Author: Oliver The Brainy Owl

Oliver, whose musings speak for & to us is our Mascot. Inspired by his namesake the erudite neurologist & writer Late Professor Oliver Sacks, he shares periodically, pearls of wisdom about the brain and mind. Hailing from a long lineage that has been associated with health over millennia, Oliver traces his ancestry to Athena & Minerva the Greek & Roman goddesses of health, philosophy & magic. Not to be mistaken for his comic counterpart...

Asma – Building Rapport

Post author By Oliver The Brainy Owl
Post date May 11, 2021

Asma – Building Rapport

Biography

Asma was the second born of two daughters to parents who were both working professionals and of a middle class background. Since the mother had some minor complication in the first delivery and as there was an eight-year gap between the two pregnancies with maternal age at 30 years, a planned, elective Cesarean was carried out. The delivery was conducted at term and the developmental milestones of infancy and early childhood were normal.

The maternal grandparents lived close to Asma’s home and looked after the two grandchildren when the parents were at work. In the Indian grandparenting context, this was carried out diligently, with focus on every aspect of traditional child development, covering the spectra of nutritional requirements, discipline, academic performance and physical, mental and spiritual growth. Asma’s attention-seeking behavior, temper tantrums and need to win every event she took part in might have been influenced by the environmental situation, but it was distinctly excessive on any account.

Exploring the Condition

Premorbidly, Asma was described as being intelligent, cheerful, sociable, enthusiastic about participation in extracurricular events like dance and music, and though a slow learner at school, she was keen on overcoming her academic deficiencies with added effort, which the teachers recognized and were lenient when marking her.

Asma’s clinical problems manifested at the age of six years, with two types of bizarre episodes of a repetitive, stereotypic nature. The first involved jumping up and down 10-20 times, in a seated position, clapping hands and bursting into unprovoked laughter, which could not be described as totally mirthless. She was aware and able to answer questions during the episodes, which were associated with sweating and terminated, after a couple of minutes in a cough, as if she was choking. These episodes occurred frequently.

The second type, 15-20 episodes in 24 hours, occurred both while awake and in sleep initially, and later was confined to the sleep stage. The attack was of arousal, stare, movement of hips up and down 5-10 times rhythmically (pelvic thrust), followed by a smile, hyperventilation and incomprehensible muttering for a few minutes and back to sleep. Initially she was responding to call during these episodes, but later she became unresponsive right through the episode. After basic seizure screening, in a city Epilepsy Clinic, which included neurological assessment, EEG and MRI neuroimaging, anticonvulsant therapy had been initiated, with some control of the frequency of seizures. Meanwhile, behavioural patterns, which were a clear departure from the norm for Asma had peaked, which caused great alarm to the family and school teachers at the mainstream school where she had studied from lower kindergarten class. The Principal of the school, who had known many childhood neuropsychiatric problems sorted out for them by the TriMed and Neurokrish team, referred the child to the medical facility, with a word of encouragement to the dispirited parents.

Our Healing Approach

When Asma presented to our service, accompanied by her parents, a month after the initial symptoms, she had clusters of 5-6 one-minute seizure episodes packed into 1 hour of daytime sleep and 3-4 two-minute nocturnal episodes. Bedwetting occurred once in two days, and only at night. The abnormal behaviours ranged from hyperactivity, aggression, abusive behaviour, biting, spitting, excessive and disorderly eating, to bullying other children, lying and employing overtly manipulative behaviours and defiant behaviour towards figures of authority. This was reported after detailed assessment by the Child Behaviour Therapist of Neurokrish.

The TriMed-Neurokrish team was alerted to gear up to fulfil their individual and collective roles in remedying the enormous challenge posed by Asma’s health problems. They had to bring into action (with mild variations, to suit the individual and the situation) the protocol for ‘Comprehensive Care for Epilepsy’- a best practice model for a resource-poor country like India, developed by Dr. E. S. Krishnamoorthy, to suit the sociocultural milieu and fine-tuned over the years of its use by him and his team members.

The basic requirement is a multidisciplinary team, which provides treatment, therapies, counselling and hand-holding for the patient and parents to get over the worst initial phase and to participate with hope even as they witness a palpable shift towards the positive phase of patient management.

Detailed medical and neurological examination of Asma revealed no overt clinical markers – neurological, endocrinal or genetic, suggesting a developmental disability or heritable trait. Repeated electroencephalograms (EEG’s) were abnormal with bilateral spike and wave dysfunction but failed to reveal any localization or lateralization of epileptiform activity. There was no suggestion of any syndromic epileptic disorder. Detailed testing of hematological, biochemical, endocrinal and metabolic, infectious and inflammatory parameters was non-contributory. Repeated MRI scans were taken, including a 3 Tesla MRI scan, the last, to define even a minute lesion if present It failed to reveal any neurodevelopmental markers of significance. We looked for hippocampal sclerosis, cortical dysplasia and hypothalamic hamartomas in particular and these were eliminated.

It was the turn of the clinical psychologist to assess the patient using standard assessment scales; Binet-Kamat Test for general mental ability, screening test for specific learning disability, NIMHANS Neuropsychological Battery for Children for profiling the neuropsychological component and Raven’s Control Projection Test, to assess the child’s attitude towards parents, friends, likes, dislikes, fears and worries. On these tests, she was found to have bright normal intellectual ability with an IQ of 119, mild difficulty in (the ‘three R’s’ as they were referred to in the colonial days! – ‘a’ being silent in arithmetic in its verbal rendering) reading, writing and arithmetic. She fell behind what was expected at her age. She also had problems in the areas of working or online memory, comprehension, attention (more frontal lobe related), visuospatial ability and mild memory deficit.

The projection test revealed “fighting with friends, problems at school and fear of ghosts”. While the child was cooperative and it was possible for the psychologist to establish rapport with her easily, she had a tendency to stray into phases of inattention, verbosity, playfulness and gnosis. This resulted in tests being incomplete. Given her general levels of comprehension, her ‘show of indifference’ to the overall predicament struck one as being altogether incongruous.

“The basic requirement is a multidisciplinary team, which provides treatment, therapies, counselling and hand-holding for the patient and parents to get over the worst initial phase…”

The Diagnosis

Asma was diagnosed to have epilepsy with complex partial seizures originating from frontal lobe. Behavioural problems are known to occur in complex partial seizures of frontal origin, as are the selective areas of learning disability. Her inability to keep up with the class, further aggravated the abnormal behaviour, as she was obsessed with being a winner every time.

The child was started on Levetiracetam and Clobazam, two of the anticonvulsants in the list of drugs of choice for this type of seizure disorder, in a girl child of pre-pubescent age. Risperidone in small doses was introduced in an attempt to control difficult behaviours. Multidisciplinary interventions included behavioural therapy, neurodevelopmental and task-based occupational therapy (specifically with focus on attention, fine motor skills and handwriting) and remedial educational support after school for dysgraphia and dyscalculia. With family counselling, it was possible to persuade the family to cooperate even more, as they developed awareness of the child’s genuine health problem and the basis of the multidisciplinary approach. The management protocol was complimented by working with the school, counselling the Head and the teachers, developing a joint statement of special needs and building a therapeutic alliance with her concerned but informed and enthusiastic parents and grandparents. Developing a process of continued and consistent communication between the family, school and treatment team was well established, and continued over several years.

Over weeks, with titration of anticonvulsant drug dosage, her episodes remitted. With optimal use of risperidone and the therapies, her behavior pattern also became more manageable. Her problems with inattention, learning and academic performance did however continue. Although through the six-year period of comprehensive care, Asma had managed to remain in mainstream education, and continued to work with her behavioral therapist and special educator, she was advised by Dr. Krishnamoorthy to drop a year and to consider more flexible educational streams in order to cope and with less tension all round, as stress of studies, a board exam to face, failures etc., could exacerbate the seizures and the behavioural problems. Following this advice and guidance, her parents sought admission for Asma in a city special school offering the National Open School stream. This stream allows choice of subjects with which the candidate is comfortable and he/she can take the school leaving examination, covering 2 or 3 subjects at a time at a hassle-free pace.

Epilepsy

The onset of any form of epilepsy can be devastating to the patient and family. It may repeat frequently or be moderate to severe, and persist through the lifespan, affecting education, employment, marriage and even independent living. Early diagnosis and treatment with anticonvulsants is essential. What is equally important is to have continued specialized and comprehensive epilepsy care to give the person with epilepsy a quality of life. Complex partial epilepsy of frontal origin are very uncommon, and can pose a diagnostic dilemma, unless the clinician has a clear knowledge of the condition. This is where a health care provider can draw from literature on the subject and know what others have said about it. A much cited author Williamson (1985), described “the complex partial attacks of frontal origin as brief, frequent attacks, complex motor automatisms, kicking, thrashing, pelvic thrusting, vocalization, while consciousness is maintained”, pretty much what our patient presented with.

Braakman (2012) undertook a comprehensive neuropsychological study of 71 children with cryptogenic (with no detectable lesion) frontal lobe epilepsy (FLE) to report that, “Across measures, the patients demonstrated a host of cognitive and behavioral impairments”, which again goes with Asma’s clinical picture and further confirmed by the presence of gelastic epilepsy. Gelastic epilepsy (‘laughing epilepsy’- Gelastikos in Greek meaning laughter) is a very rare epilepsy form, and is most frequently due to a benign tumour in the hypothalamus, but may also originate from the frontal or temporal lobe. Unnwongse (2010) recorded the symptomatic zone of laughter in the frontal lobe of a patient with gelastic epilepsy, employing intracranial video EEG. Benge (2014) observed that Executive Functioning, which is the ability to initiate volitional responses, plan, decide, and monitor performance is one of the most frequently impaired cognitive constructs in FLE. The frontal lobes have a critical role to play in memory functions as well, including organization and encoding of information to be learned, memory retrieval, and prospective memory. Attention and working memory difficulties may add to the cognitive deficit.

With all these areas of deficit, it is not surprising that the patient manifest learning disability. The clinical psychological assessment at baseline with performance score recording, when the patient started the treatment regimen, followed once in 3-6 months, will give a clinical evaluation of the progress, status quo or even regressive tendency, correlating with the real world patient’s all round performance, and carry with it projection and prognostication value.

Braakman HM, Ijff DM, Vaessen MJ, Debeij-van Hall MH, Hofman PA, Backes WH, et al. Cognitive and behavioural findings in children with frontal lobe epilepsy. Eur J Paediatr Neurol. 2012; 16: 707-715.
Williamson PD, Spencer DD Complex partial seizures of frontal origin Ann Neurol 1985 Oct.; 18,(4), 497-504
K. Unnwongse, Wehner T, Singaman W Gelastic Epilepsy and the anteromesial superior frontal gyrus Epilepsia Vol 51, issue 10, 19th March 2010
Jared F Benge, J Michael Therwhanger, Batool Kirmani The Neuropsychology of Frontal Lobe Epilepsy: A Selective Review of 5 Years of Progress. J. of Neurological Disorders and Stroke, Special issue on Epilepsy, May 2014, 2 (3), 1057

Our Focus:

Comprehensive Epilepsy Care

Comprehensive Epilepsy Care is about targeting patients, caregivers, healthcare professionals and society at large with focus on helping the person with epilepsy minimize stigma, achieve optimal activities of daily living (ADL), health related quality of life (HRQoL); social, educational and occupational milestones. It enquires into the goal of each treatment or therapy employed within a time frame, while including the patient’s (and their relatives) subjective evaluations and perspectives. There is considerable evidence to suggest that information, education and understanding help people deal with their condition better, as ‘knowledge is power’. There is also evidence in epilepsy that psychosocial interventions improve outcome. For the team to plan the intervention effectively, it is imperative that the problems diagnosed in the clinical or lab setting is converted to understanding their real world correlates and this derived knowledge is applied towards holistic and individualized patient care.

Looking Ahead

Asma has remained seizure free, has not shown any further behavioral decompensation and remains aligned with the therapeutic team and school. The parents express their heartfelt thanks everytime they come to TriMed for follow up. The Child Behaviour Therapist, in her inimitable way says that she will take Asma’s self confidence and self esteem to the next level as she enjoys total rapport with Asma (as with other children), teases and chides her and in turn hugs her to show appreciation. The Trimed-Neurokrish team is happy to deliver patient-centred, holistic healthcare with patience and diligence as a team in the midst of a modern consumerist healthcare environment.

Tags anti-social behaviours, anticonvulsant therapy, Child Behaviour Therapist, Comprehensive Care for Epilepsy, frontal lobe complex partial seizures, holistic healthcare, hyperactivity, Neuropsychiatry, Seizures

Adolescents Anxiety Autistic Spectrum Disorder (ASD) Buddhi Stories Children Featured Neurodevelopmental Disability (NDD) Patient Stories

Surya – Conquering Anxiety

Post author By Oliver The Brainy Owl
Post date May 11, 2021

Surya – Conquering Anxiety

Biography

Surya was the first born, delivered full term by lower segment Caesarian section, the indication being a big baby weighing 3.4 kg with a large head and cephalo-pelvic disproportion. The Apgar score was 9/10 (excellent). There was no neonatal seizure or any other health-related event of significance in the neonatal period or in infancy. With the passage of a few months the parents noted that the infant’s response to familiar people, even to them, lacked spontaneity, and eye contact was sparing. He was preoccupied with repetitively examining one favourite toy over a long period of time and this form of restricted play continued into childhood. He did not walk till almost 2 years, and even when he did, he was awkward and had frequent falls in the early phase. It was, however, the delay in the speech/language milestones with the first few meaningful words expressed at 2 years, that caused greatest parental concern.

At this stage, a diagnosis under the broader umbrella of Autism Spectrum Disorder (ASD) – Pervasive Developmental Disability – not otherwise specified (PDD-NOS) was arrived at by the specialist in USA and early therapies were started. The parents stuck to the specialist advice to confine the child’s exposure to a single language and English served the school and home front. On joining school at three years, there was some improvement in his verbal expression, but by 4 years, with the family back in India, from abroad, he had achieved wider language and communication capability. This is the magic gift that Indian children born abroad receive on exposure to the Indian milieu, even short-term, where grandparents, aunts, uncles and cousins, chatter incessantly, not necessarily in English, but also in their child-focused affection, rally round to address the child face-to-face!

Exploring the Condition

Surya’s speech, which lacked clear enunciation, accent and prosody, and had a nasal quality, required special attention and the child had regular speech therapy from the age of 4 years, aside from occupational therapy and special education outside mainstream schooling. Surya manifested restlessness, easy distractibility, poor motivation, social anxiety and on occasions, impulsivity, which also required correction. When he was brought by his parents to TriMed-Neurokrish two years back, at age 9 years, they appeared as stressed as Surya himself. As a high performing ASD, he had managed to barely cope with mainstream schooling upto the primary grades (ICSE Board syllabus), with poor math skills and dyslexia. Anxiety was mounting as he progressed to high school level with its academic demands. To add to the displeasure at school, he was bullied by the other children, who did not let him join them in the ball games offered, as he was slow and clumsy. When this awkwardness was analyzed by the specialist, it pointed to poor hand-eye co-ordination as a main cause. School refusal started to set in and the parents recognized the red flag signal which called for more intensive professional attention. A close friend suggested TriMed-Neurokrish as a possible solution to the child’s learning disability and emotional problems.

Surya had got this far academically, without major behavioural problems, as all along, the mother had dynamically participated in fulfilling his study requirements and emotional needs and the school had been supportive. His mother, a well educated, perceptive lady, continued to follow the special education methods at home, which she observed during the child’s sessions with the special educator. His spelling skills took a big leap forward when he was taught by the phonetic method. The mother spent long hours with Surya over his homework, partly by following rote learning methods, though by elaborating on the topics’ ramifications, she managed to bring in some conceptual learning, which ensured better retention and recall in him. Math skills were just picking up at a basic level, but Surya was happy to run up to the corner store to purchase some small items of grocery the mother requested, and managed every time to bring back the correct change.

Our Healing Approach

At TriMed-Neurokrish, a comprehensive assessment, by the team members was carried out with meticulous care. The child was thin built, with dysmorphic features, with a narrow face, low set ears, close set eyes, and a tendency to keep the lips parted slightly, the last due to a chronic sinusitis and nose block. No other abnormal systemic signs were observed and laboratory tests were unremarkable, except for low D3 levels, which was corrected with oral medication. We had a team meeting to formulate a list of priority moves to gain effective control in the management of Surya’s educational and psychosocial problems. A diagnosis under High functioning Autism Spectrum disorder – Pervasive Developmental disorder not otherwise specified (PDD-NOS)/Asperger’s syndrome (based on the Sohn Grayson Rating Scale) with Learning Disability (LD) was arrived at, and the broad management plan was discussed.

The immediate goal was:

To reduce Surya’s anxiety levels and get him to attend school regularly, a few hours initially, progressing to full day attendance
To overcome separation anxiety when the mother dropped him at school and left
To motivate him to engage in other activities than studies
To work on his fears and phobias of ‘robbed’, ‘kidnapped’, ‘killed’ which disturbed him
To offer caregiver support to the mother who was highly stressed

By way of medication, Surya was given Attentrol – (Atemoxitine) to improve his attention on tasks along with a anxiolytic.

The Clinical Psychologist found his academic performance adequate, based on the NIMHANS Battery (Specific Learning Disability Index). Regarding his special academic needs, with long term coaching outside school, Surya was able to cope with reading, writing (including spelling), at his 8th grade levels, with math ability at 5th grade levels. His handwriting skills were poor due partially to defective fine motor control and his focusing power on tasks required reinforcing with repetition. All these deficits put together made him very anxious regarding coping with studies.

Our intensive therapy for Surya followed our protocol for children with Neurodevelopmental Disorders (NDD) and included a combination of two Ayurveda treatments (Shirodhara & Abhyangam), Play Yoga, Neurodevelopmental Therapy (NDT, a combination of physical and occupational therapies, in his case with a handwriting focus) and psychological therapy (behavioral and family). Sessions of NDT and BT often continue for months in regular periodicity, and include weekend opportunities to meet with peers (also in therapy), socialize, and develop skills of emotional expression. Later, understanding his fondness for ‘gadgets’ we involved him in a cognitive enhancement program using structured computer based gaming to enhance specific cognitive skills.

Our team, after much deliberation, suggested to the parents, special education for Surya at a school of excellence, and with the Open School Examination system offered there, he settled to a comfortable pace of school work.

The special educators of the school, in dialogue with Surya’s parents, chose subjects for him that he would be able to comprehend and work out in a relaxed manner, and which would lead him to a future career as a high performing ASD. In this more relaxed school environment, the child overcame his fears and the separation anxiety was no longer a problem. Day-to-day, moment-to-moment caregiver stress was significantly reduced in the mother, who decided to expose Surya to other activities than studies as suggested by the TriMed-Neurokrish team. Coaching in swimming and keyboard playing were chosen as two diverse activities (with the mother joining the coaching sessions as well) which would benefit physical fitness, cognitive ability, concentration, fine motor activity, musical sensitivity, sensory integration and many other finer aspects of development in the child.

Surya’s motivation and empathy to go with the mother did not last for long and the ASD trait of preference for routine and repetitive activity prevailed. He preferred to unobtrusively sit watching his mother, as she completed the courses successfully and went on to the next level of training with the hope that perhaps Surya would get back to these activities some day with gentle persuasion and the slow but sure outcome of goal-directed CBT! She brushed aside this wishful thought and got back to the present with its encouraging progress in Surya.

He was however, enjoying his Behaviour Therapy and Cognitive Enhancement sessions at Trimed-Neurokrish and the team members gave of their best to sustain Surya’s interest through the sessions. He continued to listen to music, most often a favourite tune and beat repeatedly. He responded positively to engage in a short-term novel activity for which he was rewarded. In a BT session to learn how to tie his shoe-lace, his motivation was that he would get new shoes, and sure enough he mastered the skill in two days! What worked towards motivating Surya without fail was the reward in the form of a car ride, to undergo any new learning process. So the team went through BT for activities of daily living, interaction with strangers, mentoring and token economy, in a graded manner, to more advanced cognitive enhancement paradigms of arithmetic tasks, logical reasoning and critical thinking. Incorporating the subject’s areas of special interests in therapy, using visual aids and including parents in therapy sessions, the benefits of cognitive behavior therapy and cognitive enhancement became apparent.

“In this more relaxed school environment, the child overcame his fears and the separation anxiety was no longer a problem.”

Our Focus:

Autistic Spectrum Disorder

Autistic spectrum disorder (ASD) is a group of developmental disabilities that can cause significant social, communication and behavioral challenges. Autism represents an unusual pattern of development beginning in the infant and toddler years. Language and communication, learning, thinking, problem solving, social interaction, stereotypy and other behavioural patterns, lack of empathy and performance of activities of daily living may show varied levels of involvement. Neuropsychiatric and neuropsychological evaluations in Autism have revealed selective dysfunction of ‘social cognition’, with sparing of motor, perceptual and basic cognitive skills1. According to DSM IV the spectrum of autistic disorders comprise autistic disorder, Asperger’s syndrome, pervasive developmental disorder not otherwise specified, including atypical autism (PDD-NOS), Rett’s syndrome, and childhood disintegrative disorder. When full criteria of the five under this umbrella are not met, it falls under the category of PDD-NOS. High functioning Autism Spectrum disorder – Pervasive Developmental disorder not otherwise specified (PDD-NOS)/Asperger’s syndrome is diagnosed by employing an assessment questionnaire for the subject’s parents named the Sohn Grayson Rating Scale, a questionnaire for the subject’s parents, covering the academic, cognitive, psychosocial and other domains, which may indicate a higher performance and atypical pattern of the spectrum in the subject studied, as in our patient, Surya. Before this instrument is used, there are over seven diagnostic tools for ASD, including Autistic Behavioural Checklist, Autistic Spectrum Screening Questionnaire and observational tools which must be employed on subject to be tested.

Global prevalence of ASD is about 1.5 per 1000. There has been a 600% increase in prevalence over the last two decades. In a multinational study, the point prevalence of ASD was 7.6 per 1000 or 1 in 132 in 20102. In India more children with ASD are being identified, earlier than before and as a result, early intervention is possible with developmental disability institution being made available in the public sector as well. But these are few and far between. The average age at presentation to the clinic in India was 21.23 months (SD = 2.18)3. They present clinically in a manner similar to that reported internationally. Awareness among professionals and the public is increasing over less than a decade.4 As yet, there is no aetiology-based intervention for autistic spectrum disorders (ASD). However, symptomatic treatment and therapies with a cognitive-psychoeducational/behavioural approach can be of value in moderate ASD5.

References

Vaghbatta. Shirodhara AshtangaMisra V. The social brain network and autism. Annals of neurosciences. 2014 Apr;21(2):69.Hridaya, Sutra Sasthana, Chapter 22
Baxter AJ, Brugha TS, Erskine HE, Scheurer RW, Vos T, Scott JG. The epidemiology and global burden of autism spectrum disorders. Psychological medicine. 2015 Feb 1;45(03):601-13.Ajanal Manjunath, Chougale Arun Action of Shirodhara– A Hypothetical Review J Res. Med. Plants & Indigen. Med. Sept. 2012 1; 9 : 457–463
Malhi P, Singhi P. A retrospective study of toddlers with autism spectrum disorder: Clinical and developmental profile. Annals of Indian Academy of Neurology. 2014 Jan;17(1):25.
Malhotra S, Vikas A. Pervasive developmental disorders: Indian scene. Journal of Indian Association for child and adolescent mental health. 2005;1(5).
Francis K. Autism interventions: a critical update. Developmental Medicine & Child Neurology. 2005 Jul 1;47(07):493-9.

Looking Ahead

Surya is relaxed in his new school, and stress and anxiety of school work has left him. He is catching up with many ADL, and is even more motivated to do so with a reward at the end of each novel learning process. With improved performance and by dispelling his fears and phobias through logical thinking taught to him at the CBT sessions, Surya has conquered many of his fears and phobias and to a considerable extent his social anxiety.

He continues his CBT/CET and follow up at Trimed-Neurokrish, twice a week and the team is more than pleased to receive him for his sessions, as there is good compliance and palpable progress with each visit to the clinic.

The parents are at peace and are relieved to have found a centre which offers a holistic approach towards Surya’s all round development.

Tags Asperger’s syndrome, Autism Spectrum Disorder, conceptual learning, dysmorphic features, Goal Oriented CBT, hand-eye co-ordination, Learning Disability, Neurodevelopmental Therapy, Pervasive Developmental Disability(NOS), phonetic learning, Play Yoga, Reward Based Learning, Social Anxiety

Adults Buddhi Stories Epilepsy & Seizures Featured Memory Problems Patient Stories

Joseph – His Unedited Life

Post author By Oliver The Brainy Owl
Post date May 11, 2021

Joseph – His Unedited Life

Biography

Equipped with a Masters in Political Science, a supportive wife and 2 young children and a video-editing job in a reputed TV channel, which he carried out with a natural flair, Joseph had his stars to thank for a comfortable and fulfilling life. He had always been hardworking, an amiable companion at work, a good husband and a loving father. It was not just the sudden onset of seizures that disrupted his life flow, but the inability to work, the prominent cluster of neurobehavioural symptoms, the agitation, the paranoia, which mounted within a few weeks of the seizure onset. Back at work after recovery from the subacute phase, he could not perform. To make matters worse, the software of the editing platform had been updated with a newer version, during the period of his absence!

When Joseph presented to us over three years back with a cluster of seizure episodes, delirium and subsequent neurobehavioral symptoms, one needed to step back and view the sequence of events that led to this acute/subacute symptom complex that altered the course of his life so dramatically. The hospital which had received Joseph as an emergency had done well to manage the acute phase of the illness. The patient was diabetic and on oral medication with moderate control of blood sugar levels. Other laboratory parameters were within the normal range. The MRI showed bilateral hippocampal atrophy and the EEG recorded bilateral epileptiform dysfunction. A course of IV methylprednisolone brought about some control of the acute phase of the illness.

Exploring the Condition

However, Joseph continued to have seizures, poor recent memory, mood swings, irritability and aggression. He was unable to return to work both due to cognitive deficits which acted as impairment to his job performance and also due to poor social tolerance, to interact with team members. This came to the notice of the TV channel in which he was Senior Video Editor and the managerial staff of the channel took it upon themselves to support and take an active role in the neurorehabilitation process of the patient. It was then that they stumbled upon Neurokrish – The Neuropsychiatry Center where they met Dr. Ennapadam S Krishnamoorthy. After a detailed interdisciplinary evaluation of his clinical profile, a discussion was held with the family and employer’s Chief Medical Officer on Joseph’s protracted cognitive and neurobehavioural sequelae and its impact – personal, familial and occupational. Concerned that their key employee should continue to work with them, the employer readily offered to support his care in all possible ways. The family too was committed to helping him get back on his feet.

Most importantly, the doctor was the purveyor of good news – that recovery from the ravages of a significant brain inflammation was possible, with medication, prolonged therapy and psychosocial support. “Patience and gentle persuasion are the key” he said, in a convincing voice, persuading and encouraging patient, family and employers, through the long dreary days and months of targeted therapy.

Understanding Joseph

The enormity of the challenge of comprehensive neurorehabilitation for Joseph descended on us, fully, only when the clinical psychologist along with some other TriMed-Neurokrish team members, tried to unravel from basic literature, the complex demands on the video editor of a TV channel. With this background knowledge the cognitive retraining and cognitive behaviour therapy interventions could be individualized more effectively. A brief account of the video editor’s role would not be out of place here.

Video Editing

Although video editing may be considered a creative act, it requires working through a well-established, predictable set of steps. The first step is the importing and ingesting phase, followed by rough edits to the footage, dragging clips into the timeline, synchronizing the audio track and then fine-tuning the clips. Once the structure is set at this level, some additional post-production steps are required, namely, adding transitions between clips and various kinds of video filters, which change the visual quality of one or more clips to impact on the tone and texture of a piece. Titles are added and finally the color grading is done. In short, TV video editing calls for thematic conceptualization and sequencing in a timeline as executive function, with clarity of online working memory, pattern recognition and creative abilities, visual and auditory sensitivity, coupled with addressing the emotional element of a broadcast, team work and alert, timely delivery of the end product. This end product must capture the main features of the program, have a flow and continuity and appeal to the viewer expectations to create an overall impact!

Our Healing Approach

We came to the diagnosis that his symptoms were provoked by an underlying antibody syndrome – Autoimmune Limbic Encephalitis (LE). Detailed assessment for a possible malignancy was carried out, to rule out Paraneoplastic Limbic Encephalitis A second course of IV methyl prednisolone (the first having been given during admission in the acute phase), intensive cognitive rehabilitation and stress management was the doctor’s well considered management schedule, along with the other integrative therapies .Other medication included Levetiracetam for seizures, Donepezil for memory, Clobazam (for seizures and anxiety), Piracetam and Gingko Biloba (cognitive enhancers). He was under regular antidiabetic medication with his Diabetologist who also saw him through an unexplained acute skin reaction together with a dermatologist.

Cognitive Retraining (CRT) sessions were focused on improvement of sustained attention and memory enhancement. Tasks followed were the cancelling of digits for attention and verbal games, reading and visual memory games. He was able to recall from a small paragraph initially, to quarter of a page at mid therapy and half a page of details by the end of ten sessions of CRT.

Cognitive Behaviour Therapy (CBT) was given for his neurobehavioural symptoms. Family counseling, worksite review, and introduction of Joseph’s family members as his treatment monitors were other focused methods to enhance patient motivation and to see him progressively attain his premorbid state at home, in the community and at his workplace

Our Ayurveda Consultant prescribed Shirodhara, the calming effect of which has been elaborated in the ancient texts. We have observed remarkable improvement in some of our patients with neurobehavioural problems who have undergone this procedure and we saw it succeed once again in Joseph.

Within a three month period of therapy, with the overall feeling of well being and improvement in his cognitive ability, that glimpse of hope of recovery sparked off definite positive trend in his attitude, with less agitation and irritation, a more focused goal to help himself and to take maximum advantage of the therapies and counseling offered to him by the TriMed-Neurokrish team. From this point the improvement in his condition was by leaps and bounds and there was no looking back.

Our Integrative Medical Therapy

Shirodhara is a classical and well-established procedure, as described in the ancient Ayurvedic treatises, of slowly and steadily dripping medicated oil or other liquids onto the forehead. Shira – head, is the ‘Seat of the Mind’ and Dhara signifies flow – a constant flow of the medicated, warm liquid – oil, milk, buttermilk or coconut water onto the forehead of the subject, lying supine on the Ayurvedic massage table in the yogic Shavasana posture of complete relaxation of body and mind.
The liquid is gently poured, in a constant stream, ‘the size of the little finger’ from a height of 8-10cms from a special vessel, (protecting the eyes), onto the centre of the forehead for a minimum duration of 30 minutes and a maximum of 60 minutes. The liquid is allowed to flow down the scalp and is collected from the table, warmed and reused during the procedure. Shirodhara may be repeated 2-3 times with an interval of 7, 14 or 21 days, depending on the severity of the disease/disorder.
The constant flow of fluid stimulating the Sthapani Marma (this ‘vital spot’ being one of the 37 vital spots of the head, the whole body consisting of 107 such spots) indirectly stimulates the pituitary gland, at which brain level (Sthapani), the liquid flow occurs. The Ayurvedic texts mention the master gland and other endocrine glands and their function and clearly outline the calming neurobehavioural benefits of the procedure. The centre of the forehead, which was evolution-wise related to the third eye, is also connected atavistically to the pineal gland. This spot is known as Agnya Chakra, one of the vital energy centres in the yogic tradition. Focusing on Agnya Chakra with closed eyes during meditation leads to psychosomatic harmony.
As the oil drips on the Agnya Chakra, the authors propose, that the meditation-like effect is a consequence of stillness of mind leading to adaptive response to the basal stress. Shirodhara is popularized today by the modern health spas as a sure way to ‘rejuvenation and stress relief’! However, the ancient texts lay emphasis on its role in neurological and psychological disorders, headache and insomnia, and mention other indications and contraindications.

References

Vaghbatta. Shirodhara Ashtanga Hridaya, Sutra Sasthana, Chapter 22
GS Lavekar, TV Menon, Bharthi, A Practical Handbook of Panchakarma Procedures (2009) Central Council for Research in Ayurveda and Siddha, Dept. of AYUSH, Ministry of Health and Family Welfare GoI, New Delhi
Ajanal Manjunath, Chougale Arun Action of Shirodhara– A Hypothetical Review J Res. Med. Plants & Indigen. Med. Sept. 2012 1; 9 : 457–463
Kalpana D. Dhuri, Prashant V. Bodhe, Ashok B. Vaidya . Shirodhara: A Psycho-physiological Profile in Healthy Volunteers J Ayurveda Integr Med. 2013 Jan-Mar; 4(1): 40–44.

Our Neuropsychiatry Focus

Autoimmune Limbic Encephalitis is a rare disorder, characterised by the subacute onset of seizures, short-term memory loss, and psychiatric and behavioural symptoms. This type of limbic encephalitis is associated with Voltage-Gated Potassium Channel (VGKC) or N-methyl-D-aspartate receptor (NMDAR) antibodies.

The emphasis in the management of autoimmune LE is on its timely recognition, in order to rule out malignancy and to initiate treatment early. This potentially life-threatening disease responds well to immunomodulatory therapy.
The diagnosis of Paraneoplastic Limbic Encephalitis (PLE) is difficult because clinical markers are often absent and the LE symptoms usually precede the diagnosis of cancer or may mimic other complications. The clinical diagnosis of PLE requires :
- a compatible clinical picture;
- an interval of <4 years between the development of neurological symptoms and tumour diagnosis;
- exclusion of other neuro-oncological complications.

References

M.J. Thieben, ; Lennon, V.A. Boeve B.F. Aksamit A.J.,Keegan M, Vernino S. Potentially reversible autoimmune limbic encephalitis with neuronal potassium antibody Neurology April 2004;62:1177–1182
Guetekin SH, Rosenfeld MR, Voltz R, Eichen J, Posner JB, Dalmau J Paraneoplastic limbic encephalitis: neurological symptoms, immunological findings and tumour association in 50 patients. Brain. 2000 Jul;123 ( Pt 7):1481-94

Looking Ahead

At work a change in the software platform used, resulted in Joseph’s problems being magnified. No longer could he work on the auto-pilot, with skills learnt over two decades suddenly becoming obsolete. Supported by the three legged stool, his family, his employer and our therapeutic team, all working in tandem, he has managed to overcome these many hurdles. Apart from therapy and rehabilitation, he has benefitted too from a second course of intravenous steroids. Titrating his drug prescription, avoiding drugs that have unacceptable side effects and responding to his changing situation have all been necessary.

Two years on, the transformation of Joseph is remarkable. He is seizure free, composed, communicates clearly and well, manages well at work having learnt to use the new software platform, and enjoys a close trusting relationship with his family. He still has some residual memory and cognitive dysfunction and attends our centre for periodic cognitive retraining sessions. This father of two, the sole breadwinner of a young family, has managed to retain his job, thanks to the therapeutic alliance between his family, employer and our treating team. Indeed, his employer’s corporate social responsibility in walking the distance with Joseph deserves special commendation. This editor’s life continues unedited, thanks to the science of modern medicine, the wisdom in our ancient medical systems and the goodness that continues to exist in our society.

Tags Agnya Chakra, Autoimmune Limbic Encephalitis, bilateral epileptiform dysfunction, bilateral hippocampal atrophy, CBT, Cognitive retraining, corporate social responsibility, delirium, Diabetes, immunomodulatory therapy., neurorehabilitation, NMDAR, seizure, Shirodhara, VGKC

Adults Anxiety Buddhi Stories Depression Featured Patient Stories

krishna – A Quest of the Mind

Post author By Oliver The Brainy Owl
Post date May 11, 2021

Krishna – A Quest Of The Mind

School days had been fun, playing team games at school and with the neighbours’ children in the sprawling campus all evening and on weekends. This did not deter him from achieving 90% and above in all the subjects in school and in the 10th standard Board Examination. 11th and 12th were in one of those cram schools, with 10-hour teaching schedules, which prepare children for the IIT entrance examination. IIT proved elusive and Krishna joined a reputed private engineering college and stayed in the hostel attached to the institution.

Biography

It is not clear whether it was the initial ragging, or the continuous teasing by the seniors in the hostel that made Krishna progressively more anxious and to withdraw socially; or indeed whether these were early manifestations of his mental health condition; whatever it was, seemed to viciously erode his self confidence in stages. He had been at the butt end of jokes even at school, as he was prone to get some facts wrong in areas of common knowledge, which he would blurt out impulsively. The inherent social awkwardness became magnified into loss of self-esteem and social withdrawal in the new environment, away from home and away from his childhood friends. Class grades plummeted by end of 2nd year at Engineering College and he had accumulated arrears in a few subjects. Clearing them seemed insurmountable even as his mental turmoil increased. By the 3rd year, he had to take a break from studies and later returned to the college, commuting from the home of his paternal grandparents (who lived in the same city where he attended college), for a period of six months, after which he opted to brave the hostel milieu, cleared the arrears and completed the course effectively, receiving a choice of campus placement.

Exploring the Condition

Krishna had thus been through a four year period of waxing and waning symptoms of social anxiety, with significantly reduced social interaction from about 17 years of age. He had a once in three month follow up with a psychiatrist over the previous couple of years and was on antidepressant medication, a low maintenance dose of Fluoxetine. On this medication and some counseling, Krishna was managing his daily activities and work performance satisfactorily, till 6 months prior to his consultation with us, when his condition turned for the worse.

In the competitive job scenario, Krishna found the IT project job very stressful as he could not grasp the concept of project ideas conveyed to him over the phone, often within a brief communication and consequently could not reply relevantly to suit the demands of the foreign clients. Being inherently a high achiever and wanting to please, he found this situation beyond his coping ability. An acute phase of illness set in, with marked loss of appetite, insomnia, loss of weight, fatigue, poor self-care, poor concentration, total inability to attend office, social isolation and subsequently led to a state of almost catatonic mutism During this period he had delusions of reference (others are talking and commenting about me) and experienced mental confusion. He appeared to be out of touch with reality and in a state of acute psychosis. Krishna was forced to go on medical leave.

It is at this point that the highly concerned, well educated, discerning parents made inquiries for a place that could offer sustained therapies and close follow up. He was admitted for a few days for comprehensive assessment and investigations and management of the acute psychotic state by the TriMed-Neurokrish team.

The case called for elaborate psychological testing. These assessment scores are touched upon here, without too much explanation, for the lay reader to appreciate the need for a scientific and evidence-based approach to a neuropsychiatric case which depends not only on the clinical acumen of the Neuropsychiatric Consultant as Head of the Group, but that clinical judgement is dependent on inputs from other team members, to estimate the degree of mental disturbance and to guide the course of management.

Our Healing Approach

During assessment at Trimed-Neurokrish, Krishna admitted to have gone through similar, but less alarming phases of physical limitation and mental turmoil which he had not expressed clearly to anybody. Self perception and perception of the environment became progressively maladaptive in a range of social and personal contexts, and the subjective distress kept mounting. He had experienced suicidal ideation 2 years earlier.

He also described vividly ‘catastrophic scenarios that he had witnessed in his mind’ (possibly delusional) for e.g., an unknown person to the patient, whose tongue had been lengthened infinitely to be placed with precision under a running truck and the vivid, gruesome picture of the resultant trauma and bleeding. On further questioning, there is no history of manic or hypomanic phase or of drug abuse; no clear family history of major depression.

On medical leave, out of the stress-inducing situation in his work space and on integrated therapy and medication at Trimed-Neurokrish, Krishna soon came out of his acute psychotic state dramatically and settled to a preparedness to face the real world. In this phase, he was reported to have improved insight and judgment, understood he had a problem which impaired his capacity to cope with workplace stress and to engage in social interaction with his peers. He wanted to overcome this state, and be able to get back to his routine in better shape.

The patient was cooperative for the psychological testing. The 42 responses to the Rorschach test met the criteria for the Coping Deficit Index. Thematic Aperception Testing pointed to the need for achievement, security, nurture, the conflict arising out of lack of ego strength and fear of rejection. The Neuropsychiatric Inventory score was 4-5 on anxiety, delusion, night time behaviour and appetite, and low on the depression scale. A diagnosis of late onset Persistent Depressive Disorder (dysthymic disorder) was arrived at.

Krishna was on regular medication for over 2 months:

Dicorate ER 750mg ( Divalproex)
Olanzipine (10mg + 2.5mg) at bedtime and (20 mg + 10mg) in the morning
Vitamin and Calcium supplements

He responded well to the integrated therapy with a total of 15 sessions of Reflexology, Acupuncture and Yoga and over 10 hours of Cognitive Behaviour Therapy and some sessions of parental counselling.

An individualised short course CBT was initiated, setting attainable goals which helps in bringing the them back to their normal level of functioning.

In PERSISTENT DEPRESSIVE DISORDER, the patient suffers a pervasive sad mood for over 4 years with barely any symptom-free period. The symptoms cause significant distress or impairment in social, occupational, educational, employment and other important areas of functioning.

Dysthymics however, may be pushed into major depression and subsequent acute psychosis Often this occurs at times of high stress and is linked to strong emotions and feelings, for example worry, anxiety, fear, depression or feeling overwhelmed by events. Lack of appetite, difficulty sleeping, lack of energy, poor self-esteem, difficulty with concentration or decision making,and a feeling of hopelessness, peaking to result in a phase of acute psychosis. It has been suggested that in dysthymic disorder, to compensate for the lack of social and real life interaction, the patient can create elaborate and complex fantasy inner worlds within their minds. According to DSM V criteria, individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.

Our Focus:

Cognitive Rehabilitation

A person who suffers from dysthymic disorder has generally learned to live with a fair amount of chronic unhappiness in their lives and so the therapist cannot go by the mood on a particular dayl He must first identify the thoughts associated with the patient’s distress. In dysthymia, these thoughts may concern the patient’s self-view, his or her representation of a significant relationship, or a meaningful situation.

Goals will vary according to type of therapy. The emphasis in Cognitive Therapy is to effect changes in one’s faulty or distorted way of thinking and perceiving the world. Interpersonal therapy focuses on an individual’s relationships with others and how to improve and strengthen existing relationships and an attempt to accommodate new ones. Solution-focused therapy looks at specific problems affecting the person’s life in the present and examines how to best go about changing the person’s behavior to solve these difficulties. Social skills training focuses on teaching the client new skills on how to become more effective in social and work relationships.

REFERENCES

Dean Schuyler Evidence–based Review Short-term cognitive therapy shows promise for dysthymia Vol. 1, No. 5 / May 2002

Looking Ahead

Krishna continued to suffer from low self-esteem and a pervasive sad mood, with occasional congruent delusions of reference and delusional exaggerated fantasy, when assessed midway from onset of the integrated therapy. By the end of the intensive integrated therapy sessions at TriMed-Neurokrish, he was much more stable, and was on the bench at his IT job, preparing with a greater level of confidence for active work to be initiated with the clients.

Tags CBT, Cognitive Rehabilitation, delusional exaggerated fantasy, delusions of reference, Family Counselling, integrated therapy, major depressive disorder, Perception, Persistent Depressive Disorder, Social Anxiety, Thematic Aperception Testing

Buddhi Stories Dementia Elders Featured Patient Stories

Bharadwaj – The Resurrection

Post author By Oliver The Brainy Owl
Post date May 11, 2021

Bharadwaj – The Resurrection

Biography

Bharadwaj at 74 years was alert, active, enjoyed life as a whole and the company of his son, daughter, their spouses and their children. Born into an illustrious industrial house of Madras, he pursued his engineering studies abroad and came back to join, along with his 3 brothers, the industry founded by his father. In contrast to Jayaraman our other patient with dementia, here was Bharadwaj, with a huge extended family, all living close by, with him and his wife living with the son’s family, with a doting daughter and family next door. Socializing within this inner group, with true camaraderie and meeting over a meal on the multiple Indian festive occasions with exchange of gifts, and taking turns in singing south Indian classical music compositions solo or in groups was the traditional practice, a form of partial community living which could curb individuality, but did have its benefits for extended families that kept in close touch. There was support through thick and thin from extended family, close family ties among large extended families being common till 3-4 decades ago. The advantages of such mutual support is slowly being eroded as families scatter and few of the younger generation, who migrate to greener pastures in the quest of employment and upward mobility, are left behind.

Exploring the Condition

Bharadwaj’s loss of cognitive ability was subtle and demonstrated itself as changes in mood and behavior. His family noticed several changes in him over time; he became progressively withdrawn socially, spoke very little, stopped watching TV or reading the newspaper. In stages, fatigued, depressed and lacking motivation, he confined himself to bed, and with less physical activity, he became a near recluse in the midst of the over-reaching social interaction around him. More worryingly, for the family, the gregarious family man became paranoid and prone to spells of aggression, a change that was both frightening and distressing. No amount of coaxing and cajoling from his son, daughter and other close family members could shake his resolve to slowly fade away. It is in this mood that he was brought to TriMed-Neurokrish, stubborn as a mule and refusing to co-operate for the comprehensive assessment and showing resistance to undergo therapy.

Bharadwaj was not diabetic or hypertensive. His lab reports were unremarkable. He had followed the middle path in his lifestyle, well-disciplined, with no excesses, and no smoking or drinking. He was, however, addicted to south Indian classical music, and would venture into complex pre-composed music, and sing along with his daughter in a state of joy and sheer abandon as the melody flowed in an unfettered cascade. Where had that music gone?

It was the gentle persuasion of the daughter and daughter-in-law on the one hand, and the professional prowess of the TriMed-Neurokrish team on the other, that saw the thawing of Bharadwaj‘s adamant early phase, and he entered the phase of acceptance of the assessment and integrated therapy, though rather grudgingly to start with. A diagnosis of Dementia, stage 2 was made, knocking threateningly at the doors of stage 3 if not intensively managed. His behavioural manifestations were those of apathy, irritability and aggression on the Neuropsychiatric Inventory (NPI).

Our Healing Approach

Bharadwaj was already on Admenta (memantine) and Cognix (piracetam) along with a mood elevator prescribed by a Neurology Consultant, who had seen him in early 2015. We added a small dose of an antipsychotic, Olanzapine. With strengthening of the lower limbs and gait training, Bharadwaj became less dependent as he walked with minimal support, and his low back pain, and body pain, which he had brought upon himself with poor physical activity, was under control. Abhyanga (Ayurvedic whole-body warm, herbal oil massage), Shirodhara (Ayurvedic therapy that involves gentle pouring of liquids over the forehead) and Acupressure ran parallel, as part of the intensive therapy. Reflexology was also introduced. It was a slow and tedious process that shook off the negative apathetic behaviour and veered Bharadwaj toward a more positive behaviour.

Reflexology

Reflexology is an ancient traditional massage form, involving particular areas of feet, hands and ears which are believed to represent specific human internal organs and body systems. These areas have been mapped elaborately especially to guide foot reflexology. The skilled massage can achieve positive changes in the function of these organs and systems and is also effective in neck, upper back, lower back, painful disorders of the spine, and knee pain. In the book “Relieving Pain At Home” authored by William H. Fitzgerald (1917), an ENT specialist, he observes “Humanity is awakening to the fact that sickness, in a large percentage of cases, is an error of body and mind”, echoing the modern concept of body-mind link in many chronic medical conditions. Reflexology as a discipline shares the common belief of the ancient therapies, in that of opening of any block in the energy channels of the body.

Our Focus

Cognitive retraining is a therapeutic strategy that seeks to improve or restore a specific person’s skills in the areas of paying attention, remembering, organizing, reasoning and understanding, problem-solving, decision making, and higher level cognitive abilities. The primary aim of this therapy is to train the patient to overcome the cognitive difficulties that interfere with day to day activity, towards gaining independence in activity.

Retraining usually begins with simpler cognitive skills like attention, short term memory and information processing and then proceeds to more complex skills like problem solving, and executive function. Each identified lost skill is retrained using graded practice of activities. Cognitive retraining involves repetitive practice that focuses on the skills of interest. Repetition is essential for the newly retrained skills to become automatic. Cognitive retraining requires a quiet room without distractions and the patient must be able to relax to receive optimum benefit from the retraining.

References

Alex Bahar-Fuchs A, Clare L, Wood B Cognitive Training and Cognitive Rehabilitation for persons with mild to moderate dementia of the Alzheimer’s or vascular type: a review Alzheimers Res Ther. (2013) 5 (4): 35

Malhotra S,. Bhatia MS, Rajender G, Sharma V, Singh TB Current Update on Cognitive retraining in Neuropsychiatric disorders Review Article Delhi Psychiatry Journal (Oct. 2009) 12 ( 2 ): 213-218.

Looking Ahead

At the 6 month follow up, Bharadwaj is well overall, except for the occasional disturbances at night.

Aricep (donepezil) 10mg – 1-0-0
Admenta (memantine) 10mg – 0-0-2
Cognix Plus (piracetam + gingko biloba) 1-0-1
A to Z 1-0-0
Supracal A (calcium + D3) 1-0-0
Epitril 0.5 mg (clonazepam) was prescribed SOS at bedtime

He continues his therapies once a week. Bharadwaj walks with a little support within the house, is more independent in his self care, but needs help with soaping himself, and toweling after a bath. He socializes with immediate family members and language is more fluent and the content shows improvement. The lyrics of familiar songs are well recalled and musically expressed, as they go with the melody and the beat. Being able to sing puts him in a mood of elation. Perhaps most striking, he has islands of great clarity in thought and expression now. Recently, while watching a cricket match (another of his erstwhile passions) on the television, he regaled his family to their delight with comparisons, about the innings being played and another famous one from cricketing history. The family is pleased to see Bharadwaj enjoy some quality of life and never miss the once a week therapies.

Tags Cognitive retraining, Dementia, Loss of cognitive ability, Neuropsychiatric Inventory, Reflexology

Buddhi Stories Elders Epilepsy & Seizures Featured Patient Stories Stroke & Cardiovascular Diseases

Devi – The Iron Lady

Post author By Oliver The Brainy Owl
Post date May 11, 2021

Traumatic Brain Injury Dialogue- Buddhi Clinic

It was the harvest festival of South India, Pongal – the day of Thanksgiving to the Sun God – the beginning of the new Tamil month, Thai, and as the popular saying goes, “Thai brings in its wake, new hope and cheer”. The house had to be decorated with flowers and the pot of rice with all its special ingredients had to be allowed to boil over, symbolic of plenty, peace and prosperity. Families would gather to celebrate the joyous occasion together. The festivities would continue over 4 days – cattle pampered with special food, decked with bells, cowrie shells and flower garlands and rejoicing covered every aspect of agricultural life. Urbanisation had not taken away from marking this day of festivity every year, when man, beast, the sun and rain gods and the earth, all came together to celebrate the yield of man’s toil, in the form of nature’s harvest bounty. It was a celebration of life and all living things in an environment of harmony, peace and goodwill to all.

Biography

January 14th, 2015, 6 am on Pongal day and the 80 year old lady Mrs. Devi was already up, bathed and dressed in the exquisite new Kanchipuram sari gifted to her by her family for the festive occasion. The gift was also to mark a warm home-coming, after three months of grappling with the acute phase and serious sequelae of a cerebrovascular event she had miraculously conquered. The spirit of Pongal which signifies the unity of all living things on the face of the earth and the five elements, seemed to echo the principles of Yoga, acupuncture, Ayurvedic massage and other forms of traditional Medicine of the East, which follow the tenet that the body heals itself. Mrs. Devi had undergone these alternative therapies in the subacute and rehabilitation phase of the stroke.

Was Devi slowly reclaiming her original, premorbid personality, which many could have envied? She had been active and on her toes from dawn to dusk, warm in her relationship with the members of her family and friends alike, a good wife, a loving mother, a doting grandmother and a charming and gracious host. As a homemaker, home and hearth were always her priority, but it was the joy of giving of her best that made her unique! The grandchildren swore that only grandma could make such exotic ‘meen kozhumbu’ (fish curry). The daughters’- in – law sharpened their culinary skills, with Devi overseeing the making of the new recipe, or produced the most intricate rangoli designs on the floor in their courtyard, with her active participation, or just tucked the children in bed before going out for a function with their respective husbands, with the assurance that Devi was there to keep a watchful eye on them, even through their deep slumber.

Exploring the Condition

Mrs Devi, a known hypertensive on regular antihypertensive medication for 6 years, (Tab Telma 40 mg. 1-0-0 and Tab. Tazloc 20mg.-0-0-1), had an episode of seizure followed by difficulty in speaking and weakness of the right upper and lower limbs in mid October 2014, when she was admitted to a leading hospital in Chennai.

Frisium (Clobazam) and Dicorate (Divalproex Sodium) tablets were added to her drug regimen as anticonvulsant therapy. A diagnosis of left middle cerebral artery (MCA) infarct was made, confirmed by CT scan and routine stroke management initiated. All seemed well till 3rd November, when she developed acute breathlessness and emergency tracheostomy was performed, following which she was on ventilator support for a period of ten days. On inpatient treatment, she recovered, was able to talk normally, walk, and attend to her activities of daily living with partial support.

A second episode of seizure and loss of consciousness occurred, The repeat MR imaging revealed bilateral subarachnoid haemorrhage, with oedema and mass effect. There was a 50-60% block of the right internal carotid artery and a small berry aneurysm of the left middle cerebral artery. After a stormy period in ICU, she slipped into deep coma. The hospital indicated to the family that continued intensive care while required, did not guarantee a good prognosis.

At this point, she was transferred at the family’s initiative to Trimed-Neurokrish care in our partner hospital. At the time of take over, Devi was barely conscious, had the tracheostomy tube, feeding tube and catheter in place, was severely paralysed on the left side, with not even a flicker of muscle contraction and had excessive throat secretions and severe chest congestion.

The Diagnosis

The first stroke was an infarct, due to lack of blood supply to a well – defined vascular territory of the brain, the first indicator of a cerebrovascular deficit. The second stroke was the result of a bleed from the berry aneurysm into the subarachnoid space. Was there a minor re-bleed resulting in the first respiratory distress event, or was it caused purely by aspiration, and secondary chest congestion and infection? Initially, the tracheostomy tube was blocked requiring constant attention and had to be replaced by a metal tube, and this was electively removed after a few months of stabilization of the patient’s condition by the ENT surgeon.

Saccular Cerebral Aneurysms, also known as Berry Aneurysms, are intracranial aneurysms with a rounded appearance and account for the majority of intracranial aneurysms. They are also the most common cause of non-traumatic Subarachnoid Haemorrhage (SAH). SAH accounts for 3% of all strokes, and 50% are fatal
Sudlow and Warlow, 19971

Of those who survive, “All in all, only a small minority of all patients with SAH have a truly good outcome.”
Johnston 19982

Aneurysmal Subarachnoid Haemorrhage (aSAH): The prevalence of intracranial aneurysms from various parts of India varies from 0.75 to 10.3%, with higher numbers of cases being diagnosed due to increasing age of the population and improvements in imaging techniques. Surgical clipping of aneurysm is not much resorted to in India
Koshy 20103

Un-ruptured aneurysms are asymptomatic making it difficult to identify the patients with un-ruptured aneurysms and prevent subarachnoid haemorrhage
Shingare 20114

There is familial predisposition to SAH, with 5-20% having a positive family history. Hypertension, excessive alcohol consumption and smoking are the other risk factors. Though a very severe headache of sudden onset is the typical history, as in the case of Devi, seizure may mark the onset, with loss of consciousness initially and in an obtunded state over several days. The risk of rebleeding gradually decrease between 1-6 months. MRA is a feasible tool for detecting aneurysms.

1 Sudlow CL, Warlow CP. Comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. Stroke 1997; 28: 491–9.

Our Healing Approach

After the TriMed-Neurokrish comprehensive assessment, overseen by our neurologist and rehabilitation physician, supported by our chest and ENT physician, we optimised all Devi’s medication including broad spectrum antibiotics, bronchodilators and nebulisation, and the patient’s condition stabilized. We introduced moderate dose intravenous steroids to kick start brain function. We also started to deliver to her, on the bedside, an integrative therapy program. She was discharged after an ENT opinion was obtained on the tracheostomy status and the cardiologist opinion. She continued therapy at home.

The patient was readmitted 3 weeks later into the ICU with acute symptoms following a probable aspiration. Endotracheal secretion culture and sensitivity was positive for Klebsiella pneumoniae and Pseudomonas aeroginosa, and treated with the antibiotic of choice. Suction of the lung secretions and chest physiotherapy was part of the intensive treatment of this second episode of acute respiratory distress. This was followed by stepping up the alternative therapies and the patient’s recovery has been on a remarkable upward curve.

Our Focus:

Devi had undergone Yoga, Ayurvedic massage, acupuncture, acupressure, reflexology and other forms of traditional Medicine of the East over the subacute and rehabilitation phase of the stroke. All these forms of what is globally termed Complementary and Alternative Medicine (CAM) sets its strong belief in the body healing itself, empowered by the energy centres in the body and the flow of this energy through specific channels. Any block in the energy flow causes ill health. Traditional knowledge-based interventions released these blocks, to pave the way to recovery. The TriMed-Neurokrish technique is to encourage the CAM procedures of the trained team, to complement the astute Allopathic diagnosis and management, cognitive therapies and counseling. It allows patient participation in his/her own healthcare, along with family members, who witness the palpable improvement in the patient’s health condition.

A little detail of the yoga breathing patterns and exercises that benefitted Devi and its rationale in yogic terms, will not be out of place in its elaboration here.

Yoga asanas involve movements (bending, stretching, rotating), that stimulate ‘injured’ parts of the body by increasing the blood supply, followed by phases of total relaxation, Savasana, between movement phases. In the case of Devi, our Naturopathy & Yoga doctor believed that the group of asanas that stretch and strengthen the thoracic cage muscles, to encourage full excursion of the chest wall in efficacious breathing would benefit her most as therapy and eliminate her acute respiratory episodes. Considering her age and health state, the therapist chose to put her on a simple but an intensive asana regimen which he stepped up in a graded manner. Padahasthasana involves a set of asanas with stretching and touching toes standing and in a seated position, with outstretched lower limbs. Thadasana is standing upright ‘like a mountain’, stretching backward and bending forward to touch toes on the same side. Trikonasana: standing and bending diagonally to touch toes on the opposite side; repeating stretches in the seated position – Paschimottanasanas – seated and bending forward to touch toes; also bending diagonally to touch toes on opposite feet, alternately. Rhythmic abdominal breathing accompanies these movements, with the inhalation phase accompanying the stretch and exhalation phase, the bending.

Breath is the essence of Prana – the ‘life force’. Pranayama, alternative nostril breathing in Padmasana meditative seated posture, seeks to harness this prana. By focusing the mind totally on the rhythmic breathing, the body channels are opened, allowing energy to flow freely and connect with the life force. In modern scientific terms, the role of the autonomic nervous system in this breathing pattern has been recognized, with increase in sympathetic inputs. As a result, concentration and clarity of thought develops. Prana provides the strength, power and vitality required to carry out higher level activity. Attentive awareness of the breath can gently lead the aspirant to the art of meditation.

Chinmudra is hand gesture with opposition of the thumb and index finger bilaterally and the other fingers are outstretched and facing upwards. Chinmudra in yogic meditative posture enhances Ekagrhachittam – one-pointed concentration of the mind during meditation. When the finger touches the thumb a circuit is established, which allows the energy that would normally dissipate into the environment, to travel back into the body. When the fingers and hands are placed on the knees, in the meditative seated posture, the knees are sensitized, creating another pranic circuit that maintains and redirects prana within the body. As the palms face upwards in Chinmudra, the chest and heart area are opened up as well.

Why this thumb and index finger alignment in yoga gesture, towards deep concentration? It makes us look for a link with theories regarding the evolution and attributes of thumb opposition in the early homo sapien, employment of toys which encourage a pincer grip for toddlers in the Montessori system of child education, the Neuroscience concept in modern Medicine of the homunculus, where the cortical motor (and sensory) representation of the thumb is enormous, with the index finger next in line, the maximum use of the index finger for serious Braille reading.

“It is specifically the opposition between the thumb and index finger that has made it possible to execute the extremely refined movements that have produced the whole of human culture — from architecture to writing, from music to painting, and all the technology that enriches our lives.”

Looking Ahead

With the last admission for the aspiration pneumonia, Devi had left behind the roller coaster ride through various catastrophic health events. She was alert and poised to instruct her daughters-in-law on making the rice dish to perfection and all the other delicacies for lunch, when the whole family would feast together. Till the previous year, she had led the women of her household by nonchalantly tossing in hand-measured quantities of ingredients with the flourish of the seasoned cook that she was. This year she had to be content with gesturing the instructions with her hands, with the occasional word thrown in. She knew that the cashew-nut jar was on the topmost shelf, out of reach of the children, the jaggery in the jar could not be adequate and more had to be purchased from the corner store. All these minor details of the kitchen front, her culinary skills her motivation and leadership quality returned and she was to participate in yet another family Pongal festivity.

The family members felt that the level of recovery was well beyond all expectations and recollected their shocked state and hopelessness when they saw their dear one being wheeled into the hospital in an obtunded state for the second time in a month. The TriMed-Neurokrish team gave of their best, with total co-operation from the family. But it was the Iron Lady, the patient herself, with her ekagrhachittam or single –pointed intent, focus and willpower that saw her in this recovered state, with some residual visual deficit, a more subdued, rasping voice due to left laryngeal nerve palsy, mild gait disability, but with a mind to overcome even these residual problems or accept the discomfort they posed, with cheer, to lead from the front once again, as was her nature.

Tags acupuncture, Allopathic diagnosis, Aneurysmal Subarachnoid Haemorrhage, Ayurvedic Massage, berry aneurysm, Breath, cerebrovascular deficit, cerebrovascular event, Chinmudra, Complementary and Alternative Medicine, hypertensive, left middle cerebral artery infarct, Prana, seizure, stroke, Yoga

Adolescents Autistic Spectrum Disorder (ASD) Buddhi Stories Children Depression Featured Patient Stories

Ragini – Her Uphill Battle

Post author By Oliver The Brainy Owl
Post date May 11, 2021

Ragini – Her Uphill Battle

Biography

It was a full term natural delivery. The newborn was small at 2.7 kgs. There was no complication of pregnancy and mother and infant were well. Motor milestones followed a normal curve, but language was delayed till the age of five years. Strangely, musical expression preceded language and by 2 years 6 months, Ragini lisped in melodic sequences, as melody with lyrics came with ease. She belonged to yet another traditional south Indian family where music occupies the whole day, from the TV devotional music broadcast at the break of dawn, the bathroom singing by the father relaxing through an evening lukewarm shower after the day’s work, till into the night, when the mother sings the infant to sleep – that ‘soporific lullaby’ which never fails! However, nurture alone cannot explain the child’s musical ability, which advantage she carried without losing ground, into adolescence and adult life with formal vocal classical music instruction. The family being resident in the West, she received higher grade training in Western classical music as well and got into the stride of it with no extra effort.

Exploring the Condition

Ragini had poor communication skills, sub-average intelligence on the Wechsler Intelligence Scale for Children (WISC), language processing difficulty, perceptual thinking deficit and social fears and phobias when examined in childhood. She became irritable and frustrated, as coping with routine stresses, given her condition, became increasingly difficult over the years, and she showed significant disruptive behaviour at about 10 years of age by way of aggression. Following a psychiatric assessment, she was started on Tab. Risperidone, an atypical antipsychotic to control the irritability of the Autistic Spectrum Disorder (ASD) and to reduce her depression. She continued Risperidone till the age of 19 years, went through mainstream schooling, as she was a high functioning ASD, and successfully completed a Certificate Course in Vocational training.

In 2013, Risperidone had to be withdrawn, due to tardive dyskinesia, and Clonazepam SOS was prescribed. Two years passed peacefully, off medication. With the support of her well educated, discerning parents empathetic to her needs, Ragini established her own space in her music studio, where she could listen to music, catalogue the music videos in her collection in the studio library, and even give musical training to groups. All this was encouraged by her parents, mindful of her problems as it also represented an attempt to organize herself into some self employed music-related career, in an area closest to her heart. However, largely alone in the studio also left her isolated and socially withdrawn. Perhaps due to this a feeling of helplessness, hopelessness and worthlessness descended upon her, and she had suicidal ideation. She was emotionally sensitive, eager to please, but did not have the ability to take criticism. Symptoms that started insidiously, reached a peak within 6 months, in mid-2015. She became severely depressed.

Escitalopram (antidepressant) and Quitiepine (an atypical antipsychotic) prescribed by the psychiatrist could not bring about any control. After a further 5 months of rapid mood swings, crying, shouting, explosive episodes of dyscontrol and threats of leaving home, the mother brought Ragini to India, hoping that a change of environment would help in some way to ease mounting family tensions. She had information about the multidisciplinary approach and integrated therapy offered by TriMed-Neurokrish and fixed an appointment for Ragini.

Our Healing Approach

It was not easy for the team at TriMed-Neurokrish to thaw the ice and make Ragini accept that the specialist team was there to help her. Once this was achieved even partially, with gentle persuasion, the flow of the assessments became smoother, with cooperation from the patient. The diagnosis and plan of management fell in place with the detailed clinical history of events that led up to the mental state at the time of assessments and clinical examination.

Her Rorschach Inkblot test produced 22 responses, meeting the perceptual thinking and coping deficit index. She had severe depression and a feeling of worthlessness. EEG showed significant epileptiform activity without localization or lateralisation. She had a past history of episodes of stare with momentary loss of consciousness. Blood test and MRI/MRA brain were unremarkable.

The Diagnosis was Autistic Spectrum Disorder (High Functioning) with Rapid Cycling Affective Disorder and Episodic Dyscontrol Syndrome. Arriving at a suitable drug regimen was more difficult and prolonged, with loss of precious time, as 2 anticonvulsants used as thymoleptic agents had to be rejected as Oxcabamazepine produced a moderate allergic response, and even worse, Lamotragine produced a Steven Johnson’s type adverse drug reaction. After allowing time for recovery from these drug reactions, the patient was stabilised on a drug regimen which she tolerated well, along with an extended program of therapies running parallel.

The regular medication was

Lithium (sustained release) 400mg – 1/2-0-1
Olanzapine 10mg – 1/2-0-1
Escitalopram 1-0-0
Lorazepam 2mg – 0-0-1
Vitamin supplements

The mood stabilising, antidepressant and anxiolytic effect of this drug combination was reinforced with 24 sessions of CBT, individual psychotherapy and family education, 11 of physiotherapy (grade 2), 34 of Acupuncture, 20 of Reflexology, 34 sessions of Shirodhara and whole body massage and 24 sessions of Yogasana, intensive and daily over the initial phase and then spaced out to 3-4 days a week.

“There is considerable evidence suggesting that a subset of Pervasive Developmental Disorder (PDD), youth with extreme disturbance of mood suffer from a symptom cluster that is phenomenologically consistent with the syndrome of Bipolar Disorder (BPD)”

Joshi, 20091

Longitudinal studies are essential for observing the onset and progression of co-morbid condition of Bipolar disorder in ASD.

“It is of importance to recognise both the psychiatric diagnoses of ASD and overlapping BPD in order to plan the drug regimen, therapies and set realistic treatment goals.”

Looking Ahead

Following the extended therapy program and after being stabilized on the drug regimen, there is a definite return of Ragini’s lost self esteem, which had been shattered during the downhill phase. Her mood swings are minimal, and there is no episodic dyscontrol. The mother admits that she came with the hope of some relief of Ragini’s symptoms of aggression and dyscontrol. She got much more from the team at TriMed-Neurokrish, she confessed, and feels that the situation is under control and has the hopes to settle her daughter’s future plans of home and career within reasonable goals.

Tags acupuncture, ASD, autistic spectrum disorder, bipolar disorder, CBT, Episodic Dyscontrol Syndrome, integrated therapy, multidisciplinary approach, PDD, physiotherapy, psychotherapy, Rapid Cycling Affective Disorder, Risperidone, tardive dyskinesia, WISC, Yoga

Adolescents Children Expert Blogs Neurodevelopmental Disability (NDD)

Understanding Developmental Disability

Post author By Oliver The Brainy Owl
Post date May 8, 2021

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

What is neurodevelopmental disability?

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

Why NDD?

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

Who is at risk?

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

When should we suspect NDD?

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

Why should we take action early?

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

Where should I take my child, when in doubt?

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

How should I progress once diagnosed?

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

Tags ADHD, autistic spectrum disorder, Caregiving, cerebral palsy, childhood epilepsy, Development Disabilities, International Day of People with Disabilities, Lerning Disability, NDD, neurodevelopmental disability

Adolescents Adults Cerebral Musings Children Elders Expert Blogs Featured

The Quintessential Rational Mind

Post author By Oliver The Brainy Owl
Post date May 8, 2021

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

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

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

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

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

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

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

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

On Perception and Memory

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

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

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

The Rational Mind

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

Tags anosognosia, Buddha, Buddha Purnima, contemporary philosophy, Delusion, Mana, Metaphysical, Perception, Rationality, Schizophrenia, Truism, Truth

Adults Cerebral Musings Expert Blogs

Neurological Borderlands

Post author By Oliver The Brainy Owl
Post date May 8, 2021

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

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

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

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

Tags Behaviour, Brain Interface, Cognition, Neurology, Scientific Advances, Specialized Professions

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