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Author: Dr. Ennapaddam S Krishnamoorthy

An international academic leader with multiple professional affiliations, past & current, he is the immediate Past President of the International Neuropsychiatric Association. In his 3 decade long career in the brain & mind interface Dr. Krishnamoorthy has occupied academic, professional, social impact & entrepreneurial leadership roles.

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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. sharing a romantic walk on the seashore, with profound insights on music, gourmet preferences and each other’s lives, her appointments at work, clearly being forgotten. 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. The roller-coaster of his mania takes over both their lives for a few hours, as street food, shopping for a piano for him and clothes for her, intimate moments in a swanky hotel room, and a visit to the opera follow one another in rapid succession. His attempt to conduct the opera, notwithstanding his later justifications about how Bach should really be played, result in his return to psychiatric care. 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; the changes of mood and impulsive actions that accompany this disorder. 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. The hypo-manic state where euphoria is predominant and actions expansive; the full blown state of mania where the person loses the ability to reason and is out of touch with reality; alternating with states of depression or low mood, poor appetite, low energy levels and insomnia characterise this disorder. 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. In one rather fetching moment, our heroine drops Mr. Jones at his doorstep, and as he crosses the road to his house, tosses across his medication, “your chemicals”; as she drives away Mr. Jones is seen tossing the pills into the litter bin, and walking nonchalantly home. 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

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Canine Neuropsychiatry Featured

A Rottweiler’s multiverse

Before you judge the breed, think again

My name is Kaiser, and I am a Rottweiler who lives in Chennai. The person writing this on my behalf is dad, the leader of our pack. I am of German and Serbian stock, and my origins go back to Rottweil in Germany, a town founded by Romans in a cattle-herding region. I owe my large head and snout to the mastiffs I was bred from, and my intent watchfulness to my role as a guardian. Indeed, butchers would hang their purses around our necks to keep them safe.

To my family, I am an affectionate goofball, prone to sit on their feet unmindful of my size. I calm down to the meaningful Malayalam song Manushyan Madhangalai Shrishtichu by K.J. Yesudas, written by Vayalar Rama Varma for the movie Achanum Bappayum. That together with my penchant for tearing newspapers and disliking men in uniform has led dad to conclude that I must have been a left-leaning, chai-sipping newshound in my last birth (notice the oxymoron).

My greatest joy is my morning walk with dad, our “me time”. Because I am hyperactive (dad says ADHD), I am sensitive to my environment — joggers, people who look me in the eye, whirring cycles and mopeds, people sporting helmets, umbrellas, head-covers, my list is long. My usual response is to charge in the general direction of the offender, and after a few surprises (torn sleeves, falling men and himself included), dad muzzles and harnesses me for these excursions.

Here are a few classes of humans I meet every day.

The dogo-philic: they love us and want to play, little realising that I, Kaiser (that’s German for Emperor), do not care for trifles.

The dogo-phobic: I can spot them a mile away, but they cross the road to avoid us; no fun but no trouble either.

The dog-agnostic: folks who don’t seem to recognise “the dog walking”. Here I am, 45 kg, deep-chested, big-headed, putting on my best swagger, and they walk right into us, preoccupied with their phones, companions, or thoughts. Being agnostic of me is not really wise, methinks!

The dog-walkers: Unlike us, many of these folks are not purposeful walkers; they amble, stop to socialise, hang around street corners. I believe it was George Bernard Shaw who said “Golf is a good walk spoilt!”. Now let’s paraphrase that, shall we? And of their dogs, the wise ignore me, the foolish bark, and the insane wail!

The talkers: “It’s good to talk,” says a popular telephony brand, but some take that slogan too seriously. When folks want to chat or socialise, I can be quite upfront about my disapproval. Those who don’t give up are greeted with a leap in their direction, which never fails to get them scurrying along.

The term multiverse was coined by American philosopher William James in 1895 to refer to the confusing moral meaning of natural phenomena. As a much misunderstood breed, I have described my multiverse to you. Despite my many redeeming qualities, the world views me with trepidation, not understanding that my responses are wired into me, through nature and nurture, by my evolved status as a guardian breed, created for humankind, by humankind, of humankind. Before you judge me and my fellow-Rotties, think again!

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Canine Neuropsychiatry Featured

Lessons from a bullmastiff

The writer is all praise for the pet he brought home as a puppy and who is now a loyal companion.

About a year ago, I became the fortunate owner of a Bullmastiff. An eternal dog-lover, I acquired my first dog, a Beagle, when I was 11 years old. Over time, in my journey to middle age, I have experienced life with three other (all long-lived) dogs — a Labrador, German Shepherd and Basset Hound. En route, thanks too in part to my professional predilections, I have developed an interest in dog behaviour and temperament. My focus on the mastiffs as a generic breed, followed my search for a guard dog, one that could innately discriminate friend from foe, and innocuous experience from potential danger. My search ended when my sister found a home-bred Bullmastiff litter on Facebook, culminating in a frantic drive to Bengaluru with my 9-year-old son, to choose our puppy. Thus began our tryst with a mastiff.

Widely described as “reliable, devoted, reserved, protective, alert, docile, loyal, calm, powerful, courageous and loving,” the Bullmastiff shares the characteristics of the Molosser dogs used by gamekeepers to guard the old English estates. Indeed, its progenitor, the English Mastiff, while alert and formidable, was thought to be too slow and plodding to take on the poacher and his dog, the lurcher. By crossing the English Mastiff with the Old English Bulldog (now extinct) in the late 19th Century, the compact, muscular and agile Bullmastiff came into being.

Legend has it that it was introduced at a fair, when a man challenged those present to try and outrun his dog; the man who tried, failed gloriously in his attempt, being brought down thrice by the Bullmastiff. Only one of about 13 mastiff breeds, the tallest being the Great Dane and the largest the English Mastiff (Argentina, Brazil, North America, parts of Europe and Eurasia, Tibet, all being represented in the mastiff family), the Bullmastiff is a large domestic dog with a solid build and a short muzzle.

I was inclined to choose a male puppy, having never brought up a female dog. Surprisingly, the advice I received from the breeder was to choose a female, as I would not, as a first time Mastiff owner (albeit experienced dog lover), cope with a male. I was also advised to build a dominant relationship with my dog, an egalitarian relationship being unsustainable with this breed.

“This is not a Labrador that you are taking home” said the gentleman repeatedly, with genuine concern. As it happens, Layla the Enchantress (as we named her), chose us and we were soon on our way home. In the car, all of two months old, she was composed in a way that was hard to believe. We would stop ever so often to give her a drink of water and/or a loo break, on the six-hour drive to Chennai, and she cooperated as if she had done it many times before, not soiling the car once, nary a whimper. Arriving home, we soon settled into a routine of feeds, exercise, toilet training and play.

Over a few days, Layla settled into our home having explored every nook and corner. In weeks, we could see why she was the “Gamekeepers’ Guard Dog”. Every sound was attended too, every person considered an intruder until introduced, every shadow a reason for suspicion. Indeed, late one night when she was asleep inside a bedroom, our son quietly brought in his friend for a natter. Any illusion of having cheated young Layla was destroyed in minutes, as she emerged from her apparent slumber, growling, the hair over her spine erect (distinctly coloured too), and proceeded to search the house until she had identified the intruder’s location and barked at him, until introduced properly. Indeed, the mastiff will not attack an intruder; instead it will rush towards him barking (a formidable sight), corner him and continue to bark until reassured.

Our morning walks are a daily highlight and eagerly anticipated. Within minutes of setting off, Layla “will do her jobs”, ensuring the remainder of the walk is a holy communion between man and beast. Indeed, by the time she was four months old, I had her walking “off leash” on the footpaths alongside the arterial roads near our home. Not once has she lost her composure, even when we come across another excited dog. Not once has she attempted to leave my side, except when I have meandered from my usual path into unfamiliar territory. Not once has she attempted to lead me; instead in classic pack animal behaviour, she waits at doorways, gates, even pathway dividers, for me to lead the way, acknowledging my pack leadership. Not once have I had to strike her, raising my voice, even an angry glance being enough for her to alter her behaviour suitably.

It is not that she has not tried to push the envelope, that being the predilection of this breed. Everyone is tested for their ability to “stand up”. For those who fail the test, Layla is the pack leader, and they must therefore follow her. The few who succeed are rewarded with loyalty and obedience that is par compare. Only one person, though, is given the privilege of being the “master”, and accorded unquestioning obedience and unbridled affection. From knowing which piece of furniture to occupy and which ones to avoid; begging for a scrap of food with immense dignity, yet never grabbing it from the table, even unattended; sitting still in a public place with amazing grace, surrounded by a hundred curious strangers, the Mastiff demonstrates a poise that is both awe-inspiring and endearing.

Many dog breeds have superior intelligence and can be trained to perform a range of often astonishing tasks. What intrigues me about the mastiff is its “sixth sense”, the instinct to modulate its behaviour in accordance with the human species; to have a place for everyone in its heart, and for everyone to have a place in its social pecking order. The innate power to discriminate between different human beings, their relevance to context and intentions.

Of course, the Mastiff is not alone in being able to do this. Among snakes, the King Cobra is thought to share this unique sixth sense. Indeed, herpetologist Romulus Whitaker describes rather eloquently, an incident during the making of his documentary, when he got too close to a King Cobra, who proceeded to warn him by rushing in his direction without biting and when the offence was repeated, proceeded to bite his behind. Whitaker credited being alive to his thick jeans. Other examples of the “superior intellect” this 12-18 feet long king of snakes possesses, are permitting its trainer to kiss the top of its head (as it stands erect, hood spread out) and indeed permitting lady trainers to dance for an audience with its head inside their mouth, both these being part of public performances in South East Asia. Once again, the innate ability to distinguish friend from foe and build a relationship with a “master” appear to be unique to this sub-species. Of course, stories abound among those interested in the animal kingdom about unique human-animal bonding: many dog breeds, elephants, the big cats, dolphins and killer whales, all being included.

So what is it about these sub-species that confers upon them such uniqueness? From my Bullmastiff, I have learnt the importance of mutual respect; of routines and predictability in interaction; of being assertive without being aggressive or offensive; of integrity and faithfulness; and of demonstrating love unabashedly when it is due. When Layla joins me on my favourite couch, sits on my head, all 50 kg of her, demanding to be petted at the end of a long working day, I am reminded that the best form of love is “tough love”. Indeed!

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Art & The Unquiet Mind

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. 

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Canine Neuropsychiatry Featured

Temperamental, Indeed

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!

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The quintessential rational mind

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.

Emphasis on empirical evidence: The Buddha laid the foundations of scientific spirit and enquiry 2500 years ago.

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. 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.

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The stress vortex

On World Heart Day we explore stress, that important concept that underlies cardiac disorders and appears to predict coronary crisis.

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?

Six friendly men of stress:

Rudyard Kipling, the India-born British author famously said (to paraphrase him), “I have six friendly men, they taught me all I know; their names are, who, what, why, when, where and how”. Let’s begin our journey by exploring the six friendly men of stress (see box).

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.

Managing Stress:

A number of strategies can help in stress management. Some of these are outlined herein (see box).

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.

Dr. E.S. Krishnamoorthy is a Senior Consultant in Clinical Neurology & Neuropsychiatry based in Chennai. Interact with the author on www.neurokrish.com

Some 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.”

Be happy and keep your heart healthy!

DR. ENNAPADAM S.KRISHNAMOORTHY

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Buddhi Clinic: Leading the Way in Integrated Care for the Brain and Mind

In today’s fast-paced world, a large section of the population is denied the opportunity to manage chronic diseases through a wellness, holistic and healing-oriented approach.

Dr. Ennapadam S Krishnamoorthy

The burden of chronic disorders is largely attributed to the perils of modern medicine that prioritises cure through prescription drugs instead of focusing on the entire continuum of human healthcare engagement: rejuvenation, restoration and rehabilitation. The end result: an unhealthy ageing population.This is where India’s ancient and holistic Ayurvedic system as a viable form of alternative medicine comes in. It is about time medical practitioners harnessed the full potential of Ayurveda as it’s based on a strong foundation of scientific research, much like modern medicine’s tenets. 

In recent years, a growing body of research points to integrated medical treatments—a combination of complementary (alternative) and modern (allopathic) medicine—gaining popularity. While modern medicine’s thrust is on cure, integrative medicine focuses on disease prevention, comfort and care.

However, despite the marked shift in patients’ preference for alternative forms of healing, I observed a deficit of innovation in therapies that are based on integrative medicine. This is where Buddhi Clinic’s genesis and my entrepreneurial journey can be traced. 

I realised there was no other healthcare outfit in the world that provides a unique 360° evaluation of body, brain and mind through an integrated approach. At Buddhi, we take a holistic approach to diagnose a medical condition that combines the scientific rigour of modern medicine’s diagnosis and drug treatments with the therapeutic benefits of ancient healing traditions. 

In essence, my long-term vision for our healthcare startup that was founded as a project in 2009 and company in 2013, is to make complementary and alternative medicine (CAM) gain acceptance as mainstream therapies. From my experience, I realised this would be possible only by seamlessly integrating them with modern medicine. 

Let me tell you how this is done at Buddhi Clinic.

A Game-Changer in Brain and Mind Integrated Therapy

We are the pioneers and innovators of integrated care for the brain and mind. What sets Buddhi Clinic apart from the rest is that we don’t follow a cookie-cutter approach to diagnosis and treatment. Our raison d’être lies in being able to provide unique personalised treatment strategies for patients that is managed by interdisciplinary process-driven programmes. 

Since several neurological and mental health disorders and disability are longstanding issues, patients need continuous and comprehensive care. Thus, we strive to offer a better quality of daily life to our patients by curating a range of therapeutic solutions based on considerable clinical and empirical research, and our team’s extensive experience.

Buddhi Clinic’s focus is on neurology and mental health rehabilitation and therapy. We have also created a range of interventions for pain, mental health, lifestyle and disablement conditions. 

While our diagnostic approach and internal treatments are allopathic, we also rely on traditional healing therapies to restore the equilibrium of your brain and mind interface. Buddhi Clinic’s seamlessly integrated approach offers 14 non-pharmacological treatment modalities that are an amalgamation of modern science and ancient wisdom.

We offer treatment programmes for each condition customised for children, adults and the elderly. These include: Ayurveda, Acupuncture, Acupressure, Naturopathy- water, mud, aroma and magnet treatments; Reflexology and Yoga; and Rehabilitation therapies – speech, neurodevelopmental, physiotherapy and a range of specialized psychological therapies. We have also curated treatment combinations for Psychology – CBT, CRT, Behavioural, JPMR, ERP, EMDR; and Neuromodulation or brain stimulation (a full house of treatments). 

Empowering the Patient Based on the “McDonald’s Model”

One of the guiding principles behind founding Buddhi is respecting and understanding patient preferences and engaging patients in shared decision-making. Towards this end, we perceive our startup to be the McDonald’s of “Brain and Mind Care and Rehabilitation”. 

Similar to how a customer can curate his meal in a McDonald’s outlet, Buddhi Clinic, too, offers patients the choice to curate integrated treatment programmes tailored to their specific needs. This is called the “choice model” and is better suited for mild impairment and chronic or progressive health conditions. In such situations, we give patients the choice and flexibility to select a combination of modern and ancient interventions rather than rely on a single medical treatment, procedure and therapy. It is our belief that for best treatment outcomes, the patient should be in control of his own decisions regarding his healthcare options.

That said, our team also draws up a “prescription model” when the patient suffers from a chronic condition and requires continuous restoration and rehabilitation.

Crucially, at Buddhi Clinic, we adopt a holistic approach to healing our patients and focus on their overall wellness and recovery that goes beyond cure. We think different—not just about illness or disablement but also about ability and enablement. 

Research and Innovation Led Approach

Nothing fulfils me more than making sustained efforts to give our patients a better quality of life. Our patient-focused approach includes continuously monitoring their progress and offering them quality pre-treatment, mid-treatment and end-of-treatment assessments. 

Over the years, we have delivered quality healthcare to over 10,000 patients who have received an excess of 1,00,000 interventions. Our success stories that cover conditions such as autism, epilepsy, depression, Parkinson’s disease and dementia, among others, are documented as detailed case studies in ‘Buddhi Books’. The books are aimed at fostering the spirit of research and continuous learning to enable children, adults and elders achieve a better quality of daily life.

Buddhi Clinic also endeavors to offer innovative products and services to enhance the integrated approach to long-term brain and mind care. For instance, we use Transcranial Magnetic Stimulation (TMS) to treat neurological and psychiatric disorders. Transcranial Direct Current Stimulation (tDCS) and transcutaneous auricular Vagus Nerve Stimulation (taVNS) are also the Neuromodulation innovations we bring in. While the former two, rTMS and tDCS stimulate specific brain pathways for specific conditions and outcomes, the latter tAVNS stimulates the auricular (ear lobe) branch of the vagus nerve (ABVN), an easily accessible target that innervates the human autonomic nervous system. Like this, there are other innovations in the pipeline that we hope will lead to paradigm disruption in this space.

Building a Service-Oriented Approach

In order to create a healing environment based on holistic principles, we aim to continue to provide personalised and meaningful patient experiences at competitive rates. Since today’s patients have greater discernment, patient satisfaction is paramount to us. Our service-oriented approach helps us deliver, on an average, 10-20% more therapy to each paying client, apart from serving the disadvantaged at low cost or free of cost.

In the coming years, it is our goal to collaborate with doctors and diverse talents in the healthcare sector to serve populations beyond Chennai and India. Our objective is to demonstrate our capability as pioneers and leaders in integrated care with a brain and mind focus. 

One of my key learnings as a healthcare entrepreneur has been that it’s not enough to achieve a robust bottom line growth. It is equally important to sustain it by creating impact at scale through a committed patient-focused approach.

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The Curious Case of Vincent van Gogh

Vincent van Gogh is one among many famous personalities in history who have rightly or wrongly been credited with having suffered from epilepsy. It seems fairly clear that Vincent van Gogh did suffer from symptoms of brain and mind; seizures, hallucinations, mood swings and explosive impulsive behavior that have been variously attributed to bipolar disorder, Meniere’s disease and interestingly, personality features linked with epilepsy.

Van Gogh was not just a productive painter (over 2000 works in a relatively short lifetime); he was a very prolific letter writer. Indeed, in one very productive period in Arles (1888-1889) he is believed to have produced 200 paintings and 200 watercolors, a painting every 36 hours; he also managed to write to his brother Theo, an art dealer in Paris, and to fellow impressionists, 200 letters filling 1700 pages, the shortest six pages long.

van Gogh was probably hypergraphic, both in letter and painting, the latter having been described as a manifestation of hypergraphia by Michael Trimble, the eminent London-based Behavioral Neurologist. van Gogh had a history of seizures, probably even experiencing one while painting the portrait “Over the Ravine” revealed in the rough brush strokes and resulting in a torn canvas.

He also probably demonstrated other traits of the Geschwind Syndrome: intense mood swings, with irritability and anger; and a spectrum of sexual behavior (hyposexuality, hypersexuality, bisexuality and homosexuality). The last (among others) was with Paul Gauguin, in an intense argument with whom he experienced hallucinations (a voice that asked him to kill).

Provoked to be aggressive, he then experienced a biblical injunction “And if thine offend thee, pluck it out” and turned the razor, famously, on to his own ear (self portrait with a bandaged ear).

Indeed, his relationship with Gauguin was typically intense. van Gogh was observed by Gauguin to experience difficulty in terminating arguments and discussions (emotional stickiness). Another intense argument is thought to have resulted in van Gogh’s suicide: he threatened his physician with a pistol, was rebuffed, left the office, and shot himself in the chest.

He died two days later. It is noteworthy that van Gogh was the son of a preacher and started his life as one (probable hyper-religiosity). Indeed, it has been proposed by the neurologist and art scholar Prof. Khoshbin that van Gogh had all the five core traits of Geschwind Syndrome ( http://goo.gl/VyjxzK ). His extraordinary creativity and inspired genius makes his case all the more curious, indeed!

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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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