Lack of a national commitment to improve adult vaccination is a major shortcomings of adult vaccination in india ,no media publicity even I have not seen anything during my service spanning 4 decades from rural dispensary to distt level hospital.
COMBINATION OF ALL THE GIVEN FACTORS IS THE REASON FOR LACK OF VACCINATION OF ADULTS.... MOREOVER OUR GOVTS ARE NOT TAKING ANY INITIATIVE FOR ADULT VACCINATION AT GROUND LEVEL.....
A combination of many factors,viz,illetracy,religious taboes,lack of awareness & knowledge about the purpose & outcome of vaccination,economic preoccupatio,and a little lazin
No 3 mainly, other s also matter but less.
Socio economic factor
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14 year old girl brought with complaints of absent interactions with peers and teachers in school .Sitting eyes apparently closed inside class room .Not making eye contact with anyone. Deterioration in academic functioning also noticed. Decline started since four years which is gradual and interest in extracurricular activities is also coming down and absent now. Inside family atmosphere she functions well and takes initiatives to do outside trip to play areas,parks, cinemas. Irritability and occasional destructive behaviour also present inside house ,no change in biological functioning reported. Whenever her school mates visited her house she was in distress and there was irritability.Recently she seems to wear a scarf over head when she goes to outside house where there is likely to meet her school mates.Some excessive concern about cleanliness also noticed. Family history of depression in mother delusional disorder in father and suicide and substance use disorder in second degree relatives.Interpersonal issues between parents present. MSE revealed Poor but possible rapport, Slightly reduced range of affect, slightly reduced reactivity, low mood , sibling rivalry,no egodystonic distress regarding her problems also noticed.No hallucinations or delusion .No depressive or suicidal ideation. Unable to self appreciate fully her dysfunctions and unable to elaborate on reasons. physical examination nil significant.No history of abuse reported. How you proceed with the case ?Dr. Saleem Pallisserikuzhiyil1 Like22 Answers
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A 45 yrs old married women came to opd with complaints of ,her lower end of vagina has teared and has sever stress duty to same , because of that she would not like to go anywhere, Had took multile consultancy with gynaecologist.But she didn't satisfied and her Symptoms increase over time ,lead to familial conflict, social withdrawal sleep impaired started Olanzapine 5mg to 20mg with BZD sos,And confrontation of her delusion also done. later add on TFP has tried but after 15 days,no improvement.(Not able to tolerate clozapine)Finally pt post for ECT 6 given and seen better for week and then again start asking about her somatic delusion but distress was not present .Then we plan to replace TFT with T.Pimozide 2mg and go upt T.pimozide 4 mg.and 3 session of behavioral therapy. Patient discharge after a week on Olanzapine 20mg and Pimozide 4mg with significant improvement atleast Her insight 4/6.Kindly give your valuable opinion ThanksDr. Yusuf Khan8 Likes15 Answers
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A 30 year old male patient came with complaints of preoccupation with cleanliness repeated hand washing repeated checking ghabrahat episodes mild irritability since last 1 year patient has h/s/o manic episode one and a half year ago for which patient has taken medications for around 3 months (reports n/a). pt. is smoking bidhi × 6 years about 15/day wt will be ur complete DX. how will u manage this patient.Dr. Khan Parvaiz Ahmad2 Likes13 Answers
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1 month back pt came n today in follow up ---- son with father ... came to me with the ... son complaining of acidity n ulcer ....... for 12 months ... & not improving in the same .... so i thought of refering him to my collegue as it is not my case .... on asking to consult Gastro enterologist - he said ... i had been to 10 Gastro enterologist ... & 6 times Gastroscopy .. & one time Biopsy .... & he also gave names of Dr also ................ then i asked .. did you showed the file or previous doctor to them .... for which he said ..no ... if i show them they will not do Gastroscopy ..... n they will not diagnose my case ....... but the last doctor came to know all of this so he a sked me to show or consult Psychiatrist for the unresolvled complained as there is none pathology inside ... he was most to the time was preoccupied with the pain in abdome - a cidity n whether i am having peptic ulcer or not .... /... all the time i gave to him ... approx 45 minutes ...his main preoccupation n topic was ... i am suffering from acidity n peptic ulcer n it is because of the biopsy taken ... n since then i am suffering from ... inspite of nicely explained by Gastro doctors ... that it is not so ....... so suggest the diagnosis ,... treatment n management of such disorder which in psychiatry are called as Somatic Symptom disorder ... SSD .... a false belief ... unshakable belief ... unable to convince ... keep on going to doctor again n again ... believeing in what they said ..may be for heart problem ...keep on going to cardiologist ... n do not mind in wasting money .. in consultation investigation n costly investigation ....Psycho ----- ---- somatic .... today in folllow up he has shown lot of improvement... with therapy ..... so please suggest what can be done ... then i shall be sharing the new therapies added ....Dr. Vinod Kumar Goyal2 Likes9 Answers
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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 Likes8 Answers