Real world experience of Endoxifen augmentation therapy in a case of resistant OCD Sivabalan Elangovan, Jayashri Sundaramoorthy, Saritha Dhuruvasan Biomedicine India, 2023 About 40%–60% of obsessive-compulsive disorder patients do not achieve full remission even when treated with selective serotonin reuptake inhibitor and cognitive behavioural therapy. Here, we describe a case of a 30-year-old female suffering from OCD, who was not improved even after fluoxetine 80 mg per day and behavioural therapy and was successfully treated with low dose fluoxetine (60 mg/day) and Endoxifen (8 mg/day).
A case of vocal tics presented as chronic cough treated with risperidone Dhruvasan Saritha, Sivabalan Elangovan Indian Journal of Psychiatry, 2023 Cough is a common symptom among children, which is usually associated with respiratory tract infections, allergies, and asthma. However, in some cases, cough can be a symptom of an underlying neuropsychiatric disorder such as psychogenic tics and vocal tics. Psychogenic cough is one of the important differential diagnoses of persistent cough,[1] another neuropsychiatric condition that can mimic cough is Tourette’s syndrome.[2] Tourette’s syndrome is a neurological disorder consisting of chronic motor tics and involuntary vocalizations. Some of these vocalizations include coughing, grunting, and wheezing.[3] Vocal tics are characterized by sudden, involuntary movements or sounds, which can mimic a cough or a sneeze.[4] In this case report, we present the case of an 11-year-old boy who had a persistent cough that was unresponsive to the conventional physical treatment and was diagnosed with vocal tics. The patient was treated with risperidone, which led to a complete improvement in symptoms in 4 weeks. An 11-year-old boy was referred to our Psychiatric clinic by his Pediatrician due to a persistent cough that had been ongoing for three months. The boy had no developmental delay, no significant medical history and psychiatric comorbidities, no allergies, and no history of smoking exposure. No family history of tics disorders. The boy’s physical examination was unremarkable, with no evidence of respiratory distress, wheezing, or crackles. His chest X-ray was normal, total count, other infective profiles are in normal range, and pulmonary function testing showed normal results. No KF ring in the ophthalmic examination. The patient was treated with conventional physical treatment, including bronchodilators, corticosteroids, and antibiotics, but his cough persisted. Further history revealed that the boy had been experiencing sudden, involuntary movements that resembled a cough or a sneeze. These movements occurred several times a day and were not associated with any specific triggers and importantly not present during sleep. The patient and his family reported that these movements had started six months before the cough and had gradually increased in frequency. The patient also reported experiencing a sense of relief after the movements, which suggested that they might be tics. After a thorough evaluation, the patient was diagnosed with respiratory tics. The patient was started on risperidone, an atypical antipsychotic medication. The patient’s parents were counseled about the potential side effects of the medication, including sedation, weight gain, and extrapyramidal symptoms. The patient’s parents agreed to start the medication, and the patient was started on 1 mg of risperidone at bedtime, which was increased to 2 mg after one week. Follow-up evaluation showed that the patient’s cough had significantly improved after two weeks of treatment. The patient was able to attend school without any difficulty, and his parents reported that the sudden movements had decreased in frequency. The patient was continued on the same dose of risperidone for another two weeks. After four weeks of treatment, the patient’s cough had completely resolved, and the sudden movements had stopped. Vocal tics are a rare but well-described phenomenon in the literature. They are usually classified as a subtype of motor tics, which are sudden, repetitive, stereotyped movements or vocalizations that are not voluntarily suppressible. Vocal tics are characterized by sudden, involuntary movements or sounds that mimic coughing, sneezing, or clearing of the throat.[4] The prevalence of vocal tics in children is unknown, but it is estimated to be less than 1%. Vocal tics of persistent cough can be a challenging diagnosis to make, as they can mimic other respiratory disorders such as asthma, postnasal drip, and chronic obstructive pulmonary disease. The diagnosis is usually made based on the history of sudden, involuntary movements or sounds, which is not present during sleep and the absence of any underlying respiratory pathology. In this case, the patient’s normal physical examination, negative infective parameters, normal chest X-ray, and normal pulmonary function testing suggested that the cough was not due to any underlying respiratory pathology.[5] Antipsychotic medication is the first-line treatment for respiratory tics. Risperidone is the most used medication, and it has been shown to be effective in reducing the frequency and severity of tics. The mechanism of action of antipsychotic medication in respiratory tics is not well understood, but it is believed to be related to the modulation of dopamine receptors in the brain. The duration of treatment for vocal tics is variable and depends on the individual patient’s response to medication. In this case, the patient’s cough had completely resolved after four weeks of treatment. We made a diagnosis of transient tics disorder subsequently in which, the patient was able to discontinue the medication. However, some patients may require long-term treatment to maintain symptom control. Vocal tics are a rare but well-described phenomenon in the literature. They can be challenging to diagnose, as they can mimic other respiratory disorders. Antipsychotic medication is the first-line treatment for vocal tics, and risperidone is the most used medication. Clinicians should carefully monitor patients for the development of side effects associated with antipsychotic medication. The duration of treatment for vocal tics is variable and depends on the individual patient’s response to medication. This case highlights the importance of considering neuropsychiatric disorders in the differential diagnosis of persistent cough in children. Early recognition and appropriate treatment can lead to the complete resolution of symptoms and improve the quality of life for affected patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Is gender dysphoria a mental illness? The problem of overdiagnosis and medicalization in psychiatry ManikInder Singh Sethi, Sivabalan Elangovan Indian Journal of Psychiatry, 2021 Sir, This letter is in response to the case report of the 17-year-old boy from a lower socioeconomic background diagnosed with gender dysphoria (GD) which was published in your journal.[1] We would want to take this opportunity to highlight that it is important to understand that, sex and gender are not dichotomous categories but fall on a continuum. Hence, it is imperative that we know the difference between biological sex, gender identity, and gender presentation.[2] As in this case, the reader does not get a full picture about the subject's gender identity and gender presentation. If for the sake of argument, we presume that the subject who is biologically a male identifies as a female and was hence diagnosed with GD and then arises the issue of labeling the subject's sexual orientation as homosexual. In our opinion, if the subject identifies as a female and prefers a male sexual partner, then the orientation is heterosexual, because of his female gender presentation. The treatment modality would depend once we establish the cause of the subject's distress, i.e. if it is associated with not being comfortable with the assigned gender at birth or if it is due to their sexual orientation. There is robust evidence to prove that psychotherapy is the mainstay treatment in such cases.[3] Gender reassignment treatments may be required depending on the client's request. In line with minority stress theory, psychiatric morbidity in LGBTQ+ community is already high.[3] To diagnose gender incongruence as a mental disorder in a historically disadvantaged community further increases stigma, rather then helping them.[4] To be more inclusive in our practice, it is being advocated to routinely ask about the client's preferred pronouns or use gender neutral pronouns such as singular they/them and respected person.[2] The new transgender persons (Protection of Rights) Act, 2019, pave way to ease the process to self-identify their gender by a transexual, as upheld by a recent judgment by the Bombay Supreme court and has removed the role of physical screening by doctors.[5] As psychiatrists, we should be considerate about the sociocultural implications of shelving a person in one of the diagnostic categories. We need to be sensitive while applying the Diagnostic and Statistical Manual of Mental Disorders-5 diagnosis of GD to transexual persons, as not all transexual persons suffer from GD. The renaming of “transsexualism” to gender incongruence and re-classification from mental disorders to a separate chapter (chapter 17) called “conditions related to sexual health” in International Classification of Diseases (ICD) 11th Revision is a welcome step. This diagnosis is more appropriate as it uses the terms which have less psychopathological connotations, i.e., dislike or discomfort instead of distress.[4] Our hope is that in future, WHO takes the same route as homosexuality, demedicalize being transexual by completely removing it from ICD. To ensure medical service utilization and for administrative purposes, it can be added in the “Z” category of ICD. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
