Glucose-6 Phosphate Dehydrogenase Deficiency and Psychotic Illness
Mr. T, a 28-year-old unmarried male, from a lower socioeconomic status family of Dehradun, India; presented to the Outpatient Department of the Institute of Human Behavior and Allied Sciences (IHBAS); An Institute providing Quality Care in Mental Health, Neurosciences and Behavioral Sciences in Northern India; with abnormal behavior, which was unmanageable at home. He was admitted at IHBAS; on detailed assessment, it was found that the patient was a diagnosed case of G6PD Deficiency since his childhood. He had 13 years of psychiatric illness, which was of insidious onset. It was a continuous course, with several exacerbations, and the duration of the last exacerbation was for one-and-a-half months preceding the index admission. His illness was characterized by muttering to self, unprovoked aggressive behavior, irritability, over-talkativeness, which was difficult to be interrupted, and claiming that the rays of the sun and moon enter his brain and make him hit his family members and destroy the household articles. He would also claim that planets Mars and Saturn were exerting a bad impact on his physical health and making him physically weak. He also statedthat these two planets would insert various thoughts into his mind and would take away his thoughts from his mind, against his wishes, following which his mind would go blank for a few minutes. The patient would also frequently complain of hearing voices of Pakistani troops marching toward Dehradun, his native place; in clear consciousness through his ears and he would hear voices of Pakistani soldiers telling him that they would kill him and destroy his nation. The patient would be distressed due to these voices and on several occasions would be found responding to these voices. He also used to claim that he possessed special powers, due to which he had cured his father's diminished vision, and would also claim to cure his earache. His other family members shared none of these beliefs. During exacerbations of his illness, he would donate the fruits and vegetables of his shop to people, at times he would even donate the day's earning to beggars, and would also smoke bidis excessively. His sleep would also decrease by about three hours a day and he would eat more food than his usual pattern.\nDuring all these 13 years, the patient had never been asymptomatic, although the intensity and frequency of his symptoms would decrease with treatment. He had both affective as well as psychotic symptoms all through his illness. There was a past history of repeated hemolytic crises in the form of bleeding from the gums, till 12–13 years of age, but there was no history of recent hemolytic crisis. Since 1993, the patient had been tried on three different classes of antipsychotics, in adequate doses, for adequate durations, but with poor response. Mood stabilizers were also tried, with some improvement in symptoms. He had a history of three prior admissions and also had a family history of psychotic illness in his mother and two elder sisters, who were maintaining well on treatment. The patient's birth and developmental history was uneventful and he had a well-adjusted, pre-morbid temperament.\nOn physical examination, black discoloration of the gums of both upper and lower jaws was present and the rest of the physical examination was within normal limits. On mental status examination; his psychomotor activity and rate of speech were increased; reaction time was decreased, and there was pressure of speech. Affect was euphoric, with full range and reactivity, thought content revealed delusion of persecution, delusion of control, delusion of grandiosity, and delusion of thought insertion and thought withdrawal. He also had second and third person auditory hallucinations, with impaired judgment and poor insight into illness. All routine investigations were within normal limits (Hb-14g / dl, PCV-40.6%, MCV-98.6fl, MCH-32.4pg, MCHC-32.9g / dl, S.Bilirubin-0.88mg / dl, and no RBCs were detected in the urine examination).\nFollowing discussions during the hospital stay, he was diagnosed as a case of Schizophrenia Paranoid Subtype, as per ICD-I0.[] However, a differential diagnosis of Schizoaffective Disorder Manic Subtype was also entertained, in view of the prominent manic symptoms during the course of illness. During his stay of three weeks, he gradually improved and was discharged. The patient later dropped out of follow-up.