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Category: Adolescents

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Stimulation for the brain!

What is deep brain stimulation?

Our brain is a wonderful organ. Designed by the chief architect, this is the most complex CPU ever built. Like our computer’s CPU, this CPU in our body can also be thought of a bundle of electrical wires criss-crossing in a highly complex fashion. Every once in a while, there can be something that happens to cause some malfunction in this circuit. DBS can be thought of as an operation to set right this malfunction by inserting a pacemaker into the brain.

Miss J, a 22 year old girl had been diagnosed with a brain tumour as a child and had undergone radiation for that. While the tumour was successfully treated, this radiation to the brain had a nasty side-effect. Some of the circuitry in her midbrain had been altered, leaving her with a permanent tremor in the right hand and leg.

She was suffering silently for more than 10 years, not knowing that this problem has a solution in the form of DBS! While the damage to the brain that is an inevitable consequence of radiation cant be undone, by placing a pacemaker into the brain, the imbalance in her movement circuitry could be modulated.

The result is almost instantaneous since the operation is done with the patient awake in the operating room. Once the electrode reaches the correct area in the brain and electrical current is sent through it, the tremor reduces immediately and her slow movements become rapid.

DBS is helpful in a wide variety of conditions apart from tremors. It is very useful to improve the symptoms of Parkinson’s disease, Dystonia, drug resistant Epilepsy, Obsessive compulsive disorder, major depression and Chronic Pain syndromes.

The deep area in the brain which is stimulated varies according to the condition treated. However, in all conditions the patient is awake during surgery and is being tested with stimulation and a wide variety of observations are done as and when surgery is in progress. Therefore, the success of surgery involves the active co-operation of the patient.

Before surgery is considered, all patients undergo a detailed assessment to look for factors in favour and against surgery.

Each patient and family are thoroughly counselled about what to expect before, during and after surgery. After successful surgery, they need to be followed up for programming sessions where the stimulator is turned on and tuned in order to achieve the best clinical benefit with the least side-effects.

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Adolescents Adults Children COVID-19 Elders Epilepsy & Seizures Expert Blogs Featured

Managing epilepsy during COVID-19

Epilepsy is the most common serious neurological disease affecting over 50 million people worldwide and an estimated 5 million plus people in India.

People with epilepsy have recurrent, unprovoked seizures and these have to be differentiated from provoked seizures that follow a tumour, stroke, infection, inflammation, metabolic disease (like very low or very high blood sugar) and so on. A seizure is an electrical storm in the brain; a short circuit in the brain’s normal electrochemical activity.

World Epilepsy Day or Purple Day just passed us on 26th March. In this time of COVID let’s ask ourselves what the implications are for people with epilepsy. Here are some common FAQs.

Can COVID-19 cause epilepsy?

According to the International League Against Epilepsy, there is no direct evidence that the coronavirus infection can directly cause epilepsy. However, like all infections that can cause high fever, breathing difficulties and other problems with normal functioning, being infected can result in a person who is susceptible to epilepsy, suffer breakthrough episodes.

Does epilepsy or its treatment make one more susceptible to COVID-19?

At present there is no information to suggest that either epilepsy or epilepsy treatment (anti-epileptic drugs, most commonly) will in any way make a person susceptible to COVID-19. Indeed, there is no suggestion that people with epilepsy have any special immune vulnerability either. However, the stress a pandemic of this nature can induce in people, the sleep deprivation and attendant lifestyle changes, can all make a person already vulnerable to seizures, express them more frequently.

What should I do if I have a seizure in this time of COVID-19?

If one has never had a seizure before in their lives, it is obviously imperative that they consult a neurologist, urgently and undergo relevant investigations as advised. As most routine clinics are cancelled, the emergency room of a hospital may be a better point of access at this time. However, for people with pre-existent epilepsy, a single seizure is no reason for panic. Call your usual doctor and discuss what you can do to manage your epilepsy better; follow your doctors advice.

Avoid visiting clinics and hospitals for single breakthrough seizures unless you feel it is absolutely necessary. However, if seizures cluster together, or indeed a person suffers continuous seizures with no recovery of consciousness in-between, what is called “status epilepticus”, it must be treated as an emergency.

What precautions should a person with epilepsy take at this time?

People with epilepsy are advised to stock up adequately on their anti-epileptic drugs, as even missing a single dose can cause a breakthrough seizure for some. Compliance with drug treatment is extremely important for people with epilepsy. Stress is inevitable and managing it with meditation, yoga, a healthy diet and lifestyle are all possible. Many good online tutorials exist on all the above. If one is very stressed out an online consultation with a psychiatrist or psychologist can be helpful. Sleep deprivation is another risk factor for people with epilepsy; adequate rest and sleep are therefore very important. Sleep can be disturbed due to stress or indeed due to excessive exposure to digital media — televisions, computers, tablets and smartphones.

Good sleep hygiene: making oneself clean and comfortable before going to bed, making the temperature and lighting in the room ambient and suitable to the extent possible, putting way all digital media and retiring to bed with either a book or gentle instrumental music (if one must have a distraction) are all encouraged.

Are there special precautions?

Unless one is a healthcare worker or otherwise at high risk of exposure, no special precautions are recommended. If a person with epilepsy belongs to this category, they are encouraged to speak with their usual doctor about drug prophylaxis and other precautions. For all other people with epilepsy, the principles of social distancing, avoiding unnecessary contact with people outside one’s immediate family, or indeed taking due care around anyone who is symptomatic of COVID, is adequate.

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

Isra – Teen Tantrums

Isra – Teen Tantrums
Isra – Teen Tantrums

Biography

Isra was born of a full term Caesarian section, the indication being cord around the neck. Her weight was 2.7 kgs and her birth cry was normal. There was clear regression of motor, verbal, visuospatial and personal/social domains at 1.5 years with progressive impaired eye contact, temper tantrums and hyperactivity. There was a history of recurrent cough, cold and fever in childhood, and one such episode of high fever with pustules on the skin, at 5 years of age, was diagnosed as *Kawasaki disease and treated. This resulted in further behaviour problems with significant issues in the subdomains of major life areas, communication, domestic life, interpersonal interaction -abusive/ assaultive/ destructive and self-injurious behaviours.

Over the past 2 years, the above traits have peaked and she throws tantrums if her demands are not met, well above what could be dismissed as aberrant adolescent behaviour. Isra has special preferences for certain colours/textures and her express demands can range from a new dress of a particular colour to a pongal/vadai for breakfast. She has an ‘inappropriate attachment’ (as the technical jargon goes) to handwash solution -which she will grab from the table or even from the handbag of the teacher at Vidya Sagar and tuck it away – this is perhaps indicative of a preference for non-social stimuli which provides intense interest in the sensory aspects of the object (and event). She prefers solitary activity in her little corner in the institution and resists if required to transition to another place.

Receptive language is good but she vocalises sparingly. She reads sentences with effort and writes. She has echolalia and repetitive hand movements. At home, she listens repeatedly to music albums that appeal to her on the tablet and is able to crop songs on the computer with ease.

Since her behaviour problems have decreased over the past 2 months, Isra has been selected by the institution to register for the Open School Board Examination, and her first examination is Home Science. She enjoys painting/baking -which are among her five subjects for the course.

*Kawasaki disease may be caused by cerebral vasculitis resulting in patchy ischaemic areas and damage to the central nervous system which may alter neurological function for some time after the acute phase of the illness, with increase in long-term behavioural difficulties. CNS pathology on SPECT is evidence that behavioural changes arise secondary to a cerebral vasculopathy, and are not merely due to the psychological complications of an acute severe illness.

Assessment Reports

The Clinical Specialists Observations –

Behavioural problems for 10 years, intermittent over the past 2 years. Intact systemic examination on General Clinical examination. Neuropsychiatric Inventory revealed psychomotor agitation, dysphoric affect, grossly intact Higher Mental Functions, impaired insight and judgement and no focal deficits.

EEG Report :

Rest EEG taken on a standard 10-20 system shows background activity of alpha waves at 8-9 Hz, mixed with slow waves over the posterior head region. No paroxysmal activity is seen. No increased activity on photic stimulation. The client did not co-operate for eye-opening/eye-closure. A borderline normal record.

DST:

Age of 10 years was attained, based on parameters of functioning.

ISAA SCORE:

85 – indicating mild autism

CBCL:

Internalizing syndrome – withdrawn/depressed, thought problems, attention deficit. Externalizing syndrome – aggressive behaviour, attention deficit, overeating, poor bladder/bowel control.

VSMS:

Social age attained is 4 years and 6 months with a social quotient of 29, indicating severe deficit in social adaptive behaviour.

ICF Neurodevelopmental Disability Assessment

Body function issues are present in mental functions mainly, but no structural deficit observed or reported. Under limitations of activity, significant issues present in subdomains of communication, domestic life, major life areas, interpersonal interaction and relationship. As regards environmental influences, both parents and the institution proved to be facilitators.

Response To Therapy

She was not co-operative for the therapy initially. She was restless and resisting therapy but settled down subsequently. She is currently on Lamotrigine, Risperidone, Haloperido A combination of thyme-leaved Gratiola (Brahmi), Indian Pennywort (Madhukapami), Winter Cherry (Ashwagandha), Clonidine, Atomoxetine, Multivitamin-Multimineral supplements (rich in Vitamin B12, Calcium and Phosphorous).

Reviewed One Month After The End Of Therapy:

With the therapies and the modified drug regimen, Isra has become quieter with a better attention span and improved academics. The mother is the best judge and she is convinced of the palpable improvement in Isra and expresses her wish to continue therapy.

Prof. Dr. ESK suggested looking for any residual clinical and lab signs of inflammatory disease, autonomic symptoms and hip dysplasia to identify the rare possibility of an associated auto-immune disorder. This trend of thought was probably triggered by the acute illness in Anamika’s past history with the diagnostic label of Kawasaki Syndrome which has a close likeness and forms the differential diagnosis for Lupus Erythematosis (LE). LE is an auto-immune disease with periodic behavioural problems and these problems are immensely treatable or controllable. He also suggested maintaining a monthly behaviour chart to check if the immediate premenstrual phase causes increase in the aberrant behaviour pattern.

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Adolescents Anxiety Attention Deficit and Hyperactivity Disorder (ADHD) Buddhi Stories Featured Patient Stories Traumatic Brain Injury

Dharmendra – A New Leaf

Dharmendar – A New Leaf
Dharmendar – A New Leaf

Biography

It was yet another of those days when the young man had taken out his father’s car, lent to him grudgingly, with the mother peeping through the bedroom window of the palatial mansion to warn her son not to speed on the road. Dharmendra turned around to wave reassuringly to the parents as he took off at a respectable pace towards the gate. Once on the highway, with the heady sea breeze blowing on his face and his companions cheering him on, Dharmendra pressed the accelerator. That ill-fated night, Dharmendra, at the wheel, swerved to avoid a speeding motor bike and hit the roadside tree. His two companions escaped with mild injuries but Dharmendra suffered Traumatic Brain Injury (TBI). The road traffic accident was to change the course of his life drastically.

Dharmendra was admitted to a reputed city hospital in a semi conscious state, and was under acute care and close neurosurgical monitoring for several days. No seizure was reported. He was treated with corrective surgery for major physical injuries, which needed immediate attention as these multiple injuries, if left unattended, could add to the burden of brain trauma. 

The traumatic brain injury (TBI) was managed conservatively. He mercifully escaped the worst immediate sequelae of TBI. He had recovered full orientation at discharge with loss of the right little finger in the accident, what appeared a small price to pay for the consequences of daredevil speeding on the highway.

But when Dharmendra was brought to us at Trimed-Neurokrish, 2 months later by the desperate parents, (who had heard of our holistic approach to neurorehabilitation from a friend) we knew at a glance that TBI had played havoc with his personality, mood and affect and to a lesser extent his cognitive ability. His explosive, impulsive behaviour was what we faced initially, with an air of intellectual superiority thrown in, which did not make our approach to him any easier. Management of behavioural complications of TBI is challenging and requires a multidisciplinary approach. With gentle persuasion, comprehensive all round assessment by our team members was made possible. We set about facing the major challenge we had taken on with that team spirit of hope and goodwill which has served us on many occasions.’’

Exploring the Condition

Dharmendra was in his 1st year Engineering course when he met with the accident. When he joined engineering college, the parents felt that he had become more mature, stable in his ways and was now a responsible individual, and breathed a sigh of relief. He had been a handful, especially for his mother, from childhood. He had performed below average in school. He had shown frequent irritability, anger and defiance towards figures of authority. He had been diagnosed with Attention Deficit Hyperkinetic Disorder (ADHD) with associated Oppositional Defiant Disorder (ODD) and treated for it as a child.

These underlying childhood behaviour disorders have an add-on effect on personality traits at the phase of post TBI recovery. The symptom complex was suggestive of a frontal lobe syndrome. After thawing the ice, during the first few difficult interviews, the clinical psychologist managed to record the chameleon-like changes in the colour of his moods and affect: easy going, emotionally expressive, cooperative, sensitive, keen to do the right thing on the one hand, on the other hard headed, adventure loving and prone to risk behaviours. He was prone to exhibiting high levels of anxiety, building up to a pitch to manifest anger, even rage, an episodic dyscontrol syndrome. Once the episode passed, Dharmendra was at peace with himself and with the rest of the world as if nothing had happened. Was he aware of these monstrous flare-ups in the early phase of his neurorehabilitation? Probably not.

Further psychological testing showed him to be intellectually average, with poor mathematical ability, but adequate ability in language and other subjects and fair visuomotor ability. He had taken to excessive substance abuse, smoking, and was addicted to video gaming. On physiotherapy assessment, the patient’s physical health was very satisfactory, free in activities of daily living (ADL), a Barthel Index of 100; normal gait and balance, poor ability to run due to poor endurance, with no subjective reporting of pain. 

Frontal Lobe Syndromes

The degree of dysfunction caused by frontal lobe damage depends on the abilities and traits before the TBI, as well as the extent, location, and nature of the damage as a result of the TBI. To assess the frontal lobe damage, your physicians should give you a complete neuropsychological evaluation. The testing measures speech, motor skills, social behavior, spontaneity, impulse control, memory, problem solving, language, and more.

In a direct injury, the frontal and temporal poles receive the maximum impact. MRI brain revealed only a brainstem injury, but multiple networks from and to the frontal lobe, the limbic system, subcortical structures, brainstem etc. may account for the manifest frontal lobe syndrome (mainly dorsolateral prefrontal syndrome) in the patient. Aside from this, white matter lesion in the network cannot be picked up by standard MR imaging.

Frontal lobe damage affects most aspects of behavior, mood, and personality. Patients with dorsolateral frontal lesions tend to have lack of ability to plan or to sequence actions or tasks, poor attention span, a poor working memory for verbal information (if the left hemisphere is predominantly affected) or spatial information (if the right hemisphere mainly affected) Patients with orbitofrontal lesions tend to have problems of disinhibition, emotional lability, and memory disorders, Personality changes from orbitofrontal cortex damage includes impulsiveness.

References

  •  Jeffrey L.Cummings, MR Trimble. Concise Guide to Neuropsychiatry and Behavioral Neurology. II ed., American Psychiatric Publishing Inc, 2002, chapt. 5: 71-86Andrea E. Cavana Tourette Syndrome – Clinical Review , BMJ, Aug 2013 ; 347 :1-6
  • RTA statistics – global and Indian: According to the WHO statistics, (2016) about 1.25 million people die each year globally as a result of road traffic accidents. Road traffic injuries are the leading cause of death among young people, aged 15–29 years. The newly adopted 2030 Agenda for Sustainable Development with over 150 nations participating, has set a road safety target of halving the global number of deaths and injuries from road traffic crashes by 2020.
  • The detailed age profile of accident victims in India other than the drivers (Ruikar 2011), revealed that the age group between 25 and 65 years accounted for the largest share, 51.9%, of total road accident casualties, followed by the age group between 15 and 24 years, with a share of 30.3%
  • WHO fact sheet on road traffic Injuries (reviewed in Nov. 2016) Manisha Ruikar National statistics of road traffic accidents in India –Symposium- Polytrauma Management, rehab- J  Ortho, traumatology,rehab 2013   Vol 6. :1 : 1-6

Our Healing Approach

Dharmendra was given long term medication with constant monitoring and titration of the drug dosage. He was on Oxcarbamazepine & Levitiracetam (both for the control of seizure/episodic dyscontrol), Sertraline (antidepressant), Atomoxetine (to encourage mental alertness, attention) and vitamin supplements. He had had long sessions of cognitive behaviour therapy, distributed over 24 staggered sessions.

The integrative therapy included apart from continued sessions with the clinical psychologist using an eclectic combination of Cognitive Behavior Therapy (CBT), Relaxation Training (Jacobson’s Progressive Muscle Relaxation) and Family Therapy; 15 sessions of Acupuncture, 15 of Reflexology, 10 Abhyangam and 10 Shirodhara. The scientific principle behind these therapies is to remove blocks in the energy channels of the body and to reestablish the free flow of bodily energies in the path to recovery.

On this regimen and the integrated therapies, the spells of anger and dyscontrol became progressively less frequent and less intense. Running parallel, his cognitive ability also improved. The Trimed-Neurokrish team came to a consensus that Dharendra was ready to go back to college after these three months of intensive therapy.

Formal parent education sessions, for them to understand clearly that Dharmendra’s behaviour was not willful, but part of the frontal lobe syndrome, was an important exercise, and was carried out meticulously, resulting in the full support of the parents towards medical management of their son. 

Dharmendra returned to 2nd year Engineering in the college after a long gap. He seemed to cope, but tended to sleep in class miss special classes, with increasing arrears, which made him anxious and as a result to increase the number of cigarettes he smoked. The parents showed great concern and follow up sessions with Trimed-Neurokrish had to be more frequent. Divalproex & Olanzapine- Fluoxetine were added to the drug regimen (replacing Levetiracetam and Sertraline), with subsequent control of these worrying symptoms. The patient went through the second year of Engineering College with occasional problems.

Looking Ahead

Dharmendra settled well, with improvement in cognition, better memory and attention and more stable behavior in his 3rd year Engineering. He still has rare dyscontrol episodes but these are few and far between. Periodic psychological sessions continue both scheduled and on demand. With improved academic performance, and in a mood of goal orientation,  he managed to clear his academic arrears  and seems well on his way to facing a professional career of significance. When will he be allowed to drive the car again, he wonders. His own, this time!

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Adolescents Buddhi Stories Children Epilepsy & Seizures Featured Patient Stories

Asma – Building Rapport

Asma – Building Rapport
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.

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

Surya – Conquering Anxiety

Surya – Conquering Anxiety
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

  1. Vaghbatta. Shirodhara AshtangaMisra V. The social brain network and autism. Annals of neurosciences. 2014 Apr;21(2):69.Hridaya, Sutra Sasthana, Chapter 22
  2. 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
  3. 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.
  4. Malhotra S, Vikas A. Pervasive developmental disorders: Indian scene. Journal of Indian Association for child and adolescent mental health. 2005;1(5).
  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.

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

Ragini – Her Uphill Battle

Ragini – Her Uphill Battle
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.

Categories
Adolescents Adults Bipolar Disorder Children Elders Epilepsy & Seizures Expert Blogs Featured

The Curious Case of Vincent van Gogh

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

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

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

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

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

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

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

Categories
Adolescents Adults Cerebral Musings Children Elders Expert Blogs

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

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

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

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

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

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

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

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

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

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

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

Categories
Adolescents Children Expert Blogs Neurodevelopmental Disability (NDD)

Understanding Developmental Disability

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

What is neurodevelopmental disability?

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

Why NDD? 

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

Who is at risk?

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

When should we suspect NDD?

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

Why should we take action early?

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

Where should I take my child, when in doubt?

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

How should I progress once diagnosed?

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

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