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   Table of Contents - Current issue
January-June 2020
Volume 4 | Issue 1
Page Nos. 1-109

Online since Saturday, May 30, 2020

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The etiology behind pseudoseizures Highly accessed article p. 1
Neena S Sawant
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Nonsubstance or behavioral addictions: Neuropsychological underpinnings and psychosocial interventions Highly accessed article p. 5
Anuradha Sovani
This review article focuses on a number of behavioral addictions that involve the use of technology, rather than the use of substances or drugs of abuse. Much debate has evolved around the overuse of social media and the Internet, smartphones and screens of all sorts, addiction to pornography, online gaming, gambling, and even shopping. The article outlines neuropsychological studies which explain the brain basis of these addictions and focuses on psychosocial interventions which may provide relief to the addict. Dopamine and serotonin are seen to play a major role in addictive disorders, and dopaminergic mesolimbic pathway involved in gambling addiction is similar to those involved in substance-based addictions. Impulsive behaviors that are characteristic of gambling disorder can be due to changes in the fronto-striatal circuits. The ventral striatum is seen to drive behavior and the prefrontal components involving ventromedial prefrontal cortex fail to control inhibitions. Altered activity in the midbrain and striatum is also observed during the making of impulsive choices, which are often at the heart of behavioral addictions. Some studies show that individuals addicted to social networking sites and those showing screen dependence, behaviors that often involve value-based decisions, are seen to have smaller areas of striatum and amygdala. Impaired executive functioning and inhibitory control, both of which are typical to addiction, are connected to lower functional connectivity in fronto-striatal circuits. The article goes on to review psychosocial interventions that can be explored, including behavioral, cognitive behavioral, and sociocognitive models.
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Tardive dyskinesia: Prevention and newer management strategies Highly accessed article p. 10
Sreelakshmi Vaidyanathan, Suyog Vijay Jaiswal
Tardive dyskinesia (TD) is a condition where we have a limited understanding of the cause and of management. The delayed-onset movements can occur due to prolonged exposure to dopamine receptor-blocking agents (DRBAs). They can be physically disabling and lead to ridicule and stigmatization. TD also interferes with treatment adherence. The increased trend of prescriptions for off-label use of various DRBAs, especially antipsychotics, has increased the risk of TD. No currently available antipsychotic is free of the risk of TD, though the atypicals have a lower risk. The Abnormal Involuntary Movements Scale is the most widely used and recommended tool for the assessment and monitoring of TD. Varied treatment strategies have been tried including cessation of the DRBA, switch to a lower potency antipsychotic, and concomitant use of other medications such as clonazepam and Vitamin E. Most of these strategies have minimal evidence. The recent US Food and Drug Administration approval of two VMAT2 inhibitors, deutetrabenazine and valbenazine, for the treatment of TD has brought some relief to these patients. Cost may be a limiting factor in their use. Nonpharmacological treatment such as deep-brain stimulation, botulinum toxin, and electroconvulsive therapy is to be used only in intractable/incapacitating movements. Despite these newer options, the best strategy in the management of TD continues to be prevention. Judicious use of antipsychotics, regular monitoring of patients on DRBAs, and early diagnosis and intervention are strategies that significantly reduce the development of TD and improve the quality of life of patients.
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Profile of “Suspected Suicide Attempters” based on variations in intent Highly accessed article p. 20
Bharathi Gunjahalli, M Punith, SV Santosh
Background: Suicide and attempted suicide are on a rise in India. Suicide attempt is an area which is well researched. However, there is a dearth of studies that focus on any other/absence of suicidal intent in “suspected suicidal attempters” (SSA). The present study aimed at identifying the presence or absence of intent in SSA to gain insight into the preventive methods. Methods: This study was based on cross-sectional baseline data of an ongoing prospective study of suicide attempters undertaken in General Hospital Psychiatry Unit. Convenient sampling was done; data were collected using semi-structured pro forma. Consenting medically stable SSA referred for psychiatric evaluation were included, and grouped based on variations in intent. Using SPSS software version 20.0, descriptive and inferential statistics were done. Results: Two hundred and forty-two participants were included in the study. Majority of participants (73.55%) with suicide intent were impulsive and 15.29% were planned. About 11.16% of participants had no intent (accidental incidents). Participants in accidental group were significantly older and more often diagnosed with alcohol use disorder (AUD) than the other two groups. Significantly, more number of agriculturists attempted impulsively/accidentally. Planned attempters significantly had less social support, higher suicide intent, and were more depressed. Conclusions: A tetrad of rural background, agriculturist, poisoning with pesticides, and AUD was seen in accidental and impulsive attempters, a noteworthy finding requiring imposing restrictions on the availability of alcohol and pesticides to prevent such occurrences. Accidental incidents as a group need further research and classification for its clinical and legal impact.
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Depression and anxiety in patients with chronic liver disease and their relationship with quality of life Highly accessed article p. 28
Arka Banerjee, Amlan Kusum Jana, Samir Kumar Praharaj, Debabrata Mukherjee, Suddhendu Chakraborty
Background: Chronic liver disease (CLD) is a long-standing and debilitating condition where comorbid psychiatric conditions add on to the morbidity. The current study aims to observe how comorbid clinical anxiety and depression affects the overall picture. Aims: To observe how depression and anxiety influences the overall outcome of CLD patients. Settings and Design: It was a hospital-based cross-sectional study. Materials and Methods: Seventy-five consecutive CLD patients were assessed for depression and anxiety through the Hospital Anxiety and Depression Scale and for quality of life (QOL) through the abbreviated version of WHOQOL scale. Statistical Analysis: The data were analyzed using the Statistical Package for the Social Sciences 16.0 for Windows. Patients were grouped as with or without anxiety and depression. The groups were compared using Mann–Whitney U-test and Fisher's exact test for continuous and categorical variables, respectively. Results: Both anxious (P = 0.005) and depressed (P < 0.001) patients were significantly older than their nonanxious and nondepressed counterparts. Significantly higher proportion of patients with depression were married (P = 0.002) and employed (P = 0.014) than those without. Both the patients with anxiety and those with depression had significantly poorer QOL in all measurable domains than those without anxiety or depression. Conclusion: When clinically significant anxiety and depression are present as comorbidities in CLD patients, they significantly worsen the QOL in them.
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Stigma and discrimination in patients with schizophrenia and bipolar mood disorder p. 33
Kanika S Kumar, Ganpat K Vankar, Arvind D Goyal, Animesh S Sharma
Context: Stigma associated with mental illness is devastating and can be detrimental to recovery. Many people with serious mental illness are challenged with the symptoms and disabilities caused by the disease. In addition, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness. Aims: The aims were to study and compare stigma and discrimination in patients with schizophrenia and bipolar mood disorder. Settings and Design: This is a cross-sectional study of 100 patients selected by purposive random sampling from the psychiatry outpatient department of a tertiary care hospital. Materials and Methods: Fifty patients suffering from schizophrenia and fifty patients suffering from bipolar affective disorder (BPAD) according to the International Classification of Diseases 10 were interviewed. The Discrimination and Stigma Scale (DISC) 12 was used to assess stigma and discrimination of the patients. The DISC 12 asks participants about the experiences of discrimination in various areas of life including employment; mental health care; and interactions with friends, neighbors, and family. Statistical Analysis Used: Statistical analysis was done by using descriptive and inferential statistics using Chi-square test and Student's unpaired t-test. Results: Overall, patients of both schizophrenia and bipolar disorder suffer from stigma and discrimination of the same magnitude. Unfair treatment was similar in both the disorders, while overcoming stigma, stopping self, and positive treatment were significantly higher for patients suffering from schizophrenia as compared to BPAD. Conclusions: Irrespective of diagnosis, mental illnesses evoke stigma and discrimination which impact the lives of people with schizophrenia.
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Knowledge and attitudes toward schizophrenia among high school adolescents p. 40
Seema S Anis, Ganpat K Vankar, Khushboo R Kansal, Taskin N Jambusarwala, Vishal P Gor
Context: Poor awareness about schizophrenia and stigma toward people with schizophrenia is an important factor impacting early detection, support, and treatment. Aims: This study aims to assess the knowledge and attitude of adolescents in 9th to 12th classes in high schools toward people with schizophrenia. Settings and Design: The descriptive, cross-sectional study was conducted in 4 schools as part of a schizophrenia awareness program. Subjects and Methods: This was a descriptive, cross-sectional study to assess the knowledge and attitude of high school children toward schizophrenia. A self-report questionnaire was administered with sections containing case vignette-based knowledge and attitude toward schizophrenia. Statistical Analysis Used: Chi-square and “t”-test were done to find the association between demographic characteristics, knowledge level, and attitude. Results: Of 1540 students, about half of all respondents had average knowledge and only 10.5% students had a good knowledge score. Although knowledge level of boys and girls was similar, boys had more positive attitude toward people with schizophrenia as compared to girls. Good knowledge was associated with less distancing with person with schizophrenia. About 45% adolescents believed that people with schizophrenia are more prone to violence. Counseling and psychotherapy were endorsed as helpful compared to antipsychotic drugs and electroconvulsive therapy. Traditional healers were perceived as harmful. The adolescents were more ready to befriend the patient, meet him, and have him in the neighborhood but less ready to work with him or to get him married in the family in the future. Conclusions: There are important knowledge gaps in adolescents. Educational interventions should aim at correcting myths and especially emphasized effective treatment methods.
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WhatsApp use and its impact on relationships among doctors: A cross-sectional pilot study p. 48
Abhijeet D Faye, Sudhir H Bhave, Sushil Gawande, Rahul Tadke, Vivek C Kirpekar, Abhijit Pakhare, Deepika Singh
Background: Social media like WhatsApp is known to affect relationships of an individual, and busy professionals like doctors appear no bar. The objectives of this study were to analyze the pattern of WhatsApp use in specialist-doctors and to study its effect on their relationships. Materials and Methods: This was a cross-sectional pilot study. Consecutively selected hundred married specialist doctors were assessed using self-reported validated questionnaire including questions related to demographics, WhatsApp use, and effects on relationships in a tertiary care center. Statistical analysis was performed using mean, standard deviation, t-test, and Chi-square test. A value of P < 0.05 was considered statistically significant. Results: Participants of various specialties, with a mean age of 41.5 years reported regular WhatsApp-use (89%) of mean duration 2.5 years with 19% spending >2 h/day. About 62% reported using WhatsApp during personal time, leading to reduction in time spent with spouse (37%), impairment in household responsibilities (24%), disturbances in social-activities (26%) and craving. About 36% reported negative effects on married life. 21% reported inability to spend quality-time with spouse, 24% had concern about spouse's WhatsApp-use, 25% reported reduced cohesion between them and 22% felt that excessive use can create doubts in spouse's mind. Those aged <40 years had significantly higher total duration and time spent/day on WhatsApp and reported more conflicts with spouse and reduced expression of love. Conclusion: Inappropriate WhatsApp use can affect many aspects of life of doctors including relationships though exact causal relation is not demonstrated and it should be used judiciously.
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Frequency and characterization of depression in schizophrenia p. 56
Mridula Pradeep, Avudaiappan Sankaran
Context and Aims: The prevalence of depression in schizophrenia has been reported to be varying according to the stage of illness (early vs. chronic) and state (acute or postpsychotic). The presence of positive symptoms, extrapyramidal side effects, and insight have been said to predispose depression in a stable patient with schizophrenia. However, not many Indian studies have examined depression in patients with stable schizophrenic symptoms. Thus, we aimed to study the prevalence of depression and its correlates in a sample of stable patients with schizophrenia. Subjects and Methods: Eighty subjects of both genders, attending a tertiary care center, were consecutively taken up for the assessment. A semistructured pro forma was administered for all the subjects after getting informed consent. Positive and Negative Symptom Scale, Calgary Depression Scale for Schizophrenia (CDSS), Hamilton Depression (HAMD) Rating Scale, Extrapyramidal Symptom Rating Scale, Schedule for Assessment of Insight (SAI), and Global Assessment of Functioning Scale (GAF) were used to assess the patients. Results: In this study population, 34.5% had depressive symptoms. The study group had mild depression associated with schizophrenic psychopathology. The study populations did not have significant extrapyramidal symptoms during the assessment. The CDSS score and HAMD score had a significant positive correlation with SAI score. HAMD score had a negative correlation with GAF. Conclusions: This study demonstrates that patients with schizophrenia have significant depressive symptoms. These depressive symptoms appear to be independent of extrapyramidal symptoms and correlate positively to schizophrenic psychopathology. Poor insight may have led to low severity of reported depressive symptoms.
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Neurocognitive impairment in patients with bipolar disorder: Comparison between first episode and multiple episodes p. 63
Rashmin Achalia, Garimaa Achalia, Sudhir Chaudhary, Mahesh Chopade, Varsha Kaginalkar, Abhijit Sable, Arpitha Jacob, Ganesan Venkatasubramanian, Naren P Rao
Background: Several lines of evidence in the last few years have suggested the critical role of neurocognitive deficits in functional recovery of patients with bipolar disorder (BD). However, whether these deficits are static or progressive with the course of the illness is still debated. Surprisingly, the effect of multiple episodes on neurocognitive deficits in BD is rarely examined in first-episode Indian patients. Hence, in this study, we aimed to examine the difference between first episode mania and BD patients with multiple episodes. Methodology: Thirty patients with the Diagnostic and Statistical Manual of Mental Disorders-IV BD-I (13 with first-episode mania; 17 with multiple episodes) and 30 age- and sex-matched healthy volunteers (HV) were recruited in the study. Clinical severity was assessed using structured rating scales. All patients performed tests to measure executive functions, namely continuous performance test, Stroop color word interference test, and Wisconsin Card Sorting Test. Differences between groups were examined using the analysis of covariance with age and sex as covariates with Bonferroni post hoc analysis. Results: There was a significant difference between groups on the performance of all three tests with patients performing poorer than HV. While the HV differed from both first episode mania and BD with multiple episodes, there was no difference between the two patient subgroups. There was no significant correlation between clinical variables and scores on neurocognitive tests. Conclusions: The study findings, with respect to cognitive function, supports neurodevelopmental than neurodegenerative hypothesis. Findings indicate the need to assess cognitive functions in all patients with BD including first episode BD.
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Unraveling the net of self-esteem, stress, and coping skills in the era of internet addiction p. 70
Amey Y Angane, Kranti S Kadam, Geetanjali S Ghorpade, Vishnu B Unnithan
Introduction: Internet is one of the most popular forms of media, but heavy use may result in negative effects like decreased self-esteem. New and unexpected life changes in medical students cause increased perception of stress leading to internet addiction as a way of coping. The purpose of this study was to assess the prevalence of internet addiction in medical students, to assess the level of perceived stress and self-esteem in them, and to obtain the correlation between internet addiction with perceived stress as well as self-esteem. Various coping strategies implemented by students using internet were found. Methodology: A cross-sectional study with 200 students recruited by stratified random sample technique was undertaken. After taking informed consent, participants were assessed on Young's internet Addiction Test (YIAT-20), Rosenberg's Self-Esteem Scale, Cohen's Perceived Stress Scale-10, and Brief COPE Scale. Two groups were made using YIAT-20, those having internet addiction and those without, the two being compared. Results and Discussion: Mean age of medical students was 19.16 years (±1.45). Meantime of internet usage was 107.15 min (±67.99) per student per day. The prevalence of internet addiction was 18%. The group of students that had internet addiction showed high perceived stress (P = 0.001) and low self-esteem (P < 0.0001). Internet use had a positive correlation with perceived stress (r = 0.2866) and a negative correlation with self-esteem (r = −0.2918). Students with internet addiction used more emotion-based coping skills rather than task-oriented coping skills (P = 0.0032). Conclusions and Implications: Medical students having internet addiction were found to have higher levels of perceived stress, lower levels of self-esteem and predominantly emotion-based coping skills when compared to students having average internet use who have task-oriented coping skills.
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Sexual and physical abuse among patients with psychogenic nonepileptic seizures: A comparative study p. 76
Anand Thaman, Naina Sharma, Rajeev Gupta
Introduction: Psychogenic nonepileptic seizures (PNES) are the events with altered state of consciousness, sensations, perceptions, and involuntary motor activities which look similar to epilepsy but in the absence of any electrical discharges in the brain. The etiology of PNES is generally associated to psychosocial factors. Earlier traumatic life experiences, especially sexual abuses are considered as an important predisposing cause among PNES patients. Aims and Objectives: The aim of the current study was to survey various aspects of sexual and physical abuse in PNES patients and to compare it with epilepsy and healthy control group. Materials and Methods: Three groups (PNES, epilepsy, and healthy control) with 50 patients/participants in each were compared for the incidents of sexual and physical abuse. Semi-structured interview was conducted to explore the experiences of those patients/subjects who acknowledged about their traumas and consented to talk about it. Results: Incidents of sexual and physical abuse were found higher in the PNES group as compared to epilepsy and healthy controls. Other aspects of traumas such as nature, severity, frequency, psychological and physical consequences were found also comparable. Conclusion: PNES patients experienced more traumatic events which need to be explored for its therapeutic management.
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Risperidone-Induced sexual dysfunction reverted with aripiprazole: Experience from two cases p. 81
Shreyasee S Bhowmick, Vinodkumar M Darji, Nimesh C Parikh, Nilima D Shah
Antipsychotic agents are effective in schizophrenia by alleviating positive and negative symptoms, but also have the potential for inducing sexual dysfunction by causing hyperprolactinemia. This may have a negative impact on treatment compliance. Risperidone is associated with a high rate of sexual dysfunction compared to olanzapine, clozapine, quetiapine, and aripiprazole. However, the partial dopaminergic agonism of aripiprazole at D2receptor may explain why its use does not usually cause this side effect and may even revert it when added to another antipsychotic. We present here two cases of schizophrenia, who were treated with risperidone, and complained of sexual dysfunction during follow-up. After the addition of aripiprazole and reducing the dose of risperidone, this side effect reverted without a negative impact on treatment adherence or therapeutic efficacy.
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Schizophrenia with segawa syndrome: A therapeutic challenge p. 84
Disha Devang Parikh, Smita Nikhil Panse
Segawa syndrome is inherited dystonia characterized by gait disturbance and dystonia. The patients benefit from the treatment with levodopa. Although behavioral changes are known to be associated with this condition, there is limited literature on psychosis. Levodopa has been known to induce psychosis, while antipsychotics can exacerbate dystonia. Hence, a calculated approach is required for adequate management of both the conditions. This case report describes a 32-year-old male with dystonia for 20 years and psychotic symptoms for 16 years. He was on levodopa 250 mg BD for 5 years but was taking three times the prescribed dose for 3 years along with erratic antipsychotic treatment. He was successfully treated with levodopa 250 mg BD to control his dystonia symptoms and clozapine 200 mg for psychotic symptoms. Schizophrenia with Segawa syndrome is a rare presentation. The case was challenging owing to the complexity of presenting symptoms as well as the treatment.
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The brain sees what the eyes don't! visual hallucinations in a blind female suffering from schizophrenia p. 87
Niharika Tushar Shah, Amey Yeshwant Angane
While visual hallucinations are more common in organic disorders, they have also been reported in 27% of patients in schizophrenia with a more severe psychopathological profile and a less favorable prognosis. There is literature on visual hallucinations in psychiatric illnesses, eye diseases, and organic disorders individually, but visual hallucinations in a psychiatric disorder with an eye disease have not been reported. Here, we report a 55-year-old female who developed complete blindness and was diagnosed with retinitis pigmentosa and macular degeneration at 8 years which is a case of schizophrenia for the past 30 years and presented with visual hallucinations for the past 1 year. She was successfully treated with antipsychotic medications.
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Obsessive compulsive disorder with psychotic features as neuropsychiatric manifestation of fahr's disease p. 90
Ajinkya Sureshrao Ghogare, Shruti Rajendra Agrawal, Pradeep Shriram Patil, Ganpatlal Kodarbhai Vankar
Fahr's disease (FD) is a rare neurological disorder characterized by idiopathic bilateral basal ganglia calcification. It manifests as psychiatric, cognitive, and neurological manifestations. FD is distinct from Fahr's syndrome, in that the latter is having the symptoms generated by preexisting disease and abnormalities evident on blood investigations. In this case report, we present a case of FD presenting as obsessive compulsive disorder with psychotic features.
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Improving the mental health and wellbeing of the health-care workers and the community through collective actions: Corona virus disease 2019 pandemic p. 94
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
The Corona Virus Disease-2019 (COVID-19) pandemic is a public health emergency of international concern and has affected the health status of thousands of the people across the world. As the disease is transmitted between humans by close contact, steps have been taken by the nations to close educational institutions and workplaces to minimize the risk of disease transmission. At the same time, some of the nations have even imposed lockdown within their settings. However, such actions have disturbed the routine schedule of many people and at times compelled both elderly and young people into loneliness. Even the health professionals, who are fighting against the infection for improving the health of other individuals, have to deal with lots of mental stress and workload pressure leading to physical and mental exhaustion. In conclusion, in the global fight against the COVID-19 pandemic, it is essential to acknowledge our fears and apprehensions about the disease and not undermine it. However, the need of the hour is to understand these aspects and respond to them with the concerted assistance of individual, communities, health sector, and policy makers.
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Employing behavioral tool to define the response to corona virus disease-2019 pandemic in the European Region p. 96
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
The Corona Virus Disease-2019 (COVID-19) pandemic has impacted all the dimensions of health, routine welfare measures and livelihood of the general population worldwide. It is important to acknowledge that the containment of the outbreak cannot be effectively accomplished or sustained without the active support and engagement of the members of the community. Thus, it becomes extremely crucial to assess the behavioral change in the community, which will eventually determine the rate of transmission. In order to assess all these dimensions, a behavioral tool has been developed in the European region and it is anticipated that the obtained information can help the local and national stakeholders to coordinate their interventions and strategies for mounting a better public health response against the infection. In conclusion, in order to ensure that the public health response to COVID-19 pandemic are relevant and actionable, there is an indispensable need to understand the behavioral insights of the members of the community. This aspect of the disease containment is an important domain as our success will be eventually determined by the extent to which people are informed and willing to adhere to the interventions implemented by the Governments.
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Severe antidepressant discontinuation syndrome for fluoxetine p. 98
Harish Kulkarni, Shambhavi Kulkarni, Mahtav Saiyad
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Role of add on rTMS in management of insomnia p. 100
Sujita Kumar Kar, Asish Kumar, Apoorva Upadhyay
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Multiple adverse events of valproate in a patient with bipolar affective disorder p. 102
Mansoor C Abdulla
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Acute phenytoin toxicity: An overview p. 104
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
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Knowledge of yoga and its application in psychiatry p. 105
Manan Kirankumar Desai
Since ancient times, yoga has been conceived as plural in its composition, meanings, and practices with singularity in its objective to promote mind–body fitness. In contemporary times, hatha yoga (physical yoga) is getting further diversified into different styles. Deeper understanding of these forms of yoga reveals that certain components including ethical and moral principles, posture (asana), breathe regulation (pranayam), chanting particular sounds (mantra), introspection (pratyahar), contemplation (dharana), and meditation (dhyan) are common among these. First, yoga can induce harmony in mind–body functioning. Second, being experientially rooted, it can be adopted considerably with much ease in comparison to the existing psychological practices. Third, it has promising potential to address the mental health concerns of the people because training and taking the service of yoga is cost-effective. Fourth, it can also alleviate multiple physical, emotional, and social sufferings holistically. Gradually, demand for personalized, eclectic, and intuitive therapeutic approaches is on rise for psychiatric disorders and mental well-being.
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Book review: A natural history of rape: Biological bases of sexual coercion – Randy Thornhill and Craig T. Palmer p. 108
Hrishikesh Bipin Nachane
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