Letters to Editor
Dissociative identity disorder: An uncommon psychiatric disorder reported Sir, Dissociative Identity Disorder (DID) is an enigmatic disorder in psychiatry, with a prevalence of around 0.1‑1%. It has been often wrongly diagnosed as schizophrenia, bipolar affective disorder, impulse control disorder, or borderline personality disorder among others. We are presenting one such case. Ms. M, a nineteen year old college going girl was brought for consultation by her mother for repeated attacks of amnesia and poor impulse control related symptoms like irritability, destructive behaviour and self harm. On further enquiry, the patient gave a history of being accused of lying and being hypocritical since she was in the sixth grade; having no memory of how she landed up in unexpected places (a nearby zoo/friend’s place); having a sense of being estranged, hearing voices in her head of her mother talking with other people. Her mother gave a history of being able to see 3 different states in her daughter‑ a nineteen year old intelligent college student; a trusting state in which she speaks in a childish voice and having high risk behaviour (like going off with strangers, taking drinks mixed with intoxicants, not recognizing treating doctors); and an aggressive state in which she is easily irritable, paces about and attempts to harm her mother or herself. She (patient) herself is unaware of these episodes and states.
On admission, organicity was ruled out by appropriate tests. She was put on a mood stabilizer and anti depressive agents for symptomatic control. Safety and security was established. The patient narrated her abuse (during adolescence) in one of the other dissociative states. This could have been misdiagnosed as psychosis, intermittent explosive disorder, depressive disorder, or borderline personality disorder. The keen observation by the mother (who herself had possession syndrome and depression earlier in life) helped in the diagnosis. A treating clinician must be aware and be on the lookout for dissociative states and be prepared for therapeutic work with such patients.
Siva Shankar Priya, Nambi Siva
Department of Psychiatry, Sree Balaji Medical College and Hospital, Chrompet, Chennai, Tamil Nadu, India E‑mail: [email protected] Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.120565
Studies on posttraumatic stress disorder: Challenges ahead Sir, Disaster studies play an important role in the area of research being unique in its methodology and also on the enormous impact it would have on affected population. Disaster studies have a set of inherent difficulties associated with them. They can only attain the status of quasi‑experimental design, with comparison groups and not controls. Since disasters occur unpredictably, pretest data on victims are usually not available. Researchers can seldom obtain access to the disaster at its onset, and if they do find access, the exigencies of the situation usually preclude administration of standard instruments in a standardized fashion. Additionally, the statistical analysis of a nested case control model must take into account the way in which controls are sampled from the cohort. Performing logistic regression on nested case controls can result in biased Indian Journal of Psychiatry 55(4), Oct-Dec 2013
estimates whose null distribution is different than what is assumed. The study by Pyari and her colleagues[1] attempted in evaluating the risk factors associated with posttraumatic stress disorder (PTSD) in the 2004 tsunami. Disaster studies should focus on understanding what aspects of disaster are most devastating, and what characteristics of individuals make them vulnerable. The authors have done so to include an exhaustive list of risk factors. However, other important risk factors like traumatic brain injury, premorbid trait anxiety, coping skills, ethnicity, and immigration could be incorporated.[2] It would also have been fruitful to include traumatic brain injury as risk factor for PTSD as studies estimate its frequency between 17 and 33%.[3] Children and adolescents, an important vulnerable group could have also been studied by the authors. 403
Letter to Editor
The authors have used the impact of event scale (IES)[4] to diagnose PTSD. This scale is not a diagnostic tool for PTSD, but pick up of persons having intrusive and avoidance symptoms of PTSD. This scale does not rule out comorbid conditions mimicking PTSD as the authors themselves found low specificity in the pilot study.[1] The authors could have used revised version of IES developed by Weiss and Marmar,[5] that also included hyperarousal symptoms. It was also not clear as to why the cutoff for cases above the 70th percentile of the IES score was chosen. The authors have missed reference for the social support scale used. The study was conducted 6 months after the tsunami over a period of 1‑year and evaluated the PTSD symptoms only in the week preceding the administration. Possibly, the authors might have missed a considerable numbers of patients with PTSD as the disorder uncommonly has delayed onset. Nonetheless, keeping the limitations of designing and carrying out disaster studies, the authors have done an admirable task at studying the risk factors associated with PTSD in developing countries like ours. There is a further need for studies analyzing interventions in the post disaster period and preventive methods for the vulnerable population along with transcultural issues like manifestation of PTSD and community response to disaster. Such studies would bear important implications at both the clinical and administrative arena.
Pallavi Sinha, Amit Garg, Om Prakash
Department of Psychiatry, Institute of Human Behavior and Allied Sciences, Dilshad Garden, New Delhi ‑ 110 095, India. E‑mail: [email protected] REFERENCES 1.
2.
3. 4. 5.
Pyari TT, Kutty RV, Sarma PS. Risk factors of post‑traumatic stress disorder in tsunami survivors of Kanyakumari District, Tamil Nadu, India. Indian J Psychiatry 2012;54:48‑53. Perilla J, Norris F, Lavizzo E. Ethnicity, culture, and disaster response: Identifying and explaining ethnic differences in PTSD six months after Hurricane Andrew. J Soc Clin Psychol 2002;12:20‑45. Rattock J, Ross B. Post traumatic stress disorder in the traumatically head injured. J Clin Exp Neuropsychol 1993;15:403. Horowitz M, Wilner N, Alverez W. Impact of Events Scale: A measure of subjective stress. Psychosom Med 1979;41:209‑18. Weiss DS, Marmar CR. The Impact of Event Scale‑Revised. In: Wilson JP, Keane TM, editors. Assessing Psychological Trauma and PTSD: A Practitioner’s Handbook. 1997, New York: Guilford Press. p. 399 411. Access this article online Quick Response Code
Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.120568
Prolonged, self‑administration of ultra‑high doses of quetiapine Sir, The maximum licensed dose of quetiapine across diagnostic indications is 800 mg/day; in mood disorders, however, doses around 300 mg/day are usual. Herein, we report a patient who self‑administered two and a half times the maximum dose each day for 2 months. A. J. is a 30‑year‑old male with no past history of substance abuse. After the first episode of mania, he was treated to remission and then maintained on lithium (800 mg/day), haloperidol (5 mg/day), trihexyphenidyl (4 mg/day), and quetiapine (100 mg at night). He did not report for follow‑up until 3 months later, when it was found that on his own initiative and during the first month after remission, he had gradually increased the dose of quetiapine from 100 mg to 2,000 mg at night. He explained that his sleep had been poor; after raising the dose of quetiapine, his sleep had normalized in duration and restorative quality. He had continued quetiapine 2 g nightly (along with his other medications) for the next 2 months without apparent detriment. Mental status and physical examination findings were within 404
normal limits. His blood pressure was normal. Cognition for everyday functions was unaffected. With the exception of Serum glutamic oxaloacetic transaminase (SGOT) and Serum glutamic pyruvic transaminase (SGPT), which were elevated to a little above twice the laboratory reference range, hematology, liver function, renal function, serum electrolyte, and electrocardiogram (ECG) test results were within normal limits. Quetiapine levels could not be assessed because the facilities for the assay were unavailable. Quetiapine was abruptly withdrawn and oxazepam (30 mg nightly) was introduced to manage possible withdrawal symptoms; the other medications were continued. No discontinuation symptoms developed. Three weeks later, all liver function tests were normal. Euthymia was maintained. Patients have survived 20-24 g overdoses with quetiapine;[1,2] a dose of 2 g/day, therefore, is not large in comparison. However, this dose is markedly above 300 mg/day, a dose that is common in patients with mood disorders. What is additionally unusual is that the ultra‑high dose was continued without adverse consequences for 2 months. The gradual dose up‑titration reported may explain why adverse Indian Journal of Psychiatry 55(4), Oct-Dec 2013
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.
Dissociative identity disorder: An uncommon psychiatric disorder reported Sir, Dissociative Identity Disorder (DID) is an enigmatic disorder in psychiatry, with a prevalence of around 0.1‑1%. It has been often wrongly diagnosed as schizophrenia, bipolar affective disorder, impulse control disorder, or borderline personality disorder among others. We are presenting one such case. Ms. M, a nineteen year old college going girl was brought for consultation by her mother for repeated attacks of amnesia and poor impulse control related symptoms like irritability, destructive behaviour and self harm. On further enquiry, the patient gave a history of being accused of lying and being hypocritical since she was in the sixth grade; having no memory of how she landed up in unexpected places (a nearby zoo/friend’s place); having a sense of being estranged, hearing voices in her head of her mother talking with other people. Her mother gave a history of being able to see 3 different states in her daughter‑ a nineteen year old intelligent college student; a trusting state in which she speaks in a childish voice and having high risk behaviour (like going off with strangers, taking drinks mixed with intoxicants, not recognizing treating doctors); and an aggressive state in which she is easily irritable, paces about and attempts to harm her mother or herself. She (patient) herself is unaware of these episodes and states.
On admission, organicity was ruled out by appropriate tests. She was put on a mood stabilizer and anti depressive agents for symptomatic control. Safety and security was established. The patient narrated her abuse (during adolescence) in one of the other dissociative states. This could have been misdiagnosed as psychosis, intermittent explosive disorder, depressive disorder, or borderline personality disorder. The keen observation by the mother (who herself had possession syndrome and depression earlier in life) helped in the diagnosis. A treating clinician must be aware and be on the lookout for dissociative states and be prepared for therapeutic work with such patients.
Siva Shankar Priya, Nambi Siva
Department of Psychiatry, Sree Balaji Medical College and Hospital, Chrompet, Chennai, Tamil Nadu, India E‑mail: [email protected] Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.120565
Studies on posttraumatic stress disorder: Challenges ahead Sir, Disaster studies play an important role in the area of research being unique in its methodology and also on the enormous impact it would have on affected population. Disaster studies have a set of inherent difficulties associated with them. They can only attain the status of quasi‑experimental design, with comparison groups and not controls. Since disasters occur unpredictably, pretest data on victims are usually not available. Researchers can seldom obtain access to the disaster at its onset, and if they do find access, the exigencies of the situation usually preclude administration of standard instruments in a standardized fashion. Additionally, the statistical analysis of a nested case control model must take into account the way in which controls are sampled from the cohort. Performing logistic regression on nested case controls can result in biased Indian Journal of Psychiatry 55(4), Oct-Dec 2013
estimates whose null distribution is different than what is assumed. The study by Pyari and her colleagues[1] attempted in evaluating the risk factors associated with posttraumatic stress disorder (PTSD) in the 2004 tsunami. Disaster studies should focus on understanding what aspects of disaster are most devastating, and what characteristics of individuals make them vulnerable. The authors have done so to include an exhaustive list of risk factors. However, other important risk factors like traumatic brain injury, premorbid trait anxiety, coping skills, ethnicity, and immigration could be incorporated.[2] It would also have been fruitful to include traumatic brain injury as risk factor for PTSD as studies estimate its frequency between 17 and 33%.[3] Children and adolescents, an important vulnerable group could have also been studied by the authors. 403
Letter to Editor
The authors have used the impact of event scale (IES)[4] to diagnose PTSD. This scale is not a diagnostic tool for PTSD, but pick up of persons having intrusive and avoidance symptoms of PTSD. This scale does not rule out comorbid conditions mimicking PTSD as the authors themselves found low specificity in the pilot study.[1] The authors could have used revised version of IES developed by Weiss and Marmar,[5] that also included hyperarousal symptoms. It was also not clear as to why the cutoff for cases above the 70th percentile of the IES score was chosen. The authors have missed reference for the social support scale used. The study was conducted 6 months after the tsunami over a period of 1‑year and evaluated the PTSD symptoms only in the week preceding the administration. Possibly, the authors might have missed a considerable numbers of patients with PTSD as the disorder uncommonly has delayed onset. Nonetheless, keeping the limitations of designing and carrying out disaster studies, the authors have done an admirable task at studying the risk factors associated with PTSD in developing countries like ours. There is a further need for studies analyzing interventions in the post disaster period and preventive methods for the vulnerable population along with transcultural issues like manifestation of PTSD and community response to disaster. Such studies would bear important implications at both the clinical and administrative arena.
Pallavi Sinha, Amit Garg, Om Prakash
Department of Psychiatry, Institute of Human Behavior and Allied Sciences, Dilshad Garden, New Delhi ‑ 110 095, India. E‑mail: [email protected] REFERENCES 1.
2.
3. 4. 5.
Pyari TT, Kutty RV, Sarma PS. Risk factors of post‑traumatic stress disorder in tsunami survivors of Kanyakumari District, Tamil Nadu, India. Indian J Psychiatry 2012;54:48‑53. Perilla J, Norris F, Lavizzo E. Ethnicity, culture, and disaster response: Identifying and explaining ethnic differences in PTSD six months after Hurricane Andrew. J Soc Clin Psychol 2002;12:20‑45. Rattock J, Ross B. Post traumatic stress disorder in the traumatically head injured. J Clin Exp Neuropsychol 1993;15:403. Horowitz M, Wilner N, Alverez W. Impact of Events Scale: A measure of subjective stress. Psychosom Med 1979;41:209‑18. Weiss DS, Marmar CR. The Impact of Event Scale‑Revised. In: Wilson JP, Keane TM, editors. Assessing Psychological Trauma and PTSD: A Practitioner’s Handbook. 1997, New York: Guilford Press. p. 399 411. Access this article online Quick Response Code
Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.120568
Prolonged, self‑administration of ultra‑high doses of quetiapine Sir, The maximum licensed dose of quetiapine across diagnostic indications is 800 mg/day; in mood disorders, however, doses around 300 mg/day are usual. Herein, we report a patient who self‑administered two and a half times the maximum dose each day for 2 months. A. J. is a 30‑year‑old male with no past history of substance abuse. After the first episode of mania, he was treated to remission and then maintained on lithium (800 mg/day), haloperidol (5 mg/day), trihexyphenidyl (4 mg/day), and quetiapine (100 mg at night). He did not report for follow‑up until 3 months later, when it was found that on his own initiative and during the first month after remission, he had gradually increased the dose of quetiapine from 100 mg to 2,000 mg at night. He explained that his sleep had been poor; after raising the dose of quetiapine, his sleep had normalized in duration and restorative quality. He had continued quetiapine 2 g nightly (along with his other medications) for the next 2 months without apparent detriment. Mental status and physical examination findings were within 404
normal limits. His blood pressure was normal. Cognition for everyday functions was unaffected. With the exception of Serum glutamic oxaloacetic transaminase (SGOT) and Serum glutamic pyruvic transaminase (SGPT), which were elevated to a little above twice the laboratory reference range, hematology, liver function, renal function, serum electrolyte, and electrocardiogram (ECG) test results were within normal limits. Quetiapine levels could not be assessed because the facilities for the assay were unavailable. Quetiapine was abruptly withdrawn and oxazepam (30 mg nightly) was introduced to manage possible withdrawal symptoms; the other medications were continued. No discontinuation symptoms developed. Three weeks later, all liver function tests were normal. Euthymia was maintained. Patients have survived 20-24 g overdoses with quetiapine;[1,2] a dose of 2 g/day, therefore, is not large in comparison. However, this dose is markedly above 300 mg/day, a dose that is common in patients with mood disorders. What is additionally unusual is that the ultra‑high dose was continued without adverse consequences for 2 months. The gradual dose up‑titration reported may explain why adverse Indian Journal of Psychiatry 55(4), Oct-Dec 2013
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.
