Letters to Editor
Another issue was the impact of life event and unusual experience.[8] eight months back, the patient’s father had similar complaint of hearing voices and committed suicide. The event helped to develop delusional beliefs in him that he was going to die and this lead him to severe distress.[9] Trauma may adversely affect hearing impaired due to possible difficulties in social understanding and misattribution of the causes. Some other issues were the difficulty in providing appropriate care of multidisciplinary approach compatible to the culture of hearing impaired, informed pharmacotherapy, eliciting different types of psychotic symptoms, empathizing and offering other effective psychological intervention, explaining common side effects likely to experience etc., At present, guidelines on assessment and management of hearing impaired psychiatric patients with psychotic disorders is scarce in the scientific literature.[10] Development of culturally and linguistically appropriate assessment tools such as structured clinical interviews, symptom inventories, screening measures and tests of cognition is urgently needed. Similarly, appropriately modified evidence based psychotherapy and multidisciplinary approach is also needed. Finally, training provider in assessing the hearing impaired patient population should become a standard part of the diversity‑related curriculum of physician training programs.
REFERENCES 1. World Health Organization. Fact sheet. Deafness and hearing loss. Available from: http://www.who.int/mediacentre/factsheets/fs300/en/. [Last accessed on 2013 Jun 23]. 2. Øhre B, von Tetzchner S, Falkum E. Deaf adults and mental health: A review of recent research on the prevalence and distribution of psychiatric symptoms and disorders in the prelingually deaf adult population. Int J Ment Health Deafness 2011;1:3‑22. 3. Barnett S. Cross‑cultural communication with patients who use American Sign Language. Fam Med 2002;34:376‑82. 4. World Health Organization. International Statistical Classification of Diseases and Related Health Problems 1989, Revision (ICD‑10). Geneva: World Health Organization; 1992. 5. Evans JW, Elliott H. Screening criteria for the diagnosis of schizophrenia in deaf patients. Arch Gen Psychiatry 1981;38:787‑90. 6. du Feu M, McKenna PJ. Prelingually profoundly deaf schizophrenic patients who hear voices: A phenomenological analysis. Acta Psychiatr Scand 1999;99:453‑9. 7. Atkinson JR. The perceptual characteristics of voice‑hallucinations in deaf people: Insights into the nature of subvocal thought and sensory feedback loops. Schizophr Bull 2006;32:701‑8. 8. Jones EG, Ouellette SE, Kang Y. Perceived stress among deaf adults. Am Ann Deaf 2006;151:25‑31. 9. Chadwick P, Birchwood M. The omnipotence of voices. A cognitive approach to auditory hallucinations. Br J Psychiatry 1994;164:190‑201. 10. Landsberger SA, Sajid A, Schmelkin L, Diaz DR, Weiler C. Assessment and treatment of deaf adults with psychiatric disorders: A review of the literature for practitioners. J Psychiatr Pract 2013;19:87‑97. Access this article online Quick Response Code Website: www.indianjpsychiatry.org
Dushad Ram, Vinay Kumar, T. S. Sathyanarayana Rao
Department of Psychiatry, JSS Medical College Hospital, JSS University, Mysore, Karnataka, India. E‑mail: [email protected]
DOI: 10.4103/0019-5545.148539
Internet gaming disorder: Application of motivational enhancement therapy principles in treatment Sir, Though Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM‑5) does not recognize this as an official category, internet game addiction (IGD) is becoming a serious problem in countries which have wide access to the internet.[1,2] DSM‑5 presently proposes and encourages further research into this disorder before committing to it and defines it under section III.[3] Conceptually, the gamut of internet addiction (IA) has been proposed on lines of substance abuse, with negative effects on socio‑occupational functioning,[1] and found to cause changes in brain regions akin to chemical dependence.[2] Though motivational enhancement therapy (MET) remains a cornerstone for treatment of drug addiction, its applications in IA and IGD have been sparse. The purpose of this report was to describe a pilot intervention using MET‑cognitive behavior therapy (CBT) principles to treat IGD in an adolescent. 100
Index patient Master D.R., a 14‑year‑old boy, younger of the two siblings, with nil contributory past, family and personal history; easy going premorbid temperament; was brought by his parents with complaints regarding his negative attitude, depression, and overuse of internet for 2 years. The problems have started when his elder sister met with an accident and was admitted to the hospital. Patient was left alone at home as his parents busied themselves with her care, and he started playing internet games to overcome this loneliness. He started enjoying these games and time spent on games increased gradually, with consequent deterioration in social and peer relationships, studies and attitude toward his parents. He started skipping school, spending money at internet parlors and on buying games. As his parents became aware of it and confronted him, patient expressed his frustration with the situation, and desire to reduce the hours. However, he reported an inability, in spite of repeated attempts, to control his behavior and continued Indian Journal of Psychiatry 57(1), Jan-Mar 2015
Letters to Editor
spending around 3–5 h on playing games on weekdays and up to 13 h on weekends. Our baseline assessment revealed an average IQ. ESDST, BVMGT, and TAT were administered which revealed adequate attention, concentration, and visuomotor coordination. There was conflict with authority figures and needs were aggression and achievement. Main emotions were guilt, sadness, and anger. IA Test (IAT) score[4] was 83. Initial therapy sessions consisted of rapport building with patient, detailed interview, and primary case formulation. At this point, he was at contemplation stage of motivation. Subsequent sessions were held in an empathetic atmosphere, with emphasis on patient’s psycho‑education and cost‑benefit analysis of the behavior. His level of motivation improved to “preparation” stage. As the urge for gamming was accompanied with physiological and emotional arousal, Jacobson’s progressive muscle relaxation was initiated. Further sessions focused on assessment of game addiction and creating a contract for behavior modification. Patient agreed to try to reduce the time spent on games and increase on other healthy activities. The contract was in written form and signed by patient, his mother, and therapist; and tokens were introduced as positive reinforcement. As sessions progressed, he began spending less time on weekdays, but continued with excess on weekends, and the later did not respond satisfactorily.
when gains had consolidated. He appeared for his exams and scored quite well. He reduced his time on playing online games even on weekends, and IAT score came down to 48. There are not many studies for intervention of IGD. In our case, IGD began in response to the relative neglect of the child and the consequent boredom, and was consolidated by subsequent negative reinforcements. We emphasize on varied antecedents and consequences for development of IGD, like in our case, and on their adequate assessment to plan individual interventions. Given the still‑shrouded nature of this disorder, there is no available guideline on management. Our report discusses an interesting application of the tested MET‑CBT principles in ameliorating IGD.
Shuvabrata Poddar, Neha Sayeed, Sayantanava Mitra1
Department of Clinical Psychology, Central Institute of Psychiatry, Ranchi, 1Department of Psychiatry, Sarojini Naidu Medical College, Agra, India E‑mail: [email protected] REFERENCES 1. 2. 3.
Patient was next encouraged to be conscious of how his time was spent more on games than intended, and of thoughts, emotions and behaviors (TE and B) contributing to this. He was asked to record his TE and B related to games in a format. Major determinant was found to be boredom. In subsequent sessions, he was given two pieces of paper every week: One for recording his activities and time, another for recording his TE and B related to games. The main issue for him was managing his boredom. Based on his suggestion, it was agreed upon that if he drew cartoons instead of playing games, he would be allowed to ride scooty (reinforcer) for 1 h. There was improvement, and therapy was terminated
4.
Block JJ. Issues for DSM‑V: Internet addiction. Am J Psychiatry 2008;165:306‑7. Wallace P. Internet addiction disorder and youth: There are growing concerns about compulsive online activity and that this could impede students’ performance and social lives. EMBO Rep 2014;15:12‑6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. Young KS. Internet addiction test. Available from: http://www.netaddiction. com/resources/internet_addiction_test.htm. [Last accessed on 2014.05.12].
Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.148540
A case of tics presenting as chronic intractable cough successfully treated with tetrabenazine Sir, Gilles de la Tourette syndrome is a motor disorder. The prevalence of Tourette syndrome is stated to be about 4.9/10,000 males and 3.1/10,000 females.[1] Indian Journal of Psychiatry 57(1), Jan-Mar 2015
Prevalence studies indicate a 10‑fold higher rate of Tourette syndrome among children compared with adults.[2] Tic disorders presenting during adulthood have infrequently been described in the medical literature. Most reports depict adult onset secondary tic disorders caused by 101
Copyright of Indian Journal of Psychiatry is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Another issue was the impact of life event and unusual experience.[8] eight months back, the patient’s father had similar complaint of hearing voices and committed suicide. The event helped to develop delusional beliefs in him that he was going to die and this lead him to severe distress.[9] Trauma may adversely affect hearing impaired due to possible difficulties in social understanding and misattribution of the causes. Some other issues were the difficulty in providing appropriate care of multidisciplinary approach compatible to the culture of hearing impaired, informed pharmacotherapy, eliciting different types of psychotic symptoms, empathizing and offering other effective psychological intervention, explaining common side effects likely to experience etc., At present, guidelines on assessment and management of hearing impaired psychiatric patients with psychotic disorders is scarce in the scientific literature.[10] Development of culturally and linguistically appropriate assessment tools such as structured clinical interviews, symptom inventories, screening measures and tests of cognition is urgently needed. Similarly, appropriately modified evidence based psychotherapy and multidisciplinary approach is also needed. Finally, training provider in assessing the hearing impaired patient population should become a standard part of the diversity‑related curriculum of physician training programs.
REFERENCES 1. World Health Organization. Fact sheet. Deafness and hearing loss. Available from: http://www.who.int/mediacentre/factsheets/fs300/en/. [Last accessed on 2013 Jun 23]. 2. Øhre B, von Tetzchner S, Falkum E. Deaf adults and mental health: A review of recent research on the prevalence and distribution of psychiatric symptoms and disorders in the prelingually deaf adult population. Int J Ment Health Deafness 2011;1:3‑22. 3. Barnett S. Cross‑cultural communication with patients who use American Sign Language. Fam Med 2002;34:376‑82. 4. World Health Organization. International Statistical Classification of Diseases and Related Health Problems 1989, Revision (ICD‑10). Geneva: World Health Organization; 1992. 5. Evans JW, Elliott H. Screening criteria for the diagnosis of schizophrenia in deaf patients. Arch Gen Psychiatry 1981;38:787‑90. 6. du Feu M, McKenna PJ. Prelingually profoundly deaf schizophrenic patients who hear voices: A phenomenological analysis. Acta Psychiatr Scand 1999;99:453‑9. 7. Atkinson JR. The perceptual characteristics of voice‑hallucinations in deaf people: Insights into the nature of subvocal thought and sensory feedback loops. Schizophr Bull 2006;32:701‑8. 8. Jones EG, Ouellette SE, Kang Y. Perceived stress among deaf adults. Am Ann Deaf 2006;151:25‑31. 9. Chadwick P, Birchwood M. The omnipotence of voices. A cognitive approach to auditory hallucinations. Br J Psychiatry 1994;164:190‑201. 10. Landsberger SA, Sajid A, Schmelkin L, Diaz DR, Weiler C. Assessment and treatment of deaf adults with psychiatric disorders: A review of the literature for practitioners. J Psychiatr Pract 2013;19:87‑97. Access this article online Quick Response Code Website: www.indianjpsychiatry.org
Dushad Ram, Vinay Kumar, T. S. Sathyanarayana Rao
Department of Psychiatry, JSS Medical College Hospital, JSS University, Mysore, Karnataka, India. E‑mail: [email protected]
DOI: 10.4103/0019-5545.148539
Internet gaming disorder: Application of motivational enhancement therapy principles in treatment Sir, Though Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM‑5) does not recognize this as an official category, internet game addiction (IGD) is becoming a serious problem in countries which have wide access to the internet.[1,2] DSM‑5 presently proposes and encourages further research into this disorder before committing to it and defines it under section III.[3] Conceptually, the gamut of internet addiction (IA) has been proposed on lines of substance abuse, with negative effects on socio‑occupational functioning,[1] and found to cause changes in brain regions akin to chemical dependence.[2] Though motivational enhancement therapy (MET) remains a cornerstone for treatment of drug addiction, its applications in IA and IGD have been sparse. The purpose of this report was to describe a pilot intervention using MET‑cognitive behavior therapy (CBT) principles to treat IGD in an adolescent. 100
Index patient Master D.R., a 14‑year‑old boy, younger of the two siblings, with nil contributory past, family and personal history; easy going premorbid temperament; was brought by his parents with complaints regarding his negative attitude, depression, and overuse of internet for 2 years. The problems have started when his elder sister met with an accident and was admitted to the hospital. Patient was left alone at home as his parents busied themselves with her care, and he started playing internet games to overcome this loneliness. He started enjoying these games and time spent on games increased gradually, with consequent deterioration in social and peer relationships, studies and attitude toward his parents. He started skipping school, spending money at internet parlors and on buying games. As his parents became aware of it and confronted him, patient expressed his frustration with the situation, and desire to reduce the hours. However, he reported an inability, in spite of repeated attempts, to control his behavior and continued Indian Journal of Psychiatry 57(1), Jan-Mar 2015
Letters to Editor
spending around 3–5 h on playing games on weekdays and up to 13 h on weekends. Our baseline assessment revealed an average IQ. ESDST, BVMGT, and TAT were administered which revealed adequate attention, concentration, and visuomotor coordination. There was conflict with authority figures and needs were aggression and achievement. Main emotions were guilt, sadness, and anger. IA Test (IAT) score[4] was 83. Initial therapy sessions consisted of rapport building with patient, detailed interview, and primary case formulation. At this point, he was at contemplation stage of motivation. Subsequent sessions were held in an empathetic atmosphere, with emphasis on patient’s psycho‑education and cost‑benefit analysis of the behavior. His level of motivation improved to “preparation” stage. As the urge for gamming was accompanied with physiological and emotional arousal, Jacobson’s progressive muscle relaxation was initiated. Further sessions focused on assessment of game addiction and creating a contract for behavior modification. Patient agreed to try to reduce the time spent on games and increase on other healthy activities. The contract was in written form and signed by patient, his mother, and therapist; and tokens were introduced as positive reinforcement. As sessions progressed, he began spending less time on weekdays, but continued with excess on weekends, and the later did not respond satisfactorily.
when gains had consolidated. He appeared for his exams and scored quite well. He reduced his time on playing online games even on weekends, and IAT score came down to 48. There are not many studies for intervention of IGD. In our case, IGD began in response to the relative neglect of the child and the consequent boredom, and was consolidated by subsequent negative reinforcements. We emphasize on varied antecedents and consequences for development of IGD, like in our case, and on their adequate assessment to plan individual interventions. Given the still‑shrouded nature of this disorder, there is no available guideline on management. Our report discusses an interesting application of the tested MET‑CBT principles in ameliorating IGD.
Shuvabrata Poddar, Neha Sayeed, Sayantanava Mitra1
Department of Clinical Psychology, Central Institute of Psychiatry, Ranchi, 1Department of Psychiatry, Sarojini Naidu Medical College, Agra, India E‑mail: [email protected] REFERENCES 1. 2. 3.
Patient was next encouraged to be conscious of how his time was spent more on games than intended, and of thoughts, emotions and behaviors (TE and B) contributing to this. He was asked to record his TE and B related to games in a format. Major determinant was found to be boredom. In subsequent sessions, he was given two pieces of paper every week: One for recording his activities and time, another for recording his TE and B related to games. The main issue for him was managing his boredom. Based on his suggestion, it was agreed upon that if he drew cartoons instead of playing games, he would be allowed to ride scooty (reinforcer) for 1 h. There was improvement, and therapy was terminated
4.
Block JJ. Issues for DSM‑V: Internet addiction. Am J Psychiatry 2008;165:306‑7. Wallace P. Internet addiction disorder and youth: There are growing concerns about compulsive online activity and that this could impede students’ performance and social lives. EMBO Rep 2014;15:12‑6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. Young KS. Internet addiction test. Available from: http://www.netaddiction. com/resources/internet_addiction_test.htm. [Last accessed on 2014.05.12].
Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.148540
A case of tics presenting as chronic intractable cough successfully treated with tetrabenazine Sir, Gilles de la Tourette syndrome is a motor disorder. The prevalence of Tourette syndrome is stated to be about 4.9/10,000 males and 3.1/10,000 females.[1] Indian Journal of Psychiatry 57(1), Jan-Mar 2015
Prevalence studies indicate a 10‑fold higher rate of Tourette syndrome among children compared with adults.[2] Tic disorders presenting during adulthood have infrequently been described in the medical literature. Most reports depict adult onset secondary tic disorders caused by 101
Copyright of Indian Journal of Psychiatry is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
