study was conducted at a tertiary health care centre in Jabalpur (M.P.) which included a total of 150 consecutive cases of bipolar disorder and schizophrenia. These patients were assessed with help of assessment tools such as YMRS, HAM-D and BPRS. The stressful life events were assessed in the pre-onset period and quantified using the Presumptive Stressful Life Events Scale (PSLES). Statistical analysis was done using Chi-square tests and odds ratio. Results: Pre-onset stressful life events were significantly more prevalent in bipolar disorder (66%) than in schizophrenia (46.4%). Patients with bipolar disorder had more than twice the odds of reporting stressful life events as compared to patients with schizophrenia (OR=2.23). This difference was statistically significant (χ² = 5.52, p = 0.019). In cases of both these disorders, the most frequent pre-onset stressful life events were family conflicts and broken engagement or love affair. Conclusion: Pre-onset stressful life events must be carefully assessed, as they influence current episode outcomes and help prevent recurrence, ultimately improving functional recovery and quality of life in affected patients.

Intensive

Shreshkar Anand, Akash Kumar 1 , Rashmi Shukla 2 , Kunwar Akhilesh 3 AIIMS, 1 Department of Psychiatry, AIIMS, Raebareli, 2 Department of Psychiatry, KGMU Lucknow, 3 Department of Psychiatry, Autonomous State Medical College, Hardoi, Uttar Pradesh, India Background: Trichotillomania is a chronic psychiatric disorder characterized by recurrent hair-pulling with limited treatment options. Role of repetitive transcranial magnetic stimulation (rTMS) as an effective adjunctive treatment has been explored but limited evidence exists. Aims: To describe the clinical response to intensive low-frequency rTMS targeting the SMA in a patient with chronic, treatment-resistant trichotillomania. Methods: A 34-year-old female with 20-year history of trichotillomania and comorbid dysthymia for past 2 to 3 years, presenting with irresistible urges to pull hair despite multiple failed cessations attempts and minimal response to Selective serotonin reuptake inhibitor (SSRI) on outpatient basis. rTMS was considered given poor response and potential role suggested by previous literature. The patient received intensive low-frequency rTMS targeting the SMA. Stimulation parameters included 1-Hz frequency, 100% resting motor threshold (RMT = 67%), with 30 pulses per train and 20 trains per session. Two sessions were delivered daily, separated by a 15-minute interval, amounting to a total of 20 sessions over 10 days. SSRI treatment was continued and habit reversal training was provided concurrently. Results: Significant clinical improvement was observed. More than 70% reduction in MGH-HPS scores and about 45% reduction in YBOCS scores reduced. There were no adverse effects noted. Follow-up showed sustained improvement with visible hair regrowth over 1.5 years. Conclusion: Intensive low-frequency rTMS over SMA demonstrated substantial improvement in treatment-resistant trichotillomania. Prior evidence on role of rTMS exists but is limited. Hence more such studies may be carried out to build stronger evidence.

Invisible

Ankur Nayan, Krishna Kumar Carpenter VKSGMC, Neemuch, Madhya Pradesh, India Background: Olfactory Reference Syndrome (ORS) is a rare psychiatric condition characterized by a persistent false belief that one emits a foul or unpleasant body odour, often leading to significant distress, social avoidance and repeated medical consultations. Patients commonly seek help from non-psychiatric specialties such as dermatology or dentistry due to the somatic focus of symptoms. Early identification and psychiatric intervention are crucial for improving functional outcomes. Aims: To assess a case of Olfactory Reference Syndrome and highlight the importance of psychiatric diagnosis and management. Methods: A 30 year old female was referred from the Dental OPD to the Psychiatry Department at a tertiary health care centre in Neemuch, (M.P). She had a persistent belief of bad smell emanating from her mouth. Detailed psychiatric evaluation and exclusion of organic causes were conducted. A diagnosis of Olfactory Reference Syndrome was made as per DSM-5-TR under Other Specified Obsessive-Compulsive and Related Disorders.The patient was started on Fluoxetine 20 mg/day, titrated up to 40 mg/day, and later augmented with Risperidone 2mg/day. She also received psychoeducation and supportive psychotherapy. Results: Following treatment with SSRI and augmentation with anti-psychotics, the patient showed marked improvement over subsequent weeks. Her preoccupation with perceived odour, associated distress, and reassurance-seeking behaviors reduced significantly, leading to complete symptomatic remission. Conclusion: This case highlights the need for awareness among medical professionals regarding psychiatric conditions like Olfactory Reference Syndrome. Early referral and appropriate psychiatric management can result in full recovery, preventing chronicity and improving quality of life in affected individuals.

Knowledge

Arnab Deb Dr. BS Kushwah Institute of Medical Sciences and Rama Hospital, Kanpur, Uttar Pradesh, India Background: There is rising trend of transgender individuals seeking for medical, surgical and psychological treatment in India. Many studies have shown an inadequate knowledge and wrong attitude of healthcare professionals including doctors towards transgender patient’s healthcare. Aim: This study aims to assess the knowledge, attitude and beliefs of resident doctors towards transgender patient’s healthcare. Methods: A google form that includes demographic details, The Medical Practitioner Beliefs and Knowledge about Treating Transgender Patients (MP-BKTTP) survey scale, and The Medical Practitioner Attitudes Towards Transgender Patients (MP-ATTS) survey scale was sent to 293 resident doctors of Agartala Government Medical College via email. Results: Response rate was low (18%) with highest by the Senior Resident doctors (82%). The mean item score across the MP-BKTTP scale was 3.49 (SD = 1.07). This reflects fairly accurate understanding of transgender health needs. 98% participants expressed willingness to treat transgender patients but 84.9 % wanted better medical education to provide appropriate care to them. The overall mean item score was 3.32 (SD = 1.31) for MP-ATTS Scale, indicating more variability and ambivalence in general attitudes of resident doctors than their knowledge and belief. Conclusion: The findings of our study also highlighted the need of inclusion of transgender healthcare related topics in medical curriculum. Further research is indicated in this field.

Nocturnal

Sanchita Pandey, G. Prasad Rao Asha Hospital, Hyderabad, Telangana, India Introduction/Background: Adult-onset nocturnal enuresis is an uncommon symptom that often leads to psychiatric or urological referral. However, it can rarely be caused by nocturnal epilepsy, presenting as isolated bedwetting due to transient loss of bladder control during seizures. This atypical presentation is frequently overlooked, which can delay diagnosis and appropriate treatment. Case Description: A 21-year-old female B.Tech student residing in a hostel reported recurrent nocturnal enuresis occurring 5-6 times annually, mainly in early morning hours. She had no prior history of childhood enuresis, limb movements, or seizure-like activity and no family history of epilepsy. Physical and neurological examinations were normal, and urinalysis was unremarkable. Electroencephalography revealed epileptiform spikes in the parietal and temporal regions consistent with focal nocturnal epilepsy. Discussion/Conclusion: This case highlights that nocturnal epilepsy can manifest solely as recurrent adult-onset enuresis without classical seizure features such as tonic-clonic activity. EEG is essential to differentiate epileptic from primary enuresis cases. Recognizing this presentation enables early diagnosis and targeted antiepileptic therapy, preventing misdiagnosis and unnecessary investigations.

Pentothal

Sayan Mondal, Parthasarathi Kundu IPGMER and SSKM hospital, Kolkata West Bengal, India A 24 years old male hailing from rural area of West Bengal, belonging form lower-middle socioeconomic class presented at OPD with complaints of inability to speak and social isolation since last 3 years. According to informant, 1 year back of onset of these symptoms he developed suspiciousness towards his relatives, self-muttering and frequent anger outburst insidiously for which he was prescribed multiple antipsychotics from different psychiatrists. On taking medications, his psychotic symptoms resolved but gradually he developed mutism. He started communicating only by non-verbal means, answering only by facial expression and incomprehensible sounds on asking him something. However, he was compliant to take medicines but no significant improvement was noted on oral medication. Patient was admitted at indoor and interviewed serially, was given oral anti-obsessive and antipsychotic agents but verbal communication was not established. Decision of narcoanalysis was made by treating team and following proper protocol patient was slowly infused Inj. Thiopental, Inj. Ketamine and Inj. Midazolam over a duration of one hour in OT with the help of anesthesiologists. Patient was interviewed in structured way throughout the process following a pre-formed questionnaire. He was at the verge of emotional breakdown for 3 times in response to certain questions but did not communicate verbally throughout the period. Postoperatively no significant adverse reaction occurred other than fever for which he was managed conservatively. He was discharged with Tab Fluoxetine 80 mg, Tab Clomipramine 75 mg, Tab Haloperidol 20 mg, Tab Trihexyphenidyl 2 mg and Tab Lorazepam 4 mg.

Phenytoin

Sanjeev, Tanu Kundal 1 Adesh Medical College and Hospital, 1 Department of Psychiatry, Adesh Medical College, Shahbad, Haryana, India Background: Phenytoin continues to be prescribed for generalized tonic-clonic seizures in resource-limited settings due to low cost and availability. However, it is associated with a spectrum of adverse drug reactions (ADRs), including cutaneous, endocrine, neurological, and psychiatric complications. Early recognition is essential to minimize morbidity. Case Description: This is the case of a 34-years-old female with epilepsy since adolescence, treated since 25 years with phenytoin 300 mg HS and phenobarbitone 30 mg HS. Initially well controlled, she later developed breakthrough seizures with missed doses or stress. Over time, multiple ADRs emerged: dermatological (generalized rash, hypersensitivity, facial pruritic lesions), endocrine (gingival hyperplasia, hirsutism), and neuropsychiatric (vertigo, disequilibrium, irritability, cognitive slowing, impaired memory and concentration). Psychiatric morbidity was prominent, with persistent low mood, anhedonia, irritability, fatigue, and deliberate self-harm following psychosocial stressors including marital discord, divorce, separation from her daughter, and a recent miscarriage. Management: Causality assessment suggested probable phenytoin-induced ADRs. A plan was made to slowly taper down the dose of phenytoin and switch to a non-aromatic antiepileptic medication (e.g., levetiracetam), monitor dermatological recovery, and initiate psychiatric treatment with an SSRI appropriate for epilepsy. Psychoeducation on adherence, seizure triggers, and ADR recognition was provided. Conclusion: This case highlights the broad ADR profile of phenytoin and its contribution to psychiatric morbidity in women with epilepsy. Integrated neuropsychiatric care and timely rational antiepileptic substitution are crucial for improving both seizure outcomes and mental health. Key words: Phenytoin, adverse drug reaction, epilepsy, depression, self-harm, women’s mental health

Psychosis

K. Keerthana, G. Anuhya Guyton GHMC, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Tuberous sclerosis complex (TSC) is a rare multisystemic genetic disorder, It usually affects the central nervous system and presents with a multitude of symptoms such as seizures, skin abnormalities, behavioral problems. Psychosis has been rarely reported in patients with TSC. Aim: This case report aims to describe the psychiatric presentation of a patient with TSC, outline the diagnostic process, and emphasize the importance of recognizing the psychiatric presentation to ensure timely evaluation and management. Methods: A case of 39 Yr old female with TSC came with the complaints of talking to self, laughing to self, anger outburst, physically and verbally abusive, decreased sleep and decreased appetite for the past 1 month and history of seizures present since 16 years of age and on the physical examination she was found to have ash-leaf spots, adenoma sebaceum, shagreen patches, periungual fibroma and MSE revealed delusion of persecution, delusion of reference with insight 0/5. Family history significantly showing similar complaints in her sister suggesting genetic predisposition. CT brain showing cortical tubers. Results: A provisional diagnosis of secondary psychotic syndrome due to Tuberous sclerosis complex (6E61) was made using ICD-11 and the patient was managed with T.Haloperidol 30mg, T.Quetiapine 50mg, T. Trihexyphenidyl 2mg,T.Phenytoin 300mg, T.Sodium valproate 1000mg, T.Clobazam 10mg, Along with the psychotherapy and Over a 2-week inpatient period, a significant improvement in symptoms. Conclusion: This case highlights the psychiatric presentation in Tuberous sclerosis. Psychiatric intervention and collaborative management with neurology are crucial for favorable outcomes.

Recurrent

Ankit Saini, Priya Ranjan Avinash 1 , Robin Victor 1 , Praveen Rikhari 1 , Simrat Kaur 1 Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, 1 Department of Psychiatry, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India Introduction: Acute and Transient Psychotic Disorder (ATPD) is characterized by the rapid onset of psychotic symptoms—typically within two weeks—followed by a complete recovery. Recurrent episodes, while less common, present significant diagnostic challenges in differentiating the condition from chronic disorders such as Schizophrenia or Bipolar Affective Disorder. Case Description: A 26-year-old female, preparing for teaching exams, presented with a 20-day history of irrelevant talk, decreased sleep, and odd behavior. Symptoms emerged suddenly following a birthday phone call, beginning with social withdrawal and progressing to delusions of guilt, persecution, and being controlled by external spirits. The patient exhibited significant religious preoccupations, including a ritualistic chanting episode on a roof holding a religious flag. Physical aggression was noted during transit to the hospital. History and Examination: The patient had a similar episode in February 2024, which resolved within 10 days on Olanzapine. She remained asymptomatic until medication was discontinued. Mental Status Examination revealed a blunt, unstable affect and impaired personal judgment, while cognitive functions remained intact. Conclusion: Based on ICD-10 and DSM-5 criteria, a diagnosis of Recurrent ATPD (Brief Psychotic Disorder) was made due to the sudden onset, polymorphic symptoms, and history of full remission. This case emphasizes the role of socio-cultural themes in symptom manifestation and underscores the necessity of guided medication maintenance to prevent relapse in recurrent cases.

Screening

Siddarth Seenivasa, Suvarna Jyothi Kantipudi Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India Acute-onset neuropsychiatric symptoms, such as sudden obsessive-compulsive behaviors, tics, anxiety, emotional dysregulation, and sensory changes, can signal conditions like Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) and PANDAS. Early identification is essential, particularly in low- and middle-income countries (LMICs), where culturally validated screening tools remain limited. This scoping review aims to map existing screening and diagnostic measures used to detect acute-onset neuropsychiatric symptoms in adolescents and evaluate the evidence supporting their validity, reliability, and cross-cultural applicability. Following the PRISMA-ScR framework, we developed a comprehensive search strategy using databases such as MEDLINE, Cochrane, and PsychInfo combining MeSH terms and title/abstract keywords for acute-onset symptoms, adolescent populations, and screening or diagnostic instruments. Eligible studies included human participants under 18 years and any tool assessing OCD, tics, anxiety, mood changes, or sensory disturbances with sudden onset. Two reviewers independently screened titles, abstracts, and full texts, and charted data on tool characteristics, psychometric properties, diagnostic performance, cultural adaptations, and use within LMIC settings. Preliminary findings highlight substantial reliance on Western-developed instruments with limited evaluation in diverse cultural contexts. Very few tools explicitly assess acute onset or rapid symptom escalation, and even fewer have undergone translation, cultural adaptation, or validation in LMIC populations. This evidence gap underscores the urgent need for context-sensitive assessment measures to support early identification and equitable neuropsychiatric care globally. This review will provide clinicians, researchers, and policymakers with a comprehensive evidence map and guide priorities for tool development and cross-cultural validation.

Suspected

Akash Srivastava, Deepak Charan, P. K. Pardal Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India Introduction: Phenothiazines are known to cause cutaneous adverse effects, most notably hyperpigmentation. While chlorpromazine is most frequently implicated, trifluoperazine despite its widespread use is rarely reported. Its melanin-binding and photosensitizing properties suggest a possible pigmentary effect, but divalproex sodium can also induce hyperpigmentation, creating diagnostic uncertainty when both drugs are used together. Aim: To present five cases of hyperpigmentation temporally associated with trifluoperazine and assess how concurrent divalproex sodium use complicates causal interpretation. Case Reports: Case 1: A 25-year-old woman on trifluoperazine monotherapy developed progressive hyperpigmentation over sun-exposed areas. Case 2: A 25-year-old man on trifluoperazine and valproate developed facial pigmentation; switching to olanzapine led to complete resolution in three months. Case 3: A 23-year-old man on trifluoperazine and valproate developed nasal-tip pigmentation that improved within one month after switching to risperidone. Case 4: A 17-year-old male on trifluoperazine, valproate, and clonazepam developed nasal-tip pigmentation; follow-up was unavailable. Case 5: A 27-year-old man on trifluoperazine and valproate developed facial hyperpigmentation; follow-up details were missing. Discussion: All cases showed a temporal link between trifluoperazine initiation and pigmentation onset. Improvement after discontinuation in two patients supports a possible drug-induced reaction. However, concurrent divalproex sodium in most cases represents a major confounder. Incomplete dechallenge and limited follow-up further weaken causal certainty. Conclusion: Trifluoperazine-induced hyperpigmentation is plausible but not definitive due to significant confounding from divalproex sodium. Clinicians should monitor for pigmentary changes and apply structured causality assessments in patients receiving combination psychotropics.

Swallowed

Akash Chotulal Gorana, Prajakta Patkar, Alka Subramanyam, Neena Sawant TNMC BYL Nair Hospital, Mumbai, Maharashtra, India Background: Trichobezoars are rare but serious gastrointestinal concretions formed from ingested hair, occurring predominantly in children and adolescent females. In childhood, they often remain undetected because symptoms are vague and children may conceal hair-pulling behaviour due to shame or lack of awareness. Poor impulse control in this age group may represent a behavioural marker for underlying psychiatric or neurodevelopmental vulnerabilities such as Obsessive-Compulsive Disorder (OCD), Attention-Deficit/Hyperactivity Disorder (ADHD), or Autism Spectrum Disorder (ASD), where repetitive urges and impaired inhibition are common. Without timely recognition, trichobezoars may rapidly enlarge, leading to gastric outlet obstruction, nutritional deficiencies, and potentially life-threatening complications. Cases: Case 1: A 10-year-old girl presented with chronic abdominal pain and a long history of ingesting non-food items including plastic, balloons, cloth, stones, and hair. Extensive gastrointestinal evaluations were inconclusive until psychiatric assessment revealed pica with trichotillomania. A multidisciplinary approach involving occupational therapy, Conner’s assessment, stool testing, and iron studies guided further management. Case 2: A 14-year-old girl presented with severe abdominal pain, vomiting, constipation, and weight loss. Imaging confirmed a large gastric trichobezoar requiring surgical removal. Psychiatric evaluation identified trichotillomania with trichophagia. Treatment with fluoxetine 40 mg/day and psychotherapy produced significant improvement in hair-pulling urges and overall impulse control. Conclusion: These cases highlight how somatic presentations may mask underlying psychiatric or neurodevelopmental conditions. Surgery alone is insufficient without long-term psychiatric care. Early identification, multidisciplinary collaboration, and addressing impulse-control difficulties are essential to prevent recurrence and ensure sustained recovery. Key words: Pediatric psychiatry, trichobezoar, trichophagia, trichotillomania

Synthetic

Rajkumar Sanahan All India Institute of Medical Sciences, New Delhi, India Background: Synthetic cannabinoids (SCs), including products marketed under misleading labels such as Cannapain,have emerged as potent psychoactive substances. Unlike natural cannabis, most SC preparations lack cannabidiol (CBD), which mitigates the psychotomimetic properties of THC, thereby increasing vulnerability to psychosis. Despite rising global concern, reports from India remain limited. Case Presentation: We describe a 33-year-old male with cluster-A premorbid traits and a seven-year history of heavy cannabis use who transitioned over the past 1.5 years to daily SC consumption in the form of online-purchased pills and oils. Psychotic symptoms persecutory and referential delusions with hallucinatory behaviour initially emerged with cannabis use but intensified markedly after initiating SCs, with only partial remissions during brief abstinent periods. On admission, he exhibited agitation and aggression requiring rapid tranquillisation. Routine urine toxicology was negative for cannabinoids, consistent with the detection limitations for SCs. A diagnosis of synthetic cannabinoid dependence and SC-induced psychotic disorder (ICD-11) was made, supported by a Cannabis Use Disorder Identification Test-Revised (CUDIT-R) score of 26. Risperidone was discontinued due to adverse effects, and haloperidol up to 10 mg was initiated, resulting in mild improvement (Brief Psychiatric Rating Scale score reduced from 40 to 38). Psychoeducation, N-acetylcysteine up to 1200 mg, and relapse-prevention counselling were provided. Discussion and Conclusion: This case highlights the strong psychosis-inducing and dependence-forming potential of SCs, the diagnostic challenges related to routine toxicology, and the increasing online accessibility of unregulated SC products. Enhanced clinical vigilance, regulatory oversight, and improved laboratory detection are essential to mitigate associated psychiatric harms.

Transient

Meghna Kemprai, Deepanjali Medhi 1 , Suresh Chakravarty 1 Gauhati Medical College and Hospital, 1 Department of Psychiatry, Gauhati Medical College and Hospital, Guwahati, Assam, India Overview: Alcohol-induced psychosis is a reversible psychiatric condition associated with prolonged and in heavy alcohol use. It commonly presents with vivid hallucinations, disturbed sleep, sensory changes and behavioural alterations, while orientation is usually preserved. Timely recognition is very important, as this condition often resolves fully with abstinence, vitamin supplementation and short-term use of psychotropic medications. Distinguishing it from primary psychotic disorders such as schizophrenia is essential because the treatment approach and long-term prognosis differ significantly. Case: A 55-year-old male from Arunachal Pradesh with a 30-year history of chronic alcohol consumption presented with tingling sensations in all limbs, reduced sleep and vivid auditory and visual hallucinations. He described hearing threatening voices and seeing unknown women beside him at night. On mental status examination, he was fully oriented but had prominent hallucinations. Neurological evaluation revealed right-sided facial paralysis. A diagnosis of Transient Alcohol-Induced Psychosis was made. He was treated with benzodiazepines for withdrawal symptoms, antipsychotics for hallucinations, vitamin supplementation and supportive care. His symptoms improved significantly within a few days, and he was discharged in a clinically stable condition. Discussion- Alcohol-induced psychosis typically occurs during heavy consumption or early withdrawal. The rapid resolution of hallucinations, intact orientation and absence of chronic psychotic features helped differentiate this case from schizophrenia. The associated facial paralysis may be linked to alcohol-related neuropathy or nutritional deficiency. Early stabilisation prevents complications such as delirium tremens and reduces relapse risk. Conclusion: This case highlights the importance of recognising alcohol induced psychosis and differentiating it from primary psychiatric illnesses.

Treatment

Kurakula Lakshman, J. Bhargav Reddy Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Treatment-resistant schizophrenia (TRS) is characterized by persistence of symptoms despite the use of 2 antipsychotics for atleast 6 to 8 weeks of each drug. This case report emphasizes the challenges in managing Treatment resistant schizophrenia and the effectiveness of multidisciplinary approach in managing a case of treatment resistant schizophrenia. Case Summary: A 27year old male born out of nonconsanguineous marriage, presented with suspiciousness, irrelevant talk, talking to self and laughing to self, disorganized behaviour, aggressive behaviour, irritability, decreased selfcare, staying aloof, decreased sleep for 5 years increased since 2months causing severe functional impairment in the patient. A detailed evaluation confirmed schizophrenia continuous currently symptomatic. Results: Patient started on Risperidone slowly increased to 16 mg for 6 weeks but symptoms persisted, so switched to Aripiprazole slowly increased to 30 mg for 6weeks still symptoms persisted, so switched to Amisulpride but still symptoms persisted now currently on Clozapine 350 mg concurrently 8 ECT’S are given and still going there is 50% reduction in symptoms but till irrelevant talk is present. Conclusion: This case underscores that meticulous longitudinal documentation of treatment trials, adherence, and clinical response is essential to diagnose Treatment resistant Schizophrenia and to plan evidence-based interventions. A systematic use of standardized case records, clear treatment plans, and multidisciplinary care can improve symptom control and safety in Treatment resistant Schizophrenia. The case highlights the need to consider timely transition to clozapine and adjunctive psychosocial interventions to optimize long term outcomes.

Unmasking

Manasvi Sharma, Rakesh Ghildiyal Mahatma Gandhi Mission Institute of Health Sciences, Mumbai, Maharashtra, India Background: Tramadol is a synthetic opioid analgesic widely used in clinical settings as it is perceived to be safe. However, increasing evidence highlights the propensity of this medication to cause dependence and neuropsychiatric adverse effects. Aim: To present case report on Tramadol induced psychosis Case Description: 42-year-old female, presented with agitation, suspiciousness, disorganized behaviour, poor self-care, auditory hallucinations, disturbed sleep and overfamiliarity with overtalkativeness. Patient had body pain she was prescribed Tramadol. Over time, her pain gradually reduced but her consumption of the tablet increased from 2 to 16 tablets per day. After two years of starting medications, she started exhibiting inappropriate behaviour i/f/o self-muttering, self-smiling and would respond irrelevantly at times. She had suspiciousness i/f/o delusion of reference and delusion of infidelity. Her self-care deteriorated. She also exhibited overtalkativeness. She has never abstained from Tramadol during her entire course of illness. Discussion: Tramadol HCl has been associated with a spectrum of neuropsychiatric symptoms. µ-opioid receptor activity alongside modulation of serotonergic and adrenergic pathways, may contributes to these effects. Emerging evidence also suggests that tramadol and its active metabolite can inhibit NMDA receptors, which can contribute to hallucinations, delusions, and other psychotic features. Persecutory delusion, in addition to auditory and visual hallucinations, secondary to tramadol use has been reported in one patient. Conclusion: While tramadol is often viewed as having fewer adverse effects than traditional opioids, these findings highlight need for clinical awareness of its potential to induce psychiatric symptoms, particularly in susceptible individuals or at higher doses.

Unveiling

Pabina Pius Puthur, Sheena Varughese, Joice Geo Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India Alcohol use among women in India is undergoing a silent yet significant transformation, influenced by rapid sociocultural shifts, evolving gender roles, and changing access patterns. Kerala, despite high literacy and health indices, continues to report concerning rates of alcohol-related morbidity, though research specific to women remains sparse. We present two clinical cases highlighting the emerging trend of alcohol use disorder among women in rural Kerala. Case 1: A 37-year-old married postgraduate tuition teacher from rural Pathanamthitta with a one-year history of progressive alcohol consumption presented with irritability, sleep disturbances and withdrawal symptoms. Her average drink was 5-7 units of brandy, reinforced by household availability through her alcohol-dependent father. Clinical evaluation showed tremors, icterus and elevated liver enzymes. She was managed with benzodiazepine-assisted detoxification and thiamine, following which she maintained abstinence at one-month follow-up. Case 2: A 26-year-old 12th failed unmarried unemployed woman from rural Alappuzha started using alcohol over two months, consuming average of 3 units of rum at a local studio under external social influence, showing increased frequency, impaired judgement and reduced appetite. She underwent inpatient detoxification and remained abstinent on follow-up. These cases mirror research from Assam, Karnataka, Telangana and Bengaluru showing increasing female alcohol consumption, preference for locally brewed or discreetly available alcohol, and specific gender-linked psychosocial vulnerabilities. The findings emphasize the urgent need for gender-sensitive screening, early primary-care identification, culturally informed preventive interventions and stigma-free access to addiction services. Strengthening awareness, community education and multidisciplinary care holds promise for reducing long-term consequences among women.

Adjunctive

Shreeya Basu King George’s Medical University, Lucknow, Uttar Pradesh, India Background: Post-stroke aphasia often persists despite standard rehabilitation, particularly in the chronic phase. While speech-language therapy (SLT) remains the mainstay of treatment, neuromodulation techniques such as high-definition transcranial direct current stimulation (HD-tDCS) and repetitive transcranial magnetic stimulation (rTMS) are increasingly explored as feasible adjuncts to enhance neuroplasticity and support language recovery. Aims: To explore the role of neuromodulation alongside SLT in a patient with chronic mixed aphasia following a left middle cerebral artery (MCA) infarct. Methods: A 55-year-old right-handed man presented with non-fluent speech, impaired naming, repetition and comprehension, along with right-sided weakness after a left MCA infarct. MRI revealed chronic infarct changes involving the left frontal-insular-perisylvian region. He initially received HD-tDCS (2 mA, 30 minutes, 4×1 montage; cathode over right inferior frontal gyrus), which was discontinued after three sessions due to local skin irritation. He was then started on low-frequency rTMS (1 Hz, 1000 pulses/session) over the same target, delivered as an adjunct to ongoing SLT. Results: The patient showed improved speech initiation and increased communicative responsiveness during therapy. rTMS was well tolerated, with no additional adverse effects. Conclusion: This case demonstrates the therapeutic potential and clinical viability of combining neuromodulation with SLT in managing chronic post-stroke aphasia. Targeted stimulation may help activate residual neuroplasticity even in later stages of recovery. Achieving optimal results depends on personalising the choice of modality and stimulation parameters to the patient’s specific language deficits, lesion profile, and side-effect tolerance. Further controlled studies are necessary to refine individualised approaches to aphasia rehabilitation.

Adolescent

Athira M. Anil, S. V. Santosh Hassan Institute of Medical Sciences, Hassan, Karnataka, India Background: Organic mood disorders in adolescents are uncommon and often present with complex neuropsychiatric profiles. Structural brain changes, refractory epilepsy, metabolic abnormalities and ENT pathology may contribute to mood disturbances. Aims: To present a rare case of an adolescent female with refractory epilepsy, bilateral frontal cortical atrophy with gliotic changes, metabolic abnormalities and comorbid organic mood disorder. Methods: An 18-year-old female with a 5-year history of GTCS and 3-year history of depressive symptoms irritability, low mood, crying spells, hopelessness, worthlessness and one unnoticed suicide attempt was evaluated. Neuropsychological assessment showed intact planning, attention (forward 5 digits, backward 2 digits), Go-No-Go test, right-left orientation, visuospatial skills, and calculations. Psychotic features were absent. MRI brain revealed well-defined T2W/FLAIR hyperintense signals in bilateral frontal cortex,underlying white matter suggesting gliosis, volume loss and mild ex vacuo dilatation of bifrontal cortical sulci, Sylvian fissures and anterior bodies of the lateral ventricles. CT brain and ENT imaging showed bifrontal atrophy, bilateral maxillary, ethmoidal and sphenoid sinusitis and a left nasopharyngeal mucosal polyp. Laboratory evaluation showed homocystinuria and megaloblastic anemia. Results: The constellation of bilateral frontal gliosis, cortical atrophy, neuroregression, metabolic abnormalities, chronic sinusitis and longstanding epilepsy supported a diagnosis of organic mood disorder with OCPD traits. Treatment with antidepressant,mood stabiliser and antiepileptics led to significant improvement in depressive symptoms on follow-up. Conclusion: This rare case highlights the importance of identifying structural, metabolic and neurological contributors to mood symptoms in adolescents, emphasizing multidisciplinary evaluation in complex organic mood disorders. Structural, metabolic insights unlock new paths to adolescent healing.

Assessment

Puffin Mehta, Sanjay Pattanayak, Nandita Hazari VIMHANS, New Delhi, India Background: Ambivalence is a key cognitive-affective feature of OCD. In the context of OCD, two major forms of ambivalence are typically studied self and interpersonal ambivalence. Guidano and Liotti (1983) introduced self-ambivalence, referring to conflicting self-beliefs such as feeling both worthy and unworthy. Interpersonal ambivalence denotes holding both positive and negative feelings toward others, manifesting in OCD as exaggerated responsibility and prosociality alongside latent aggression or distrust. Aim: To study the relationship between ambivalence and OCD severity. Methods: This cross-sectional study was conducted at VIMHANS, New Delhi. 73 adults (18-60 years) diagnosed with OCD were recruited. OCD illness severity was assessed using the YBOCS and obsessive beliefs using the Obsessive Beliefs Questionnaire (OBQ-44). Self and interpersonal ambivalence were evaluated using Self-Ambivalence Scale (SAS) and Relationship Interpersonal Beliefs and Attitudes Questionnaire (RIBAQ). Functional impairment was assessed by Work and Social Adjustment Scale (WSAS). Results: Most OCD patients demonstrated moderate-to-high self-ambivalence and moderate interpersonal ambivalence. Both self ambivalence and interpersonal correlated positively with obsessive beliefs (OBQ-44) (r = 0.438, p < 0.001; SAS) (r = 0.392, p = 0.001; RIBAQ) respectively but not with YBOCS, (r = 0.153, p = 0.195) and (r = 0.184, p = 0.119) respectively suggesting ambivalence is more related to underlying obsessive cognitions than overt symptom severity. However, Ambivalence correlated with WSAS, indicating it’s contribution to socio-occupational dysfunction. Conclusion: Self and interpersonal ambivalence correlate strongly with obsessive belief systems (OBQ) and not with symptom severity (YBOCS) but influence social functioning.

Behavioral

Mohit Singh, Jayati Simlai, Abhishek Kumar Ranchi Institute of Neuro Psychiatry and Allied Sciences, Ranchi, Jharkhand, India Background: Achondroplasia, the most common skeletal dysplasia, is primarily characterized by disproportionate short stature and distinct craniofacial features. Although the disorder is largely orthopaedic, individuals with achondroplasia may experience behavioural and affective disturbances stemming from psychosocial stressors, neurobiological vulnerability, or secondary medical complications. Reports of psychiatric manifestations n achondroplasia remain limited. Case Description: A 30 year-old married, unemployed male from a lower socio-economic rural background (Bokaro, Jharkhand), with known features of achondroplasia, presented to the psychiatry outpatient Department with irritability, abusive behaviour, self-laughing. self-muttering, and frequent crying spells for the past one year, along with decreased sleep and appetite for the past three months. There was no past psychiatric or substance use history, no family history of mental illness. Examination revealed short stature with rhizomelic limb shortening and macrocephaly, with intact cognitive functions. Mental status examination showed irritable affect, occasional irrelevant speech, and possible auditory hallucinations. Discussion: While achondroplasia itself does not predispose specific psychiatric syndromes, secondary behavioural and affective symptoms may emerge due to psychosocial challenges, stigma, and biological tress factors. Early psychiatric intervention promotes better functional and emotional outcomes. Conclusion: This case emphasizes the need for a multidisciplinary approach and routine psychiatric evaluation in individuals with achondroplasia presenting with behavioural changes, ensuring timely diagnosis and effective management. The patient was started on Tablet Sodium Valproate 500 mg HS, Risperidone 4 mg HS, Trihexyphenidyl 2 mg morning. and Lorazepam 2 mg HS, with notable symptomatic improvement on follow-up.

Challenges

Pragya Verma, Fiona Mahapatro DY Patil School of Medicine, Navi Mumbai, Maharashtra, India Background: Depression frequently coexists with medical illnesses, with MDD affecting nearly one in four patients with medical comorbidities. Lack of awareness about psychiatric symptomatology, stigma, and financial constraints delay diagnosis and treatment, worsening morbidity and quality of life. Integrating psychiatric care into routine medical services is essential for improving outcomes in this population. Objective: To present a case-based illustration highlighting effective strategies for managing depression in a patient with various medical comorbidities. Methods: A 34 year-old homemaker from a low socioeconomic background, admitted under Gynaecology for hemoperitoneum secondary to corpus luteal cyst rupture and with a history of RHD, was referred to Psychiatry for disturbed sleep. She underwent multiple hospitalisations, including an ICU stay. Serial clinical interviews helped the patient identify and acknowledge a broader constellation of symptoms beyond her initial complaint. Results: A diagnosis of PDD with MDD with anxious distress was made. Once medically stable, psychotropics were initiated- T. Escitalopram and T. Clonazepam, with dose titration based on symptom severity and medical status. Patient was counselled regarding illnesses and it’s course, mind-body interactions and coping strategies. Structured psychoeducation was provided for her family. Coordination between medical teams ensured safe management. Over follow-up, the patient achieved remission in symptoms, despite fluctuating medical status. Conclusion: Depression may present subtly in individuals with other medical ailments; hence, detailed psychiatric assessment is warranted even on minimal indication, as integrated care significantly improves outcomes.

Compulsion

Samyadip Bardhan, T Naga Laxmi Osmania Medical College, Hyderabad, Telangana, India Background: Voyeuristic disorder, classified under paraphilic disorders in both ICD-11 and DSM-5-TR, is characterized by recurrent and intense sexual arousal from observing unsuspecting individuals during private activities, accompanied by impaired control, distress, or functional impairment. Evidence for pharmacological treatment, particularly with selective serotonin reuptake inhibitors (SSRIs), remains limited and largely based on case reports. Case Presentation: We report the case of an adult male who presented with recurrent, persistent, and distressing urges to observe individuals undressing without their awareness. The urges were experienced as ego-dystonic, associated with mounting internal tension and subsequent transient relief, and resulted in significant psychosocial distress and impaired functioning. There was no history of psychotic symptoms, mood disorder, substance use, or neurological illness. The clinical presentation fulfilled diagnostic criteria for voyeuristic disorder as per ICD-11 and DSM-5-TR. Intervention and Outcome: The patient was treated with paroxetine, gradually titrated to a therapeutic dose. Over the course of treatment, there was a marked reduction in the frequency and intensity of voyeuristic urges, along with improved impulse control and reduced preoccupation. Conclusion: This case supports the role of SSRIs, particularly paroxetine, in the management of voyeuristic disorder, possibly through serotonergic modulation of impulsivity and compulsive sexual urges.

Conversion

Akanksha Shankar King George’s Medical University, Lucknow, Uttar Pradesh, India Background: Functional neurological symptom disorder (conversion disorder) can mimic postoperative complications, particularly in aesthetic surgery where unexpected neurological deficits provoke unnecessary interventions. Facial paralysis after blepharoplasty usually raises concern for iatrogenic nerve injury; however, psychogenic causes must also be considered to avoid misdiagnosis. Case Presentation: Within 24 hours following an elective upper eyelid blepharoplasty, a 34-year-old female experienced sudden unilateral facial paralysis affecting the forehead, eyelid closure, and nasolabial fold. Neurological assessment was done in suspicion of perioperative nerve damage. During the inspection, irregularities such as varying weakness, a maintained corneal reflex, and spontaneous emotional facial movements were discovered. MRI of the brain and facial nerve circuits were normal, and electrophysiological investigations revealed normal nerve conduction. Significant marital conflict and elevated preoperative anxiety were identified by the psychosocial history. Conversion disorder was diagnosed based on the clinical discrepancies and the lack of anatomical abnormalities. With the help of brief CBT, psychoeducation, anxiolytic, and reassurance, the patient recovered completely in ten days. Discussion: This case emphasizes the importance of distinguishing functional neurological symptoms from true nerve injury in the postoperative setting. Psychological distress and perioperative anxiety can manifest as acute neurological deficits, and early recognition can prevent unnecessary surgical or diagnostic interventions. Conclusion: Conversion disorder should be included in the differential diagnosis of facial paralysis following blepharoplasty when findings are inconsistent with anatomical patterns. Collaboration between plastic surgery and psychiatry enhances diagnostic accuracy and clinical outcomes.

Cotard’S

Payal Tulsan, Soumya Tandon Sir Ganga Ram Hospital, New Delhi, India Background: Lewy body dementia (LBD) is a neurodegenerative disorder marked by fluctuating cognition, recurrent visual hallucinations, rapid eye movement (REM) sleep behavior disorder, and marked antipsychotic sensitivity. Psychiatric symptoms may precede cognitive decline. Cotard’s syndrome, characterized by nihilistic delusions, is an exceptionally rare presentation in LBD and may obscure the underlying organic pathology. Aims: To report a rare case of Cotard’s syndrome as the initial psychiatric manifestation of LBD and to emphasize the need to consider organic etiologies in late-onset psychotic depression. Methods: A comprehensive clinical evaluation, including mental status examination, cognitive screening, laboratory investigations, structural neuroimaging, and functional neuroimaging, was conducted in a 64-year-old female presenting with severe depressive symptoms, nihilistic delusions, visual hallucinations, and cognitive decline. Treatment response and follow-up were documented. Results: Pharmacological management with rivastigmine (3 mg), venlafaxine (50 mg), and low-dose quetiapine (12.5 mg) resulted in partial improvement in mood, nihilistic delusions, sleep, and oral intake, with minimal improvement in cognitive functioning on follow-up. Discussion: This case highlights an atypical psychiatric presentation of LBD in which severe depression with nihilistic delusions and hallucinations masked the underlying neurodegenerative process, posing a diagnostic challenge. In the absence of early parkinsonian signs or structural imaging abnormalities, the presentation closely mimicked a primary psychiatric disorder. Functional neuroimaging played a crucial role in establishing the diagnosis. The case underscores the importance of vigilance for organic causes in late-onset psychosis and the cautious use of antipsychotics in suspected LBD to prevent adverse outcomes.

Delusional

Rageri Pavan, K. Lokesh Kumar Bhaskara Medical College, Hyderabad, Telangana, India Background: Delusional parasitosis is a somatic-type delusional disorder characterised by a fixed false belief of being infested with insects despite lack of evidence. Patients often first seek help from primary care or traditional healers, especially in rural settings, leading to delayed psychiatric intervention and significant distress. Aims: To describe the clinical features, evaluation, and management of a 56-year-old woman from a rural background with delusional parasitosis, and to emphasise diagnostic challenges in low-resource settings. Methods: A comprehensive psychiatric interview, mental status examination, dermatological assessment, and routine medical investigations were conducted. Collateral history from family members was included. Dermatology opinion was taken to exclude organic causes. Diagnosis was made as per ICD-11 criteria. The patient received antipsychotic medication, psychoeducation, and family counselling. Results: The patient, Santhamma, a 56-year-old woman from a rural agricultural family, reported a two-year history of sensation of insects crawling under her skin, leading to repeated scratching and use of home remedies. Prior to psychiatric referral, she sought help from local healers and primary health workers, resulting in multiple ineffective treatments. Dermatological evaluation was normal. Mental status examination revealed a well-formed somatic delusion, anxiety, sleep disturbance, and poor insight. She was initiated on risperidone and supportive psychotherapy. After six weeks, she showed notable reduction in preoccupation with infestation, improved sleep, and better engagement with treatment. Conclusion: This case highlights how rural background, limited awareness, and reliance on traditional treatments may delay recognition of delusional parasitosis. Early referral, integrated care, and structured psychoeducation can improve clinical outcomes.

Dermatitis

Mansi Ranga King George’s Medical University, Lucknow, Uttar Pradesh, India Background: Dermatitis artefacta (DA) is an uncommon psychodermatological condition involving self-inflicted skin lesions, often accompanied by limited insight. Although more frequently associated with mood or personality disorders, DA may also occur in schizophrenia, complicating diagnosis and treatment. Case Presentation: A 31-year-old woman with a 12-year history of schizophrenia was admitted with worsening persecutory delusions, auditory hallucinations and behavioral disorganization. She displayed multiple linear excoriations and erosions across the face, arms, legs and back, all in accessible areas and in different stages of healing. She denied self-infliction, and family members reported recent scratching behavior. Screening for delusional parasitosis and excoriation disorder was negative. Initial treatment with olanzapine (titrated to 30 mg/day) and intramuscular haloperidol yielded limited improvement. A broad medical work-up including autoimmune markers and cardiological evaluation was unremarkable. Dermatology consultation confirmed DA on clinical grounds, and topical wound care was initiated. Brain CT excluded organic contributors. Because of persistent psychosis and continued skin manipulation, chlorpromazine was added and escalated to 600 mg/day. Modified electroconvulsive therapy (six sessions) resulted in marked clinical stabilization, cessation of skin picking and progressive healing of lesions. No new lesions emerged during the remainder of hospitalization. Conclusion: This case illustrates the diagnostic challenges of DA in schizophrenia, particularly when denial of self-injury coexists with poor insight. Early dermatology-psychiatry collaboration and timely optimization of antipsychotic treatment were crucial. The patient’s improvement following electroconvulsive therapy suggests a potential role for this intervention when DA presents alongside refractory psychotic symptoms.

Diagnostic

Rohit Singh, Sumit Sharma Base Hospital, Delhi Cantt, New Delhi, India Background: Traumatic brain injury sustained at high-altitude presents distinctive neuropsychiatric challenges. Early post-traumatic syndromes may overlap with epileptic phenomena, making it difficult to distinguish organic sequelae from emerging primary psychosis. This diagnostic ambiguity is particularly relevant in military settings, where environmental stressors and operational demands influence symptom evolution. Case Description: A 36-y/o soldier sustained a high-altitude head injury followed by fluctuating cognitive decline that was insidious in onset but gradually progressive. He was initially diagnosed as Transient Global Amnesia based on early memory disturbances but, after experiencing a documented seizure episode, the diagnosis was revised to Transient Epileptic Amnesia . Over time, he developed poor self-care, irritability, apathy, social-withdrawal, and functional deterioration. Subsequent neuropsychiatric evaluations revealed thought derailment, persecutory and referential ideation, and vague auditory hallucinations, along with negative symptoms. Despite normal MRI, PET-CT, autoimmune /metabolic workups, his symptoms evolved beyond what TEA or post-traumatic syndrome could explain. Initial treatment addressed organic and epileptic components, but interdisciplinary Neurology-Psychiatry review later supported a transition toward Other-Primary Psychotic Disorder. Optimization with antipsychotics yielded gradual improvement. Discussion: This case highlights the diagnostic complexity involved in differentiating organic syndromes like TEA from the emergence of functional psychosis following TBI. It demonstrates how post-traumatic and epileptic features may mask or precede a primary psychotic condition. Long-term neuropsychiatric follow-up and interdisciplinary collaboration are essential in such evolving presentations. Conclusion: High-altitude traumatic brain injury can initiate chronic neuropsychiatric sequelae that may ultimately evolve into independent psychotic disorders, emphasizing the importance of of early evaluation and longitudinal monitoring.

Efficiency

M. Sundhara Pandiyan Institute of Mental Health, Chennai, Tamil Nadu, India Background: Large Language Models (LLMs) have potential for efficiently extracting psychiatric symptoms from unstructured clinical text (descriptive psychopathology), but concerns exist regarding their consistency and reliability compared to human clinical judgment. Aim: To quantitatively and qualitatively compare the consistency of psychiatric symptom deduction among five distinct LLMs (ChatGPT, Perplexity, Grok, Gemini, Copilot) Methods: 1. Input Preparation: Create a standardized set of descriptive psychopathology vignettes (e.g., patient notes, interview excerpts) covering a range of psychiatric conditions and symptom complexity 2. Initial Deduction: Submit each vignette to all five LLMs and record the symptoms/diagnostic impressions they initially deduce 3. Consistency Test (Second Guessing): Challenge each LLM’s initial output by asking a follow-up question (e.g., “Are you sure? Consider an alternative diagnosis,” or “Did you miss symptom X?”) and record if the model reverts, defends, or alters its deduction 4. Rating: Compare the consistency of the initial deduction and the robustness against the “second guess” across the models. Results: LLMs are efficient tools for initial symptom identification and assessment support, but their consistency and diagnostic reliability for final psychiatric deduction still require human-expert oversight and continuous technical refinement to mitigate risks like hallucination and atypical interpretation. Conclusion: This study will demonstrate the comparative reliability and robustness of current-generation LLMs in psychiatric symptom extraction, highlighting which models can be more consistently relied upon as clinical support tools and where vulnerabilities (like susceptibility to challenge or hallucination) persist.

Evaluation

Peddesugari Harika, T. V. Pavan Kumar, Raj kiran Donthu NRI Academy of Medical Sciences, Guntur, Andhra Pradesh, India Background: Suicidal behaviours are a major global public health concern, accounting for 1.3% all deaths worldwide. Pharmacological treatments and electroconvulsive therapy are the mainstays, but the acceptability and response depends on lot of patient factors. So, it is essential to explore alternative approaches for suicidal intervention. Repetitive Transcranial Magnetic stimulation, uses pulsed magnetic fields to influence cortical neuron membrane potentials, there by affecting brain metabolism and neural activity. This can lead to series of physiological and biochemical changes relevant to mood regulation and suicidality. Aim: To evaluate the efficacy of rTMS in reducing suicidal ideation in patients with depression. Methods: This is a case series involving eight patients diagnosed with depression and rated using the Modified Scale for Suicidal Ideation and Montgomery Asberg Depression Rating Scale at two time-points, once beginning of rTMS after ten sessions. The data is represented as means, frequencies, standard deviations and visually represented using line graph. Results: Patients’ MADRS scores improved from a mean 29.5 (baseline, SD 2.8) to 2.25 (day 10, SD 2.4) and the MSSI scores improved from 18.61 (baseline, SD 0.6) to 0.87 (day 10, SD 1.2). Conclusion: This study even though limited by the sample, demonstrates that rTMS when given along with pharmacotherapy, can augment and aid in clinical recovery with ten rTMS sessions. Robust evidence with larger sample, longer duration of follow-ups, and comparision with other modalities are required. Key words: Modified, suicidal ideation, transcranial magnetic stimulationdepression

Initiation

Vishakha Prakash Katare, Tanu Singla 1 , Abhay Bhat 1 Grant Government Medical College and JJ hospital, 1 Gokuldas Tejpal Hospital, Mumbai, Maharashtra, India Background: Naltrexone is a widely used pharmacological agent for alcohol use disorder (AUD). Its use is generally cautioned in individuals with cardiac conduction abnormalities such as right bundle branch block (RBBB). Evidence regarding its safety in such cases is limited. Aims: To describe the safe initiation of naltrexone in a patient with incidentally detected RBBB and mildly elevated troponin levels. Methods: A single patient case was evaluated clinically, with ECG, cardiac biomarkers, and continuous monitoring before and after initiating naltrexone. Clinical stability, ECG changes, and troponin trends were documented. Results: A 31-year-old male with AUD undergoing routine pre-treatment evaluation was found to have RBBB on ECG. He was asymptomatic and hemodynamically stable. High-sensitivity troponin I was mildly elevated initially but decreased on repeat testing at 3 hours. No arrhythmias or instability were noted during monitoring. After cardiology consultation, naltrexone was initiated. The patient tolerated the medication well, with no worsening of conduction abnormality, no rise in cardiac biomarkers, and no cardiac symptoms on follow-up. Conclusion: This case demonstrates that naltrexone may be safely initiated in select asymptomatic and stable patients with incidentally detected RBBB when thorough evaluation and monitoring are ensured. It contributes to the limited evidence regarding naltrexone use in conduction abnormalities and underscores the importance of individualized cardiac risk assessment.

Interictal

K. Pradhyumna, Sharanabasappa Sapthagiri Institute of Medical Sciences, Bengaluru, Karnataka, India Background/Introduction: Interictal psychosis with hyperreligiosity is a rare phenomenon in epilepsy, particularly in patients with temporal and limbic dysfunction. These experiences, often linked with temporal lobe epilepsy (TLE), may occur alongside alcohol dependence and withdrawal, complicating diagnosis and treatment. Methodology: This case report integrates clinical data, neuroimaging, EEG findings, and a literature review to explore the interplay of epilepsy, hyperreligiosity, and substance use disorders. Results: A 38-year-old male presented with unusual religious behavior, delusions, and chanting following alcohol abstinence. MRI revealed thickening of the insular cortices bilaterally, likely contributing to emotional and behavioral dysregulation . EEG was normal. His hyperreligiosity included persistent prayers, delusions of divine communication-mystical experiences, and hallucinations. These symptoms aligned with interictal psychosis, supported by a history of alcohol withdrawal/generalized tonic-clonic seizures, and inconsistent adherence to antiepileptic therapy. Literature highlights the role of bilateral dysfunction and right temporal involvement in such cases. Conclusions: This case emphasizes the need for multidisciplinary care, combining neurology, psychiatry, and addiction management. Neuroimaging findings suggest a structural basis for hyperreligiosity, underscoring the importance of recognizing these manifestations in epilepsy for accurate diagnosis and treatment.

Late Onset

Ayisha Salwa, S. Madhusudhan 1 Bangalore Medical College and Research Institute, 1 Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India Introduction: Medical and neurological disorders can lead to late-onset psychosis. Secondary (organic) psychosis should be considered when symptoms occur without prior psychiatric history and correspond with an underlying medical condition. Common medical causes include vitamin B12 deficiency, thyroid or adrenal dysfunction, hepatic or renal failure, and neurological conditions. Case Summary: A 52-year-old woman with no personal or family psychiatric history presented with four months of delusions of persecution and reference, auditory hallucinations, somatic passivity, irritability, and sleep disturbance. There was no substance use or prior medical illness. Examination revealed tachycardia, hypotension, pallor, pedal edema, generalized hyporeflexia, knuckle hyperpigmentation, and dry mucosa, with no focal neurological deficits. Her PANSS score was 110. Persistent hypotension required fluid correction for multiple days. Investigations revealed megaloblastic anemia due to vitamin B12 deficiency (80 pg/mL), iron deficiency (Hb 10 g/dL, MCV 127 fL, platelets 72,000/cumm), and severe hypothyroidism (T3 0.2 ng/mL, T4 100 µIU/mL). Cardiac workup showed low-voltage ECG; CT brain- normal. She was treated with parenteral vitamin B12, oral iron, thyroxine 100 µg/day, and low-dose olanzapine. At discharge, she was free of hallucinations and delusions. At six-week follow-up, she remained asymptomatic despite stopping antipsychotics, confirming secondary psychosis due to combined vitamin B12 deficiency and hypothyroidism. Discussion: Vitamin B12 deficiency causes demyelination and impaired neurotransmitter synthesis, while hypothyroidism leads to metabolic slowing and limbic dysfunction (myxedema psychosis). Their coexistence likely amplified neuropsychiatric symptoms. Complete resolution with medical treatment highlights the need to screen metabolic and endocrine causes in late-onset or atypical psychosis.

Management

Jyotik Tarak Bhachech Safalya Mind and Body Clinic, Ahmedabad, Gujarat, India Ekbom syndrome, also known as delusional parasitosis, is a challenging psychiatric condition classified as a monosymptomatic somatic type of delusional disorder in the DSM-5. [1] It is characterized by a fixed, false belief of being infested by insects or microorganisms, despite contradictory medical evidence. [11] The condition has a reported prevalence of 3% to 7% in primary care settings and is often undiagnosed or misdiagnosed. [2,7] We present the case of a 48-year-old female with a two-year history of delusional parasitosis, manifesting as sensations of insects crawling and biting beneath her skin, accompanied by mood disturbance and tactile hallucinations. [11] Extensive medical and neurological workup, including laboratory tests and a brain MRI, was normal, ruling out secondary causes. [10] Initial treatment involved psychoeducation, Opipramol, and Etizolam. After gradually titrating Opipramol to 50mg three times a day and discontinuing the benzodiazepine, the patient reported a marked improvement in her somatic delusion and developed good insight. Her Brown Assessment of Belief Scale (BABS) score dropped from 19/24 to 8/24. [4] This case illustrates the effectiveness of Opipramol, a thymoleptic agent with high sigma receptor affinity, combined with supportive behaviour therapy (psychoeducation), in achieving remission and restoring insight in a case of Ekbom syndrome. [5,9]

Medication

Shweta, Sandeep Grover, Subho Chakrabarti PGIMER, Chandigarh, India Background: Available data suggests that about 50% of patients with schizophrenia are poorly adherent to their medications. However, the data is mainly in the form of cross-sectional studies. Aim of the study: To longitudinally evaluate the medication adherence in patients with schizophrenia receiving second generation antipsychotics. Methodology: 100 patients diagnosed with schizophrenia receiving a second-generation antipsychotic were evaluated on Medication Adherence Questionnaire (MAQ), and Compliance Rating Scale (CRS). They were also assessed on Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms (SANS), Clinical Global Impression (CGI) and Social and Social and Occupational Functional Assessment Scale (SOFAS) at the baseline and 6 months later. Both the periods considered the medication adherence over the period of previous 6 months. Results: The mean age of the participants was 35.6 years (SD: 9.9) with slight male preponderance (56%). Majority of the patients were below graduate (74%), from nuclear family (78%) and urban locality (67%). On MAQ, 69% of the patients were fully adherent on both the assessments and 31% were non-adherent. On CRS, 88% of the study participants were rated as adherent on both the occasions. Conclusion: The findings of the present study suggest that only 12-31% of patients on second generation antipsychotics are non-adherent over time and the prevalence of non-adherence is influenced by the assessment method.

Misleading

Jyotika, Bhupendra Yadav AIIMS, Bilaspur, Himachal Pradesh, India Case of a 15-year-old boy presenting with mutism, pica, and autistic-like behaviours which was preceded by exposure to severe bullying with extreme social and familial humiliation both physically and verbally. The patient exhibited school refusal, food refusal, poor self-care, aggression, and emotional withdrawal. Upon detailed psychiatric evaluation, psychosocial assessment, IQ assessment and neurological testing led to a diagnosis of Childhood Depression. Treatment was started with fluoxetine, olanzapine, and adjunctive sessions of intravenous ketamine yielded significant improvement in communication and affect. The psychosocial factors were addressed through counselling, individual and family therapy sessions. However after few days of discharge, the patient had to be readmitted due to relapse with similar symptoms with deliberate self harm and severe aggression after multiple critical comments from his family members especially mother; which the family members felt were said in a playful manner. Family members were unable to understand the gravitas of the situation and rationale for symptoms of the patient. Pharmacological treatment was continued with dosage adjustments with more focus given on extensive individual and family therapy sessions. This case highlights the complex psychosocial contributors to depressive presentations in children and highlights the importance of early recognition and multimodal treatment in culturally sensitive contexts.

Nomophobia

Soumya Ranjan Mishra, Suprakash Chaudhury 1 Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, 1 DY Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India Background: Nomophobia no-mobile-phone phobia describes the fear or discomfort experienced when individuals are separated from their mobile phones, adversely affecting their functioning. Aim: To assess Nomophobia and its association with social anxiety, sleep disturbances, and personality traits among medical students. Materials and Methods: A cross-sectional survey was conducted among undergraduate, postgraduate, and superspecialty medical students in a medical college. Consenting participants completed a self-designed questionnaire along with the Nomophobia Questionnaire (NMP-Q), Liebowitz Social Anxiety Scale (LSAS), Big Five Inventory-10 (BFI-10), and Epworth Sleepiness Scale (ESS). Data analysis was performed using SPSS 20. Results: Among 199 students, 68.34% demonstrated moderate to severe Nomophobia. Age significantly influenced Nomophobia severity, with students aged 21-25 showing higher scores. Significant positive correlations were observed between NMP-Q scores and LSAS Fear, LSAS Avoidance, and ESS, indicating that higher Nomophobia was linked to increased social anxiety and daytime sleepiness. Most participants exhibited some degree of social anxiety, with moderate to marked levels being common. Regression analysis showed that social anxiety dimensions significantly predicted NMP-Q scores. Conclusion: Nomophobia is highly prevalent among medical students, with two-thirds experiencing moderate to severe levels. Significant contributing factors include age, duration of medical training, and stress levels. Strong associations were found between Nomophobia, social anxiety, personality traits, and daytime sleepiness. Social anxiety-both fear and avoidance emerged as major predictors of Nomophobia. These findings highlight the need for targeted interventions to reduce Nomophobia and promote better mental health and academic functioning among medical students.

Parasocial

Bonjeet Nath, Uddip Talukdar 1 Gauhati Medical College and Hospital, Guwahati, 1 Department of Psychiatry, Nagaon Medical College and Hospital, Nagaon, Assam, India Background: The death of Assamese cultural icon Zubeen Garg prompted widespread mourning, reflecting strong parasocial bonds between the artist and his audience. Such one-sided yet meaningful emotional attachments can influence psychological responses to loss. However, the mental-health impact of this event on the Assamese population has not been empirically studied. Aims: To assess psychological distress following Zubeen Garg’s death; estimate the proportion of individuals experiencing clinically significant distress; and examine differences in distress across sociodemographic groups. Methods: A cross-sectional online survey was conducted from 28 September to 28 November 2025 among adults (>18 years) aware of the event. Participants completed the Impact of Event Scale-Revised (IES-R). Descriptive statistics summarized demographic and distress profiles. As the data were non-normally distributed, Mann-Whitney U and Kruskal-Wallis tests assessed group differences, with p 33, suggesting clinically significant psychological distress. Distress varied significantly across sociodemographic variables: younger adults (18-35 years), females, and unmarried participants reported higher distress. Occupational differences were notable, with students and unemployed individuals showing the highest scores. Conclusion: A substantial proportion of respondents experienced clinically meaningful distress following Zubeen Garg’s death, underscoring the psychological impact of parasocial grief. Sociodemographic variations indicate that this grief response is not uniform. These findings highlight the need for mental-health professionals and public health systems to recognize and address celebrity-related distress within community support strategies.

Pellagrous

Devika, S. V. Santosh, M. Punith Hassan Institute of Medical Sciences, Hassan, Karnataka, India Background: Alcohol Use Disorder (AUD) is associated with multiple nutritional deficiencies, among which niacin deficiency (pellagra) remains under-recognized. Its neuropsychiatric manifestations frequently overlap with delirium tremens and Wernicke’s encephalopathy, creating diagnostic challenges. Aim: To present a case series of seven individuals with alcohol dependence syndrome who developed pellagra, emphasizing diagnostic dilemmas and the critical role of niacin replacement. Methods: Seven patients admitted for complicated alcohol withdrawal with delirium were evaluated clinically and biochemically. Dermatological consultation confirmed pellagra in all patients. Management included benzodiazepine-based detoxification, parenteral thiamine, multivitamins, and oral nicotinamide. Key Observation: In the initial patients, delirium worsened after tapering the benzodiazepines, despite adequate dosing. These patients showed rapid and significant improvement in delirium within 48-72 hours of starting nicotinamide, highlighting a major missed contributor niacin deficiency. Results: All patients demonstrated marked improvement in neuropsychiatric symptoms and gradual resolution of dermatitis following nicotinamide therapy. At two-week follow-up, all were abstinent and showed further dermatological healing. Conclusion: Pellagra should be strongly considered in alcohol-dependent individuals presenting with delirium, photosensitive dermatitis, and gastrointestinal symptoms especially when delirium persists despite adequate benzodiazepine therapy. Early recognition and niacin supplementation can be lifesaving.

Persistent

Utkarsh Modi Christian Medical College, Vellore, Tamil Nadu, India Introduction: Bipolar disorder is characterized by recurrent episodes of mania, hypomania and depression. Although literature describes prolonged mood disorders such as Cyclothymia and Dysthymia, the concept of Chronic Mania is underexplored and rare. We describe a case report of a young male with chronic mania. Case Report: 29 years old male with a past history of cannabis use, presented with complains of persistent elated mood, increased psychomotor activity, increased speech, grandiose ability, and intermittent aggression. He exhibited transient persecutory delusions with the worsening of his mood symptoms. Medical workup for organic causes was normal. Although his symptoms improve transiently with medications, he never attained complete remission of his symptoms and he would have worsening of his mood state, while on medications. He had failed trials of Risperidone, Quetiapine, Lithium and Olanzapine. He was initiated on a combination on Lithium + Valproate + Olanzapine, with which he showed minimal gains. He never attained premorbid functioning and was planned for Clozapine trial. Discussion: Chronic mania is a rare clinical entity under the pervasive mood disorder category. It is often associated with poor functional outcomes, with most cases being treatment refractory. In this case report, we highlight the treatment challenges and discuss the relevant literature published related to chronic mania.

Phenotypic

Ashvin Chouhan, Simran Sandhu, Abhay Paliwal, Manju Rawat 1 MGM Medical College, Indore, 1 ESIC, Indore, Madhya Pradesh, India Introduction: Obsessive-Compulsive Disorder (OCD) demonstrates significant heritability (40-65%), yet monozygotic (MZ) twins often exhibit discordant symptomatology, underscoring the role of non-genetic factors. This case series explores this paradox and its implications for personalized treatment. Methods: We present two twin pairs: 35-year-old monozygotic males and 19-year-old dizygotic females. A comprehensive clinical assessment confirmed OCD diagnosis in all four individuals, with severity measured by the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Treatment involved tailored pharmacotherapy and cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP). Results: Striking phenotypic discordance was observed. The MZ twins presented with divergent symptom dimensions: one with contamination obsessions/compulsive washing, the other with symmetry obsessions/mental rituals. Both required differential pharmacological augmentation despite identical genetics. The DZ twins also presented with divergent phenotypes (harm obsessions vs. contamination/checking) but demonstrated a shared susceptibility to fluoxetine-induced cutaneous hyperpigmentation, a rare adverse drug reaction. Both pairs showed significant improvement on tailored regimens, though response variability was noted. Conclusion: These cases highlight that genetic liability for OCD is not deterministic. Phenotypic expression and treatment response are shaped by a complex interplay of non-shared environmental and potential epigenetic factors. The concordant adverse reaction in DZ twins suggests a heritable pharmacogenetic vulnerability. These findings strongly advocate for a personalized, dimension-focused treatment approach and underscore the critical importance of eliciting family medication history to predict tolerability and optimize care. Key words: Discordant phenotypes, obsessive-compulsive disorder, personalized medicine, pharmacogenetics, twins

Poststroke

Diksha Das, Pulakesh Sarmah Gauhati Medical College and Hospital, Guwahati, Assam, India Background: Emotional incontinence is characterized by sudden, uncontrollable episodes of crying or laughing, often triggered by minor or emotion-laden stimuli. Stroke is the most common neurological cause. Aims: To describe the presentation, diagnostic evaluation and management of a patient with post-stroke emotional incontinence. Methods: A descriptive case-based approach was used, documenting clinical history, mental status findings, investigations and treatment response. Results: A 41-year-old male presented with frequent crying spells, tearfulness and irritability. Four days prior, he experienced sudden deviation of the mouth, weakness in all four limbs, and transient bowel and bladder incontinence. He had a history of stroke three months earlier and had recently been diagnosed with hypertension and diabetes. Mental status examination revealed low mood and a labile affect, with abrupt crying episodes during conversation. EEG showed diffuse right hemispherical cortical dysrhythmia. MRI/MRA revealed a subacute right frontal lobe infarct with adjacent astrogliosis in the right temporal and bilateral frontal regions. The patient was started on mirtazapine 15 mg at bedtime and lamotrigine, titrated from 25 mg to 50 mg twice daily. His symptoms gradually improved, and he was discharged after 12 days. Conclusion: Post-stroke emotionalism is common yet under-recognized. Although neurologically driven, it can lead to significant psychological distress and functional impairment. Early identification and appropriate treatment can reduce symptoms and improve engagement in rehabilitation.

Predicting

T. Naveen Keerthi MIMER Medical College Pune, Maharashtra, India Background and Objectives: Reduced hippocampal volume is consistently associated with Major Depressive Disorder (MDD), yet its predictive value remains limited due to the absence of a mechanistic framework linking structural atrophy to functional risk. Most studies offer only statistical associations, leading to uncertainty about causality. This study aimed to address this gap by developing an integrated, mechanistically informed model that predicts MDD risk from hippocampal volume. Methods: A synthetic dataset of 500 data points, derived from meta-analytic means and standard deviations of MDD and control cohorts, was used. The analysis involved two steps: (1) a logistic regression model estimating the probability (p) of MDD as a function of hippocampal volume (V); and (2) a novel mechanistic circuitmodel conceptualizing hippocampal integrity as voltage and depressive load as resistance, following the derived relation . The resulting current (I), representing functional output, was used as the predictor in the regression, modeling nonlinear vulnerability to depression. Results: Depressed subjects showed significantly lower hippocampal volumes (2.73 ± 0.46) than controls (3.28 ± 0.37). The integrated model achieved an AUC of 0.720, indicating good discriminative power. A threshold volume of 1.1348 corresponded to a high-risk probability (p > 0.8). The circuit output (I) correlated strongly with p, supporting the hypothesis that structural loss amplifies functional deficits. Conclusion: This study introduces a transparent, interpretable framework linking hippocampal structure to MDD risk. The defined anatomical cutoff highlights hippocampal volume as a potential biomarker, warranting validation with real neuroimaging datasets.

Predictive

Anupam Tamuli, Suresh Chakravarty, Deepanjali Medhi, Raj Kr Seal Gauhati Medical College and Hospital, Guwahati, Assam, India Background: Dreams represent a unique extension of emotional processing. Contemporary continuity theories propose that waking affect directly influences dream content, yet fine-grained longitudinal data linking daily mood, sleep duration, and dream tone remain scarce. Aims: 1. To examine associations between daily positive/negative affect and emotional tone of dreams. 2. To determine whether sleep duration predicts dream positivity. Methods: A 30-day single-subject longitudinal design was undertaken on a healthy adult. Pre-study evaluation included mental status examination and EEG to exclude psychiatric or neurological abnormalities. Daily mood was assessed using the Positive and Negative Affect Schedule (PANAS). Sleep duration was logged nightly. Dream diaries recorded dream recall, vividness, and emotional tone (positive/mixed/negative). Psychoactive substances, including alcohol and nicotine, were strictly avoided throughout the study. Statistical analysis included Pearson correlation, multiple linear regression, and ANOVA to test overall model significance. Results: Across 30 nights, dream tone distribution was: 36.67% positive, 43.33% mixed, and 20% negative. Positive affect correlated significantly with positive dream tone (r = 0.407, p = 0.026), while negative affect correlated with mixed/negative tone (r = 0.235, p = 0.0211). Longer sleep duration was associated with more positive dreams (r = 0.375, p = 0.041). Multiple linear regression revealed that PA, NA, and sleep duration collectively predicted dream tone (ANOVA p = 0.039, R² = 56.93%). Conclusion: Daily emotional states and sleep duration meaningfully shape dream emotional tone. These findings support the continuity hypothesis and suggest that dream tone may serve as a simple, low-cost emotional biomarker in clinical practice.

Pregabalin

Roopa, K. Jayanth Kumar, Sudharani P. Naik Kanachur Institute of Medical Sciences, Mangalore, Karnataka, India Background: Pregabalin, a GABA analogue used for neuropathic pain and fibromyalgia, binds the α 2 δ subunit of voltage-gated calcium channels, reducing excitatory neurotransmitter release and raising neuronal GABA. Although not traditionally seen as a drug of abuse, growing concern exists regarding its potential for abuse and dependence. Aim: To raise awareness of abuse potential associated with pregabalin. Methods: A 31-year-old married male with secondary education and a family history of alcohol use consuming pregabalin for 1 year often obtained without prescription. Use caused early work departure,mild interpersonal conflicts, and sleep disturbance on reduction. Past substance use was reported, abstinent since two years. Results: On examination, the patient was oriented, with coherent speech and a euthymic affect, had strong desire to use pregabalin despite attempts to cut down, and motivation was in the contemplation stage. He was diagnosed with mental and behavioral disorders due to use of other substances (pregabalin dependence) as per ICD-10. Pregabalin was tapered and substituted with diazepam which was gradually tapered off. A strict no-reissue policy was followed. MET was provided weekly for one month, then biweekly for next month, during which he remained drug-free without withdrawal symptoms. His family was psychoeducated, and follow-up was arranged to prevent relapse. Conclusion: This case illustrates pregabalin dependence likely driven by its euphoric, GABAergic effects, easy availability, and low cost. Pregabalin should be used cautiously in history of substance use. Management relied on symptomatic treatment guided by clinical experience as there are no structured protocol.

Prevalence

P. Shilpa, G. Bharathi Hassan Institute of Medical Sciences, Hassan, Karnataka, India Background: Depression is a common mental health condition among the elderly and is particularly prevalent in institutionalized settings. Social isolation, loss of independence, chronic medical illnesses and reduced family support increase susceptibility to depression in this population. Early detection is vital to minimize morbidity and enhance quality of life. This study evaluates the prevalence of depression among residents of old age homes. Aims and Objectives: To determine the prevalence of depression among elderly individuals residing in old age homes and to analyze its distribution across age and sex. Methodology: A cross-sectional descriptive study was conducted among 50 elderly residents aged more than 60 years in selected old age homes in Hassan. Socio-demographic information was collected following informed consent. Participants with severe cognitive impairment or major psychiatric illness were excluded. Depression was assessed using the Geriatric Depression Scale (GDS-15). Data were analyzed using descriptive statistics. Results: The study included 22 males (44%) and 28 females (56%). Of the total 50 participants, 26 (52%) had depressive symptoms, with 14 (28%) showing mild, 8 (16%) moderate, and 4 (8%) severe depression. The mean age was 71.8 years, and depression prevalence increased with advancing age, ranging from 42.9% in the 60-69 age group to 63.6% in those aged >80. Females showed a higher prevalence (18/28; 64.3%) compared to males (8/22; 36.4%). Conclusion: Depression is highly prevalent among institutionalized elderly. Routine screening, psychosocial interventions, and enhanced support systems are necessary to improve mental well-being in this vulnerable population.

Real World

Yakshdeep Dave, Zahran Qureshi, Anuj Dwivedi, Girish Kulkarni Torrent Pharma, India Background: Depression is a chronic and recurrent psychiatric disorder associated with significant disability and socio-economic burden. Real-world data on its utilization patterns and associated co-morbidities in Indian patients remain limited. Aim: We aimed to assess the utilization pattern & clinical utility of sertraline in the treatment of depression among Indian patients. Methods: This retrospective, cross-sectional, multicentric observational study included 2,997 patients suffering from depression across India. Data on demographic details, medical history, and treatment characteristics were collected using a structured case report form and analysed descriptively to meet the study objectives. The study was initiated only after obtaining approval from the Sangini Hospital Ethics Committee. Results: Among enrolled patients, 57.8% were newly diagnosed, and 73.2% reported no family history of depression. The majority (47.2%) had a disease duration of 1-3 years, while 24.3% had a history of addiction. Sertraline 50 mg once daily was the most frequently prescribed dose (52.4%), followed by 100 mg (33.3%) and 25 mg (14.3%). Monotherapy was used in 56.8% of cases, while 43.2% received combination therapy. Sertraline was given with other antidepressants like escitalopram (22.1%), fluoxetine (9.5%), mirtazapine (5.4%), desvenlafaxine (4.8%) and vilazodone (4.6%). Anxiety (47.7%) was the leading psychiatric co-morbidity, and diabetes (17.8%) was the most common non-psychiatric condition, with anti-diabetic medications co-prescribed in 16% of patients. Conclusion: Sertraline is predominantly prescribed as a once-daily 50 mg monotherapy for 3-6 months. The findings highlight the chronic nature of depression and underscore the importance of individualized management considering psychiatric and metabolic co-morbidities.

Reigniting

Poushali Dutta, U. Shrinivasa Bhat KSHEMA, Mangaluru, Karnataka, India Background: Electroconvulsive Therapy (ECT) is an effective option for severe psychiatric conditions unresponsive to medications. In older adults, treatment is often complicated by comorbidities, drug interactions, and reduced medication tolerance. Modified ECT (MECT) provides a safe alternative in such situations. This report describes two late-life cases demonstrating substantial recovery following MECT. Case Presentation: Case 1: A 73-year-old woman with severe depression with psychosis and comorbid Parkinson’s disease, hypertension, and diabetes presented with low mood, crying spells, persecutory delusions, and passive death wishes. She showed poor tolerance and minimal response to multiple medications, including mirtazapine, clonazepam, and quetiapine, developing hyponatremia. She received 21 MECT sessions between December 2024 and October 2025, achieving gradual improvement in mood, irritability, social functioning, and complete resolution of psychotic features, with no significant adverse effects. She remains stable off medication. Case 2: A 74-year-old man with treatment-resistant psychosis exhibited religious delusions, auditory hallucinations, and disorganized behavior. Several antidepressant and antipsychotic trials resulted in inadequate response and intolerance. After 10 MECT sessions between October 2024 and October 2025, he showed marked reductions in delusions, improved thought organization, and better self-care, experiencing only brief post-ictal confusion. He also remains stable without medication. Discussion: These cases highlight the safety, tolerability, and effectiveness of ECT in geriatric patients with complex medical and psychiatric conditions. Conclusion: ECT remains a highly effective yet underutilized intervention in late-life psychiatry, offering rapid symptom relief by directly modulating brain circuits and avoiding pharmacologic limitations, especially in treatment-resistant or drug-intolerant geriatric depression and psychosis. For publication

Repetitive

Vijay Niranjan, Simran Sandhu, Pali Rastogi MGMMC, Indore, Madhya Pradesh, India Background: Cerebral palsy (CP) is a non-progressive neurodevelopmental disorder frequently associated with motor and speech impairments due to disrupted cortical connectivity in perisylvian language areas. Repetitive transcranial magnetic stimulation (rTMS), a non-invasive neuromodulatory technique, may enhance neuroplasticity and improve communication outcomes in such cases. Case Presentation: A 3.5-year-old female child with spastic CP and severe speech delay limited to cooing and non-specific vocalisations underwent a 30-session rTMS protocol. Stimulation alternated between Broca’s (F7) and Wernicke’s (T5) areas using high-frequency (15 Hz) pulses at 40% of motor threshold, lasting approximately 5.2 minutes per session. Following treatment, caregivers observed subjective improvement in vocal initiation, imitation, and attention to verbal cues. Discussion: This case illustrates the feasibility and safety of high frequency rTMS in a young child with CP and severe speech delay. While subjective benefits were noted, the absence of measurable improvement aligns with prior studies reporting variable language outcomes. Evidence suggests that combining rTMS with structured speech therapy may better facilitate activity-dependent neuroplasticity and functional reorganisation. Conclusion: rTMS targeting language-associated cortical regions may serve as a safe adjunct in managing speech delay in CP, though its independent efficacy remains uncertain. Controlled trials are needed to establish optimal protocols and evaluate long-term benefits. Key words: Broca’s area, cerebral palsy, neuromodulation, neuroplasticity, rTMS, speech delay, wernicke’s area

Uncovering

Shivanee Kumari Deen Dayal Upadhyay Hospital, New Delhi, India Background: Dissociative convulsions are seizure-like episodes without a neurological basis, often linked to unresolved psychological stress. Psychotherapy is the standard treatment, yet some cases remain resistant, necessitating alternative approaches such as drug-assisted interviews. Lorazepam has emerged as a safer option than amobarbital for facilitating emotional expression, owing to its lower risk of respiratory depression and the availability of a specific antidote. Aims: To illustrate the effectiveness of lorazepam-assisted interviews in uncovering repressed emotional conflicts in a patient with dissociative convulsions and in guiding subsequent therapeutic interventions. Methods: A 35-year-old priest presenting with non-epileptic convulsions unresponsive to routine evaluations and psychotherapy underwent 6 lorazepam-assisted interview sessions. Oral doses ranged from 2-4 mg to induce a relaxed, suggestible state. Each 40-45-minute session was structured to build rapport, facilitate emotional expression, and work toward resolving psychological conflicts. Results: By the 3rd session, the patient experienced emotional catharsis and disclosed sexual dysfunction, internal religious conflict, guilt, and marital dissatisfaction. These insights revealed underlying depression. Treatment with escitalopram and Gottman Method Couples Therapy was initiated. Within 1-month, convulsive episodes reduced significantly, and the patient demonstrated improved emotional well-being and interpersonal functioning. Conclusion: Lorazepam-assisted interviews may be especially beneficial for patients with dissociative disorders unresponsive to conventional psychotherapy, as they facilitate the expression of repressed emotions and help direct focused therapeutic interventions. This case highlights the clinical value of benzodiazepine-facilitated interviews in uncovering hidden stressors and tailoring effective treatment strategies for dissociative convulsions.

Unreported

H. V. Roja Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India Sexual dysfunction is a common yet often overlooked complication among psychiatric patients, especially those receiving selective serotonin reuptake inhibitors (SSRIs). Despite its significant impact on treatment adherence, self-esteem, and quality of life, patients rarely volunteer sexual concerns unless specifically asked. Objective tools such as the Arizona Sexual Experiences Scale (ASEX) and International Index of Erectile Function (IIEF) help uncover dysfunction that may otherwise go unnoticed. This study assessed the prevalence of unreported sexual dysfunction in psychiatric outpatients with mild or remitted symptoms. Methods: Twenty adult outpatients receiving treatment for depression or anxiety were evaluated using ASEX and IIEF. Symptom severity was assessed with HAM-A and HAM-D. Demographic details and medication profiles were collected to examine associations with sexual dysfunction. Results: Although none of the patients reported sexual problems spontaneously, objective measures revealed substantial dysfunction. The mean ASEX score was 16.95, with several patients crossing the dysfunction threshold ( >19). Male participants showed mild to moderate impairment on IIEF. Most patients were in mild or remission states (mean HAM-A/D = 6.2). Sertraline was prescribed to 30% of patients, with 50% experiencing dysfunction, while 65% received escitalopram, of whom 30.8% developed dysfunction. Dysfunction affected males and females equally (n = 4 each). Conclusion: Sexual dysfunction remains underrecognized in psychiatric practice due to low patient disclosure and insufficient clinician inquiry. Routine, structured screening is crucial to identify this hidden burden and enhance overall treatment outcomes and quality of life.

Unresolved

Nithin S. Gowda, Roshan V. Khanande, Ruchira Das Central Institute of Psychiatry, Ranchi, Jharkhand, India Background: Chronic mania, defined as persistent manic symptoms for >2 years without remission, affects 13-15% of bipolar disorder patients. Young-onset chronic mania often presents with refractory clinical courses, imposing significant therapeutic burdens and functional impairment. Limited Indian data exists on pragmatic management approaches for this presentation. Aims: To characterize the treatment challenges in young-onset chronic mania, highlighting clinical phenomenology and polypharmacologic interventions. Case Presentation: A 19-year-old unmarried male from Jharkhand, India, with no significant psychiatric family history, presented with a 2-year, 6-month continuous history of increased energy, over-talkativeness, overfamiliarity, wandering behavior, disinhibited behavior, and sleep disturbance. Illness onset followed a trivial febrile illness, without neurological complications. Routine blood investigation, TFT, and NCCT brain were unremarkable. Trials of a combination of valproate 1700 mg, olanzapine 30 mg, risperidone 8 mg, and aripiprazole 30 mg, along with lithium 600 mg augmentation, over 1 year yielded an inadequate response with emerging extrapyramidal symptoms. A diagnosis of other manic episodes was made according to ICD-10 and other bipolar type 1 disorders as per ICD-11. Management and Outcome: On the latest admission, combination therapy with lithium 1200 mg, haloperidol 15 mg, and amisulpride 1000 mg reduced the YMRS score from 39 to 18 at discharge. Carbamazepine 800 mg was added without further benefit, alongside family psychoeducation and behavioral interventions. At a recent follow-up, carbamazepine was stopped and clozapine 100 mg was initiated, leading to improved disinhibition and reduced extrapyramidal symptoms. Conclusion: Young-onset chronic mania requires early recognition, rational polypharmacy, and multidisciplinary management.

Alternative

Vasundhara Bhushan, Mansi Saxsena Institute of Mental health and hospital, Agra, Uttar Pradesh, India Background: Paediatric catatonia is a poorly understood and rare phenomenon . Most documented cases have a psychiatric aetiology. Because of the varied presentation and treatment considerations specific to the paediatric population, identification and management can be challenging. Additionally, few definitive guidelines or practice parameters are available for paediatric patients. The first-line treatment for catatonia is pharmacologic, and when treatment fails or is inadequate, electroconvulsive therapy (ECT) has been shown to be safe and effective but sometimes if ECT is not available or contraindicated, alternative treatment options should be explored. Case Report: A 14-year-old male presented with abrupt onset psychotic symptoms in opd,was given injection of haloperidol 5mg and promethazine 25 mg IM,12 hrs later presented with abrupt onset catatonia (withdrawal, holding of food and saliva in mouth, posturing, negativism). After doing lorazepam challenge test patient showed improvement onBush-Francis Catatonia Rating Scale(BFCRS) and patient was given oral lorazepam upto 8mg on which he had little improvement. ECT as treatment option declined by family. Later adjunctive memantine 20mg was given for short course due patients incomplete response on lorazepam and his poor oral intake . Patient showed marked improvement with it. This case showed resolution of catatonia (negativism, mutism, and withdrawal) with memantine when conventional treatments are limited or show partial response or are unavailable.

Association

Krishna Kumar Carpenter, Ankur Nayan VKSGMC, Neemuch, Madhya Pradesh, India Background: Vitamin D and Vitamin B12 deficiency have been implicated in the etiology of Major Depressive Disorder (MDD). However, studies have explored whether these deficiencies differ between individuals with depression precipitated by external stressors versus those without identifiable stressors. Aims: To assess the association between the serum levels of Vitamin D and Vitamin B12 in the patients diagnosed with Major Depressive Disorder; with and without precipitating stressors. Methods: A cross-sectional study was conducted at a tertiary health care centre in Neemuch (M.P.) which included 100 MDD patients without any stressor and 100 MDD patients with a stressor. The stressors were quantified using the Presumptive Stressful Life Events Scale (PSLES). Patients were subjected to the serum analysis of both vitamins and were categorized as sufficient/insufficient/deficient. Statistical analysis was done using Chi-square tests and odds ratio. Results: Vitamin D levels were significantly associated with stressor status among MDD patients (p =.005); patients without stressors showing higher odds of vitamin deficiency (OR =2.61). Vitamin B12 levels also showed a significant association with stressor status (p =.041); patients without stressors having higher odds of vitamin deficiency (OR =1.91). Conclusion: Both vitamin deficiencies are significantly associated with non-stressor presentation, suggesting possible biological contribution to depression; independent of external life events. Further there is a need of thorough analysis of these vitamin levels and thereafter supplementation as a part of management of MDD cases.

Cannabidiol

Ananya Chawla, Rajnish Raj, Akshika vermani Government Medical College, Patiala, Punjab, India Introduction: Cannabidiol (CBD), a non-psychoactive phytocannabinoid, has demonstrated anticonvulsant, anxiolytic, and analgesic effects through its interaction with the endocannabinoid system and multiple neuromodulatory pathways. While its role in treatment-resistant epilepsy is increasingly recognized, emerging evidence also supports its utility in functional pain and other neuropsychiatric conditions. Real-world clinical data from routine psychiatric settings, however, remain limited. Aims: To present clinical observations from three patients treated with CBD for distinct neuropsychiatric conditions and to highlight its therapeutic potential across diagnostic domains. Methods: This observational case series includes three patients initiated on adjunctive CBD oil as part of routine clinical care. Clinical outcomes were assessed through seizure logs, symptom severity reports, and functional status over 6-12 months. Adverse effects and tolerability were recorded. Results : Case 1: A 20-year-old male with treatment-resistant seizure disorder achieved complete seizure freedom for 12 months and showed marked improvement in academic and social functioning. Case 2: A 24-year-old female with focal epilepsy and frequent breakthrough seizures reported >70% reduction in seizure frequency, better sleep regulation, and improved daily performance after CBD initiation. Case 3: A 32-year-old male with somatoform pain disorder demonstrated significant reduction in pain intensity, reduced analgesic dependence, and improved occupational functioning. No major adverse events were reported. Conclusion: Across three diverse clinical presentations, CBD demonstrated meaningful benefits with excellent tolerability. These findings support its potential as a valuable adjunctive intervention in epilepsy and functional.

Comparative

Smriti Gulati, Shivananda Jena Maulana Azad Medical College, New Delhi, India Background: Migraine and tension-type headache (TTH) are globally prevalent disorders often precipitated by specific triggers. While trigger management is a key component of care, comparative data on trigger profiles between migraine and TTH, particularly within Indian clinical settings, remains limited. Aim: This study aimed to identify and compare the prevalence of behavioral, environmental, somatic, and dietary trigger factors in patients diagnosed with migraine and TTH. Methods: A cross-sectional observational study was conducted at a tertiary care psychiatry OPD in New Delhi. The sample included 100 patients (50 migraine, 50 TTH) aged 18-65 years, diagnosed using ICHD-3 criteria. Participants were assessed using a semi-structured proforma and a specific trigger checklist. Statistical associations were analyzed using Chi-square and Fisher’s exact tests. Results: 88% of participants identified at least one trigger, with similar high rates in migraine (86%) and TTH (90%). Behavioral triggers were most common (81%), with stress (70%) and sleep deprivation (35%) being the leading factors across both groups. Significant differences were found in specific categories: somatic triggers like eye strain (32% vs. 8%, p=0.003) and posture (18% vs. 4%, p=0.025) were significantly more prevalent in TTH. Conversely, dietary triggers (56% vs. 30%, p=0.009), specifically fatty meals (p=0.032), and hormonal changes (p=0.017) were significantly more common in migraine Conclusion: While stress and sleep disturbances are universal precipitants, distinct profiles exist: TTH is associated with somatic strain, whereas migraine is influenced by dietary and hormonal factors. These findings highlight the need for diagnosis-specific trigger management.

Deciphering

Gourab Bhattacharya, Souvik Dubey 1 Institute of Psychiatry, IPGMER and SSKM Hospital, 1 Bangur Institute of Neurosciences, IPGMER and SSKM Hospital, Kolkata, West Bengal, India Background: Neurodevelopmental syndromes presenting with global developmental delay, microcephaly, and stereotypic hand movements often resemble the Rett spectrum, despite normal MECP2. Chromosome 13q deletions are well-known causes of severe developmental delay and behavioral disturbances. Recently identified heterozygous variants in SRRM2 gene have been associated with intellectual disability and autistic traits. Co-occurrence of a major chromosomal deletion with a rare monogenic variant complicates diagnosis and may result in mixed phenotypes. Case Presentation: A 15-year-old female exhibited severe developmental delays, profound language impairment (expressive > receptive), microcephaly, and stereotypic hand-writhing movements. She achieved motor milestones late, beginning to walk around age three. Behavioral issues included impulsivity and poor social skills. Dysmorphic traits included a depressed nasal bridge, hypertelorism and facial hypoplasia. MRI indicated cerebral atrophy, while EEG results were normal. Genetic evaluation revealed heterozygous SRRM2 missense variant (p.His2176Leu; VUS), and ~12.9 Mb heterozygous deletion at chromosome 13q33-q34. Discussion: The patient’s phenotype is consistent with chromosome 13q deletion syndrome, with the SRRM2 variant potentially acting as a modifier and influencing communication and behavior. The identification of dual genomic findings through exome and microarray testing is gaining recognition, leading to mixed neurodevelopmental presentations. Conclusion: A rare co-existence of SRRM2 p.His2176Leu (VUS) and chromosome 13q deletion was identified in a child with severe neurodevelopmental impairment. This dual finding expands the phenotypic spectrum and underscores the importance of genomic testing.

Early Onset

Rohit Singh, Punnet Khanna, Pushpender Kumar Base Hospital, Delhi Cantt, New Delhi, India Background: Inhalant use disorder is an under-recognized but potentially life-threatening form of substance use disorder in children. While initiation typically occurs during adolescence, onset in early childhood is rare, particularly in those with neurodevelopmental vulnerabilities. Indian literature on early-onset inhalant dependence in children with intellectual developmental disorder (IDD) remains sparse. Case Presentation: 9½-year-old boy with a history of perinatal hypoxic-ischemic encephalopathy (stage II), who subsequently developed intellectual developmental disorder with partial functional catch-up. The child exhibited longstanding hyperactivity, impulsivity, poor attention, and impaired social judgment. At approximately seven years of age, he initiated petrol inhalation after exposure during vehicle refueling. Over the next two years, his inhalant use escalated to frequent daily huffing, characterized by active seeking behaviors, wandering away from home and school, concealment, and high-risk practices. Petrol inhalation was consistently followed by a transient reduction in hyperactivity and restlessness, reinforcing continued use. When access was restricted, the child developed marked irritability, restlessness, sleep disturbance, and behavioral dysregulation, which subsided after inhalation. The course was complicated by episodes of altered sensorium, unsteady gait, a prolonged missing episode, and physical injury. Discussion: This case highlights the role of neurodevelopmental vulnerability, impulsivity, and behavioral reinforcement in the early onset of inhalant dependence. The calming effect of petrol inhalation may act as maladaptive self-regulation in hyperactive children with limited cognitive insight. Conclusion: Children with intellectual developmental disorder and hyperactivity represent a high-risk group for early-onset inhalant dependence. Early identification, caregiver education, and multidisciplinary intervention are essential to prevent serious morbidity and mortality.

Fluctuating

Rohit Singh, Pankaj Kumar Sharma 1 Base Hospital Delhi Cantt, Army College of Medical Sciences, 1 Base Hospital Delhi Cantt New Delhi, India Background: Olanzapine overdose typically manifests with central nervous system depression, anticholinergic features, and mild cardiovascular instability. The clinical assessment becomes more challenging in individuals with intellectual disability, where baseline communication limitations may mimic or mask toxicity. This case presents a detailed 48-hour, hour-by-hour clinical and biochemical profile of a moderate-dose olanzapine overdose. Case Presentation: A 22-year-old male with IDD accidentally ingested approximately 75 mg of olanzapine. On arrival, he was drowsy but arousable, with stable vitals (BP 110-120/74-82 mmHg, HR 96-109/min, SpO 2 98-99% room air). Gastric lavage and activated charcoal were administered promptly. Initial ABG revealed mild hypercapnia (pCO 2 46.7 mmHg) with normal pH. Baseline renal, liver, and electrolyte parameters were within normal limits.During the first 24 hours, he demonstrated fluctuating consciousness levels (RASS -3 to +1), briefly becoming agitated during emergence from sedation. No extrapyramidal signs, rigidity, autonomic instability, or hyperthermia were noted. Hourly vitals remained stable, ECG showed NSR throughout, and urine-output was adequate. Serial laboratory assessments revealed normal hepatic/renal function, stable electrolytes, and a resolving stress leukocytosis (WBC 11.7 to 8.7*10³/µL). By 48 hours, the patient was alert (RASS -1), responding appropriately to verbal commands, and maintaining excellent cardiopulmonary stability. Discussion: Despite moderate-dose olanzapine ingestion, the patient exhibited a benign course with no serious complications. Careful monitoring allowed differentiation between drug-induced sedation and baseline intellectual disability. Conclusion: Moderate olanzapine overdose may present with fluctuating sedation but typically resolves with supportive care. Detailed serial monitoring assists in ruling out NMS, EPS, cardiac instability, and other life-threatening complications.

Key In Lock

Payal Tulsan, Sankalp Jain Sir Ganga Ram Hospital, New Delhi, India Background: Key-in-lock syndrome is a rare and often overlooked form of urinary incontinence in which certain environmental cues trigger a sudden and uncontrollable urge to pass urine. Such presentations are particularly uncommon in elderly individuals without any detectable neurological or urological disorder. Aims: This case report aims to describe an unusual presentation of key-in-lock syndrome precipitated by visual and auditory water-related stimuli, and to highlight the contribution of conditioning, anxiety, and depressive symptoms to its progression. Methods: We evaluated a 74-year-old woman who presented with stimulus-bound urinary urgency and incontinence. A comprehensive psychiatric assessment, detailed mental status examination, standardized rating scales, physical and neurological examinations, and appropriate laboratory and imaging investigations were undertaken to exclude organic pathology. Management included psychoeducation, behavioural interventions, pharmacotherapy, and supportive psychotherapy. Results: Detailed evaluation with standardized rating scales revealed mild to moderate anxiety, moderate depression. Following four weeks of combined behavioural and pharmacological treatment, she showed marked improvement, with a reduction in urinary episodes, improved mood, and better social engagement. Conclusion: This case emphasizes key-in-lock syndrome as a conditioned and potentially reversible phenomenon, significantly influenced by psychological factors. Early recognition and a holistic biopsychosocial approach can result in meaningful symptom relief and reduce associated emotional distress and functional impairment in elderly patients.

Lepromatous

Sameer Raghunath Bhoye Government Medical College, Chhatrapati Sambhajinagar, Maharashtra, India Background: Lepromatous leprosy is a chronic infection caused by Mycobacterium leprae, known for its dermatological and neurological complications. However, psychiatric manifestations often driven by neuropathy, stigma, disability, and chronic infection remain under-recognized. Aim: This report describes behavioural disturbances in patient with leprosy. The patient, 38 year old male, labourer presented with progressive nodular skin lesions for 2 years, followed by glove-and-stocking anaesthesia. Repeated unnoticed trauma led to a chronic, foul-smelling ulcer on the left foot. Over the one month, he developed severe irritability, verbal outbursts, and episodes of aggression towards family and strangers, alongside sleep disturbance and social withdrawal. Examination revealed diffuse nodular infiltrated lesions present all over the body. The infected ulcer measured approximately 4.2 cm. Lab investigations showed mild anaemia and deranged liver function tests. Mental status evaluation showed irritability, labile affect, irrelevant speech, persecutory ideas, and absent insight, suggesting behavioural disturbance likely secondary to chronic illness or organic psychosis. The patient was diagnosed with multibacillary lepromatous leprosy with a chronic ulcer and comorbid behavioural disturbance. Management included multidrug therapy (Rifampicin, Clofazimine, Dapsone), wound care, protective footwear, and psychiatric treatment with Risperidone 8mg and Lorazepam 2mg. Supportive psychotherapy, family counselling, and linkage to rehabilitation services were initiated. Conclusion: This case highlights the dual burden of physical morbidity and psychological dysfunction in leprosy. Early psychiatric evaluation, integrated medical care, and community-based rehabilitation are essential for optimising outcomes and reducing stigma associated with the disease.

Mirtazapine

V. Akshai, Suvarna Jyothi Kantipudi Sri Ramachandra Medical College, Chennai, Tamil Nadu, India Background: Hyponatremia is the most common fluid and electrolyte balance affecting upto one third of hospitalised elderly patients with SIADH being one of the commonest causes of hyponatremia.Hyponatremia represents a potentially dangerous condition especially in elderly patients when presenting with delirium.As per the systematic review(Moscona-Nissan, López-Hernández, & González-Morales, 2021) the mirtazapine induced hyponatremia is rare and less well documented with incidence of 3.26%.SIADH is the commonest cause,most common in elderly and female patients, is dose independent. Aim: To highlight mirtazapine induced SIADH with the below case report. Case Vignette: 72Y/M case of Dementia with BPSD,comorbid with T2DM/SHTN/CAD/Parkinsons disease was started on TAB.Mirtazapine 3.75mg.Serum sodium was 134meq/l before initiating Mirtazapine .15 days after initiation of Mirtazapine the patient has developed acute onset confusion and restlessness with fluctuating sensorium.Serum Sodium was 122meq/l,BUN 8mg/dl, Serum creatinine 0.6mg/dl,Urine spot sodium was 31.1mmol/l, Serum osmolality was 253mOsm/kg Serum Uric acid 2.5mg/dl ;RBS,Serum cortisol,TFT,LFT were within normal limits,2D echo was normal,has euvolemic status clinically,not on any antidepressants and not on diuretics or any other hyponatremia causing drugs,MRI brain shows diffuse cerebral cortical atrophy.Mirtazapine was stopped and advised fluid restriction,high salt diet.Hyponatremia has improved to 133 meq/l and confusion,restlessness has resolved. Conclusion: The likelihood of Mirtazapine use causing hyponatremia was probable(score 7) as per Naranjo Adverse drug reaction probability scale.Even though Mirtazapine is commonly considered as an alternative to other antidepressant induced SIADH,baseline evaluation and regular monitoring should be done especially in elderly patients with risk factors.

Nutritional

Kashish Singhal, Shubham Fojdar 1 Sankalp De-Addiction Treatment Centre, Hyderabad, Telangana, 1 ESIC Hospital, Alwar, Rajasthan, India Introduction: Depression is a widespread mental health disorder impacting over 280 million individuals globally. It is characterized by persistent feelings of sadness, loss of interest, fatigue, and impaired cognitive function. While its etiology includes genetic, psychological, and social factors, increasing attention is being given to the role of nutritional deficiencies in the onset and progression of depressive symptoms. Role of Vitamin B12 and Folate: Vitamin B12 and folate are essential micronutrients involved in neurological and psychological health. They play critical roles in neurotransmitter synthesis, DNA methylation, and homocysteine metabolism. Deficiencies in these nutrients are associated with neuropsychiatric manifestations such as irritability, cognitive decline, and depressive episodes. Dietary Patterns and Mental Health: Beyond individual nutrients, overall dietary patterns significantly influence mental well-being. Diets rich in whole grains, fruits, vegetables, and omega-3 fatty acids are correlated with improved mood and lower depression risk. In contrast, processed foods, high sugar intake, and saturated fats are linked to poor mental health outcomes. Public Health Implications: In regions affected by under nutrition and restricted dietary diversity, addressing nutritional deficits may serve as a preventive and therapeutic component in depression management. Nutritional screening, dietary education, and integration into mental health programs can enhance holistic psychiatric care. Key words: Depression, dietary patterns, folate, mental health, Vitamin B12

Obsessional

Animesh Jain, Sreya Banerjee, Maviya Pathan Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India Background: Obsessive-compulsive disorder (OCD) frequently co-occurs with depressive disorders, with prevalence rates of comorbidity ranging from 60-70%. While typical OCD presentations involve recognizable compulsions, obsessional ruminations without overt rituals pose diagnostic challenges, particularly when they manifest as unusual behaviours that may mimic psychotic phenomena. Aims: To describe an unusual presentation of OCD where obsessional ruminations manifested as repetitive self-muttering, leading to initial diagnostic uncertainty. Methods: We present a case of a 33-year-old male with 16-year illness duration, admitted for suicidal risk. Results: The patient developed persistent low mood, anhedonia, and intrusive ego-dystonic thoughts about past negative remarks following academic failure at age 17. To neutralize distress from these intrusive ruminations, he began verbalizing the thoughts aloud repetitively, experiencing temporary relief thereafter. This self-muttering behaviour was initially misattributed to psychosis, resulting in multiple antipsychotic trials including clozapine which failed to improve and potentially worsened the obsessional symptoms. Over subsequent years, he developed classical checking compulsions and ego-dystonic harm-related obsessions. Progressive worsening of depressive symptoms culminated in a suicide attempt. Mental status examination revealed obsessional thoughts with preserved insight (Grade IV). A diagnosis of recurrent depressive disorder (severe episode) with comorbid OCD (mixed obsessional thoughts and acts) was formulated. Conclusion: Obsessional ruminations may present atypically as repetitive verbalization, potentially mimicking psychotic self-talk. Careful phenomenological assessment distinguishing ego-dystonic obsessions from psychotic phenomena is crucial to avoid diagnostic misattribution and inappropriate treatment.

Paradoxical

P. Gopika, Anoop Vincent Sree Narayana Institute of Medical Sciences, Ernakulam, Kerala, India Background: There are studies highlighting the promising potential of Nicotinamide mononucleotide and brassica campestris L. Standardized to sulforaphane capsules, as an adjunctive intervention for autism spectrum disorder, demonstrating its efficacy in reducing core symptoms, improving social communication and addressing repetitive behaviors. Aim: This case report highlights a suspected behavioural adverse reaction to Nicotinamide mononucleotide and brassica campestris L. Standardized to sulforaphane capsules ( Altibrain- of Celagenex research ( India) pvt ltd), a nootropic agent, in a child with autism spectrum disorder. Methods: 12 year old child with autism spectrum disorder, who was on clonidine, fluvoxamine,risperidone, divalproex sodium, when presented with mild irritable symptoms, was started on Nicotinamide mononucleotide and brassica campestris L. Standardized to sulforaphane capsules, a nootropic, which acts as a cognitive enhancer. Results: After 5 days of starting above mentioned drug, child was brought to psychiatry out patient department for worsening of symptoms of irritability and hyperactivity. Drug was discontinued and symptoms reduced within 2-3 days. Conclusion: This reaction suggests a behavioural adverse effect, highlighting the increased sensitivity of children with autism spectrum disorder to neuroactive medications. - This case underscores the need for individualized risk assessment to improve patient safety.

Perceptions

Sidharth Kadganchikar, Srilaxmi, Vijay Kumar bandaru, P. Sindhuri Government General Hospital, Sangareddy, Telangana, India Background: Although national guidelines recommend complete abstinence from alcohol during pregnancy, toddy (kallu), a traditional palm liquor (4 - 6%ABV) is widely consumed in rural Telangana during pregnancy and perceived as beneficial. Empirical evidence documenting these cultural beliefs is limited. Aims: To explore perceptions and practices in toddy use among woman of rural telangana. Methods: A qualitative study was conducted among 16 women attending the maternal and child hospital in Sangareddy district. In depth interviews were conducted in the local language, covered alcohol history, cultural beliefs, social influences, and healthcare interactions. Audio-recorded interviews were transcribed and thematically analyzed using a hybrid inductive-deductive coding approach. Results: Most participants endorsed at least one perceived benefit of toddy in pregnancy. Common beliefs included: (1) facilitating the delivery process; (2) cleaningthe baby in the womb to prevent white coating at birth; (3) promoting good fetal development; and (4) improving maternal health through better sleep. These practices were strongly reinforced by elders and cultural traditions. Only a minority reported receiving advice from healthcare providers, and such advice was either unclear or disregarded. Conclusion: Toddy consumption during pregnancy in rural Telangana is culturally sanctioned and perceived as beneficial, with limited awareness of harms and minimal healthcare influence. These findings highlight the need for culturally sensitive antenatal education and integration of substance use screening and counseling into routine obstetric care.

Pheniramine

Anaf Kololichalil, Siddharth Sarkar 1 , K. Muhammad Jadeer 1 AIIMS, 1 NDDTC, AIIMS, New Delhi, India Pheniramine, an antihistamine commonly used as a diluent in injection drug use in India, is rarely systematically assessed during clinical interviews. Given its short urinary detection window (approximately 1-4 days), urine drug screening (UDS) may offer objective insights into recent exposure and injection practices. Aims: To assess the prevalence of pheniramine detection on UDS among people who inject drugs (PWID) and examine its association with self-reported recency and frequency of injection drug use. Methods: This cross-sectional study included PWID recruited solely on the basis of a history of injection drug use at a tertiary-care addiction treatment centre. Information on injection frequency and time since last injection episode was collected. Pheniramine use as a diluent was not systematically elicited. UDS was performed to detect pheniramine, and associations with injection recency and frequency were analysed descriptively. Results: Pheniramine was detected in 43.4% of daily injectors. Detection was highest among those reporting injection within the last week (59.1%) and within the last three days (50.0%), followed by those injecting on the day of assessment (43.5%). Positivity declined with increasing time since last injection, to 31.8% among those injecting within the last month and 21.1% among those whose last injection was over six months prior. Detection across injection frequency categories remained consistently high (40-46%). Conclusions: Pheniramine detection on UDS is common among PWID and strongly associated with recent injecting behaviour. Discrepancies between reported recency and biological detectability highlight limitations of self-report and underscore the value of UDS in identifying unrecognised diluent exposure.

Problematic

K. Rashmi KVG Medical College Hospital, Sullia, Karnataka, India Schizophrenia is a complex behavioral and cognitive syndrome .Problematic Internet Use (PIU) is a maladaptive pattern of online activity causing dependence, leading to significant psycho-socio-occupational impairment.In schizophrenia, it may contribute to maladaptive avoidance yet offer symptom relief. Due to associated stigma of mental illness, internet tends to became a source of symptom awareness and guidance., psychoeducation is highly necessary. We would like to discuss interplay between PIU and psychosis, and its potential beneficial use.

Psychiatric

S. Yashwanth, M. Gangadhar Rao Andhra Medical college, GHMC, Visakhapatnam, Andhra Pradesh, India Introduction: Wilson’s disease (WD) is a rare autosomal recessive disorder caused by ATP7B gene mutation on chromosome 13, resulting in copper accumulation in the liver, basal ganglia, cornea, and kidneys. Thirty percent of WD patients present with psychiatric symptoms; behavioural and personality disorders occur in 46-71%, commonly irritability, aggression, and antisocial behaviour. Case Presentation: A 24-year-old male presented with 2 months of social withdrawal, decreased activities, reduced sleep and appetite, followed by 7 days of acute fearfulness, suspiciousness, family aggression, and trunk-predominant involuntary movements worsened by walking. He had similar symptoms 2 years prior, treated successfully with olanzapine 10 mg and trihexyphenidyl 2 mg for 6 months before discontinuation. Mental status examination revealed incoherent speech, persecutory ideation, second-person auditory hallucinations, and grade 1 insight. Neurological examination showed generalized reduced power (4/5) with marked hand grip weakness (2/5), hyperreflexia, and bilateral extensor plantars. Bilateral Kayser-Fleischer rings and symmetrical T2 hyperintensities in bilateral thalamus confirmed WD. Management: Diagnosed with secondary psychotic syndrome due to Wilson’s disease (ICD-11: 6A40.1), he received olanzapine, trihexyphenidyl, and copper chelation therapy with significant 3-week improvement. Conclusion: Neuropsychiatric symptoms may precede or overshadow neurological and hepatic manifestations in Wilson’s disease, potentially delaying diagnosis. Early recognition through clinical suspicion and targeted investigations is essential for timely intervention.

Psychogenic

Yanamala Akhil Raj, J. Bhargav Reddy Government Hospital For Mental Care, Andhra Medical Collage, Visakhapatnam, Andhra Pradesh, India Background: Intractable vomiting in adolescents often requires detailed medical and neurological evaluation. In individuals with genetic syndromes and structural brain anomalies, symptoms are frequently attributed to organic pathology, which may lead to overlooking an underlying psychogenic etiology. Aim: To report a case of psychogenic vomiting in an adolescent with Turner syndrome and incidentally detected Dandy-Walker malformation. Case Discussion: A 16-year-old female patient with a known diagnosis of Turner syndrome presented with persistent vomiting for three months. Neuroimaging performed during evaluation incidentally revealed Dandy-Walker malformation. In view of the structural brain abnormality, vomiting was initially attributed to raised intracranial pressure and a cystoperitoneal shunt was performed. However, no clinical improvement was observed postoperatively. Further investigations, including abdominal ultrasonography and upper gastrointestinal endoscopy were unremarkable. In the absence of identifiable organic pathology despite persistent symptoms, psychiatric evaluation was sought. Results: Detailed assessment revealed significant psychosocial stressors including poor self-esteem, body image concerns and social anxiety, likely related to Turner syndrome-associated psychosocial vulnerabilities. A diagnosis of psychogenic vomiting was made, and the patient was started on escitalopram 10 mg/day. Within 3-4 weeks of initiating psychiatric treatment, there was a marked reduction followed by complete resolution of vomiting, with concurrent improvement in anxiety symptoms. Conclusion: This case highlights the importance of considering psychogenic causes of functional symptoms in adolescents, even in the presence of significant structural brain abnormalities. Early psychiatric evaluation, appropriate management and a multidisciplinary approach may reduce morbidity in complex adolescent presentations.

Risperidone

Anshika Tyagi Bharati Vidyapeeth Deemed to be Medical College and Hospital, Sangli, Maharashtra, India Background: Disulfiram-induced psychosis arises from Dopamine hydroxylase inhibition causing dopaminergic hyperactivity. Antipsychotic-induced akathisia is frequent & associated with suicidality & poor adherence. Coexisting bipolar affective disorder, alcohol dependence & intellectual disability further complicate diagnosis & management. Case Presentation: 33 y/o male with Bipolar Affective Disorder, Alcohol Dependence Syndrome & Intellectual Disability developed acute psychosis on Disulfiram. Risperidone given for psychotic symptoms, led to severe akathisia within 5 days with complaints of restlessness, urge to move, palpitations & insomnia. Assessment : Severity was rated using the Barnes Akathisia Rating Scale (BARS) Over 10 days, BARS improved from 9 (severe) to 4 (marked akathisia) with parallel improvement in symptoms & functioning. Neurological examinations: Bradykinesia & Rigidity present. Management: Risperidone was withdrawn. Conventional management with Propranolol & Benzodiazepines produced minimal benefit, prompting addition of Mirtazapine 15mg & Pregabalin 450mg, producing progressive relief with reduced restlessness & restored sleep & functioning. Conclusion: This case highlights the complex interaction of Disulfiram-induced psychosis, Bipolar Affective Disorder & Risperidone-induced akathisia in Intellectual Disability & suggests Mirtazapine with Pregabalin as a potential option when first-line strategies for akathisia are ineffective, meriting further study.

Unconscious

Neha Sumedh Shende, Nimisha Mishra, Sunil Ku Ahuja, Amrendra Ku Singh Shyam Shah Medical College, Rewa, Madhya Pradesh, India Introduction: Sleep-Related Eating Disorder (SRED) is a parasomnia characterized by recurrent episodes of involuntary eating and drinking during partial arousals from sleep. While often idiopathic, it can be secondary to medications, particularly Zolpidem, a non-benzodiazepine hypnotic used for insomnia. Recognition is crucial to avoid misdiagnosis as a primary eating disorder or malingering. Case Description: A 35-year-old woman with chronic insomnia was prescribed Zolpidem 5 mg at bedtime. Shortly after initiation, she began experiencing recurrent nocturnal episodes of eating unusual, often uncooked food items (e.g., raw grains) without any conscious awareness. These episodes were directly observed by family members, while the patient had complete amnesia for the events the following morning. There was no prior history of eating disorders, substance use, or psychiatric illness. Examination and DiagnosticsExam: Patient was conscious, cooperative, and fully oriented. General physical and systemic examinations were normal. Mental Status Examination: Revealed no perceptual abnormalities, thought disorder, or mood disturbance. Investigations: Routine blood tests (CBC, metabolic panel) were unremarkable. Diagnosis: Zolpidem-Induced Sleep-Related Eating Disorder, based on the clear temporal link to drug initiation and eyewitness corroboration. Management and Outcome: Zolpidem was immediately discontinued, and sleep hygiene measures were reinforced. The nocturnal eating episodes ceased completely following the withdrawal of Zolpidem. No other pharmacological intervention was required. The patient remained symptom-free at follow-up, confirming the drug-induced etiology.

Unexplained

Dev Himanshubhai Desai, Abhimnayu Sinha, Reetika Thakur, Bhushan Chaudhari Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India Background: ICD-11 defines Bipolar I, mania without psychosis, as a sustained period of elevated or irritable mood with increased activity lasting at least one week. Patients may present with euphoric, irritable, or delirium-like affective states. However, an abrupt onset of delirium in a patient showing steady improvement during treatment for mania is highly unusual and sparsely documented in available literature. Aim: To describe a rare case of sudden, unexplained delirium in a patient improving from a manic episode and explore the potential role of medication interactions. Methodology: A 41-year-old male with Bipolar I disorder, mania, was evaluated clinically, monitored with serial mental status examinations, and investigated for metabolic, neurological, and structural causes of acute delirium. Laboratory tests, MRI brain, and serum divalproate levels were obtained. Medication review and stepwise withdrawal were conducted to identify potential pharmacological contributors. Results: Patient initially responded well to olanzapine and divalproate, with a marked reduction in YMRS score. On day 24, following an additional nighttime dose of clonazepam for insomnia, he developed acute disorientation, visual misperceptions, agitation, and incomprehensible speech. Electrolytes, serum ammonia, MRI, and neurological evaluation revealed no organic cause. Divalproate levels remained therapeutic. All psychotropics were withheld, after which the patient regained full orientation within three days. The most plausible explanation was a rare, undocumented interaction between olanzapine, divalproate, and clonazepam. Conclusion: This case highlights that delirium may emerge abruptly in treated mania despite normal investigations. In such presentations, immediate discontinuation of potentially interacting psychotropics may be essential, and further research into rare drug-interaction-related delirium is warranted.

Unravelling

A. P. Sathishkumar, Neha Sharma Armed Forces Medical College, Pune, Maharashtra, India Dhat syndrome is a culture-bound syndrome predominantly reported in young adult males from South-East Asia and is characterised by distress attributed to perceived semen loss, often accompanied by somatic, anxiety, and depressive symptoms. Late-onset presentations are uncommon. We report a case of a 38-year-old male from a low socioeconomic background who presented with headache, easy fatigability, sleep disturbance, and cognitive preoccupation with semen loss, which he attributed to autoerotic practices. Clinical evaluation revealed megaloblastic anaemia (Hb 9.5 g%), for which he received vitamin B12 and folate supplementation, resulting in haematological and partial symptomatic improvement. However, persistent anxiety and maladaptive beliefs regarding semen loss led to significant psychosocial dysfunction. He was subsequently diagnosed with Dhat syndrome and managed with culturally sensitive psychoeducation, cognitive restructuring, coping skills training, and relaxation techniques, leading to marked clinical improvement within four weeks. This case highlights the importance of identifying underlying medical conditions, addressing cognitive misattributions, and recognising the evolving role of sociocultural and digital influences in late-onset Dhat syndrome.

Unshackling

Shradha Khatri, Virendra Vikram Singh, Bikram Datta, Carol Panjrattan AMC, Bengaluru, Karnataka, India The recent events have brought focus on workplace mental health in India. In today’s fast-paced corporate world, mental health is not just a personal matter it’s a business priority. High stress levels, burnout, interpersonal conflicts, and emotional fatigue can silently impact productivity, employee morale, and overall workplace culture. A healthy workforce is important for every industry. Traditionally, industries have catered for health issues both in institutional as well as referral setups. However, these services provided limited mental health support at work place. Some industries like military and railways have their in-house mental health service setup, a large number of the workplaces did not have any such services for various reasons including stigma and priorities. Industrial psychiatry is a specialized branch of psychiatry focused on mental health issues within workplace and industrial settings, aiming to prevent, manage, and treat psychiatric conditions that arise in relation to employment and industrial environments. A psychiatrist in this setup has an additional understanding of workplace, its demands and impact on mental health. Prepandemic it was rare to discuss matters of mental health in the workplace. Employees with mental health issues feared being looked down upon or losing job. Situation was worse for addictions. The stigma around mental health at work is receding, there is need to unshackle mental health at workplace. Many workers these days expect mental health benefits as part of the employment deal. Thus, it’s time to discuss Industrial Psychiatry, the opportunities, challenges and way out for positive workplace mental health.

Autoimmunity

V. S. Sai Rawya Katragadda, H. Rupa Lakshmi, P. Ranjit Kumar Alluri Sita Rama Raju Academy of Medical Sciences, Eluru, Andhra Pradesh, India Introduction: Sjogren’s syndrome (SS) is an autoimmune disorder characterised by the infiltration of mononuclear cells and subsequent damage to the salivary and lacrimal glands. Syndrome can either be secondary Sjogren’s syndrome, occurring with another autoimmune disease, or primary Sjogren’s syndrome (pSS) when it manifests independently. The prevalence is approximately of 0.1% to 3% of the general population. Beyond classical dryness, SS can present with neurologic and psychiatric manifestations, including rare autoimmune psychosis. Case Vignette: A 28 year old female with past history of hypothyroidism on levothyroxine 25 mcg, presented with complaints of acute onset of generalised weakness and loss of consciousness and was brought to emergency department. On day 3 of admission, she developed symptoms of dry mouth, dry eyes, auditory hallucinations, visual hallucinations, irritability, occasional self talk, with intact orientation and attention. No history of seizures, fever, headache, head trauma. MRI brain revealed bilateral symmetrical T2\FLAIR hyperintensities in subcortical and deep white matter. Anti Nuclear Antibodies (ANA) profile by Immunoblot assay tested positive for antigens SS-A/Ro60 and SS-A/Ro52. Case Management: For above complaints she was referred to psychiatry; Treatment initiated with tab.QUETIAPINE 50 mg 0-0-1 & SOS, subsequent dose titrated upto 400mg/day and following which patient improved symptomatically. Conclusion: Provisional Diagnosis: 6E61.0: SECONDARY PSYCHOTIC SYNDROME, WITH HALLUCINATIONS (ICD-11) 4A43.20 Primary Sjogren syndrome(ICD-11).

Cybersuicide

Anna Sehgal, Jigyansa Ipsita Pattnaik Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India Introduction: Internet-based pro-suicide communities and online suicide pacts are an emerging challenge in adolescent psychiatry. Unlike traditional pacts involving known relationships, these digital interactions often occur between young strangers with depression, requiring updated risk assessment and intervention strategies. Methods: Five cases (ages 14-19) were identified over 18 months in an adolescent psychiatry emergency and inpatient setting. All demonstrated significant suicide-related internet use (SRIU) uncovered during structured assessment. A standardized SRIU protocol explored general online habits, suicide-specific behaviors, digital social networks, and protective online engagement. Interventions included safety planning, supervised internet use, digital literacy psychoeducation, family involvement, and connection to pro-recovery online resources. Results/Cases: Five patterns emerged: (1) Pro-suicide forum immersion 17-year-old female researching sodium nitrite. (2) Online suicide pact 19-year-old male planning charcoal burning with a Reddit stranger. (3) Method-focused research 16-year-old female with BPD stockpiling pills. (4) Social media contagion 15-year-old male developing acute ideation after a celebrity suicide. (5) Predatory exploitation 14-year-old female groomed by an adult encouraging live-streamed suicide. All showed escalation linked to online exposure. Four stabilized within 12-16 weeks; one required 24 weeks. Conclusion: Systematic assessment of online activity revealed critical risks that would have been missed otherwise. Tailored, multi-level interventions addressing individual vulnerabilities, family dynamics, and digital behavior were most effective. Routine SRIU assessment should be integrated into adolescent suicide evaluations. Key words: Cybersuicide, online suicide pacts, pro-suicide communities

Departmental

Payal Tulsan, Rajesh Goyal Sir Ganga Ram Hospital, New Delhi, India Background: Departmental stores are designed environments that influence consumer cognition, emotion, and behavior through the application of psychological principles. Drawing on cognitive, behavioral, and social psychology, retail settings utilize sensory stimuli, spatial organization, and choice architecture to shape attention and decision-making, often outside conscious awareness. From a psychiatric perspective, these mechanisms parallel processes involved in reinforcement, impulse control, habit formation, and reward processing. Aim: To examine the psychological principles embedded in departmental store design and their influence on consumers’ thoughts, emotions, and purchasing behavior. Methods: A narrative review was conducted using standard psychiatry and psychology textbooks, including the Comprehensive Textbook of Psychiatry and Morgan’s Psychology, supplemented by selected literature from consumer psychology and behavioral economics. Common retail strategies were identified and mapped onto established psychological constructs such as conditioning, priming, heuristics, social influence, and affective modulation. Results: Departmental stores consistently employ sensory priming, strategic product placement, limited-choice frameworks, and social proof. These techniques increase dwell time, enhance positive affect, reduce cognitive load during decision-making, and promote impulsive and unplanned purchasing behavior. Discussion: Retail environments function as applied psychological settings that subtly engage cognitive biases and emotional vulnerabilities. Understanding these influences has relevance for mental health, particularly in relation to compulsive buying behavior and impulse-control difficulties. Awareness of the psychological design of retail spaces may support more mindful consumer choices.

Dissociation

Palak Kaur, Shakshi Srivastava Wellbeing Mind and Body Clinic, Amritsar, Punjab, India Epileptic seizures and PNES are frequently difficult to differentiate, as PNES represent manifestations of dissociative or conversion disorders that closely resemble epileptic events. Shared clinical features such as brief unresponsiveness, involuntary motor movements, or sensory alterations often lead to misdiagnosis. Consequently, individuals are commonly prescribed anti-epileptic medications unnecessarily, while appropriate psychological intervention is delayed. PNES arise from involuntary dissociative mechanisms through which psychological distress is expressed in the form of discrete physical episodes. The present study aimed to examine the misinterpretation of dissociative symptoms as neurological conditions, particularly seizure-like episodes, and to identify common factors contributing to diagnostic confusion across thirty clinical cases. A detailed review of 30 clinical case records was conducted, incorporating medical histories, neurological evaluations including routine and prolonged EEG monitoring, and structured psychological assessments. Each case was analyzed for symptom onset, associated stressors, diagnostic trajectory, and final clinical formulation. Standardized dissociation measures and structured interviews were utilized to aid diagnostic clarification. Results revealed that patients frequently presented with seizure-like symptoms, including shock-like sensations, transient paralysis, sensory disturbances, or brief episodes of unresponsiveness. These presentations prompted extensive neurological investigations and multiple trials of anti-epileptic drugs, despite consistently normal EEG and neurological findings. Subsequent psychological evaluations confirmed that these episodes reflected dissociative mechanisms consistent with conversion symptomatology or PNES. In conclusion, distinguishing dissociative episodes from epileptic seizures remains challenging due to overlapping clinical features. Early psychosocial screening and trauma-informed assessment are essential for improving diagnostic accuracy and treatment outcomes.

Dissociative

Prasoon Sharma, Vrinda Kabra, Vignesh Kuppusamy, Ganesh Meena, Preethy Kathiresan, Koushik Sinha Deb All India Institute of Medical Sciences, Delhi, India Background: Dissociative Motor Disorders (DMD) are characterized by motor or sensory symptoms arising from unconscious psychological conflicts and not attributable to neurological or medical conditions. Impaired self-agency, wherein movements are experienced as involuntary, has been proposed as a key mechanism. In patients with schizophrenia, differentiating dissociative motor symptoms from antipsychotic-induced movement disorders can be challenging. Reports of dissociative motor symptoms co-occurring with schizophrenia are rare, with none documented from India. Aim: To report a diagnostically challenging case of dissociative motor symptoms in a patient with schizophrenia. Methods: A single-case report with a review of relevant literature. Results: A 24-year-old male with an eight-year history of treatment-resistant schizophrenia presented with episodes of involuntary upward rolling of the eyes following clozapine dose titration. Detailed evaluation revealed almost daily episodes lasting 10-30 minutes over the past three months, consistently precipitated by psychosocial stressors and excessive worry, with no clear temporal relationship to clozapine dosage. The eye movements varied in direction and were distractible, suggesting a dissociative phenomenon rather than an oculogyric crisis. The patient was initiated on escitalopram, titrated to 20 mg/day, while clozapine was optimized to 350 mg/day. Significant improvement in dissociative & psychotic symptoms was observed. Conclusion: This case highlights the importance of detailed history-taking and clinical examination in distinguishing dissociative motor disorders from antipsychotic-induced movement disorders. It adds to the limited literature on dissociative phenomena in schizophrenia and underscores the need for diagnostic vigilance in complex psychopharmacological contexts.

Distribution

Anshu Devi, Anshu Sharma Department of Psychiatry, Muzaffarnagar Medical College and Hospital, Muzaffarnagar, Uttar Pradesh, India Approximately 26 million to over 90 million for all Intellectual disabilities reported in India with prevalence rater of 2.3% of population. The different sources has different estimate of intellectual disabilities. The socio economic strata and need socio governmental support may vary. Aim and Objectives: To estimate the socio governmental strata and estimate their need to support intellectual disabilities in deficient population. Tools: WAIS -R, MODIFIED CKUPPASWAMY SCALE for urban population and Uday pareek scale for rural population and formulated questionnaires. Methods: The score of selected different severity of 50 intellectual disabilities of were assessed and estimated on wais -r and kuppuswamy and uday pareek scale . They were also assessed on formulated questionnaires to assessed support need. Results and Conclusion: The persons of different intellectual disabilities had different need and high expectation of governmental supports are required according to their severity.

Escitalopram

Savita Patel Government medical College, Satna, Madhya Pradesh, India A 28-year-old woman developed secondary amenorrhea six weeks after starting escitalopram for Depression. Pregnancy and other causes were excluded; mild hyperprolactinemia was found. Menses resumed after discontinuing escitalopram and switching to sertraline. This case emphasizes recognizing rare SSRI-related menstrual disturbances for timely management.

Intracranial

V. Swaathi KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India Background: Intracranial arachnoid cysts are usually asymptomatic, but lesions involving the posterior fossa have been linked to diverse psychiatric presentations, including psychosis and obsessive-compulsive symptoms. We describe a young man with intrusive harm obsessions and unusual disrobing behavior in whom a retro cerebellar arachnoid cyst was detected. Case Description: A 26 year old man with past diagnoses of depression and brief psychosis presented with 4 days of repetitive mental images of his family being harmed, associated with compelling commandsto scream or disrobe to prevent catastrophe. The images were experienced as intrusive and distressing; he acknowledged they might be irrational but felt unable to resist them, with transient relief after the behaviors. There were no other obsessions, delusions or hallucinations. One year earlier he had developed excessive religiosity centered on a yoga center, culminating in an admission at our hospital with a diagnosis of psychosis not otherwise specified and partial response to risperidone. On current admission he was markedly agitated with frequent screaming and disrobing episodes. Routine blood tests, toxicology and thyroid profile were normal. Brain MRI revealed a retro cerebellar arachnoid cyst (2.7×4.6 × 3.2 cm) with inferior vermian hypoplasia. Neurosurgical opinion favored conservative management. He improved with olanzapine, sertraline and low dose aripiprazole, though residual obsessive imagery persisted. Discussion: This case highlights the diagnostic challenge of disentangling psychosis from obsessive-compulsive phenomena in the context of an organic brain lesion. Careful phenomenological assessment and neuroimaging in atypical or fluctuating presentations may help identify potentially contributory structural pathology.

Multisensory

Abhinav Pradeep, Neha Sharma Armed Forces Medical College, Pune, Maharashtra, India Background: Charles Bonnet Syndrome (CBS) is classically characterized by complex visual hallucinations occurring in cognitively intact individuals with significant visual impairment. While visual hallucinations are the hallmark feature, atypical presentations involving non-visual sensory hallucinations and delusional elaboration are increasingly recognized but remain underreported, particularly in elderly populations. Such presentations frequently lead to diagnostic confusion with primary psychiatric or neurodegenerative disorders. Aims: To describe atypical and multisensory presentations of Charles Bonnet Syndrome in visually impaired elderly individuals and to highlight associated diagnostic and therapeutic challenges. Methods: This case series describes three elderly female patients with significant visual impairment secondary to ocular pathology who presented with hallucinations. Comprehensive clinical evaluation included ophthalmological assessment, neurological examination, neuroimaging, electroencephalography where indicated, and cognitive screening using standardized tools. Psychiatric assessment focused on the phenomenology of hallucinations, level of insight, and presence of delusional beliefs. Patients were followed longitudinally after initiation of treatment. Results: All patients demonstrated preserved cognitive function with no evidence of primary psychiatric or neurological illness. Two patients exhibited classical complex visual hallucinations, while one presented predominantly with auditory hallucinations following cataract surgery. One patient developed prominent persecutory delusions accompanying visual hallucinations. Neuroimaging and neurological evaluations were unremarkable in all cases. Treatment with low-dose risperidone resulted in significant improvement and eventual resolution of hallucinations, with no recurrence following gradual tapering. Conclusion: These cases broaden the clinical spectrum of Charles Bonnet Syndrome by illustrating multisensory and delusion-associated presentations. Awareness of such atypical manifestations is crucial to prevent misdiagnosis and unnecessary long-term antipsychotic treatment.

Parkinsonism

Sukriti Soni, Prerana Narayanan Adichunchanagiri Institute of medical Sciences, B.G Nagara, Karnataka, India Introduction: Alcohol Dependence Syndrome (ADS) withdrawal symptoms typically resolve upon consuming alcohol. However, the presence of ADS can obscure unrelated underlying pathology, creating a risk of confirmation bias, as demonstrated in this case where movement disorder symptoms were initially misattributed to alcohol withdrawal. Case Description: A 56-year-old male with a 26-year history of ADS presented with tremors, sleep disturbance, palpitations, and excessive sweating. Crucially, his tremors did not improve with alcohol consumption. A neurological exam revealed bradykinesia, mask facies, and cogwheel rigidity, leading to a Parkinson’s Disease (PD) diagnosis. Treatment with carbidopa/levodopa (25mg/100mg TDS) completely resolved his resting tremors and improved rigidity/bradykinesia. Discussion: This case highlights the potential for confirmation bias, where movement disorder symptoms were misleadingly linked to alcohol withdrawal, delaying the correct diagnosis of PD. Conclusion: Clinicians must maintain vigilance and a broad differential diagnosis to avoid diagnostic biases that negatively impact patient care and outcomes. Key words: Alcohol withdrawal, parkinson’s disease

Pimavanserin

Bhavya Rohit Bhansali, Kenil Jagani PDU Government Medical College and Hospital, Rajkot, Gujarat, India Background: Pimavanserin, a selective 5-HT2A inverse agonist, has shown potential as an adjunctive agent for persistent psychotic symptoms in schizophrenia. Evidence from small trials and case reports suggests benefit in residual positive and negative symptoms with good tolerability, although larger studies show mixed efficacy, highlighting the need for further clinical exploration. Aims: To evaluate the clinical effectiveness and tolerability of pimavanserin augmentation in schizophrenia patients with inadequate response to standard antipsychotic therapy. Methods: Three patients diagnosed with schizophrenia continuous who demonstrated suboptimal response to ongoing treatment received pimavanserin 34 mg/day as augmentation. PANSS(positive and negative symptoms scale) scores were recorded at baseline and after 6 weeks. Side effects were monitored. Results: Case 1: PANSS improved from 76 (P-16, N-27, G-33) to 40 (P-9, N-11, G-20), showing marked clinical improvement and no adverse effects.Case 2: PANSS improved from 78 (P-24, N-18, G-36) to 61(P-13, N-16, G-32), showing moderate improvement, mainly in positive symptoms.Case 3: PANSS changed from 74 (P-16, N-24, G-34) to 68 (P-16, N-21, G-31), showing minimal improvement; well tolerated, and further augmentation with amisulpride was initiated. Conclusion: Pimavanserin augmentation was well tolerated and associated with variable but clinically meaningful improvement in two of three patients with persistent psychotic symptoms. These findings highlight it’s potential as an adjunct in treatment-resistant schizophrenia, warranting further validation through larger controlled studies. Key words: 5-HTâ‚ a inverse agonist, augmentation therapy, pimavanserin, schizophrenia

Pseudocyesis

Somya Tuteja, Abhinav Agrawal Government Medical College and Hospital, Chandigarh, India Aim: To present and analyse a case of a young female with schizophrenia who developed a fixed belief of pregnancy, and to differentiate delusional pregnancy from pseudocyesis through clinical and psychopathological evaluation. Methods / Case Summary: A 27-year-old unmarried female with a five-year history of continuous psychotic illness presented with delusion of love, delusion of reference, misinterpretation, bizarre belief of soul being trapped,somatic passivity, auditory hallucinations, low mood, and marked functional decline. During the illness course, she developed a persistent conviction of being pregnant, attributing it to perceived sexual acts involving a known male. She reported nausea, abdominal heaviness, and weight gain, which she interpreted as pregnancy related. On examination, there were no objective signs of pregnancy. Urine pregnancy test was negative, and physical and gynaecological evaluations were normal. Despite receiving evidence, she maintained the belief. The belief existed within a larger psychotic framework and was not accompanied by physiological changes typical of pseudocyesis. Results / Discussion: The persistence of conviction despite contradictory evidence, absence of bodily signs, and presence of multimodal hallucinations and delusions indicated delusional pregnancy, not pseudocyesis. Her explanation that the foetus remained 2-3 months old for two years due to lack of soul/energyreflected psychotic distortions characteristic of schizophrenia. Conclusion: This case underscores the importance of detailed psychopathological assessment in differentiating delusional pregnancy from pseudocyesis. Recognizing delusional pregnancy prevents unnecessary obstetric evaluations and supports timely optimization of antipsychotic treatment and psychoeducation.

Psychosocial

Rajat Pareek, Farheen Sultana 1 Osmania Medical College, 1 Department of Psychiatry, IMH, OMC, Hyderabad, Telangana, India Introduction: Hematohidrosis is rare condition in which blood-tinged fluid is excreted through intact skin. Pediatric presentations are uncommon and may occur alongside emotional or psychiatric disturbances. Awareness of this mind-body interface assists in timely diagnosis, reduces unnecessary investigations, and highlights the need for multidisciplinary care. Case Report: An 11-year-old girl presented with recurrent, brief episodes of spontaneous blood-stained sweating over the face, eyes and scalp, resolving without pain or dermatological lesions. Examination between episodes was normal. Routine laboratory investigations, including complete blood counts, coagulation profile, and liver and renal function tests, were within normal limits. Dermatology assessment confirmed intact skin, supporting a diagnosis of hematohidrosis. Psychiatric evaluation revealed persistent low mood, irritability, anger outbursts at home, reduced interest in activities and academic decline. Psychosocial stressors related to school were noted. The clinical picture was consistent with childhood depression, with no history of self-harm or substance use. The patient was initiated on Escitalopram 5 mg od and Olanzapine 2.5 mg hs, with supportive counselling, stress-management strategies, and family psychoeducation. Over follow-up, there was improvement in mood, irritability with better daily functioning. The frequency of hematohidrosis episodes reduced gradually. Conclusion: This case highlights the coexistence of hematohidrosis and depressive symptoms in a child facing psychosocial stress. Comprehensive evaluation,integrated psychiatric and medical management can lead to improvement in psychological distress and somatic manifestations.

Relationship

M. N. Prerana Prasad, Hasitha Pamidimukkala JJMMC, Davangere, Karnataka, India Introduction: Body image is perception of one’s body size, shape, and form, encompassing thoughts and feelings toward it. Negative body image, characterized by dissatisfaction with one’s physical appearance, is linked to poor mental health. Social media, particularly visual platforms, leads to constant exposure of idealized and unrealistic body images, heightening body dissatisfaction Aim: This study aims to explore relationship between body image satisfaction and social use Methodology: This observational, cross-sectional survey involved medical students and interns in a Karnataka college. Those with diagnosed medical or psychiatric illnesses and incomplete forms were excluded. Social media usage data and the Body Self-Image Questionnaire (BSIQ) were collected. Statistical analysis was performed with IBM SPSS Version 25. Results: Median age of the sample (N=90) was 26 years (20-43years). 94.4% were using Instagram, and rest were using Whatsapp, Twitter, Youtube Facebook, Reddit and Snapchat. Mean BSIQ score was 75.29, showing 75.6% had body dissatisfaction. Significant association was found between type of content followed, self-comparison with online content, replication of online trends, and mood secondary to online activity with body self-image. No significant association was found between body dissatisfaction and time spent online. Conclusion: Considerable influence of social media on body image perception was noted highlighting need for more body positive content on social media, and addressing the prevalent body image dissatisfaction in young adults.

Star Crossed

Kriti Choudhary, Suresh Gupta, Brijrani Singh Sawai Man Singh Medical College and Attached Group of Hospitals, Jaipur, Rajasthan, India Background: Mixed personality disorder is a chronic and pervasive condition in which an individual exhibits clinically significant traits of multiple personality disorder clusters without meeting full criteria for any single personality disorder. When accompanied by dissociative features, the clinical picture becomes more complex and diagnostically challenging. Dissociative symptoms such as depersonalization, derealization, dissociative amnesia, and identity disturbances often emerge in the context of early life stress, emotional dysregulation, or trauma-related vulnerability. Case Description: A young female exhibited recurrent fantasy-based sexual experiences involving a known person, described with vivid detail but without fixed delusional conviction. She intermittently recognized these experiences as unusual. Episodes were associated with dissociative fugue, marked by sudden travel away from home and partial autobiographical amnesia. No evidence of psychosis, substance use, or neurological disorder was found.

Stigmatizing

Yogender Malik, Adwitiya Ray Pt.B.D.Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India Background: Youths with Substance use disorders (SUDs) frequently encounter stigma. Stigma influences their willingness to seek support. Terms such as addictor alcoholicmay reinforce negative identities, contributing to avoidance of disclosure and delaying help-seeking. Understanding youth perspectives on stigmatizing language is essential for improving treatment engagement. Aim: To explore how youths perceive and use stigmatizing versus non-stigmatizing language related to SUDs, and how such language influences their help-seeking behaviour. Methods: This descriptive qualitative study used purposive sampling to recruit 60 participants aged 19-25 years who were abstinent or in supervised treatment for SUDs. Data collection used demographic survey, Social Identity Mapping (SIM) task, and in-depth face-to-face semi-structured interviews. In SIM task, participants visually mapped their social networks, identifying key individuals and each connection’s influence and substance-use status. A stigma-related language codebook was developed to classify negative or culturally derogatory substance-use terms. All labels used in SIM diagrams and interviews were categorized as stigmatizing or non-stigmatizing. Thematic analysis explored how stigmatizing language related to help-seeking behaviour, comfort with disclosure and willingness to seek support from formal services or informal networks. Results: Participants mostly rejected stigmatizing labels such as addictor alcoholic.They felt these terms were identity-defining and judgmental. Participants preferred person-first or recovery-focused language-person with addictionor in recovery.Stigmatizing language was linked to fear of judgment, less willingness to disclose substance use, and hesitation to seek professional help. While non-stigmatizing terms made participants more comfortable sharing their experiences. Conclusion: Stigmatizing language strongly influences adolescents’ help-seeking.

Transcranial

Mark Paramlall BIPA/Dalhousie University, Halifax, Canada Background and Purpose: Traumatic brain injury (TBI) is a leading cause of chronic disability, often causing debilitating cognitive impairments across domains like attention, memory, and executive function, severely affecting daily life. The complex pathophysiology includes tissue damage and secondary injury mechanisms. Crucially, no pharmacological treatments are yet approved for TBI-related cognitive dysfunction, highlighting the need for alternative therapies like transcranial direct current stimulation (tDCS). Methods: A comprehensive search spanned databases such as Allied & Complementary Medicine, APA PsycInfo, ClinicalTrials.gov, Embase, and MEDLINE, among others. The query linked tDCS and TBI with terms like “cognition,” “memory,” “attention,” and “executive.” Results were restricted to English publications between January 2000 and November 2025, considering document status, type, and English language, with duplicates removed. Results: From 114 abstracts, over 60 full-texts were reviewed. Results were notably heterogeneous, but most studies favored anodal stimulation targeting the dorsolateral prefrontal cortex (DLPFC). Some investigations reported improvements in attention, memory, and executive functions, yet the overall evidence base was limited by methodological variability. Conclusion: In conclusion, anodal tDCS, particularly to the left DLPFC, appears most promising for cognitive improvement in moderate-to-severe TBI patients in chronic phases. However, data for mild TBI is sparse, and optimal stimulation parameters need further study. Future research must focus on standardized protocols, long-term outcomes, and integration with cognitive rehabilitation.

Co Occurrence

Laya Sarkar Institute of Psychiatry- Centre of Excellence, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India Frontotemporal dementia refers to a group of clinical syndrome characterised by Frontotemporal lobar degeneration. Three core clinical syndrome include Behavioural variant frontotemporal dementia and primary progressive aphasia . Primary progressive aphasia has 2 variants, semantic variant and non fluent variant. This case reported here of a 51 year old female patient with history of diabetes and hypertension presented with history of symptoms of changes in her behaviour, with occasional anger outburst, with increased compulsive shopping behaviour, lack of self control in spending for past 12 years, gradually patient developed Parkinsonism symptoms including decreased arm swing, rigidity of hands for past 10 years. For past 2-3 years, she presented with urinary and fecal incontinence, imbalance while walking, repeatative behaviour like frequently touching her nose, over utilisation behaviour like picking everything near by object and putting inside her mouth and difficulty recognising faces . In past 3 weeks, she had shown decrease speech output. After admission her blood reports were in normal limit . She was started on following medication Tab Syndopa 110 mg, Tab Amlodipine 5 mg, Tab Telmisartan 40 mg, Tab Metformin 1000mg, Tab Quietiapine 25 mg, Tab Sertraline 25 mg but with minimal response. Because frontotemporal dementia is accompanied by Parkinsonism, antipsychotics may exacerbate the problem. This case emphasises the importance of multidisciplinary approach to management.

Complications

Himanshu Mittal, Mona Srivastava IMS, BHU, Varanasi, Uttar Pradesh, India Background: Modified Electroconvulsive therapy (M-ECT) is a safe and effective treatment for severe depression, particularly in urgent situations such as after a suicide attempt. However, medical complications may arise when toxic substances ingested during the attempt interact with anesthetic agents used in M-ECT. Careful preM-ECT evaluation is therefore essential to prevent adverse outcomes. Case Presentation: We report the case of a 55-year-old female, admitted to the psychiatry department following a alleged suicide attempt by ingesting Organo Phosphorus poison (commonly used as an insecticide). Initial management stabilized her medically, and subsequent psychiatric assessment revealed depressive symptoms with active suicidal Ideas Due to the severity of her condition, MECT was planned. During the first MECT session, the patient experienced prolonged paralysis following induction with a standard short-acting Succinyl-choline. Emergency supportive measures were initiated. Further review indicated that Organo-Phosphorous poison had interfered with Succinyl Choline metabolism, leading to extended muscle paralysis. Discussion: This case underscores the importance of detailed toxicology assessment and metabolic evaluation in patients presenting after ingestion of unknown or corrosive substances prior to MECT. Coordination between psychiatry, anesthesiology, and emergency medicine is crucial for preventing potentially life-threatening interactions. Conclusion: MECT remains a vital intervention in acute suicidal depression; however, thorough pre-procedure screening for substance ingestion and careful anesthetic planning are mandatory to ensure patient safety. This case highlights the importance that not only the attempt but the mode of attempt the patient had used should be thoroughly evaluated. Key words: Anesthetic interaction, depression, modified-electroconvulsive therapy, organo-phosphorous poisoning, patient safety, suicide attempt

Effectiveness

Amar Shinde Jagruti Rehabilitation Centre, Pune, Maharashtra, India Background: Alcohol use in India affects nearly 160 million individuals, with 5.2% requiring treatment for dependence. Chlordiazepoxide, remains the gold standard therapy for alcohol withdrawal syndrome (AWS); however, Indian data on its safety and effectiveness are limited. This is an interim analysis of the ongoing study. Objective: To evaluate the efficacy and safety of chlordiazepoxide in managing AWS using the CIWA-Ar scale across deaddiction centers. Methods: This prospective, multicenter, open-label study is being conducted across five Indian deaddiction centers, targeting 300 adult AWS patients (18-60 years). Participants received chlordiazepoxide (starting dose 100-150 mg/day) for 12 days, with CIWA-Ar assessments on Days 0, 6, and 12. The primary endpoint was percentage reduction in CIWA-Ar score from baseline to Day 12. Secondary endpoints included liver function tests (LFTs), time to symptom control, incidence of rebound symptoms, dropout rate, Delerium Tremens, outcomes of mild liver dysfunction and safety outcomes. Results: Interim analysis (n=113; as of November 1, 2025) showed a significant reduction in mean CIWA-Ar scores from 16.4 (Day 0) to 7.2 (Day 12). About 93 (82%) of patients improved from moderate to mild withdrawal severity, with no rebound symptoms, DT, or dropouts reported. Only 5 patients demonstrated deranged LFTs with mild liver dysfunction at baseline. Mean ALT (78.5 to 49.2 IU/L) and AST (77.8 to 34.2 IU/L) showed remarkable decline by Day 12, indicating improved hepatic function. Conclusion: Interim findings demonstrate that 12-day chlordiazepoxide therapy improves the CIWA-Ar scores and hepatic function with well-tolerated treatment and no safety concerns.

Idiosyncratic

Nagalapuram Jeevan Rishi, Jyostna Bhukya Department of Psychiatry, Andhra Medical College, Government Hospital for Mental Care, Visakhapatnam, Andhra Pradesh, India Background: Obsessive-Compulsive Related Disorders (OCRDs), including trichotillomania and excoriation disorder, may present atypically in individuals with Intellectual Developmental Disorder (IDD). Cognitive limitations can modify symptom expression, leading to idiosyncratic, symbolic, and potentially self-injurious behaviors that pose diagnostic and therapeutic challenges. Aim: To highlight atypical hair-pulling and skin-picking behaviors in IDD and examine the clinical rationale for using low-dose selective serotonin reuptake inhibitors (SSRIs). Methods: A 20-year-old female with moderate IDD presented with irritability, sleep disturbance, anger outbursts, hair pulling, and repetitive cheek picking over several months, resulting in a 6 × 3 cm excoriated lesion. The behavior was often performed in front of a mirror, with the patient using a razor blade to create symbolic patterns resembling the letter B,which she showed to others. These repetitive, tension-relieving behaviors were consistent with body-focused repetitive behaviors. She had comorbid hypothyroidism on treatment. Pharmacological management included lithium carbonate, aripiprazole, and quetiapine, with persistent obsessive-compulsive features. Fluoxetine 20 mg/day was added to target the obsessive-compulsive dimension. Results: Following initiation of fluoxetine, there was a marked reduction in hair-pulling and skin-picking behaviors within three days. Conclusion: This case emphasizes early recognition of OCRDs with trichotillomania and excoriation disorder in individuals with IDD. Targeting the underlying obsessive-compulsive mechanisms with SSRIs can result in rapid and significant improvement. Awareness of atypical presentations in neurodevelopmental disorders is essential for effective intervention and improved quality of life.

Investigating

Neerupreet Kaur Dhillon, Harish Kumar, Bhagwat N. Rajput World College of Medical Sciences and Research and Hospital, Jhajjar, Haryana, India Background: The management of treatment-resistant schizophrenia (TRS) in older adults remains an under-recognized challenge. Age-linked pharmacodynamic changes, cognitive decline, and multisystem comorbidities reduce antipsychotic responsiveness. Objective: To present clinical trajectories and therapeutic outcomes from a series of elderly TRS case reports in a tertiary setting. Methods: We present a series of individual case reports of elderly ( >60 years) patients with treatment-resistant schizophrenia, each showing inadequate response to two or more adequate antipsychotic trials. Clinical details including illness duration, symptom profile, past treatments, clozapine feasibility, and augmentation strategies were documented and compared to identify common patterns and management challenges. Results: All cases showed longstanding illness with persistent negative symptoms. Clozapine was tried in all cases, with variable degrees of response across individuals. Treatment required individualized titration due to heightened sensitivity to adverse effects and the presence of medical comorbidities.

Posttraumatic

Dev Himanshubhai Desai, Nikhar Satyapal, Bhushan Chaidhari Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India Background: Neuropsychiatric disturbances following traumatic brain injury(TBI) may include behavioural dyscontrol, emotional instability, and, less commonly, secondary delusional disorders. Othello syndrome is characterised by morbid jealousy and delusional beliefs of spousal infidelity and has been documented after neurological insults and may present diagnostic and therapeutic challenges. Early recognition is crucial, as such symptoms often remain overshadowed by other post-traumatic deficits. Aim: To present a case of Othello syndrome developing after severe TBI and highlight the association between right frontal-temporal injury and secondary delusional psychopathology. Methodology: A detailed clinical evaluation, mental status examination, and neuroimaging review were conducted for a 19-year-old male who developed behavioural changes and delusional infidelity following a road traffic accident. The patient’s symptom evolution, imaging findings, and treatment response were documented over serial follow-ups. Results: Within weeks of injury, the patient exhibited severe irritability, aggression, hypersexuality, and persistent delusional accusations toward his wife. MRI revealed right basifrontal and anterior temporal haemorrhagic contusions, subdural and subarachnoid haemorrhages, and diffuse axonal injury, correlating with behavioural dysregulation. Initial treatment with olanzapine reduced general irritability but not delusional infidelity or hypersexual behaviour. Subsequent addition of risperidone led to improved behavioural control. No prior psychiatric illness was noted, supporting a diagnosis of secondary psychotic syndrome per ICD-11. Conclusion: This case underscores the need for a comprehensive psychiatric assessment in TBI patients presenting with behavioural change. Right frontal and temporal lobe injury may play a key role in the emergence of Othello syndrome, providing insight into the neuroanatomical basis of secondary delusional disorders.

Psycho Social

Dheeraj Kattula, Jona Rai 1 , Shanthi Johnson 2 , Jansi Rani 3 Departments of Psychiatry and 3 Biostatistics, Christian Medical College, 2 College of Nursing, Christian Medical College, Vellore, Tamil Nadu, 1 School of Nursing, The Duncan Hospital, Raxaul, Bihar, India Background: Social media addiction is increasingly conceptualised as a behavioural addiction with potential adverse psychological and social consequences among young adults. Despite widespread digital engagement, Indian data examining its psycho-social correlates in non-medical college populations remains limited. Aim: To estimate the prevalence of social media addiction and to compare selected psycho-social correlates between college students with and without social media addiction. Methods: A comparative study was conducted among students of a general degree college in South India. 470 were screened using the Bergen Social Media Addiction Scale. From this cohort, 144 students were selected through computerized stratified random sampling and classified into addiction and non-addiction groups. Psychological well-being, personality traits, family functioning, motives for social media use, and coping styles were assessed using standardized instruments. Data were analysed using descriptive statistics, independent t-tests, chi-square tests, and multivariate logistic regression. Results: The prevalence of social media addiction was 78.4%. Students with social media addiction reported significantly longer daily duration of use and greater engagement with video-sharing platforms. Significant group differences were observed in psychological well-being, neuroticism, family affection, and coping styles, with greater reliance on maladaptive and avoidant coping strategies among those with addiction. Multivariate analysis identified total duration of social media use and engagement with video-sharing platforms as significant predictors, explaining 55% of the variance. Conclusions: Social media addiction was highly prevalent and associated with multiple psycho-social vulnerabilities. The findings highlight the importance of early identification and psychosocial interventions to promote healthier digital engagement among college students.

Psychodynamic

S. V. Subhash, K. Shankar Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India Background: In adults with Autism Spectrum Disorder (ASD), impaired social cognition, rigid behavioral patterns, and difficulty interpreting internal states often contribute to inappropriate sexual behaviors. When combined with low literacy and limited coping strategies, sexual impulses may become repetitive, stimulus-bound, and socially disruptive. Case Description: A 51-year-old married male with ASD (education till 4th standard) presented with repeated public masturbation on a specific road after watching women fetch water from a hand pump. He demonstrated minimal awareness of social boundaries and was unable to identify early arousal cues. He also exhibited hypersexual behavior towards his wife with demands for prolonged intercourse. Family stress was heightened due to his younger son’s intellectual disability. Assessment and Formulation: • Impaired impulse control and poor understanding of privacy • Sensory driven arousal triggered by a specific visual stimulus • Behavioral rigidity characteristic of ASD • Severely limited mentalization, making urge identification difficult. Due to low literacy, urge diaries were not feasible. Intervention: 1. Behavioral training using simple pictures to teach public vs. private acts 2. Redirection strategies, instructing masturbation only in a closed room 3. Stimulus control, modifying his walking route to reduce exposure to the triggering location 4. Spousal psychoeducation to set sexual boundaries 5. Supportive psychodynamic techniques focusing on impulse regulation 6. Pharmacotherapy with Escitalopram 30 mg/day to reduce compulsive sexual behavior, intrusive urges, and mood-related impulsivity. Outcome: Within 2-3 sessions, public masturbation reduced markedly, and he consistently shifted the behavior to private spaces. Family distress decreased, and marital dynamics improved.

Reintegration

Prerna Nigwal, Richa Choudhary MGM Medical College, Indore, Madhya Pradesh, India Alcohol-related psychosis (ARP) is an acute, reversible psychotic disorder associated with heavy or chronic alcohol consumption. This case report describes the emergency presentation, clinical management, and successful reintegration of a 45-year-old man brought by police after being found wandering naked, verbally abusive, and responding to hallucinations. Mental status examination revealed irritability, impaired judgment, poor insight, heightened psychomotor activity, and persistent auditory hallucinations. A pungent odor of alcohol, elevated liver enzymes, and stable neurological investigations supported the diagnosis of alcohol-related psychosis with differential consideration of unspecified psychosis. The pathophysiology of ARP involves dysregulation of multiple neurotransmitters: increased dopaminergic activity in mesolimbic pathways, altered serotonin receptor binding and transporter availability, and chronic alcohol-induced imbalance of GABA and glutamate systems, contributing to withdrawal-related agitation and hallucinosis. The patient was admitted under Section 89 of the Mental Healthcare Act, 2017, due to impaired decision-making capacity and risk to self and others. Management included intramuscular haloperidol, intravenous lorazepam, thiamine supplementation, IV fluids, and supportive care. Over 5-7 days, the patient showed significant improvement, becoming calm, cooperative, and regaining decision-making capacity. A structured psychosocial rehabilitation plan facilitated reconnection with his family. This case demonstrates the importance of early identification, prompt pharmacological intervention, detoxification, and multidisciplinary rehabilitation in the treatment of ARP. The rapid recovery highlights the reversible nature of alcohol-induced psychosis when appropriately managed.

Strengthening

Shreya Suresh, Suvarna Jyothi Kantipudi, Susan J. Wenze 1 Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India, 1 Lafayette College, Easton, Pennsylvania, USA One in 7 Indians, approximately 200 million people, experiences a mental health disorder at any given time. Despite this fact, less than 1% of India’s national health budget is allocated to mental health services, and only 10% of Indians with mental health needs utilize available care. Community mental health initiatives, implemented by non-governmental organizations (NGOs), hold promise as a way to fill this gap, yet little is known about what makes such initiatives effective or not. This study aimed to explore community mental health stakeholders’ perspectives on necessary steps to further democratize mental health and well-being in India. Fifteen semi-structured interviews were conducted with psychiatrists (n = 2), psychologists (n = 4), social workers (n = 3), community field workers (n = 3), and service users (n = 3) at 2 mental health NGOs in Chennai, Tamil Nadu. Key themes that emerged from the interviews included the importance of making initiatives engaging, dismantling traditional power dynamics, collaborating with myriad partners, focusing on health and flourishing, and addressing context-specific barriers and needs. Study findings underscore the importance of thinking creatively about mental health service delivery, maximizing existing resources, and advocating for sustainable policy changes. Such tactics have potential to improve mental health literacy and promote mental health and well-being in India through a community-based approach.

Understanding

Raman Deep AIIMS, New Delhi, India Background: Psychiatric disorders are associated with elevated long-term cardiovascular disease (CVD) risk. Although this relationship is known, how these individuals understand their health risks and what shapes their readiness for preventive behaviors remains less explored. Developing a culturally-grounded intervention demands examining patients’ health perceptions, practices, and the psychological and contextual barriers. Aim: As part of a project to adapt a brief-intervention to reduce CVD risk in depression, we qualitatively explored behavioral, cognitive, and contextual factors influencing readiness for lifestyle modification among stable patients in psychiatric setting to understand Indian cultural perspective. Methods: Thirty adults (18+ years), with equal gender distribution, attending the psychiatry OPD, primarily with depressive/mood and anxiety spectrum disorders stabilized on treatment, participated. Purposive sampling was used. Semi-structured interviews examined themes related to health, diet, physical activity, and substance use. Results: Participants largely equated health with physical well-being. Dietary behaviors were shaped by gender roles, joint family norms, convenience, cultural patterns, and affordability. Adherence was hindered by fatigue, anhedonia, low motivation and caregiving role at home. Physical activity was preferred indoors or with company, mainly walking or traditional exercises. Substance use was linked to social contexts and stress. Barriers included depressive symptoms, limited social support, and incompatibility with work routines. Facilitators involved psychoeducation, family support, responsibility toward dependents, and structured routines. Cognitive barriers such as all-or-none thinking, low confidence, poor decision-making, and meaninglessness impeded change. Conclusion: Findings provide key insights to inform the development and cultural adaptation of motivational intervention to prevent long-term CVD risk in psychiatric setting.

Benzodiazepine

Deepali Negi, Roshan Bhad, Gurveen Kaur National Drug Dependence Treatment Centre, AIIMS, Delhi, India Alcohol dependence is a chronic relapsing condition often complicated by physical, psychological, and social sequelae. Despite standard detoxification and rehabilitation protocols, a subset of patients undergoes recurrent relapses, leading to difficult recovery and increase in the burden of care. We present a series of three cases, all men, who sought treatment at our centre for alcohol dependence. Each had a history of multiple relapses and significant complications including hepatic dysfunction, cognitive impairment, and psychosocial deterioration. Conventional treatment approaches had limited success in sustaining abstinence in these patients. After detoxification low dose benzodiazepine was continued under close clinical supervision. Each case was monitored over a six-month period, with individualized dosing regimens and adjunct psychosocial support. Outcomes were assessed across domains including relapse frequency, biochemical markers, and social functioning. Preliminary findings suggest that benzodiazepine maintenance, when cautiously administered, may offer a viable harm-reduction strategy for treatment-refractory alcohol dependence.

Disorientation

B. Jayachandra, Jayanth Kumar Kanachur Institute of Medical Sciences, Mangalore, Karnataka, India Introduction: Consciousness refers to awareness of oneself and the surrounding environment, with disturbances ranging from full alertness to coma. Vigilance is the ability to remain alert despite drowsiness, while orientation enables accurate recognition of time, place, and person. Delusional Misidentification Syndromes (DMSs) are rare psychiatric conditions in which individuals persistently misidentify people, places, or events. These syndromes may also involve altered time perception, leading to significant distortions in reality interpretation. Case Description: Mr. M., a 57-year-old married farmer from rural Kasargod with primary education, has had schizophrenia for 30 years and inconsistent treatment for 15 years. His history included poor medication compliance, wandering tendencies, four months of reduced sleep, irrelevant speech, beliefs of possessing special powers, and impaired functioning. Physical examination revealed no neurological abnormalities. On mental status examination, he was conscious, cooperative, and well-kempt, with appropriate eye contact. Psychomotor activity and speech were normal, and attention was sustained. He was oriented to person but demonstrated delusional misidentification of place along with persecutory and bizarre delusions. He reported auditory hallucinations of God speaking positively to him. Judgment was impaired, and insight was absent. Conclusion: Delusional Misidentification Syndromes represent significant disturbances in reality testing, particularly in schizophrenia. Reduplicative paramnesia highlights the extent to which recognition of place and identity can be distorted. When accompanied by altered time perception, these symptoms further disrupt an individual’s connection to reality. Early identification supports accurate diagnosis and targeted intervention. Key words: Auditory hallucinations, delusional misidentification, disorientation, reduplicative paramnesia, schizophrenia, time perception

Hypersexuality

Sneha, K. Kiran Kumar, T. Sudharshan Vydehi Institute of Medical Sciences, Bengaluru, Karnataka, India Introduction: Hypersexuality is a complex behavioural presentation encountered across psychiatric, neurological, and personality disorders. When accompanied by wandering behaviour, aggression, and emotional dysregulation, diagnostic clarity becomes challenging. Frontal-subcortical dysfunction and small-vessel ischemic changes may contribute to impaired impulse control and disinhibition. This case highlights such a multifactorial behavioural syndrome requiring detailed biopsychosocial evaluation. Aim: To describe a diagnostically challenging case of hypersexuality with wandering behaviour and personality traits, and to emphasize the value of neurocognitive assessment and MRI findings in understanding behavioural dysregulation. Methods: A comprehensive psychiatric evaluation, mental status examination, and neuropsychological testing (MMSE, FAB, ACE, IPDE) were performed. MRI brain (T2/FLAIR sequences) assessed structural abnormalities. Biopsychosocial factors and treatment response were monitored during admission. Results: A 43-year-old male presented with a 10-year history of hypersexuality, repeated absconding episodes, irritability, and anger outbursts. Neuropsychological assessment revealed preserved global cognition with mild executive dysfunction and mild cognitive impairment. IPDE suggested impulsive, dissocial, and borderline personality traits. MRI brain demonstrated bilateral frontal and right parietal T2/FLAIR hyperintensities consistent with chronic small-vessel ischemic changes. Absence of distress or compulsive features ruled out ICD-11 Compulsive Sexual Behaviour Disorder. Partial behavioural stabilization was achieved with risperidone, clonazepam, psychoeducation, and family supervision. Conclusion: This case underscores the importance of integrating neurocognitive testing and neuroimaging when evaluating complex behavioural presentations.

Ocd Compulsion

Sampad Kumar Naik, Haseeb Khan, Astha Singh, Natasha, Saurabh Upadhyay Department of Psychiatry, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India Introduction: Obsessive-Compulsive Disorder (OCD) commonly involves themes like contamination, checking, or intrusive thoughts of harm or morality. However, it can manifest through rare and interesting obsessions and compulsions, reflecting its diverse nature. This report highlights a unique thought of losing her mother-related obsession and compulsion of bathing. Case Report: A 15-year-old female presented to the Psychiatry Outpatient Department with persistent, intrusive thoughts about losing her mother when someone passes between her and her mother. To alleviate the resulting anxiety, she feels compelled to hold her mother’s hand for most of the day, which offers only temporary relief. Her anxiety intensifies when others approach, as she perceives them as potential threat that they might pass between her and her mother. She also has restricted her mother from performing routine household activities, including cooking, insisting on constant holding of her hand even when she uses the bathroom. If anyone walks between her and her mother, she feels compelled to take bath to neutralize these thoughts. These symptoms have caused significant impairment in her functioning. Discussion: This report outlines a rare OCD presentation marked by obsessions and compulsions driven by fear of losing her mother. Such atypical forms expand the understanding of OCD beyond common patterns. Early recognition of these unusual features supports timely diagnosis, targeted intervention, and improved overall functioning. Conclusion: This case shows OCD may appear in atypical forms beyond common themes. Early recognition, tailored treatment, and family psychoeducation are key to effective management and better overall outcomes.

Socio Cultural

Aishwarya Mittal, A. K. Seth, Anuj Mittal 1 Santosh Medical College and Hospitals, Ghaziabad, Uttar Pradesh, 1 Deen Dayal Upadhyay Hospital, New Delhi, India Background: Gender dysphoria (GD) refers to incongruence between an individual’s assigned sex at birth and their experienced gender, causing severe distress and functional impairment. In India, sociocultural stigma, lack of awareness, and limited access to gender-affirmative care hinder help-seeking and societal acceptance, leading to increased psychological distress. Aim: This case report illustrates the clinical presentation, impacts of socio-cultural pressures and events in the Indian context and a 20-year psychological journey of a GD patient. Case Presentation: A 42-year-old individual assigned female at birth, identifying as male, presented with increased anxiety, insomnia, and depressive symptoms with suicidal ideations, multiple suicide attempts; has been under the care of mental health experts for the past 20 years. Due to family pressure, patient married a biological male 15 years ago, but got divorced by mutual agreement. Patient opted for gender reassignment surgery, after which most of her family disowned her. Clinical evaluation confirmed DSM-5-TR criteria for Gender Dysphoria, with comorbid severe depression and generalized anxiety. Outcomes/Results: At six-month follow-up, the patient demonstrated marked improvement in mood, reduced anxiety, greater functionality and reported improved self-confidence. Family members display increasing acceptance following structured counselling but revert back to a denial- like state. Conclusion: This case highlights how a person of GD suffers throughout their life because of identity suppression by family, causing conflicts and exacerbation of psychiatric symptoms. It also explains that early intervention, family engagement, and culturally sensitive counselling significantly improves mental health, psychosocial outcomes for individuals with GD in resource- and/or stigma-constrained settings.

Childhood Onset

Ananya Malhotra, R. Amrtavarshini 1 , M. N. Anil Kumar 1 , Pooja Bangera 1 , Atri Chatterji 1 Kasturba Medical College, 1 Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India Background: Intermittent Explosive Disorder (IED) is characterized by recurrent verbal or physical aggression disproportionate to provocation, causing distress or impairment. The prevalence of IED in adolescents is nearly 8%, with a mean onset around 11 years. Childhood-onset IED is rare and often difficult to diagnose due to developmental immaturity and frequent comorbidity with Attention Deficit Hyperactivity Disorder (ADHD) and conduct problems, leading to diagnostic confusion with other disorders of impulsive aggression. Aims: To describe the clinical profiles, comorbidities, and short-term treatment outcomes of children diagnosed with childhood-onset IED. Methods: Three children diagnosed with IED using the Structured Clinical Interview for DSM-5 (SCID-5) and detailed clinical evaluation were reviewed. Data on developmental, family, and school history, temperament, electroencephalography (EEG) findings, comorbidities, treatment, and outcomes were collected. Treatment response was assessed qualitatively based on clinician-rated improvement in the frequency and severity of aggressive outbursts over follow-up. Results: All three children were male (aged 7-10 years). Two had comorbid ADHD, and all exhibited brief, impulsive aggression disproportionate to triggers, followed by remorse. EEGs showed epileptiform activities. Treatment was individualized fluoxetine, carbamazepine, and clonidine were prescribed based on symptom profile and comorbidity with significant reduction in aggression and improved emotional regulation. Cognitive behavioral therapy (CBT)-based anger management further enhanced outcomes. Conclusion: Though impulsive aggression is common in early childhood, IED is a rare diagnosis in this age group. Childhood-onset IED may be confused with ADHD, oppositional defiant disorder, or mood disorders. Comorbidities are common, and individualized multimodal treatment is essential.

Neuromodulation

Pushkar Saini, Mustafa Ali, Vishav Institue of Human Behaviour and Allied Science, New Delhi, India Background: Modified electroconvulsive therapy (mECT) is a well-established neuromodulation treatment for severe depressive episodes. While generally safe, rare paradoxical reactions such as catatonia may occur. Aims: This case report aims to raise awareness that catatonia can be precipitated in patients on mECT. Methods: Thorough clinical examination and daily observation were done to rule out catatonia before the start of mECT. Detailed neurological examination and blood investigation were done to rule out any neurological or metabolic causes. Catatonic signs were assessed by Brush-Francis Catatonia Rating Scale. Results: A 45-year-old male with diagnosis of Recurrent Depressive Disorder, current episode severe without psychotic symptoms. Initially, he was treated with venlafaxine and lithium for 5 days, followed by administration of mECT. Initial improvement was noted in MADRS scores following 3 mECT sessions. However, after the 4th session, patient exhibited catatonic symptoms, including posturing, mutism, negativism, withdrawal, and decreased input/output, which were not there while the patient was on psychotropics alone. These symptoms resolved within 48 hours following discontinuation of mECT and administration of a lorazepam challenge test, indicating lorazepam-responsive catatonia precipitated by mECT. Conclusion: Case demonstrates catatonia as a possible but uncommon side effect of mECT in patients. Catatonia is highly responsive to benzodiazepines, prompt identification is critical. Clinicians using neuromodulation therapies should be vigilance for emergent catatonic features to ensure timely diagnosis and effective intervention.

Capgras Delusion

D. C. Monith, G. Anuhya Guyton 1 Andhra Medical College, Government Hospital for Mental Care, 1 Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Capgras syndrome is a rare delusional misidentification disorder observed in various psychiatric conditions, particularly schizophrenia. It is characterized by the belief that familiar people, places, or objects have been replaced by imposters. Aim: To describe the clinical characteristics and manifestation of Capgras syndrome in a female patient with schizophrenia. Methods: A 65-year-old married female with a 25 year history of schizophrenia, previously stable on risperidone, experienced a relapse - a breakthrough episode. She presented with suspiciousness, Talking to self, Physically abusive on Husband, Anger outbursts, Examination revealed Normal psychomotor activity, Coherent and relevant speech, Delusion of Infidelity, delusions of persecution and a fixed Capgras delusion, believing Her Husband is not her Husband, he is looking like him but not the same, and Grade 0 insight. Results: She was treated with Clozapine 150mg/day and Amisulpride 200mg/day underwent 8 ECT sessions over three weeks, resulting in complete resolution of her misidentification delusion and overall symptom improvement. Conclusion: This case highlights Capgras syndrome as a dominant psychotic theme in schizophrenia, occurring independently of an organic substrate. It underscores the importance of recognizing delusional misidentification and demonstrates that targeted antipsychotic treatment and ECT can effectively resolve the symptoms.

Fever Associated

Rahul Sahare, Abhay Paliwal, Riya Gangwal, Pali Rastogi MGM Medical College, Indore, Madhya Pradesh, India Background: Psychosis temporally associated with recent febrile illness is increasingly reported, especially in low- and middle-income countries. Yet, systematic prospective data on this phenomenon remain sparse. Aim: To describe the clinical features, short-term outcome, and diagnostic stability of fever-associated Acute and Transient Psychotic Disorder (ATPD), and to contextualize findings within the infectious-inflammatory hypothesis of psychosis. Methods: Eight first-episode ATPD patients with documented fever (≥38°C) within seven days of psychosis onset were enrolled at a tertiary hospital in Central India and followed for six months. Diagnosis was based on ICD-10-DCR criteria, confirmed by two independent psychiatrists. Structured assessments included the Brief Psychiatric Rating Scale (BPRS-18) and the Global Assessment of Functioning (GAF). A comprehensive fever-of-unknown-origin (FUO) workup was conducted to rule out infectious, autoimmune, or neurological causes. Results: The mean age was 28.6 ± 4.8 years; five were female. Psychotic symptoms appeared within one to five days of fever onset. Baseline BPRS averaged 52, reducing to <19 by one month. Hallucinations, delusions, disorganized behavior, and affective lability were predominant. ATPD subtypes included F23.0 (n=6) and F23.1 (n=2). CRP was transiently elevated in two patients (7-14 mg/L), normalizing within a week. All patients received risperidone (2-4 mg/day) for 4-6 weeks. At three months, all patients achieved GAF >70. No diagnostic transitions or relapses occurred at six months. Conclusion: Fever-associated ATPD may represent a self-limiting, para-infectious psychosis with a benign trajectory. Recognizing this clinical entity may promote early diagnosis, prevent mislabeling with chronic psychiatric disorders, and limit unnecessary long-term antipsychotic exposure.

Hemisomatognosia

Harshita Rai, Sabari Sridhar Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India A 28 years old male, formally educated till 10th standard,working in a shoe company, 1st born of non consanguineousmarriage, from lower socio economic status of urban background who presented to our outpatient psychiatry service with a 3 day history of subjective disappearanceof sensation and ownership of the left side of her body. The patient described the left arm and leg as feeling not part of me,accompanied by intermittent paresthesia but without overt motor weakness or sensory loss on clinical examination. Substance use was not clearly established as patient was very guarded.There was no history of trauma, or significant medical illness. Mental status examination revealed intact cognition, normal mood and affect, and absence of psychotic features; however, he demonstrated persistent conviction of altered body ownership. Neurological examination and bedside cognitive tests were unremarkable except for inconsistency between subjective experience and objective findings. Neuroimaging (MRI brain) showed no abnormality.Neuropsychological testing showed deficits in proprioceptive integration and spatial attention. A multidisciplinary provisional diagnosis of hemisomatognosia was made. Psychological assessments showed clinically significant scores in Dependent personality traits with negativist pattern. He scored high in anxiety under clinical syndrome in MCMI.Further probing gave high scores in drug dependence pattern.Management included structured psychoeducation, cognitive rehabilitation focusing on body awareness, and supportive psychotherapy to reduce distress and functional impairment. Pharmacotherapy with a low-dose atypical antipsychotic was considered to target fixed abnormal beliefs when present.

Neuropsychiatric

Prachi Dixit, Neena Sawant 1 , Karishma Rupani, Utkarsh Mestri KEM, 1 B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India Introduction: Childhood-onset psychosis is rare and often poses diagnostic challenges, requiring extensive evaluation to rule out underlying organic or genetic causes. Mitochondrial disorders, although uncommon, can manifest with neuropsychiatric symptoms. This case highlights a child presenting with psychosis and behavioral abnormalities later found to have a pathogenic variant in the MT-ND6 gene, associated with mitochondrial disorders. Case: A 12-year-old male presented with a 4-year history of progressive aggressive and assaultive behavior, muttering and smiling to self, language regression, and cognitive decline, with worsening symptoms over the past 6 months. Initial investigations, including normal EEG and negative Wilson’s disease markers, did not reveal any neurological disorder. MRI of the brain showed a large arachnoid cyst in the left anterior temporal lobe, for which excision and right amygdalectomy were performed. Post-surgery, the patient’s behavior deteriorated further, and multiple trials of antipsychotics provided minimal improvement. A follow-up MRI revealed residual cyst and encephalomalacia in the left temporal region. Genetic testing via whole exome sequencing identified a pathogenic variant in the MT-ND6 gene, associated with mitochondrial encephalopathy and other neurodegenerative conditions. The child was managed symptomatically with antipsychotics for behavioral control and is under regular follow-up with psychiatry and genetic pediatrics. Conclusion: This case underscores the importance of considering mitochondrial disorders, such as those related to MT-ND6 gene mutations, in the differential diagnosis of childhood onset psychosis, particularly in the presence of neurological findings. Early recognition and a multidisciplinary approach can help manage complex psychiatric and neurological manifestations effectively.

Psychiatrists’

Parameshwaran Ramakrishnan 1,2 1 The AdiBhat Foundation of India, New Delhi, India, 2 Tower Health Phoenixville Psychiatry, Drexel University College of Medicine, PA, USA Background: Empathic listening (EL) assessments in psychiatry and chaplaincy are believed to induce self-transcendent experiences. However, neuroscientific studies of it are sparse. Aim: To report a methodology for electroencephalogram-based objective correlations of self-transcendent experiences among care providers (psychiatrists and chaplains) and their care recipients during empathic listening assessments. Methodology: Nine participants (2 EL-trained clinicians, a psychiatrist and a chaplain, and 7 untrained students: 4 medical, 3 theological) engaged in empathic listening across 12 dyads. Trained providers led six intervention dyads; untrained student-led dyads served as controls in the remaining six. Sessions averaged 34.3 minutes (SD = 4.25). Pre-/post-session wellness was measured using the Visual Analog Scale (VAS). EEG data (Delta-Gamma bands) were recorded via Muse® headsets during all sessions. Qualitative data were analyzed using autoethnography and grounded theory. Results: EL in trained-provider dyads demonstrated the mindfulness-to-transcendence (MT) framework, characterized by sequential alpha-theta-gamma EEG activity. Gamma predominance, marking self-transcendence, correlated with self-reported awe and healing experiences. Gamma synchronization (with 0-1 minute lag), indicative of the we-modeor non-dual empathic state, was observed in all trained-dyads. Care recipients in the trained-dyads showed significantly higher post-session VAS well-being scores (p < 0.001) compared to controls. Control-dyads lacked sustained gamma activity and neural synchrony, paralleling muted subjective experiences. Conclusion: Portable EEG devices offer a viable method for the evidence-based study of self-transcendence and its healing in EL assessments in psychiatry and chaplaincy. EEG correlates demonstrating connectedness, empathy, and transcendence supports an evidence-based approach to spiritually informed psychiatric assessment and care.

Clozapine Induced

Dhruv Sojitra, Rashmita Saha, Anusha Garg Institute of Human Behaviour and Allied Science, Delhi, India Background: Clozapine is the gold standard for treatment-resistant schizophrenia (TRS), with a known side-effect profile primarily involving hematological and cardiac risks. Neurological adverse events like cerebellar ataxia are uncommon and underreported. Case Presentation: A 39 year old male with a 10 year history of TRS exhibited persistent negative symptoms and partial response to haloperidol and amisulpride. Clozapine was started and titrated to 300 mg/day. Initial improvement was noted in psychotic symptoms (PANSS score improvement), but at this dose, the patient developed tachycardia, hypotension, dizziness, and notable gait instability progressing over 10 days, culminating in a fall causing nasal bleeding. Cerebellar examination before initiation was normal. These clinical features were compatible with clozapine-induced cerebellar ataxia, prompting dose reduction and haloperidol augmentation. Discussion: Clozapine-induced ataxia is a rare but important adverse effect, primarily observed in intoxication but also at therapeutic doses in rare instances. Early detection via regular neurological examination, including gait and coordination evaluation, is essential to prevent serious complications. Conclusion: This case underscores the necessity of vigilance for neurological side effects such as ataxia during clozapine therapy in TRS. Prompt recognition and management can prevent morbidity and facilitate safe continuation or timely regimen adjustment.

Electroconvulsive

Gagan Hans, Sakshi Panwar, Tanmay Dey Sarkar 1 , Uma Sharma 1 Departments of Psychiatry and 1 NMR, AIIMS, New Delhi, India Background: Electroconvulsive therapy (ECT) is an effective neuromodulation treatment for patients with treatment-resistant depression (TRD), but its effects on brain structure and neurochemistry are still not fully understood. Aims: We aim to investigate the structural and neurochemical changes in patients with TRD after 4 weeks of ECT. Methods: Twenty TRD patients and sixteen healthy controls (HC) underwent MRI scanning. Patients were scanned on two occasions, before ECT and after four weeks of treatment while HC underwent one scan of MRI. Structural MRI (3D T1-weighted) and magnetic resonance spectroscopy (MRS) data were acquired at 3 Tesla (3T). MRS voxels were placed in the anterior cingulate cortex (ACC) and right hippocampus. Volumetric analysis was performed using FreeSurfer v7.2.0, normalized to intracranial volume, and neurochemical analysis using Osprey v2.6.6. Results: There was a significant increase in total choline levels (p=0.029) in TRD patients as compared to HC at baseline, which may indicate enhanced cell membrane turnover. There was also a significant reduction in right amygdala volume (p=0.038) in TRD patients as compared to HC at baseline. A non-significant trend toward a decreased right insular volume was also observed (p=0.080) in patients with TRD in comparison to HC. Structural imaging also showed increased volume of both right amygdala (p<0.001) and the right insula (p=0.005) post ECT treatment in patients with TRD. Conclusion: Our results demonstrate significant neurochemical and structural alterations between patients and HC at baseline and changes in patients after ECT treatment.

Mindfulness Based

Saumya Rathi, G. K. Vankar Parul Institute of Medical Science and Research, Waghodia, Gujarat, India Background: Panic disorder involves recurrent, unexpected panic attacks accompanied by persistent worry and avoidance. While CBT with pharmacotherapy remain first-line treatments, many individuals prefer non-pharmacological strategies. Mindfulness-based interventions, particularly body scan meditation, may help patients reinterpret and tolerate bodily sensations that typically trigger panic. Aim: To describe the therapeutic process and clinical outcomes of an eight-week mindfulness-based body scan intervention in a patient with panic disorder who declined pharmacotherapy. Methodology: A 28-year-old woman with moderate panic disorder (PDSS score: 15) participated in weekly 60-minute mindfulness sessions over eight weeks, supplemented by daily home practice. The intervention included psychoeducation, guided body scan exercises (10-30 minutes), gradual interoceptive exposure, and integration of mindfulness into daily activities. Progress was monitored using clinical interviews, a mindfulness diary, functional improvement, and serial PDSS scores. Results: Early sessions triggered mild anxiety when focusing on bodily sensations; however, consistent practice led to increased interoceptive awareness, reduced catastrophic interpretations, and decreased experiential avoidance. At week eight, her PDSS score decreased to 4, indicating minimal symptoms. Follow-up at three months showed sustained remission with no recurrence of panic attacks. Conclusion: Mindfulness-based body scan practice served as both an exposure and self-regulation strategy, enabling the patient to break the fear cycle. This low-cost, accessible intervention demonstrated substantial improvement without pharmacotherapy, highlighting its value as a complementary approach in the psychological management of panic disorder. Key words: Neurological soft signs, positive symptoms, schizophrenia

Psychiatric Onset

Simpi Bhowmick, M. Raghuram 1 Varun Arjun Medical College and Rohilkhand Hospital, Banthra, 1 Department of Psychiatry Dr. Varun Arjun Medical College, Shahjahanpur, Uttar Pradesh, India Introduction: Huntington’s disease (HD) is a rare, fatal, autosomal dominant neurodegenerative disorder caused by abnormal expansion of CAG trinucleotide repeats in the huntingtin gene on chromosome 4. Although the classic presentation involves choreiform movements, cognitive decline, and behavioural disturbances, a minority of patients develop prominent psychotic features resembling schizophrenia. Psychosis is more frequently associated with early-onset HD and paternal inheritance. This report describes an atypical early-onset case of HD in a young adult presenting predominantly with psychotic symptoms. Materials and Methods: This descriptive single-case study was compiled using clinical history, neurological examination, mental status assessment, neuroimaging findings, and molecular genetic testing of a 29-year-old male previously diagnosed with HD. Additional information was collected from caregivers and family members. All data were obtained during inpatient and outpatient evaluations at a tertiary-care centre. Results: The patient presented with a 2-month history of persecutory delusions, third-person auditory hallucinations, aggression, and social withdrawal. He also had a 2-year history of progressive involuntary choreiform movements starting in the hands and later involving all limbs and face. Neurological examination revealed hypotonia, ataxic gait, unclear hypophonic speech, and generalized chorea. MRI showed disproportionate cerebral and basal ganglia atrophy. Genetic testing confirmed an expanded allele with 51 CAG repeats. A strong paternal family history of chorea and. Key words: Case report, huntington’s disease, paranoid schizophrenia, psychotic features

Disulfiram Induced

Shubha Bagri, Hemant Choudhary 1 , Vaibhav Patil 1 All India Institute of Medical Sciences, 1 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India Background and Aim: Disulfiram is widely used as an aversive agent in alcohol dependence treatment. Beyond aldehyde dehydrogenase inhibition, it inhibits dopamine beta-hydroxylase, elevating central dopamine levels and potentially precipitating neuropsychiatric complications including catatonia. Recognition of this rare adverse effect is crucial, as early intervention can prevent life-threatening complications. We report a case of disulfiram-induced catatonia with reproducible symptom recurrence upon rechallenge. Method: Clinical case presentation. Results: A 39-year-old male with alcohol dependence syndrome, without prior psychiatric history, was initiated on disulfiram 500mg. Following dose escalation to 1000mg, he developed progressive neuropsychiatric deterioration initially forgetfulness, insomnia, and anxiety, evolving over two weeks into catatonia with mutism, negativism, posturing, rigidity, stereotypy, and food refusal (BFCRS=23). MRI brain, liver function, and metabolic panels were unremarkable. Intravenous lorazepam challenge produced dramatic improvement (BFCRS reducing to 6 within 15 minutes). Despite initial recovery with modified ECT and lorazepam during hospitalization, catatonic symptoms recurred upon disulfiram re-initiation post-discharge, establishing clear temporal causality. Complete resolution occurred following permanent disulfiram discontinuation, lorazepam maintenance, and acamprosate initiation for craving management. Conclusions: This case demonstrates dose-dependent disulfiram-induced catatonia with reproducible symptom recurrence upon rechallenge, strengthening causal association. Clinicians prescribing disulfiram, particularly at doses exceeding 500mg, should maintain vigilance for emerging neuropsychiatric symptoms. Early recognition and prompt benzodiazepine administration are essential for favorable outcomes. Key words: Alcohol dependence syndrome, catatonia, disulfiram, dopamine beta-hydroxylase, lorazepam challenge, organic catatonia

Neurocysticercosis

Bhavya Banda, D. Vishnu Priya, R. Kishore Kumar, P. S. Murthy Santhiram Medical College and Hospital, Nandyal, Andhra Pradesh, India Introduction: Neurocysticercosis (NCC), a common parasitic infection of the central nervous system, can present with diverse neuropsychiatric manifestations, complicating diagnosis when psychological symptoms coexist. Dissociative disorders especially in sociocultural contexts where possession states are common idioms of distress may mimic or mask neurological pathology. This case illustrates the difficulty of differentiating dissociative phenomena from organic brain disease. Case Presentation: A 23-year-old married woman developed abrupt abnormal behavior following family conflict, including trance-like states, deity-possession-like experiences, poor responsiveness, and impaired childcare. Neurological examination showed no focal deficits. Contrast-enhanced MRI revealed a ring-enhancing lesion in the left frontal cortex and multiple bilateral frontoparietal hyperintensities consistent with NCC. Despite structural abnormalities, high suggestibility and symptom reversibility supported a diagnosis of concurrent dissociative/conversion disorder. She was treated with olanzapine, benzodiazepines, and supportive psychotherapy, resulting in marked symptomatic improvement within days, alongside plans for antiparasitic management. Discussion: This case demonstrates the diagnostic pitfalls encountered when dissociative symptoms coexist with neuroimaging abnormalities. Frontal lobe involvement may influence behavior, yet psychosocial stressors and cultural expression patterns can produce clinical pictures resembling organic disease. Accurate diagnosis requires integrating neuroimaging, psychiatric evaluation, and sociocultural understanding. Conclusion: NCC presenting with dissociative symptoms can lead to misdiagnosis if assessed from a purely neurological or psychiatric perspective. A multidisciplinary, culturally informed approach is essential for appropriate management. Key words: Conversion disorder, cultural psychiatry, diagnostic dilemma, dissociative disorder, multidisciplinary management, neurocysticercosis

Neurodevelopmental

Mohit Singh, Abhishek Kumar, Jayati Simlai Ranchi Institute of Neuro Psychiatry and Allied Sciences, Ranchi, Jharkhand, India Background: Marfan syndrome is an inherited connective tissue disorder caused by mutations in the FBN1 gene with cardinal cardiovascular, musculoskeletal, and ocular features. Neurodevelopmental comorbidities such as autism spectrum disorder (ASD) or intellectual disability (ID) are rare and underreported. Presenting a case of a child with Marfan phenotype, early-onset seizures, and complex behavioral symptoms raising a diagnostic overlap between ASD and ID. Aim: To highlight the complex neuropsychiatric presentation in a child with Marfan syndrome, focusing on the diagnostic overlap between ASD and seizure-related behavioral manifestations, and to underscore the importance of early developmental assessment and multidisciplinary evaluation in syndromic cases presenting with severe intellectual disability. Case Description: A 14-year-old male presented with aggression, stereotyped sniffing behavior, poor social interaction, hypersensitivity to sound, and dependence for self-care. He had a history of three generalized seizures between ages 3.5 and 8.5 years, with no recent episodes. Phenotypic evaluation suggested Marfan syndrome, meeting the Revised Ghent criteria. IQ assessment revealed a score of 24 (severe ID), with a Social Quotient of 31. Despite features suggestive of ASD, the diagnosis was deferred due to diagnostic limitations of ASD tools in severe ID (IQ <35). Conclusion: This case of Marfan syndrome exhibits complex neurobehavioral profile consisting of IDD, generalised seizures, ASD and cognitive impairment. Increased clinician awareness critical for early recognition and better outcomes. Key words: Autism spectrum disorder, intellectual disability, marfan syndrome, neurodevelopment, seizure disorder

Olanzapine Induced

Saumya Mishra JNMC Medical College, Belgaum, Karnataka, India Background: Olanzapine is a commonly prescribed second-generation antipsychotic with a generally favorable safety profile. However, hematological toxicity especially pancytopenia is exceedingly rare and often under-recognized. Pancytopenia involves the simultaneous reduction of red blood cells, white blood cells, and platelets, leading to fatigue, infection risk, and bleeding tendencies. Early identification is essential because timely discontinuation usually results in full recovery. Case Description: A 46-year-old female from a rural background presented with irritability, disorganized behaviour,reduced sleep for three days, muttering to herself, andincreased religiosity. She had a history of one psychotic episode that previously improved with olanzapine but had discontinued due to improvement and also pancytopenia after starting of olanzapine in 2023. On this admission, she was diagnosed with Acute Transient Psychotic Disorder . Olanzapine 10 mg was initiated increased to 20mg. Within 10 days, CBC revealed a progressive decline in all three cell lines: haemoglobin decreased to 10.1 g/dL from 12.9g/dL, WBC count as low as 2.5 × 10³/µL from 7.9 × 10³/µL, and platelets decreased to 59,000 from 87,000. Peripheral smear showed reduced cell count with normal morphology. Viral markers (HBV, HCV, HIV) were negative, and liver functions were normal. USG revealed splenomegaly, which may have contributed but did not fully explain the acute decline. Management and Outcome: Olanzapine was cross tapered with aripiprazole upto 20mg,. Supportive treatment including antibiotics, multivitamins, and regular CBC monitoring was provided. Blood counts gradually improved following drug cessation. Conclusion: This case highlights a rare but serious instance of olanzapine-induced pancytopenia. Clinicians should maintain vigilance, perform periodic CBC.

Reduced Penetrance

Ashish Ranjan Panda, Santhosh Goud, Vishal Indla Indlas Hospitals, Vijayawada, Andhra Pradesh, India Introduction: Neurodegenerative disorders involving simultaneous cerebellar, basal ganglia, and frontal-subcortical dysfunction may present with complex neuropsychiatric phenotypes. Distinguishing between behavioral variant frontotemporal dementia (bvFTD), spinocerebellar ataxias, Huntington-like syndromes, and vascular contributions is diagnostically challenging. This case demonstrates a rare triad of progressive ataxia, choreiform movements, and frontotemporal behavioral disinhibition, integrating neurology and psychiatry perspectives. Clinical Case: A 61-year-old male presented with a four-year history of gait ataxia, dysarthria, frequent falls, and involuntary oro-limb movements. Parallel psychiatric deterioration included emotional dysregulation, irritability, impulsive aggression, disinhibition (including nudity), ritualistic doubts, and executive dysfunction. Cognitive testing showed fluctuating frontal deficits (ACE-R 74/100 → 89/100 after stabilization). There were no features of psychosis, mania, or delirium. MRI brain revealed diffuse cerebellar atrophy, moderate cerebral atrophy, and chronic lacunar infarcts in fronto-parietal regions, indicating combined cerebellar and frontal-subcortical degeneration. EEG was normal. Autoimmune and paraneoplastic panels were negative, excluding reversible encephalopathies. There were no signs of Wilson disease, and electrophysiology showed no major peripheral neuropathy. Family history showed suicide and psychosis, supporting a neurodegenerative basis. The clinical triad progressive cerebellar ataxia, Huntington-like chorea, and bvFTD-like behavioral syndrome suggested a mixed neurodegenerative-vascular overlap syndrome, most consistent with spino-cerebellar ataxia with frontal-subcortical involvement. Conclusion: This case illustrates the diagnostic complexity of overlapping motor and behavioral neurodegeneration. The combination of cerebellar ataxia, chorea, and frontotemporal behavioral changes highlights the need for integrated neuropsychiatric assessment and multidisciplinary management in atypical movement-behavior syndromes.

Sertraline Induced

Aniket Sureshrao Lambat, Harshali More Grant Government Medical College, Mumbai, Maharashtra, India Background: Sialorrhoea refers to excessive salivation due to overproduction or impaired clearance of saliva. Antidepressant medications, particularly tricyclic antidepressants and, less commonly, selective serotonin reuptake inhibitors (SSRIs), are usually associated with decreased salivation and complaints of dry mouth. Reports of hypersalivation with SSRIs are very rare. Case Description: A 41-year-old female diagnosed with Functional Neurological Symptom Disorder was started on sertraline 25 mg/day, which was gradually increased over three months to 125 mg/day. After increasing dose, she developed excessive salivation, causing difficulty while talking and wetting of her pillow during sleep. She was referred to neurology, ENT, and dental departments to rule out local or neurological causes; all assessments were unremarkable. On reducing the dose of sertraline, the hypersalivation was decreased and after stopping sertraline it was resolved completely within a few days, suggesting a probable causal relationship. Discussion: Although uncommon, sertraline-induced hypersalivation may occur as an idiosyncratic adverse effect. The mechanism may involve serotonergic modulation of salivary nuclei or enhanced parasympathetic activity. Recognition of this reaction can help avoid unnecessary investigations and improve treatment adherence through timely intervention. Conclusion: Sertraline-induced sialorrhoea is a rare but reversible adverse drug reaction. Clinicians should consider medication-related causes when evaluating new-onset hypersalivation in psychiatric patients. Key words: Adverse drug reaction, hypersalivation, psychiatry, selective serotonin reuptake inhibitors, sertraline, sialorrhoea

Non Pharmacological

Raman Deep AIIMS, New Delhi, India Background: Adults with depressive disorders are at increased long-term cardiovascular disease (CVD) risk through behavioural and biological mechanisms. Non-pharmacological strategies may influence shared determinants of depression and CVD. However, evidence on their effect on validated 10-year CVD risk scores remains uncertain. Aim: To conduct systematic search and summarize available evidence to inform development of a culturally adapted brief intervention for cardiovascular risk reduction in psychiatric settings. Methods: A systematic search (2004-2024) was conducted in MEDLINE/PubMed, Embase, Scopus, PsychInfo, Google Scholar, and grey-literature sources using terms covering depressive disorders, structured non-pharmacological interventions, cardiovascular risk estimation, comparison groups, and randomized or synthesized evidence. Eligible studies were randomized controlled trials or systematic reviews evaluating defined non-drug interventions in adults with depressive disorders and reporting validated 10-year CVD risk estimates or all components required for their calculation. Results: Seventy-three studies met initial eligibility criteria. After screening and appraisal, seven were retained as most relevant. Only one randomized trial directly assessed the impact of a non-pharmacological intervention on estimated 10-year CVD risk in depression. Commonly reported behavioral risk factors included inactivity, unhealthy diet, tobacco use, alcohol consumption, and sleep disturbance. Most interventions were single-component, usually exercise-based, and delivered in person. Evidence from South Asia, including India, was minimal. Conclusion: Evidence on non-pharmacological interventions to modify validated 10-year CVD risk in adults with depression is limited and heterogeneous. Findings highlight the need for context-specific, multidimensional behavioral approaches and provide groundwork for designing a tailored brief intervention for Indian psychiatric settings.

Pramipexole Induced

Rishabh Nagar, Surendra Paliwal 1 Central Institute of Psychiatry, 1 Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India Introduction: Psychosis is well- known as a highly relevant psychiatric symptom in Parkinson’s disease (PD).While visual hallucinations are most frequent, delusions are rarer, affecting approximately 7% of patients. Othello Syndrome (delusion of infidelity) is a complex form of psychosis strongly associated with Dopamine Agonists (DAs). We present a case demonstrating the refractoriness of Pramipexole-induced Othello syndrome to targeted antipsychotic therapy, highlighting the drug’s critical causal role. Case Description: A 61-year-old male with PD, on Levodopa/Carbidopa 75/300 mg and Entacapone 200 mg, was started on the DA Pramipexole 3.15 mg for motor control. He soon developed a severe, fixed delusion of infidelity (Othello syndrome), discretely, without other psychotic features. The patient was treated with the specific antipsychotic Pimavanserin 34 mg, but the delusion persisted and failed to improve over several months, indicating therapeutic resistance. Discussion and Conclusion: We speculate that Pimavanserin’s failure to resolve the delusion while the patient remained on Pramipexole was the result of drug’s potent D3-receptor agonist activity which served as a persistent, overriding driver of the psychosis. Upon Pramipexole cessation, the patient experienced a significant and lasting reduction in the delusion’s intensity, confirming the role of Pramipexole in the causation of delusion. For complex, DA-induced delusions, drug withdrawal can be arguably most effective intervention, taking precedence over antipsychotic dose escalation or switching to new antipsychotic. Key words: Delusion of Infidelity, dopamine agonist, othello syndrome, parkinson’s disease, pimavanserin, pramipexole, psychosis

Risperidone Induced

Apurva Parashar, Apurva Parashar, Shikha Adil, Udit Kumar Panda Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India Background: Risperidone is an atypical antipsychotic with a favourable tolerability, efficacy profile, but rare cutaneous adverse drug reactions (CADRs). Such reactions may complicate long-term psychiatric treatment, especially in patients requiring sustained antipsychotic therapy. Reporting these cases is essential for improving clinical awareness and guiding safer medication choices. Since Risperidone is widely used for psychosis, even rare ADRs warrant documentation. Case Presentation: A 36yrs/female with a 10-year history of psychotic illness has been on multiple Psychotropics with poor compliance. During the recent admission, within 48-72 hours of receiving Tab Risperidone 4mg/day with Trihexyphenidyl 2mg/ day, she developed generalized erythematous pruritic rash with raised lesions without mucosal or systemic involvement, and blood investigations were normal. No alternative triggers were identified. With Tablet Cetirizine and Prednisolone, Symptoms resolved completely after 10 days of stopping Risperidone. She continued to improve on Tab Haloperidol 10mg/d and was on Trihexyphenidyl 2mg. On further evaluation, as reported by parents, she had developed similar skin reaction on taking Risperidone 2 mg in 2016. The rash resolved within 10 days of discontinuing Risperidone. She has a history of tolerating Asenapine, Trifluoperazine, and Olanzapine for three years, without any dermatological reactions. Discussion: Temporal association, reproducibility on re-challenge (although unintentional), and complete resolution on withdrawal fulfil WHO-UMC criteria for a probable risperidone-induced hypersensitivity reaction, possibly Type I/IV or mast-cell mediated. Conclusion: This case underscores recurrent risperidone-induced cutaneous hypersensitivity and highlights the need for monitoring, prompt withdrawal, documentation, and avoidance of re-exposure. Individualized antipsychotic selection remains essential for long-term management.

Acute To Maintenance

Sandhya Verma King George’s Medical University, Lucknow, Uttar Pradesh, India Background: Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by bradykinesia, rigidity, tremor, and postural instability. As the disease advances, gait impairment and motor fluctuations may become refractory to optimized dopaminergic therapy. Repetitive transcranial magnetic stimulation (rTMS) is increasingly explored as a non-invasive adjunct for motor symptom improvement in PD. Aims: To evaluate the impact of acute-to-maintenance multisite theta-burst stimulation (TBS) augmentation in a patient with persistent motor impairment despite optimized pharmacotherapy. Methods: A 73-year-old man with a 4-year history of idiopathic PD continued to experience disabling motor symptoms despite stable dopaminergic treatment. He received multisite TBS targeting Cz, C3, C4, and the supplementary motor area (SMA), administered twice daily, six days per week, during the acute phase. This was followed by maintenance TBS delivered twice daily twice weekly for 4 weeks, then weekly, and subsequently biweekly. A total of 84 sessions were completed without modification of his medication regimen. Results: The multisite TBS protocol was well tolerated across all 84 sessions, with no adverse effects reported. The patient demonstrated marked motor improvement, with UPDRS-III scores decreasing from 81 at baseline to 38 during maintenance therapy a 53.1% reduction in motor symptom severity. Notably, these gains occurred without any adjustment in dopaminergic dosing, underscoring the potential additive benefit of neuromodulation. Conclusion: Multisite rTMS produced substantial and sustained motor recovery in this patient with advanced PD. These findings highlight the potential of rTMS as an effective, non-invasive adjunctive therapy for motor symptoms in PD.

Aripiprazole Induced

Ashwin Vasantrao Walke, Mujahid Shaikh Grant Government Medical College, Mumbai, Maharashtra, India Background: Aripiprazole is widely prescribed in adolescents due to its favourable safety and tolerability profile. Ocular adverse effects are rare, but reversible myopic shifts have been reported. Early recognition prevents unnecessary investigations and improves adherence. Aim: To report a rare case of aripiprazole-induced acute transient myopia in an adolescent. Case Description: A 15-year-old female with schizophrenia was started on aripiprazole 15 mg/day due to worsening psychotic symptoms. Approximately one month after initiation, she developed gradually progressive bilateral blurring of vision without headache, photophobia, ocular pain, vomiting, or neurological complaints. Ophthalmic examination revealed visual acuity of 6/36 in both eyes with normal anterior and posterior segments. Cycloplegic refraction demonstrated a -1.75 D myopic shift bilaterally. Systemic evaluation and laboratory findings were unremarkable. Dose reduction produced partial improvement. Complete resolution occurred within three weeks of discontinuing aripiprazole, with unaided visual acuity returning to 6/6 OU. The temporal pattern and clinical findings strongly suggested a drug-induced refractive change. Results: The distinct temporal association, absence of alternative causes, and full reversibility after stopping the drug supported the diagnosis of aripiprazole-induced transient myopia. Discussion: Transient myopia associated with aripiprazole is rare and may result from ciliochoroidal effusion, ciliary body edema, and anterior displacement of the iris-lens diaphragm, causing a reversible refractive error. Timely detection avoids unnecessary imaging, reduces anxiety, and improves adherence. Conclusion: Aripiprazole can rarely induce acute, reversible myopia in adolescents. Clinicians should routinely assess for visual disturbances in patients receiving this medication. Key words: Adolescents, antipsychotic-induced myopia, aripiprazole, ocular adverse effects, transient myopia

Dyke Davidoff Masson

K. M. Sarita Gandhi Medical College, Bhopal, Madhya Pradesh, India Background: Dyke-Davidoff-Masson Syndrome (DDMS) causes unilateral cerebral hemiatrophy from early brain insults like infantile encephalitis, resulting in hemiparesis, spasticity, seizures, and neurodevelopmental challenges. In India, delayed diagnosis and limited rehabilitation perpetuate lifelong disability, shackling societal integration. This case demonstrates effective spasticity management in an adolescent with DDMS, aligning with ANCIPS 2026’s theme of unshackling psychiatry through multidisciplinary care. Aim: To report clinical, radiological, and functional outcomes following targeted rehabilitation in an 18-year-old female with left hemiplegic cerebral palsy due to right-sided DDMS. Methods: An 18-year-old female presented with 17-year history of left upper/lower limb weakness and tightness following fever/jerky movements at 11 months. Assessment used Modified Ashworth Scale (MAS) for spasticity and MRC grading for power. MRI (Mar 2023) confirmed right hemicerebral atrophy with gliencephalomalacia and Wallerian degeneration. Interventions at GMC Bhopal ward included Botulinum toxin A (100U in left FCU/FDS/FCR), Baclofen 20mg BD, NMES, stretching exercises, and resting hand splint. Results: Pre-treatment: MAS 2-3 (left elbow/wrist flexors); left wrist/finger power 5 poor. Post-intervention: MAS improved (elbow flexor 3†’2, finger flexor 3†’1); wrist extension power fair. Facial asymmetry and abnormal gait persisted but stabilized. No seizures; normal labs (TSH 2.17 µIU/mL, Hb 11.2g/dL). Discharged on Baclofen 10mg TDS with home exercises. Conclusion: Botulinum toxin and rehabilitation significantly reduce spasticity and enhance function in adolescent DDMS. Integrating neuroimaging and PMR into child psychiatry protocols can liberate neurodevelopmental potential, supporting scalable community models.

Electrocardiographic

D. C. Monith, N. Prasanna Kumar 1 Andhra Medical College, Government Hospital For Mental Health, 1 Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Background: Neurodevelopmental disorders (NDDs), including Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), and Intellectual Developmental Disorder (IDD), are associated with neurobiological and autonomic nervous system alterations. These autonomic influences may extend to cardiac conduction and repolarisation, potentially manifesting as electrocardiographic (ECG) changes. Children with NDDs are frequently exposed to psychotropic medications, some of which are known to affect ECG parameters such as heart rate and QTc interval. Despite these considerations, systematic data describing routine ECG findings in children with NDDs, particularly from Indian clinical settings, remain limited. Aim: To assess and describe electrocardiographic changes and determine the prevalence of conduction abnormalities in children diagnosed with neurodevelopmental disorders. Methods: This cross-sectional observational study will be conducted at a tertiary care teaching hospital. Children aged 5-16 years with clinically diagnosed NDDs, as per DSM-5/ICD-11 criteria, will be recruited consecutively. Sociodemographic details, clinical diagnoses, symptom severity measures, comorbidities, and medication exposure will be recorded. Each participant will undergo a standard 12-lead resting ECG. ECG parameters assessed will include heart rate, cardiac rhythm, PR interval, QRS duration, QT and corrected QT (QTc) intervals, cardiac axis, and wave morphology. ECG findings will be analysed descriptively, and subgroup analyses will be performed across diagnostic categories and medication status. Conclusion: This study aims to characterise ECG profiles in children with neurodevelopmental disorders and provide clinically relevant data to inform cardiac monitoring practices. Findings from this study may help guide safer psychotropic medication use and support the development of evidence-based screening strategies in child and adolescent psychiatric settings.

Lumateperone Induced

Varchasvi Mudgal, V. S. Pal, Priyash Jain MGM Medical College, Indore, Madhya Pradesh, India Background: Lumateperone is a novel antipsychotic approved for bipolar depression. While generally considered safe, data on treatment-emergent mania remain limited. Case Presentation: We describe a 32-year-old male with Bipolar I Disorder who developed mania shortly after lumateperone initiation for his seventh depressive episode. The manic switch occurred despite concurrent lamotrigine and quetiapine. Symptoms resolved following discontinuation of lumateperone and initiation of lithium. Conclusion: This case highlights the potential for lumateperone-induced mania, even in the presence of mood stabilizers, underscoring the need for close monitoring.

Obsessive Compulsive

Anuragini Suresh, W. J. Alexander Gnanadurai, A. Balaji Department of Psychiatry, Government Kilpauk Medical College Hospital, Chennai, Tamil Nadu, India Background: Tuberculosis is among the oldest and most devastating infectious diseases worldwide. Central nervous system involvement, especially in the pediatric population, is a rare and severe manifestation.While seizures, fever and headache are well-recognized symptoms, the emergence of obsessive-compulsive disorder (OCD) during treatment is atypical. Patient Profile: An 11-year-old boy had complaints of recurrent headaches, intermittent fever, and seizures.MRI Brain confirmed CNS tuberculoma. He was commenced on ATT with Isoniazid, Rifampicin and Ethambutol with a later chest X-Ray showing calcific spots, confirming Tuberculosis. After one year on ATT, the patient developed significant obsessive-compulsive symptoms, including contamination obsessions, intrusive thoughts of harm to his parents, cleaning compulsions and checking compulsions, for which he was referred to Psychiatry leading to a diagnosis of OCD secondary to an organic cause.Patient was started on Tab.Escitalopram while ATT and antiepileptic therapy were continued.A follow-up MRI Brain showed a calcified granuloma in the precentral gyrus with no active disease, and ATT was completed after 18 months.Currently, he remains on antiepileptics and Tab.Escitalopram and Tab.Clomipramine. Discussion: This case underscores the unusual aspect of the emergence of OCD symptoms during treatment.The pathogenesis of OCD in this patient may be multifactorial: direct neurobiological effects of CNS tuberculoma, secondary network dysfunction, or an adverse effect of ATT (notably isoniazid).This case highlights the importance of vigilance for rare psychiatric complications such as OCD, which may arise either from the disease itself or as an adverse effect of therapy, and which require timely recognition and management.

Varicella Associated

Neha Srivastava, Subho Chakrabarti, Anshul Sharma Post Graduate Institute Of Medical Education and Research, Chandigarh, India Background: Neuropsychiatric complications following varicella infection are well documented in children but under-recognized in adults. Emerging evidence suggests that immune-mediated mechanisms, including seronegative autoimmune psychosis, may underlie persistent affective and behavioral symptoms following viral infections. Aim: To describe a young adult with chronic affective blunting, avolition, and catatonia following varicella infection, who demonstrated remarkable improvement with immunotherapy. Case Presentation: A 27-year-old male with no previous psychiatric history developed persistent social withdrawal and functional decline following a varicella infection in 2019. Over the next six years, he manifested prominent negative symptoms including avolition, anhedonia, social withdrawal, and poverty of speech, that were minimally responsive to antidepressants. He later presented with catatonic features in the OPD and showed complete resolution of catatonia following a lorazepam challenge, though his negative symptoms persisted. Extensive evaluation, including MRI brain, CSF analysis, and an autoimmune encephalitis panel, was unremarkable except for elevated VZV IgG, raising suspicion for autoimmune psychosis. He was subsequently treated with IV dexamethasone (8 mg/day for 3 days), after which he exhibited significant improvement in affect, speech initiation, and social engagement over 2-3 weeks. Conclusion: This case highlights the need to consider post-varicella immune-mediated neuropsychiatric syndromes in patients with atypical negative symptoms and treatment resistance. Early immunomodulatory treatment may significantly alter the course of illness.

Medication Associated

Sneha, K. Kiran Kumar 1 , R. Sudharshan Vydehi Institute of Medical Sciences, Bengaluru, Karnataka, India Background: Vivid dreams are intensely realistic and emotionally charged dream experiences linked to several psychotropic agents, including SSRIs, SNRIs, SARIs (e.g., trazodone), melatonin, and nicotine replacement therapy (NRT). Studies report vivid dreams or nightmares in 25-30% of SSRI users, 8-12% of melatonin users, and 35-50% of NRT users. Trazodone is known to increase REM density and provoke vivid or bizarre dreams. Reported dream types include nightmares, high-intensity realistic dreams, and erotic dreams, with nightmares more common in anxiety, depression. Younger adults (20-40 years) and females demonstrate higher dream recall and increased reporting. Identifying demographic and drug-specific patterns aids clinical decision-making. Objectives: To describe four adult psychiatric cases with medication-related vivid dreams and examine associated demographic and pharmacological factors. Methods: Four adults from outpatient psychiatry underwent detailed clinical interviews and medication timeline analysis to establish associations with vivid dreams. Results: Patients ranged from 28-42 years (mean ~35), with equal gender distribution. Literature suggests vivid dreams are more common in younger adults and females; similar patterns emerged in recall quality in our cases. The most frequent psychiatric diagnosis was depressive disorder, followed by anxiety and personality traits. Implicated medications vortioxetine, nicotine patch, melatonin, and trazodone mirror drug groups most often associated with vivid dreams. Conclusion: Vivid dreams are common across antidepressants, melatonin, and NRT, particularly in younger adults and mood-disorder populations. Routine screening and individualised medication modification are essential for good clinical outcome.

Neuroimaging Positive

Bulagakula Vahini, B. Swapna The Oxford Medical College Hospital and Research Centre, Anekal, Karnataka, India Organic neurological conditions may present with acute psychiatric symptoms, leading to misdiagnosis and delay in appropriate management. This case series highlights patients initially treated as psychiatric presentations but subsequently found to have significant neurological pathology. Five cases were identified. • Case 1: A 60-year-old male, chronic smoker, presented with withdrawn behaviour and reduced interaction for 8 days; a psychiatric diagnosis of NDS with Brief Psychotic disorder was made, imaging revealed Normal Pressure Hydrocephalus (NPH) • Case 2: A 36-year-old female with no psychiatric or substance-use history presented with decreased interaction and withdrawn behavior and irrelevant talk for 4 days, a psychiatric diagnosis of Brief Psychotic disorder was made, imaging confirmed NPH • Case 3: A 48-year-old male presented with irritability, agitation, and confused behavior of 2 days duration with H/O fall 1 month back, psychiatric diagnosis of Brief Psychotic disorder was made, CT showed a right temporal-parietal Subdural Hemorrhage (SDH) • Case 4: A 32-year-old male with occasional alcohol use presented with irrelevant talk, aggression, and disturbed sleep for 1 day, initially diagnosed with Brief Psychotic Disorder, later diagnosed with an Epidural Hemorrhage (EDH) • Case 5: A 28-year-old female patient with disturbed sleep and visual hallucinations for 13 days a psychiatric diagnosis of Brief Psychotic disorder was made, later diagnosed with tumefactive demyelination with suspected left optic neuritis. Acute psychiatric symptoms may be the initial manifestation of significant neurological disease. Incorporating neuroimaging in atypical, sudden-onset, or treatment-resistant psychiatric presentations is crucial for timely diagnosis and improved outcomes.

Methylphenidate Induced

Aniket Awasthi, P. Sai Kiran, N. Uma Jyothi GMC, Guntur, Andhra Pradesh, India Background: Methylphenidate is a commonly used medication for attention-deficit/hyperactivity disorder (ADHD) in children and is generally regarded as safe. Nonetheless, acute pancreatitis has only rarely been linked to its use, and very few pediatric cases have been described. Aims: To present a case of acute pancreatitis that developed shortly after the initiation of methylphenidate in a child newly diagnosed with ADHD. Methods: A 9-year-old boy started on oral methylphenidate 10 mg/day developed irritability, poor appetite, and progressively worsening abdominal pain after 6 days of treatment. He underwent clinical assessment, laboratory testing, and abdominal ultrasonography. Other common causes of pediatric pancreatitis including infections, trauma, metabolic abnormalities, biliary issues, and exposure to additional medications were evaluated to rule out alternative explanations. Results: The child exhibited marked epigastric tenderness and mild guarding without fever or jaundice. Serum amylase (600 U/L) and lipase (570 U/L) were significantly elevated, with mildly increased aminotransferases and normal bilirubin. Ultrasonography showed an enlarged, hyperechoic pancreas with a slightly dilated duct (2.2 mm) and minimal intraperitoneal fluid, fulfilling INSPIRE criteria for acute pancreatitis. The liver and gallbladder appeared normal. No secondary cause was identified. Methylphenidate was discontinued, and conservative management with nil per oral intake, nasogastric decompression, and intravenous fluids led to steady improvement, allowing discharge in stable condition. Conclusion: Although rare, acute pancreatitis may occur in association with methylphenidate therapy. Clinicians should consider this diagnosis when children receiving stimulant medication present with persistent abdominal pain.