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Month: May 2021

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Adolescents Adults Cerebral Musings Children Elders Expert Blogs

Why Humans Like to Cry? Tragedy, Evolution & The Brain

Professor Michael Trimble the renowned British Neuropsychiatrist begins this,  his second popular science work, by stating affirmatively that emotional crying is unique to the human species. He goes on to dismiss as myths reports about apes, elephants and dolphins being capable of crying for emotional reasons. Not only is emotional crying unique to us, says the good professor, we have through our tradition of “tragedies” converted it over centuries, into an fine art form.

Music, gave rise to the birth of tragedy, which according to Nietzsche contains a fusion of Apollonian beauty with Dionysian creative energy and art.

Many other philosophers have taken up this two god theme- Mann, Hesse & Ibsen to name a few. “Apollo is the cold hard separatism of Western personality and categorical thought. Dionysius, is energy, ecstasy, hysteria, promiscuity, emotionalism, heedless indiscriminateness of idea or practice….Complete harmony is impossible, our brains are split and the brain is split from body. The quarrel between Apollo and Dionysius is the quarrel between the cortex and the older reptilian limbic brain”.

And thus does Trimble set the stage for his dissertation. From why and how we humans cry, through the neuroanatomy of the limbic system and it’s association areas, its neurobiological links with the lacrimal gland which causes us to tear (both in joy and sorrow); through the power of aesthetics- art, poetry, literature, painting, archeology, but most of all and most significantly so, according to the author, music!

What follows is a smorgasbord of philosophical, neurobiological, cultural and literary information; pearls of wisdom in every page. The “cutaneous shiver” of William James, and Shelley’s verse on the power of music, all find a place in the author’s evocative descriptions.

“I pant for the music which is divine
My heart in its thirst is a dying flower;
Pour forth the sound like enchanted wine,
Loosen the notes in a silver shower;
Like a herb less plain for the gentle rain,
I gasp, I faint, till they wake again.”

Using the theory of mind as the centrepiece of his dissertation, the author delves into the role of altruism and empathy in the development of the human social brain, which a number of studies of emotional-facial recognition using MRI scans have pointed to. “The evolution of cognitive empathy with corresponding increase in the size of the human pre-frontal cortex, provides experimental and neuroanatomical evidence explaining, from a neurobiological perspective, the human ability to feel the sadness of others, and cry emotional tears”. From an anthropological perspective, he also links empathy and tears to an awareness of the self: which according to Clive Finlayson “produced an animal capable of locating itself in space and time, an animal that became aware of the consequences of its own behaviour and mortality”.

The importance of language and linguistic processing is well brought out in the book. “Linguistic representations can influence how emotional states are represented and thus experienced”. Trimble points to the right hemisphere of the brain, quoting Norman Cook “At every level of linguistic processing that has been investigated experimentally, the right hemisphere has been found to make characteristic contributions, from the processing of affective effects of intonation, through the appreciation of word connotations, the decoding of metaphors and figures of speech, to the understanding of the overall coherency of verbal humour, paragraphs and short stories”. Trimble also points to the amygdala as a central organ that modulates human emotion, alluding to the elegant work of Zeki and colleagues who have used functional imaging to extensively study emotion.

Of music, Trimble points to, apart from linguistic impact, the triadic quality of the tonal Western harmonic system, whereby the tonic pitch on which harmonies are built, by means of progression from chord to chord, using such musical techniques of composition such as repetition, modulation and transformation, move away from these centres only to return with harmonic resolution. Through this “acousamatic” quality, calm and tension are developed, discord requiring a return to concord, provoking restlessness, suspensions and anticipation all requiring resolution. At these moments of “chills” or “shivers down the spine”, scientists have described changes in brain imaging (MRI and PET) involving the amygdala, insula, cingulate, per-frontal cortex and limbic association areas. Further, music has been demonstrated to elicit autobiographical memories, thus underlining its power to influence human emotion.

The author concludes that “Tears are an accompaniment of tragedy as an art form, and they reflect the tears of everyday human tragedy, which is linked to loss and mourning. These feelings have arisen in the course of our long evolutionary history, notably with the rise of self-consciousness, the development of small communities, the growing potential of love and hence an even greater sense of loss”.  As Semir Zeki, Professor of Neuroesthetics, University College of London has elegantly put: “This book is not a page turner. It is much better than that, one that is full of insights and of material for reflection on almost every page”.

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Adolescents Children Expert Blogs Neurodevelopmental Disability (NDD)

Understanding Developmental Disability

Sad but true! One in five children, in a developing nation like India, emerge into this world with their innate human capital compromised. A range of neurodevelopmental disorders (NDD) are the outcome of such compromise: learning disability, childhood epilepsy, cerebral palsy, mental retardation, attention deficit and hyperactivity disorder, autistic spectrum disorder; conditions that strike early and leave lasting impact on the child. On the occasion of the International Day of People with Disabilities (3rd December) we delve further.

What is neurodevelopmental disability?

A range of conditions that follow abnormal brain development and impact on motor function (strength, dexterity, coordination); or cognitive function (intelligence, learning, aptitude); or emotions & behavior (temperament, mood swings, emotionality, aggression, hyperactive-impulsive behaviours, socialization issues etc.). In all these instances, there are demonstrable changes in the brain and its development, either structural or in it’s functioning.

Why NDD? 

While some humans have NDD imprinted in their biological code (through genetic, hormonal, and other neurobiological factors), for many others, the causes lie in critical stages of development, with a range of factors causing compromise. Factors that affect maternal health around conception and through pregnancy; trauma through injury, drugs (both prescription and non-prescription), alcohol, smoking; exposure of the pregnant mother to infections or toxins; and maternal malnutrition, commonly compromise this desired state of “optimality”. Factors affecting the child include birth trauma and infection through poorly planned and executed deliveries, neonatal compromise (asphyxia, jaundice, early trauma through accidents or abuse, infections, malnutrition); untreated epilepsy; other progressive neuropsychiatric disorders etc. Contributory factors include late recognition of the problem, failure to be evaluated in formal medical settings, and the failure to seek and secure early interventions.

Who is at risk?

The global lesson from the “Human Genome Project” was that about 10% of all neurological conditions are explained by abnormalities in a single gene. The majority of disorders were thus deemed to be multifactorial- more than one genetic abnormality being responsible, with strong contributions from environmental events that have impact. This probably holds good for NDD as well. In general, having a parent or first degree relative affected by a neuropsychiatric or developmental condition, may double the risk of NDD.

When should we suspect NDD?

At the one end of the spectrum are children with overtly manifested disability with severe problems that are apparent early and demand medical interventions. They only form the tip of the iceberg. The larger group who go undetected, are children with minimal brain dysfunction. Typically, they are slow-learners in school, who find academic progress challenging; may be clumsy and lack dexterity, with poor handwriting; or indeed demonstrate a range of emotional and behavioral patterns.

Why should we take action early?

These children are often the poor performers and/or perceived troublemakers in school. Rather than receiving special attention, they are at worst punished and at best ignored, in many mainstream schools. Without adequate help and support, these children will slowly and surely slide down the educational scale, out of mainstream schooling, into special schooling systems that cannot really tap their potential. Further, children who do not receive support are likely to feel stigmatized and lose their self-confidence.

Where should I take my child, when in doubt?

Your pediatrician should be the first port of call. The class teacher may also have valuable inputs. When either pediatrician or class teacher (or both) suspect a problem, more specialized inputs become necessary. Problems in learning and intelligence are best assessed by a clinical psychologist; problems in motor or other brain function (like epilepsy) by a neurologist, sometimes with the assistance of an occupational therapist; problems in behavior by psychiatrists, often with the assistance of a counselor. When language development is affected, ENT doctors supported by speech and language therapists may need to be consulted. In many instances, comprehensive assessment requires a team approach. Depending on the problem the specialists consulted may require a range of laboratory tests- brain scans, brain wave (EEG) and other electrophysiological tests; blood and urine tests including hormonal assays and so on.

How should I progress once diagnosed?

  • Your pediatrician should be your primary support
  • Your child’s school needs to be briefed transparently and kept in the loop. Don’t worry about being asked to leave. If the school cannot accept the problem and work with you, it may not be the best place for your child.
  • Identify a team of professionals; be consistent in your interactions and regular in follow up. Make sustainable plans and set realistic goals. Prepare for the marathon, not a sprint.
  • Don’t focus only on the disability; your child may also have special interests and abilities. Put focus on them too.
  • Don’t be preoccupied by academic results; focus on overall development.
  • Caregiving is challenging and tiring; share the care as a family, develop your own support networks with other parents and keep your spirit up.
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Adolescents Adults Cerebral Musings Children Elders Expert Blogs Featured

The Quintessential Rational Mind

The day of Vaisakh Purnima (May 27 this year), is significant for three reasons. It was on this day that Gautama Buddha was born as Prince Siddhartha at Lumbini in Nepal in 560 B.C; the day when he attained enlightenment at Gaya in India; and the day he attained Nirvana (Unity with the Absolute) in 480 B.C. It is, therefore, observed as Buddha Purnima, worldwide. To mark this day in 2010, we examine the rational mind, as conceived by Buddha.

It has become fashionable and commonplace to associate Buddhism with the metaphysical. This is in stark contrast with Buddha’s emphasis on rational thought and insistence on empirical verification. He encouraged the development of theories that were verifiable and was strongly opposed to dogma, which he viewed as an impediment to the truth. To him the truth was supreme, and ideas that hinder the discovery of truth best avoided. He believed in full freedom in thought and action; “the gates of freedom will cease to be gates, if people start clinging to the gates.”

Buddha also had very interesting, remarkably contemporary views on the mind and some of these are enumerated below.

On Thoughts and Ideas: The very first verse of the Dhammapada translates as“you are nothing but your mind”, based on which, “Sarvam Buddhimayam Jagat” has been proposed. The word used by Buddha ‘ mana’ translates both as thoughts and as mind, and can be interpreted to mean the brain. Buddha’s emphasis is on the flow of thoughts and the continuous change in the thinking process. In his concept, ideas are not constant, they change all the time. Ideas have no independent origination; they have ideas preceding and following them. Consequently, all ideas are interrelated and there are no stand alone or absolute ideas. The thinker, the thought and the concepts therein cannot be separated. Interestingly, this concept has parallels in modern psychiatry. A primary delusion, a first rank symptom of Schizophrenia is said to arise when the person, following a “delusional mood” has a thought “out of the blue” and “without antecedents”. To have such a thought that has no thoughts preceding it, and possibly therefore no basis in fact, was abnormal to the Buddha, and remains so in modern concept.

On Perception: Both the Surangama Sutra and the Lankavatra Sutra attribute perception, physical and emotional, to the mind. “Both delusion and enlightenment originate within the mind and every existence or phenomenon arise from the functions of the mind.” The Surangama Sutra poses an interesting question: “A man opens his hand and the mind perceives it; but what is it that moves? Is it the mind, or is it the hand? Or is it neither of them? If the hand moves then the mind moves accordingly, and vice versa; but the moving mind is only a superficial appearance of mind”. According to the Buddha, all perception had basis within oneself. This concept of the Buddha has neuro-scientific underpinnings. If one were to replace the “mind” as Buddha called it, with “brain” as he probably meant, and is contemporary concept; that all our perception and action has basis in the brain, is truism. Prof. VS Ramachandran has described in his book Phantoms in the Brain, novel representation areas for human body parts that have been amputated, developing in the brain.

This illustration leads to another important question, namely, what is ‘me’ and what is ‘mine’? Buddha, through fables, encourages us to think about this existential dilemma. The parable is about a man who takes shelter in an abandoned structure on a stormy night. Sitting in a corner of a dilapidated room he sees around midnight, a demon enter, with a corpse. The demon leaves the corpse on the floor; suddenly another demon appears and claims the corpse. Both demons turn to the man and ask him to decide on the ownership of the corpse. Being truthful, he indicates he saw the first demon bring in the corpse. On hearing this, the second demon is enraged, tears away and eats the hand of the unfortunate man, which the first demon, immediately replaces with the one taken from the corpse. After the demons leave, the man wonders and thinks aloud, “the replaced hand is ‘mine’ but is it ‘me’?

Again, the questions raised have neuro-scientific relevance. After damaging physical trauma, and transplants, it is well reported that people sometimes feel dissociated from their new organs. Indeed, having an organ replaced can be a life-changing experience. At another level, damage to the brain, the parietal lobe in particular, can result in the sufferer neglecting his body parts, as he does not recognise them as his own. The phenomenon of anosognosia, leading to neglect of one half of the body (hemi-neglect), is a well described phenomenon after a stroke. Here, the person sees the paralysed limb lying beside him on the bed, but is unable to recognise it as his own.

Buddha did, therefore, begin the mind-matter debate much before it became fashionable in contemporary philosophy. He placed human emotion firmly within the organ he referred to as the mind, which we now understand to be the brain. His statement – “If we learn that there is no world of delusion outside the mind, the bewildered mind becomes clear” – is remarkably accurate.

On Perception and Memory

Buddha made a distinction between the flow of thoughts and the stock of memory influencing our perception. In his view our perceptions are influenced by our memory. Thus we view the present through the coloured glass of past experience and do not see things as they exist or as they are constituted. When a person perceives an object, both the memory of the same or similar object and the feelings the person had on the earlier occasion are rekindled. Moreover, comparisons are made between imaginary constructions of the object and the object itself. However, this distinction between stock and flow is more analytical than exclusive. Indeed, stock and flow interact all the time.

This view mirrors our current understanding of how the limbic system in the brain works. It has been proposed that the hippocampus is the storehouse of memories. Adjacent and connected to it by a chemical rich neural network is the amygdala, an organ deeply concerned with human emotion.

Any external stimulus results in activation of both organs; thus when a person sees a snake, his memory (and learning) tell him that it could be dangerous, and he experiences fear as a consequence. Memory and emotion are therefore in continuous interplay, as conceived by Buddha.

The Rational Mind

Buddha’s understanding of the human mind (and brain) was unique; both rational and contemporary. He encouraged debate and discourse; raised questions more often than he provided answers; encouraging his followers to think like him, with freedom. He recognised the pitfalls of blind faith, unquestioning belief and intolerance of contradictory ideas. He laid emphasis on empirical verification and on understanding the world, as it is and as it is constituted. Indeed, through his radical empiricism, he laid the foundations of scientific spirit and enquiry 2500 years ago. His was the quintessential rational mind.

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Cerebral Musings Children Expert Blogs

The Predominance of Brain Dominance

On the threshold of a new academic year, parents and students are again confronted by the dilemma of career choices. But insights from neurological and behavioural sciences can help you make an appropriate choice.As schools and colleges reopen, those of us with an interest in brain development and behaviour are witness to, yet again, a stream of anxious parents and their wards seeking advice and support. Course and career choices that young people are about to embark on challenge the best equipped families and provoke considerable debate (and conflict). What is clearly apparent is that both parents and their wards have not, in most cases, prepared themselves adequately for these unique milestones.

We live in an aspirational society, where higher standards of achievement are generally, constantly, being set as the norm. Also one where success has acquired many new connotations! This has its effect on both parents and their wards. Many people set as targets for their children all those goals they wanted to achieve (or wish they had achieved) but couldn’t. Others are keen to ensure their wards follow in their own footsteps, in the belief that this will give them “a leg up” in their careers. What gets forgotten amidst these parental aspirations is that the child may not share these parental goals, nor have the aptitude and ability to see them to fruition. Youngsters too, influenced as they are by a changing society, sometimes set unreasonable targets for themselves; targets for which they may not necessarily have the ability, aptitude or at a pragmatic level, wherewithal. Peer pressure also plays on both parents and their wards. One often encounters otherwise relaxed parents degenerating into a state of panic at the thought of admissions and career choices. There is no doubt therefore that this scenario causes much distress to all concerned.

Help at Hand: A question that is not asked often enough is whether there is a science that will help us approach career and course choices logically. Today, neurological and behavioural scientists have a sophisticated understanding of human brain development and behaviour. Application of even working knowledge in these fields can help both parents and their wards. The concept of hemispheric dominance, i.e. which side of the brain has a more dominant effect in the concerned individual, is one example of how brain function may influence aptitude, learning, behaviour and consequently success.From a cognition perspective, people who are left brain dominant have a better verbal memory, better linguistic abilities, reasoning and logical skills and better vocabulary! From a behavioural perspective, these left brain dominant individuals tend to be more ideological and philosophical in their approach; more motivated by social and pragmatic, rather than emotional concerns; more diligent, purposeful, capable of greater tenacity and driven more often by a sense of duty. On the other hand, people with right brain dominance have a better visual memory, better perception of space, better appreciation of the fine arts, and greater creative ability. They also tend to be more mood and emotion driven in making their choices. As a consequence, they may work with inspirational bursts of energy, not for reasons of purpose, duty, outcome or workplace ethic alone. Those in the creative professions are commonly observed to have such predilections. Put simply, left brain dominant individuals think with their heads; those who are right brain dominant, with their hearts!

Plenty of Options: Can these concepts be useful in making course and career choices? Courses and careers that leverage on a person’s natural aptitude and ability are most likely to be enjoyed and to result in successful outcomes. Pre-eminent among these for the left brain dominant individual are careers that demand literary learning, verbal memory, logical reasoning and diligence; medicine, law, business studies, accounting and finance, computing, research, some humanity disciplines (philosophy, psychology, sociology, history, economics etc.), teaching conventional subjects, to name a few important choices. On the other hand a right brain dominant person may choose the fine arts, theatre, cinema, music, architecture, design, advertising and media, and a range of other careers that demand creative endeavour. Indeed, it may not be just in the choice of careers that brain dominance plays a role. Even within these professions, brain dominance may help define specialisation, role functioning and ability.Parents and their wards may therefore do well to consider these factors in making decisions about courses, careers ands the future. The rapid strides that we have made in economic and social development in urban India have engendered a certain egalitarian ethos in our work places and across professions. No longer does one have to be a doctor, lawyer, accountant, bureaucrat or manager in order to “succeed”. While these career choices remain rather more secure and acceptable across social strata, the career buffet that the young person is presented with today accommodates a range of aptitudes and abilities, with differences in qualification or educational endowment not really being reflected in the pay cheque, in the grossly discriminatory manner so familiar even a decade ago. Young people today have the option of starting work relatively early in life, with fewer formal qualifications, often being paid better for their efforts than older, more experienced and perhaps better qualified individuals in their own families. When such glasnost has percolated into the workplace, then pray why the angst and obsession about traditional and safe career choices? Why not just allow young people to make the choices their brains are dominant for; accepting thereby the predominance of brain dominance!

Facts:

  • Courses and careers that leverage on a person’s natural aptitude and ability are most likely to be enjoyed and to result in successful outcomes.
  • Reading the brain Put simply, left brain dominant individuals think with their heads; the right brain dominant, with their hearts! Why not just allow young people to make the choices their brains are dominant for? Both parents and wards are not prepared adequately to tackle these unique milestones.
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Adolescents Adults Canine Neuropsychiatry Cerebral Musings Children Elders Expert Blogs Featured

Temperamental, Indeed

Life with my pet canines is not just joyful and entertaining; it reveals to me each day, profound neuro-scientific insights. Carlo, my German Shepherd, is a classic example of his breed; in looks and temperament. A “Master’s” dog, his life revolves around my routines. A glance in his direction, slight change in tone, low whistle, all will ensure his immediate compliance with “his Master’s” desires. Obedient and devoted to a fault, Carlo is also extremely high strung and anxious, alert to every change in his environment, and protective of it; so much so that I rarely catch him in fitful slumber. Blessed with an uncanny sixth sense for “his Master”, a trait that his breed is famous for, Carlo actually heads for the gate, minutes before my arrival at home from work. Not one to break rules, he will not enter a room or defile a piece of furniture, once forbidden. Natty and fastidious about his appearance, he remains shiny coated through the week, not an ounce of dirt on him, nor a doggy odour.

Unpredictable and Wilful: Contrast this with my later acquisition Coco, a Basset Hound. A handsome specimen with the classic sad and droopy face, jowls et al, Coco suffers from both occasional seizures and frequent mood swings. An approach in his direction, with best intentions, can evoke dramatically different responses: from a friendly, excited, tail-wagging welcome, to total loss of control; sometimes a resentful, even angry growl, bark or snap in the general direction of approach. Unpredictable mood swings from hypomania and hyperactivity to depression and profound apathy characterise his eventful existence. Disobedient, wilful and obstinate, he can be depended on to do exactly the opposite of what is intended, oblivious to “his Master’s” pleas, commands and threats. Indeed so agnostic is Coco of his surroundings that he can collapse like a sac, his numerous folds spread around him, in fitful slumber, no matter what the circumstances are. House rules mean little to this brat! Stride he will into any room at will, climb on any piece of furniture that strikes his fancy; and somehow manage at least once in each week to manifest for our benefit the pinnacle of filth; no part of the garden, however muddy, having been spared during his meanderings.

Not surprisingly, he emits a profound doggy odour so striking that dog lovers claim it should be bottled and sold (Chanel by Coco is our private joke). Guests without a fondness for canines, beat a hasty retreat from our abode when he decides to bless our company with his presence.

The contrasts in doggy behaviour become most apparent in our morning walk together. Carlo, the German Shepherd, needs no leash, walking three to four kilometres on the footpath that runs alongside arterial roads near our home. Rarely straying more than 10 feet from “his Master”, purposeful in his stride, nary a glance asunder, whatever the provocation, Carlo is the epitome of walking propriety, even his ablutions being timed for completion at a certain discreet spot.

Coco, the Basset Hound, on the other hand, treats the walk as a grand exploration of sorts; an opportunity to experience for himself this beautiful world that the good God has created. Constantly tugging at his leash in an angle perpendicular to the general direction of travel; sparing no human, animal or plant form en route from his nasal excursions, Coco is anything but purposeful about his morning constitutional, his ablutions being intermittent and erratic, intruding into the well directed journey of his fellow canine and Master, much to their combined annoyance. No order is heard, let alone obeyed; no single purpose complied with, other than that, which his doggie mind is set on.

My clinical experience in brain and mind matters has led me to conclude that Carlo, my German Shepherd, is left-brained and Coco, my Basset Hound, right-brained. The concept of hemispheric dominance, i.e. which side of the brain has a more dominant effect in the concerned individual, is one example of how brain function may influence behaviour and temperament.

Left brain dominant individuals tend to be more ideological and philosophical in their approach; more motivated by social and pragmatic, rather than emotional concerns; more diligent, purposeful, capable of greater tenacity and driven more often by a sense of duty.

On the other hand, right brain dominant people have a better appreciation of the world around them, greater creative ability; a proclivity for the finer aspects of life; and tend to be more mood and emotion driven in making their choices; both day to day ones and those that are life-defining. Put simply, left brained individuals think with their heads, the right brained with their hearts; and can be quite a study in contrasts, experiencing great difficulty understanding one another. Little wonder then that many professional and personal relationships run into rough weather; the two parties failing to understand each other’s contrasting preferences and predilections.

Unique Temperamental Attributes

Carlo and Coco have taught me that brain dominance is not an exclusive prerogative of the human race. And love them as I do, equally, I have learnt through them to celebrate rather than despair in these unique temperamental attributes conferred on us by our brain, that marvellous wonder of creation. To understand my family and friends better by observing their brain dominance. To choose correctly my activity companions: left brained for the purposeful and right brained, the hedonistic; and to tailor my expectations of them, appropriately. Carlo and Coco have enhanced my understanding of human nature; and thanks in part to them, I find myself at peace with my fellow men; well most of the time. It is a dog’s life, indeed!

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Adults Elders Expert Blogs Featured

The Stress Vortex

The word stress, used loosely today in society, has many connotations and can imply a range of circumstances from ordinary workplace or familial dissonance to serious mental disturbance. Crucially, what starts off as a minimal disturbance in one sphere of activity can have significant ramifications that affect many life spheres, if left unattended.

Life and society in the 21st century are profoundly stress generating. While a range of reasons may be held responsible, central to all manner of stress genesis is “the yawning gap between expectation and reality”. Modern lives have spiralled unthinkingly into a vortex, driven by predominantly Western economic models: of unremitting desire, relentless aspiration, pursuit of material gain, needless and thoughtless consumption, transient and elusive fulfilment, and unfettered hedonism. Stress is a natural accompaniment, a constant companion, as new desires replace the old, and the gap between expectation and reality remains constant, if not ever-widening.

Can we escape this vortex? Reduce, even remove, the negative factors that perpetuate stress in our lives? Transform ourselves into that epitome of self-management that others look up to?

Sources of stress

The Psychological Conflict Hypothesis: The concept of a psychological conflict comes from Freudian thought and is believed to underlie emotional stress. Freud proposed that we have both an unconscious and a conscious mind and that there were inherent conflicts between the primitive urges (Id), the unconscious (ego, current awareness) and the feedback from the moral agency (super-ego). While Freud emphasised sexual urges, psychological conflicts are generally believed to have their genesis in the dissonance that can arise between our inner urges and socially permissible actions; a dissonance that may defy resolution.

The Self Actualisation Hypothesis:

Proposed by Maslow, it assumes that each individual has to ascend different steps of the self-actualisation pyramid. At the very bottom of the pyramid are the person’s survival needs; after which appear, progressively, security needs, social needs and ego needs in that order (see box). When all these needs are addressed to a significant extent, the person achieves a state of self actualisation, of fulfilment and being content with one’s lot. Stress is a constant companion at various points on the self-actualisation pyramid and disappears when self actualisation is achieved. However, Maslow’s rather utopian view of the lasting self-actualised state of being may not hold true in the fast-paced modern world, where events often outpace individual development in most unexpected ways.

The Locus of Control Hypothesis:

An important psychological construct used to explain the development of depression, an important consequence of stress is the locus of control hypothesis. It has been observed that rats placed in connected cages soon learn to avoid the cage that habitually gives them an adverse stimulus such as an electric shock. However, when the rat receives shocks in an unpredictable manner, it becomes listless, withdrawn and inactive, a state of “learned helplessness”. This has led to the understanding that internal locus of control (where the person feels in control of his circumstances) is protective from emotional stress; while an external locus of control (being controlled by one’s circumstances), makes one vulnerable to it. In the years of post-war industrialisation this phenomenon was recognised in “assembly line workers” who had little control over the nature or pace of their work and were expected to perform a repetitive task for hours on end. Interestingly, our much vaunted IT revolution has ushered in a new generation of “assembly line workers” who operate on international time and in response to international demands, often with little control over their workspace destiny.

The Coping Hypothesis:

One point which eludes us when we are in a stressful situation is that there are, usually, only two ways out. Take for instance the example of a very short-tempered boss who reacts without provocation. One can either attempt to modify the situation (i.e. bring about a change in the boss so that he loses his temper less); or one can modify one’s own expectations (i.e. accept that boss with his short temper and learn to work around it). No prizes for guessing which is the easier pathway here. It is often said for this reason

“when you cannot modify the situation, modify your expectations”.

Coping strategies are of two kinds: i. Problem-focused coping where the attempt is to short-circuit negative emotions by modifying, avoiding or changing the threatening situation and; ii. Emotion-focused coping where the attempt to moderate or eliminate unpleasant emotions by rethinking in a positive way. Some strategies employed include relaxation, denial and wishful thinking.

In many circumstances, both approaches are combined in the effort to overcome stress.

Preventing Stress

The prevention of stress is achieved through good self management. The key to self management lies in being mindful: of oneself and the world around. Inexorably linked with this mindfulness is developing a better understanding of oneself and one’s fellowmen. Caught as one is in the vortex of modern existence, mindfulness can often be elusive, as the roller coaster of life takes us from one event to the next.

The famous Tibetan Buddhist teacher and philosopher Sogyal Rimpoche differentiates the active laziness of the West whereby unimportant tasks become responsibilities, part of a rigid schedule, and begin to dictate one’s existence (appointments, schedules, waiting times); from the passive laziness of the East, hanging out in front of the roadside stall with film music blaring, watching the world go by.

Neither, he contends, is ideal; instead, he highlights the importance of spirituality and contemplation and the need for us to devote some time in each day to examining the deeper meaning of life. In his view “Our task is to strike a balance, to find a middle way, to learn not to overstretch ourselves with extraneous activities and preoccupations, but to simplify our lives more and more. The key to finding a happy balance in modern lives is simplicity.”

It must be noted that stress clearly has its benefits. Imagine if you did not feel stressed out in advance of an interview or exam; your preparation and performance are both likely to be sub-optimal. Some stress is therefore necessary in order for human beings to “survive”. Too much stress, on the other hand, can be unproductive, even wasteful; resulting in much negative energy being expended. What we must try and achieve, therefore, is a fine balance between ambition and motivation on one hand and equanimity of mind on the other. And, while we strive to control our own destinies, by being in control of our lives and circumstances, our destiny may have other plans, that we cannot fathom; plans that we must learn to accept and live with. Perhaps, therein lies the key to effective stress management.

Heart Facts:

  • Stress impacts on the heart: it can cause myocardial infarction (heart attacks) and sudden death. It can affect the regulation of your heart beat by the central nervous system.
  • The INTERHEART study investigated the relationship between chronic stressors and Myocardial Infarction in about 25,000 people from 52 countries. After adjusting for other risk factors, those who reported “permanent stress” at work or at home had double the risk for developing a heart attack (MI).
  • The broken heart syndrome , sudden ballooning of the heart apex (left ventricle) follows acute stress. Often there is no evidence of obstructive blood vessel disease. Episodes of intense emotional or physiological stress are reported prior to presentation and maybe the triggering factor. Even when intense bouts of emotion don’t kill, they may cause long-lasting heart damage.
  • The Whitehall II study found over a two-fold increased risk for new coronary heart disease in men who experienced a mismatch between effort and reward at work. High-risk subjects were those who were competitive, hostile, and overcommitted at work, in the face of poor promotion prospects and blocked careers.
  • Cardiac syndrome X affects women more; there is angina-like chest pain and a positive response to the treadmill test with normal heart circulation. Cardiac syndrome X patients report more depression, anxiety and somatic (physical) concerns; they also have better prognosis.
  • Depression is a primary risk factor for Ischemic Heart Disease and an independent secondary risk factor for Heart Attacks. Depression also has a direct impact on cardiac risk factors such as diabetes, hypertension and obesity. Depression after myocardial infarction more than doubles the risk of death and of another heart attack. People who suffer chronic anxiety are more likely than others to suffer heart attack. Emotional trauma such as the death of a spouse, mental or physical abuse, or post-traumatic stress disorder (PTSD) increases risk of heart attack.
  • People with Type D personalities (characterised by pessimistic emotions and inability to share emotions with others) and Type A personalities (characterised by anxiety directed outward as aggressive, irritable, or hostile behaviours) are more likely than others to suffer heart attacks.
  • Freud said that happiness comes when one has pleasure in love and work. Research shows that marital stress in women and both marital and work stress in men greatly increase the risk of death due to a cardiac event. A famous doctor has observed “where can he go if he is unhappy at work and at home?” The implied, if somewhat flamboyant, answer was always “to an early grave.”
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Adolescents Adults Cerebral Musings Children Elders Expert Blogs

In a New Light

An exploration of Jiddu Krishnamurti’s well-documented ‘transformational’ experience that lead him to a state of god-intoxication.

Jiddu Krishnamurti! The name conjures up many images: benevolent soul who dominated the spiritual world; silver-haired seer with unparalleled vision and verbal felicity; educationist and thinker par excellence; institution builder; diminutive gentle giant with the unique ability to usher peace and joy into troubled lives and minds. In Toto, an enlightened soul, supremely in touch with himself and the world.

How did he evolve to this enlightened state? Was he born with a special mind? Was he transformed by experience, education and mentorship? Or, did he have a moment of spiritual awakening that changed his life forever, as his associates and biographers say? Unlike many world seers whose transformational experiences are hearsay, JK’s was well documented by those close to him at that moment. It is the subject of this exploration.

Well known, but worth recapitulating. Born to a poor rural Brahmin family in the now famous Rishi Valley area in Andhra Pradesh, JK moved to Madras as a young boy. Frail and unremarkable, he was spotted playing on the banks of the Adyar River by C.W. Leadbeater, an associate of Annie Besant, founder of the Theosophical Society. He came under their combined influence. Identified as “the chosen one” by them, he was told he should await the emergence of the master. His transformational experience occurred soon after. Noteworthy that he awaited “the Master” living in a beautiful place, surrounded by mountains.

The Turning Point: Described by his brother Nithya, who was with him during this period, the transformation begins with JK feeling ill; the sequence of events leading to the turning point is summarised in the box titled “The Prelude”.The setting for the transformation is described, “We were a strange group on the verandah. The sun had set an hour ago and we sat facing far off hills, purple against the pale sky in the darkening twilight, speaking little, and a feeling came upon us of an impending climax; all our thoughts and emotions were tense with a strange peaceful expectation of some great event”.JK is described as sitting under a roof of delicate leaves, black in a starlit sky. He is heard murmuring “unconsciously”; then a sigh of relief. “Oh, why didn’t you send me out here before?” This is followed by the weary repetition of a daily “mantra”. Then, silence.JK on the transformed mind: “I was supremely happy for I had seen. Nothing could be the same again. I have drunk at the clear and pure waters at the source of the fountain of life and my thirst was appeased. Never could I be thirsty, never more could I be in utter darkness. I have seen the light. I have found compassion, which heals all sorrow and suffering; it is not for myself but for the world. I have stood in the mountain top and gazed at the mighty beings. Never can I be in utter darkness. I have seen the glorious and healing light. The fountain of truth has been revealed to me, the darkness has been dispersed. Love in all its glory has intoxicated my heart; my heart can never be closed. I have drunk at the fountain of joy and eternal beauty. I am god intoxicated!”In a letter to Leadbeater written two days later, he goes on to say… “After August 20th I know what I want to do and what lies before me – nothing but to serve the Masters and the Lord. Now I feel I am in the sunlight with the energy of many, not physical but mental and emotional. My whole life, now, is, consciously on the physical plane, devoted to the work and I am not likely to change.”His words were, as the world later discovered, remarkably prophetic.

The Clinical-Science Perspective: The spectrum of symptoms during the prelude: pain, increased temperature, altered consciousness, exaggerated response to sound and touch (“exaggerated startle”) and repeated episodes of shaking with teeth clenched and fists closed indicate a seizure syndrome — an electrical storm in the brain. There are unusual features: quiet when comforted; quiet during mealtimes; having memory of the event and the ability to describe it later. All these are not normally encountered in a seizure syndrome. Was JK then experiencing psychosomatic symptoms: physical symptoms that have no physical cause and are underpinned by severe psychological stress?In this particular situation one must not forget that he was a mere slip of a boy, aged 16. He had been told that he was the “chosen one” and that he was to await “the Master”, a much anticipated event, both for him and those around him. Were his experiences brought on by the weight of collective expectation?He has said himself, “I wanted to meet with the Master as soon as I could. I thought about it every day but this was done most casually and carelessly. I realised where I was wrong and thereafter meditation became easy. I realised that there was a need to harmonise all my other bodies with the Buddhic plane (highest plane of consciousness) by keeping them vibrating at the same rate as the Buddhic. The main interest was to see Lord Maithreya and the Master.”Freud proposed that the human tendency is to repress emotional conflicts that are anxiety provoking and so the conscious mind cannot possibly contemplate them. Emotional repression results in these conflicts remaining firmly rooted in the sub-conscious mind. Inevitably, there are times when repressed emotions transcend to the conscious, but given their unacceptable nature, manifest as a physical symptom. Medical men term this “hysterical conversion”. These and other explanations for the events leading to JK’s transformational experience are outlined in the box titled “Neuropsychiatric Interpretations of JK’s Turning Point”.

Trinity Talking Eureka Moments: Should the clinician hesitate to make a diagnosis here? JK’s experience was not followed by any decompensation in mental faculties. Indeed, they were enhanced! He underwent a positive transformation and went on to occupy a special place in the world, beginning his journey as a spiritual leader. Further, the experience was not repeated; and it was both shared and documented; all of which render it less likely to be “a figment of the imagination”. JK is described by his biographers as being reticent in describing and discussing his experience, for a number of reasons that people have thought fit to attribute.

I for one wonder if transformational experiences reflect unique moments when one is in touch with one’s soul, that undeterminable part of the human psyche. Perhaps they represent a union between the brain (cognition), mind (emotion) and soul (realisation): a trinity talking “eureka” moment. Moments in which there is sudden clarity, often following a period of confusion and turmoil. Moments of insight, decision, and action.

Interestingly, both functional Magnetic Resonance Imaging (fMRI) and electroencephalogram (EEG) studies in Carmelite nuns, when they were “in a perceived state of union with god” have revealed activation of several brain regions concerned with emotion, memory and judgment, the temporal and frontal lobes and the connections that link them. It has also been suggested in these studies that personality rather than personal orientation may have a significant role in determining such experiences. Of course, what we do not know is whether these brain changes precede and therefore are presumably responsible for transformational experiences; or indeed whether they are the result of such a transformational experience.

The Transformed Mind: Transformational, life-changing experiences are well described among many seers, and often are a defining part of their reaching enlightenment. Our look at JK’s turning point indicates that they defy conventional paradigms of understanding in clinical science. Positive transformation in the JK mould may well require a very special and unburdened mind: sans expectation, dogma, and prejudice; explaining perhaps the early age at which many seers attained realisation. Perhaps, too, it needs in some instances, preparation, opportunity, encouragement and mentorship, all of which JK enjoyed. Most importantly, perhaps, transformation requires that Eureka moment, when the brain, mind and soul trinity are talking to one another!

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A Fine Balance

Once again, in October, I had the privilege of attending Chennai’s international festival of short films on mental health, “Frame of Mind” organised by SCARF (the Schizophrenia Research Foundation India). My task was to interact with the audience after the Richard Gere film, “Mr. Jones” about an extraordinarily charming man with bipolar affective disorder (manic depressive illness).

The film begins with the protagonist wanting to fly off the high roof of a building he is working on. His childhood desire to fly — matched by his firm belief while in a manic state, about his ability to do so — makes a potent and heady combination. As he watches a plane fly overhead and prepares to launch himself off the roof in pursuit, he is saved by his colleague’s presence of mind, thus landing in a psychiatric treatment facility.

Being a Hollywood film it needs a heroine; in this case a female psychiatrist of Swedish origin, whose first encounter with Mr. Jones at the facility she works in, leads to his choice of her as his doctor. Even from the beginning the relationship develops along rather unusual lines. She recognises his problem as being bipolar disorder and that he needs continued treatment rather than discharge. Her attempt to convince the court that he must be held against his will, and treated, fails. She leaves the courtroom disappointed and frustrated, only to have him request a ride home, as he has no money.

Blurring lines: The lines become blurred as professional and client proceed to not only have lunch en route, they also end up having a most enjoyable afternoon together. While the film thus portrays the human being within the patient and the professional, it also serves to disappoint the professional viewer, as the very foundations of therapeutic relationships and of appropriate behaviours within their context come crashing down.The film follows Mr. Jones through a manic phase of illness during which he is seen withdrawing his entire bank balance in one go, proceeding to invite the rather pretty and flirtatious bank clerk for an afternoon of fun. Poignant moments in the film ensue: when asked about his mania he says, rather emphatically, “of course I am happy; I am ecstatic!” revealing his distinct preference for that euphoric state of mind. Another moment of truth is when he ticks off his psychiatrist for asking intrusive and personal questions, pointing out that it is rude to do so. That psychiatric illness is dehumanising and strips the sufferer of his dignity, even through these seemingly mature and civil interactions, is well brought out here.

Mr. Jones slips, (as he inevitably must) from the high of mania, into the depth of depression. His distress, despair and pathos are well brought out, moments of anguish being portrayed sensitively. Once again, however, the rather unusual client-therapist relationship comes to the fore.

In general, physical closeness between client and therapist is discouraged; a firm professional handshake being, perhaps, the only physical contact endorsed; children and the elderly being possible exceptions. Here, client and therapist share hugs rather freely and with complete abandon. His long stay in the treatment centre where his therapist works, allows us brief insights into the lives of other patients and therapists, their trials and tribulations. An act of violence against our heroine by another deluded inmate, and Mr. Jones’ extraordinary presence of mind in saving her, result inevitably in increased closeness.

Dealing with Rejection: It is only in cinema that a professional psychiatrist and a client admitted under her care go for a drive together, get drenched in the rain and end up making love. Nevertheless, these actions seem to bring about awareness in our heroine, about having crossed a professional line, and she seeks to remedy matters by discussing the situation with a professional colleague, taking herself off the Mr. Jones’ case.

Her rejection of Mr. Jones also brings to the fore earlier rejections by those he is intimate with, but who cannot deal with his bipolar tendency. She finds out that “Ellen”, his former girlfriend whom he often refers to as “dead”, is indeed alive. Mr. Jones merely deals with her rejection of him as “death”; death for him perhaps of an ideal, a persona; of hope and long cherished dreams. The tribulations of those who live with bipolar disorder sufferers come to the fore here.

Rather poignantly, the bank clerk who spent a roller coaster day with our protagonist visits his psychiatrist to enquire about his well being. Her inability to understand how such a remarkably funny, engaging and talented person like Mr. Jones could possibly be ill is common experience. While all of us experience some mood swings, they are usually in consonance with our circumstances and proportionate to them, which is not the case in bipolar disorder.

The film also brings out the common biological explanation for this condition, that it is due to a chemical imbalance in the brain, and that there is need for compliance with drug treatment, so necessary here. This failure of patients to be compliant with treatment, one of the greatest challenges in managing psychiatric illness, is well portrayed.

Issues to the fore: During the audience discussion, the ability of Mr. Jones to choose whether he needs admission or not; the long conversations and therapeutic sessions he has with his psychiatrist; the need for a court order for his treatment are issues that come to the fore. Many wonder whether such interactions are at all possible in the Indian context and indeed whether they exist.

Professionals in the audience hasten to point out that Hollywood has undoubtedly taken liberties, and that there are cultural differences between the American setting and ours; that civil liberties for the person with mental illness are common around the world, although lack of awareness and education lead to their being transgressed in low and middle income countries. The ongoing redevelopment of India’s Mental Health Act is also discussed.

The client-therapist relationship comes in for much discussion; professionals in the audience ruing the unfortunate tendency among filmmakers to portray such romantic relationships. A call to filmmakers for more accurate portrayals of mental illness and therapeutic relationships is made. However, the group also acknowledged that film, like other art forms, is a caricature and thrives on dramatisation and exaggeration. View it with a pinch of salt is the common refrain.

The film ends where it begins. Mr. Jones is on the roof again, although his dejection and despair make us wonder whether it is to fly with childlike abandonment, or to die in abject surrender. True to cinematic endeavour, the heroine arrives in the nick of time to save his life and the couple unite in romance, her professional vows seemingly a distant memory. Will Mr. Jones’ ever get better? Will his heroine ever get to practice psychiatry again; lose, as she will, her medical license for consorting with a client? Will they live happily ever after?

The viewer is left with these and other questions as this rollercoaster of a film ends. It does underline for us, clearly, the travails of bipolar disorder, the importance of mental equilibrium, and of maintaining in our lives, a fine balance.

Quick facts: Psychiatric illness is dehumanising and strips the sufferer of his dignity, even when interactions are mature and civil The failure of patients to be compliant with treatment, is one of the greatest challenges in managing psychiatric illness There is an unfortunate tendency among film makers to focus on romantic relationships between therapists and their clients.

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The Entrepreneurial Mind

Many years ago, I remember watching a BBC program on the qualities of entrepreneurship. A diverse group of young individuals who did not know each other and had no knowledge of each other’s identity were being put through a series of tests, to identify secret entrepreneurs in their midst. One test stands out in my mind: the participants were asked to aim for and hit a target from a distance of their choice. Needless to say, the greater the distance from which one tried to accomplish the task, the more the rewards and indeed, the risks. Interestingly, the entrepreneurs in the group were the ones who chose to try from seemingly impossible distances. This appetite for risk is well recognized as being a quintessential entrepreneurial quality. But pray, what else characterizes the entrepreneurial mind? This is the subject of our exploration.

Five Minds!

Howard Gardner has described “the five minds” that are necessary for leadership. He begins with “the disciplined mind” acquired through years spent in scholarship, a craft or a profession, which he estimates takes the average person a decade to master. He prescribes that the disciplined mind emerges from consistent work done to develop skill sets and a knowledge base. This concept of “the disciplined mind” necessitates education and/or training, of course. But is education or training an essential pre-requisite for the entrepreneur? Many famous entrepreneurs have had very limited formal education, and in many instances have dropped out of the educational system, only to prosper. Famous examples of people who did not survive the educational system for a variety of reasons include Bill Gates, Richard Branson, Steve Jobs and our own Dhirubhai Ambani; all synonyms of successful entrepreneurship. So is education at all necessary for entrepreneurial excellence?

John Warrilow in a recent article identifies some reasons why an MBA may be bad for entrepreneurship.

1. Causal rather than Effectual Reasoning:

Entrepreneurs use effectual reasoning (they assess what resources they have and ask themselves what can be created) while conventional CEO’s use causal reasoning (they set goals and develop systematic plans to achieve those goals). MBA programs teach causal rather than effectual reasoning.

2. Adaptive rather than Innovative Thinking:

Adaptors are cautious and pragmatic. They take others ideas and try to innovate them, incrementally. On the other hand innovators overturn other ideas, challenge conventional concepts and are into big-bang thinking. MBA programs teach adaptive thinking rather than innovation, which is an entrepreneurial quality.

The advantages of the disciplined mind notwithstanding, one must address the question therefore, whether formal education is necessary for entrepreneurship, or whether indeed it is an impediment for success. John Warrilow points out that an MBA is bad for entrepreneurs also because “your classmates will not be entrepreneurs” and “you will waste 40% of your risk free years in a classroom”. It is a truism that the higher one climbs on the academic ladder, the more one usually has by way of formal employment opportunities, and the greater are the risks when one chooses to pursue an entrepreneurial venture in favor of well paid employment. Thus, too many years spent in education maybe a disincentive for risk, that important entrepreneurial quality. On the other hand it has to be acknowledged that formal education such as an MBA does bestow on one credibility, a critical element for entrepreneurial progress, at least in the early years. A doctor turned entrepreneur recently remarked to me, rather ruefully, that it took an ivy league MBA for people to be convinced about the seriousness of his entrepreneurial intent and ability.

Howard Gardner goes on to describe “the synthesizing mind” as learning to integrate disparate sources of information, identifying the links between them. Synthesis he says is identifying the jobs that need to be done and the people available to do those jobs. Synthesis is the identification of priorities and the way forward, balancing past visions with future aspirations. Synthesis enables one to examine new ideas in the light of one’s knowledge base. In this concept one needs the discipline of education combined with the ability to integrate disparate sources of information, an ability that usually comes with work experience.

Gardner then describes “the creating mind”, more a function of the leader than of the manager. Entrepreneurs are leaders and are generally bestowed with a strong sense of creativity, the ability to innovate and think out of the box. In general, the leadership of organizations require the development of compelling narrative, which then gets embodied in the leaders life. Good leaders (and entrepreneurs) are therefore expected to live by the principle “my life is my work; my work is my life” and to bring about changes to the lives of those

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Neurological Borderlands

In response to my attempts to discuss cognition and behaviour relating to a particular patient, whom I was presenting at a clinical case conference, a senior professor of neurology once said “I have little interest or belief in these modern supratentorial matters”. Although surprised and somewhat miffed, I took heart in the knowledge that I was not a stranger to this experience. The great father of cognitive and behavioural neurology, the legendary Norman Geschwind, is also reported to have had several similar experiences, when he set off on his journey exploring the brain, mind and cognition interface. Thanks to his brilliance, tenacity and the legions of pupils he managed to influence, the behavioural neurology interface that he gave life to is thriving today, in a way that he himself would have probably found unimaginable. Perhaps what surprised me most was that my own experience of rejection came almost three decades later, and the proponent was a neurologist somewhat junior to Norman Geschwind himself.Neurology is an academic specialty and one that has traditionally chosen to reside in ivory towers. Rather typical of this environment, many neurologists have been slow to accept and explore the rich interface that exists between their specialty and other aspects of medicine, science and indeed the humanities. However, both in the science and in the practice of medicine there exists many a rich example of such interfaces that occupy the borderlands of this great and noble specialty. In modern times the neuroscience arena has been revolutionised by advances in molecular and cellular understanding, neurogenetics, neuroimaging, neurophysiology, computational systems, neuropharmacology and other related areas of science and medicine.

Another quiet revolution has been taking place in neurology. Many centres world over have begun to develop clinical and research expertise in the interface between neurology and other areas of clinical medicine. Cognition and behaviour are now old examples of this interface that have advanced to becoming distinct specialties in their own right. Neuro-opthalmology, Neuro-radiology, Neuro-psychology and Neuro-rehabilitation are other examples of interface disciplines that have seen tremendous advances clinical, service development and research. Neuro-genetics, Neuro-epidemiology and Neuro-immunology are leading scientific disciplines today and have great prominence in academic institutions and specialist centres. Other emerging areas that are making progress, thanks to the efforts of individual clinician-academics, people of stature in different parts of the world, include Neuro-otology, Neuro-pulmonology, Neuro-cardiology, Neuro-gastroenterology, Neuro-urology, Neuro-oncology and Neuro-gynaecology etc. The momentum for such development has come mainly through interested clinician-academics in neurology and other branches of medicine, people with commitment, tenacity and foresight.

Significant contributions to these neurological borderlands have also begun to emerge in the research arena. A range of professionals from many scientific disciplines; biochemists, pathologists, microbiologists, pharmacologists, physicists and computational experts has begun to make inroads into neuroscience, often through major collaborative research programs. The humanities have not been left behind either with philosophers, psychologists, social scientists, behavioural scientists, linguists, nurses, health service professionals and many others taking part in interdisciplinary research at the neuroscience interface. However, despite these changes, the neurological borderlands remain largely ignored. The do not always form part of neurological curricula, nor do their proponents, laudable though their efforts, receive adequate attention as serious professionals in the neurological mainstream. Indeed, these specialists are often relegated to the very borderlands that they espouse and fail to find a befitting position within the rigid hierarchy of traditional academia, institutional or indeed that of learned societies.

In a world that is increasingly interdisciplinary, progress of any specialty is determined by its ability to incorporate and interface with the different disciplines that surround it: clinical, research and academic. The organisation and delivery of neurological services at the community level also demands a considerable interface between neurology and these borderlands, clinical, biological and psychosocial.  Such efforts must therefore transcend convention; beyond clinical work; beyond the biological sciences; beyond medicine and its specialties; to areas that appear peripheral but are nevertheless relevant. The neurological mainstream must develop an awareness and interest in these borderlands and make every effort to incorporate them in clinical, research and service development relevant to neurology. A failure to recognise this need to expand neurological horizons will only result in neurology failing to retain its rightful place under the sun, as the queen of medical specialties.

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