7+5=13

This is the bimonthly inhouse magazine of department of Psychiatry of Gauhati Medical College, Guawahti, Assam, India entitled 7+5=13. This magazine is primarily a small educational work from a group of Psychiatry students. This magazine brings you case studies, some scietific articles and also some semi-scietific readings.

The materials published here has been passed through books of psychiatry; but the author does not take the responsibility of any of the materials being perfect or up to date.


7 + 5 = 13,





the inhouse bimonthly magazine of deptt. of Psychiatry, GMCH.
Vol I, No. 1,

Editor Dr. Chayanika Sarma, MB BS, MD std (Psy).

Editorial board
Dr. S. Chakravarty,MB BS, MD (Psy),Assoc. Prof., Deptt of Psychiatry.
Dr. Nahid S IslamMB BS, MD std (Psy).
Dr. Sangeeta DattaMB BS, MD std (Psy).
Dr. Kamal N. KalitaMB BS, MD std (Psy).
Dr. Lakhimi BargohainMB BS, MD std (Psy).
Dr. Shyamanta DasMB BS, MD std (Psy).
Dr. Raj Konwar.MB BS, MD std (Psy).
Dr. Debajit GogoiMB BS, MD std (Psy).
Dr. Uddip TalukdarMB BS, MD std (Psy).
Dr. Raj Kumar SealMB BS, MD std (Psy).
Dr. Pranjal DeyMB BS, MD std (Psy).

Cover DesignDr. Uddip TalukdarMB BS, MD std (Psy).

INDEX
January- February, 2005.

Content
Editorial
Case Discussion Dr. Shyamanta Das
Dr. Kamal N. Kalita
Dr. Chayanika Sarma
Dr. Raj K. Seal

Is Schizophrenia A Neurodevelopmental Disorder
Dr. S. Chakravarty
Sigmund Freud Dr. Raj Konwar

How Safe Is TV ? Dr. Raj K. Seal


page 1
EDITORIAL


Honourable reader,
If one is questioned what one opines regarding the department of Psychiatry, GMCH, obviously most will held forth the view that it is a section of GMCH, wherein patient’s with psychiatric illness come for diagnosis and treatment. But we, the post graduate students of the department, held an entirely different notion. For us, the department is our academy. The eminent psychiatrists here are our esteemed teachers who enlighten us with knowledge.
With the ardent desire to learn more, and with a galaxy of alluding dreams in mind, we proceeded to publish this bimonthly magazine christened 7+5=13.
You may be presuming, why this name? Well, psychiatry is a part of behavioural science where definite groups of symptom do not lead to a diagnosis of a specific disease. It is a relative science where diagnosis is mostly based on symptomatology and clinical assessment taking the social, economical and cultural basis of the patient. The causative factors of the illness cannot be searched for in the laboratories, but it remains hidden in the surrounding atmosphere, his obligations and day to day activities, and other varied aspects of his life. But we profoundly long that a say will dawn when this name will prove wrong and psychiatry too will be 7+5=12.
We have initiated our maiden effort with only a fragment of our yearnings. But hope we will continue expanding pages, with your encouragement and guidance.
In this issue we included write-ups faculty’s desk, also of our colleagues and case studies among others. Coming issues also include contributions from other luminaries in this and related field, working in various setups. Our initial issues will include material strictly for the people of psychiatry and related society. But we aspire to include later, articles for the general public also.
We have ventured out with a noble goal, and aspire to go a long way. In every step we will seek the able guidance from our faculty members. As without them enlightening our ways we cannot continue the journey further. Psychiatry is a vast ocean of knowledge, and we hardly know thoroughly of a single droplet.
We heartily welcome suggestions, constructive criticism form our valued readers. As beginners we are prone to commit errors. We give the full liberty to every reader to correct us any moment and will appreciate their endeavour. Fruitful feedbacks will give us scope for further improvement. Longing for your support at every step.


editor




page 2

Case Discussion
REGRESSION TOWARDS CHILDHOOD
Dr. Shyamanta Das
PG Std (Psy), GMCH


Case
XX is a 22-year old unmarried, unemployed Hindu female hailing from lower middle class joint family of rural background who for 5 years has been symptomatic with odd behaviour, fearfulness, suspiciousness, laughing and crying due to no apparent reason, muttering, wander some as well as disinhibited behaviour along with disturbed sleep. She would keep on staring at the mirror for prolonged periods, and smiled at her image. At times would keep on looking at the wall and make postures with her hands as if putting make-up on her face. Would complain of seeing snakes and worms. Initially she was withdrawn, later on became over familiar. Onset was insidious, course is progressive and the severity of symptoms has increased in the last 3 months.
Failure in examination is an exacerbating factor.
Elder sister is a known psychiatric patient and is under treatment.
Premorbidly she was obedient, soft-spoken, and warm-hearted. Offering helping hand at the domestic responsibilities. Conforms to social and cultural norms, maintaining relationship with brothers, but quarrelsome with her sister.
Developed friendship with peer groups. Took part in social activities and used to participate in school games.
Studied up to class X, and then gave up due to lack of interest and illness.
Failed in class VII and again in HSLC test examination.

On mental status examination, she is a fair-complexioned; pyknic built female in early 20’s, does not look ill with increased grooming and increased psychomotor activity. She is co-operative but rapport could not be established. Normal reaction time with irrelevant, incoherent speech. Subjectively feels sad, objectively feels elated. Affect is inappropriate. Ambivalence is present with delusion of persecution as well as auditory hallucination. Difficult to draw attention and ill-sustained concentration. Memory and orientation was intact, but judgment and memory impaired as well as abstract thinking. Intelligence is below average and insight is grade II.

Discussion
Disorder of content of thinking as well as breaks or interpolations in the train of thought, resulting in incoherence of speech and irrelevant speech in this patient leads us to thinking the line of schizophrenia.
In this case, affective changes are prominent, behaviour irresponsible and unpredictable; mood inappropriate and often accompanied by giggling or self-
satisfied, self-absorbing smiling; thought is disorganized and speech rambling and incoherent. These points are in favour of hebephrenic variety. This form of schizophrenia is usually starts in the age group 15 and 25 years. Hebephrenia should normally be diagnosed for the first time only in adolescents or young adults.
Although delusions and hallucinations are present but are not prominent. The pre morbid personality is characteristically, but not necessarily, rather shy and solitary. For a confident diagnosis of hebephrenia, a period of 2 or 3 months of continuous observation is usually necessary; in order to ensure that characteristic behaviours are sustained.
Although the patient is having delusions of persecution and hallucinatory voices, these are not threatening or commanding in nature and also the age of onset is early which does not conform to a diagnosis of paranoid type of schizophrenia.
In schizoaffective disorder (manic type), schizophrenic and manic symptoms are both prominent in the same episode of illness. The abnormality of mood usually takes the form of elation, irritability and persecutory ideas. There is increased energy, over activity, impaired concentration, and a loss of normal social inhibition. Delusions of persecution as well as hearing voices are of varied kind may be present. But these are usually accompanied by self-esteem and grandiose ideas, excitement, aggressive behaviour and delusion of reference. Also this disease has an acute onset and full recovery is there within a few weeks. Thus the patient does not fulfill this diagnosis.

Conclusion
XX can be diagnosed to be a patient of hebephrenic schizophrenia, course continuous, ICD diagnosis F20.10 with differential diagnosis of paranoid schizophrenia and schizoaffective disorder, manic type (F25.0).


Case Discussion 2
Dr. Kamal Narayan Kalita
PG std, (Psy), GMCH


Mr. X, 29 years old single, male was found to be withdrawn, confined to himself for 2 months. He kept to himself for 2 months. He kept brooding, was inattentive in his job and expressed guilt over his mismanagement of money. He kept on talking about some people running after him desperately to kill him and according to him they were hired by his employer. Suddenly few days before Magh bihu he heard on radio his father’s voice advising him to confess his act of misusing the money. So he gave in written to his employer about it, and promised to return the amount he had already spent. On returning home, he behaved like a zombie and started talking about his identity which he said not to be real. He considered himself to be an illegitimate child of someone else, who was brought up by his ‘so called’ father. He also stated that he can not think with his mind alone and whenever he thinks it is shared by others by means of radio waves and are transmitted in television and radio. He expressed his wish to as he feels he is not worthy of living and also had done some evil things like having illegitimate relationship with a girl and a tribal woman. He viewed that all his actions were actions were programmed very long back and God is using him like a guinea-pig for some experiments.
According to him, he also heard some voices speaking to him in derogatory way and heard his girlfriend’s voice making some odd sounds where she was miles away at that time. His sleep and appetite were reduced significantly.
His physical examination and routine laboratory investigations revealed no abnormality. His father was a learned person, alcoholic had frequent quarrel with his wife in intoxicated state. He was very protective towards his children and was a dominant person. The patient’s uncle is a psychiatric patient receiving long acting antipsychotic drugs and maintaining his social and personal life normally. The patient’s early developmental history did not reveal any significant findings. He was a bright student and secured high level of education and also has some computer education. Premorbidly he was honest, amiable, responsible, conscientious person having hobbies of cricket, music and movies.
On MSE examination, patient was co-operative, talked relevant and coherent and had broadcasting of thoughts. Delusion of control present (as his actions are programmed beforehand by a special ‘software’) and also some sort of experimenting is being done on him (delusion of persecution). His employer is coming to him regularly in disguise of some other person to harm him (FRIGOLI phenomenon). Delusion of reference and referential thinking is present. His higher mental functions are found intact.


Diagnosis
He was provisionally diagnosed to be a case of paranoid schizophrenia and was given Olanzepine 20 mg per day. He responded to the treatment and showed significant improvement. On follow up he was found to be socially functioning and is continuing his duties.


Case discussion 3

Dr. (Miss) Chayanika Sarma,
PG std (Psy), GMCH

Patient X, 18 years, male was brought to the OPD with complaints of low self esteem, lack of interest in his studies and other activities, withdrawn behaviour, irritability, disturbed sleep for 2 years, irrelevent talking, occasional destructive behaviour, decreased personal care, suspiciousness and fearfulness for 1 year and over religiousness, inappropriate crying, expressing death wish, guilty feeling, illogical thinking and hearing voices for 10 days.
Onset was insidious and course continuous and progressive. Patient has some definite stress factors prior to onset of symptoms, like failure to cope with the studies, feeling of inferiority for his physique, which he considered unattractive, unable to adjust with his class mates in the newly joined institution.
There is no history of significant disease in the past.
History of psychiatric illness is present in both paternal and maternal families.
Pre morbidly patient was introvert in nature, had good academic performances and good social interaction.

MSE findings
Speech was found relevant and coherent, spontaneous. Non-voluble, but had increased prductivity, pressure and had reduced reaction time. Increased PMA.
There is also loosening of association, tangentiality, circustantiality, thought block, illogical thinking. Ambivalency, thought withdrawal and thought broadcasting are also present.
Objective mood was elated with appropriate affect. But rapport was poor.
There was delusion of persecution in the form of persecution (in the form of family members, neighbours and relatives conspires against him), delusion of reference (the people around talk ill of him), also delusion of grandiosity (having extra ordinary power for doing extra ordinary things) and delusion of control (by an unseen super power).
Ideas of helplessness, occasional death wish without suicidal ideas, strong guilt feeling.
Auditory hallucination (2nd person – in the form of crying female voices talking their worldly woes).
Memory was intact and oriented to time, place and person.
Insight to the illness was grade I.

Interpretation
From history and MSE findings, the case was diagnosed to be a case of paranoid schizophrenia (F20.0)

Follow-Up
The patient showed significant improvement at the time of discharge. On follow-up after 1 month also significant improvement was noticed. But discontinuation of medication led to relapse after a gap of 1 week and had to be admitted again. But since the discharge second time, he is showing improvement and now has returned to his normal activities.

Discussion
Though in the patient, both affective and schizophrenic symptoms were present, the two groups of symptoms did not appear simultaneously. Affective symptoms preceded schizophrenic symptoms by 1 year. This rules out the diagnosis of schizoaffective disorder. The affective symptoms can be regarded to be ‘prodrome of schizophrenia’.
Though affective symptoms are present, but presence of first rank symptoms of schizophrenia rules out diagnosis of MDP.
Risk of schizophrenia is increased in first degree relatives of patient with schizophrenia and schizoaffective disorder.
Possible familial links between schizophrenia and mood disorder remain controversial as per studies.
Stressful life events often provoke the disorder.
Short episode, with no previous psychiatric illness, prominent affective symptoms, paranoid type of onset, goof previous personality, good work record, good social relationship and good compliance carries good prognosis in predicting outcome of schizophrenia. Younger age of onset, unmarried, male sex emotional over involvement by family members are associated with poor outcome, at the same time.




Sigmund Freud
Dr. Raj Konwar
PG std (Psy),GMCH

"A man should not strive to eliminate his complexes but to get into accord with them: they are legitimately what directs his conduct in the world." --- Sigmund Freud





Freud was the founding father of psychoanalysis, which is a major school of psychology
His theory about sexuality being the center of psychopathology as well as the major drive of all individual developments has made him one of the most controversial yet most influential scientists of this century.

Birth
Freud was born on May 6, 1856, Freiberg (now Pribor), a rural town in Moravia, which was then part of the Austro-Hungarian Empire (now part of Czechoslovakia). He died in London on September 23, 1939.

Childhood
Sigismund Schlomo Freud (later shortened to Sigmund Freud by himself) was born to middle-class Jewish parents. When Freud was four, his family moved to Vienna, Austria, where Freud spent most of his life until 1938, when he was forced to flee to England because of the Nazi invasion.
Freud's father, Jacob Freud, was a wool merchant. Freud's mother, Amalia, was Jacob's second wife and 20 years younger than her husband. Freud had two much older half-brothers from his father's first marriage and seven younger siblings. One of the older half-brothers had a son who was about Freud's age. And Freud had a nanny who was Catholic and thought of as Freud's second mother. The unusual family situation, especially the complex relationships Freud had with his father and his nanny, was believed to have helped shape some of Freud's psychoanalytic notions, such as the Oedipus Complex.

Career
At age 17 Freud entered the University of Vienna to study medicine. Freud was a diligent student and a believer of the theory of evolution and the methods of natural science. Later, Freud, as a neuropathologist, became a respected physician. He became interested in the treatment of an emotional disorder known as hysteria when he studied under the famous French neurologist, Jean-Martin Charcot. Back in Vienna, Freud collaborated with Josef Breuer, another physician and physiologist. Breuer had a patient, known as Anna O, suffering from hysteria, which apparently paralyzed her. During her treatment, Freud and Breuer discovered that recalling traumatic experiences with the help of hypnosis would help relieving her symptoms. In 1895, Freud and Breuer published Studies in Hysteria, which documented "the cathartic method", also known as the "talking cure".

Freud continued to develop and publish his theories. The Interpretation of Dreams, published in 1900, and Three Essays on the Theory of Sexuality, published in 1905, made Freud famous. But his theories, especially the part about infantile sexuality, were severely criticized by the intellectuals in 20th century Vienna. Freud and his work, however, persevered and gradually gained a loyal following that included Alfred Adler and Carl Jung (who later parted their ways with Freud). The "International Psychoanalytical Association (IPA)" was founded in 1910. The psychoanalytical magazine "Imago" was founded in 1912. Eventually, the society at large began to recognize the extraordinary effort Freud had made in understanding the human mind. In 1935, just before his eightieth birthday, Freud was appointed Honorary Member of the prestigious British Royal Society of Medicine.

Today, the controversy over Freud's theories remains. Those theories, however, have forever changed the Western views of psychopathology, day-to-day life, and the world.

Publications by Freud

1895 Studies in Hysteria
1900 The Interpretation of Dreams
1901 The Psychopathology of Everyday Life
1905 Three Essays on the Theory of Sexuality
1905 Jokes and their Relation to the Unconscious
1905 Fragment of an Analysis of a Case of Hysteria
1907 Delusions and Dreams in Jensen's Gradiva
1913 Totem and Taboo
1915 A letter to the publisher of A Young Girl's Diary
1923 The Ego and the Id
1930 Civilization and its Discontents
1939 Moses and Monotheism

How Safe Is TV?
Dr Raj Kumar Seal
1st year PG(Psychiatry)

Educational psychologist Jane Healy held forth the view that television and other screen media has a very detrimental effect on language formation in children. According to him, screen media has dramatically decreased the amount of time that parents and children spend talking. On an average, American parents spend only 38.5 minutes per week in meaningful conversation with their children compared to the three to four hours daily that children spend with screen.

Again, TV language is fast, loud, simplistic and accompanied by over-stimulating visual images. Even slow programmes geared especially to toddlers, are unable to match the interactive, reciprocal and cumulative efforts of a parent and child telling a story together. Children fail to hear basic elements of speech properly, so they learn these elemental building blocks incorrectly. Some children start going to school mastering the verbal skills they need to start reading. If screen media are inimical to language development in young children, there are some activities that optimizes some of its negative effects. One such activity is story telling. Story telling has a very good impact in development of language and creative thoughts. It aids in solving problems and resolving trauma. Story telling is also the mechanism which teaches children about their cultures and acquints them with serious aspects of life. The various characters depicted in the stories carry a lesson for the children. For example, in European tales, what character is as effective as the Big Bad Wolf in teaching children not to open doors to strangers, not to deviate from the scheduled path and to avoid talking to strangers? One important aspect of story telling is building skill of conversation. The amount and quality of a discussion between parents and children is one of the greatest predictors of how efficient reading skills a child may develop in the future. TV is an indispensable part of life which has various beneficial affects also.

For development of language, parents should device various ways:
Children who are not verbally fluent should not be exposed to screen media on a regular basis. This is consistent with the recommendation of the American Academy of Psychiatrists, as per which, children under two years should not watch television.
Children should be told stories like fairy tells and about interesting events that occurred during the childhood and younger stage of the parents themselves, which carried a meaningful message for them.
Parents should spend adequate time in conversing with their children.
These are only few examples. Various other means which contribute towards language formation of kids should be explored into.

Is schizophrenia a neurodevelopmental disorder?
Dr. Suresh Chakravarty
Asso. Prof. of Psychiatry, GMCH

In the 1980s, a number of research groups began to speculate that schizophrenia might have a significant developmental component (Feinberg, 1982; Schulsinger, 1984; Murray, 1985). Several lines of evidence support the hypothesis that schizophrenia is a neurodevelopmental disorder, resulting from neuronal injury occurring early in life that interferes with normal brain maturation (Andreasen et al, 1986; Weinberger, 1987). In 1987, Murray and Lewis summarized the evidence in an editorial in the British Medical Journal entitled – ‘Is schizophrenia a neurodevelopmental disorder?’ – since then researchers have increasingly answered the question in the affirmative. In this review we consider how new information has caused the original ‘doomed from the womb’ hypothesis to evolve.

We begin by discussing the strongest evidence implicating a role of deviant development i.e., that concerning the characteristics of preschizophrenic children.

Fish (1977), pointed out that the increased prevalence of neurological signs in multiple sensorimotor systems in the offspring of schizophrenics was consistent with an ‘inherited neurointegrative deficit’. High risk studies concur showing that 25% to 50% of children born to mothers with schizophrenia have developmental abnormalities especially poor motor coordination in early childhood and attention and information processing deficit later (Amminger GP, 1999; Erlenmeyer K, 2000; Ott St, 2001). Cannon et al (1999) compared elementary school records of 400 preschizophrenic children and 400 healthy controls born in Helsinki between 1951 and 1960. Poor performance in sports and handicrafts which may indicate motor coordination deficits, were risk factors for schizophrenia. These findings are consistent with the high-risk and other birth control studies, and also the poor motor coordination seen in childhood videotapes (Walker EE, 1993; 1996). Premorbid social, cognitive and motor dysfunctions are significant indicators of vulnerability to schizophrenia. Such vulnerability being the result of familial (genetic and shared environmental) factors (Cannon, 2000; Bearden CE, 2000; Rosso, 2000).

David et al (1997) investigated the association between IQ and the later development of psychosis in a cohort study of nearly 50 000 eighteen years old males who were conspricted into the Swedish army in 1969 to 1970. By 1983, 195 subjects in the cohort had been admitted to hospital with schizophrenia and another 192 with nonschizophrenic psychosis. There was a highly significant association between low IQ scores and the subsequent development of schizophrenia. Indeed, the relationship between schizophrenia and IQ was linear, with risk gradually increasing as IQ fell at all levels of intellectual ability.

Davidson et al (1999) examined assessment scores for nearly 10,000 sixteen and seventeen years old boys entering the Israeli army. Deficit in social functioning, organizational ability and intellectual functioning predicted later hospitalization with schizophrenia. The authors suggested that low IQ itself a causal factor, increasing the risk for schizophrenia. It could act independently or be one of the means by which other genetic or environmental influences exerts their effect or both. The authors suggest that low IQ could compromise information processing, leading eventually to the psychopathology of schizophrenia or alternatively that high IQ may be protective.

The observation that perinatal complications often precedes the development of severe neurological and psychological disorders, such as cerebral palsy and mental retardation, have led investigators to explore the role of perinatal and obstetrical complication in the etiology of schizophrenia. Many small case control studies reported an excess of obstetric complication (OC) among patient with schizophrenia. Firstly, Geddes and Lawrie (1995) confirmed an association between OCs and schizophrenia with an odd ratio of approximately 2. Secondly, Geddes et al (1999) examined 11 studies, which used the Murray & Lewis scale (1989) to interview mothers retrospectively about their offspring’s gestation. Premature rupture of membrane, premolarity and the use of resuscitation or intubator emerged as significant risk factors. In the last few years, a number of large registered longitudinal studies (Table I) have been published. Despite occasional inconsistencies, the new evidence overwhelmingly support the notion that exposure to the OCs is a risk factor for schizophrenia. The mechanism underlying the link between OCs and schizophrenia point to fetal/neonatal hypoxia (Dalman et al, 1999; Rosso et al, 2000; Zornberg et al, 2000). According to Cannon et al (2000), the odds of schizophrenia increase linearly with an increasing number of hypoxia/ischaemic complications. A plausible model is that those with a genetic liability to schizophrenia may be especially sensitive to the excitotoxic effects of hypoxia on the foetal/neonatal brain (Cannon et al, 2000; Fearon P, 2000)
.

Study Sample; Method and Main findings
Jones et al, 1998 1966-born cohort with 76 subjects had developed
11 017 Finnish subjects. schizophrenia at age 28.
Linked psychiatric and Schizophrenic patients were
obstetric case registers. significantly more likely than
Follow-up at age 28 years controls to have had perinatal
brain damage or to be premature

Study Sample, Method and Main findings
Hultman et al, 1999 Swedish population-based Schizophrenic patients were
cohort study. Comparison more likely than controls to
of obstetric records for 167 have OCs, especially if male.
patient/control pairs linked Schizophrenia was associated
to psychiatric register with multiparity and maternal
bleeding in pregnancy
Dalman et al, 1999 Same cohort as Hultman 238 subjects developed
et al. Follow-up of 507 516 schizophrenia during follow-
children born in the late 1970s up. Schizophrenia was
associated with OCs.
Preeclampsia was the
strongest individual risk factor

Kendell et al, 1996 115 case-control pairs Schizophrenia was associated
from the Scottish with a significant excess of
population born in 1971 OCs, especially peeclampsia
to 1974. Linked obstetric and infants requiring hospital
and psychiatric records neonatal care
Kendell et al, 2000 Reanalysis of same Selection bias was detected
Scottish sample in the control group of the
1996 study. Reanalysis showed
no significant association between
OCs and schizophrenia
Byrne et al, 2000 Compared obstetric records Global rate of OCs did not
of 431 patient/control pairs. differ between patients and
Linked with psychiatric controls. Male patients with a
case register young onset had significantly
more OCs than controls
Cannon et al, 2000 Prospective cohort study The odds of schizophrenia
(NCPP). Comparison of increase linearly with increasing
72 patients, 63 unaffected number of hypoxia-associated
siblings, and 7941 controls OCs
Rosso et al, 2000 1955 Finnish birth cohort. Hypoxia-associated OCs
80 patients, 61 unaffected significantly increase the odds of
siblings, and 56 matched early-onset schizophrenia (but
controls not of later-onset cases)
contd…..
Study Sample and method Main findings
Zornberg et al, 2000 Prospective cohort study Hypoxic/ischemia-related fetal/
(NCPP). 603 individuals neonatal OCs were associated
born between 1959 and with striking increase in risk for
1966 were followed for schizophrenia and other
23 years after early nonaffective psychoses (5.7%
childhood assessments vs 0.4% for nonexposed)
Brown et al, 2001 Comparison of 70 young The subjects prenatally exposed
adults from the rubella- to rubella had a substantially
exposed 1964 birth cohort, higher risk for nonaffective
against 1510 unexposed psychosis compared with
controls from the ECA and unexposed controls (RR:5.2)
the Albany/Saratoga studies
Wahlbeck et al, 2001 Cohort study of 7086 Finnish Intrauterine and childhood
Subjects. Linked obstetric malnutrition was associated
and school health records with increased lifetime risk
with psychiatric register for schizophrenia
Dalman et al, 2001 Case-control studies There was a strong association
recruiting from the between signs of asphyxia at birth
Stockholm psychiatric and schizophrenia with an odds ratio
register: 524 patients of 4.4 (95% CI: 1.9-10.3), after
with schizophrenia and adjusting for other OCs, maternal
1043 controls matched history of psychosis, and social class
by age, gender, hospital,
Thomas et al, 2001 and parish of birth. OC The increased risk of schizophrenia
data were obtained from associated with OCs (asphyxia in
birth records particular) was not significantly
modified by gender, maternal history
of psychosis, or age of onset.
Limited statistical power
Table I. Register-based studies of obstetric complications (OCs) and schizophrenia. NCPP, National Collaborative Perinatal Project;
ECA, Epidemiologic Catchment Area; RR, relative risk; CI, confidence interval.
An increase in minor physical anomalies is a consistent finding among patients with schizophrenia (O’Cullaghan, 1991; Griffiths TO 1998; McNeill TF et al, 2000) and this has been interpreted as a marker of altered development. Epidermal ridges appear on the hand between weeks 12 and 15 of life and after this period they remain unchanged (Rackie P, 1988). Dermatoglyphic abnormalities are found in excess in schizophrenia (Fananas et al, 1990; Bracha HS, 1991; Fananas L et al, 1996) and this has been interpreted as a marker of altered development.
A slight increase in risk for schizophrenia exists among individuals born in late winter/early spring (Bradburry T et al, 1985; Davies et al, 2000). These results point towards an etiological agent acting during gestation, birth or early childhood rather than around the time of onset. Some studies suggested this seasonal effect could be secondary to exposure to influenza in the uterus during winter (Sham PC, 1993; Takei N, 1996). Intrauterine rubella infection has also been put forward as a potential risk factor for schizophrenia (Brain AS, 2001).
The most consistent deviances described in schizophrenia are an increase in ventricular size and subtle global and regional cortical volume reduction (Johnstone E et al, 1976; Lewise et al, 1990; Wooddruf et al, 1994; Ch na et al, 1995; van Horn, 1992). Wright et al (2000) carried out a meta analysis of 58 MRI studies, which included 1588 patients with schizophrenia. The mean lateral ventricular volume was greater (126%) then that of controls and the mean cerebral volume was smaller (98%). Relative to the cerebral volume reductions, the regional volumes of the subjects with schizophrenia were 98% for the frontal lobes, 94% for the amygdale/hippocampus, and 96.5% for the thalamus. Recently voxel-based method of analyzing structural MRI images have enabled the whole brain to be examined and implicated partially the medial temporal region, insula and anterior cingulated (Wright et al, 1995; Sigmundsson, 2001). Thus the ‘lesion’ occurs well before the onset of the illness and interacts with maturation events such as neuronal precursor glial proliferation and migration, axonal and dendritic proliferation, myelination of axons, programmed cell death and synaptic pruning (Liborman 1999a) and is in all likelihood a non-progressive disease process (Lewis 1997). Support for the neurodevelopmental model includes the fact that the majority of patients with schizophrenia do not have a course of illness marked by progressive deterioration such as found in dementia. In addition, brain morphological abnormalities commonly found in this illness, such as enlarged ventricles and reduced mesolimbic structures, do not appear to be progressive and, in fact, are present at the onset of illness. Moreover, gliosis, which occurs during active pathological process as part of the cellular reparative process in mature brains is not commonly found in postmortem studies of schizophrenia (Falkai et al, 1986; Roberts, 1987; Roberts G et al, 2000).
Interpretations:-
A neurodevelopmental model of schizophrenia has provided the primary conceptual underpinning of the movement toward the early intervention and prevention. According to this approach, schizophrenia results from a basic biological error that occur very early (probably prenatally), often involves a genetic component, and leads to a combination of structural, functional and /or biochemical abnormalities in the developing brain. These abnormalities, in turn, result in a biological susceptibility to illness that may or may not be triggered by later, poorly understood stressors. Since schizophrenia is typically not expressed clinically until late adolescence-early childhood, a considerable developmental period is thus available during which preventive treatment can be initiated.
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Murray RM, Lewis SW et al. Towards an etiological classification of schizophrenia. Lancet 1985; 1: 1023-26
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Davidson M, Reinchenberg A et al. Behavioural and Intellectual marker for schizophrenia in apparently healthy male adolescent. Am J Psychiatry 1999; 156: 1328-1335
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How Safe Is TV?
Dr Raj Kumar Seal
1st year PG(Psychiatry)
Educational psychologist Jane Healy held forth the view that television and other screen media has a very detrimental effect on language formation in children. According to him, screen media has dramatically decreased the amount of time that parents and children spend talking. On an average, American parents spend only 38.5 minutes per week in meaningful conversation with their children compared to the three to four hours daily that children spend with screen.
Again, TV language is fast, loud, simplistic and accompanied by over-stimulating visual images. Even slow programmes geared especially to toddlers, are unable to match the interactive, reciprocal and cumulative efforts of a parent and child telling a story together. Children fail to hear basic elements of speech properly, so they learn these elemental building blocks incorrectly. Some children start going to school mastering the verbal skills they need to start reading. If screen media are inimical to language development in young children, there are some activities that optimizes some of its negative effects. One such activity is story telling. Story telling has a very good impact in development of language and creative thoughts. It aids in solving problems and resolving trauma. Story telling is also the mechanism which teaches children about their cultures and acquints them with serious aspects of life. The various characters depicted in the stories carry a lesson for the children. For example, in European tales, what character is as effective as the Big Bad Wolf in teaching children not to open doors to strangers, not to deviate from the scheduled path and to avoid talking to strangers? One important aspect of story telling is building skill of conversation. The amount and quality of a discussion between parents and children is one of the greatest predictors of how efficient reading skills a child may develop in the future. TV is an indispensable part of life which has various beneficial affects also.
For development of language, parents should device various ways:
Children who are not verbally fluent should not be exposed to screen media on a regular basis. This is consistent with the recommendation of the American Academy of Psychiatrists, as per which, children under two years should not watch television.
Children should be told stories like fairy tells and about interesting events that occurred during the childhood and younger stage of the parents themselves, which carried a meaningful message for them.
Parents should spend adequate time in conversing with their children.
These are only few examples. Various other means which contribute towards language formation of kids should be explored into.