Published online: 2019-09-25

Letters to the Editor Beyond Bounds of Reality: Acute Stress Disorder Presenting with Delusional Misidentification Syndromes

Sir, became calm but harbored the delusions. Supportive Delusional misidentification syndrome (DMS) is characterized counseling sessions involving the patient and her husband by the consistent misidentification of persons, places, addressed the underlying conflicts resulting in significant or events with delusional conviction.[1] DMS encompasses reduction of anxiety. The Brown Assessment of Beliefs hypoidentification (Capgras) and hyperidentification Scale[6] was used to calibrate the rate of resolution of types (Fregoli syndrome, intermetamorphosis syndrome, and delusions (D1 and D2) [Figure 2]. Even as the psychotropics syndrome of subjective doubles).[2] DMS was observed in were stopped within a week, fortnightly follow‑up sessions various affective and psychotic illnesses.[2,3] We present the were continued for 3 months without any relapse of clinical scenario in which acute stress disorder manifested with symptoms. Written informed consent was obtained from the a combination of Capgras (D1) and Frégoli delusions (D2). patient and her husband. We also discuss their psychopathological evolution and their The patient had an abrupt onset of illogical and incorrigible response to psychosocial interventions. beliefs in response to acute stress. The ideas germinated Mrs. S, with no past or family history of psychiatric illness, independently and acquired delusional dimensions: was enduring a long‑standing marital conflict. When her conviction, pressure, extension, bizarreness, and deviant [7] husband sold their land for financial reasons, she strongly behavior. Their psychopathological origin concords protested. Her fracas with the buyer ended in the latter with the two‑factor theory of DMS: one inducing the suing her. The distraught husband demanded police action delusion and defining its content (imminent threat from and threatened of divorce. Both the events catalyzed the persecutor and her husband), the other which hinders intense anxiety resulting in psychomotor agitation and rejecting that belief (intense anxiety and a threat to [3] disturbed sleep. Soon, she claimed that her real husband was self‑existence). Neurobiological studies indicate a missing and that the land buyer had taken on her husband’s dysfunctional connectivity between the face‑processing appearance. She vouched that the bald head and an abrasion areas and temporal lobes in DMS which is reflected as visual [8] on the leg resembled the persecutor (D1). Hours later, she processing and memory deficits in the patient. Although perceived that her persecutor (land buyer) had camouflaged the antipsychotics could have influenced the response,

as her neighbors plotting to kill her (D2). Her beliefs were stress‑induced short‑lasting psychopathology resolving with unshakeable even with family’s counter‑arguments. Her psychosocial interventions along with a complete remission agitation and suicidal behaviors necessitated hospitalization. in the follow‑up pointed toward a diagnosis of “acute stress A detailed history ruled out any manic or depressive or reaction.” other psychotic symptoms. She displayed deficits in visual Our report will add to the existing literature that DMS can processing, memory, and attention according to the Montreal occur in neurotic disorders among various other psychiatric Cognitive Assessment test [Figure 1].[4] A Diagnostic and disorders. Cognizance of the association between “acute Statistical Manual of Mental Disorders‑5 diagnosis of stress disorders” and DMS will guide our assessment “Brief psychotic disorder” was entertained.[5] Her baseline and treatment strategies. Future research should ascertain blood biochemistry was unremarkable. Within 3 days of their diagnostic stability and devise appropriate treatment risperidone 2 mg/day and benzodiazepines, the patient guidelines.

Figure 2: The figure depicts the rate of resolution of delusion as corroborated by the Figure 1: Findings from Montreal Cognitive Assessment test. Each domain-wise scores in the Brown Assessment of Beliefs Scale. The blue line represents Capgras distribution of scores is depicted in the figure delusion and the orange line represents Fregoli delusion

S124 Journal of Neurosciences in Rural Practice ¦ Volume 7 ¦ Supplement 1 ¦ December 2016 Letters to the Editor

Financial support and sponsorship Manual of Mental Disorders, Fifth Edition. Arlington, VA, Nil. American Psychiatric Association, 2013. 6. Eisen JL, Phillips KA, Baer L, Beer DA, Atala KD, Rasmussen Conflicts of interest SA. The Brown Assessment of Beliefs Scale: Reliability and There are no conflicts of interest. validity. Am J Psychiatry 1998;155:102‑8. 7. Kendler KS, Glazer WM, Morgenstern H. Dimensions of Karthick Subramanian, Vikas Menon, Tess Maria Rajan delusional experience. Am J Psychiatry 1983;140:466‑9. Department of Psychiatry, Jawaharlal Institute of Postgraduate 8. Margariti MM, Kontaxakis VP. Approaching delusional Medical Education and Research, Puducherry, India misidentification syndromes as a disorder of the sense of uniqueness. Psychopathology 2006;39:261‑8. Address for correspondence: Dr. Karthick Subramanian, Department of Psychiatry, Jawaharlal Institute of Postgraduate This is an open access article distributed under the terms of the Creative Commons Medical Education and Research, Puducherry, India. Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, E‑mail: [email protected] and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. References Access this article online 1. Feinberg TE, Roane DM. Delusional misidentification. Psychiatr Quick Response Code: Clin North Am 2005;28:665‑83, 678‑9. Website: www.ruralneuropractice.com 2. Christodoulou GN, Margariti M, Kontaxakis VP, Christodoulou NG. The delusional misidentification syndromes: Strange, fascinating, and instructive. Curr Psychiatry Rep 2009;11:185‑9. DOI: 3. Coltheart M, Langdon R, McKay R. Schizophrenia and 10.4103/0976-3147.196453 monothematic delusions. Schizophr Bull 2007;33:642‑7. 4. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. How to cite this article: Subramanian K, Menon V, Rajan TM. Beyond J Am Geriatr Soc 2005;53:695‑9. bounds of reality: Acute stress disorder presenting with delusional 5. American Psychiatric Association: Diagnostic and Statistical misidentification syndromes. J Neurosci Rural Pract 2016;7:S124-5.

Does Lack of Resources within the Family Starting Point to Social Exclusion for Persons with Brain Cancer?

Sir, illness, behavioral problems, and social stigma associated with Medical and psychiatric social workers (MPSW) play a the illness. Adding to that, a lack of knowledge and family crucial role in multidisciplinary health‑care team and render resources, they did not ready to take the patient home. Thus, services in a health‑care setup in particular neurosurgical and left the patient alone in the hospital and departed to home. neuro‑oncology setup.[1] The MPSWs involve in psychosocial This dimension is important, yet over looked by Health Care need assessment, care plan, and implementation of psychosocial Professionals including MPSWs when rehabilitation is planned interventions for the needy, i.e., persons with medical illness for persons with chronic illness. and their family members. The psychosocial interventions The caregiver burden is highly found among caregivers and includes such as pre-admission counselling, psychotherapeutic family members in the palliative care.[2] The family resources interventions, behaviour modification, psycho-education, such as family acceptance, existing living environment, rendering help in social welfare benefits, rehabilitation services, family dynamics, knowledge on illness, caregiving roles and pre-discharge counselling, follow-up and referral services. responsibilities, crisis and behavior management, coping MPSWs also keenly involved in doing home visits in the abilities, supervision on drug adherence, day‑to‑day medical cases of abandoned and unknown cases to trace out the care, financial constraints, emergency medical care, social family members. The frequency of abandoned cases with support, caregiver supportive groups, respite care, ways of medical illness has been increasing. Recently, our MPSWs social stigma, and feasibility for arranging the employment team did a home visit of an abandoned person who has been facilities for the patient need to be assessed before rehabilitation suffering from brain cancer for the last 10 years. Armed with and reintegration at home. If found in adequate, the intensive the names and address that were given by the patient, the psychosocial need assessment needs to be done and provides MPSWs team was able to trace out the family residency and appropriate biopsychosocial interventions to the patient, family family members with the help of local volunteers and police members, and caregivers for the successful rehabilitation. personnel. MPSWs team found that the patient was abandoned In addition, connecting with local health‑care workers, and excluded from the family because of his chronic medical nongovernmental organizations, and palliative care teams

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