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Indian Journal of

Psychiatry OFFICIAL PUBLICATION OF THE INDIAN PSYCHIATRIC SOCIETY

July–September 2005

Volume 47, Number 3

ISSN 0019-5545 EDITORIAL

Taking psychiatry to the public in the Third World: Potential and pitfalls

CASE REPORTS Folie à deux 131

NIMESH G. DESAI

P.N. SURESH KUMAR, N. SUBRAMANYAM, BIJU THOMAS, ABU ABRAHAM, KISHORE KUMAR

Paroxetine overdose ORIGINAL RESEARCH PAPERS REM sleep latency and neurocognitive dysfunction in schizophrenia

133

139

169

Convulsions in the treatment of obsessive– compulsive disorder

173

SOUMYA BASU, SUBHASH CHANDRA GUPTA, S. HAQUE NIZAMIE

144

MITA MAJUMDAR, YVONNE DA SILVA PEREIRA, JOHN FERNANDES

Perception of burden by caregivers of patients with schizophrenia

Factitious schizophrenia

SANDEEP GROVER, SURESH KUMAR, SURENDRA KUMAR MATTOO, NITESH PRAKASH PAINULY, GAURAV BHATEJA, RAJINDER KAUR

LATHA SRINIVASAN, R. THARA, S.N. TIRUPATI

Stress and anxiety in parents of mentally retarded children

167

ARUN K. GUPTA, PANKAJ VERMA, SAMIR K. PRAHARAJ, DIPAYAN ROY, ANURADHA SINGH

MRINMAY DAS, RUCHIKA DAS, UDAYAN KHASTGIR, UTPAL GOSWAMI

Cognitive dysfunction and associated factors in patients with chronic schizophrenia

164

GRAND ROUNDS IN PSYCHIATRY Obsessive–compulsive disorder: An interface with possible psychotic features 148

175

K. NAGARAJA RAO, SUDARSHAN C.Y., PREETHI PAI

SUNIL SRIVASTAVA

Group meetings of caretakers of patients with schizophrenia and bipolar mood disorders

BOOK REVIEW 153

The ECT handbook

179

Reviewed by B.N. GANGADHAR

ISMAIL SHIHABUDDEEN T.M., GOPINATH P.S.

LETTER TO THE EDITOR BRIEF RESEARCH COMMUNICATIONS Assessment of the domains of quality of life in the geriatric population

157

ANKUR BARUA, MANGESH R., HARSHA KUMAR H.N., SAAJAN MATHEW

Family support group in psychosocial rehabilitation L. PONNUCHAMY, BAIJUMON K. MATHEW, SHEEBA MATHEW, G.S. UDAYAKUMAR, S. KALYANASUNDARAM, DHARITRI RAMPRASAD

Sexual dysfunction in India

181

C. ANDRADE

‘MY VOICE’ Who is a good psychiatrist?—A collective view 160

NIRMALA SRINIVASAN

IPS AWARD RULES Rules and regulations pertaining to awards of the Indian Psychiatric Society

182

Indian Journal of

Psychiatry OFFICIAL PUBLICATION OF THE INDIAN PSYCHIATRIC SOCIETY

Honorary Editor

Journal Committee

Nimesh G. Desai Professor and Head, Department of Psychiatry, and Medical Superintendent Institute of Human Behaviour & Allied Sciences (IHBAS) Dilshad Garden, Delhi 110095 Dir: 011-22113395 Mobile: 09810797933 Fax: 011-22583589 e-mail: [email protected]

A.K. Agarwal C.R. Chandrashekar S.M. Channabasavanna K.A. Kumar K. Kuruvilla Savita Malhotra Roy Abraham K. (ex officio)

Honorary Associate Editor

Dinesh Bhugra (UK) Haroon Rashid Choudhary (Pakistan) George Christodoulou (Greece) William Eaton (USA) Marc Galantar (USA) Rohan Ganguly (USA) Helen Hermann (Australia) Mohan K. Isaac (Australia) M.S. Keshavan (USA) Nalaka Mendis (Sri Lanka) Juan Mezzich (USA) M.K. Nepal (Nepal) Vikram Patel (UK) Rudra Prakash (USA) Antti Prakaslahti (Finland) Pedro Ruiz (USA) Shekhar Saxena (WHO)

S.N. Sengupta Tel: 011-22595651 Honorary Deputy Editors Deepak Kumar Mobile: 09810145451 Rupali Shivalkar Mobile: 09312667822 Honorary Assistant Editor Saurabh Mehrotra Mobile: 09899811058 Editorial Board S. Adarkar C. Andrade A. Avasthi Vivek Benegal R. Chandrashekar S.K.Chaturvedi B.S. Chavan A.N. Chowdhury M. Gowri Devi B.N. Gangadhar Sanjay Gupta K.S. Jacob Rakesh Lal

Mustaq Margoob T. Murli S. Haque Nizamie S.R. Parkar G. Prasad Rao T.S.S. Rao R. Sathianathen Henal Shah Pratap Sharan P.S.V.N. Sharma Amool R. Singh Prathap Tharyan M. Varghese

Editorial and Production Consultants BYWORD, New Delhi e-mail: [email protected]; [email protected] Published by Nimesh G. Desai on behalf of the Indian Psychiatric Society Printed at Indraprastha Press (CBT) 4 Bahadurshah Zafar Marg New Delhi 110002

S.C. Malik D. Nagaraja G.G. Prabhu Anil V. Shah S.D. Sharma J.K. Trivedi P. Raghurami Reddy S. Nambi (ex officio)

International Advisory Board

ISSN 0019-5545

Mike Shooter (UK) Bruce Singh (Australia) J. Srinivasaraghavan (USA) Rajiv Tandon (USA) Mitchell Weiss (Switzerland) Statistical Consultants A. Indrayan S.N. Dwivedi C.B. Tripathi Information Science Consultants R.P. Kumar H.S. Siddamallaiah Distinguished Past Editors N.N. De L.P. Verma A.N. Bardhan Lt. Col. M.R. Vachha A. Venkoba Rao B.B. Sethi S.M. Channabasavanna A.K. Agarwal K. Kuruvilla J.K. Trivedi Utpal Goswami T.S.S. Rao

1949 to 1951 1951 to 1958 1958 to 1960 1961 to 1967 1968 to 1976 1977 to 1984 1985 to 1988 1989 to 1992 1993 to 1996 1997 to 2002 2003 2004

Subscription Subscribers should contact the office of the Honorary Editor, IJP for subscription requests. Annual subscription rates for year 2005 (5 issues, postage included) are as follows: Institution Individual India Rs 3,500 Rs 2,400 Overseas US$ 140 US$ 100

(total 5 issues). The IJP publishes original work in all fields of Psychiatry. All correspondence including manuscripts for publication should be sent to the Honorary Editor, Indian Journal of Psychiatry, Department of Psychiatry, Institute of Human Behaviour & Allied Sciences (IHBAS), Dilshad Garden, Delhi 110095, India, e-mail: [email protected].

Queries from member/non-members about missing or faulty copies should be addressed within three months. Payment should be in the form of Bank Draft in favour of ‘Honorary Editor, Indian Journal of Psychiatry’, payable at Delhi.

Copyright: @ 2005 The Indian Psychiatric Society. Unless so stated, the material in the Indian Journal of Psychiatry does not necessarily reflect the views of the Editor or the Indian Psychiatric Society. The publishers are not responsible for any error or omission of fact.

Advertisements Correspondence related to booking of advertisements should be addressed to the editorial office. The Indian Journal of Psychiatry is an official publication of the Indian Psychiatric Society. It is published quarterly with one additional supplement

The appearance of advertisements or product/services information in the various sections in the Journal does not constitute an endorsement or approval by the Journal and/or its publisher of the quality or value of the said product or of claims made for it by its manufacturer.

EXECUTIVE COUNCIL OF THE INDIAN PSYCHIATRIC SOCIETY

OFFICE BEARERS President S. Nambi (Chennai) Tel: 044-24617397, Mobile: 9444018671 e-mail: [email protected]

DIRECT MEMBERS Col. S. Chaudhury (Pune) U.C. Garg (Agra) N.R. Arun Kishore (Trichur) Vinay Kumar (Patna)

Vice President Asit Baran Ghosh (Kolkata) Tel: 033-23218159, Mobile: 9830045425 e-mail: [email protected] Honorary General Secretary Roy Abraham Kallivayalil (Kottayam) Tel: 04822-200200, 210799(R), Mobile: 9447020020 e-mail: [email protected] Honorary Assistant Secretary Verghese P. Punnoose (Kottayam) Tel: 0481-2585734(R), 0481-2597311 Honorary Treasurer Asim Kumar Malik (Kolkata) Mobile: 09830045662 e-mail: [email protected] Honorary Editor Nimesh G. Desai (Delhi) Tel: 011-22113395, Mobile: 9810797933 e-mail: [email protected]

P.M. Madhavan (Ottapalam) Amaranath Mallik (Kolkata) G. Prasad Rao (Hyderabad)

CHAIRPERSONS OF COMMITTEES Awards

:

P. Kulhara

CME

:

R. Sathianathen

Constitution

:

Ramanan Earat

Ethics

:

A.K. Agarwal

International Affairs

:

Vihang Vahia

Journal

:

Nimesh G. Desai

Membership

:

R.R. Ghosh Roy

Mental Hospitals

:

Sailen Deuri

Parliamentary

:

P.K. Chaturvedi

Psychiatry Education

:

T.S.S. Rao

Finance

:

P. Joseph Varghese

Immediate Past President J.K. Trivedi (Lucknow) Tel: 05222371481, Mobile: 9839016510 e-mail: [email protected] Immediate Past General Secretary S. Nambi (Chennai)

ZONAL REPRESENTATIVES North Zone

: Nimesh G. Desai (Delhi) Roop Sidana (Sri Ganganagar)

South Zone

: Ramanan Earat (Palakkad) P. Joseph Varghese (Kochi)

East Zone

: Prabir Paul (Kolkata) P.K. Singh (Patna)

West Zone

: Mukesh P. Jagiwala (Surat) Govind M. Bang (Nagpur)

Central Zone

: Nand Kishore (Dehradun) Sarvesh Chandra (Bareilly)

SPECIALTY SECTIONS Chairperson

Convenor

Biological Psychiatry K.S. Ayyar

Sanjay Gupta

Child Psychiatry

Anirudha Deb

V. Jayanthini

Community Psychiatry Shubangi Parkar

B.S. Chavan

Forensic Psychiatry

Jayanta Chatterjee

Kuruvilla Thomas

Geriatric Psychiatry

Charles Pinto

K.S. Shaji

Military Psychiatry

S. Sudarsanan

A.A. Pawar

Private Psychiatry

Sunil Mittal

N. Dinesh

Rehabilitation Psychiatry

T. Murali

Tophan Pati

Desai: Taking psychiatry to the public in the Third World

131

EDITORIAL

Taking psychiatry to the public in the Third World: Potential and pitfalls NIMESH G. DESAI

The need for and correctness of knowledge reaching the larger proportion of the human population, ‘the masses’ or ‘the public’, is high in almost all disciplines but particularly so in science because it is meant to serve the purpose of improving human existence. The growth and expansion of science has made this task progressively more difficult due to the increasingly ‘technical’ nature of scientific concepts and language. Although the recognition for public education in science or carrying science to the public is reaching imperative levels, the strategies and mechanisms for doing so are becoming more complex. The justification for disseminating knowledge to the public in the field of medical or health sciences is unarguable, since it has the potential to enhance participation in treatment and other health-related behaviour. The need for effective communication of scientific knowledge on illness and health is matched by the complex nature of the communication strategies required to disseminate the ‘technical’ nature of information and knowledge. These complexities need to be factored in to ensure that the correct scientific information becomes available to the public for better understanding and implementation. Psychiatry, a medical discipline and yet with significant differences, has its advantages and disadvantages in reaching its message to the public. The larger field of mental health, of course, has its own dilemmas in public education, what with its issues of multidisciplinary identity and amorphous concepts. The debate whether psychiatry or mental health should be the focus of public education is a valid one in itself, but to examine the task of taking psychiatry to the public is a useful first step. Psychiatry, being less technology-based as compared to other medical disciplines, should have had an advantage in its conceptualizations and syntax, and yet this does not seem to have been the case. ‘Psychobabble’ or psychological ‘mumbo–jumbo’ does not enthuse the public or help in understanding the concepts. The fact that psychiatry deals with abnormal functioning of the psyche, using terms from psychology, which have different connotations in dayto-day parlance, makes the task of communicating these concepts more difficult. Moreover, the belief of the lay people in general, and of opinion-makers in particular, that they already know enough about the functioning of the human

mind, if not also the reasons thereof, renders them not very receptive to the efforts by professionals. The self-proclaimed ‘expertise’ that many members of the public seem to have on issues of psychiatry does make the task of taking the concepts in psychiatry to the public difficult. It has been argued that the distinction between writings in psychiatry and those in journalism were narrowed because ‘as with everything else, we can blame Freud who wrote directly for the public, and whose case histories can be consumed as fiction’.1 It must also be recognized that it was Freud who was most influential in taking the concepts to the public. Herein lies one inherent pitfall. The scientific concepts in psychiatry to be conveyed to the public will have to be communicated in a style and syntax that is simple and narrative, and yet avoid the risk of becoming too non-scientific or journalistic. This dilemma of maximizing the potential of reaching out to the larger public in a meaningful manner and the pitfall of compromising on the scientific content is reflected much too often in the efforts by professionals in the popular media. On the other hand, the considerable sensationalization of stories related to mentally ill persons or their actions by journalists is often seen as excessive by professionals. The impact of such patterns on suicidal behaviour has been controversial and, although the evidence is not substantive, the print media in the western world generally seem to have a self-imposed code of not highlighting the details of the method of suicide and of toning down excesses.1 It has recently been documented that the public in the UK seemed largely ignorant of the work of psychiatrists.2 Some argue that it is reticence on the part of psychiatrists that contributes to the lack of knowledge. An experiment in Norway showed that a coordinated press campaign reduced the duration of untreated psychosis in one of the counties from 118 weeks to 26 weeks.1,3 Effective collaboration between psychiatrists and media workers has been difficult because of the differences in their respective functioning and approaches. While media workers are narrative-based, creative, plain-speaking, anti-authority and guardians of the public interest with emphasis on the public’s right to know; psychiatrists are evidence-based, scientific, contemplative, jargon-using guardians of the public, with the added role of being keepers of

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their patients’ secrets.1 But are these differences impossible to transcend? The proliferation of the media of mass communication from radio to television and the internet makes it difficult for psychiatrists to stay insulated. At the same time, the lure of appearing on the radio or television does not always match the substantiveness of the message intended to be conveyed. One producer has recommended daytime television as a suitable forum for mental health issues, while the counterview is that no group which has successfully fought discrimination has achieved equality by arousing pity, and so ‘television is the worst medium through which to consider exploring the complex biopsychosocial origins of mental illness and its treatment, and such programmes are [almost] all in the worst possible taste’.1,3 The large proportion of violence-related issues in the television news coverage of mental health issues has been cited to suggest that ‘television in general, and television news in particular, is a major reservoir of stigma’. 4 The tendency of some psychiatrists to opine on every aspect of medical, social and political life or ‘demand hegemony over them’5 has been cautioned against in the western world and is a clear danger in Third World countries.1 The dilemma here obviously is of the potential of reaching out to a large number of people through the audiovisual media and the pitfall is the risk of being too eager to analyse or put a label on every aspect of human behaviour. It is also questionable whether the public perception of, or attitude towards, mentally ill persons is modified by the didactic approach adopted by television programmes or documentary films on mental illness. The pitfall of increasing the stigma by ill-conceived documentary approaches or merely losing sight of people’s interest is significant, but needs to be countered by actively exploring the potential for narrative-based or simulated portrayals. Barring a few exceptions, popular cinema has generally been known to depict mentally ill persons and psychiatrists in a negative light. The debate between the creativity of the artist, namely the director or the scriptwriter, versus their social responsibility, is delicately balanced. Ever so often, psychiatrists and their associations protest about the portrayal of a mentally ill person or a psychiatrist in a particular film, even when dispassionate understanding would suggest that the said portrayal was the reflection of the prevalent social perception of the phenomenon. The pitfall remains that overprotestation would jeopardize the opportunity of changing such perceptions and portrayals! The role of effective services, especially if they are delivered in a user-friendly manner, in taking psychiatry to

the public, has been not adequately recognized, despite the evidence about its usefulness,6,7 although not everyone in clinical psychiatry services is keen to share information with patients.8 It has been found in the UK that most patients would like their psychiatrists to consider their preferences and want to be involved in decisions about their care.9 There is no reason to believe that it would be any different in the Third World because it has been suggested that clinicians generally underestimate their patients’ desire for information.10 Most importantly, a systematic evaluation of awareness programmes by the Mental Health Awareness Action (MHAA) programme in the UK has found that the key active ingredient identified by all groups was the testimonies of service users. The statements of service users (consumers) about their experience of mental health problems and of their contact with a range of services had the greatest and most lasting impact on the target audiences in terms of reducing the mental health stigma.11 It would seem that besides other activities that we may involve ourselves in, one of the best, if not the surest, way of taking psychiatry to the public is to carry out our clinical work competently and sensitively, as well as relate with the experiences of consumers.

REFERENCES 1. Byrne P. Psychiatry and the media. Advances in Psychiatric Treatment 2003;9:135–43. 2. Williams A, Cheyne A, MacDonald S. The public knowledge of psychiatrists: Questionnaire survey. Psychiatric Bulletin 2001;25:429–32. 3. Salter M, Byrne P. The stigma of mental illness: How you can use the media to reduce it. Psychiatric Bulletin 2000;24:281–3. 4. Philo G. Media and mental distress. London: Longman; 1996. 5. MacDonald A. Commentary on delirium: The role of psychiatry. Advances in Psychiatric Treatment 2001;7:442–3. 6. Timms P, Hart D, Cohen A, et al. Help is at hand on the web— what do our readers think? Psychiatric Bulletin 2005;29:24–7. 7. Dosani S. A helping hand: Providing information to patients and the public. Psychiatric Bulletin 2005;29:1–2. 8. Coulter A. Partnerships with patients: The pros and cons of shared clinical decision-making. Journal of Health Services Research Policy 1997;2:112–21. 9. Coulter A, Entwistle V, Gilbert D. Sharing decisions with patients. Is the information good enough? BMJ 1999;318:318–22. 10. Strull WM, Lo B, Charles G. Do patients want to participate in medical decision making? JAMA 1984;252:2990–4. 11. Pinfold V, Thornicroft G, Huxley P, et al. Active ingredients in anti-stigma programmes in mental health. Int Rev Psychiatry 2005;17:123–31.

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Das et al.: REM sleep latency and neurocognitive dysfunction in schizophrenia

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ORIGINAL RESEARCH PAPER

REM sleep latency and neurocognitive dysfunction in schizophrenia MRINMAY DAS, RUCHIKA DAS, UDAYAN KHASTGIR, UTPAL GOSWAMI

ABSTRACT Background: Cognitive deficits—the hallmark of schizophrenic deterioration—still remain elusive as far as their pathophysiology is concerned. Various neurotransmitter systems have been implicated to explain these deficits. Abnormalities in cholinergic neurotransmission in the brain are one of the postulations; acetylcholine has also been postulated to regulate rapid eye movement (REM) sleep, especially REM latency. Thus, REM latency in patients with schizophrenia might provide a non-invasive window to look into the cholinergic functions of the brain. Aim: To study REM sleep measures and neurocognitive function in schizophrenia, and the changes occurring in these parameters following pharmacological treatment. Methods: Thirty subjects (15 with schizophrenia and 15 normal non-relative controls) were evaluated in this study. Most patients with schizophrenia had prominent negative symptoms and deficits in the performance in neurocognitive tests battery. They were treated with antipsychotics for a variable period of time and posttreatment evaluation was done using the same battery of neurocognitive tests and polysomnography. Patients were either drug-naïve or kept drug-free for at least two weeks both at baseline as well as at the posttreatment stage. Results: A positive correlation between the severity of negative symptoms and neurocognitive deficits (especially on the Wisconsin Card Sorting), and a negative correlation between these two parameters and REM latency was observed. Conclusion: It can be hypothesized that the acetylcholine deficit model of dementia cannot be applied to schizophrenic dementia, rather a hypercholinergic state results. This state warrants anticholinergic medication as a treatment option for negative symptoms of schizophrenia. Key words: REM sleep latency, neurocognitive deficits, negative symptoms, schizophrenia Indian J Psychiatry 2005;47:133–138

INTRODUCTION Cognitive impairment is a central manifestation of schizophrenia.1,2 It impacts on the quality of life of patients and on the cost of illness to society. 3 In recent years, researchers have attempted to identify and quantify the deficits through neuropsychological, neurophysiological and imaging studies of the brain; they have tried to identify specific regional brain abnormalities corresponding to these deficits. Using neuropsychological tests, some investigators have reported relatively greater left hemispheric deficits among patients with schizophrenia.4,5 Others have found a more generalized and non-specific pattern of neurocognitive dysfunction.6 Many investigators have focused on neuropsychological evidence of frontal lobe dysfunction in schizophrenia, and some supportive evidence has been reported.7,8 Cerebral blood flow

studies9 and positron emission tomographic investigations10 have provided further evidence of frontal lobe dysfunction in schizophrenia. More recently, neuroradiological metabolic studies have hypothesized abnormal connectivity between the frontal lobe and temporal areas, and have suggested an association between these functional abnormalities and cognitive impairment. 11 Despite these attempts, defining neurocognitive deficits along biological lines have remained elusive.12 As the pathophysiology of cognitive impairment in schizophrenia is unknown, no rational pharmacotherapy for this condition can be devised. Despite the fact that patients with schizophrenia do not show cholinergic deficits, drawing a similarity between Alzheimer disease and neurocognitive deterioration in schizophrenia, cholinomimetics might be tried to improve cognitive dysfunction in schizophrenia.13

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On the other hand, it has been shown that shortened rapid eye movement (REM) latency is a non-specific finding, is present in depressive illness, and correlates negatively with the severity of negative symptoms of schizophrenia.14,15 Cholinomimetic drugs have been used to show their REM latency-reducing property, with the hypothesis that increased cholinergic function or decreased aminergic function or both might be responsible for shortened REM latency. Here lies the paradox that cognitive impairment (hypocholinergic state), shortened REM latency and increased severity of negative symptoms (hypercholinergic state) are present in the same patient and at the same time. To understand the paradox, we measured the REM latency vis-a-vis negative symptoms and cognitive function. We studied REM sleep measures and neurocognitive functions in schizophrenia. The changes occurring in these parameters following pharmacological treatment were also studied.

METHODS Subjects There were a total of 30 subjects (15 cases with schizophrenia and 15 normal controls) in the current investigation. All the patients with schizophrenia were recruited from among those seeking treatment at the OPD and inpatient services of the Department of Psychiatry, Lady Hardinge Medical College and Associated Hospitals, New Delhi. The clinical staff of the department had been told that the investigators were seeking previously unmedicated (drug-naive) or currently medication-free (for at least two weeks) patients with schizophrenia and were asked to contact the investigators. Given the rarity of such subjects, continuous surveillance of inpatient admissions was also maintained. The patients being considered for this study were interviewed to determine whether they met the DSM-IIIR16 criteria for chronic schizophrenia, as confirmed by the Structured Clinical Interview for DSM-IIR, Patient version (SCID-P).17 The interview was supplemented by a review of the patients’ records and an interview of family members. Patients who did not meet the inclusion criteria or met the exclusion criteria (Box 1) were kept out of the study. The patients we studied were chronically disabled but did not need acute hospitalization. Box 1. Exclusion criteria for selection of schizophrenics • History of or presence of current organic diseases • History of alcohol or other substance abuse or dependence • Patients with epilepsy or mental retardation • Patients with serious suicidal or homicidal potential • Patients with primary neurological disorders or any other Axis 1 disorder apart from schizophrenia • Patients with primary sleep disorders

Informed consent was taken from the subjects who were able and willing; alternatively, if the subjects were judged to be incompetent to give written informed consent, the same was obtained from significant relatives. A battery of relevant investigations was done to rule out any other medical, surgical or neurological disorder. A semistructured proforma devised for the study was used to collect sociodemographic information and historical data, with special reference to clinico-symptomatological, course-related and treatment outcome variables, including data on standard physical and detailed mental status examination. Over a period of 13 months, a total of 23 drug-naive or psychoactive medication-free (for at least two weeks) patients were approached to participate in this study. Two patients refused. Four patients required medication to control agitation before they could be studied and hence were excluded. A seventh patient was excluded as his illness turned out to be schizoaffective disorder. Thus, of the original cohort of 23, 15 patients fulfilled the inclusion and exclusion criteria and were included in the study. Subjects in the control group were selected from the clinical/paraclinical staff members of the department as well as healthy attendants who were not biologically related to the inpatients. The age, sex and educational status of the control group were matched as closely as possible with that of the index group (Table 1). The mean age of the patient group was 32.1±6.7 years (range: 22–46 years) and that of the control group 31.0±8.1 years (range: 19–45 years). The majority of the subjects (both cases and controls) were educated till higher secondary (10+2), without any skew between the grouping, and the groups were comparable. The average duration of illness was 4.6±4.1 years; 60% of the cases were diagnosed with paranoid, and 20% each with residual and undifferentiated schizophrenia. Of the 15 cases, 3 patients were drug-naive, 2 had been medicated for 1 year, 2 for 6 months, 2 for 3 months, 3 for 5 weeks and 3 for 2 Table 1. Sociodemographic and clinical profile of the study groups Variable Age (in years; mean±SD) Sex (M/F) Duration of illness (in years; mean±SD) Course of illness Chronic–stable Waxing–waning Progressively deteriorating Subtypes Paranoid Residual Undifferentiated Duration of medication (in months; mean±SD)

Indian Journal of Psychiatry 2005;47:133–138

Index cases

Normal controls

32.1±6.7 8/7 4.6±4.1

31±8.1 8/7 0

3 8 4

— — —

9 3 3 6.3±2.4

— — — —

Das et al.: REM sleep latency and neurocognitive dysfunction in schizophrenia

weeks. Therefore, the mean duration of medication was 6.3±2.4 months. The Positive and Negative Syndrome Scale (PANSS),18 Montgomery–Asberg Depression Rating Scale (MADRS),19 Abnormal Involuntary Movement Scale (AIMS),20 Simpson– Angus rating scale (to measure extrapyramidal side-effects)21 were administered to each subject to obtain a set of baseline measures in keeping with the aim of the study. The Global Assessment of Functioning (GAF) Scale of DSM-IV22 was applied to assess the current level of global functioning.

REM sleep study procedure Polysomnography was conducted on two consecutive nights in the sleep laboratory. Recording on the first night allowed acclimatization of the subject to the sleep laboratory environment. The polygraphic data of only the second night were used in the analysis. Sleep was recorded in the laboratory on a 24-channel polygraph (MPA-S Medilog instruments, Oxford). An electroencephalogram (EEG), an electro-oculogram (EOG) and a bipolar submental chin electromyogram (EMG) recorded the sleep state. The EEG consisted of a C4-scalp placement referenced to linked mastoids. The EOG consisted of electrode placement at the outer canthi of the eye with the derivation of each eye also referenced to the linked mastoids. All electrode impedances were determined to be less than 5000 ohms. The filter setting was 1–30 Hz for the EEG, 0.3– 30 Hz for the EOG and 10–90 Hz for the submental chin EMG. All sleep recordings were scored in 30 second epochs following Rechtschaffen–Kales criteria.23 Sleep onset was defined by the first minute of 10 consecutive minutes of stage II non-rapid eye movement (NREM) sleep, with no more than 2 intervening minutes of stage I sleep or awakening, following lights out. REM sleep was defined as not less than 3 consecutive minutes of REM sleep, with no less than 20 minutes of NREM sleep (stages I through IV) subtending any two REM periods. Sleep architecture was defined in terms of percentage of sleep time spent in NREM stages I through IV and REM.

Assessment of cognitive functions To test cognitive functions, a battery of tests was applied by means of a computer-assisted NeuroScan machine utilizing STIM software (Neurosoft Inc. 1990, STIM Audio system). The following tests were used: Card Sort, Visual Continuous Performance Task (VISCPT), Stroop and Spatial Task. The Card Sort program has been modelled after the Wisconsin Card Sorting Test (WCST),24,25 which was designed to test ‘abstract behaviour’ and ‘shift of set’. The program presents the subjects with a set of four card-like stimuli with a different pattern on each. The patterns contain different shapes in different colours. A probe stimulus is presented in the lower portion of the screen. The subject was required to

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choose the card from among the original four that best matched the probe stimulus. There were three randomly varied response contingencies. First, the subjects might be required to respond on the basis of the colour of the image on the card. Second, the subjects might be required to respond on the basis of the pattern of the image. Third, the subjects might be required to respond on the basis of the number of images on the card. The patients were not informed of the correct principle but a feedback on whether they were correct or not was given after their matching of each card. Once the criterion of 10 correctly sorted cards is attained, the principle is changed; the patient is not informed of this change. The test proceeds until the patient has completed six sorting categories, each consisting of 10 consecutive cards. The types of errors that are elicited may vary, although the most sensitive response type with respect to frontal lobe dysfunction is the perseverative response, reflecting subjects’ difficulty in shifting their strategies or cognitive sets. The Visual Continuous Performance Task (VISCPT) was used to test the attention span. In this program, user-created visual stimuli which could be precisely timed at rates were presented on the computer screen. The subject had to press the left button of the mouse when a ‘0’ appeared and the right button for all other digits that appeared on the screen. Spatial Task was used to test spatial memory. In this test, the number of object locations, and the time between stimulus element presentation and response could be varied. The scoring percentage of right/wrong among the total number of stimuli presented tested the spatial memory. Stroop Test26 was used as a measure of reading fluency and frontal lobe dysfunction. This task required subjects to rapidly shift the perceptual set when viewing names of colours that appeared in matching or non-matching colours. The Stroop program allowed the presentation of up to four different words in four different colours (e.g. red, yellow, green and blue). The program randomly presented the words in congruent and incongruent colours. The patients were first familiarized with the tests and were then helped to give the test on their own, after which the data were taken for analysis. Following the baseline assessments, patients in the schizophrenic group were allocated to either the haloperidol or risperidone group. Seven patients were treated with haloperidol as the main antipsychotic and the remaining 8 with risperidone for a variable period, ranging from 4 weeks to 14 weeks. Next, various measures including symptom profile, sideeffects profile, level of functioning, sleep polygraph measures were repeated for the entire cohort of patients with schizophrenia keeping them off medications for two weeks before the test. The normal healthy controls also underwent the same evaluations, including a polysomnography study and neurocognitive assessment, but only once.

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Das et al.: REM sleep latency and neurocognitive dysfunction in schizophrenia

Table 2. Psychopathology scores of the index group Score (mean±SD) Parameter PANSS Positive subscale Negative subscale General psychopathology subscale

Before treatment

Table 3. Sleep (REM latency) and cognitive function test measures in the study groups Index cases

After treatment Parameter

19.1±6.4 27.0±6.3 40.6±4.4

8.3±1.3 16.1±5.0 22.4±2.9

MADRS 18.6±7.2 11.6±4.8 AIMS* Simpson–Angus rating scale (for extrapyramidal symptoms) score† PANSS: Positive and Negative Syndrome Scale; MADRS: Montgomery–Asberg Depression Rating Scale; AIMS: Abnormal Involuntary Movement Scale *Three out of 15 patients had been suffering from mild to moderately severe tardive dyskinesia which neither deteriorated nor improved with treatment of short duration. † Among the experimental group, 11 patients developed antipsychotic-induced minimal to mild extrapyramidal symptoms that were significantly more than in the control group.

RESULTS Clinical profile of the patients Table 2 shows the mean psychopathology scores in the index group, both before and after treatment with antipsychotics. All the three subscale scores of the index group (positive, negative and general psychopathology subscales in PANSS) were significantly more than those of the control group (significant at p