Dr. E.S. Krishnamoorthy , Behavioural Neurologist & Neuropsychiatrist, Founder of Buddhi Clinic in conversation with Dr. Sameer Parikh and Ms. Gayathri Prabhu.
Dr. E.S. Krishnamoorthy, Behavioural Neurologist & Neuropsychiatrist, Founder of Buddhi Clinic in conversation with Dr. Sameer Parikh who trains doctors, psychologists, and other mental health specialists, and Ms. Gayathri Prabhu who teaches literary studies at Manipal University and is an author of a memoir, “If I Had To Tell It Again” and has written few other novels like Maya and The Untitled. Dr. Sameer is the author of two books, one for children and one for adults.
Mental health. A word that is highly neglected by Indian society. In India, experiencing mental health issues is seen with suspicion, and individuals suffering from mental illnesses face stigma. Mental problems are frequently thought to be the result of a lack of discipline and determination. Mental health stigma, as well as an absence of availability, affordability, and knowledge, contribute to major disparities in treatment. ‘There is a deficit of experts and I don’t think it will compensate for a long time because the deficit is too high’ said Dr. Sameer Parikh. He also added how important it is to address mental health issues in the early stage and find preventive measures for them. While finding the solution to an issue, we should also make the effort to learn more about mental health and the doctors should take the initiative to impart the knowledge to the rest of the world. Another insightful thing mentioned by Dr. Sameer was that teachers and counsellors who work with adolescence will know what mental health issues they go through and how they can tackle them. ‘True change of mental health advances can only happen with the help of teachers and not purely by experts because we don’t have as many’ he added.
When Dr. Krishnamoorthy asked Ms. Gayathri Prabhu about how depression or any mental health issue of a person can affect their family member or the caretaker, she read a small part of her book where she wrote about her father’s illness. It reads, ‘Why? It is always the first question depression sparks. Where did this come from? Not asked from a diagnostic mood but in avoidance or curiosity or habit. If it is here, if it is in our mind, we need to ask what is to be done.
If mental health issues remain a stigma, then help-seeking behaviour will be prevented. If people don’t seek help, then there won’t be any change in the issues in society. ‘Help-seeking is not going to a doctor. Help-seeking is starting a conversation. Recognizing you have a problem and you need to find a solution’ informed Dr. Sameer. Ms. Gayathri said that stigma is her fear. It is an individual’s fear. When a person wants to seek help, they keep anticipating the reaction of society and this stops them from asking for help.
It is critical to remember that determining mental disease can only be done by establishing screening benchmarks. There is also an urgent need to dispel the myth that mental health is just the prevalence of mental health issues. Long-delayed debates and efforts to address the issue of access to mental health care are now making their intentions clear. Careful mapping and investigation are required to provide quality data, which is required to grasp the scope of the problem.
Dr. Krishnamoorthy has covered everything from adolescence depression to substance abuse in The Hindu Lit For Life (LFL) 2019.
Dr. E.S. Krishnamoorthy , Behavioural Neurologist & Neuropsychiatrist, Founder of Buddhi Clinic in conversation with Dr. Pratima Murthy, Dr. Shekhar Seshadri, and Dr. Soumitra Pathare.
The world has experienced a surge in the concern over mental health during the Covid-19 times, the concern has been to the extent that words like pandemic, covid, lockdown, quarantine and many more have come to be associated with ‘mental health.’ Dr. E.S Krishnamoorthy, Behavioural Neurologist & Neuropsychiatrist, Founder of Buddhi Clinic, virtually sat down with Dr. Shekhar Seshadri, child psychiatrist, a senior professor in the department of child and adolescent psychiatrist and dean of the behavioural sciences division; Dr. Soumitra Pathare, a consultant psychiatrist and director of the center for mental health, law and policy: Indian law society, Pune; Dr. Pratima Murthy, Professor and Head of the Department of Psychiatry, NIMHANS.
Dr. E.S Krishnamoorthy began the panel discussion by pointing out the irony of a world which changed due to a virus instead of wars and governments. He also noticed that the thing that changed the most is the impact that the pandemic has had on the mental health of people and awareness about the importance of mental health.
“There is no health without mental health,” Dr. Pratima Murthy observed. She explained that the initial stage of the lockdown was met with a positive response but it was soon overpowered by anxiety over sickness, family and hospitalization. She proceeded to exemplify the following with a personal experience while simultaneously pointing out that the most difficult part of the whole experience was the loneliness of the mental trauma, sickness and death due to the pandemic. Dr. Seshadri added onto the topic raised by Dr. Pratima and discussed the patterns of coping and stress of children during Covid-19 and their lack of understanding regarding the pandemic, angst about hospitalization and grief over loss of their parents, social interactions and predictability. He also mentions “intolerance of unpredictability.” Dr. Soumitra Pathare took over and talked about the emergence of awareness of mental health in Middle class India and the hoarding of the meager human resources for mental health by the privileged class of people.
Dr. E.S Krishnamoorthy questioned Dr. Pratima Murthy on the impact of the pandemic on women and she explained that there is a treatment gap and the services are not gender sensitive along with economic disparities, multiple roles expected of them and the stigma around seeking help. She also talked about the increase in domestic violence and the burden over working women to take care of their children, compared to working men.
When questioned by Dr. E.S Krishnamoorthy about the impact of the pandemic over the special needs children, Dr. Seshadri responded that pandemic and covid have a disproportionate response on the more vulnerable people. He carried on by explaining the difference between equality and equity and related it to the issues faced by the special needs children. Contrasted to him, Dr. Pathare discussed the discrimination faced by adults with mental illnesses and the ignorance of the authorities, even during covid, to include them in the ‘at-risk’ population until ordered to do so by the SCI. Contrary to that, the hospital of Dr. Pratima made sure to protect the individuals with mental illnesses and recognise them as “at-risk” individuals.
The discussion moved onto the vulnerable groups of India, Dr. Pratima talked about addicts and their problems; girl child and children with lack of technology; chemical and behavioral addictions. Dr. Seshadri stated that developmental psychology hasn’t considered the evolutionary impact of the Pandemic on the young children.
The panel moved onto the subject of suicide, domestic violence and alcohol consumption as well as the connection between the three. Dr. Pathare talked about the dependency on alcohol and the lack of alcohol without access to treatment during the lockdown.
The discussion concluded with highlighting the positive aspects of technology and the interconnectedness it provided to people during the times of stress and anxiety. The panel proved that the existence of Covid-19 had a toll on not only the physical well being of the citizens but also the mental health.
Dr. E.S. Krishnamoorthy , Behavioural Neurologist & Neuropsychiatrist, Founder of Buddhi Clinic in conversation with Dr. Prabha Chandra, Professor of Psychiatry & Incharge of NIMHANS centre of well being & Ms. Sunena Gupta who was then a student at UC Berkeley and some one who has turned around her self-image, overcome chronic illness & mental health issues through art.
Sunena is a disciple of the esteemed Guru, Mulla Afsar Khan at the Singapore Fine Arts Society and her production in 2020 “Colours of Hope” exhibits her passion for using dance for creating awareness around social issues. What has been commendable is her willingness and ability to share her personal journey.
How the contrasting behaviour of two dogs can give one an insight into brain dominance and enhance understanding of human nature.
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!
A lawyer who quit his profession because he could not pay attention to what his opponent was saying in court. A start-up founder, brilliant at strategizing, lost money because he could not send invoices on time.
And then we take you back 500 years to the story of Leonardo Da Vinci, one of the greatest artists the world has ever known, but also, a scientist-painter who never got around to finishing what he started. He would procrastinate, skip from one task to another, and in his lifetime managed to complete only 20 works of art, leaving countless unfinished.
Attention Deficit Disorder (ADD), say mental health experts, brain disorder that affects adult’s ability to pay attention, control moods and complete tasks, explains the behaviour.
Though not recognised as a mental disorder till the 1960s, studies have found that there are more than 350 million adults affected with ADD globally (says a study published in 2021 in the Journal of Global Health) and has been shown to be progressively increasing over the years. And the pandemic seems to have more adults seeking help for the condition, says neuropsychiatrist Dr. Ennapadam S Krishnamoorthy, founder of Buddhi Clinic in Chennai & Coimbatore.
“The Frontal lobe of the brain is the executive brain, responsible for planning, organisational skills, focus, and time management. It is also the site of the social brain, which gives one the ability to regulate behaviour. Both these are affected in those with ADD,” he says. The shift to remote working and months spent in isolation during the pandemic resulted in social cues from the environment being r replaced b y cognitive cues, which a person with ADD tends to struggle with, explains Dr Krishnamoorthy. “For instance, a person with ADD may do certain tasks in the office only when they are reminded of it by a colleague. The social cues are not there when you are working from home, and those with ADD may lose track of their daily tasks.”
There is a misconception that Attention Deficit Hyperactive Disorder (ADHD) presents only in children, but that is not so, explains Dr. Krishnamoorthy. In adults “Hyperactivity” is replaced with impulsivity, which is why it is referred to as ADD.
Sonal Singh, a certified ADHD/ADD coach, says the condition is exaggerated in times of transition, like when one goes from college to work, or is promoted from executive manager, moves cities, and so on. “Neurotypical people find it easier to adjust to change,” says Sonal, who adds that in the past couple of years, startup founders have begun to make up for a larger part of her clientele. “These are otherwise bright young adults with high IQs, but have difficulty focusing and paying attention.”
Chennai based psychiatrist Dr. N. Rangarajan though believes people sometimes reach out for a clinical diagnosis to validate their difficulties in coping with change. “Several of my patients seek help for self-diagnosed conditions that readymade online tests tell them they have. ADD needs to be clinically diagnosed. For some it may just be merely about learning to accept change.”
A Study published in the Indian Industrial Psychiatry Journal indicates that 17% to 22% of adults reporting to psychiatric services reporting for other mental conditions have been found to have ADD. In some cases says Dr. Krishnamoorthy ADD can masquerade as depression or anxiety, which also affect working (short-term) memory and the ability to pay attention. “In these cases, if the mental health issue is sorted out, the problems of attention deficit will disappear.”
One of the most visible signs of ADD is procrastination. “The person will be brilliant at ideating, but find it impossible to send an email or file an invoice” says Sonal.
King’s College London researcher Professor Marco Catani, who presented his hypothesis on da Vinci in 2019, in the journal “Brain’, attributes his explanation of the painter’s ADD to historical records which showed he ‘spent excessive time planning projects but lacked the perseverance’. “Those with ADD may also make promises they don’t keep because they have forgotten almost as soon as they made them. This can play havoc with both work life and personal relationships,” says Sonal . “In the end, ADD is all about emotional regulation. “ And the first step is to pay attention to the signs.
An examination of the Buddha’s views on the mind. Two and half millennia after his time, shows them to be remarkably rational and contemporary.
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.
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. V.S. 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.
This week, we at Buddhi Clinic inaugurate our new centrally located World Class Resource Hub,representing excellence in brain & mind care.With cutting edge diagnosis, comprehensive neurorehabilitation, mental health care and holistic wellness, expertly curated to suit each individual patient, Buddhi Clinic achieves a whole new milestone, another global first from Chennai.
FOUNDERSPEAK! We care about the elder, who cared for us when we were growing up. Elders are vulnerable to neuropsychiatric conditions — Parkinson’s disease, Alzheimer’s Dementia, Stroke and Depression. Accordingly, tremors, slowness & stiffness, forgetfulness, falls & paralysis, mental depression are all problematic and often difficult to treat. At Buddhi Clinic we bring together cutting edge modern science, the wisdom of ancient healthcare traditions & comprehensive rehabilitation under one roof. Explore Buddhi Clinic & Experience World Class Care.
BEYOND MEDICATION: Our Buddhi Clinic mantra is to integrate the best of modern science & the wisdom of ancient healthcare traditions for people with a range of brain & mind conditions across the lifespan. With 15 different non-pharmacological therapies under one roof, we offer world class multidisciplinary, multicomponent & holistic care. View our diversity of experience on www.buddhiclinic.com or read our expert blog on “falling men, failing neurons”to learn more.
20/A3, K. B. Dasan Road, Teynampet, Chennai, 600018
To know more visit www.buddhiclinic.com Or contact 9500010056 (Chennai) & 9500010066 (Coimbatore)
Having spent a few decades taking care of elderly family members and several patients , my experiences have changed my perspective of elder care over the years .
With modern medicine focusing as always on prolonging life with cutting edge advancements, quality of life of elders with residual disability is often the casualty. Few elders have spoken to their families about how they wish to be medically managed when the need arises. In such cases, whether the person ends up in the icu, hooked on to the ventilator or on lesser interventions, depends entirely on the family’s wishes.
There is the ever vacillating family, torn between doing ‘all it can’ and ‘ all it should’ in spite of continued guidance and handholding. Needless to say , we get to see more and more families not willing to subject their critically ill elders to prolonged isolation and interventions when quality of life is a distant dream in a hospital setting. And then there are elders who have clearly spelt out that their final exit must be at home amidst their loved ones. However, elders do despair when confronted with disabilities such as pains , imbalance , difficulties with getting around , digestion woes , insomnia and memory issues setting in and disrupting their lives.
Catching the morning sun in a well lit part of the house while sipping on a hot cup of tea or coffee does a lot for the moods and the bones.For the more able , a morning walk , taking in the sounds and smells of the outdoors in the company of fellow walkers , is a good start to the day.For the less abled, gentle rehabilitation in the form of physical exercises , massages , speech and memory exercises , yogasanas and pranayama go a long way in enabling independance and enthusing them. A daily activity schedule which could include chanting, colouring , listening to music , helping with simple chores at home and family members chatting over a meal with family or an occasional drive , would make life less weary.
With some guidance , many of them are able to use gadgets and happily browse , chat , solve sudoku and crosswords. Setting up the house to enable easy mobility and safety with antiskid mats , grab bars and stable chairs instills confidence and encourages independance.
Gentle measures which focus on a good quality of life would be the sensible approach to address chronic conditions, in the sunset years.
Buddhi Clinic’s Brain and Behaviour Dialogue with the legendary Prof. Michael R Trimble of University College, London, curated and presented by Neurokrish
The Buddhi Clinic virtual programme on 26/12/2020 was a ‘ Brain and Behaviuor Dialogue‘. Prof Ennapadam S Krishnamoorthy, who was Raymond Way Fellow in Behavioural Neurology and Neuropsychiatry, UCL, from 1997, under the mentorship of Prof. Michael R. Trimble, introduced his guru of many years. He gave a brief outline of Trimble’s illustrious career and observed that there could be no better person to elucidate the Brain and Behaviour interface .
As Chair in Behavioural Neurology and Neuropsychiatry of the Raymond Way Research unit, Institute of Neurology, Queen Square, London, and Professor in the same disciplines, Trimble established a unique system of academic mentorship over three decades. This led to neuropsychiatry worldwide remaining associated with the Raymond Way group long after the trainees and fellows left Queen Square. As a sensitive clinician, committed researcher and erudite scholar, Trimble had chosen the less trodden path, to establish neuropsychiatry as a recognised global academic and clinical discipline.
Krishnamoorthy set the ball rolling with “What made you choose Neuropsychiatry?” Trimble observed that the term ‘Neuropsychiatry’ was always a problem, with neurologists in Europe using it vaguely to indicate psychosomatic disorders; Freud unable to give it true meaning in his attempt, through a psychoanalytic viewpoint; the Behaviourists reluctant to give up their simplistic ‘stimulus-response paradigm’!
Trimble observed that it was the dawn of a new era when EEG evidence of the pathophysiology in a neurological disorder, with associated psychological problems, emerged in the late 1950s. Frederic Gibbs’ pioneering EEG studies in Boston, recorded the anatomical localisation of a form of seizure to the temporal lobe, which was replicable over a number of patients. This established the relationship between anterior temporal lobe abnormality and the psychopathology of epilepsy. Modern Neuropsychiatry took a definitive step forward in the 1960s and 1970s, with the discovery of the structure, function and circuitry of the limbic system of the brain. Trimble recalled that as the only Behavioural Neurology consultant in UK for a long spell, he participated in the ‘neuropsychiatric awakening’ of the 1970s, and enjoyed lecturing on limbic neuroanatomy. Neuroimaging resulted in several other revelations in the brain-behavior link. The Raymond Way group, were involved in early PET studies in the 1990s that showed the volume of the hippocampus to be smaller in schizophrenia patient.
Trimble’s dictum is that every neurologist must aim at proficiency in neuroanatomy. This should include brain dissection and not learning through anatomical waxwork models! One wonders if every step in Trimble’s higher education and training trajectory, toward specialisation in Behavioural Neurology, was planned by him well ahead, in order to achieve the thoroughness and authority in his field, which his professional career reflects. Trimble’s first degree was in Neuroanatomy with Sir Solly Zuckerman, followed by MPhil in Psychopharmacology before he trained at Radcliffe Infirmary for MRCP, at National Hospital, Queen Square in Neurology and at Maudsley in Psychiatry. As Johns Hopkins Fellow, he was exposed to American psychiatry for the first time. Though there was demand for his expertise in new drug development, in temporal lobe epilepsy, in particular, he opted for association with the legendary Prof Lennart Heimer, in his research lab. Trimble enjoyed being in his old familiar ground of animal studies, primatology and neuroanatomy, but this time round with years of clinical and scientific expertise behind it. In the four-author publication on ‘Anatomy of Neuropsychiatry’ (dealing with the latest discoveries in limbic system-basal ganglia circuitry, structure, function and pathology), with Heimer as lead author, Trimble, provided the valuable link between basic science sections and clinical neuropsychiatry.
Why did Prof. Trimble go into the field of Neuraesthetics?
As emeritus professor, since 2004, Prof. Trimble had the ‘leisure’ to consolidate his kaleidoscopic professional experiences and find the link to integrate them with his natural inclination towards creativity and the Arts. This resulted in three book publications, which go to form the subject of this online Brain and Behaviour dialogue. The rich fare presented, moved seamlessly from ‘Psychoses of Epilepsy’, championing the right brain along with other neuroscientist thinkers, to the power of the human voice in music at a Wagner opera; why Gana the gorilla at the Muenster zoo, who grieved the loss of her son did not cry ? or why humans, on occasion, find the need to move beyond the mundane, towards ‘a transcendental state of consciousness’?
The Soul in the Brain: The Cerebral Basis of Language, Art, and Belief
Johns Hopkins University Press (2007)
This was the first book discussed. In this provocative study, Prof. Trimble alludes to the interrelationship between brain function, language, art—especially music and poetry—and religion. Inspired by the writings and reflections of his patients, Trimble was drawn into the study of their individual artistic ability, in which he observed a clear pattern. He came to the conclusion that writing effective poetry is probably incompatible with certain disorders-schizophrenia being one, and seems to be highly restricted by epilepsy. Even in the literature, there are very few acknowledged poets with schizophrenia- as the content, metre and prosody cannot be sustained by them. “To be a musician of the canon with schizophrenia seems impossible, as a compositional score, of say Wagner or Brahms, have notes that go on and on and must follow a trend to cohere with the same narrative over a long period”. However, there were patients with manic depressive psychosis (bipolar disorder) who were capable of poetry and music. Another study by the Raymond Way group showed that some patients with temporal lobe epilepsy were ‘hyperreligious’, well above the expected range of involvement in religion. Hypergraphia was another unique temporal lobe phenomenon, but the content of the voluminous pages of writing was poor and lacked cogency.
The ‘Soul in the Brain’ brings together poetry, music (and going back to Greek culture, which offers a third element within Greek theatre) and dancing. This ‘total work of art’, integrating music, poetry and dancing, has ‘movement’. Trimble referred to the German term–‘Gesamkunstwerk’ for this integration of different art forms to create a single cohesive whole. This term finds acceptance in English in the field of aesthetics. “Movement in the arts affects our brain and ourselves in a different way, and that is where neuroaesthetics comes in” Trimble explained. His own keen interest in opera, drew him deeper into the realm of Neuroaesthetics and the role of the brain and mind.
The story of creativity started with language. Broca localized language to a small area in the left anterior frontal region, based on the study of his stroke patients. Hughlings Jackson, a contemporary of Broca, was skeptical about his findings and maintained that a higher order brain function like language could not be confined to a small circumscribed area. Hughlings Jackson, with his visionary understanding of the working of the human brain and mind, well ahead of his times, could be called the founder of modern Neuropsychiatry, Trimble opined.
Scientists were preoccupied with language syntax, and if this was in place and a lesion did not involve the left hemisphere, language was assumed to be normal. It took deeper study of patients with lesion of right anterior frontal region by experts, to spot the subtler missing elements in language, elements which boost its richness, namely, the emotional tone and prosody, (the latter so important to poetry). There was poverty of creative expression, of metaphors and other semantic aspects of language. Language is accompanied by gesticulation. There was slow acceptance, that it required the coordination of both hemispheres to make language.
Going back in time to ancient Greek culture, Trimble traced it to Athens and to the Festival of Dionysus, celebrated to this day, with much music , dance, revelry and abandon, in the spirit of freedom, reminiscent of the romantic era. Of the arts, linking music with religion became prominent during the Renaissance period and resulted even in moving small operas into churches. Opera marked the highpoint of Western musical culture in the 19th and 20th century. Trimble observed that the propensity to art occupies a spectrum, and varies between individuals and also periods in history, e.g., between the Baroque and Romantic periods of Western culture. Ancient Greek cultural music and art forms had a profound impact in shaping European culture through the ages.Interestingly, Iain McGilchrist conceives that it is “the brain that has shaped the world”, in his book, ‘The Master and His Emissary’!McGilchrist, neuropsychiatrist, philosopher and thinker, it was, who put creativity and art forms in the field of neuroaesthetics.
Trimble recalled how another undisputed champion of the right brain, John Cutting and he, had long discussions on this subject, while at the Maudsley as colleagues. Cutting was a neuropsychiatrist, with special interest in schizophrenia. His vehement disagreement with the right brain being assigned ‘minor hemisphere’ status, featured in his profuse writings. Trimble had also associated with Norman Geschwind, who had published his elaborate work on the laterality of brain function.
Why Human Like to Cry :Tragedy, Evolution and the Brain
Oxford University Press (2012)
The second book discussed:
What makes humans *cry?
In 2007, Gana the gorilla in the Muenster zoo, held up her son who died suddenly, and indicated her distress and grief, but did not cry, even as the humans watching her shed tears of compassion. Crying is an attribute exclusive to humans, adding to the other evolutionary attributes of homo sapiens.
Tears can signal pain or distress from one person to the other. When the mother sees the baby’s tears, it signals hunger or perhaps some discomfort. She cuddles and comforts the baby and each time this repeats, the bonding becomes stronger. When one looks at the large human face, and then within a short span of time, tears roll down the cheek of that face, the latter state of intense feeling creates a surge of emotion and compassion in the beholder.
Tears can also emerge as a result of aesthetic experience. Beauty, the art forms, and relating to memories of the past can evoke strong emotions. Proust describes
*Crying’ involves shedding of tears. It may be in the form of sobbing, weeping, etc
the archaeologist who bursts into tears on beholding an ancient Assyrian sculpture. It was a spontaneous mark of reverence for an artifact of the past. Trimble expressed concern that the Western world seems to be moving away from the past – be it from parents and family, a historical monument, or even the four walls of the house where one spent one’s childhood. This is a great pity, as these memories and emotions form the core of aesthetic values and in its absence, one may not be moved by a strain of music or a beautiful face – and probably be the loser!
Crying may follow a deep religious experience or listening to music or while at an opera. “Music appears to be the art form most likely to make us cry”, says Trimble. A study by his team, interviewing participants of the study, revealed that 80% cried to music, and 60% to poetry. Reading a novel, with continuity of the narrative almost equaled music in its impact on the reader. Another study of lottery participants left the team puzzled over why the winner cried. It came about that the ‘tears of joy’ made their appearance when the winner shared the news and bonded with the family and dear ones. Trimble confessed that tears well up in his eyes when he is at a Wagner opera, where the power of the human voice in music can raise the emotional response to its heights. It was acceptable to cry at the opera or in church, especially for men !
Greek tragedy explored many themes around human nature and it heavily influenced the theatre of the Renaissance.In the Renaissance period, in church, every member of the congregation was expected to cry, especially the men. If they failed to concur, they could be severely reprimanded, as crying was considered part of the religious experience, sacred and symbolic of grieving for the loss. He referred to the practice of lamentation,the passionate expression of grief or sorrow, from the Book of Lamentations of the Old Testament. He made a biblical reference to ‘Lacrima Christi’, which literally means ‘Tears of Christ’. William James, the modern psychologist and great thinker elaborated on a variety of religious experiences. He observed that the human mind is in search of a transcendental idea. A deep religious experience can provide this. William James on consciousness : “Consciousness, does not appear to itself chopped up in bits”. There is a continuous flow of thought in our minds, one leading to the other, which he referred to as ‘stream of consciousness’.
Trimble observed that our emotional response to tragedy and crying for emotional reasons have evolved over several millions of years. Then, why are people ashamed of crying ?
One of the more recent major discoveries of highest significance to neuropsychiatry is the mirror neuron. It goes beyond the scope of functional neuroimaging in some areas, as the presence of mirror neurons in the human brain allows identification with the other. This could be through the other person’s facial expression. But tears are an even surer signal from one person to another of emotional feelings; it arouses ‘with’= ‘com’- passion and feeling ‘in’= ‘em’ -pathy. Though the appearance of tears may be physical, put in the metaphysical context, it is a link from one person to the other, by what is termed empathy. ‘Theory of Mind’ is a complex human ability of social cognition, which is required to empathise and must have evolved towards fulfilling emotional reaction; chimpanzees do not have this highly evolved ability of social cognition, though they may imitate an action, like picking up a banana, due to the presence of some mirror neurons, but not beyond this.
Though the human brain circuitry for emotional tears is widespread, it links the cerebral cortex, especially anteriorly, with those areas associated with the representation of emotion-the limbic system and to the autonomic nervous system for the release of emotional tears. This highly evolved circuitry is not present in primates, again pointing to the hand of evolution.
The Intentional Brain: Motion, Emotion and the Development of Modern Neuropsychiatry Johns Hopkins University Press (2016 )
This was the third book discussed:
‘The Intentional brain’ puts together information it has accumulated over several hundred years-over 2000 years. Trimble’s purpose of the book may be conveyed briefly, by quoting from the preface to the book. “The book is not simply about Neuropsychiatry as a medical discipline, but it is in many ways much more a reflection on the way the brain and its functions have been viewed over the centuries, as well as the huge change in orientation, germinating within romanticism, which has given us an understanding of our dynamic, active, creative brain”. This was in stark contrast to the Baroque period, which was restrictive and had some strict formulations for literature, music, and other art forms.
Modern research has focused on the brain as a predictive organ. Trimble’s view of the dynamism of the brain and how we receive the world, borders on the transcendental! “The way we greet the world and the way the world greets us and the world is embodied within us and our need to control it”, he says and goes on to “ We go out in the world expecting something, greet the world with hope of fulfillment, moment by moment. If not fulfilled, there has to be some reconciliation.” If this does not happen, an alternative path is taken, as each situation demands, laying down a novel brain circuitry. The belief that the brain is a passive organ with a stimulus evoking a response, assumes that with repetition of this pattern, neural tracks are laid down, which subsequently guide the automatic response which has been preset.
Trimble spoke about the Baroque period, which was restrictive. The Age of Enlightenment brought further strictures in the belief that science offered the solution to everything. Almost as a reaction to the progressively tightening fetters, both political and social, imposed by earlier periods, there arose an intellectual movement, and with it an explosion of art, music, literature, and the glorification of nature and the past in poetry by the romantics of the 19th century. We enjoy much of this freedom, culture and art forms even today, but some nations show signs of repression, curbing freedom of speech and of the press and increasing inequity which could be possibly labelled the post-post modern age! McGilchrist puts the blame of all the unsavoury components of modernity squarely on people paying less heed to the right brain.
Iain McGilchrist, in his voluminous book, “The Master and His Emissary’, describes the evolution of Western culture, as influenced by specialised hemispheric functioning. He designates the right brain, with its greater contributionto creativity and the arts, (and perhaps to humanity) as the Master, and the left brain as the emissary in the “divided brain”. He is wary of the Western world today becoming increasingly dominated by the left brain which he believes may be to our detriment.
Prof Trimble concluded with “The Intentional Brain is how the brain works and we have got it wrong for 2000 years!” His appeal to appreciate the art forms in order to live life fully continues into his next book, from which he shared a sentence – “ A world without music is not human”.
Dr. Subbulakshmy Natarajan MBBS, DCN (Lond.), PhD, FRCP (Edin.)
Research Consultant, Neuroscience India Group (NSIG)
Adjunct Faculty Public Health Foundation of India
Prof. Michael Trimble is no stranger to the Chennai audience as he has visited at our invitation on several occasions. He came first at the invitation of Prof. Krishnamoorthy Srinivas as the TS Srinivasan orator for 1998. It is of interest to note that in the topic of his oration ‘Towards a Neuropsychiatric Theory of Literary Creativity’, the central neuroaesthetic theme of the books discussed here was already taking shape, to be consolidated in his retirement days. At several points of the dialogue Prof. Trimble, in a chatty way, would stop to address Prof. Ennapadam S Krishnamoorthy to revive the memories of the significant clinical and research work done together in the Raymond Way unit.
The programme saw good audience participation. During question time there was reference to Indian art forms and some thought-provoking questions, which Prof. Trimble answered at length.