WHAT IS DELUSION ?

Quoting the definition – “It is a false belief brought about without appropriate external stimulation and inconsistent with the individual’s own knowledge and experience”. In simple term, delusional patient see things in places where normal people don’t. It’s all in his head & is unreal.

Among many type of delusions yet discovered by the medical science is one of the rare kind, known with the name of Capgra’s Delusion.

CAPGRA’S DELUSION

Capgra’s Delusion is a rare kind of delusional disorder in which the patient seems to be perfectly normal physically and mentally but he is delusional about the people and things around him for being just an impostor of who or what they really are.

An example: He sees his mother and is assured that the lady in front of him looks exactly like his mother but refuses to accept her as his real mother and claims her being just an imposter of his mother, pretending to be his mother.

Its not just the loved ones they get delusional about. They often tend to “impostorify“:

• The house they have been living in
• Other inanimate objects like chair, book, lamp, etc.
• Their pet
• And amazingly, sometimes even their real self.

A short cartoon about the illness:

AN EXPLANATION THEORY FOR CAPGRA’S DELUSION

According to the theory of visual-emotional disconnection:

When we look at the object or some faces, the message reaches the visual centre of the brain via visual pathway then it gets relayed to amygdala which is the gateway to the limbic system containing the emotional centre of the brain. So, when those objects or faces are familiar to us, an emotional response is shown or even other emotional response like fear is reflexively shown by us when we see a lion. But, in the patient with Capgra’s delusion, the message reaches upto the visual cortex in the brain so he recognizes the person in front of him being his mother evoking the previous memories, but the fibers that help relaying information from the visual cortex to amygdala is damaged as a result of any head injuries or accidents causing no emotional response towards the person or object in front of him due to which he thinks the object or person to be an impostor as he doesn’t feel any emotional attachment with them. Owing to an intact connection between the hearing cortex and the amygdala, the delusion doesn’t occur when talking to a person in phone.

COMMONLY ASSOCIATED WITH CAPGRA’S DELUSION ARE

• Schizophrenia
• Head injury
• Epilepsy
• Alzheimer’s disease

Causes

Mental retardation affects about 1 – 3% of the population. There are many causes of mental retardation, but specific reason can only be found in only 25% of cases. Causes of mental retardation can be roughly categorized as:

A) Infections (present at birth or occurring after birth)

1. Congenital CMV
2. Congenital rubella
3. Congenital toxoplasmosis
4. Encephalitis
5. HIV infection
6. Listeriosis
7. Meningitis

B) Chromosomal abnormalities

1. Chromosome deletions
2. Chromosomal translocations
3. Defects in the chromosome or chromosomal inheritance (Eg- fragile X syndrome, Angelman syndrome, Prader-Willi syndrome)
4. Errors of chromosome numbers (such as Down syndrome)

C) Genetic abnormalities and inherited metabolic disorders

1. Adrenoleukodystrophy
2. Galactosemia
3. Hunter syndrome
4. Hurler syndrome
5. Lesch-Nyhan syndrome
6. Phenylketonuria
7. Rett syndrome
8. Sanfilippo syndrome
9. Tay-Sachs disease
10. Tuberous sclerosis

D) Metabolic

1. Congenital hypothyroid
2. Hypoglycemia (poorly regulated diabetes)
3. Reye syndrome
4. Hyperbilirubinemia (very high bilirubin levels in babies)

E) Nutritional

1. Malnutrition

F) Toxic

1. Intrauterine exposure to alcohol, cocaine, amphetamines, and other drugs
2. Lead poisoning
3. Methylmercury poisoning

G) Trauma (before and after birth)

1. Intracranial hemorrhage before or after birth
2. Lack of oxygen to the brain before, during, or after birth
3. Severe head injury

H) Unexplained

Symptoms

A family may suspect mental retardation if the child’s motor skills, language skills, cognitive and social skills do not seem to be developing, or are developing at a far slower rate than the expected. The degree of impairment from mental retardation varies widely, from profoundly impaired to mild or borderline retardation. Failure to adapt normally and grow intellectually may become apparent early in a child’s life. In the case of mild retardation, these failures may not become recognizable until school age or later.

1. Language delay: One of the first signs may be language delays, including expressive language (speech) and receptive language (understanding). Danger sign include no mama/dada/babbling by 12 months, no 2-word phrases by age 2, and parents reporting they are concerned that the child may be deaf.
2. Fine motor/adaptive delay: Significant delays in activities such as self-feeding, toileting, and dressing.
3. Gross motor: Subtle delays in gross motor acquisition, or clumsiness.
4. Cognitive delay: Difficulties with memory, problem-solving and logical reasoning.
5. Social delays: Lack of interest in age-appropriate toys and delays in imaginative play and reciprocal play with age-matched peers.

Family history: It is recommend that the evaluation of a child with MR should include an extensive family history, with particular attention to family members with mental retardation, developmental delays, consanguinity, psychiatric diagnoses, congenital malformations, miscarriages, stillbirths, and early childhood deaths.

Exams and Tests

The diagnosis of MR requires an intelligence deficit of at least 2 standard deviations (SDs) below the mean IQ. Equivalent deficits in at least 2 areas of functional life skills or adaptive skills also must be present to meet the diagnostic criteria for MR. Adaptive skills encompass functional life skills within the domains of communication, self-care, home living, social and interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety.

IQ scores can vary based on age, instrument, and practitioner. IQ scores can be measured using assessment instruments, such as the Stanford-Binet, Wechsler Adult Intelligence Scale (WAIS), or Wechsler Intelligence Scale for Children (WISC-IV). Nonverbal children can be tested with the Leiter International Performance Scale (Leiter-R).
The second component of diagnosis, adaptive skills, is usually measured with a self-reported or parent/caregiver-reported inventory, such as the Vineland Adaptive Behavior Scales, Second Edition (VABS-II).

Treatment

The primary goal of treatment is to develop the person’s potential to the fullest. Special education and training may begin as early as infancy. This includes social skills to help the person function as normally as possible. It is important for a specialist to evaluate the person for other affective disorders and treat those disorders. Behavioral approaches are important for people with mental retardation.

No specific pharmacologic treatment is available for cognitive impairment in the developing child or adult with MR. Medications, when prescribed, are targeted to specific comorbid psychiatric disease or behavioral disturbances.

Prevention

1. Genetic: Prenatal screening for genetic defects and genetic counseling for families at risk for known inherited disorders can decrease the risk of inherited mental retardation.
2. Toxic: Environmental programs to reduce exposure to lead, mercury, and other toxins will reduce toxin-associated retardation. Increased public awareness of the risks of alcohol and drugs during pregnancy can help reduce the incidence of retardation.
3. Infectious: The prevention of congenital rubella syndrome is probably one of the best examples of a successful program to prevent one form of mental retardation. Constant vigilance helps reduce retardation that results from infection.

Statistics show that more than 15% of the population is affected by clinical depression at some point. Most people prone to depression do not seek professional treatment, attributing their feelings to a bad mood that will pass. If left untreated, depression can get worse, and may even lead to suicide in some people.

Causes of Depression

There are various theories that suggest a multiple number of reasons, both internal and external factors which can cause depression.

1) Genetic is thought to be one of them. With this theory the family and their behavior has a predisposition towards depression.

2) It has also been noted that changes in the brain structure or even brain functions may be one of the causes of depression.

3) Low self-esteem and pessimism are thought to be the other causes of depression. With these mood traits a person suffering from low self-esteem will regard themselves with feelings of pessimism, worthlessness, a desire to end their life and perhaps even attempts at suicide. In this case the person who suffers from low self-esteem and depression will only see the negative aspects of life. These low self-esteem and pessimistic feelings maybe some of the causes of depression, as they invoke the response towards depression.

4) Being overwhelmed by stress can easily lead a person into a state of depression. As more stress enters our lives, depression begins to set in.

Low self-esteem, pessimism and stress are considered to be psychological causes of depression.

5) Other causes of depression can include any physical changes that occur to our bodies. Severe medical conditions like Parkinson disease, heart attacks, strokes and diabetes can make the individual believe that there is nothing worthwhile living for. This emotional state in many cases causes the person to drop into a depression phase. And depression, in turn delays the rate of recovery.

Clinical Features

Depression affects people across all age ranges, genders, ethnicities, cultures and religions.

The common symptoms of clinical depression can be broken up into three categories. Any combination of these symptoms that last for more than a two week period of time signifies that someone is suffering with depression.

Physical Symptoms:

1. Sleep problems either insomnia or oversleeping and not having normal sleep patterns.
2. Lack of energy and chronic fatigue
3. Appetite changes leading to weight gain or loss.
4. Headaches, digestive problems, back pain and other physical symptoms for which there is no medical illness.

Behavioral Symptoms:

1. Loosing interest in hobbies and activities that were once enjoyable.
2. Withdrawing from social functions and obligations.
3. Memory loss, inability to concentrate and make good decisions.
4. Lack of concern over personal appearance, responsibilities and work.

Emotional Symptoms:

1. Feelings of hopelessness, worthlessness and guilt.
2. Continual feelings of sadness or not feeling whole.
3. Constant crying and weeping.
4. Irritable feelings including anxiousness and agitation.
5. Feeling like committing suicide.

If any combination of these symptoms last for more than two weeks then a diagnosis of clinical depression will be made in most cases.

Treatment

Before any sort of cure can be administered the depression sufferer must admit that they have depression. The time to cure clinical depression is when the symptoms are noticed early and acted upon without delay. It is therefore, critical for everyone to be aware of the symptoms, and to take action as soon as possible, to avoid needless suffering on the part of the depressed.

Some of these treatments are long term and can eventually cure the depression sufferer of their aliment. Other medications act only as a way of controlling the bouts of depression. Many of these treatments work best in conjunction with each other. At the present the medication that is prescribed for depression is that of antidepressants.

1) Antidepressants are classified as TCA (Tricyclic Antidepressant Drugs), SSRI (Selective Serotonin Reuptake Inhibitors, RIMA (Reversible Inhibitors of Monoamine Oxidase), MAOI (Monoamine Oxidase Inhibitors) and SNRI (Serotonin and Noradrenaline Reuptake Inhibitors). All of these cures for depression work by altering the chemical patterns within the brain.

2) Cognitive-behavioral therapy is another proven form of cure for depression. With this therapy you relearn your reaction to situations that can lead you into depression. Also you learn how to cope with the day to day situations that you will find yourself in. This way the problems can’t overwhelm you and make you feel like a failure for not being able to solve them quickly.

Article by: Dr. Mandeep Kunwar

• Acne is almost always seen in the teenage years,
• severity of disease differs per individuals
• Peak severity is in the late teenage years But acne may persist into the third decade and beyond, particularly in females.

Main Problem- issues relate to under-treatment and lack of clinical interest or insight into the patient’s condition.

Aetiology or Causes-
There are three pathogenetic factors :

1. Increased sebum excretion. There is a clear relation between severity of acne and sebum excretion rate. In the complete absence of sebum, acne does not occur, however, acne may improve in the third and fourth decades despite high sebum excretion. Sebum excretion is therefore necessary for the development of acne but is not sufficient to cause acne on its own.
2. Infection with Propionibacterium acnes. This bacterium colonises the pilosebaceous ducts and acts on lipids to produce a number of pro-inflammatory factors.
3. Occlusion or blockage of the pilosebaceous unit.

Clinical features
Lesions are usually limited to

• face,
• shoulders,
• upper chest and back.
• upper arms

Seborrhoea (greasy skin) is often clinically obvious.

• Open comedones (blackheads) due to plugging by keratin and sebum of the pilosebaceous orifice, or closed comedones (whiteheads) due to accretions of sebum and keratin deeper in the pilosebaceous ducts, are usually evident.
• Inflammatory papules, nodules and cysts occur , with one or two types of lesion predominating.
• Scarring may follow.

Scars ( Source Wikipedia)
Physical acne scars - “Icepick” scars. This is because the scars tend to cause an indentation in the skin’s surface. There are a range of treatments available. Although quite rare, the medical condition Atrophia Maculosa Varioliformis Cutis also results in “acne-like” depressed scars on the face.
Ice pick scars: Deep pits, that are the most common and a classic sign of acne scarring.
Box car scars: Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.
Rolling scars: Scars that give the skin a wave-like appearance.
Hypertrophic scars: Thickened, or keloid scars.

Before treatment.

Clinical variants of acne.

Conglobate acne refers to severe acne with many abscesses and cysts, marked scarring and sinus formation.
Acne fulminans refers to the presence of severe acne accompanied by fever, joint pains and markers of systemic inflammation such as a raised ESR.
Acne excoriée refers to the effects of scratching or picking, principally on the face of teenage girls with acne.
Infantile acne is rare and is thought to be due to the sebotrophic effects of maternal hormones on the infant.

• A mild form of acne dominated by the presence of comedones may be due to exogenous substances such as tars, chlorinated hydrocarbons or oily cosmetics.
• A primarily pustular rash may also be seen in those being treated with corticosteroids, lithium, oral contraceptives and anticonvulsants. These forms of acne are usually clinically distinct from the usual variety developing in adolescence.
• Individuals with moderate or even severe acne very rarely have any other systemic disorder. However, individuals with polycystic ovary syndrome are more likely to have severe acne, and clinical hints-for instance, menstrual irregularities-require investigation. If there is associated cutaneous virilism or other features of an androgen-secreting tumour, further investigations and expert endocrinological assessment are warranted.

Investigations
- rarely required.

Management

• Tretinoin cream.
• Benzoyl peroxide.
• Local antibiotics (clindamycin or erythromycin) are used more widely than previously
• The principal oral antibiotic is oxytetracycline, taken on an empty stomach not with food, in a dose of up to 1.5 g a day if tolerated. In general, oxytetracycline has a good safety profile even with long-term use.
• Minocycline may be used if the response to oxytetracycline is inadequate or because of the ease of dosing. It is, however, associated with autoimmune hepatitis and remains a second- rather than first-choice drug.
• Before an antibiotic is deemed not to have worked, the individual must be treated continuously for up to 3 months. If after 3 months there is little response to oxytetracycline the patient should be changed to erythromycin up to 1 g per day in divided doses. Patients need to remain under review.
• In women, oestrogen-containing oral contraceptives can be a useful adjunct in therapy. There is a small reduction in sebum secretion with oral oestrogens. An oral anti-oestrogen, cyproterone acetate, is occasionally added in doses of 50-100 mg daily on days 5-14 of the cycle to enhance the effects of sebum reduction. If these topical and systemic agents fail to produce an adequate clinical response within 3-6 months the patient should be referred for specialist opinion and consideration for treatment with isotretinoin (13 cis-retinoic acid).
• Isotretinoin has revolutionised the treatment of severe or moderate acne in patients unresponsive to other therapy.

Physical measures

1. Cysts can be incised and drained under local anaesthetic.
2. Intralesional injections of triamcinolone acetonide (0.1-0.2 ml of a 10 mg/ml solution) hasten the resolution of stubborn cysts.
3. Scarring following acne is seen a lot less commonly if patients receive adequate care. Small, deep acne scars can be excised and other forms of more extensive but shallower scars can be treated by carbon dioxide laser.
4. Dermabrassion

Photo Therapy

1. Red and Blue light
2. Photodynamic therapy
3. Laser treatment.

SUBMITTED- DR. S. M. PALIKHE, MBBS .