There might be some underlying psychological trauma. We need to find out the same. There are multi-dimensional factors. There is a strong family history of various psychiatric disorders, interpersonal issues in parents, decline in academic activities, also in relating to peers and teachers also. Establishing a good rapport is the first thing. Medications have little or no role in this case except for some irritability issues. Concern regarding cleanliness is to be evaluated further. Psychological counseling is the main stay of treatment. Step by step she will reveal her issues, address them accordingly. Follow her up very frequently, at short intervals.
Thanks this can be a case of sexual exploitation by others or TV or pronography or video conferencing ....or you tube - which results into confusion about sexuality or role of sexuality or hatred towards with preoccupation in mind ...about that sexual ... act .. for which at this age she is not aware of or given the thinking that it is a bad touch ..... or in some cases they have seen parents into compromising position for which she is unable to understand . this might lead to such deterioration if mental state is normal .... to rule out childhood schizophrenia .. n other neuro disorder
Bullying/school phobia Counselling individual/ with parents/feedback from teachers /to find out the cause may be helpful, D/d separation anxiety /learning disorder
Proper counselling . Detailed history regarding domestic violence/sexual abuse . Such a common scenario in our country . Where female choose to keep quite n suffer due to social pressure .
At second session rapport seems improving and she expressed an idea that some bad will happen to her if she talks to them but unable to elaborate further and lack of concern for the dysfunctions is striking .IQ and adaptive functioning is good and LD is to be probed.Family intervention partially failed because father is not willing to attend sessions.Started on fluoxetine and mother was asked to keep close watch for any personally significant stressors.By four weeks it seems irritability and distructive behaviour is significantly reduced and patient subjectively report she feels more comfortable now.Morher was given psychoeducation .Lack of clarity in diagnosis and need for regular follow up and serial MSE explained to her .As she was from a far distant place a report provided to her stating differential diagnosis of 1 )OC , Depression, Anxiety spectrum disorders 2) Prodrome of Psychosis 3) Dysfunction related to Possible ongoing Abuse or personally significant stressors. Report may be helpful if she turn up to any other therapist.
Current picture may resemble depression with some anxiety and OC features. But onset at such a young age(10) and somewhat atypical features with bizarre behaviours point to psychosis very likely in future. We may go for psychological tests in addition to serial MSE. I think treatment may be started with antipsychotics with antidepressant action ( like olanzapine) with special attention to OC symptoms.
It is a case of Depression with psychosis Rx 1. Anti depressants antipsychotic drugs under the guidance of a psychiatrist 2. psychological counselling
I think its important to rule out whether shes a slow learner ..borderline to dull normal intelligence. Or specific learning disability. The apparent inattentiveness in class and staring into space may be related to academic difficulties. And the irritability and destructiveness at home may be when she is pressurized to study and feels misunderstood. The fact that academic 'decline' is noted since around class 5 may be linked to the fact that till this time many children can compensate for their deficits if they study very hard or their parents sit with them..after this the increasing complexity of academics makes it impossible for them to keep up. The scarf may be an effort to remain unrecognized by schoolfriends, she may have been bullied. The fact that MSE is not yielding much may be another pointer to the presence of subnormal intelligence. Comorbid depression/dysthymia in v/o academic and interpersonal stressors is highly likely. IQ and SLD assessment can be considered. SSRI may be helpful. She would benefit from focusing on her strengths and appropriate vocational training.
B4 to start medication for her problem, it is better to establish confidence in her AND find out the hidden cause of"not going to school and wearing a scarf ".
Rule out autisim encourage school play friends making play activity in family
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ORS previously included in Psychotic spectrum have been moved to the OC spectrum in DSM five. Olfactory Reference Syndrome with Suicidal Attempt Treated with Pimozide and Fluvoxamine ￼ Introduction The symptoms of Olfactory Reference Syndrome (ORS) were first described in a case series of 36 patients by Pryse-Phillips in 1971. Although published literature on the subject spans more than a century, areas of controversies persist in terms of the nosology and treatment of the disease. The core symptomatology of ORS is characterized by a preoccupation with the belief that one emits an offensive odor, which is not perceived by others. Other terms that have been used in literature to describe the disease include delusions of bromosis, hallucinations of smell, chronic olfactory paranoid syndrome, olfactory delusional syndrome, monosymptomatic hypochondriacal psychosis, olfactory delusional state, olfactory hallucinatory state, and autodysomophobia. The characterization of this syndrome has been a moving target; it appears in the DSM 5 under “Other Specified Obsessive-Compulsive Disorders” as well as under the “Glossary of Cultural Concepts of Disease,” as a variant of Taijin Kyofusho, a disease characterized by “anxiety about and avoidance of interpersonal situations, due to the thought, feeling, or conviction that one’s appearance and actions in social interactions are inadequate or offensive to others.” ORS was first categorized as an atypical somatoform disorder in the DSM-III and then as a delusional disorder in DSM-IV-TR and now under Other Specified Obsessive-Compulsive Disorders in DSM 5. The controversy surrounding its classification stems from the supposed preferential response of the condition to Selective Serotonin Reuptake Inhibitors (SSRIs) suggesting a possible associational overlap with Obsessive-Compulsive Spectrum Disorders and its very strong comorbidity with depressive disorders but, despite this preference, reports of the utility of antipsychotics such as Quetiapine, Risperidone, and Pimozide have also been reported in literature. The clinical course of ORS is chronic and debilitating for the patient and their families; although the clinical presentation may be confused with primary psychotic disorder, there is no clear evidence that this disorder leads to or is associated with schizophrenia. Pryse-Phillips, in his seminal paper, highlighted the importance of depression as the most common psychiatric comorbidity with ORS but other comorbidities have also been described in literature including bipolar disorder, personality disorders, schizophrenia, hypochondriasis, alcohol and substance use disorders, Obsessive-Compulsive Disorder (OCD), and body dysmorphic disorder. Case Report A case of a 75-year-old African American woman, widow, unemployed, and domiciled with a past medical history of hypertension, osteoarthritis, and asthma. The patient was brought to the Emergency Room by Emergency Medical Services (EMS) on account of an attempted suicide due to a 3-year history of “bad odor coming from my vagina.” The patient reported that the foul smell from her vagina was making her body “rotten.” She reported that “the smell came back recently and it is stronger.” Although she has been having the odor for the last 3 years, it has only recently gotten worse, the culmination of which resulted in her attempted suicide this time. She reported that she has seen several gynecologists who have treated her to no avail and later advised her to see a psychiatrist. She stated that there is a “devil” in her body that does not let go and she said, “I need help.” The patient has a significant impairment in social functioning evidenced by a reported avoidance of social events; she could no longer go out to the store for her basic needs; according to the patient’s son, she has also stopped going out to get groceries or to the church. She reported that she has been unable to have any romantic relationships because of her “odor.” The patient stays at home all day, showers several times daily, and has tried many vaginal products and creams but all in vain. Diagnosis At the time of initial evaluation, the patient appeared paranoid, reporting that people stayed away from her because of her smell. She also endorsed ideas of reference claiming that people around her cover their noses, stand next to windows, or look at her in “a certain way” and then talk about how much she “stinks” to each other. She endorses profound feelings of hopelessness, helplessness, and guilt and was tearful during the interview. Other symptoms reported were poor sleep, feeling less energetic, decrease in concentration, and anhedonia. She also endorsed active suicidal ideation, imagining waking up dead every morning due to her odor, and attempted to stab herself in order to “end my mystery” which led to this current admission. She also reported that she had lost up to 20 pounds in last 3 months. The patient was initially diagnosed with schizophrenia but later revised to Olfactory Reference Syndrome (ORS) in view of an extensive review of her symptoms and collateral information. Treatment The patient was admitted to the inpatient psychiatric unit and placed on 1: 1 constant observation for active suicidal ideation. Laboratory investigations including urine toxicology, liver function, urea, creatinine, electrolytes, and antinuclear antibodies, syphilis, and human immunodeficiency virus serology were all within normal limits or negative. She was started on Risperdal 2 mg PO twice daily for psychosis, Escitalopram 20 mg PO daily for depression, and Trazodone 50 mg PO HS for sleep. Neurological and gynecological consults were sought and the MRI of the brain obtained revealed no significant findings and was otherwise unremarkable. After a week, the patient’s delusions about her vaginal smell got even worse. She would not go outside of her room even for meals which were offered to her in the room because she thought that people could smell her vaginal odor. She also spent very long hours in the showers and demanded to take showers several times daily; her requests put a strain on the staff of the unit and on other patients who needed to use the same facilities. The patient’s medications were reviewed and she was started on Pimozide 1 mg PO twice daily and Fluvoxamine 25 mg PO daily based on the revision of her diagnosis to ORS. Risperdal, Citalopram, and Trazodone were discontinued. The patient made remarkable progress in the next few days. Pimozide was optimized to 2 mg PO twice daily and Fluvoxamine to 75 mg PO daily during the course of her hospitalization. She remained adherent with her medications and no side effects were noted. The patient and nursing staff agreed to a 70% symptomatic improvement in the patient’s symptoms; her affect was brighter; she was able to go outside of her room for meals and group therapy and socialize with other patients and staff. She became amenable to dissuasion regarding her previously held delusions and denied any depressive symptoms and no longer needed 1: 1 constant observation as she was no longer suicidal. She appeared future-oriented and motivated to go back home and resume her social life again. She was discharged back to her apartment and was provided with an outpatient appointment for aftercare. The team followed up with the patient patients several months after her discharge and she continued to maintain a remission of her symptoms. Discussion This patient believed that her vagina was emitting such a strong odor that she attempted to take her own life after 3 years of significant distress. Her belief was accompanied by ideas of reference; that is, she thought that other people took special notice of the odor in a negative way; she performed repetitive behaviors of multiple daily showers and use of vaginal washing soaps daily. Although not an official diagnostic criterion, our patient met the provisional criteria set by the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group criteria for Olfactory Reference Syndrome : (A)Preoccupation exists with the belief that one emits a foul or offensive body odor, which is not perceived by others. (B)The preoccupation causes clinically significant distress (e.g., depressed mood, anxiety, and shame) or impairment in social, occupational, or other important areas of functioning. (C)The symptoms are not a symptom of schizophrenia or another psychotic disorder and are not owing to the direct physiological effects of a substance (e.g., drug abuse or medication) or a general medical condition. The comorbidity with Major Depressive Disorder in our patient is of particular significance. The importance of this comorbidity is well known and has been reported in the literature. In this case, our patient reported several symptoms suggestive of Major Depressive Disorder evidenced by her profound feeling of hopelessness and guilt; she has lost interest in everything; she reported insomnia and poor appetite with a significant amount of weight loss. All the patient’s symptoms, although rooted in the context of her perception that she was smelling, were nonetheless significant to the point that she attempted suicide. The use of Pimozide and SSRIs in the treatment of monosymptomatic hypochondriacal states has been consistently reported in the literature. The combination of these medications in the index case yielded excellent results. Although the reliability of the diagnostic criteria is not yet established and ORS is not a stand-alone diagnosis in the DSM-5, it merits consideration in patients who present with monosymptomatic hypochondriacal illnesses, as this diagnostic consideration may influence the treatment and eventually the potential course of the illness as with our patient who after three years of a distressing illness is currently in remission with proper treatment. Keywords Olfactory Reference Syndrome, suicide attempt, Pimozide, Fluvoxamine Author : Jegede, et al.Dr. Saleem Pallisserikuzhiyil9 Likes10 Answers
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Ginkgo biloba has many health benefits. It’s often used to treat mental health conditions, Alzheimer’s disease , and fatigue . It’s been used in traditional Chinese medicine for about 1,000 years. It came on the Western culture scene a few centuries ago, but has enjoyed a surge of popularity over the last few decades. ADVERTISEMENT USES Uses of ginkgo biloba Ginkgo is used as an herbal remedy to treat many conditions. It may be best known as a treatment for dementia , Alzheimer’s disease, and fatigue. Other conditions it’s used to treat are: • anxiety and depression • schizophrenia • insufficient blood flow to the brain • blood pressure problems • altitude sickness • erectile dysfunction • asthma • neuropathy • cancer • premenstrual syndrome • attention deficit hyperactivity disorder (ADHD) • macular degeneration Like many natural remedies, ginkgo isn’t well-studied for many of the conditions it’s used for. HEALTH BENEFITS Health benefits of ginkgo biloba Ginkgo’s health benefits are thought to come from its high antioxidant and anti-inflammatory properties. It may also increase blood flow and play a role in how neurotransmitters in the brain operate. Some studies support the effectiveness of ginkgo. Other research is mixed or inconclusive. In 2008, results of the Ginkgo Evaluation of Memory (GEM) study were released. The study sought to find out if ginkgo would reduce the occurrence of all types of dementia, including Alzheimer’s disease. It also looked at ginkgo’s impact on: • overall cognitive decline • blood pressure • incidence of cardiovascular disease and stroke • overall mortality • functional disability The GEM study, the largest of its kind to date, followed 3,069 people age 75 or older for 6 to 7 years. Researchers found no effect for preventing dementia and Alzheimer’s disease in study participants who either took ginkgo or a placebo. And a 2012 meta-analysis found ginkgo had no positive effects on cognitive function in healthy people. Still, a 2014 study showed ginkgo supplementation may benefit people who already have Alzheimer’s and take cholinesterase inhibitors, common medications used to treat the condition. The GEM study also found ginkgo didn’t reduce high blood pressure . There was also no evidence ginkgo decreases the risk of heart attack or stroke. It may, however, reduce the risk of peripheral artery disease caused by poor blood circulation. According to a 2013 systematic review , ginkgo can be considered an adjuvant therapy for schizophrenia. Researchers found ginkgo seemed “to exert a beneficial effect on positive psychotic symptoms” in people with chronic schizophrenia who take antipsychotic medication. Researchers in that study also found positive study results for ADHD, autism, and generalized anxiety disorder, but indicated more research is needed. According to an older review of evidence study, ginkgo may improve erectile dysfunction caused by antidepressant medications. Researchers believe ginkgo increases the availability of nitric oxide gas which plays a role in increasing blood flow to the penis. Ginkgo may help relieve premenstrual syndrome (PMS) symptoms, according to a 2009 study . During the study, participants taking either ginkgo or a placebo experienced a reduction in symptoms. Those taking ginkgo had significantly more relief. ADVERTISEMENT RISKS Ginkgo biloba risks Ginkgo is generally safe for healthy people to use in moderation for up to six months. Severe side effects are rare. Still, the Food and Drug Administration (FDA) doesn’t regulate ginkgo and other over-the-counter herbal supplements as strictly as other drugs. This means it’s hard to know exactly what’s in the ginkgo you buy. Only buy a brand of supplement you trust. Ginkgo may cause an allergic reaction in some people. Your risk may be higher if you’re allergic to urushiols, an oily resin found in poison ivy, sumac, poison oak, and mango rind. Ginkgo may increase bleeding. Don’t use ginkgo if you have a bleeding disorder or take medications or use other herbs that may increase your risk of bleeding. To limit your bleeding risk, stop taking ginkgo at least two weeks before undergoing a surgical procedure. Don’t take ginkgo if you’re on any medications that alter clotting. Don’t take it if you’re taking NSAIDS like ibuprofen, too. Ginkgo can have serious side effects. If you’re on any medication, let your doctor know the dose you plan on taking. Ginkgo may lower blood sugar. Use with caution if you have diabetes or hypoglycemia or if you take other medications or herbs that also lower blood sugar. Don’t eat ginkgo seeds or unprocessed ginkgo leaves; they’re toxic. Due to the potential bleeding risk, don’t use ginkgo if you’re pregnant. Ginkgo hasn’t been studied for use in pregnant women, breastfeeding women, or children. Other potential side effects of ginkgo are: • headache • vomiting • diarrhea • nausea • heart palpitations • dizziness • rash TAKEAWAY Takeaway There was a time ginkgo seemed like a magic bullet for preventing age-related memory loss and other health conditions. But research to date doesn’t support much of the enthusiasm. Most evidence for ginkgo is anecdotal or decades old. Still, research has shown ginkgo may slow the progression of Alzheimer’s disease, help treat some common mental health conditions, improve sexual function, and improve blood flow to the peripheral arteries. Don’t replace a current medication with ginkgo or start taking ginkgo to treat a serious condition without consulting youDr. Tapan Kumar Sau5 Likes9 Answers
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#CAP2020 DSM 5 CRITERIA FOR ADHD:- People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development: Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted Is often forgetful in daily activities. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Is often “on the go” acting as if “driven by a motor”. Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or games) In addition, the following conditions must be met: Several inattentive or hyperactive-impulsive symptoms were present before age 12 years. Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities). There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning. The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). Based on the types of symptoms, three kinds (presentations) of ADHD can occur: Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months. Because symptoms can change over time, the presentation may change over time as well. REFERENCE(S) :- 1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext 2. https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_ADHD.pdf 3. https://www.ncbi.nlm.nih.gov/books/NBK223473/Dr. Jayita Tyagi2 Likes1 Answer
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Bi - Polar Disorder A person with bipolar disorder probably doesn’t fit the stereotype you have in mind. You might be surprised to learn that bipolar disorder isn’t just classified by out-of-control highs or suicidal lows. While these ups and downs certainly happen, there are also periods of normalcy mixed in on a regular basis. Another common misconception about people diagnosed with bipolar disorder is that they spend more time experiencing depression as opposed to mania. This is because people suffering from bipolar disorder are more likely to seek help when they are having a depressive episode than when having a manic episode. In fact, many people suffering from bipolar disorder keep their illness private for fear of judgment or punishment, especially in the workplace. What is bipolar disorder? Bipolar disorder, or “manic-depressive illness,” is a chronic mental illness. People with bipolar disorder often experience uncontrollable high and low moods known as mania and depression, respectively. A person’s medical history is important to accurately diagnose bipolar disorder because it is not a one-size-fits-all disease. People with depression only, also called “unipolar depression,” do not experience the highs and lows of mania. However, some people with depression may also experience some manic symptoms, this is known as “major depressive disorder.” The symptoms of bipolar disorder can also mimic those of other ailments, and people with bipolar disorder typically have another disorder or disease such as anxiety disorder, thyroid disease, migraines and headaches, so it can be hard for a doctor to make an accurate diagnosis. The condition can be controlled with self-management, a good treatment plan, and a high level of support. Four basic types of bipolar disorder Bipolar 1 Disorder Manic episodes lasting at least 7 days; or by symptoms so severe that the person needs immediate medical attention. Depressive episodes usually occur as well. Likely to experience depression along with the manic and depressive episodes. Bipolar II Disorder A distinct pattern of depressive and hypomaniac episodes, but not as severe as manic episodes experienced with Biopolar I. Cyclothymic Disorder Numerous periods of hypomaniac symptoms along with numerous periods of depressive symptoms lasting for at least 2 years in adults and 1 year in children and adolescents; however, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode. Other Specified and Unspecified Bipolar and Related Disorders Bipolar symptoms that do not match the criteria of Bipolar I, Bipolar II, or Cyclothymic Disorder. Mania is buying 3 new televisions on impulse; thinking you can buy your favorite restaurant; or deciding to run a 5K with no training–and insisting you will come in first. Hypomania is mania with a tether, and while it may lessen some of the financial and personal disasters sparked by unchecked mania, it can still feel like going the wrong way on a one-way road. What are the symptoms of bipolar disorder? Bipolar symptoms include extremely intense emotions/feelings, changes in activity level, disturbed sleep patterns, and other unusual behaviors. These tell-tale periods of symptoms are called “mood episodes.” To gauge the severity of a mood episode, one should compare the intensity of the attitudes and behaviors experienced during these unusual periods of time to what is typical and normal for that person. While jumping out of a moving car is not typical for most people, something like blabbering and talking fast may be normal for one person but not for another. Some people with bipolar disorder experience hypomania, a less severe form of mania. During a hypomania episode, a person may feel energized, productive, and euphoric — yet they may still feel in control. However, to others that know them well, the mood swings and fluctuations in attitudes and energy levels are very apparent and are a cause for concern. Without proper treatment, people with hypomania may develop severe mania and depression. A person with severe episodes may also experience psychotic symptoms which tend to match the extreme mood, e.g., hallucinations or delusions. A person having a manic episode may believe he is something he is not, e.g., rich or famous; while a person having a depressive episode may believe he is worthless or a failure. Sometimes a person with bipolar disorder who occasionally has psychotic symptoms may be misdiagnosed with schizophrenia. How is bipolar disorder diagnosed? No single cause has been identified for bipolar disorder. Scientists believe several factors may contribute to the illness, including genetics, stress, and the structure of the brain itself. It is important to talk to your healthcare professional(s). It is a good idea to get a complete physical and routine lab tests to rule out other conditions. If no obvious cause for the symptoms is found, a mental health professional, such as a psychiatrist who is experienced in diagnosing and treating bipolar disorder can perform a mental health evaluation. To be diagnosed with bipolar disorder, a person has to have had at least one episode of mania or hypomania. Bipolar disorder does not discriminate – it can affect anyone The average age of onset of bipolar disorder is 25. Every year, 2.9% of the U.S. population is diagnosed with bipolar disorder, with nearly 83% of cases being classified as severe. Bipolar disorder affects men and women equally. What is the treatment for bipolar disorder? Ironically, conventional drugs used to treat bipolar disorder are mostly psychotropic drugs that can induce more of the symptoms a sufferer is trying to beat, like anxiety, nervousness, impaired judgment, mania, hypomania, hallucinations, feelings of worthlessness, psychosis, and suicidal thoughts. Lithium is the best known medication for treating the disorder because it is a mood stabilizer and is effective in treating both mania and depression, as well as for preventing relapse. The bad news is that one-third of the patients who have taken lithium for over ten years have developed chronic renal failure from the drug, according to a study in the Journal of Psychopharmacology. Sometimes antidepressants are used to treat bipolar depression, but this can be controversial because of the possibility that an antidepressant can trigger a switch into mania. Behavioral or family focused therapies, as well as complementary health approaches such as meditation, faith and prayer, play a big part in developing self-management strategies for coping with bipolar disorder.Sushmita Haodijam4 Likes5 Answers
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A 23 year male with abnormal behaviour has never went to school after 5th standard and also not went out side from his home since last 5 to 6 years has always found to be engaged in online Videos game, has multiple suicide attempted whenever tried to stop him. Seen very violent with name of doctors or treatment. even not talking medicine of general illness. Parent are also not much aware about his illness ,his father came for consultation in my opdg with a note written by his son . NOTE HAS SO BIZZARE THOUGHT. file have attached kindly read and give ur valuable opinions.Dr. Yusuf Khan10 Likes16 Answers