Bengal Journal of Private Psychiatry

Review Article

Gadget addiction, Technostress & Internet addiction:

Upcoming challenges
Bhattacharyya Ranjan1, Ghosal Malay2, Chakraborty Kaustav3, Mandal Supriya Kumar4

1. Assistant Professor & HOD, Deptt of Psychiatry, Murshidabad Medical College & Hospital, West Bengal, India.
2. Assistant Professor, Deptt of Psychiatry, College of JNM & Hospital, Kalyani, West Bengal, India.
3. Assistant Professor, Deptt of Psychiatry, Murshidabad Medical College & Hospital, West Bengal, India.

Corresponding Author: Dr Ranjan Bhattacharyya. MD, DNB (Psychiatry), PhD trainee,

Asst Professor & HOD, Deptt of Psychiatry,Murshidabad Medical College & Hospital,West Bengal, India.
Mob: 9433053389. Email: drrbcal@gmail.com. Website: www.drranjanbhattacharyya.com

Background: The modern gadgets and technology have become predominant determinants of socioeconomic
status and not only is restricted to teenagers but is spreading fast across generations.
Introduction: Addiction to technology is causing significant loss of productivity as well as problems in
interpersonal relationships.
Materials & Methods: It has been postulated that rather than a separate entity, internet addiction is a
manifestation of a variety of depression, anxiety, impulse control disorders or pathological gambling. .
Results: There have been rehabilitative measures to correct internet overuse.
Discussion: Technophobia is the fear or dislike of modern technology particularly computers.
Conclusions: Let us welcome the technological revolutions with a widespread awareness of its potential danger.
The generation of today needs to move ahead with bright vision and better tomorrow.

BACKGROUND: relationships. 'Emotions' have been replaced by

The list of modern day gadgets is exhaustive and includes
Laptops, iPads, iPods, Video games, Smart phones and
playstations. These modern gadgets and technology have
become predominant determinants of socioeconomic
status and is not only vastly popular amongst teenagers and
young adults but is fast spreading across all generations.
This increasing dependence on technological gizmos has
far-reaching consequences.
Parents often complain that their son or daughters are
increasingly addicted to their mobile phones or play video
games and watch television the whole day. Human
intelligence has evolved, so have our gadgets and the
internet. Mechanised communications in social networking
sites have largely replaced warm interpersonal interactions
that once formed the basis of lasting bonds and
Emoticons. It would not be wrong to say that Man has
become slaves to the modern day gadgets. In the words
of the Michael Condry the chief operating and
development officer of Sledgehammer Games. All these
gadgets, the phone and the computer, they expose the
inside of your brain in a way that's bad. People prefer to
spend their weekends and spare time at home in front of
these gadgets. Children spend hours and hours in front of
laptops playing video games and social networking. Even
pornography, erotica, dating websites and sex games are
just a small'click' away. The parents are not fully aware of
the provisions of family filter , internet site selection, and
channel selection in televisions. As a result children are
often exposed to the harmful effects of these materials.
Children are becoming lazy, inactive and more aggressive.

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Bengal Journal of Private Psychiatry
They are addicted to video games which often contain
materials of extreme violent nature. Tender childly
emotions have been replaced by rudeness adamance and
defiance. The nuclear family structure and busy modern
day schedule of working parents have made the
opportunity of priceless human interactions bleaker.In
today's world, people are preferring to socialize on the
internet more and more rather than face-to-face. There are
frequent brawls between the parents and children.
Children no longer respect their parents and more than
often parents view children as their competitors rather than
their predecessors.Albert Einstein once expressed his
concern that technology will surpass human interaction.
That day has arrived.
Internet Explorer - Logoff Warning
Fig 1: Technological dependence and impact on
relationships.
2
Judicious use of internet is always advisable. Google can
act as a gold mine of information for all kinds of people,
young and old. The patterns of internet addiction across
various generations are different. Selfies or "photographing
of the self" and posting the pictures in the internet are the
new trends in the social media. The internet is flooded with
pictures of models, actors and actresses who upload their
personal photographs for public view. The practice is no
more confined to the celebrities. The generation Y has
adopted this trend in no time. A recent study has explored
the relationship between selfie-posting, photo-editing and
personality disorders.1
It explored the inter-relationship between self-
objectification and the three traits (known as the Dark triad
of narcissism, psychopathy and machiavellianism). The
study concluded that posting of higher number of selfies in
the social media were directly related to narcissism and
psychopathy. Addiction to technology is causing significant
loss of productivity as well as problems in interpersonal
relationships. The internet has paved the way for the waves
of globalisation to spread its claws in the smallest
households of the country. It's high time to formulate a
comprehensive approach to curb the unrestricted use of
the internet. Recently an incident where a teenager
committed suicide on losing his mobile phone has shaken
the nation to its root. Such slavery for gadgets are indeed
worrisome. We often witness people crossing busy roads
and busy intersections and railway tracks listening to ipods
or talking over the phone. This has lead to increase in the
number of accidents.
INTRODUCTION:
Over-use of mobile phones can affect social and
psychological well-being and health.The article was about
a teenager boy from china who sold his "kidney" just to buy
an iPhone for himself. Corresponding incidences and
trends in developing nations like India are also on the rise.2
Enormous amount of research has been directed in the last
decade on mobile phone use and its influence on the human
mind and body. It has been concluded that excessive
mobile phone users may encounter increased stress,
disturbances in sleep and symptoms of clinical depression.
These symptoms are especially prominent in young adults3

Internet addiction disorder (IAD) or more commonly
called Problematic Internet Use (PIU) or Compulsive
Internet Use (CIU) or even iDisorder.4,5,6 The
nomenclature was originally proposed in a satirical hoax by
Ivan Goldberg, M.D., in 1995. However, some time later,
it started to be used as a more generalised term denoting
excessive uncontrolled use of the internet. He used the
model of pathological gambling (diagnosed by the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) as his model for the description of IAD.Lack
of standardization in identifying PIU seems to be the major
barrier in classifying this as a psychiatric disorder.7
IAD can be categorised into subtypes by the type of
activity, like gaming; online social networking; blogging;
email; viewing Internet pornography in excess; or even
Internet shopping (shopping addiction). However, all
compulsive behaviors may not be necessarily addictive.8 A
recent study suggests that the prevalence of Internet
addiction varies considerably among different countries
and is inversely related to the quality of life.9 Addiction
researchers, psychologists, healthcare providers as well as
older adolescents have contributed data to build a
conceptual model of PIU.10,11
That study put forward seven concepts, or clusters such
as: Psychosocial risk factors; Physical, Emotional, as well
as Social and Functional impairments; Risky Internet use;
Impulsive Internet use; and Internet use dependence.12
Risky Internet use are those behaviors that increase the
risk of harmful consequences. Harmful effects include
difficulty in memory and concentration, emotional
turbulence, anxiety, insomnia, compulsive disorders as well
as depression. The impulsive use is the inability to control
internet use in day-to-day life. Finally, dependent use
describes extreme situations like withdrawal symptoms.10
Internet addiction disorder is not yet listed in the latest
DSM manual (DSM-5, 2013), which is commonly used
by psychiatrists all over the world.13 The only behavioural
(non-substance related) addiction included in DSM-5 is
gambling disorder. However excessive Internet gaming is
listed in an appendix as a disorder requiring further study.14
THE NOSOLOGY AND CHANGING TRENDS:
Jerald J. Block, a leading psychiatrist observed that
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diagnosis of Internet addiction was difficult since 86% of
study subjects presented with symptoms pertaining to
various other mental health disorders.15 Young explained
"Internet addiction" as a broad term that include addiction
to 'cyber sex', 'cyber relationships', 'net compulsions',
'information and research' and 'computer gaming'. 'Internet
Addiction' is actually addiction to the 'content' available
online like gaming, shopping, gambling cyber-relations
and anonymity, hence internet serves as the tool necessary
to fuel these addictions.16 Thus, excessive Internet users
are actually not Internet addicts per say. Another study by
Young elaborated that the new users of the internet were
the ones who were addicted more than regular users who
have been using the internet over a period of a year and
were largely nondependant, conforming to the concept
that internet addiction may wane over time.17 Young the
founding member of The Centre for On-Line Addiction
claims Internet addiction covers five principal subtypes of
behavioural and impulse control disorders that include:
1. Cybersexual addiction: addiction to cybersex and
cyberporn
2. Cyber-relationship addiction
3. Obsessive online gambling, shopping or day-trading
4. Compulsive and over-excessive web surfing or
database searches
5. Obsessive computer gaming18
Hypersexuality and Internet pornography use has come
under the scanner in recent years.19,20 Internet
pornography is very common in the West.21 There has
been a dramatic rise in mental disorders as an aftermath of
pervasive internet pornography addiction.22,23
Joshua B. Grubbs, a specialist in Addictive Behavior
Patterns, that at present there is no single prevalent
consensus regarding Internet pornography addiction and
hence the defining Internet pornography use as an
addiction is very much controversial.24 The current
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) does not classify Internet pornography as an
addiction. However, hypersexuality is mentioned while
discussing other disorders.25 But there is no independant
entity as hypersexual disorder in DSM-5. While
pornography is mentioned in DSM-5, pornography is not
identified as a mental health problem. Cyber-Relationship
Bengal Journal of Private Psychiatry
addiction has been defined as an impulse-control problem
within Internet Addiction Disorder; it has been described
as an addiction to social networking in all forms.26,27
Cyber-Relationships are in essence a virtual relationship or
form of communication between two people. Anonymity
and privacy in relationships are something that are
cherished by many.Over time virtual online friends win
importance over time to real-life family and friends. People
who experience social phobia and anxiety issues can find a
suitable vent for their emotional necessities.However,
these virtual relationships have more than often devastated
real lives. Criminal intentions are always in search of weak
unsuspecting minds. The fake profiles and its dire
consequences had been cinematized in the movie named
"catfish" after the famous documentary film released in
2010. These fake profiles are often created in the social
networking sites with vile intentions and people are often
tricked into false relationships. Robbery, thefts,
kidnappings, blackmailings and even murders have been
the aftermath of such intentions. Many people have
suffered irretrievable personal losses due to internet social
networking addiction.
The term addiction or habituation has largely been
replaced by the term "dependence" Mobile phone
addiction has been added in the long list of psychoactive
substance abuse, alcohol and tobacco under ICD 10.28,29
Shambare et al. claim that cell-phone use is "possibly the
biggest non-drug addiction of the 21st century;"30 The
results of two studies aimed to explore the behavioral
aspects associated with the use of excessive use of mobile
phones clearly showed that college students, as well as non
students, reported problematic mobile phone use and their
behavior fulfilled a number of the addiction criteria. Mobile
phone use has been attributed to increasing number of
accidents and accidental deaths. Mishaps occur due to
negligence not only on the part of the driver but also on the
part of the pedestrian. In majority of accidents, talking
over phone while crossing roads or driving cars are
responsible for these mishaps. Mobiles have replaced the
warm personal interaction that once formed the basis of a
healthy familial relationship. However it has also fostered
increased connectivity across huge distances. High speed
4
internet has enabled excellent resolution in video calling,
multimedia messaging (also popular as "MMS"). These
have truly made any place in the universe "accessible" and
"within the reach" which previously was unimaginable.
Thus Internet has its fair share of goodness as well.31
MEASURING INSTRUMENTS:
Two scales, a 20-item self-reported Problematic Use of
Mobile Phones (PUMP) scale and Mobile Phone
Problem Use Scale (MPPUS), estimated the prevalence
of avid internet users among British adolescent population
and found it to be approximately 10% among those aged
1114 years and corresponding figures in India were
estimated to be 39-44%.28,32,33,34 In contrast, the
prevalence of Internet addiction was 4.9-10.7% in Korea
and is a serious public health concern.34
Addictive behaviour is more common among women as
compared to men.35 Women tend to use mobiles more for
social purposes than men do. Older people tend to use
mobiles the least for social purposes. This is the largely due
to lesser popularity and greater self-regulation among
elders.36 In another survey by Gazelle, 44% participants
reported anxiety and irritability on being unable to interact
with their phones for a week.37
Approximately, 70% people use their mobile phones
within the first hour of getting up in the morning. 56% of the
subjects check their phones before going to bed. 51%
check their phones constantly even during holidays. A
study in Egypt showed that the risk of transmitting micro-
organisms by medical staff via mobile phones is much
higher.38
Although substantial evidence is still lacking, there has
been speculation that overuse of mobile phones can lead to
cancer, specially brain cancer. In 2011, the International
Agency for Research on Cancer of the World Health
Organisation suggested that radiofrequency can be a
probable human carcinogen. Links were established
between use of mobile phones and the potential risk of
developing glioma.39
Headaches, impaired memory and concentration, fatigue ,
dizziness and sleep disturbance has been associated with
radiation sickness.40,41 A study links insomnia to the use of
cell phone before bed.In 2014, 58% WHO states issued

guidelines to the general population to cut down
radiofrequency exposure below heating guidelines. The
major recommendation was to use hands-free kits and to
reduce call time duration, apart from using text messaging
and avoiding calls with low signals or using phones with
low SAR.42 In 2015, Taiwan banned toddlers from using
mobile phones and France withdrew wifi from toddlers'
nurseries.43,44
The genera of mobile phone that are used for multitasking
could be called as "Smartphone" and had the features of
PDA (Personal Digital Assistant). In todays world,
smartphones have touchscreen, user-interface, camera,
media player, radio, innumerable apps, motion sensors and
even independant GPS navagation unit. Nowadays
smartphones have been operating high speed mobile
broadband 4G LTE internet and mobile bill payment
solutions.
Nomophobia or "no-mobile-phobia" is a new term that has
gained popularity. The psychological factors like low self-
esteem and lack of self confidence are the basis of this
behaviour. It is likely that these individuals suffer from
social phobia, social anxiety disorder and/or panic
disorder and this kind of behaviour is an external
manifestation of underlying phenomena based on the study
that investigated the anxieties suffered by 2163 mobile
phone users in Britain.45,46
Kathy Scherer,a psychologist from the The University of
Texas at Austin asserted that,"13% of college internet
users fit the criteria for Internet addicts" .In her study,
Scherer enrolled 531 college students. Further it was
revealed that "72% of the Internet addicted students were
men".47
Cyber dependency was found on an average 5% and 10%
of Web surfers in a study and depression and anxiety
disorders are common among internet addicts. 48
Compulsive Internet use has been linked to morphological
changes in the brain. A study among Chinese college cyber
addicts found reductions in the sizes of the dorsolateral
prefrontal cortex,rostral anterior cingulate cortex,
supplementary motor area and parts of the cerebellum
Although these changes can signify learning type cognitive
adaptations for efficient cyber use, there was impairment
of short-term memory and decision-making skills.49
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Bengal Journal of Private Psychiatry
Changes in the brain ultra-structure were also found in
internet addicts as revealed by a 2009 study and these
neurobiological correlates are similar to chemical addiction
as evidenced by MRI studies which revealed that internet
addicts had impaired grey and white matter integrity in the
orbitofrontal cortex of the prefrontal regions of the
brain.50,51
The orbitofrontal cortex is important to execute functions
like planning and prioritization, remembering details as well
as controlling our mention.52,53 It has been postulated that
rather than a separate entity, internet addiction is a
manifestation of a variety of depression, anxiety, impulse
control disorders or pathological gambling. Parallels have
been drawn between internet addiction and food disorders
where overeating acts as a relief from depression and
anxiety; or impulse control disorders where the person is
addicted to bidding, pornography, gaming and gambling,
whether or not they are online or offline.54,55
Byun et al. asserted the fallacies of most of the studies as
they have inconsistent criteria for defining net addicts
resulting in conspicuous sampling bias and investigates
degree of association rather than causal relationships.56
Pathological use of the internet can lead to increase in job
losses, divorce rates, financial debts and academic failures
according to a Korean study. 70% of internet users play
online games, and 18% among them are addicts of online
gaming. The gamers documented that addiction to online
games helped them to avoid stress in real life. Kimberley
Youngs questionnaire was used in this study.57,58
Young discusses the findings of Dr. Maressa Hecht-
Orzack of McLean Hospital whose set up for computer
and internet de-addiction, received patients with
depression and bipolar depression in its full depressive
swing. Also patients were largely referred from different
clinics throughout the hospital rather than direct self-
referrals.59 The instrument used to assess cyber abuse was
the Internet Addiction test by Kimberly Young classified
addictive behaviour into mild, moderate and severe
impairment. Available in three different languages, English,
Italy and French, this was the first global psychometric
measure.60
The Compulsive Internet Use scale(CIUS) developed in
2009 consists of 14 items and rated on a 5-point scale
Bengal Journal of Private Psychiatry
from 0=Never and 4=Very often. Some other scales are
Problematic and Risky Internet Use Scale (PRIUSS). The
Chen Internet Addiction Scale(CIAS) is a 4-point Likert
scale with 26 items, with a higher total score indicating
greater severity of net addiction and is applicable to both
adults and adolescents.61,62,63 In a Hong Kong based
study, 18% Chinese adolescents were reported to be net
addicts.64 Some proponents commented that those who
are lonely and depressed develop a preference for online
interaction rather than face-to-face rendezvous. This can
lead substantial negative outcomes like mood swings and
withdrawal symptoms when they were away from the
internet.The intrinsic deficit is not healed, but in turn its
severity gets exacerbated.65
Mark D. Griffith proposed six criteria for Internet
addiction and are as follows:66
1. Salience: Internet use pre-occupies individuals
personal life and thought process.
2. Mood modification: The positive experience is a
consequence of engaging to the cyberworld and
helps in avoiding situations in life that are difficult to
deal with.
3. Tolerance: Increasing the use of the internet helps to
achieve a desired level of mood elevation.
4. Withdrawal symptoms: Substantial unpleasant use on
discontinuation or reduction of internet use and
consist of physical symptoms like tremors, mood
disorders or irritability.
5. Conflict: Interpersonal conflict,conflicts with other
essential activities like job, social life or even within
the individual may result from net addiction.
6. Relapse: Recurrence of behavioral patterns
previously observed after periods of abstinence or
control.
Some researchers found on longitudinal follow up that
Internet addiction corrects itself over time.Some of the
correction measures include softwares to restrict the
content, cognitive and behavioural therapy.Rather than
total abstinence, control over the internet usage is
preferable.67
There have been rehabilitative measures to correct internet
overuse. One of such endeavour is ReSTART, a center for
residential therapy based on Seattle, Washington, USA for
6
net addicts that offers a 45-day program to wean people
from pathological internet use. 68
A somewhat harsher measure was invented in August
2013 by researchers at the MIT Media Lab, USA who
developed a USB connected keyboard accessory that
"punishes" net addicts with a small electrical jolt every time
there is excess time spent on a particular website.
Pathological gambling, according to David Hodkins,
professor of psychology at the University of Calgary , is a
separate entity altogether. The surge of globalisation has
created a desperation for 'fast' money, particularly among
young teenagers. The option of online gambling is
attractive due to lack of any social inhibition and the
widespread use of the internet where the gambling sites are
just one click away.
Online stock trading , according to Brian Bloch is very
addictive due to the sense of empowerment it generates as
traders have the ownership over when and how stocks are
traded and money distributed . The environment is free
from arrogant bosses or hectic schedules that the individual
encounters in a day-to-day life. They are enthralled into a
cycle of imperishable desire to win money that often leads
to repeated losses and bankruptcy. Video game addiction
has drawn significant attention since the past decade.70
With the advancement of technology, it has gained
phenomenal proportions. Online video games flood the
cyberspace. Cyber game addicts range from children to
adults. Andrew Doan, with a background in neuroscience
research had to fight with his mammoth internet addiction
whereby he spent approximate 20,000 hours of game play
spread over a period of nine years.
Online Gamers Anonymous, a non-profit organisation was
developed in 2002 for de-addiction support for avid
gamers include an array of discussion forums, online chat
sessions, skype communications to help recover from the
deleterious effects of internet games.71
Jim Rossignol, a finance journalist who, similar to Andrew
Doan, was a game addict himself, is now a well known
reporter of internet gaming and gaming culture.72
DISCUSSION:
Social network addiction is a behavioural problem that
necessitates a constant urge to communicate with other

people on the social media even though there is no
immediate necessity for such interaction. Facebook has
created a wave of communication addiction. It has
become a platform for social communication, fostering
relationships as well as a source of unbound entertainment.
People update their status on their facebook page,
sometimes even minute details of day to day life are
updated. Some people are in the habit of uploading their
own self-clicked pictures in the urge of getting noticed by
their peers. Sharing personal moments are very much in
vogue. Friends in social networking sites are seldom
friends in real life. Having large numbers of friends and
followers in social networking sites are regarded as indices
of high social quotient. This has lead to this "virtual world
addiction". Presently this addiction is limited to interactive
visual media for example social media like facebook. But
scientists predict the future of virtual reality to be a
computer stimulated pseudo-environment that can have
extreme potential for addiction.73
There is one TV addict in every household.Around 70% of
Americans are TV addicts.This is still on the rise, thanks to
the modern television technological advancement. LED,
Plasma TVs with mammoth screens and concept of home
theatres have created a revolution in the television world.
People are more and more drawn inside the comforts of
their homes, keeping the time for healthy social interactions
completely at bay. Addictions have lead to the loss of
valuable work hours in total laziness and lethargy.
However TV addiction is not classified as a separate
condition in DSM-IV.Technostress is the negative impact
of the modern technology and includes altered work habits
that is brought about by the use of these technologies at
office and home situations.74,75
There exists a range of symptoms that people experience
from technostress. Some of these are headache, mental
exhaustion, panic, helplessness, insomnia, loss of temper,
irritability, anger and frustration. Hours infront of the
computer can lead to physical symptoms like backache,
stiffness in the neck, shoulder and reduced job satisfaction
and productivity. Jobs that have increased likelihood of
developing technostress should employ adequate
preventive measures like periodic assessments to check
the effects of technostress on the physical and emotional
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Bengal Journal of Private Psychiatry
aspect of the employee. There should be workshops
organised for employees not only to impart knowledge and
enhance their technical skills but also to make them aware
of the deleterious effects of technostress. IT
troubleshooters should help maximise the system
accessibility and strive to make the employees more
comfortable with the system.
The principal causes of technostress are
Fast pace of technological change with lesser time for
acclimatisation
Lack of adequate training
Phenomenal workload
Absence of standardization within technologies
Reliability of hardware and software
Technophobia (from Greek techn, "art, skill, craft" and
phobos, "fear") is the fear or dislike of modern technology
particularly computers.According to Dr. Larry Rosen,
research psychologist and professor at the California State
University describes that there are three types of
technophobes- the "uncomfortable users", the "cognitive
computerphobes", and "anxious computerphobes".76
World War II and the bombings of Hiroshima and
Nagasaki worked as catalysts to the existing fear and
phobia .War technologies such as napalm, explosives, and
gases during the Vietnam War further escalated the
situation.77 The British Luddites protested the application
of the machines and argued that the skills of human labour
needed protection from destructionby the autonomy of
machines.78
New technologies often encounter conflict with established
beliefs. They contradict personal values of simplicity and
modest lifestyle. Technophobic ideas can be found in
various forms of art, from creative literature such as
Frankenstein to science fiction drama like Metropolis.
These works mainly portray the evil side of technology as
perceived by the technophobic. With the technologies
becoming increasingly complicated, people are more and
more likely to harbor anxieties relating to the use of these
advanced technologies.With the advent of modern
medicine and the likes of Louis Pasteur, Charles Darwin,
Gregor Mendel, Michael Faraday, Henri Becquerel, and
Marie Curie, and inventors such as Nikola Tesla, Thomas
Edison and Alexander Graham Bell, world was changing
Bengal Journal of Private Psychiatry
rapidly. The Romantics tended to believe in imagination
over reason, the "organic" over the. Poets like William
Wordsworth and William Blake harboured the thoughts
that the technology was polluting the perfect and pure
nature in more than singular ways. Let us welcome the
technological revolutions with a widespread awareness of
its potential danger to get addicted by limited fruitful use of
modern day gadgets the generation of today needs to
move ahead with bright vision and better tomorrow.
Digital amnesia symptoms are the habit of automatically
going online to get answers to questions. The trend to look
up information before even try to recall it prevents the build
up of long term memories. The loss of data stored in smart
phones causes immense distress, particularly among
women and people under 35. Selfitis is an obsessive
compulsive desire to take selfie and post them on social
media to make up for the lack of self-esteem and to fill a
gap in intimacy. Acute selfitis is defined as taking photos of
one's self at least three times a day and posting each of the
photos to social media. Chronic selfitis is the
uncontrollable urge to take photos of one's surroundings
round the clock and posting the photos more than six times
a day. Selfie obsession is attributed to low self-esteem as
people try to find a way to boost themselves. It could be
attributed to gain attention from the society. In India 74%
of adolescents are found moderately addicted to their
smartphones. Smartphone dependence may cause stress,
depression, anxiety, insomnia, delinquency and
aggressiveness.(Int J of Preventive Medicine).According
to researchers, the presence of ADHD increases the risk
of Internet addiction. Research suggests that adolescents
with IAD have more aggressive dispositions than others.
Early psychiatric intervention may prevent IAD. According
to recent studies on school going adolescents, boys are
more likely to have internet dependency. Secondary
school students, who suffer from IAD, may have
psychological behavioural problems like restlessness,
palpitation, tremors etc. Recent studies provide evidence
of compromised prefrontal cognitive control over
emotional interference in adolescents. Increased internet
use predicted higher levels of social support, reduced
loneliness & psychological well-being among older adults.
A survey of facebook overusers demonstrated novel self-
8
other discrepant perceptions concerning risk and benefit of
facebook. According to recent studies, late adolescents
who are victims of cyber bullying, are at higher risk of
depression of problematic alcohol use. IA prevalence is
inversely associated with quality of life reflected by
subjective (life satisfaction) and objective (environmental)
indicators. According to studies, avoidant coping and
coping inflexibility are the cause of psychological
maladjustments in Internet Addicts. Texting while driving
has become a cultural artefact, which conflicts with driver
safety as well as laws prohibiting texting while driving.
Recent studies suggest that online gaming is negatively
correlated with college engagement and academic
performance of college going students. Recent studies
suggest that the extent of social anxiety is a predictor of
preference for online social interaction & IAD
Cybersexual addiction is defined as a type of IAD where
the addict spends excessive time on websites for cybersex
or cyberporn. Data suggests that approximately 20%
internet addicts are engaged in some form of online sexual
activities. Problematic and repetitive sexual behaviour
serves as a means to escape stress and tension, becoming
a way to handle the problems. Cyberchondria is defined as
anxiety induced by health related excessive online search
causing hypochondriasis. Cyberchondria is caused by
excessive information; patient tries to convince himself that
he is suffering from illnesses, causing anxiety and
depression. Individual searching for reassurance online
may experience anxiety as a result of escalating search
behaviour.
"A person who never made a mistake never tried anything
new."
-Albert Einstein
 Bengal Journal of Private Psychiatry

Edison and Alexander Graham Bell, world was changing

rapidly. The Romantics tended to believe in imagination
over reason, the "organic" over the. Poets like William
Wordsworth and William Blake harboured the thoughts
that the technology was polluting the perfect and pure
nature in more than singular ways. Let us welcome the
technological revolutions with a widespread awareness of
its potential danger to get addicted by limited fruitful use of
modern day gadgets the generation of today needs to
move ahead with bright vision and better tomorrow.
Acknowledgements: Nil
Conflictcs of interest: Nil.
Ethical Clearance: Has been taken from the Chirman of
Institutional Ethics committee: Taken.

REFERENCES:
Fig 2: Social networking sites and their impact on
interpersonal relationship.
CONCLUSION:
The British Luddites protested the application of the
machines and argued that the skills of human labour
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Bengal Journal of Private Psychiatry
Original Article

Depression With Somatizationis HDRS Useful In Such Situations?

A Pilot Study
Sinha Mousumi1 Das Debasish2

1 Ex. Associate Professor,M.D. Midnapore Medical College, Former Resident, Calcutta National Medical College
2 Debasish Das, DPM, Consultant Psychiatrist, District Mental Health Programme, South 24 Parganas, Former
Resident, Calcutta National Medical College

ABSTRACT
Consecutive patients attending Psychiatric OPD meeting ICD-10 criteria for Depressive Episode were
included in the study provided their age were within 18-65 years and no associated general medical conditions
was present. HDRS scores were lower in patients presenting with somatic complaint and may be a cause of
somatisation. Most significant finding of our study was that, although HDRS total scores were more in
depressed patients, it had little discriminating power to distinguish depression from somatoform disorders.
The scores were heavily influenced by co-morbidity with specific gender related difference. Principal
presenting problem does not bear any relationship with HDRS score. QUEST analysis indicated only Iteam12
of HDRS-17 (Somatic Symptoms, Gastrointestinal) was best variable in differentiating between depressive
disorders and somatoform disorders. The research indicates need to study reasons for the above findings,
especially analysis to detect inherent problems of HDRS in our clinical and cultural perspective.

INTRODUCTION 1) Lack of awareness about depression amongst

Until very recently, mental diseases were neglected
worldwide perhaps because of limited mortality.
However, recent studies assessing disability-adjusted
life years (DALYs) lost due to various diseases show
that psychiatric conditions account for about 22% of
DALYs lost. Depression is by far the commonest
amongst the psychiatric causes (WHO, 1999; Murray
& Lopez, 1996). Depression has been projected to
become the second-ranked cause of lost DALYs by the
year 2020.Even presently the morbidity and disability
due to depression exceeds that of common medical
conditions like hypertension, arthritis, diabetes,
chronic lung diseases (Judd 1994). Worldwide,
depression is principal or associated reason for
attending primary care clinics in about 20-30% cases
(Ustun and Sartorious, 1995; Goldberg &Huxley,
1992).
Despite the importance of depression and availability
of highly effective treatments, the remains mostly
undetected and untreated. Main causes for this are-
common people and primary care physicians.
2) Stigma attached to mental illness.
3) Somatic presentation of depression.
Somatization is important in clinical practice because
it is very common. Study conducted by De Leon et al
(1987) on consecutive series of patients referred to
psychiatric liaison service from other hospital
departments found that nearly 50% were somatizers
and 15% had somatoform disorders. In another study,
Katon et al (1984) found that 48% of somatisers had
depressive illness and 29% had somatoform disorder.
Another issue that is likely to be complicated by the
issues is measurement of severity of depressive
disorder. The most commonly used rating scale for this
purpose is Hamiltons Depression Rating Scale
(Hamilton, 1960). However, this scale has many
shortcomings. According to Maier & Philipp (1985)
the shortcomings are- 1) Heterogeneous scale items, 2)
Unstable factor- analytic structure, 3) Missing general
factors, 4) Missing course validation and 6) Neglect of

14
 Bengal Journal of Private Psychiatry

self-reported feelings of distress in favour of assessment of Table1 shows the mean age of patients according to sex
behavioral symptoms and somatic complaints. Indeed, to and diagnosis.
Maier & Philipp (1985) an Hedlund & Vieweg (1979),
DIAGNOSIS SEX NUMBER MEAN STANDARD
Montgomery-Asberg Depression Rating Scale (MADRS) DEVIATION
(Montgomery & Asberg, 1979) is more suitable in the
presence of physical disorders with an increased somatic Depressive Episode FEMALE 24 33.42 7.37
element. Thus, HDRS might not yield good results in our without somatic MALE 14 34.14 9.09
syndrome
cultural context, where somatic manifestation has been TOTAL 38 33.68 7.93
found common. Depressive Episode FEMALE 16 36.19 10.86
Keeping in view the importance of these issues in clinical with somatic MALE 11 49.64 9.09
syndrome
practice, we decided to explore the following things- TOTAL 27 41.67 12.05
1) To compare their symptom profile of depression with FEMALE 40 34.52 8.91
TOTAL
or without somatic symptoms. MALE 25 40.96 11.87
2) To explore whether HDRS total score or individual TOTAL 65 37 10.54
item scores can assist in differentiating between
Depressive Episode without somatic syndrome and
Patients of Depressive Episode with somatic syndrome
Depressive Episode with somatic syndrome.
were older in age (41.67.12.05) than patients suffering
3) To explore whether HDRS is an effective measure of
from Depressive Episode without somatic syndrome
depression in our cultural milieu of somatic presentation.
(33.687.93). In both the diagnostic groups, female
patients were of younger age. The observed differences in
MATERIALS AND METHOD
age between the diagnostic groups and sexes was found to
Consecutive patients attending Psychiatric OPD, Calcutta
be highly significant statistically using ANOVA (both
National Medical College, meeting ICD-10 criteria for
individually and in interaction. hence, due to the difference
either Depressive Episode without somatic syndrome OR
in age between sexes, we shall use age as a co-variant in
Depressive Episode with somatic syndrome were included
our subsequent analysis.
in the study provided their age was within 18-65 years and
Table-2 Anova of Age of Patients with Diagnosis & Sex As
no associated general medical conditions was present.
Factors
Each patient was asked to mention their principal problem
which made them attend OPD and this information was Source Type III Sum d.f. Mean F Sig
of Squares Squares
recorded in a standardised format. The patients were then
administered the HDRS (17-item version) i.e. HDRS-17, Corrected
2189.469a 3 729.823 9.048 <0.001***
model
using the structured questions (translated into Bengali) as
Intercept 88277.979 1 88277.979 1094.385 <0.001***
laid down by Williams (1988). The study period was
Diagnosis 1251.710 1 1251.710 15.517 <0.001***
between June 2007 to August 2008. Appropriate
ststistical analysis was done using SPSS vesion 10.0 and Sex 753.955 1 753.955 9.347 0.003**
Diagnosis x
Answer Tree version 2.0.1 . Sex 607.369 1 607.369 7.530 0.008**
interaction
RESULTS Error 4920.531 61 80.664
Sixty-five patients were included in the study, 40 females Total 96095.000 65
and 25 males.38 patients were suffering from Depressive Corrected
7110.000 64
Episode without somatic syndrome while 27 suffered Total
from Depressive Episode with somatic syndrome. a. R2 =0.308, (Adjusted R2 =0.274).

15
Bengal Journal of Private Psychiatry

Table-3 shows the diagnostic break-up of patients TABLE-5 shows the result of ANOVA conducted on the
according to Sex. HDRS-17 scores of Table-4.
Table-5 Anova Of HDRS-17 Scores Of Patients With
DIAGNO- SEX Diagnosis & Sex As Factors
SIS FEMALE MALE TOTAL
Source Type III Sum d.f. Mean F Sig
Depressive of Squares Squares
Episode Corrected
without 24 (63.2, 60.0, 36.9) 14 (36.8, 56.0, 21.5) 38 (100.0, 58.5, 58.5) 1148.524a 4 287.131 6.689 <0.001***
model
somatic
Intercept 552.156 1 552.156 12.863 <0.001***
syndrome
Age 27.435 1 27.435 0.639 0.427, N.S.
Depressive Diagnosis 763.312 1 763.312 17.782 <0.001***
Episode 16(59.3, 40.0, 24.6) 11 (40.7, 44.0, 16.9) 27 (100, 41.5, 41.5) Sex 33.075 1 33.075 0.770 0.384, N.S.
with somatic Diagnosis x
syndrome Sex 65.832 1 65.832 1.534 0.220, N.S.
interaction
TOTAL 40 (61.5, 100, 61.5 ) 25 (38.5, 100, 38.5) 65 (100, 100, 100) Error 2575.630 60 42.927
Total 21503.000 65
Apparently, Depressive Episode without somatic Corrected 3724.154 64
Total
syndrome is far more common in female than males, but
a. R2 =0.308, (Adjusted R2 =0.262).
the difference is not statistically significant. Levenes Test of Equality of Error Variances, F (3, 61) <0.001.
Table-4 shows the HDRS-17 scores in the two diagnostic
It shows the differences statistically significant with respect
groups along with gender-wise break-up.
to diagnosis, but not with respect to sex (both alone and in
DIAGNOSIS SEX
NUMBER MEAN STANDARD combination with diagnosis).
HDRS- DEVIATION Figure 1 shows the result (i.e. ANSWER TREE) of
17 QUEST Analysis done to probe which of the many
Depressive Episode FEMALE 24 20.00 3.49
variables (i.e. HDRS-17 individual item and total score,
without somatic MALE 14 19.43 2.82
syndrome
principal presenting problem, co-morbidity, age, sex) is
TOTAL 38 19.79 3.23 best in distinguishing between Depressive Episode without
SOMATOFORM FEMALE 16 10.00 5.13 somatic syndrome and Depressive Episode with somatic
DISORDERS MALE 11 14.82 13.51 syndrome patients.
TOTAL 27 11.96 9.55 Figure-1 Answer Tree Showing The Distiguishing Variable
TOTAL FEMALE 40 16.00 6.47 For Diagnosis After Quest Analysis
MALE 25 17.00 9.26 ICD -10 DIAGNOSIS
TOTAL 65 16.54 7.63
Item12 of HDRS-17
As expected HDRS-17 score was higher in Depressive (p-value=0.0000; F=66.9340; d.f. =1,63)
Episode without somatic syndrome (20.003.49) patients
than Depressive Episode with somatic syndrome patients
(11.96 9.55). HDRS-17 sores were higher in female Score 1.1169 Score 1.1169
Depressive Episode without somatic syndrome patients Without 5(13.16%) with somatic [without 33(86.84%)
while reverse was true in Depressive Episode with somatic 24(88.89) with somatic 3(11.11%)]
syndrome patients. Indeed, HDRS-17 scores was quiet It can be seen that Item 12 of HDRS-17 (Somatic
high in male Depressive Episode with somatic syndrome Symptoms, Gastrointestinal) is best variable in this respect.
patients, 33 (86.84%) of depressed patients scored above 1.12

16

(approx.) while only 5 (13.16%) of depressed patients
scored below that score on that item.
DISCUSSION
Our study also shows that HDRS scores are lower in
patients presenting with somatic complaint. Though not
statistically significant, this might itself explain somatisation
as described below. However, strong viewpoint expressed
by (Gelder et al, 1996) that presentation of less severe
depressive disorders seems to be influenced by culture
does not seem to hold in our study.
Most significant finding of our study is that, although
HDRS scores are more in depressed patients, it has little
discriminating power to distinguish depression from
somatoform disorders. The scores are heavily influenced
by co-morbidity with specific gender related difference.
Principal presenting problem does not bear any
relationship with HDRS score. HDRS has been given a
status of very effective instrument due to its strong
psychometric properties as well as due to its
comprehensive coverage of depressive symptoms and
related psychopathology (Rehm & OHara, 1985). Many
studies, mostly in Western set-ups, have shown the total
HDRS score to be reliable and to have high degree of
concurrent and differential validity (Carroll et al, 1973).
However, our study seems to support the objections about
HDRS as expressed by Maier & Philipp (1985).
QUEST analysis indicated only 12 of HDRS-17 (Somatic
Symptoms, Gastrointestinal) are best variable in
differentiating between depressive disorders and
somatoform disorders. 33 (86.84%) of depressed patients
scored above 1.12 (approx.) while only 5 (13.16%) of
depressed patients scored below that score on that item.
This is not surprising considering the fact that anorexia has
been considered to be amongst the most reliable indicators
of depression provided medical disorders are ruled out
(Akisal, 1995). Cicchetti & Prusoff (1983) and Miller et al
(1985) have mentioned the fact that most of the individual
items of HDRS have poor discriminative validity. We
believe that HDRS, which is frequently used in drug trials,
needs a fresh study and analysis to detect inherent
problems specially in our clinical and cultural perspective.
17
Bengal Journal of Private Psychiatry
Various hypotheses have been advocated to explain
Somatization.
These include-
1) Lack of linguistic skills to express their emotional
experience (Alexithymia) (Prince, 1987). In our
study also, patients whose chief presenting problem
could not be categorized (the other category),
showed high HDRS scores, perhaps due to similar
failure to communicate distress.
2) Influence of culture in altering disease experience.
(Raguram, 1996)
3) In some patients somatisation is a result of an
unspoken contract with their doctor and may be
related to the physicians tending to organize his
patients distress into mutually preferred disease.
(Brown & Freeling, 1976)
4) According to Kirmayer (1984) stigma attached to
mental illness (i.e. its emotional distress) causes the
depressive experience to be reconstructed through
somatisation to make it less socially stigmatizing.
5) The Cartesian disjunction of mind and body, which
shaped Western philosophy and scientific thinking,
has caused mind to recede far from medical thinking,
(Eisenberg,1977) thus not considering physical
manifestation of psychological problem to be normal,
even in such Eastern cultures where the mind body
dichotomy is not a part of philosophy.
Main shortcomings of our study are-
1) Small study size, hence insufficient power to detect
small differences.
2) No parallel instrument to measure depression (like
MADRS) were used, hence comparison could not
be made.
3) Follow-up analysis to see the pattern of symptom
change in both the diagnostic groups was not
attempted.
To conclude, considering the importance of depression as
a disease, follow-up study to clarify the issues raised is
definitely needed. Such knowledge will perhaps contribute
in formulating Defeat depression like campaign in our
country and help millions of distressed in a more
comprehensive manner.
Bengal Journal of Private Psychiatry
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1. Akisal, H.S. (1995) Mood Disorders: Clinical
Features. In: Comprehensive Textbook of
Psychiatry, Vol. 1, Edn 6,pp 1129, Eds: Kaplan,
H.I. & Saddock, B.J. Baltimore: Williams & Wilkins.
2. Browne, K., &Freeling, P. (1976) The Doctor-
Patient Relationship. London: Churchill
Livingstone.
3. Carroll, B.J., Fieldings, J.M., Blashki, T.G. (1973)
Depression rating scales: A critical review. Archives
of General Psychiatry, 28, 361-366.
4. Cicchetti, D.V. & Prusoff, B.A. (1983) Reliability of
depression and associated clinical symptoms.
Archives of General Psychiatry, 40, 987-990.
5. De Leon, J., Saiz-Ruiz, J., Chincilla, A., et al. (1987)
Why do some psychiatric patients somatize? Acta
Psychiatrica Scandanavica, 76,203-209.
6. Eisenberg, L. (1977) Disease and Illness. Culture
Medicine and Psychiatry, 1, 9-23.
7. Gelder, M., Gath, D. & Cowen, P. (1996) Oxford
TextBook of Psychiatry.Oxford: Oxford University
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8. Goldberg, D., & Huxley, P. (1992) Common
Mental Disorders: A Bio-Social Model. London:
Routledge.
9. Hamilton, M. (1960) A rating scale for depression.
Journal of Neurology, Neurosurgery and
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Rating Scale for Depression-a comprehensive
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149-165.
11. Judd, L.L (1994) Mood Disorders. In: Harrisons
Principles of Internal Medicine, Vol.2, Edn.13,
Eds.Isselbacher et al, pp2402. International Edition,
Mc Graw Hill
12. Kirmayer,L.J. (1984) Culture, affect, and
Somatization, parts 1 and 2. Transcultural
Psychiatric Review 21, 159-188, 237-262.
13. Lipowski, Z.J. (1988) Somatization the concept and
its clinical application. American Journal of
Psychiatry, 145, 1358-1368.
18
14. Guggenheim, F.G. & Smith, G.R. (1995)
Somatoform Disorders. In: Comprehensive
Textbook of Psychiatry, Vol 1, Edn 6,pp 1267,
Eds: Kaplan, H.I. & Saddock, B.J. Baltimore:
Williams & Wilkins.
15. Katon, W., Ries, R.K., Klienman, A. (1984) A
prospective study of 100 consecutive somatizaton
patients. Comprehensive Psychiatry, 25, 305-314.
16. Maier, W. & Phillipp, M. (1985) Comparative
analysis of observer depression scales. Acta
Psychiatrica Scandinavica, 72, 239-245.
17. Miller, I.W., Bishop, S., Norman, W.H., Maddever,
H. (1985) The modified Hamilton Rating Scale for
Depression: Reliability and validity. Psychiatric
Research, 14, 131-142.
18. Montgomery, S.A. & Asberg, M. (1979) A new
depression scale designed to be sensitive to change.
British Journal of Psychiatry, 134, 382-389.
19. Murray, C.J.L. & Lopez, A.D. (1996) The global
burden of disease. Global burden of disease Vol. 1.
Cambridge, MA: Harvard University Press.
20. Prince, R. (1987 Alexithymia and verbal
psychotherapies in cultural context, part III, in
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Symposium. Transcultural Psychiatric Research
Review, 24, 107-118.
21. Rehm, L.P., OHara, M.W. (1985) Item
characteristics of Hamilton Rating Scale for
Depression. Journal of Psychiatric Research, 19,
31-41.
22. Ustun, T.B., & Sartorious, N. (1995) Mental Illness
in General Health Care: An International Study.
Chichester: John Wiley and Sons.
23. Williams, J.B.W. (1988) A Structured Interview
Guide for the Hamilton Depression Rating Scale.
Archives of General Psychiatry, 1988, 742-747.
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Health Report 1999: Making a difference.
Geneva: World Health Organization.

Expressive Therapy as a Psychotherapeutic Adjunct : Myth, Miracle
or a Mere coincidence.?
Chakraborty Suddhendu
Consultant Psychiatrist
West Bengal Health Service
Recent surge in the quest for alternative modes of
psychotherapy led to a retrospect into different forms of
expressive therapy as an adjunct. However this mere
consideration is not beyond intercept as these areas for
years have been known to stay in the interface between
arts and science. The argument in favour of different
modalities of art therapy suggests action within therapy
and life is rarely limited to a specific mode of expression.
(Mc Niff) While the proponents of expressive therapy tend
to emphasise the miraculous after effects, there arises
considerable debate when these effects stamped
miraculous are scrutinized under a statistical spectre.
Also a lack of protocol and series of randomized control,
cohort, and other statistically sound and cohesive studies in
this field leads many purists to consider these forms of
expressive therapy as a mere coincidental approach or a
soft psychological cheese cake. This brief discussion
would attempt to investigate into this complex logical
labyrinth.
Human mind is full of expressions. Art and other modalities
of human expression has been considered for centuries to
mould human character and mind. Confucius in around
500 BC, wrote Character is the backbone of our human
culture. Music is the flowering of character. Tolerance,
love, social harmony and creative mind have been
attempted to be correlated philosophically and artistically.
It is only till recent date after advancement of psychiatry as
a promising medical discipline that the different houses
considered loosely yet so far as an expressive therapy
needed to be defined.In brief, expressive therapy may be
defined as the Use of art, music, dance/movement,
drama, poetry/creative writing, play and sandtray within
the context of psychotherapy, counseling, rehabilitation
and health care. (Mc Niff ;1981, 1992) The definition
also includes an integrated art approach with multimodal
facets for psychotherapeutic venture. The history of use of
19
Bengal Journal of Private Psychiatry
Review Article
drama , music and art therapy dates back to the Egyptian
civilization. (Fleshman and Fryrear 1981; Gladding,
1992)The mythological contexture of music therapy dates
back to its reference in the chapter of king Saul.(1
Samuel,16:23)According to the Italian philosopher de
Feltre ,dance and play is central to a childs growth and
development(Coughlin, 1990).In 1923,during the world
war era, Joseph Munroe attempted the application of
monodrama to treat people suffering from post war
trauma. His ventures were promising which led to
contemporary physicians to term his monodramatic
approach as a miracle cure. The psychodiagnostic
importance of expressive therapy was first enquired
comprehensively by Florence Goodenough who
attempted draw therapy amongst children to explore
their inner conflicts. The other advances included use of
sand play and sandtray as a form of therapy (vick, 2003),
play therapy (Margaret Lowenfeld,1969), talking cure
(Menninger Clinic in Kansas and St. Elizabeths in
Washington DC).Use of image therapy in debriefing,
resolution while dealing with children and post trauma
stress disorder patients have also been brought under the
realm of expressive therapy (Malchiodi, 2001 ;
Pennebaker, 1997 ).
But as Abraham Maslow correctly said, If the only tool
you have is the hammer, every problem starts to look like a
nail. The exploration of different facets of expressive
therapy does not necessarily ensure its universal usage. But
this redundancy has been one of the biggest fallacies of
using these modes as a psychotherapeutic tool. A child
having no interest in poetry and not even a mere inclination
would be an absolute waste candidate for poetry therapy
and so on. Moreover the limitation of applicability of these
different forms of expressive therapy has led to a shrinkage
in the target cohort which led to the question of validity as
well. Are we really dealing with an orphan approach that
Bengal Journal of Private Psychiatry
can be deemed damn insignificant in psychiatry? The
loopholes lie in the lack of expertise of most of the
therapists to some extent. (Agell ;1982) Lack of
authentication of the approach led to establishment of
numerous associations that lacked necessary expertise,
Infrastructure and insight required to be considered
scientific. However the potential power of expression of
this therapeutic approach remains beyond doubt.
Augmentation in the process of self extrapolation by art
therapy (Gladding 1992),a cathartic approach (Rothschild
2000), expressing post traumatic experience in children
(Eliana Gil 1998) have been documented. But apart from a
spontaneous release of creative energy (Adrian Hill),
expressive therapy failed to clear the hurdle of myths and
miracles.
The significant pitfall that fails expressive modes to prove
its effectiveness as a principal form of therapy is its lack of
statistical reliability and validity. While studies conducted
with Schizophrenia, Bipolarity, and Acute psychosis failed
to show any noticeable statistical outcome on application
of these approaches (Group art therapy as an adjunctive
treatment for people with schizophrenia; multicentre
pragmatic randomized trial; Crawford et al; BMJ
2012;344;e846 pub 28 Feb 2012),lack of proper
structuring and model of execution led to difficulties in
conducting on field validation trials (A Systematic Review
of Music Therapy Practice and Outcomes with Acute
Adult Psychiatric In-Patients Catherine Carr et
al.www.plosone.org August 2013, Vol 8, Issue 8,
e70252). Another block encountered is the prevalence of
therapist bias while inferring into the results. Also the
debate that whether expressive therapies be used as a
principal psychological tool or a prognostic indicator
remains. The recent advances in the sphere of biological
psychiatry further threatens them towards the path of
oblivion. A recent debate in a social networking sight on an
issue that whether human mind should be called merely a
biological model with a few biometric dimensions leads me
to think whether any form of expressive therapy can ever
bridge the gap between coefficients and probabilities! To
add to the nightmare comes the debacle of defining the
different modes as therapy. In an attempt to define music
therapy, Avin (1975) opined Music therapy is the
20
controlled use of music in the treatment, rehabilitation,
education and training of children and adults suffering from
physical, mental and emotional disorders.This use of the
word controlled does baffle an interpreter as to whether
the entire process is therapist controlled. Perhaps this led
American Music Therapy pioneer Don Nichet to point out
that the definition of music therapy is not self evident. Sadly
enough, this opinion is applicable not only to music, but
also the other forms of expressive therapy as well.
However, despite all misfortunes, expressive therapy has
proved to some extent its effectiveness as an adjunct
beyond myths and mere miracles. In a study conducted by
Leibmann in 1994 among young offenders in prison, art
therapy proved to be an effective mode of cathartic
expression. Lizzatto used art therapy amongst substance
abusers in a study in 1989 to show a significant rise in
motivation, self esteem and abstinence. However both the
studies were more subjective than statistical. Considering
Jungs concept of Collective unconscious and Viktor
Frankls logotherapeutic approach, the modalities of
expressive therapy should better not to be judged by
numerics. Of late Silber et al investigated the value of song/
poetry writing with patients (aged 6284 yrs) diagnosed
with Alzheimers disease. 1224 men and women
participated in the group activity. A music therapist
facilitated the writing exercise by proposing the themes,
choosing music, writing the patients dictated text,
suggesting the use of metaphors and/or analogies, and
deciding when the concluding sentence had to be written.
Patients wrote songs based on descriptions and images of
seasons and the themes of love and stages of life. Results
suggest that, based on the preservation of memory for
tunes and melodies, patients were able to write songs and
poetry when assisted by appropriate stimuli and provided
encouragement (Silber, Fanny; Hes, Jozef Ph.Music
Therapy Perspectives, Vol 13(1), 1995, 31-34;
PSYCINFO). But yet again, the logical representation of
data failed to satisfy the statistical need and expectations
that would lead music therapy to be considered a serious
adjunct in the module for treating dementia patients. In a
nutshell, though expressive therapies continue to
mesmerize poetic minds of a researcher, clinical data
suggests, there is still a long path to prove them as an
effective adjunctive therapeutic maneuver towards treating

psychiatric illness. However, day to day subjective
experiences continue to argue us the fact that
nonquantifiable attributes like faith, expression, creativity
do have some role towards the process of healing in mental
illness. Thus there still remains scope for future serious
structured studies in this field overcoming economic
constraints and therapeutic bias that may unveil a new
domain of psychiatry that would establish human mind to
be beyond a mere biological model. The quest remains and
so does the hope.
REFERENCES:
1. Agell, G;The place of art in Art Therapy:American
Journal of Arts Therapy1982;21,15-18
2. Benson,H;TimelessHealing:The power and biology of
belief;1996;New York Scribners
3. Carr et al;A Systematic Review of Music Therapy
Practice and Outcome with Acute adult psychiatry in
patients;www.plosone.org.Aug2013,vol8,issue8,e70252
4. Catherine C;D.Lisa;CherylK;DiMicoli Sue et
al;Supportivea expressive group therapy and distress
in patients with Metastatic Breast Cancer;a
randomised clinical trial;JAMAPsychiatry,May
2001;vol58,no.5
5. Coughlin,E;Renewed appreciation of connection
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Higher Education1990;36,9
6. Crawford et al;Group Art Therapy as an adjunctive
treatment for people with Schizophrenia: a multicentric
pregmatic randomised trial; BMJ 2012; 344;
e846pub28
7. Donna J,Betts;Art Therapy assessments and rating
instruments: Do they measure up?; The Arts in
Psychotherapy 2006; vol.33 (5); 422-434
8. E.Gil; Essential of Play Therapy with Abused
Children; Guilford Publication, inc.72, 1998; NY;
ERIC
9. FleshmanB; FryrearJ; NelsonH; Michael H Sac; The
Arts in Therapy; Payne Whitney Psychiatric Clinic,
vol 33, issue 1, pg 64b, 65
10. Gladding ST, NewsoneDW; Art in counselling:
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Handbook of Art Therapy; 2003; Guilford Press, NY,
pg243-253
11. Kelly J;What is Art Therapy and how do we know it
works;An Australian perspective on the need for more
research;International Journal of Interdisciplinary
Social Sciences;2010;vol5;issue5;pg 255-259
12. LeardiD;PietrolettiR;Angeloni G et al;Randomised
Clinical Trial examining the effect of music therapy in
stress response to day surgery; BJP2007; vol.95;
issue8
13. Levine E;On the Playground:Child psychotherapy and
expressive art therapy:Theoretical and clinical
perspective;London;Kingsley;1999;pg.257-273
14. Liebmann M;JS Tumim;Art Therapy with
offenders;ncjrs.org;1994;Jessica Kingsley
Publication,London
15. LowenfeldM;Understanding Childrens Sand
Play:Lowenfelds World Technique;Sussex Academic
Press2004
16. Mc Niff Shaun; Art based Research; Jessica Kingsley
Publications; 1998
17. O Sarid; EHuss; Trauma and Acute Stress disorder:
A Comparison between cognitive behavioural
intervention and art therapy; The Arts in
Psychotherapy 2010; Elsevier
18. P Luzzatto;GabrielB;The Creative journey:A model
for short term group art therapy with post treatment
cancer patients;Art Therapy2000;Taylor and France
19. Silber F; HessJ; Music Therapy perspectives;
PSYCINFO 1995; vol 13(1); 31-34
20. Susan J Kelley; The use of Art Therapy with Sexually
Abused Children; Journal of Psychosocial Nursing
and mental Health; 1984; vol 22, issue 12; 12-18
21. Tally Tripp MA; A Short Term Therapy Approach to
processing trauma; Art therapy and bilateral
stimulation; Archives of General Psychiatry; 2007; vol
24; 53
22. TalwarN; Crawford Mike J; MaratosA; Music
Therapy for in patients with Schizophrenia; BJP; 2006;
189(5); 405-409
23. TinninL; Transforming the placebo effect in art therapy;
American Journal of Art Therapy; 1994;32(3);
75-78
Bengal Journal of Private Psychiatry
Original Article

Study of Psychotic Like Experiences In Mental Illness Free

College Students
Dutta Salil Kumar - Phd.
Lecturer, Department of Anthropology, Haldia Government College, Debhog, Purbamedinipur, West Bengal
Chakraborty Suddhendu, DPM, Consultant Psychiatrist, West Bengal Health Service

ABSTRACT
Background - Psychotic like experiences (PLE) have often been viewed as categorical phenomena(i.e., either
present or absent in an individual). However, the literature shows that PLEs can be found in the general population
which might support dimensional viewpoint of a continuum of psychotic phenotype, with the psychotic disorder at its
extreme end.
Aims - To determine the prevalenceof PLEs in a nonpsychotic clinical sample .
Settings and Design - Subjects from a Government college. Observational cross-sectional study was done
Methods and Material - A random sample of 306(210 male,96 female, mean age=19.82.7 years)college
students who were screened to exclude mental illness using SRQ-24 were assessed to measure PLEs using validated
local language version of CAPE-42(Community Assessment of Psychiatric Experiences).
Results - 96% endorsed at least one psychotic experience at least Sometimes, 45% endorsed at least one experience
Often or Almost always. 42% endorsed at least one experience Often or Nearly always. 3-factor structure best
represented the data and accounted for 44.8% of the explained variance. Factor 1 (6 items) - Bizarre Experiences,
Factor 2(4items )- Persecutory Ideas, Factor 3 (3 items)- Magical Thinking were found.
Conclusions - Presence of psychotic experiences in non clinical populations may represent the phenotypic expression
of the increased pronenessor risk for the development of psychotic disorders.

Key Words - Psychosis Continuum Symptoms, Psychotic like experiences, Normal population

INTRODUCTION viewpoint of a continuum of psychotic phenotype, with

Blood pressure and glucose tolerance are continuously
distributed characteristics in the general population, but
because the clinical decision to treat is dichotomous, terms
such as hypertension and diabetes are used in medicine
The psychosis phenotype is generally thought of as a
dichotomous entity that can have Psychotic like
experiences (PLE) have often been viewed as categorical
phenomena (i.e., either present or absent in an individual).
Operationalised criteria derived from clinical observations
on individuals with severe illness separate non-medicalised
experiences in the general population services (Tien,
Costa, & Eaton, 1992).1
However, the literature shows that PLEs can be found in
the general population which might support dimensional
the psychotic disorder at its extreme end. (Rose & Barker,
1978,Strauss 1969; Claridge 1997; Peters et al.1999;
Stefanis et al. 2002;Verdoux and van Os 2002).2-7
The supposition of a psychosis continuum does not
necessarily imply that there is a continuum of disorder. For
example, in the US National Comorbidity Survey,
approximately 28% of individuals endorsed psychosis-
screening questions. However, when clinicians made
diagnoses, the rate of even broadly defined psychosis was
only 0.7% (Kendler, Gallagher, Abelson, & Kessler,
1996)8,9. This suggests that the clinical definition of
psychosis may represent only a minor selection of the total
(not necessarily clinical) phenotypic continuum.
The existence of lesser states on a distributed continuum in

22

the population a risk factor for what clinicians would
call disorder (Claridge, 1997)4. In epidemiological terms,
this argument can be explored by examining the possible
combinations of underlying causes of the presumed
psychosis continuum in relation to the predicted
distribution of the trait
AIMS
To determine the prevalence of PLEs in a
nonpsychotic college student sample .
To explore nature of this PLEs
METHODS AND MATERIAL
Settings and Design-
Subjects from a Government college from Purba
Medinipur District, West Bengal. Observational cross-
sectional study was done
A random sample of 306(210 male,96 female, mean
age=19.82.7 years)college students who were screened
to exclude mental illness using SRQ-24 were assessed to
measure PLEs using validated local language version of
CAPE-42(Community Assessment of Psychiatric
Experiences).
The CAPE (Community Assessment of Psychiatric
Experiences) (Stefanis et al,2002)6 is a 42-item self-report
two dimensional scales. The first scale scores the
frequency of the experience (measured on a 4-point scale
from never,sometimes,often to nearly always, to
avoid ticking the middle box bias) and the second scale
scores the degree of distress (measured on a 4-point scale
from not distressed, a bit distressed,quite distressed
to very distressed). The CAPE provides an overall score
and a total score per dimension by adding up the number
of positive answers to the frequency question, and it
provides a distress score by adding up the scores of the
distress questions.
Sample Item of CAPE - 42
Do you ever feel as if there is a conspiracy against
you?
Never Sometimes Often Nearly always
If you ticked never, please go to question 11
Bengal Journal of Private Psychiatry
If you ticked sometimes , often or nearly
always please indicate how distressed you are by
this experience:
Please tick
Not distressed A bit distressed Quite distressed
Very distressed
STATISTICAL ANALYSIS
To determine the prevalence of psychotic-like
experiences, the participants responses were
dichotomized. Responses were recoded to 0 (never) and
1 (At least sometimes).
SPSS-15 was used for analysis-descriptive
measures-frequency,mean,sd,factor analysis of CAPE
RESULTS
96% endorsed at least one psychotic experience at
least sometimes, 45% endorsed at least one experience
often or almost always. 42% endorsed at least one
experience often or nearly always. 3-factor structure
best represented the data and accounted for 44.8% of the
explained variance. Factor 1 (6 items)- Bizarre
Experiences, Factor 2(4 items )- Persecutory Ideas,
Factor 3 (3 items)- Magical Thinking were found.
FACTOR SCALE ITEMS
NAME
FACTOR 1 Do you ever feel as if the thoughts in
Bizarre your head are not your own?
Experiences Do you ever feel as if you are under
the control of some force or power
other than yourself?
Do you ever hear voices when you
are alone?
Have your thoughts ever been so
vivid that you were worried other
people would hear them?
Do you ever feel as if the thoughts in
your head are being taken away from
you?
Do you ever hear voices talking to
each other when you are alone?
23
Bengal Journal of Private Psychiatry
FACTOR SCALE ITEMS
NAME
FACTOR 2 Do you ever feel as if you are being
Persecutory persecuted in some way?
Ideas Do you ever feel as if there is a
conspiracy against you?
Do you ever feel as if people seem to
drop hints about you or say things
with a double meaning?
Do you ever feel as if some people
are not what they seem to be
FACTOR 3 Do you believe in the power of
Magical witchcraft, voodoo or the occult?
Thinking Do you think that people can
communicate telepathically?
Do you ever feel that you are a very
special or unusual person?
DISCUSSION
High prevalence of PLEsimilar to reports using
CAPE-Yung et al, 2009Between 10.9% - 91.5%
reported some psychotic symptoms at least sometimes,
Between 0.9% - 9.1% reported some psychotic
symptoms always/nearly always
We have found three-factor solutions, namely:
1) Positive symptoms, 2) Negative symptoms, and
3) Conceptual disorganisation or Social impairment
(Liddle 1987; Venables and Rector 2000; Vollema and
Hoijtink 2000,10-12similar structure to our study reported
by Yung et al,200613-though item constituting individual
factors differs.
Transition from having one or more psychotic
symptoms to becoming a patient with a If there is a
discontinuous relationship, what are the factors that are
additionally important in bringing about an abrupt change
resulting in need for care? Symptoms vary in terms of
frequency, degree of conviction, preoccupation, influence
on behaviour, distress, and secondary attributions, all of
which may be of crucial
24
Importance in producing illness and help-seeking
behaviour. In this context, (Strauss, 1969) suggested four
criteria for defining the boundaries of clinical psychosis.
These were: the degree of the persons conviction of the
objective reality of the unusual experience, the degree to
which cultural or stimulus determination of an experience
was absent, the amount of time spent preoccupied with the
experience and the implausibility of the experience. The
evidence suggests that the implausibility of experiences and
degree of conviction may not be related to illness status
(Garety&Hemsley, 199414). However, the cultural context
of psychotic experiences and degree of preoccupation and
distress do seem to be important factors
LIMITATIONS OF THIS STUDY
1) Small sample size
2) Conducted on college students alone may not be
generalized
3) Self reported CAPE may overestimate PLE-need for
interview as check
4) Need to compare with clinical samples
5) Longitudinal follow-up
CONCLUSION
Presence of psychotic experiences in nonclinical
populations needs further exploration so as to
understand psychotic phenomena better and help
patients by possible prevention and early detection.
REFERENCES
1) Tien, A. Y., Costa, P. T., & Eaton, W. W. (1992).
Covariance of personality, neurocognition, and
schizophrenia spectrum traits in the
community. Schizophrenia Research, 7 (2),
149-158.
2) Rose, G., & Barker, D. J. P. (1978). What is a
case? Dichotomy or continuum. British Medical
Journal, ii, 873874.
3) Strauss, J.S., 1969. Hallucinations and delusions
as points on continua function. Rating scale
evidence. Arch. Gen. Psychiatry 21, 581586.
4) Claridge, G. (1997). Schizotypy: Implications for

illness and health. New York, NY: Oxford
University Press.
5) Emmanuelle R. Peters, Stephen A. Joseph, and
Philippa A. Qarety .(1999)Measurement of
Delusional Ideation in the Normal Population:
Introducing the PDI (Peters et aL Delusions
Inventory) Schizophrenia Bulletin, 25(3):553-576
6) N. C. Stefanis, M. Hanssen, N. K. Smirnis, D. A.
Avramopoulos, I. K. Evdokimidis, C. N. Stefanis,
H. Verdoux and J. Van Os (2002). Evidence that
three dimensions of psychosis have a distribution
in the general population. Psychological Medicine,
32, pp 347-358.
7) Verdoux H, van Os J. (2002) Psychotic symptoms
in non-clinical populations and the continuum
of psychosis. Schizophr Res. 2002 Mar 1;54
(1-2):59-65.
25
Bengal Journal of Private Psychiatry
8) Kendler KS1, Gallagher TJ, Abelson JM, Kessler
RC.( 1996 ) Lifetime prevalence, demographic risk
factors, and diagnostic validity of nonaffective
psychosis as assessed in a US community sample.
The National Comorbidity Survey. Arch Gen
Psychiatry. Nov;53 (11) : 1022-31.
9) Liddle PF(1987)The symptoms of chronic
schizophrenia. A re-examination of the positive-
negative dichotomy. Br J Psychiatry. 1987
Aug;151:145-51
10) Venables PH, Rector NA.(2000) The content and
structure of schizotypy: a study using confirmatory
factor analysis. Schizophr Bull. 2000;26(3):
587-602.
11) Philippa A. Garety, Daniel Freeman1999 British
Journal of Clinical Psychology (1999), 38,
113154
Bengal Journal of Private Psychiatry
Review Article

Tolvaptan Use by PsychiatristsNeed for Caution

Chakraborty Suddhendu, DPM, Consultant Psychiatrist, West Bengal Health Service

Tolvaptan is a selective,competitive vasopressin receptor 2 antagonist used to treat hyponatremia(low

blood sodium levels) associated with congestive heart failure, cirrhosis, and the syndrome of inappropriate antidiuretic
hormone (SIADH) and slowing disease progression of Autosomal dominant polycystic kidney disease. Tolvaptan was
approved by the U.S. Food and Drug Administration (FDA) on May 19, 2009, while this medicine is not a psychotropic
drug, it is being marketed among Psychiatrists for treatment of hyponatremia,which is often encountered among dementia
subjects. Being oral preparation, it is being advocated as way to avoid hospitalization. It is expensive with cost per tablet
ranging from Rs. 35-50 However, Psychiatrists possibly needs to exercise more caution about this medicine. This small
review tries to share some information for Psychiatrists about this drug.
Hyponatremia, defined as a serum sodium concentration below 135 meq/L. Figure 1 below gives a simple algorithm for
diagnosis of cause of hyponatremia.

Swap osmoles for Na+

Low Serum Na+
HYPERglycaemia
HYPONATREMIA HYPERlipidemia
Factitious
HYPERproteinemia

Glyceine washout for

TURP of hysteroscopy

ECF volume ECF volume ECF volume

Increased Normal Decreased

Urinary
Urinary Sodium Urinary Sodium
Osmolality

Uninary Na+ Uninary Na+ Osmolality Osmolality Uninary Na+ Uninary Na+
<20 mmol/L >20 mmol/L Urine < Serum Urine > Serum <20 mmol/L >20 mmol/L

Increased Interstitial - Renal failure Water Intoxication SIADH PRE-RENAL RENAL

salt - Cerebral salt wasting
Intake related In presence of Na+ loss in excess of Salt and water lost
- Liver failure Drugs: Urine Na+>20 water through kidneys
- Cirrhosis - Hypertonic saline - Tea and toast diet - Hyponatremia - Diarrhoea - Kidneys failing
- Hepato-renal - Steroids - Beer diet - Euvolemia - Sweat - Addisons
Syndrome - Early diuretics - Psychogenic - Vomiting
- CCF Polydipsia If absence of: Diuresis
- Nephrotic syndrome - Hypovolemia - Burns - Renal failure
Water overload - Hypothyroidism - Fistula (diuretic stage)
- Lune disease - SBO - Osmotic diuresis
- Cirrhosis (Raised glucose and
Cause - Heat exposure urea)
- Drugs - Diuretics (Thiazides)
- CNS - Villous Adenoma of
- Chest rectum
- Malignancy

Figure 1 of interest to Psychiatrist is Syndrome of inappropriate ADH secretionwhose causes include Amiodarone,
Carbamazepine, Cerebral disorders (e.g., tumor, meningitis), Chest disorders (e.g., pneumonia, empyema),
Chlorpromazine, Thorazine,, Ectopic antidiuretic hormone secretion, Selective serotonin reuptake inhibitors.

26

Standard protocol to treat hyponatremia as per American
Academy of Family Physicians-2015 is
CLINICAL RECOMMENDATION
In patients with severe symptomatic hyponatremia, the rate
of sodium correction should be 6 to 12 mEq per L or less
in 48 hours
A bolus of 100 to 150 mL of hypertonic 3% saline can be
given to correct severe hyponatremia
Vaptans appear to be safe for the treatment of severe
hypervolemic and euvolemic hyponatremia but should not
be used routinely
Chronic hypernatremia should be corrected at a rate of 0.5
mEq per L per hour, with a maximum change of 8 to 10
mEq per L in a 24 hour period
Where does Tolvaptan fit in
Vaptans (conivaptan and tolvaptan) are vasopressin-
receptor antagonists approved for the treatment of
hospitalized patients with severe hypervolemic and
euvolemic hyponatremia .However, their use in the
management of hyponatremia is controversial.
Tolvaptan is available as 15 mg tablet. Dose
schedule - Guidelines advocate that Tolavaptan
should be started in hospitals only where serum sodium
can be closely monitored. Indeed, if a patient stops
taking tolvaptan for any length of time, it should not
be restarted at home.Initiate and reinitiate tolvaptan in
patients only in a hospital Too rapid correction of
hyponatremia (eg, more than 12 mEq/L per 24 hours) can
cause osmotic demyelination, resulting in dysarthria,
mutism, dysphagia, lethargy, affective changes, spastic
quadriparesis, seizures, coma,and/or death. In susceptible
patients, including those with severe malnutrition,
alcoholism, or advanced liver disease, slower rates of
correction may be advisable.Tolvaptan should not be used
to treat hyponatremia and neurological symptoms due to
other causes.
27
Bengal Journal of Private Psychiatry
These drugs increased thirst, which may limit the rise in
serum sodium
Dose scheduleAdapted from Lexicomp,2016
15 mg once daily; after at least 24 hours, may increase to
30 mg once daily to a maximum of 60 mg once daily
titrating at 24-hour intervals to desired serum sodium
concentration. Avoid fluid restriction during the first 24
hours of therapy.following dose titration is recommended
(at 24-hour intervals):Change <5 mEq/L in 24 hours and
serum sodium <130 mEq/L:
Day 2: Consider titration to 30 mg once daily.
Day 3: through discontinuation: Consider titration to 60
mg once daily.m
Change >5 mEq/L in 24 hours:
Day 2: Consider maintenance dose of 15 mg once daily.
Day 3: through discontinuation: Consider maintenance of
prior current dose.
Change >8 mEq/L in 8 hours or >12 mEq/L in 24 hours:
Day 2 through discontinuation: Considerwithholding dose
and/or increase hypotonic fluid intake; monitor sodium
closely.
Serum sodium >140 mEq/L at any time: Discontinue
therapy and consider increasing hypotonic fluid
Tolvaptan can be taken before or after food intake
PRECAUTIONS
Tolvaptan is contraindicated in patients with hepatic injury
and dehydration induced hypovolemia. Do not co-
administer Tolvaptan with hypertonic saline.
Other drug interactions Tolvaptan may interact with
rifampin, rifapentin, carbamazepine, rifabutin, barbiturates,
cyclosporine, anticoagulants, anti-platelet drugs,
hyperkalemia causing drugs, itraconazole, diltiazem,
verapamil, aprepitant, erythromycin, clarithromycin and
NSAIDs.
Do not consume grapefruit, grapefruit juice or grape
wine while taking Tolvaptan.Tolvaptan may interact
with St. Johns wort.
FDA has determined that (tolvaptan should not be
used for longer than 30 days and should not be used
in patients with underlying liver disease because it
Bengal Journal of Private Psychiatry
can cause liver injury, potentially leading to liver
failure.
Other side effects include loss of appetite, Itching,
abdominal pain, diarrhoea, frequent urge to urinate,
nausea, yellow discoloration of skin, fatigue, headache,
feeling of discomfort, dry mouth, constipation, excessive
thirst, fainting, dizziness, vomiting, dark colored urine
CONCLUSION
Psychiatrists should be cautious about using Tolvaptan.
REFERENCES
1. Hoorn EJ, et al. Hyponatremia and mortality: moving
beyond associations. Am J Kidney Dis.
2013;62(1):139149.
2. Mannesse CK, et al. Prevalence of hyponatremia on
geriatric wards compared to other settings over four
decades: a systematic review. Ageing Res Rev.
2013;12(1):165173.
3. Gankam-Kengne F, et al. Mild hyponatremia is
associated with an increased risk of death in an
ambulatory setting. Kidney Int. 2013;83(4):700
706.
4. Hawkins RC. Age and gender as risk factors for
hyponatremia and hypernatremia. ClinChimActa.
2003;337(12):169172.
5. Crestanello JA, et al. Preoperative hyponatremia
predicts outcomes after cardiac surgery. J Surg Res.
2013;181(1):6066.
6. Crestanello JA, et al. Does preoperative
hyponatremia potentiate the effects of left ventricular
dysfunction on mortality after cardiac surgery? J
ThoracCardiovasc Surg. 2013;145(6):1589
1594, 1594e11594e2.
7. Vaishya R, et al. Mortality predictions in severe
hyponatraemia in emergency inpatients. J Indian
Med Assoc. 2012;110(2):9497.
28
8. Shchekochikhin DY, et al. Outcome differences in
community- versus hospital-acquired hyponatremia
in patients with a diagnosis of heart failure. Circ
Heart Fail. 2013;6(3):379386.
9. Hagino T, et al. Hyponatremia at admission is
associated with in-hospital death in patients with hip
fracture. Arch Orthop Trauma Surg.
2013;133(4):507511.
10. Korkmaz I, et al. Baseline characteristics and the
association between hyponatraemia and pulmonary
embolism prognosis. J Pak Med Assoc.
2013;63(3):331335.
11. Assadi F. Hyponatremia: a problem-solving
approach to clinical cases. J Nephrol.
2012;25(4):473480.
12. Pfennig CL, et al. Sodium disorders in the
emergency department: a review of hyponatremia
and hypernatremia. Emerg Med Pract.
2012;14(10):126.
13. Verbalis JG, et al. Diagnosis, evaluation, and
treatment of hyponatremia: expert panel
recommendations. Am J Med. 2013;126(10 suppl
1):S1S42.
14. Spasovski G, et al.; Hyponatraemia Guideline
Development Group. Clinical practice guideline on
diagnosis and treatment of hyponatraemia. Eur J
Endocrinol. 2014;170(3):G1G47.
15. Masri G, et al. Evaluation of hyponatremia. https://
online.epocrates.com/noFrame/showPage?
method=diseases & MonographId=57 [subscription
required]. Accessed October 8, 2014.
16. Sarikonda KV, et al. Hyponatremia. http://
www.essentialevidenceplus.com/content/eee/
146[subscription required]. Accessed October 8,
2014.
17. Imbriano LJ, et al. Normal fractional urate excretion
identifies hyponatremic patients with reset
osmostat. J Nephrol. 2012;25(5):833838.

Successful Treatment of Major Depressive Disorders
By SSRI In A Patient of Platelet Disorders Namely
Thromboxane A2 Receptor Deficiency
Ghosh Malati
Mukherjee Bhaskar & Sanyal Debasish
ABSTRACT
The following case report highlights about successful treatment of Major Depressive disorders in a patient of Thromboxane
A2 receptor. The treatment period was uneventful with no bleeding diathesis and all the laboratory coagulation parameters
were within normal limit.
INTRODUCTION
Platelets play a major role in normal hemostasis. They also
have a pivotal role in inflammation & atherosclerosis. Platelet
disorders can happen when there is defective platelet
function or number or both.
CASE HISTORY
A 35 yr old male presented to outdoor of psychiatry
department with low mood, loss of appetite and insomnia
for last 4 months. He was referred to psychiatry department
by his general physician on account of excessive irritability
& avoidance of work. Patient used to work in Indian Forest
Service & was very much involved with his work before.
During initial interview patient also admitted having
heaviness of head which gradually increased during the day
for the same 4 months duration. He also admitted having
feeling of helplessness & hopelessness for last 3-4 months.
He also revealed having symptoms of lack of energy,
forgetfulness, difficulty in maintaining prolonged
concentration during his professional activities. He also
admitted about having suicidal intent & about committing 2
previous suicidal attempts by taking sedatives
(benzodiazepines) within last 4 months. Both the time the
amount of sedative taken was low so appropriate treatment
could be given.
When detailed history was taken some interesting findings
came forward. It was revealed that though patient was
29
Bengal Journal of Private Psychiatry
Original Article
unmarried he was in stable relationship with a girl of his
locality for last 2 yrs. But his girlfriend had a very negative
feeling about patients choice of work & persuaded him
many a times to change job. That disapproval had a
tremendous effect on their relationship & its been a
stalemate for last 6 months. Patient also revealed that his
depression has really started after this relational dispute and
gradually progressed due to that fact only.
While corroborating patients history with his family
members (parents) it was revealed that patient had
impulsivity and frequent temper outbursts from adolescence.
But no other history of deliberate self harm before this
depressive episode was found. Neither there was history
of other cluster B personality traits. Both his parents recalled
many episodes of prolonged bleeding from seemingly
insignificant injuries but none of those episodes were severe
enough to demand medical attention.
Physical examination of patient was perfectly normal. On
mental status examination it was found had depressed mood
& mood congruent affect, suicidal ideation & intent. No
other significant disorders were found.
On past treatment records we found he was treated by
TCAs (amitryptylin) and NASSAs (mirtazapine) by
psychiatrists, but none of the drugs suited patient well and
so he discontinued all drugs after taking them for 1 weeks.
As general protocol patients blood was sent for lipid profile,
liver function test, blood sugar estimation (both fasting and
Bengal Journal of Private Psychiatry
post prandial), urea and creatinine estimation and electrolyte
estimation. Keeping his bleeding episodes in mind we took
opinion of haematologist who adviced complete blood count
including platelet count and morphology, platelet function
tests, PT, APTT & TT along with simple bleeding time &
clotting time.
While these reports were pending we prescribed the patient
Escitalopram (10 mg daily initially, gradually escalating to
20mg daily over the period of 2 weeks) and clonazepam
(2 mg daily in divided doses, gradually tapering to 0.5mg at
night over the period of 2 weeks).
Patients reports came with some astonishing findings. His
lipid profile, liver function test, blood sugar levels, urea &
creatinine levels and electrolyte level were all within normal
limits. His complete blood count was also normal so was
platelet count and morphology. But his bleeding time was
prolonged and so was platelet aggregation in response to
arachidonic acid metabolites and collagen. His coagulation
pathway was normal as evident by normal clotting time,
normal PT, APTT & TT. He was diagnosed to have TXA2
receptor deficiency by Haematology Department.
Meanwhile although patient improved on escitalopram after
finding that he has platelet functional disorder we tried to
change treatment regimen for patient, as safety of SSRI
and SNRI in platelet disorder is doubtful. We gave patient
a choice between different treatment options after explaining
his platelet function disorder to him & the risks that it possess
in the treatment of his depression. Patient refused ECT and
also refused treatment with TCAs & NASSA on the ground
of previous tolerability issue. His depression was too severe
to give NARI (reboxetine). Patient also refused CBT and
any other psychotherapy because he cant attend those
30
sessions regularly due to his job profile. And his depression
was too severe to be treated by CBT alone.
This situation leaves us with no option but to continue
escitalopram in current dose (20mg od). We kept patient
under strict observation & monitor his platelet activity while
he is under SSRI treatment by measuring repeated bleeding
time after every 2 weeks. During the whole treatment period
his bleeding time was never unusually prolonged to our
relief. He did quite well under escitalopram and his
depression responded well. Presently he is on 9th month of
therapy & he has again regained his normal personality. His
professional life is also going quite well. His personal life
troubles also improved and he has been able to make peace
in the relationship front. He has undergone an operation
during this treatment procedure in the form of laparoscopic
cholecystectomy due to chronic cholecystitis. The operation
was uneventful and recovery was uneventful in post
operative period in terms of any significant bleeding episode.
Though he received 2 units of platelet transfusion as
precautionary measure.
DISCUSSION & CONCLUSION
Safety of SSRIs in platelet disorder is a much debated topic.
Close liason with Haematologist may be helpful.
REFERENCES
1) de Abajo FJ. Effects of selective serotonin reuptake
inhibitors on platelet function: mechanisms, clinical
outcomes and implications for use in elderly
patients. Drugs Aging. 2011 May 1;28(5): 345-67.
2) Demian Halperin, Guido Reber Dialogues Clin
Neurosci. 2007 Mar; 9(1): 47-59.

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2001; 102:9-20

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American Psychiatric Association (APA). Diagnostic and
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