Thomas Issac | National Institute of Mental Health & Neuro Sciences (original) (raw)

Papers by Thomas Issac

Indian Journal of Psychological Medicine, Oct 1, 2015

others speak or gesturing what others gesture, extreme negativism or automatic obedience without ... more others speak or gesturing what others gesture, extreme negativism or automatic obedience without interpretation of the command, which is supposed to be due to inability to disobey commands. They may demonstrate waxy moldability of their body parts by others. They may maintain peculiar postures for prolonged periods of time as well as have features of purposeless stereotypies and mannerisms. Catatonia can complicate mental illness such as schizophrenia, bipolar disorders, depression, and posttraumatic syndromes. Medical causes known to be associated are autoimmune disorders, paraneoplastic syndromes, seizures, encephalitis, metabolic disorders, use of steroids, neuroleptics, phencyclidine, inhaled abuse substances and abrupt withdrawal of benzodiazepines. [3] Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V) separates catatonia from Schizophrenia resulting in diagnostic and therapeutic changes in the approach. [4] Catatonia is categorized as follows: Background: The term catatonia was first introduced in 1874 and several etiologies, both organic and psychiatric have been attributed to the clinical phenotype of catatonia. The interesting feature is their response to lorazepam irrespective of their etiology. Patients and Methods: Four patients admitted with verbal and motor unresponsiveness following febrile illness were evaluated for infective and metabolic causes. Those who qualified for catatonia as per Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria and Bush-Francis Catatonia Screening Instrument screening tool and rating scale were evaluated in detail and reported. Observations: Catatonia occurs in clusters, females are more affected than males. Electroencephalogram can be abnormal based on the precipitating symptom. Minor changes in serum total iron and transferrin saturation and nonspecific elevation of viral antibody titers are seen in some patients. Lorazepam challenge always gives the diagnosis. Result: All patients where females and had preceeding systemic or CNS infection. Three out of the Four patients where independent at the end of one month. Conclusion: Catatonia should be considered as a differential diagnosis in all children with verbal and motor unresponsiveness, which have no other explanation. Early initiation of treatment is very rewarding at least during short term follow-up.

Journal of Pediatric Neurosciences, 2015

Schwartz-Jampel syndrome is a very rare congenital myotonic syndrome with typical phenotypic and ... more Schwartz-Jampel syndrome is a very rare congenital myotonic syndrome with typical phenotypic and electrophysiological features. Diagnosis is made by awareness into the typical phenotypic characters.

Annals of Medical and Health Sciences Research, 2017

This is an open access article distributed under the terms of the Creative Commons Attribution-No... more This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Indian Journal of Psychological Medicine, Jul 1, 2015

immune complexes. Interaction between environmental factors and susceptibility genes is believed ... more immune complexes. Interaction between environmental factors and susceptibility genes is believed to result in destructive immune responses, which include activation of innate immunity in RNA protein self-antigens, DNA in immune complexes, lowered activation threshold for adaptive immunity, ineffective regulatory and inhibitory CD cells and reduced clearance of apoptotic cells and immune complexes. [1] There is excessive secretion of pro-inflammatory cytokines like interferons, tumor necrosis factor and interleukin10. [1,2] However, females are more vulnerable than the males, more so when exposed to oral contraceptives or when they are put on hormone replacement therapy as Estradiol binds to receptors on T and B cells and activates them. First episode of psychosis can occur at any age and it can be primarily psychiatric or secondary to other occult diseases. It is of great therapeutic relevance to be cautious about organic etiology as early diagnosis can help in early initiation of disease modifying treatments. To study patients who presented with first episode of psychosis and later turned out to be due to lupus erythematosus with varying periods of delay. Details of patients who were considered as treatment unresponsive psychosis and later turned out to be due to vasculitis were entered in excel sheet and analyzed. The details of patients including neuropsychological features, apparent soft signs which were initially ignored, lab data and signs during follow-up were tabulated and warning signs analysed. All our patients were highly intelligent young females and there were stressors in all of them. They presented with panic, followed by psychotic symptoms which was resistant to regular psychiatric treatment and therefore possibility of organicity explored. All of them had history of transient symptoms referable to other systems which were treated as such and patients did not volunteer the same unless questioned. During follow-up full-fledged features of SLE came up in all patients. When a young female with no past or family history of mental illness presents with psychotic features, unprovoked panic, and limbic symptoms always ask for minor or transient symptoms and signs referable to the other systems which might give valuable clues.

Annals of Indian Academy of Neurology, 2014

The clinical phenotype varies from new onset non-familial psychiatric syndrome to fatal neurologi... more The clinical phenotype varies from new onset non-familial psychiatric syndrome to fatal neurological conditions such as Creutzfeldt-Jakob disease (CJD) and Sub-Acute Sclerosing Panencephalitis (SSPE). A high degree of suspicion is essential as early diagnosis is highly rewarding with reference to the outcome. Clinical criteria for limbic encephalitis include; Age at onset >25 years, and at least one of the following; a) features suggestive of temporal lobe epilepsy. b) Short term memory loss c) exclusion of viral infections, tumors and infarcts. It is considered to be definite if clinical features are corroborated by evidence of the limbic brain inflammation or onco neuronal antibodies such as Hu, Ma2, Cv2, CRMPS, Amphiphysin or tumor detected anywhere else. It is considered as possible if the clinical criteria is satisfied and laboratory data not available. [1, 2] Limbic encephalopathy can result due to infective, autoimmune or cryptogenic causes. Infections may be herpetic or non-herpetic and autoimmune may be non-paraneoplastic or paraneoplastic. The antibodies commonly seen are directed against classic paraneoplastic intracellular antigens including Hu, Ma2, Cv2/CRMP5, Amphiphysin or cell membrane antigens such as voltage gated potassium channels (VGKC),

North American Journal of Medical Sciences, 2014

Background: Normal Percept with abnormal meaning (Agnosias) has been described from nineteenth ce... more Background: Normal Percept with abnormal meaning (Agnosias) has been described from nineteenth century onwards. Later literature became abundant with information on the spectrum of Prosopagnosias. However, selective diffi culty in identifying refl ected self images with relatively better cognitive functions leads to problems in differentiating it from non-organic psychosis. Aim: In the present study, we investigated patients with dementia who showed diffi culty in identifying refl ected self images while they were being tested for problems in gnosis with reference to identifi cation of refl ected objects, animals, relatives, and themselves and correlate with neuropsychological and radiological parameters. Patients and Methods: Five such patients were identifi ed and tested with a 45 cm × 45 cm mirror kept at 30-cm distance straight ahead of them. Results: Mirror image agnosia is seen in patients with moderate stage posterior dementias who showed neuropsychological and radiological evidence of right parietal dysfunction. Conclusion: Interpretation of refl ected self images perception in real time probably involves distinct data-linking circuits in the right parietal lobe, which may get disrupted early in the course of the disease.

Journal of Neurosciences in Rural Practice, Jul 31, 2020

Journal of geriatric mental health, 2016

Frontotemporal dementia (FTD) is a clinically and pathologically heterogeneous syndrome. It can b... more Frontotemporal dementia (FTD) is a clinically and pathologically heterogeneous syndrome. It can be classified into three clinical syndromes depending on the early and predominant symptoms: A behavioral variant FTD and two language variants namely, semantic dementia, and progressive nonfluent aphasia (PNFA) which are very rare and elude diagnosis. We report the case of an elderly homemaker who came to our institute with features of cognitive decline and behavioral problems with language deficits in the form of nonfluent speech, impaired vocabulary to three pairs of words, agrammatism, and impaired single sentence comprehension with corroborative magnetic resonance imaging findings. PNFA is a rare clinical variant of FTD and often underdiagnosed. It should be considered in elderly patients who apart from having cognitive decline, behavioral problems, and absent insight also develop limited vocabulary, especially using a set of nouns to express themselves. Speech therapy and behavioral therapy in the initial stages can be of utility.

Indian Journal of Psychological Medicine, 2016

INTRODUCTION Cortico basal degeneration (CBD) of the brain is a progressive neurodegenerative dis... more INTRODUCTION Cortico basal degeneration (CBD) of the brain is a progressive neurodegenerative disease and is a rare entity which encompasses both neurological and Psychiatric manifestations. It is reported in 5% of cases with Parkinsonism as well as has an incidence of 0.62-0.92 per 100,000 population per year and a prevalence of 4.9-7.3 per 100,000 population. [1] CBD is characterized clinically by features of Apraxia, Neglect, Cortical (parietal) sensory loss, asymmetrical myoclonic jerks, unusual symptoms like alien hand phenomena; insidious and progressive subcortical dementia, gait disturbances and parkinsonian features. [2] Due to its similarity with diseases like Frontotemporal dementia, Parkinson's disease dementia, Parkinson plus syndromes, Alzheimer's illness as well as vascular

Journal of Pediatric Neurosciences, 2015

Paroxysmal dystonias are a group of relatively benign hyperkinetic childhood movement disorders o... more Paroxysmal dystonias are a group of relatively benign hyperkinetic childhood movement disorders of varied etiology. Mitochondrial diseases are well known to produce persistent dystonias as sequelae, but paroxysmal exertion induced dystonia has been reported in only one case to the best of our knowledge. Two siblings born to consanguineous parents presented with early-onset exertion induced dystonia, which was unresponsive to diphenylhydantoin and carbamazepine. A trial with valproate in one of the siblings turned fatal within 24 h. Based on this clue, the second child was investigated and found to suffer from complex I deficiency with a paternally inherited dominant nuclear DNA mutation, which is responsive to the mitochondrial cocktail. Exertion induced dystonia can be a rare manifestation of complex I deficiency.

Annals of Indian Academy of Neurology, 2013

The diagnostic accuracy of the currently available tools carries poor sensitivity resulting in si... more The diagnostic accuracy of the currently available tools carries poor sensitivity resulting in significant delay in specific diagnosis of cortical dementias. Considering the properties of default mode networking of the brain it is highly probable that specific changes may be seen in frontotemporal dementias (FTDs) and Alzheimer's disease sufficiently early.

Sleep, May 1, 2023

Introduction: Sleep is known to be involved in cognitive processes, such as memory consolidation.... more Introduction: Sleep is known to be involved in cognitive processes, such as memory consolidation. Poor sleep is a potential risk factor for dementia. However, whether it is associated with decreased memory functions among dementia-free individuals is not well known. This study aims to investigate the effect of sleep quality on memory functions among middle and older-age adults from a rural Indian population. Methods: Participants were dementia-free, rural Indians (≥ 45 years) recruited as part of an ongoing, prospective, aging cohort study, namely Srinivaspura Aging, NeuroSenescence, and COGnition (SANSCOG) study. Cross-sectional (baseline) data on sleep quality was obtained using Pittsburgh Sleep Quality Index (PSQI). Memory functions (at baseline) were assessed using subtests, namely immediate recall, delayed recall, name-face association, semantic fluency, phonemic fluency, and semantic association, from a culturally validated computerized neurocognitive test battery. Clinical Dementia Rating (CDR) was used to classify subjects based on their cognitive status into cognitively healthy (CDR=0) and MCI (CDR=0.5). Linear regression models, unadjusted and adjusted with cognitive status, age, gender, and depression, were used for analysis. Results: In the unadjusted linear regression model 1, we found no association between sleep quality and the different subtests of memory. However, in model 2 (adjusting for cognitive status), sleep quality in persons with MCI was significantly associated with memory functions. Model 3 (model 2 + age) found that sleep quality in higher ages in MCI explained a significant variance in the association between sleep and subtests of memory function compared to cognitively healthy individuals. Model 4 (model 3 + gender) suggested that with increasing age, gender was significantly associated with sleep quality and memory among individuals with MCI compared to cognitively healthy individuals. Further, model 5 (model 4+ depression) found that depressed individuals with MCI showed a significant association between sleep quality and memory functions compared to those without depression. Conclusion: When adjusted for cognitive status, age, gender and depression, there was significant association of sleep quality and memory functions, pointing to the important role of sleep in memory functions among middle and older-aged individuals without dementia. Support (if any): SANSCOG study is funded through the Centre for Brain Research by Pratiksha Trust

Indian Journal of Psychological Medicine, Oct 1, 2014

knowledge of an object or stimulus in the presence of normal perception. Failure of this is Agnos... more knowledge of an object or stimulus in the presence of normal perception. Failure of this is Agnosia or disorder of recognition. [1] Various sensory organs convey semantic information by several modes. When a peacock is seen; its beauty is appreciated, its name is read, its shrill cry and its name heard, its silky feathers felt in concerned association areas, this polymodal information is associated and stored as lexicon in the ventral temporo-parieto-occipital region. According to Lissauer, Agnosia can be Apperceptive if the elementary information such as the size, shape, loudness, and texture are not converted into a unified image or Associative if the primary capacities are recognized but not synthesized into semantic information comparing it with previous experience. Therefore, the person can Background: Gnosis is a modality-specific ability to access semantic knowledge of an object or stimulus in the presence of normal perception. Failure of this is agnosia or disorder of recognition. It can be highly selective within a mode. self-images are different from others as none has seen one's own image except in reflection. Failure to recognize this image can be labeled as mirror image agnosia or Prosopagnosia for reflected self-image. Whereas mirror agnosia is a well-recognized situation where the person while looking at reflected images of other objects in the mirror he imagines that the objects are in fact inside the mirror and not outside. Material and Methods:: Five patients, four females, and one male presented with failure to recognize reflected self-image, resulting in patients conversing with the image as a friend, fighting because the person in mirror is wearing her nose stud, suspecting the reflected self-image to be an intruder; but did not have prosopagnosia for others faces, non living objects on self and also apraxias except dressing apraxia in one patient. This phenomena is new to our knowledge. Results: Mirror image agnosia is an unique phenomena which is seen in patients with parietal lobe atrophy without specificity to a category of dementing illness and seems to disappear as disease advances. Discussion: Reflected self-images probably have a specific neural substrate that gets affected very early in posterior dementias specially the ones which predominantly affect the right side. At that phase most patients are mistaken as suffering from psychiatric disorder as cognition is moderately preserved. As disease becomes more widespread this symptom becomes masked. A high degree of suspicion and proper assessment might help physicians to recognize the organic cause of the symptom so that early therapeutic interventions can be initiated. Further assessment of the symptom with FMRI and PET scan is likely to solve the mystery of how brain handles reflected self-images. Conclusion: A new observation involving failure to recognize reflected self-images is reported.

Annals of Indian Academy of Neurology, 2017

arthritis, lyme disease, tuberculosis and congenital small carpel tunnel, anomalous muscles, and ... more arthritis, lyme disease, tuberculosis and congenital small carpel tunnel, anomalous muscles, and persistent median artery. Harvesting practices in North India produce traction on the common peroneal nerve at the neck of the fibula as farmers kneel to reap the crop with the sickle. [2,3] Ulnar nerve entrapment in the cubital tunnel at the elbow is demonstrated in diamond workers in Mumbai and Gujarat. [4,5] Entrapment neuropathies account for 10-20% of surgical procedures in peripheral nerves. [6] The exact signs and symptoms depend on the nerve involved starting with irritative sensory features such as pain and paresthesia followed by numbness then wasting and weakness. The major mixed nerves also show features of reflex sympathetic dystrophy such as dry skin, cracked nails,

Indian Journal of Psychological Medicine, Sep 1, 2021

show the change in India's living arrangement structure. The proportion of elders living alone or... more show the change in India's living arrangement structure. The proportion of elders living alone or only with their spouses (thus independently of their children) increased from 9% to 10%. 6 According to the recent Longitudinal Ageing Study in India (LASI) wave-1 report, the prevalence of older adults living alone was 5.9%. 7 It was also interesting to find that only 14.4% are staying with spouses and children as per the LASI report. As per the United Nations' report in 2017, the proportion of older adults living alone is greater in Europe, Northern America, Australia, and New Zealand as compared to Asian, African, and South American countries. 8 Factors Contributing to Isolation The traditional Indian society had many protective factors such as joint family systems with children staying together with parents and supporting in their

Indian Journal of Psychological Medicine, Mar 1, 2016

Introduction: Vascular dementia is the second most common form of dementia and is potentially rev... more Introduction: Vascular dementia is the second most common form of dementia and is potentially reversible. Small vessel disease (SVD) closely mimics degenerative dementia in view of its sub-acute onset and progressive course. Therefore, unlike large vessel disease, Hachinski Ischemic scale score may not always reflect vascular cognitive decline resulting in diagnostic and therapeutic confusions. Therefore, there is a need for detailed neuropsychological assessment for various cognitive domains for early identification of vascular cognitive decline as it carries a very good long term prognosis for cognitive morbidity, unlike degenerative dementias. Patients and Methods: This prospective study involves thorough domain based neuropsychological assessment of patients with a radiological diagnosis of SVD involving the following parameters-digit forward and backward, category fluency, color trails, stick test, logical memory test, and bender gestalt test. Magnetic resonance imaging scans done using 3-tesla machines and SVD graded using Fazekas visual scale. Results: The mean Hachinskis score was less sensitive for differentiating vascular dementia from degenerative dementia. However, the domain based neuropsychological scores were highly sensitive showing statistically significant impairment in all 6 domains tested and compared with Fazekas 1-3 grades in imaging. Discussion and Conclusion: This study aimed at establishing an early diagnosis of vascular mild cognitive impairment using domain wise neuropsychological testing and correlating it with radiological scores. Hachinskis score is more sensitive for large vessel disease in view of acute onset and step-like progression as against steady progression in SVD. However, domain-wise testing was highly sensitive in identifying early cognitive impairment in patients with SVD, and early therapeutic interventions are highly rewarding.

Asian Journal of Psychiatry, Feb 1, 2020

Indian Journal of Psychological Medicine, Sep 1, 2016

Prion diseases are protein conformation disorders and neither caused by viroid or virus but is a ... more Prion diseases are protein conformation disorders and neither caused by viroid or virus but is a transmissible particle labeled a prion by Pruisner. Normal prion protein becomes infectious by a different folding, but the triggers are not known. Based on the characteristic brain pathology, they are grouped under spongiform encephalopathy affecting both man and animals. Estimated prevalence is one per million. Creutzfeldt-Jakob disease (CJD) registry from National Institute and Neurosciences (NIMHANS), Bengaluru, reported 69 cases in 30 years. Patients seen by our team from December 2011 to October 2015 who satisfied criteria for probable CJD were evaluated for clinical, electrophysiological, radiological, and demographic factors. None of them underwent histopathological examination of brain tissue or tonsils. Cerebrospinal fluid protein 14-3-3 was not done. All of them were followed up by telephonic inquiry for the course of the illness. All of them received symptomatic medications with anticonvulsants, flupirtine 200 mg orally daily, and other symptomatic medications. Sporadic CJD is the most common form seen in India and is probably under reported. males seem to be more affected, and the mean duration for the bed bound state is 12 months. Drugs were only effective for a very brief period in controlling myoclonus and behavior. Sporadic CJD is one of the most common and rapidly fatal forms of dementia in India. Cortical ribboning and periodic complexes are the most common laboratory findings. Familial CJD is a very rare occurrence and variant CJD is probably not prevalent. All patients with rapidly progressive dementia should be handled with biohazard precautions unless proved otherwise. Role of alcohol and smoking in the transformation of PrPc to PrPsc needs to be evaluated.

Journal of Pediatric Neurosciences, 2016

Epilepsy accounts for 1% of the global disease burden and about 8-10 million epilepsy patients li... more Epilepsy accounts for 1% of the global disease burden and about 8-10 million epilepsy patients live in India. About 30-40% of these patients become drug-resistant and land up with palliative or disease-modifying surgeries. This is a situation causing great concern in view of the psychosocial and economic burden on the patient and the family apart from severe cognitive and motor consequences, especially in children. Therefore, it is mandatory to have an insight into the wide spectrum of causes with reference to refractoriness to antiepileptic medications in children with epilepsy. Children admitted under our team with refractory epilepsy as per the International League Against Epilepsy (ILAE) criteria in the last 3 years were included in the study. Refractory epilepsy constituted 13.3% of inpatients in the pediatric group. Males dominated with 68.9% of these patients. Nearly 34.4% of these patients were found to suffer from various neurometabolic diseases. Almost 3.5% were due to pyridoxine-dependent convulsions. This group of patients showed an excellent response to dietary manipulation, disease-modifying treatment for the metabolic disorder, and supportive small-dose anticonvulsants. During follow-up, they showed very good response with reference to global development and seizure control. Pyridoxine-dependent convulsions are relatively rare forming about 3.5% of refractory epilepsies in this series. With initiation of appropriate therapy, results with reference to seizure control as well as neurodevelopment became evident within 2 weeks, and at 1-year follow-up, complete independence for majority of the needed activities is achieved with minimum cost, almost zero side effects, and absolute elimination of the need for palliative surgery.

Indian Journal of Psychological Medicine, Oct 1, 2015

others speak or gesturing what others gesture, extreme negativism or automatic obedience without ... more others speak or gesturing what others gesture, extreme negativism or automatic obedience without interpretation of the command, which is supposed to be due to inability to disobey commands. They may demonstrate waxy moldability of their body parts by others. They may maintain peculiar postures for prolonged periods of time as well as have features of purposeless stereotypies and mannerisms. Catatonia can complicate mental illness such as schizophrenia, bipolar disorders, depression, and posttraumatic syndromes. Medical causes known to be associated are autoimmune disorders, paraneoplastic syndromes, seizures, encephalitis, metabolic disorders, use of steroids, neuroleptics, phencyclidine, inhaled abuse substances and abrupt withdrawal of benzodiazepines. [3] Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V) separates catatonia from Schizophrenia resulting in diagnostic and therapeutic changes in the approach. [4] Catatonia is categorized as follows: Background: The term catatonia was first introduced in 1874 and several etiologies, both organic and psychiatric have been attributed to the clinical phenotype of catatonia. The interesting feature is their response to lorazepam irrespective of their etiology. Patients and Methods: Four patients admitted with verbal and motor unresponsiveness following febrile illness were evaluated for infective and metabolic causes. Those who qualified for catatonia as per Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria and Bush-Francis Catatonia Screening Instrument screening tool and rating scale were evaluated in detail and reported. Observations: Catatonia occurs in clusters, females are more affected than males. Electroencephalogram can be abnormal based on the precipitating symptom. Minor changes in serum total iron and transferrin saturation and nonspecific elevation of viral antibody titers are seen in some patients. Lorazepam challenge always gives the diagnosis. Result: All patients where females and had preceeding systemic or CNS infection. Three out of the Four patients where independent at the end of one month. Conclusion: Catatonia should be considered as a differential diagnosis in all children with verbal and motor unresponsiveness, which have no other explanation. Early initiation of treatment is very rewarding at least during short term follow-up.

Journal of Pediatric Neurosciences, 2015

Schwartz-Jampel syndrome is a very rare congenital myotonic syndrome with typical phenotypic and ... more Schwartz-Jampel syndrome is a very rare congenital myotonic syndrome with typical phenotypic and electrophysiological features. Diagnosis is made by awareness into the typical phenotypic characters.

Annals of Medical and Health Sciences Research, 2017

This is an open access article distributed under the terms of the Creative Commons Attribution-No... more This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

Indian Journal of Psychological Medicine, Jul 1, 2015

immune complexes. Interaction between environmental factors and susceptibility genes is believed ... more immune complexes. Interaction between environmental factors and susceptibility genes is believed to result in destructive immune responses, which include activation of innate immunity in RNA protein self-antigens, DNA in immune complexes, lowered activation threshold for adaptive immunity, ineffective regulatory and inhibitory CD cells and reduced clearance of apoptotic cells and immune complexes. [1] There is excessive secretion of pro-inflammatory cytokines like interferons, tumor necrosis factor and interleukin10. [1,2] However, females are more vulnerable than the males, more so when exposed to oral contraceptives or when they are put on hormone replacement therapy as Estradiol binds to receptors on T and B cells and activates them. First episode of psychosis can occur at any age and it can be primarily psychiatric or secondary to other occult diseases. It is of great therapeutic relevance to be cautious about organic etiology as early diagnosis can help in early initiation of disease modifying treatments. To study patients who presented with first episode of psychosis and later turned out to be due to lupus erythematosus with varying periods of delay. Details of patients who were considered as treatment unresponsive psychosis and later turned out to be due to vasculitis were entered in excel sheet and analyzed. The details of patients including neuropsychological features, apparent soft signs which were initially ignored, lab data and signs during follow-up were tabulated and warning signs analysed. All our patients were highly intelligent young females and there were stressors in all of them. They presented with panic, followed by psychotic symptoms which was resistant to regular psychiatric treatment and therefore possibility of organicity explored. All of them had history of transient symptoms referable to other systems which were treated as such and patients did not volunteer the same unless questioned. During follow-up full-fledged features of SLE came up in all patients. When a young female with no past or family history of mental illness presents with psychotic features, unprovoked panic, and limbic symptoms always ask for minor or transient symptoms and signs referable to the other systems which might give valuable clues.

Annals of Indian Academy of Neurology, 2014

The clinical phenotype varies from new onset non-familial psychiatric syndrome to fatal neurologi... more The clinical phenotype varies from new onset non-familial psychiatric syndrome to fatal neurological conditions such as Creutzfeldt-Jakob disease (CJD) and Sub-Acute Sclerosing Panencephalitis (SSPE). A high degree of suspicion is essential as early diagnosis is highly rewarding with reference to the outcome. Clinical criteria for limbic encephalitis include; Age at onset >25 years, and at least one of the following; a) features suggestive of temporal lobe epilepsy. b) Short term memory loss c) exclusion of viral infections, tumors and infarcts. It is considered to be definite if clinical features are corroborated by evidence of the limbic brain inflammation or onco neuronal antibodies such as Hu, Ma2, Cv2, CRMPS, Amphiphysin or tumor detected anywhere else. It is considered as possible if the clinical criteria is satisfied and laboratory data not available. [1, 2] Limbic encephalopathy can result due to infective, autoimmune or cryptogenic causes. Infections may be herpetic or non-herpetic and autoimmune may be non-paraneoplastic or paraneoplastic. The antibodies commonly seen are directed against classic paraneoplastic intracellular antigens including Hu, Ma2, Cv2/CRMP5, Amphiphysin or cell membrane antigens such as voltage gated potassium channels (VGKC),

North American Journal of Medical Sciences, 2014

Background: Normal Percept with abnormal meaning (Agnosias) has been described from nineteenth ce... more Background: Normal Percept with abnormal meaning (Agnosias) has been described from nineteenth century onwards. Later literature became abundant with information on the spectrum of Prosopagnosias. However, selective diffi culty in identifying refl ected self images with relatively better cognitive functions leads to problems in differentiating it from non-organic psychosis. Aim: In the present study, we investigated patients with dementia who showed diffi culty in identifying refl ected self images while they were being tested for problems in gnosis with reference to identifi cation of refl ected objects, animals, relatives, and themselves and correlate with neuropsychological and radiological parameters. Patients and Methods: Five such patients were identifi ed and tested with a 45 cm × 45 cm mirror kept at 30-cm distance straight ahead of them. Results: Mirror image agnosia is seen in patients with moderate stage posterior dementias who showed neuropsychological and radiological evidence of right parietal dysfunction. Conclusion: Interpretation of refl ected self images perception in real time probably involves distinct data-linking circuits in the right parietal lobe, which may get disrupted early in the course of the disease.

Journal of Neurosciences in Rural Practice, Jul 31, 2020

Journal of geriatric mental health, 2016

Frontotemporal dementia (FTD) is a clinically and pathologically heterogeneous syndrome. It can b... more Frontotemporal dementia (FTD) is a clinically and pathologically heterogeneous syndrome. It can be classified into three clinical syndromes depending on the early and predominant symptoms: A behavioral variant FTD and two language variants namely, semantic dementia, and progressive nonfluent aphasia (PNFA) which are very rare and elude diagnosis. We report the case of an elderly homemaker who came to our institute with features of cognitive decline and behavioral problems with language deficits in the form of nonfluent speech, impaired vocabulary to three pairs of words, agrammatism, and impaired single sentence comprehension with corroborative magnetic resonance imaging findings. PNFA is a rare clinical variant of FTD and often underdiagnosed. It should be considered in elderly patients who apart from having cognitive decline, behavioral problems, and absent insight also develop limited vocabulary, especially using a set of nouns to express themselves. Speech therapy and behavioral therapy in the initial stages can be of utility.

Indian Journal of Psychological Medicine, 2016

INTRODUCTION Cortico basal degeneration (CBD) of the brain is a progressive neurodegenerative dis... more INTRODUCTION Cortico basal degeneration (CBD) of the brain is a progressive neurodegenerative disease and is a rare entity which encompasses both neurological and Psychiatric manifestations. It is reported in 5% of cases with Parkinsonism as well as has an incidence of 0.62-0.92 per 100,000 population per year and a prevalence of 4.9-7.3 per 100,000 population. [1] CBD is characterized clinically by features of Apraxia, Neglect, Cortical (parietal) sensory loss, asymmetrical myoclonic jerks, unusual symptoms like alien hand phenomena; insidious and progressive subcortical dementia, gait disturbances and parkinsonian features. [2] Due to its similarity with diseases like Frontotemporal dementia, Parkinson's disease dementia, Parkinson plus syndromes, Alzheimer's illness as well as vascular

Journal of Pediatric Neurosciences, 2015

Paroxysmal dystonias are a group of relatively benign hyperkinetic childhood movement disorders o... more Paroxysmal dystonias are a group of relatively benign hyperkinetic childhood movement disorders of varied etiology. Mitochondrial diseases are well known to produce persistent dystonias as sequelae, but paroxysmal exertion induced dystonia has been reported in only one case to the best of our knowledge. Two siblings born to consanguineous parents presented with early-onset exertion induced dystonia, which was unresponsive to diphenylhydantoin and carbamazepine. A trial with valproate in one of the siblings turned fatal within 24 h. Based on this clue, the second child was investigated and found to suffer from complex I deficiency with a paternally inherited dominant nuclear DNA mutation, which is responsive to the mitochondrial cocktail. Exertion induced dystonia can be a rare manifestation of complex I deficiency.

Annals of Indian Academy of Neurology, 2013

The diagnostic accuracy of the currently available tools carries poor sensitivity resulting in si... more The diagnostic accuracy of the currently available tools carries poor sensitivity resulting in significant delay in specific diagnosis of cortical dementias. Considering the properties of default mode networking of the brain it is highly probable that specific changes may be seen in frontotemporal dementias (FTDs) and Alzheimer's disease sufficiently early.

Sleep, May 1, 2023

Introduction: Sleep is known to be involved in cognitive processes, such as memory consolidation.... more Introduction: Sleep is known to be involved in cognitive processes, such as memory consolidation. Poor sleep is a potential risk factor for dementia. However, whether it is associated with decreased memory functions among dementia-free individuals is not well known. This study aims to investigate the effect of sleep quality on memory functions among middle and older-age adults from a rural Indian population. Methods: Participants were dementia-free, rural Indians (≥ 45 years) recruited as part of an ongoing, prospective, aging cohort study, namely Srinivaspura Aging, NeuroSenescence, and COGnition (SANSCOG) study. Cross-sectional (baseline) data on sleep quality was obtained using Pittsburgh Sleep Quality Index (PSQI). Memory functions (at baseline) were assessed using subtests, namely immediate recall, delayed recall, name-face association, semantic fluency, phonemic fluency, and semantic association, from a culturally validated computerized neurocognitive test battery. Clinical Dementia Rating (CDR) was used to classify subjects based on their cognitive status into cognitively healthy (CDR=0) and MCI (CDR=0.5). Linear regression models, unadjusted and adjusted with cognitive status, age, gender, and depression, were used for analysis. Results: In the unadjusted linear regression model 1, we found no association between sleep quality and the different subtests of memory. However, in model 2 (adjusting for cognitive status), sleep quality in persons with MCI was significantly associated with memory functions. Model 3 (model 2 + age) found that sleep quality in higher ages in MCI explained a significant variance in the association between sleep and subtests of memory function compared to cognitively healthy individuals. Model 4 (model 3 + gender) suggested that with increasing age, gender was significantly associated with sleep quality and memory among individuals with MCI compared to cognitively healthy individuals. Further, model 5 (model 4+ depression) found that depressed individuals with MCI showed a significant association between sleep quality and memory functions compared to those without depression. Conclusion: When adjusted for cognitive status, age, gender and depression, there was significant association of sleep quality and memory functions, pointing to the important role of sleep in memory functions among middle and older-aged individuals without dementia. Support (if any): SANSCOG study is funded through the Centre for Brain Research by Pratiksha Trust

Indian Journal of Psychological Medicine, Oct 1, 2014

knowledge of an object or stimulus in the presence of normal perception. Failure of this is Agnos... more knowledge of an object or stimulus in the presence of normal perception. Failure of this is Agnosia or disorder of recognition. [1] Various sensory organs convey semantic information by several modes. When a peacock is seen; its beauty is appreciated, its name is read, its shrill cry and its name heard, its silky feathers felt in concerned association areas, this polymodal information is associated and stored as lexicon in the ventral temporo-parieto-occipital region. According to Lissauer, Agnosia can be Apperceptive if the elementary information such as the size, shape, loudness, and texture are not converted into a unified image or Associative if the primary capacities are recognized but not synthesized into semantic information comparing it with previous experience. Therefore, the person can Background: Gnosis is a modality-specific ability to access semantic knowledge of an object or stimulus in the presence of normal perception. Failure of this is agnosia or disorder of recognition. It can be highly selective within a mode. self-images are different from others as none has seen one's own image except in reflection. Failure to recognize this image can be labeled as mirror image agnosia or Prosopagnosia for reflected self-image. Whereas mirror agnosia is a well-recognized situation where the person while looking at reflected images of other objects in the mirror he imagines that the objects are in fact inside the mirror and not outside. Material and Methods:: Five patients, four females, and one male presented with failure to recognize reflected self-image, resulting in patients conversing with the image as a friend, fighting because the person in mirror is wearing her nose stud, suspecting the reflected self-image to be an intruder; but did not have prosopagnosia for others faces, non living objects on self and also apraxias except dressing apraxia in one patient. This phenomena is new to our knowledge. Results: Mirror image agnosia is an unique phenomena which is seen in patients with parietal lobe atrophy without specificity to a category of dementing illness and seems to disappear as disease advances. Discussion: Reflected self-images probably have a specific neural substrate that gets affected very early in posterior dementias specially the ones which predominantly affect the right side. At that phase most patients are mistaken as suffering from psychiatric disorder as cognition is moderately preserved. As disease becomes more widespread this symptom becomes masked. A high degree of suspicion and proper assessment might help physicians to recognize the organic cause of the symptom so that early therapeutic interventions can be initiated. Further assessment of the symptom with FMRI and PET scan is likely to solve the mystery of how brain handles reflected self-images. Conclusion: A new observation involving failure to recognize reflected self-images is reported.

Annals of Indian Academy of Neurology, 2017

arthritis, lyme disease, tuberculosis and congenital small carpel tunnel, anomalous muscles, and ... more arthritis, lyme disease, tuberculosis and congenital small carpel tunnel, anomalous muscles, and persistent median artery. Harvesting practices in North India produce traction on the common peroneal nerve at the neck of the fibula as farmers kneel to reap the crop with the sickle. [2,3] Ulnar nerve entrapment in the cubital tunnel at the elbow is demonstrated in diamond workers in Mumbai and Gujarat. [4,5] Entrapment neuropathies account for 10-20% of surgical procedures in peripheral nerves. [6] The exact signs and symptoms depend on the nerve involved starting with irritative sensory features such as pain and paresthesia followed by numbness then wasting and weakness. The major mixed nerves also show features of reflex sympathetic dystrophy such as dry skin, cracked nails,

Indian Journal of Psychological Medicine, Sep 1, 2021

show the change in India's living arrangement structure. The proportion of elders living alone or... more show the change in India's living arrangement structure. The proportion of elders living alone or only with their spouses (thus independently of their children) increased from 9% to 10%. 6 According to the recent Longitudinal Ageing Study in India (LASI) wave-1 report, the prevalence of older adults living alone was 5.9%. 7 It was also interesting to find that only 14.4% are staying with spouses and children as per the LASI report. As per the United Nations' report in 2017, the proportion of older adults living alone is greater in Europe, Northern America, Australia, and New Zealand as compared to Asian, African, and South American countries. 8 Factors Contributing to Isolation The traditional Indian society had many protective factors such as joint family systems with children staying together with parents and supporting in their

Indian Journal of Psychological Medicine, Mar 1, 2016

Introduction: Vascular dementia is the second most common form of dementia and is potentially rev... more Introduction: Vascular dementia is the second most common form of dementia and is potentially reversible. Small vessel disease (SVD) closely mimics degenerative dementia in view of its sub-acute onset and progressive course. Therefore, unlike large vessel disease, Hachinski Ischemic scale score may not always reflect vascular cognitive decline resulting in diagnostic and therapeutic confusions. Therefore, there is a need for detailed neuropsychological assessment for various cognitive domains for early identification of vascular cognitive decline as it carries a very good long term prognosis for cognitive morbidity, unlike degenerative dementias. Patients and Methods: This prospective study involves thorough domain based neuropsychological assessment of patients with a radiological diagnosis of SVD involving the following parameters-digit forward and backward, category fluency, color trails, stick test, logical memory test, and bender gestalt test. Magnetic resonance imaging scans done using 3-tesla machines and SVD graded using Fazekas visual scale. Results: The mean Hachinskis score was less sensitive for differentiating vascular dementia from degenerative dementia. However, the domain based neuropsychological scores were highly sensitive showing statistically significant impairment in all 6 domains tested and compared with Fazekas 1-3 grades in imaging. Discussion and Conclusion: This study aimed at establishing an early diagnosis of vascular mild cognitive impairment using domain wise neuropsychological testing and correlating it with radiological scores. Hachinskis score is more sensitive for large vessel disease in view of acute onset and step-like progression as against steady progression in SVD. However, domain-wise testing was highly sensitive in identifying early cognitive impairment in patients with SVD, and early therapeutic interventions are highly rewarding.

Asian Journal of Psychiatry, Feb 1, 2020

Indian Journal of Psychological Medicine, Sep 1, 2016

Prion diseases are protein conformation disorders and neither caused by viroid or virus but is a ... more Prion diseases are protein conformation disorders and neither caused by viroid or virus but is a transmissible particle labeled a prion by Pruisner. Normal prion protein becomes infectious by a different folding, but the triggers are not known. Based on the characteristic brain pathology, they are grouped under spongiform encephalopathy affecting both man and animals. Estimated prevalence is one per million. Creutzfeldt-Jakob disease (CJD) registry from National Institute and Neurosciences (NIMHANS), Bengaluru, reported 69 cases in 30 years. Patients seen by our team from December 2011 to October 2015 who satisfied criteria for probable CJD were evaluated for clinical, electrophysiological, radiological, and demographic factors. None of them underwent histopathological examination of brain tissue or tonsils. Cerebrospinal fluid protein 14-3-3 was not done. All of them were followed up by telephonic inquiry for the course of the illness. All of them received symptomatic medications with anticonvulsants, flupirtine 200 mg orally daily, and other symptomatic medications. Sporadic CJD is the most common form seen in India and is probably under reported. males seem to be more affected, and the mean duration for the bed bound state is 12 months. Drugs were only effective for a very brief period in controlling myoclonus and behavior. Sporadic CJD is one of the most common and rapidly fatal forms of dementia in India. Cortical ribboning and periodic complexes are the most common laboratory findings. Familial CJD is a very rare occurrence and variant CJD is probably not prevalent. All patients with rapidly progressive dementia should be handled with biohazard precautions unless proved otherwise. Role of alcohol and smoking in the transformation of PrPc to PrPsc needs to be evaluated.

Journal of Pediatric Neurosciences, 2016

Epilepsy accounts for 1% of the global disease burden and about 8-10 million epilepsy patients li... more Epilepsy accounts for 1% of the global disease burden and about 8-10 million epilepsy patients live in India. About 30-40% of these patients become drug-resistant and land up with palliative or disease-modifying surgeries. This is a situation causing great concern in view of the psychosocial and economic burden on the patient and the family apart from severe cognitive and motor consequences, especially in children. Therefore, it is mandatory to have an insight into the wide spectrum of causes with reference to refractoriness to antiepileptic medications in children with epilepsy. Children admitted under our team with refractory epilepsy as per the International League Against Epilepsy (ILAE) criteria in the last 3 years were included in the study. Refractory epilepsy constituted 13.3% of inpatients in the pediatric group. Males dominated with 68.9% of these patients. Nearly 34.4% of these patients were found to suffer from various neurometabolic diseases. Almost 3.5% were due to pyridoxine-dependent convulsions. This group of patients showed an excellent response to dietary manipulation, disease-modifying treatment for the metabolic disorder, and supportive small-dose anticonvulsants. During follow-up, they showed very good response with reference to global development and seizure control. Pyridoxine-dependent convulsions are relatively rare forming about 3.5% of refractory epilepsies in this series. With initiation of appropriate therapy, results with reference to seizure control as well as neurodevelopment became evident within 2 weeks, and at 1-year follow-up, complete independence for majority of the needed activities is achieved with minimum cost, almost zero side effects, and absolute elimination of the need for palliative surgery.