The course will explain fundamental concepts in research methodology. The course includes 23 Lectures covering conceptualization of a research study.

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1. CASE PRESENTATION MODERATOR PRESENTOR Dr. JAYASHREE JANAGAM Dr. M.BREETHNI Assistant professor 1 ST year PGT Department of psychiatry Department of psychiatry NHRIMH NHRIMH

2. OBJECTIVES PROVISIONAL DIAGNOSIS PATHOPHYSIOLOGY AND SYMPTOMS OF CASE DIFFERENTIAL DIAGNOSIS ANALYSIS OF SYMPTOMS EVALUATION OF SYMPTOMS MIASMATIC ANALYSIS REPERTORIAL TOTALITY PRESCRIPTION MANAGEMENT OTHER REMEDIES

3. PROVISIONAL DIAGNOSIS ALCOHOL DEPENDANCE SYNDROME ICD-10 (F10) ICD-11 (6C40)

4. DIAGNOSTIC CRITERIA OF ADS IN ICD-10&11 ICD-10 PRESENT OR ABSENT ICD-11 PRESENT OR ABSENT Craving ✅ Strong internal drive to use alcohol ✅ Impaired control ✅ Impaired ability to control use ✅ Withdrawal ✅ Physiological features (tolerance, withdrawal) ✅ Tolerance ✅ Neglect of interests ✅ Continued use despite harm ✅

5. absoab ABSORPTION OF ALCOHOL

6. NEUROCHEMICAL CHANGES DOPAMINE SEROTONIN ADENOSINE ACETYLCHOLINE CANNABINOID GABA GLUTAMATE

7. OTHER EFFECTS OF ALCOHOL TOLERANCE BLACKOUT- ANTEROGRADE AMNESIA SLEEP IMPAIRMENT- SUPPRESS REM SLEEP CEREBELLAR PROBLEMS THIAMINE DEFICIENCY INCREASED LDL,TRIGLYCERIDES,BP PERIPHERAL NEUROPATHY DECREASES WBC IMMUNOSUPPRESSION- CANCER FETAL ALCOHOL SYNDROME

8. DELIRIUM TREMENS STARTS AT 8 HRS AFTER INTAKE PEAKS ON 2ND AND 3RD DAY STARTS DIMINISH AFTER 4 TH DAY ALCOHOL ASSOCIATED PSYCHIATRIC DISORDER ANXIETY DEPRESSIVE DISORDER ALCOHOL INDUCED NEUROCOGNITIVE DISORDER

9. CIWA- Clinical Institute Withdrawal Assessment for Alcohol, Revised

10. PSYCHODYNAMIC THEORIES FREUDS PSYCHOSEXUAL STAGES -Oral stage ERIK H ERIKSON -Stage-7 Generativity versus stagnation(about 40-60 yrs)

11. COMPLETE BLOOD EXAMINATION LIVER FUNCTION TEST LIPID PROFILE BUN USG OF ABDOMEN AND PELVIS INVESTIGATION

12. COMPLETE BLOOD EXAMINATION

13. Typical Findings in A LD Clinical Significance AST - Elevated (often > ALT)hepatocellular injury AL T - Mildly elevated AST:ALT Ratio>2:1 (especially >2.5) Suggestive of alcoholic liver disease GGT - Elevated . Sensitive to alcohol use; marker of chronic intake ALP - Mild to moderately elevated . Can indicate cholestasis if very high Total Bilirubin - Elevated in advanced disease Indicates impaired L iver function or biliary obstruction Albumin - Low in chronic liver disease Prothrombin Time - Prolonged in cirrhosis or hepatitis . Indicates impaired liver synthesis of clotting factors

14. USG OF ABDOMEN AND PELVIS INCREASED ECHOTEXTURE FATTY LIVER CIRRHOSIS OF LIVER ANY KIDNEY ABNORMALITY

15. SCREENING TOOLS IN ADS CASE CAGE QUESTIONNAIRE RAPS Remorse Amnesia Performance Starter (Eye-opener)

16. AUDIT SCALE

17. MANAGEMENT COUNSELING COGNITIVE BEHAVIOUR THERAPY FAMILY SUPPORT REHABILITATION MOTIVATION REASSURANCE

18. TERMS DIFFERENT IN ICD-10 AND DSM-5

19. P DIFFERENTIAL DIAGNOSIS ?PERSONALITY DISORDER ?DELUSIONAL DISORDER ?MULTIPLE SUBSTANCE ABUSE ?DEPRESSION

20. PERSONALITY DISORDER Trait or Risk Factor Present in ASPD Contributes to Alcohol Use Impulsivity ✅ ✅ Childhood trauma ✅ ✅ Low empathy ✅ ✅ Sensation-seeking ✅ ✅ Poor judgment ✅ ✅

21. Delusion of persecution as if someone tries to kill DELUSIONAL DISORDER ELEMENTS ICD-10 ICD-11 Term used Persistent delusional disorder Delusional disorder Duration requirement ≥ 3 months ≥ 3 months Delusion type Typically non-bizarre Clearly false, not necessarily non-bizarre Hallucinations Absent or minimal May be present if tied to delusion Disorganized behavior/thought Not emphasized Must not be present As the symptoms are present only after withdrawl of alcohol , this diagnosis cant be considered

22. F19-MENTAL AND BEHAVIOURAL DISORDER DUE TO MULTIPLE DRUG ABUSE More than one drug used at a time Patterns of psychoactive substance that are chaotic and indiscriminate or which contribution of different drugs are inextricately mixed SUBSTANCE INDUCED PSYCHOTIC DISORDER The disorder typically resolves atleast partially within 1 month and fully within 6 months

23. DEPRESSION Reduced concentration or attention ✅ Reduced self-esteem or self-confidence ✅ Feelings of guilt or worthlessness (which may be delusional) Bleak or pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep (insomnia or hypersomnia) ✅ Decreased or increased appetite or weight change Psychomotor agitation or retardation ✅ DEPRESSED MOOD - Depressed mood (most of the day, nearly every day) Markedly diminished interest or pleasure in almost all activities (anhedonia) Decreased energy or increased fatigability

24. ANALYSIS OF SYMPTOMS COMMON SYMPTOMS UNCOMMON SYMPTOMS CRAVING FOR ALCOHOL DESIRE COMPANY INCREASED ANGER WITH HURTING TENDANCY PASSES DIFFICULTY WHILE PASSING STOOL LOSS OF SLEEP SLEEP ON ABDOMEN REDUCED APPETITE DREAMS OF SOMEONE TRYING TO KILL TREMOR OF TONGUE AND HANDS DESIRE FOR SOUR FOODS CONVULSION AFTER STOPPAGE OF ALCOHOL PSORIATIC PATCHES OVER HANDS <ALCOHOL DELUSION AS IF SOMEONE TRIES TO KILL BURNING PAIN IN XIPHISTERNUM VOMITING AFTER ALCOHOL

25. EVALUATION OF SYMPTOMS MENTAL GENERAL Desire company. craving for alcohol. Delusion as if someone tries to kill increased anger with hurting tendency PHYSICAL GENERAL Sleep lies on abdomen desire for sour food Passes with difficulty loss of sleep with dreams as if someone tries to kill. reduced appetite PARTICULARS Tremor of hands and tongue. Burning pain in xiphisternum convulsion after stoppage of alcohol. Vomits after alcohol Psoriatic patches over hands

26. MIASMATIC ANALYSIS PSORA SYPHILIS SYCOSIS TUBERCULAR DIFFICULTY IN PASSING STOOL DELUSION AS IF SOMEONE TRIES TO KILL LOSS OF APPETITE CRAVING FOR ALCOHOL PSORIASIS INCREASED ANGER WITH HURTING TENDANCY DESIRE FOR SOUR FOODS DESIRE COMPANY BURNING PAIN IN XIPHISTERNUM TREMOR OF TONGUE AND HANDS FUNDAMENTAL MIASM : PSORA DOMINANT MIASM :SYPHILIS

27. HAHNEMANNIAN CLASSIFICATION OF DISEASE TYPE-4 PSYCHOSOMATIC DISEASE REPERTORIAL TOTALITY

28. PRESCRIPTION SULPHURIC ACID 30/3D CRAVING FOR ALCOHOL TREMOR AND WEAKNESS GASTRALGIA AND HYPOCHLORRHYDIA HEARTBURN WITH SOUR ERUCTATION sulphuric acid mixed with 3 parts of alcohol ten to fifteen drops three times daily for several weeks to subdue the craving for liquor

29. FOLLOW UP DATE REMARKS PRESCRIPTION 14/5/25 Tremor of tongue,hands-reduced burning pain in xiphisternum reduced vomiting- nil weakness persist seizure-nil .stool passes with difficulty itching in psoriatic patches Delusion of persecution persists sulphuric acid 30/3d 16/5/25 Tremor of tongue-nil,hands-slightly burning pain in xiphisternum reduced vomiting- nil weakness persist seizure-nil .stool passes without difficulty itching in psoriatic patches,craving for alcohol-nil Delusion of persecution - NIL sulphuric acid 30/3d

30. continue 18/5/25 Tremor of tongue-nil,hands-slightly burning pain in xiphisternum -nil vomiting- nil weakness reducced seizure-nil .stool passes without difficulty itching in psoriatic patches reduced than before. craving for alcohol-nil sulphuric acid 30/3d 20/5/25 Tremor of tongue-nil,hands-slightly burning pain in xiphisternum -nil vomiting- nil weakness- nil seizure-nil .stool passes without difficulty itching in psoriatic patches reduced than before. craving for alcohol-nil sl/3d 18/5/25 Tremor of tongue-nil,hands-slightly burning pain in xiphisternum -nil vomiting- nil weakness reducced seizure-nil .stool passes without difficulty itching in psoriatic patches reduced than before. craving for alcohol-nil sulphuric acid 30/3d 20/5/25 Tremor of tongue-nil,hands-slightly burning pain in xiphisternum -nil vomiting- nil weakness- nil seizure-nil .stool passes without difficulty itching in psoriatic patches reduced than before. craving for alcohol-nil sl/3d

31. continue After the acute prescription,THE CONSTUTIONAL REMEDY was prescribed on 24/05/25 LYCOPODIUM 30/1D As there is pathology in liver , lower potency was suggested according to organon of medicine so 30th potency was prescribed Then patient discharged on 27/05/25 with marked improvement with counselling had beeb given to the patient

32. OTHER REMEDIES OF ADS CALCAREA ARSENICOSA Epilepsy with rush of blood to head. Complaints of drunkards after abstinence Hemoglobin and red corpuscles are low Confusion, Delusion, Illusion Great depression STRAMONIUM Delirium tremens. Delirium with desire to escape. Delusion about identity thinks himself tall, double or part missing Loquacious, laughing, singing, swearing, praying and rhyming Cannot bear solitude or darkness

33. CONTINUE RANUNCULUS BULBOSUS Bad effects of alcoholic bevarages Spasmodic hiccough Delirium tremens HYOSCYAMUS NIGER Disturbs the nervous system profoundly Weakness and nervous agitation Delirium with attempt to run away Low muttering speech, Deep stupor OPIUM Complete loss of conciousness Depresses higher intellectual power, lessens self control and power of concentration, judgement Delirious talk with wide open eyes.

34. COUNSELING

35. PSORIASIS 24/05/2025 27/05/2025

36. PSORIASIS Psoriasis is a chronic (long-term) autoimmune skin condition that causes the rapid buildup of skin cells. This buildup leads to scaling, inflammation, redness, and itching SITE OF LESION: Elbows, knees, scalp, presacral area and intergluteal fold DIAGNOSIS: Skin biopsy

37. Clinical Examination History : Duration, progression, family history, triggers (e.g., stress, infections, medications). Physical exam : Look for typical lesions—red, scaly, well-demarcated plaques, often on extensor surfaces like elbows, knees, and scalp. Nail involvement : Pitting, onycholysis (nail lifting), and discoloration. Joint symptoms : May suggest psoriatic arthritis. Auspitz sign - P inpoint bleeding occurs when psoriatic scales are gently scraped off, exposing the underlying capillaries in the dermal papillae.

38. SUMMARY