A lawyer who quit his profession because he could not pay attention to what his opponent was saying in court. A start-up founder, brilliant at strategizing, lost money because he could not send invoices on time.
And then we take you back 500 years to the story of Leonardo Da Vinci, one of the greatest artists the world has ever known, but also, a scientist-painter who never got around to finishing what he started. He would procrastinate, skip from one task to another, and in his lifetime managed to complete only 20 works of art, leaving countless unfinished.
Attention Deficit Disorder (ADD), say mental health experts, brain disorder that affects adult’s ability to pay attention, control moods and complete tasks, explains the behaviour.
Though not recognised as a mental disorder till the 1960s, studies have found that there are more than 350 million adults affected with ADD globally (says a study published in 2021 in the Journal of Global Health) and has been shown to be progressively increasing over the years. And the pandemic seems to have more adults seeking help for the condition, says neuropsychiatrist Dr. Ennapadam S Krishnamoorthy, founder of Buddhi Clinic in Chennai & Coimbatore.
“The Frontal lobe of the brain is the executive brain, responsible for planning, organisational skills, focus, and time management. It is also the site of the social brain, which gives one the ability to regulate behaviour. Both these are affected in those with ADD,” he says. The shift to remote working and months spent in isolation during the pandemic resulted in social cues from the environment being r replaced b y cognitive cues, which a person with ADD tends to struggle with, explains Dr Krishnamoorthy. “For instance, a person with ADD may do certain tasks in the office only when they are reminded of it by a colleague. The social cues are not there when you are working from home, and those with ADD may lose track of their daily tasks.”
There is a misconception that Attention Deficit Hyperactive Disorder (ADHD) presents only in children, but that is not so, explains Dr. Krishnamoorthy. In adults “Hyperactivity” is replaced with impulsivity, which is why it is referred to as ADD.
Sonal Singh, a certified ADHD/ADD coach, says the condition is exaggerated in times of transition, like when one goes from college to work, or is promoted from executive manager, moves cities, and so on. “Neurotypical people find it easier to adjust to change,” says Sonal, who adds that in the past couple of years, startup founders have begun to make up for a larger part of her clientele. “These are otherwise bright young adults with high IQs, but have difficulty focusing and paying attention.”
Chennai based psychiatrist Dr. N. Rangarajan though believes people sometimes reach out for a clinical diagnosis to validate their difficulties in coping with change. “Several of my patients seek help for self-diagnosed conditions that readymade online tests tell them they have. ADD needs to be clinically diagnosed. For some it may just be merely about learning to accept change.”
A Study published in the Indian Industrial Psychiatry Journal indicates that 17% to 22% of adults reporting to psychiatric services reporting for other mental conditions have been found to have ADD. In some cases says Dr. Krishnamoorthy ADD can masquerade as depression or anxiety, which also affect working (short-term) memory and the ability to pay attention. “In these cases, if the mental health issue is sorted out, the problems of attention deficit will disappear.”
One of the most visible signs of ADD is procrastination. “The person will be brilliant at ideating, but find it impossible to send an email or file an invoice” says Sonal.
King’s College London researcher Professor Marco Catani, who presented his hypothesis on da Vinci in 2019, in the journal “Brain’, attributes his explanation of the painter’s ADD to historical records which showed he ‘spent excessive time planning projects but lacked the perseverance’. “Those with ADD may also make promises they don’t keep because they have forgotten almost as soon as they made them. This can play havoc with both work life and personal relationships,” says Sonal . “In the end, ADD is all about emotional regulation. “ And the first step is to pay attention to the signs.
An examination of the Buddha’s views on the mind. Two and half millennia after his time, shows them to be remarkably rational and contemporary.
The day of Vaisakh Purnima (May 27 this year), is significant for three reasons. It was on this day that Gautama Buddha was born as Prince Siddhartha at Lumbini in Nepal in 560 B.C; the day when he attained enlightenment at Gaya in India; and the day he attained Nirvana (Unity with the Absolute) in 480 B.C. It is, therefore, observed as Buddha Purnima, worldwide. To mark this day in 2010, we examine the rational mind, as conceived by Buddha.
It has become fashionable and commonplace to associate Buddhism with the metaphysical. This is in stark contrast with Buddha’s emphasis on rational thought and insistence on empirical verification. He encouraged the development of theories that were verifiable and was strongly opposed to dogma, which he viewed as an impediment to the truth. To him the truth was supreme, and ideas that hinder the discovery of truth best avoided. He believed in full freedom in thought and action; “the gates of freedom will cease to be gates, if people start clinging to the gates.”
Buddha also had very interesting, remarkably contemporary views on the mind and some of these are enumerated below.
On thoughts and ideas
The very first verse of the Dhammapada translates as “you are nothing but your mind”, based on which, “Sarvam Buddhimayam Jagat” has been proposed. The word used by Buddha ‘ mana ‘ translates both as thoughts and as mind, and can be interpreted to mean the brain. Buddha’s emphasis is on the flow of thoughts and the continuous change in the thinking process. In his concept, ideas are not constant, they change all the time. Ideas have no independent origination; they have ideas preceding and following them. Consequently, all ideas are interrelated and there are no stand alone or absolute ideas. The thinker, the thought and the concepts therein cannot be separated. Interestingly, this concept has parallels in modern psychiatry. A primary delusion, a first rank symptom of Schizophrenia is said to arise when the person, following a “delusional mood” has a thought “out of the blue” and “without antecedents”. To have such a thought that has no thoughts preceding it, and possibly therefore no basis in fact, was abnormal to the Buddha, and remains so in modern concept.
Both the Surangama Sutra and the Lankavatra Sutra attribute perception, physical and emotional, to the mind. “Both delusion and enlightenment originate within the mind and every existence or phenomenon arise from the functions of the mind.” The Surangama Sutra poses an interesting question: “A man opens his hand and the mind perceives it; but what is it that moves? Is it the mind, or is it the hand? Or is it neither of them? If the hand moves then the mind moves accordingly, and vice versa; but the moving mind is only a superficial appearance of mind.” According to the Buddha, all perception had basis within oneself. This concept of the Buddha has neuro-scientific underpinnings. If one were to replace the “mind” as Buddha called it, with “brain” as he probably meant, and is contemporary concept; that all our perception and action has basis in the brain, is truism. Prof. V.S. Ramachandran has described in his book Phantoms in the Brain, novel representation areas for human body parts that have been amputated, developing in the brain.
This illustration leads to another important question, namely, what is ‘me’ and what is ‘mine’? Buddha, through fables, encourages us to think about this existential dilemma. The parable is about a man who takes shelter in an abandoned structure on a stormy night. Sitting in a corner of a dilapidated room he sees around midnight, a demon enter, with a corpse. The demon leaves the corpse on the floor; suddenly another demon appears and claims the corpse. Both demons turn to the man and ask him to decide on the ownership of the corpse. Being truthful, he indicates he saw the first demon bring in the corpse. On hearing this, the second demon is enraged, tears away and eats the hand of the unfortunate man, which the first demon, immediately replaces with the one taken from the corpse. After the demons leave, the man wonders and thinks aloud, “the replaced hand is ‘mine’ but is it ‘me’?
Again, the questions raised have neuro-scientific relevance. After damaging physical trauma, and transplants, it is well reported that people sometimes feel dissociated from their new organs. Indeed, having an organ replaced can be a life-changing experience. At another level, damage to the brain, the parietal lobe in particular, can result in the sufferer neglecting his body parts, as he does not recognise them as his own. The phenomenon of anosognosia, leading to neglect of one half of the body (hemi-neglect), is a well described phenomenon after a stroke. Here, the person sees the paralysed limb lying beside him on the bed, but is unable to recognise it as his own.
Buddha did, therefore, begin the mind-matter debate much before it became fashionable in contemporary philosophy. He placed human emotion firmly within the organ he referred to as the mind, which we now understand to be the brain. His statement – “If we learn that there is no world of delusion outside the mind, the bewildered mind becomes clear” – is remarkably accurate.
On perception and memory
Buddha made a distinction between the flow of thoughts and the stock of memory influencing our perception. In his view our perceptions are influenced by our memory. Thus we view the present through the coloured glass of past experience and do not see things as they exist or as they are constituted. When a person perceives an object, both the memory of the same or similar object and the feelings the person had on the earlier occasion are rekindled. Moreover, comparisons are made between imaginary constructions of the object and the object itself. However, this distinction between stock and flow is more analytical than exclusive. Indeed, stock and flow interact all the time.
This view mirrors our current understanding of how the limbic system in the brain works. It has been proposed that the hippocampus is the storehouse of memories. Adjacent and connected to it by a chemical rich neural network is the amygdala, an organ deeply concerned with human emotion.
Any external stimulus results in activation of both organs; thus when a person sees a snake, his memory (and learning) tell him that it could be dangerous, and he experiences fear as a consequence. Memory and emotion are therefore in continuous interplay, as conceived by Buddha.
The rational mind
Buddha’s understanding of the human mind (and brain) was unique; both rational and contemporary. He encouraged debate and discourse; raised questions more often than he provided answers; encouraging his followers to think like him, with freedom. He recognised the pitfalls of blind faith, unquestioning belief and intolerance of contradictory ideas. He laid emphasis on empirical verification and on understanding the world, as it is and as it is constituted. Indeed, through his radical empiricism, he laid the foundations of scientific spirit and enquiry 2500 years ago. His was the quintessential rational mind.
Buddhi Clinic’s Brain and Behaviour Dialogue with the legendary Prof. Michael R Trimble of University College, London, curated and presented by Neurokrish
The Buddhi Clinic virtual programme on 26/12/2020 was a ‘ Brain and Behaviuor Dialogue‘. Prof Ennapadam S Krishnamoorthy, who was Raymond Way Fellow in Behavioural Neurology and Neuropsychiatry, UCL, from 1997, under the mentorship of Prof. Michael R. Trimble, introduced his guru of many years. He gave a brief outline of Trimble’s illustrious career and observed that there could be no better person to elucidate the Brain and Behaviour interface .
As Chair in Behavioural Neurology and Neuropsychiatry of the Raymond Way Research unit, Institute of Neurology, Queen Square, London, and Professor in the same disciplines, Trimble established a unique system of academic mentorship over three decades. This led to neuropsychiatry worldwide remaining associated with the Raymond Way group long after the trainees and fellows left Queen Square. As a sensitive clinician, committed researcher and erudite scholar, Trimble had chosen the less trodden path, to establish neuropsychiatry as a recognised global academic and clinical discipline.
Krishnamoorthy set the ball rolling with “What made you choose Neuropsychiatry?” Trimble observed that the term ‘Neuropsychiatry’ was always a problem, with neurologists in Europe using it vaguely to indicate psychosomatic disorders; Freud unable to give it true meaning in his attempt, through a psychoanalytic viewpoint; the Behaviourists reluctant to give up their simplistic ‘stimulus-response paradigm’!
Trimble observed that it was the dawn of a new era when EEG evidence of the pathophysiology in a neurological disorder, with associated psychological problems, emerged in the late 1950s. Frederic Gibbs’ pioneering EEG studies in Boston, recorded the anatomical localisation of a form of seizure to the temporal lobe, which was replicable over a number of patients. This established the relationship between anterior temporal lobe abnormality and the psychopathology of epilepsy. Modern Neuropsychiatry took a definitive step forward in the 1960s and 1970s, with the discovery of the structure, function and circuitry of the limbic system of the brain. Trimble recalled that as the only Behavioural Neurology consultant in UK for a long spell, he participated in the ‘neuropsychiatric awakening’ of the 1970s, and enjoyed lecturing on limbic neuroanatomy. Neuroimaging resulted in several other revelations in the brain-behavior link. The Raymond Way group, were involved in early PET studies in the 1990s that showed the volume of the hippocampus to be smaller in schizophrenia patient.
Trimble’s dictum is that every neurologist must aim at proficiency in neuroanatomy. This should include brain dissection and not learning through anatomical waxwork models! One wonders if every step in Trimble’s higher education and training trajectory, toward specialisation in Behavioural Neurology, was planned by him well ahead, in order to achieve the thoroughness and authority in his field, which his professional career reflects. Trimble’s first degree was in Neuroanatomy with Sir Solly Zuckerman, followed by MPhil in Psychopharmacology before he trained at Radcliffe Infirmary for MRCP, at National Hospital, Queen Square in Neurology and at Maudsley in Psychiatry. As Johns Hopkins Fellow, he was exposed to American psychiatry for the first time. Though there was demand for his expertise in new drug development, in temporal lobe epilepsy, in particular, he opted for association with the legendary Prof Lennart Heimer, in his research lab. Trimble enjoyed being in his old familiar ground of animal studies, primatology and neuroanatomy, but this time round with years of clinical and scientific expertise behind it. In the four-author publication on ‘Anatomy of Neuropsychiatry’ (dealing with the latest discoveries in limbic system-basal ganglia circuitry, structure, function and pathology), with Heimer as lead author, Trimble, provided the valuable link between basic science sections and clinical neuropsychiatry.
Why did Prof. Trimble go into the field of Neuraesthetics?
As emeritus professor, since 2004, Prof. Trimble had the ‘leisure’ to consolidate his kaleidoscopic professional experiences and find the link to integrate them with his natural inclination towards creativity and the Arts. This resulted in three book publications, which go to form the subject of this online Brain and Behaviour dialogue. The rich fare presented, moved seamlessly from ‘Psychoses of Epilepsy’, championing the right brain along with other neuroscientist thinkers, to the power of the human voice in music at a Wagner opera; why Gana the gorilla at the Muenster zoo, who grieved the loss of her son did not cry ? or why humans, on occasion, find the need to move beyond the mundane, towards ‘a transcendental state of consciousness’?
The Soul in the Brain: The Cerebral Basis of Language, Art, and Belief
Johns Hopkins University Press (2007)
This was the first book discussed. In this provocative study, Prof. Trimble alludes to the interrelationship between brain function, language, art—especially music and poetry—and religion. Inspired by the writings and reflections of his patients, Trimble was drawn into the study of their individual artistic ability, in which he observed a clear pattern. He came to the conclusion that writing effective poetry is probably incompatible with certain disorders-schizophrenia being one, and seems to be highly restricted by epilepsy. Even in the literature, there are very few acknowledged poets with schizophrenia- as the content, metre and prosody cannot be sustained by them. “To be a musician of the canon with schizophrenia seems impossible, as a compositional score, of say Wagner or Brahms, have notes that go on and on and must follow a trend to cohere with the same narrative over a long period”. However, there were patients with manic depressive psychosis (bipolar disorder) who were capable of poetry and music. Another study by the Raymond Way group showed that some patients with temporal lobe epilepsy were ‘hyperreligious’, well above the expected range of involvement in religion. Hypergraphia was another unique temporal lobe phenomenon, but the content of the voluminous pages of writing was poor and lacked cogency.
The ‘Soul in the Brain’ brings together poetry, music (and going back to Greek culture, which offers a third element within Greek theatre) and dancing. This ‘total work of art’, integrating music, poetry and dancing, has ‘movement’. Trimble referred to the German term–‘Gesamkunstwerk’ for this integration of different art forms to create a single cohesive whole. This term finds acceptance in English in the field of aesthetics. “Movement in the arts affects our brain and ourselves in a different way, and that is where neuroaesthetics comes in” Trimble explained. His own keen interest in opera, drew him deeper into the realm of Neuroaesthetics and the role of the brain and mind.
The story of creativity started with language. Broca localized language to a small area in the left anterior frontal region, based on the study of his stroke patients. Hughlings Jackson, a contemporary of Broca, was skeptical about his findings and maintained that a higher order brain function like language could not be confined to a small circumscribed area. Hughlings Jackson, with his visionary understanding of the working of the human brain and mind, well ahead of his times, could be called the founder of modern Neuropsychiatry, Trimble opined.
Scientists were preoccupied with language syntax, and if this was in place and a lesion did not involve the left hemisphere, language was assumed to be normal. It took deeper study of patients with lesion of right anterior frontal region by experts, to spot the subtler missing elements in language, elements which boost its richness, namely, the emotional tone and prosody, (the latter so important to poetry). There was poverty of creative expression, of metaphors and other semantic aspects of language. Language is accompanied by gesticulation. There was slow acceptance, that it required the coordination of both hemispheres to make language.
Going back in time to ancient Greek culture, Trimble traced it to Athens and to the Festival of Dionysus, celebrated to this day, with much music , dance, revelry and abandon, in the spirit of freedom, reminiscent of the romantic era. Of the arts, linking music with religion became prominent during the Renaissance period and resulted even in moving small operas into churches. Opera marked the highpoint of Western musical culture in the 19th and 20th century. Trimble observed that the propensity to art occupies a spectrum, and varies between individuals and also periods in history, e.g., between the Baroque and Romantic periods of Western culture. Ancient Greek cultural music and art forms had a profound impact in shaping European culture through the ages.Interestingly, Iain McGilchrist conceives that it is “the brain that has shaped the world”, in his book, ‘The Master and His Emissary’!McGilchrist, neuropsychiatrist, philosopher and thinker, it was, who put creativity and art forms in the field of neuroaesthetics.
Trimble recalled how another undisputed champion of the right brain, John Cutting and he, had long discussions on this subject, while at the Maudsley as colleagues. Cutting was a neuropsychiatrist, with special interest in schizophrenia. His vehement disagreement with the right brain being assigned ‘minor hemisphere’ status, featured in his profuse writings. Trimble had also associated with Norman Geschwind, who had published his elaborate work on the laterality of brain function.
Why Human Like to Cry :Tragedy, Evolution and the Brain
Oxford University Press (2012)
The second book discussed:
What makes humans *cry?
In 2007, Gana the gorilla in the Muenster zoo, held up her son who died suddenly, and indicated her distress and grief, but did not cry, even as the humans watching her shed tears of compassion. Crying is an attribute exclusive to humans, adding to the other evolutionary attributes of homo sapiens.
Tears can signal pain or distress from one person to the other. When the mother sees the baby’s tears, it signals hunger or perhaps some discomfort. She cuddles and comforts the baby and each time this repeats, the bonding becomes stronger. When one looks at the large human face, and then within a short span of time, tears roll down the cheek of that face, the latter state of intense feeling creates a surge of emotion and compassion in the beholder.
Tears can also emerge as a result of aesthetic experience. Beauty, the art forms, and relating to memories of the past can evoke strong emotions. Proust describes
*Crying’ involves shedding of tears. It may be in the form of sobbing, weeping, etc
the archaeologist who bursts into tears on beholding an ancient Assyrian sculpture. It was a spontaneous mark of reverence for an artifact of the past. Trimble expressed concern that the Western world seems to be moving away from the past – be it from parents and family, a historical monument, or even the four walls of the house where one spent one’s childhood. This is a great pity, as these memories and emotions form the core of aesthetic values and in its absence, one may not be moved by a strain of music or a beautiful face – and probably be the loser!
Crying may follow a deep religious experience or listening to music or while at an opera. “Music appears to be the art form most likely to make us cry”, says Trimble. A study by his team, interviewing participants of the study, revealed that 80% cried to music, and 60% to poetry. Reading a novel, with continuity of the narrative almost equaled music in its impact on the reader. Another study of lottery participants left the team puzzled over why the winner cried. It came about that the ‘tears of joy’ made their appearance when the winner shared the news and bonded with the family and dear ones. Trimble confessed that tears well up in his eyes when he is at a Wagner opera, where the power of the human voice in music can raise the emotional response to its heights. It was acceptable to cry at the opera or in church, especially for men !
Greek tragedy explored many themes around human nature and it heavily influenced the theatre of the Renaissance.In the Renaissance period, in church, every member of the congregation was expected to cry, especially the men. If they failed to concur, they could be severely reprimanded, as crying was considered part of the religious experience, sacred and symbolic of grieving for the loss. He referred to the practice of lamentation,the passionate expression of grief or sorrow, from the Book of Lamentations of the Old Testament. He made a biblical reference to ‘Lacrima Christi’, which literally means ‘Tears of Christ’. William James, the modern psychologist and great thinker elaborated on a variety of religious experiences. He observed that the human mind is in search of a transcendental idea. A deep religious experience can provide this. William James on consciousness : “Consciousness, does not appear to itself chopped up in bits”. There is a continuous flow of thought in our minds, one leading to the other, which he referred to as ‘stream of consciousness’.
Trimble observed that our emotional response to tragedy and crying for emotional reasons have evolved over several millions of years. Then, why are people ashamed of crying ?
One of the more recent major discoveries of highest significance to neuropsychiatry is the mirror neuron. It goes beyond the scope of functional neuroimaging in some areas, as the presence of mirror neurons in the human brain allows identification with the other. This could be through the other person’s facial expression. But tears are an even surer signal from one person to another of emotional feelings; it arouses ‘with’= ‘com’- passion and feeling ‘in’= ‘em’ -pathy. Though the appearance of tears may be physical, put in the metaphysical context, it is a link from one person to the other, by what is termed empathy. ‘Theory of Mind’ is a complex human ability of social cognition, which is required to empathise and must have evolved towards fulfilling emotional reaction; chimpanzees do not have this highly evolved ability of social cognition, though they may imitate an action, like picking up a banana, due to the presence of some mirror neurons, but not beyond this.
Though the human brain circuitry for emotional tears is widespread, it links the cerebral cortex, especially anteriorly, with those areas associated with the representation of emotion-the limbic system and to the autonomic nervous system for the release of emotional tears. This highly evolved circuitry is not present in primates, again pointing to the hand of evolution.
The Intentional Brain: Motion, Emotion and the Development of Modern Neuropsychiatry Johns Hopkins University Press (2016 )
This was the third book discussed:
‘The Intentional brain’ puts together information it has accumulated over several hundred years-over 2000 years. Trimble’s purpose of the book may be conveyed briefly, by quoting from the preface to the book. “The book is not simply about Neuropsychiatry as a medical discipline, but it is in many ways much more a reflection on the way the brain and its functions have been viewed over the centuries, as well as the huge change in orientation, germinating within romanticism, which has given us an understanding of our dynamic, active, creative brain”. This was in stark contrast to the Baroque period, which was restrictive and had some strict formulations for literature, music, and other art forms.
Modern research has focused on the brain as a predictive organ. Trimble’s view of the dynamism of the brain and how we receive the world, borders on the transcendental! “The way we greet the world and the way the world greets us and the world is embodied within us and our need to control it”, he says and goes on to “ We go out in the world expecting something, greet the world with hope of fulfillment, moment by moment. If not fulfilled, there has to be some reconciliation.” If this does not happen, an alternative path is taken, as each situation demands, laying down a novel brain circuitry. The belief that the brain is a passive organ with a stimulus evoking a response, assumes that with repetition of this pattern, neural tracks are laid down, which subsequently guide the automatic response which has been preset.
Trimble spoke about the Baroque period, which was restrictive. The Age of Enlightenment brought further strictures in the belief that science offered the solution to everything. Almost as a reaction to the progressively tightening fetters, both political and social, imposed by earlier periods, there arose an intellectual movement, and with it an explosion of art, music, literature, and the glorification of nature and the past in poetry by the romantics of the 19th century. We enjoy much of this freedom, culture and art forms even today, but some nations show signs of repression, curbing freedom of speech and of the press and increasing inequity which could be possibly labelled the post-post modern age! McGilchrist puts the blame of all the unsavoury components of modernity squarely on people paying less heed to the right brain.
Iain McGilchrist, in his voluminous book, “The Master and His Emissary’, describes the evolution of Western culture, as influenced by specialised hemispheric functioning. He designates the right brain, with its greater contributionto creativity and the arts, (and perhaps to humanity) as the Master, and the left brain as the emissary in the “divided brain”. He is wary of the Western world today becoming increasingly dominated by the left brain which he believes may be to our detriment.
Prof Trimble concluded with “The Intentional Brain is how the brain works and we have got it wrong for 2000 years!” His appeal to appreciate the art forms in order to live life fully continues into his next book, from which he shared a sentence – “ A world without music is not human”.
Dr. Subbulakshmy Natarajan MBBS, DCN (Lond.), PhD, FRCP (Edin.)
Research Consultant, Neuroscience India Group (NSIG)
Adjunct Faculty Public Health Foundation of India
Prof. Michael Trimble is no stranger to the Chennai audience as he has visited at our invitation on several occasions. He came first at the invitation of Prof. Krishnamoorthy Srinivas as the TS Srinivasan orator for 1998. It is of interest to note that in the topic of his oration ‘Towards a Neuropsychiatric Theory of Literary Creativity’, the central neuroaesthetic theme of the books discussed here was already taking shape, to be consolidated in his retirement days. At several points of the dialogue Prof. Trimble, in a chatty way, would stop to address Prof. Ennapadam S Krishnamoorthy to revive the memories of the significant clinical and research work done together in the Raymond Way unit.
The programme saw good audience participation. During question time there was reference to Indian art forms and some thought-provoking questions, which Prof. Trimble answered at length.
Navin at his college, and another picture of him and his mother
The first time I met Navin was as a patient in 2018, he was admitted with Acute Liver Failure. Acute liver failure is described as a loss of liver function that occurs suddenly within days or weeks most commonly in patients who do not have any prior liver disease. As his liver was failing and his family lacked resources, they were scrambling to find competent treatment to prolong his life. The hospital reached out to me and informed me of his dire and progressively deteriorating health.
Before the onset of his disease, Navin was a happy, healthy, and vibrant high schooler living with his mom and brother. They lived in a remote part of Kumbakonam with limited access to good healthcare. His father was no more and they were struggling to find resources to support his treatment.
When I met Navin, many hospitals had certified that his chances of survival were slim to none. I could not stand idle by the sidelines and watch a vibrant young life prematurely end without a fighting chance.
The team at Liverindia set up crowdfunding resources and also undertook his treatment regiment under our wings. We collected over 30 lakhs within a week and utilized our funds for fast-tracking his operation.
In retrospect, as a doctor and an experienced surgeon, I can say that his survival was not guaranteed. However, for Navin, God was gracious. His brother was a perfect tissue match for a liver transplant. We performed a highly complex partial liver transplant and waited for a week for positive indicators on his recovery.
In some cases of Acute Liver Failure, some patients may go through episodes of memory loss (altered cognitive capability and story recall). It is a common sign of hepatic encephalopathy, an added effect due to lowered liver functioning.
Even though he was improving physically, he was unable to read or write for a prolonged period. Liverindia was invested in his care and in getting him wholly healthy again.
With the residual funds from the transplant, we transferred him to a famous neuro transition and recovery care facility called SuVitas.
“When Naveen was first transferred to SuVitas, it was obvious that he had received excellent life-saving interventions at the hospital and his family were full of hope for his recovery. His journey with us involved crafting a customized and comprehensive care plan that included medical monitoring, skilled nursing care, medical nutrition therapy, and calibrated physiotherapy in an infection-free facility. The team went above and beyond, as they always do for each patient, even to the extent of using psychological interventions for the emotional wellbeing of the family (since they were out of the station in these tough times). From being addled with limited functionality he progressed to be completely independent and being able to even sign his name – Naveen’s recovery remains a memory of pride for all of us at SuVitas.” Dr.Vijay Janagama, Founding Medical Director, SuVitas
Navin stayed there for a month, recuperated, and rejoined his classes but he relapsed and went blank during his last exams.
Following the memory relapse, Navin experienced some mental trauma and depression. Again Liverindia along with the help of Buddhi Clinic took his case to a famous Neuropsychiatrist, Ennapadam Srinivas Krishnamoorthy, a specialist in Epilepsy and Dementia.
From noted Neuropsychiatrist and Founder and Director of Neurokrish, Dr. Ennapadam Srinivas Krishnamoorthy and the team at Buddhi Clinic,
‘Navin came to us at Buddhi Clinic referred by Dr. Karthik Mathivannan, liver transplant surgeon. N had undergone a liver transplant in September 2018 for ALF following which he was comatose for 20 days.
When he came around it was found that he had significant memory complaints and swallowing difficulties, blanked out during exams. The mother reported that he had developed explosive anger episodes. This left him volatile and he cried often. He also had problems with sleeping, speech, and tremors in his upper limbs.
In line with Buddhi Clinic’s good practice, we started with a comprehensive assessment of the patient to thoroughly evaluate him across physical, behavioral, and cognitive domains. Treatment & Rehabilitation: He was inducted into our Buddhi Seva social impact program given his disability and socio-economic status. Based on this comprehensive assessment in both physical and behavioral/cognitive domains, an intensive integrative therapy program was put together in a span of 5 weeks to treat the various post coma sequalae This comprised of 20 hours of CAM treatments including 7 hours of Ayurveda therapy and 13 hours of Naturopathy therapies which helped him regain focus and improved his memory and behavior. Caregiver counseling was done for his mother to help her cope with his behavioral symptoms and reduce her anxiety.
Outcome: At the end of the therapy program, his attention and memory had improved,especially recall. He was emotionally more stable, with reduced crying spells and agitation. He was able to speak more clearly and with confidence. With significant improvements in both behavioral and cognitive domains, Navin and his mother were satisfied with the holistic approach of assessments and treatments from the Buddhi Clinic team and by the all-around gains made by the patient post-therapy.’
He recovered fully post this treatment and regained his memory completely. He is now a fully functioning adult and recently graduated college. His story truly highlights the importance of never giving up on hope and why we as Liverindia exist as medical help for the hopeless.
We walk into Buddhi Clinic one balmy Chennai afternoon, only to recognise immediately that it is unique in concept and has few parallels. Our meeting is with the founder Dr. Ennapadam S Krishnamoorthy, the current President of the International Neuropsychiatric Association and a renowned international expert on the brain and mind. His office is unlike that of any clinic or hospital. There is the lingering aroma of energising camphor; and an array of objects that reveal his diverse passions: books, artefacts, classic furniture apart from an impressive wall of awards and certificates. Seated before an arresting oil on canvas Buddha painting, the good doctor engaged Team Culturama in conversation about his uniquely successful concept chain of clinics in Chennai – Buddhi!
What does Buddhi Clinic do? We are the pioneers and innovators of integrated care for the brain and mind. Apart from diagnosis and drug treatments, a standard in most medical settings, we provide a unique 360 degrees evaluation of body, brain and mind; and a range of therapeutic solutions that bring together, seamlessly, modern science and the wisdom of ancient health care traditions. Our patients have brain mapping and Ayurveda consultations; psychological assessments and Naturopathy consultations; physical therapy, sleep analysis and neuromodulation care, all under one roof, all on one day, if they so please. Buddhi Clinic offers 14 treatment modalities in permutations and combinations curated by us through empirical research. Our primary focus is neurology and mental health rehabilitation and therapy, although our care paradigms address a range of pain, mental health, lifestyle and disablement conditions.
How do modern medicine and ancient traditions blend together? In one line – Seamlessly through our carefully curated, process driven programmes! While our diagnostic approach and internal treatments are allopathic (drawn from modern medical science), we employ 14 non-pharmacological treatments that blend modern science with ancient wisdom – Neuromodulation, Ayurveda, Acupuncture, Acupressure, Reflexology and Yoga; Naturopathy – water, mud, magnet, aroma treatments; Rehabilitation therapies – speech, neurodevelopmental, physiotherapy and a range of specialised psychological therapies. We have developed treatment programmes for each condition across the lifespan – child, adult and elderly.
How successful are your treatments? Across the lifespan, be it autism or ADHD in a child; head injury, epilepsy, anxiety, depression, sleep disorders or migraine in an adult; stroke, dementia or Parkinsonism in the elderly, we have had the most exemplary results, many people even getting off wheelchairs. What we promise our patients and their caregivers is better activities of daily living and a better quality of life. And this we have delivered consistently to the vast majority of over 10,000 patients who have walked through our portals in 10 years, receiving in total an excess of 1,00,000 interventions. Indeed, our success stories are documented in ‘Buddhi Books’ – detailed case studies that have enriched our collective learning.
What do you believe is your USP? At the Buddhi Clinic, our patients straddle the human lifespan, from cradle to nirvana. Everyone has a brain and mind; and sometimes during the course of our lives, our brain and mind malfunction, needing deconstruction and sorting out. That indeed is the raison d’être of Buddhi Clinic. Rather than rely on single solutions, drug treatments, procedures or therapy, we have created a smorgasbord of interventions, modern and ancient. We have thus enabled both opportunity for healing and as importantly, patient choice. Besides, chronic disorders are not always curable; but as the adage goes, ‘we cure sometimes, control often, but comfort always!’ Our treatments are designed to help people make unique ‘recovery journeys’; from illness to wellness, care that goes beyond cure. Finally, at Buddhi Clinic, we think different. Not just about illness or disablement; but about ability and enablement.
Our treatments are designed to help people make unique “recovery journeys”; from illness to wellness, care that goes beyond cure
Is Buddhi Clinic a private enterprise or a charity? If you are private, then why receive donations and deliver Buddhi Seva? People don’t choose their diseases and conditions; indeed, it’s quite the opposite, with conditions choosing to visit individuals, many of whom are ill prepared for such a visitation. Besides, a very large proportion of neurological and mental health disorders and disability, tend to be chronic and long standing, needing continuous and comprehensive care. In this domain, therefore, we believe that ‘there can be no healthcare without service.’ We are a private limited company but work closely and ethically with a foundation committed to helping people with disorders of brain and mind. Rather than compromise on quantum or quality of treatment, this approach helps us deliver, on average, 10% to 30% more treatment to each paying client who deserves such help, apart from serving the disadvantaged at low cost or free of cost. We would therefore describe ourselves as a responsible organisation aiming to deliver world class care with quality and social impact.
What is your vision for Buddhi Clinic? I firmly believe that most people will need a Buddhi Clinic during their lives, both because of human longevity and sociological change (nuclear families, migration across cities and cultures, etc.). Today, we are a five-centre Chennai chain and our primary goal for 2020 is to demonstrate our capability to serve other populations beyond Chennai. We are therefore closely examining opportunities to partner with doctors across relevant disciplines in a range of locations. We see ourselves as pioneers and leaders in integrated care with a brain and mind focus. Having innovated a strong model of care and a robust platform for its delivery, having hit the 10 year – 10,000 plus patients – 1,00,000 plus interventions milestones, we are seeking to be national over the next five years and eventually global. For which we are actively seeking partners, both in medicine and in management.
On World Heart Day we explore stress, that important concept that underlies cardiac disorders and appears to predict coronary crisis.
The word stress, used loosely today in society, has many connotations and can imply a range of circumstances from ordinary workplace or familial dissonance to serious mental disturbance. Crucially, what starts off as a minimal disturbance in one sphere of activity can have significant ramifications that affect many life spheres, if left unattended.
Life and society in the 21st century are profoundly stress generating. While a range of reasons may be held responsible, central to all manner of stress genesis is “the yawning gap between expectation and reality”. Modern lives have spiralled unthinkingly into a vortex, driven by predominantly Western economic models: of unremitting desire, relentless aspiration, pursuit of material gain, needless and thoughtless consumption, transient and elusive fulfilment, and unfettered hedonism. Stress is a natural accompaniment, a constant companion, as new desires replace the old, and the gap between expectation and reality remains constant, if not ever-widening.
Can we escape this vortex? Reduce, even remove, the negative factors that perpetuate stress in our lives? Transform ourselves into that epitome of self-management that others look up to?
Six friendly men of stress:
Rudyard Kipling, the India-born British author famously said (to paraphrase him), “I have six friendly men, they taught me all I know; their names are, who, what, why, when, where and how”. Let’s begin our journey by exploring the six friendly men of stress (see box).
Sources of stress
The Psychological Conflict Hypothesis: The concept of a psychological conflict comes from Freudian thought and is believed to underlie emotional stress. Freud proposed that we have both an unconscious and a conscious mind and that there were inherent conflicts between the primitive urges (Id), the unconscious (ego, current awareness) and the feedback from the moral agency (super-ego). While Freud emphasised sexual urges, psychological conflicts are generally believed to have their genesis in the dissonance that can arise between our inner urges and socially permissible actions; a dissonance that may defy resolution.
The Self Actualisation Hypothesis: Proposed by Maslow, it assumes that each individual has to ascend different steps of the self-actualisation pyramid. At the very bottom of the pyramid are the person’s survival needs; after which appear, progressively, security needs, social needs and ego needs in that order (see box). When all these needs are addressed to a significant extent, the person achieves a state of self actualisation, of fulfilment and being content with one’s lot. Stress is a constant companion at various points on the self-actualisation pyramid and disappears when self actualisation is achieved. However, Maslow’s rather utopian view of the lasting self-actualised state of being may not hold true in the fast-paced modern world, where events often outpace individual development in most unexpected ways.
The Locus of Control Hypothesis: An important psychological construct used to explain the development of depression, an important consequence of stress is the locus of control hypothesis. It has been observed that rats placed in connected cages soon learn to avoid the cage that habitually gives them an adverse stimulus such as an electric shock. However, when the rat receives shocks in an unpredictable manner, it becomes listless, withdrawn and inactive, a state of “learned helplessness”. This has led to the understanding that internal locus of control (where the person feels in control of his circumstances) is protective from emotional stress; while an external locus of control (being controlled by one’s circumstances), makes one vulnerable to it. In the years of post-war industrialisation this phenomenon was recognised in “assembly line workers” who had little control over the nature or pace of their work and were expected to perform a repetitive task for hours on end. Interestingly, our much vaunted IT revolution has ushered in a new generation of “assembly line workers” who operate on international time and in response to international demands, often with little control over their workspace destiny.
The Coping Hypothesis: One point which eludes us when we are in a stressful situation is that there are, usually, only two ways out. Take for instance the example of a very short-tempered boss who reacts without provocation. One can either attempt to modify the situation (i.e. bring about a change in the boss so that he loses his temper less); or one can modify one’s own expectations (i.e. accept that boss with his short temper and learn to work around it). No prizes for guessing which is the easier pathway here. It is often said for this reason “when you cannot modify the situation, modify your expectations”.
Coping strategies are of two kinds: i. Problem-focused coping where the attempt is to short-circuit negative emotions by modifying, avoiding or changing the threatening situation and; ii. Emotion-focused coping where the attempt to moderate or eliminate unpleasant emotions by rethinking in a positive way. Some strategies employed include relaxation, denial and wishful thinking.
In many circumstances, both approaches are combined in the effort to overcome stress.
A number of strategies can help in stress management. Some of these are outlined herein (see box).
The prevention of stress is achieved through good self management. The key to self management lies in being mindful: of oneself and the world around. Inexorably linked with this mindfulness is developing a better understanding of oneself and one’s fellowmen. Caught as one is in the vortex of modern existence, mindfulness can often be elusive, as the roller coaster of life takes us from one event to the next.
The famous Tibetan Buddhist teacher and philosopher Sogyal Rimpoche differentiates the active laziness of the West whereby unimportant tasks become responsibilities, part of a rigid schedule, and begin to dictate one’s existence (appointments, schedules, waiting times); from the passive laziness of the East, hanging out in front of the roadside stall with film music blaring, watching the world go by.
Neither, he contends, is ideal; instead, he highlights the importance of spirituality and contemplation and the need for us to devote some time in each day to examining the deeper meaning of life. In his view “Our task is to strike a balance, to find a middle way, to learn not to overstretch ourselves with extraneous activities and preoccupations, but to simplify our lives more and more. The key to finding a happy balance in modern lives is simplicity.”
It must be noted that stress clearly has its benefits. Imagine if you did not feel stressed out in advance of an interview or exam; your preparation and performance are both likely to be sub-optimal. Some stress is therefore necessary in order for human beings to “survive”. Too much stress, on the other hand, can be unproductive, even wasteful; resulting in much negative energy being expended. What we must try and achieve, therefore, is a fine balance between ambition and motivation on one hand and equanimity of mind on the other. And, while we strive to control our own destinies, by being in control of our lives and circumstances, our destiny may have other plans, that we cannot fathom; plans that we must learn to accept and live with. Perhaps, therein lies the key to effective stress management.
Dr. E.S. Krishnamoorthy is a Senior Consultant in Clinical Neurology & Neuropsychiatry based in Chennai. Interact with the author on www.neurokrish.com
Some heart facts
Stress impacts on the heart: it can cause myocardial infarction (heart attacks) and sudden death. It can affect the regulation of your heart beat by the central nervous system.
The INTERHEART study investigated the relationship between chronic stressors and Myocardial Infarction in about 25,000 people from 52 countries. After adjusting for other risk factors, those who reported “permanent stress” at work or at home had double the risk for developing a heart attack (MI).
The broken heart syndrome , sudden ballooning of the heart apex (left ventricle) follows acute stress. Often there is no evidence of obstructive blood vessel disease. Episodes of intense emotional or physiological stress are reported prior to presentation and maybe the triggering factor. Even when intense bouts of emotion don’t kill, they may cause long-lasting heart damage.
The Whitehall II study found over a two-fold increased risk for new coronary heart disease in men who experienced a mismatch between effort and reward at work. High-risk subjects were those who were competitive, hostile, and overcommitted at work, in the face of poor promotion prospects and blocked careers.
Cardiac syndrome X affects women more; there is angina-like chest pain and a positive response to the treadmill test with normal heart circulation. Cardiac syndrome X patients report more depression, anxiety and somatic (physical) concerns; they also have better prognosis.
Depression is a primary risk factor for Ischemic Heart Disease and an independent secondary risk factor for Heart Attacks. Depression also has a direct impact on cardiac risk factors such as diabetes, hypertension and obesity. Depression after myocardial infarction more than doubles the risk of death and of another heart attack. People who suffer chronic anxiety are more likely than others to suffer heart attack. Emotional trauma such as the death of a spouse, mental or physical abuse, or post-traumatic stress disorder (PTSD) increases risk of heart attack.
People with Type D personalities (characterised by pessimistic emotions and inability to share emotions with others) and Type A personalities (characterised by anxiety directed outward as aggressive, irritable, or hostile behaviours) are more likely than others to suffer heart attacks.
Freud said that happiness comes when one has pleasure in love and work. Research shows that marital stress in women and both marital and work stress in men greatly increase the risk of death due to a cardiac event. A famous doctor has observed “where can he go if he is unhappy at work and at home?” The implied, if somewhat flamboyant, answer was always “to an early grave.”
The Buddhi Clinic team first met Raja Mohan a Southern Railway employee, then in service, in early 2019. He was referred to us for rehabilitation following a stroke that had left him bed bound, paralysed and unable to care for himself. Over three months, with our then “new” brand of integrated care, #trimed, Raja Mohan made an amazing recovery, becoming completely independent and ambulant once again. So much so, that his integrative medicine rehabilitation case study was covered in Doctor #Vikatan a popular Tamil language magazine. Raja Mohan went on to rejoin work in the Southern Railway Booking Office, would walk a couple of kilometres every day to catch the bus to work, and resumed a generally active lifestyle. With multiple co-morbidities, Chronic Obstructive Pulmonary Disease (COPD), Hypertension, Diabetes, High Cholesterol levels, and Mild Cognitive Impairment (post Stroke), he remained active, followed up with all his medical specialists regularly, thanks to his loving wife, fulfilled his many roles as husband, father, sibling, uncle to his large extended family of 26 people occupying a block of apartments in Chennai, and worked till his retirement from the Railway in 2019.
Earlier this year, Rajmohan was wheeled back into Buddhi Clinic by his distraught wife. Affected by #Covid-19 he had been in hospital for two weeks, before being discharged. Wheel-chair bound, confused and disoriented, he was uncommunicative, vacant and unable to care for himself, being incontinent of urine, needing feeding by hand and assistance for all activities of daily living. In normal circumstances we would have advised admission to hospital for #delirium management and #rehabilitation. In these troubled times of a second wave, neither were hospital beds available, nor would his condition be considered a priority. Thus began our #home care protocol for #Covid-19 delirium rehabilitation with his wife and extended family assisting his recovery.
At intake the following symptoms were targeted for rehabilitation.
Poor sitting and standing balance
Difficulty in walking
Mild weakness of lt upper and lower limbs-4
Poor food intake
Dyspnea on exertion
Mild tremors in both hands
Medication was substantive and included neuropsychiatric, pulmonology, Diabetology and medical prescriptions, in total a list of about 16 different formulations including some combination drugs. The neuropsychiatric drugs included sodium valproate (for seizure prevention and behavioural control, continued from hospital), donepezil (for cognitive dysfunction, piracetam, citicholine and ginseng. No other psychotropic drugs were prescribed to manage delirium as there were no problem behaviours.
We commence care on 16th April 2021 with our physical therapist (Mobility Lab), tDCS technician (Brain Mapping Lab – Neuromodulation) and Complimentary & Alternative Medicine technician (CAM Lab) delivering 10 sessions of care each at home.
Electrotherapy, exercise therapy, gait training & manual therapy
Focal abhyangam and reflexology
tDCS- delerim protocol
With each lab tech visiting Raja Mohan two to three times weekly (as the ongoing lockdown would permit) Rajamohan made a slow and steady recovery. Indeed when reviewed by our founder Dr. Ennapadam S Krishnamoorthy on 10th May 2021 (about 3 weeks on) the clinical notes were “Has made good recovery from post Covid delirium- in home based rehab from Buddhi Clinic. Is ambulant, responds appropriately. Continues to have slowed cognition, mild tremors, some dryness of skin in the feet etc.
At our end of “first therapy cycle” case conference the outcomes were recorded as follows.
End Therapy VAS*
Raja Mohan is no longer confused or disoriented. He is completely independent in all activities of daily life, moves about freely and safely, walking with a broad based but stable gait, and responds appropriately to all questions, with some delay and slowness, but with clarity. Indeed, his wife’s comment was “you have given him a third life”, she having witnessed the devastation of neurological insult twice in the span of eight years, first a stroke and now Covid-19 delirium. From the medical perspective we learn that Covid-19 can cause delirium which is treatable, this being our third success story. From the humanistic perspective we understand the importance of faith, hope and family in rehabilitation and care.
Raja Mohan rides again and in doing so he validates for us the importance of our Buddhi Clinic’ integrated care model in #neuropsychiatry.
A conversation between Dr. Sheela Nambiar MD, Obgyn – (SN) and Dr. Ennapadam S Krishnamoorthy – (ESK), Behavioural Neurologist & Neuropsychiatrist.
SN – Welcome to you all. We are happy to be here to discuss this important topic of depression. Dr Ennapadam Krishnamoorthy is a Neuropsychiatrist in Chennai and Behavioural neurologist. He is the Founder of the Buddhi Clinic chain which offers complementary and alternative medicine, in addition to, standard neurological & psychiatric care and psychotherapy solutions.
SN – Why would you say the disease of depression has become an epidemic of the 21st century? Is it something that we are calling out more or are people more depressed than say, 20 years ago?
ESK –We understand today that depression is one of the most common medical problems worldwide, a cause of dysfunction and debilitation. At one end it is just a feeling most of us will experience at some point in our lives, due to life circumstances or, a loss. Sometimes it might last for a short spell. At other times it may last for a longer period of time and affect our lives. That is when it becomes a disability.
Let’s say, I break a leg – it is a very apparent disability. But, when I am depressed, no one else may know what I am going through, because it is so personal and internal that it cannot be communicated to others. It is a transient feeling but that which disables an individual and prevents her/ him from having a normal life.
A meta-analysis from BMJ looking at how depression has progressed actually shows that the rates have dropped from 36% to 24% in patient clinics. The paper also says you are more likely to be depressed in your 30s and 40s and then late in your life. So it’s a “U” curve. So I’m not sure if it is indeed more common than before.
SN – So what is the difference between feeling low and having a clinical depression?
ESK – The difference is in the severity. Is it significant enough to need attention? How long has this gone on? The duration can be as less as two weeks. But the most important thing to ask oneself is – ‘is it preventing me from having a normal life?’ If it is, one needs to pay attention to it.
SN – What is really interesting to me is that everybody has problems. I don’t think anyone gets away without problems. How is it that some people are able to withstand them and not become depressed, whereas others having similar issues get depressed?
ESK – So in your introduction you used the term “bio-psycho-social”. The Bio part of it is how each of us is wired. This is a combination of genetics, early upbringing and the like. This is when the brain develops. Your ‘Bio’ is influenced by your genes, by the chemistry in your brain, certain inflammations like the antibody syndrome when your body is attacked by something, the body responds by creating antibodies but which then turns against your own body’s cells. There are metabolic factors that cause depression. These could be hypothyroidism, low B12, D3, having diabetes, and certain skin conditions like atopic dermatitis. We, then, come to Psyche which is your temperament. Certain temperamental patterns, like worriers, obessesive anxious people may be more prone to depression. There are Social-environmental factors which include parenting, family, outside influences etc
So, the question “why am I getting depressed”? has multiple answers – we all have emotional scars of various kinds, some we may not even remember. We also have nurturing factors that make us stronger. People who are worriers, obsessional, anxious, tend to be more prone to becoming depressed than people who take things in their stride and just move on.
SN –And there is some research on how more creative people tend to be more prone to depression is there not?
ESK – Oh yes. There is a lot of literature on mood swings and creativity. There are a number of examples of poets, artists and people in the creative field who were depressed. That’s also because depression is more of a right-brain than a left-brain phenomenon. Having said that, there are forms of depression that are left-brain too. There is a social aspect to depression, one interesting statistic is that you are seven times more likely to have a mental health problem in the 6 months after your marriage than in any other time in your life!
But interestingly there is another counter-statistic is that one of the things that makes sure that you have a good outcome from a mental health problem is being married.
ESK – Women are twice as likely to experience depression in their lives than men are. Due perhaps to all the life events they go through and the hormonal changes.
SN – Hormonal fluxes can be quite drastic from menarche, to pregnancy and delivery to menopause. These events do influence a woman’s mood. Would you say that social support also plays a role in depression?
ESK – Absolutely. Both in protecting you against depression and in helping you overcome it. Having a good social support system, work and employment, activities you resonate with and a healthy financial status.
SN – I deal mainly with women being a gynaecologist. I find that women, once they cross the age of 40 or so, find themselves wondering what else to do, now that their children are independent Once they are given some support, they make a change that they perhaps could not attempt in their 20s and 30s. It may be maturity or that after a point they no longer want to please society, norms or the people around them all the time. One of the triggers for this change is that they start to feel depressed. Have you come across situations like this?
ESK – Absolutely! Menopause/Perimenopause also plays a role. Mood, memory etc. are affected around this time. Apart from life circumstances, there are biological changes that are happening so symptoms of depression etc. can set in.
SN – What do you have to say about this concept of depression being connected to ‘weakness’ and the stigma behind it? Does this hold back people from coming forward to get help? In fact, even family members may brush it off saying, “you need to get over it”.
ESK – That is the most common thing we say, “pull yourself together’. But they cannot! That is why one needs to understand that it is a disability. If one were paralyzed, one would not say “get up and walk”. There is, also, a burden of expectation we all place on ourselves. The expectation – to be normal and fulfil our obligations. When you are depressed, however, these obligations may seem big. Getting better, just like with a paralysis, is a slow process.
SN – Can you tell us the different symptoms experienced by a depressed person? Do different personalities express depression differently?
ESK – Children and elders express depression differently. A child might be irritable, agitated or angry. Elders might also show similar signs. Though they are both likely to be depressed. In adults, it can be expressed as low moods, or
” Anhedonia” which is the inability to feel pleasure in things you would normally find in, “Hedonism”- to seek pleasure mindlessly, or “Alexithymia” which is the difficulty in verbalizing an emotion.
Language has an interesting connection with depression. There is no word for depression in Tamil for instance. There is no word to say I am depressed in Tamil. You only express things like ‘the mind is tired”.
There are linguistic barriers to expressing depression. Our culture does not encourage you to express your emotions like Western cultures do. Most of us would not for instance, go on the Oprah Winfrey show and talk about our glorious or miserable lives! This is because our culture does not encourage us to express our emotions. People often use ‘as if” terms to talk about emotions rather than talk about their emotions directly. In a number of Indian and other native languages also lack words for certain emotions. Friends from Africa tell me they don’t have a word for depression.
SN – Coming to the treatment of depression, can you tell us something about anti-depressant drugs?
ESK – Anti-depressants have had some bad press. But they have a unique mechanism of action. We used to think they correct the chemical imbalance in the brain and that is what relieves symptoms depression. We now know that some of these drugs actually help to grow new neurons. They have a neuro-protective effect. This may be why they take a long time to produce relief from symptoms. Antidepressants take a long time – 6 weeks to 3/6 months. The most common reason for ineffectiveness of treatment is non-compliance to treatment. The second is the failure to try a drug at an adequate dosage for an adequate period of time. So, often, if 3 months later you don’t feel better, you may change your doctor, your drugs etc.
All drugs have side effects, of course. I think a patient should try anti-depressants under the guidance of a good doctor before they give up. In my experience, most people give up the treatment too easily. It requires a therapeutic alliance between patient and doctor.
SN – Can a patient go off the drugs completely at some stage?
ESK –You cannot stop them suddenly, they need to be withdrawn slowly and gently. Typically, the drug needs to be taken for at least 6-9 months.
SN – Have you come across many patients who complete the course of drugs and do well?
ESK – Depression is one condition where you can actually say you are “cured”. The chances of cure become better when besides taking medication you do other things like psychotherapy. Psychotherapy helps you understand the roots of your depression. Where is it coming from? It reflects the gap between expectation and reality. So, it is important to engage in good therapy and use this opportunity to understand oneself. Good psychotherapy will help you prevent further episodes as well.
SN – So Cognitive Behavioural Therapy would be one such form of Psychotherapy?
ESK – Yes, absolutely
SN – Talking about prevention and lifestyle management of depression, I would like to add about why exercise is so important for the management of depression. Exercise does produce endorphins; it makes you feel better and puts you in a better frame of mind. Diet is also of utmost importance. The gut produces as much if not more serotonins than the brain. The microbiome in the gut is responsible for much of your mood. If you do not feed the gut with the right kind of food, the microbiome in the gut is altered. It has been shown that people with very poor eating habits – highly processed food, sugar and so on have altered microbiome and are more prone to depression. Something as simple as a change in your diet and exercising on a regular basis can be a support system to the medication if you need it.
SN – What can you typically expect from a psychotherapist?
ESK – A good therapist is not someone who will tell you what to do. They will not advice you what to do. Instead a good therapist will show you a mirror to yourself. She/he will be able to help you understand your emotions and verbalize them. A therapist is a professional, and has no prejudices. All the solutions are within us. We may not see them. So, we may need the help of a good therapist.
SN – Is depression genetic?
ESK – Yes, when the Human genome project was underway a number of single gene disorders were discoved. Certain disorders of brain and mind also got unlocked. General thumb rule is that 10% of people have a genetic form of neurological or mental health condition.
Talking of psychotherapy – Everyone may not be suitable for psychotherapy. You cannot offer psychotherapy in all stages of depression. You may need to work with some people in other ways.
SN – Lets open the floor for questions
Question – When you are looking after family member with depression, how do you deal with them when they don’t comply with medication? What is the right approach when they refuse to take responsibility?
ESK – The role of the family and in having someone empathetic is important. Sometimes, when the patient refuses to come to the hospital we, at Buddhi Clinic will send someone to their home to try and engage with them.
Using holistic care like Yoga and Ayurveda, (which is offered at Buddhi clinic), we can get them started on a self-care journey.
Then, there are head massages. What a head massage does, which we now understand through research in other areas, is that it probably changes the energy metabolism of the brain.
So, engagement, having the family involved, offering people courses that they truly believe in and are willing to explore have a hugely beneficial effect on the management and better cure of depression. I became interested in these other forms of treatment after I found that often people with mental disorders when they try alternative forms of treatment like yoga etc. they are told to stop all other forms of treatment. So I decided why not offer them everything so they can continue their medication when required and also have the option of other treatment under supervision. We don’t understand the power of what other systems can offer.
A friend of ours who does research on Yoga has shown that after a set of Yoga sessions which are aimed at improving mood, the brain changes are the same as taking medication.
SN – With reference to this first question it is important to also rule out other disorders isn’t it? It may not be pure depression. It is possible that it may be a combination of mood disorders, psychosis and so on?
ESK – Thank you for pointing that out. It is important to recognize that what seems to be depression may be something else. It could be a disorder of the brain or body.
SN – It could be a simple deficiency like a B12 or D3 deficiency.
ESK – Yes or it may be an inflammatory condition of the thyroid for instance. Thyroiditis that is completely treatable.
Question – Is it true that depression can teach you something and it is there for a reason? Can the person be depressed because he needs to withdraw and ponder?
ESK – That’s a very interesting question. If you read the life stories of Ramakrishna Paramahansa, Jiddu Krishnamurthy and others you will find that for many, transformation and realization started with depression. “Pathos” is the word used. That does however, not hold good for everyone.
ESK – One of the things we have not mentioned about depression is the Becks Triad – this is the negative view about the world, the self and the future.CBT is circled around this thought process to identify the thoughts that are making you depressed and work on how you can re-think.Today we also have Transcranial Magnetic Stimulation TMS. For some this works very well. It modulates your brain and makes the chemicals more available. We have this treatment available at Buddhi Clinic. You need 20 sessions of about 30 minutes each. No anaesthesia is required.
Question – What do you advice people who are the caregivers of depressed people?
ESK – It has a profound effect on the family and caregivers. Caregivers go through a lot of stress. An important part of caring is to also extend it to the caregiver. Caregivers go through guilt, blame and remorse. Usually the psychotherapist is the best person to discuss this with. You don’t always have to do something active with a person who is depressed. Just sitting with them, going for a walk with them, listening to music may be sufficient. Just being there sometimes makes all the difference.
Question – What is the relationship between substance abuse and depression and what effect do they have on each other?
ESK- It is a kind of chicken-and-egg story. With some, being depressed may make them turn to substances like alcohol. In others, the alcohol is the problem and leads to depression. So, the drinking and the mood may be cyclical.
Questioner – What about food? Is that also a form of substance abuse?
ESK – There is a lot of association between eating disorders and mood. Anorexia and bulimia are associated with mood disorders. So, eating disorders and mood disorders can co-exist in a number of people. One can influence the other, the treatment of one can cure the other.
SN – There is evidence that obesity is related to depression and vice versa. So, when you are depressed, you reach for food as comfort, gain weight and then you get more depressed. Frankly I think food is as addictive as any other substance (abused), because it is so easily available, acceptable and accessible unlike alcohol and drugs. Especially sugar, not just white sugar but processed food that has added sugar is highly addictive.
SN I would like to thank Dr. Ennapadam S Krishnamoorthy who has been so generous to spare his valuable time to come here and spend this hour with us to discuss depression. It is silent, pervasive and so easy to miss. If you have any doubts about anyone (including yourself) heading down that road, there is no stigma. It is like any other disease. Just as you would not hesitate to go to a doctor to treat gastritis, there should be no stigma associated to going to a psychiatrist.
I hope Dr. ESK has made it clear and that is all the more reason we should pay close attention to it.
As World Yoga Day 2021 dawns, it could not have come at a more relevant time. For over a year, our world has been gripped within the jaws of a pandemic that comes in waves and disrupts our lives at will. It is a time when much of humanity is paralysed into inaction, by fear of an invisible enemy. Indeed, never before has Yoga and its modern offshoot, mindfulness, been so relevant. When one considers the term Yoga, one often thinks of it as being a physical discipline with mental effects; the adoption of postures in order to achieve a state of mental calmness and equanimity.
Modern science tells us that Yoga is not just about postures and mental states; it has substantive effects on the human brain, indeed effects that one is able to study on dynamic brain imaging such as functional Magnetic Resonance Imaging (fMRI).
Yoga is one of many important mindfulness traditions, perhaps the most ancient, from across the globe. Yoga which originated in India is derived from the Sanskrit word “Yuj” and means “Union”, indeed a method of spiritual union. In the Patanjali’s Yoga Sutra, the ancient and definitive treatise, it follows eight aspects or limbs- yamas (abstinence from immoral behaviour), niyamas (self-discipline), asana (physical postures), pranayama (breath control), pratyahara (sensory withdrawal), dharana (concentration, dhyana (meditation) and samadhi (pure consciousness). Let us focus on the breath, prana, which indeed is the focus of most modern mindfulness practices. Pranayama is the yogic practice of focussing on one’s breath and is meant to elevate “prana Shakti” or “life energies”. To be able “to restrain and control” one’s breathing is a very key element of the pranayama practice which is the fourth of eight limbs in the Ashtanga Yoga mentioned in the Yoga Sutras of Patanjali. Indeed, this focus on the breath is as old as The Buddha who incorporated it into his enlightenment discovery, with little success, at least initially.
And, the focus on the breath is very much part of the modern secular mindfulness practice, techniques such as Mindfulness Based Stress Reduction developed by Jon Kabat-Zinn, having made it integral practice.
Today, we think of mindfulness as secular, process driven and science based. Yet, Yoga, Tai Chi, the many martial arts traditions in the East, native traditions in the Middle-East, Africa, Latin America and among the “Indian tribes” in North America have incorporated practices that lead to “the thing called mindfulness”. At an extended University of Leiden online course that I attended, the instructor Prof. Chris de Goto described mindfulness “as a consciousness discipline that exists in the interface between science & spirituality, a kind of mental praxis”.
Yoga, therefore, is not just a “body-mind” exercise. Indeed, when things were normal and we medical professionals could meet, we the Buddhi Clinic and Trimed Therapy team had a conclave of experts across disciplines, discussing impact of these traditions on the brain and mind. In that Buddhi immersion, presenting a series of studies about Yoga conducted at NIMHANS, Prof. Gangadhar pointed out that there were positive biological and healthcare (including psychological) outcomes with its practice. Dr. Naveen Vishveshvariah of Yogakshema presented a number of research studies both those in which he was involved and others conducted and published from around the globe, that showed structured yoga practice having impact on a range of molecular, biochemical and neurophysiological parameters under study. In a review in the “Frontiers of Integrative Neuroscience”, van Aalst and colleagues* examined 34 international peer reviewed studies of Yoga using Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), or Single Photon Emission Computed Tomography (SPECT), all of which incorporate dynamic brain imaging. They found 11 morphological (structural) and 26 functional studies, including 3 studies that were both structural and functional.
Apart from increased grey matter volumes in the insula and hippocampus, key structures for memory, emotions and behaviour, they were able to demonstrate increased activation in the pre-frontal cortex and functional connectivity changes within the Default Mode Network.
Their findings mirror modern mindfulness research from around the globe, with increasing evidence that mindful states, whatever their origin, have a profound effect on the brain, memory & emotions in particular.
Which then brings us to where the brain-mind -body connection originates from. Behold the Kundalini, that ancient concept of unlimited reserve power seated in the nucleus of every form of existence. Kundalini is conceptualised as being associated with and coiling itself around the bindu (the point of utmost sensitivity); while in its uncoiled, manifested form, it exhibits nada (the continuum of utmost sensitivity). The mystic 3 coils and a half of kundalini are thought to be the basic disposition of kala (the fundamental, the evolvent principle). Kundalini is a cosmic principle; it is seated principally at the “Base Centre” called muladhara.
When aroused the kundalini ascends along the path of Susumna (the yogic channel of life) and is the nature of ejection not projection (what the source loses, the receiver gains).
The susmna and cakras are not thought to be grossly anatomical, in that certain nerve pathways and ganglia are not to be taken as their “physical and physiological basis.” The cakra is considered to be a subtler more potent apparatus, yantram, that controls the economy of our whole being, physical, vital, conscious.
Thus what does Yoga or indeed any mindfulness practice done well, evoke? Wherein does this mind body connection lie? Well consider this! You are walking down a forest path one dark and lonely evening. You come across a wild animal, say a cheetah. What happens? You are perplexed and frozen, your pupils dilate, nostrils flare, muscles tense, heart beats fast and becomes almost audible (palpitations), you start shaking, sweating and feel short of breath, you perceive a need to empty your bladder (or do so involuntarily), you feel as if you have run a mile. In short, unbeknown to you, your nervous system prepares you to fight or flee. This is the work of your Autonomic Nervous System, nerve pathways that exercise control over our everyday involuntary actions, even as we think and make important (voluntary) decisions, to talk, walk, climb, eat and so on.
This autonomous part of your nervous system (hence autonomic), which connects body and mind, is what is influenced by Yoga and mindfulness practice.
And be aware, it is intimately connected with the deep recesses of our brain, the oldest parts of our mammalian brains, the Limbic system, composed of the hippocampus, amygdala, insula, all of which have a role to play in memory and emotion. And the decisions, to fight or flee, to be aggressive or passive, are derived from the prefrontal cortex, to which the limbic system is intimately linked.
Thus, our ancients probably got it spot on when they described the kundalini and the practise of Yoga. When we practice Yoga, we influence the Autonomic Nervous System and through it the brain, thereby bringing about physiological changes, heart rate, blood pressure, breathing; mental changes, a reduction in anxiety and enhancement of mood and motivation; cognitive changes, improved attention and focus, enhanced memory and quite naturally behavioural changes, behaviour being the quintessential expression of emotion.
It falls upon us, therefore, to celebrate our ancients, who deduced all this without fancy brain imaging, neurophysiology and neuropsychology; who created perhaps India’s greatest export to the world, one that influences “the mindful neuron”!
* June van Aalst, Jenny Ceccarini & Koen van Laere. What has neuroimaging taught us on the neurobiology of Yoga? A review. Frontiers in Integrative Neuroscience, 2020; 14: 34
Dr. Ennapadam S Krishnamoorthy MBBS, MD, DCN (Lond), PhD (Lond), FRCP (Lond, Edin, Glas), MAMS (India) Founder: Buddhi Clinic
In today’s fast-paced world, a large section of the population is denied the opportunity to manage chronic diseases through a wellness, holistic and healing-oriented approach.
Dr. Ennapadam S Krishnamoorthy
The burden of chronic disorders is largely attributed to the perils of modern medicine that prioritises cure through prescription drugs instead of focusing on the entire continuum of human healthcare engagement: rejuvenation, restoration and rehabilitation. The end result: an unhealthy ageing population.This is where India’s ancient and holistic Ayurvedic system as a viable form of alternative medicine comes in. It is about time medical practitioners harnessed the full potential of Ayurveda as it’s based on a strong foundation of scientific research, much like modern medicine’s tenets.
In recent years, a growing body of research points to integrated medical treatments—a combination of complementary (alternative) and modern (allopathic) medicine—gaining popularity. While modern medicine’s thrust is on cure, integrative medicine focuses on disease prevention, comfort and care.
However, despite the marked shift in patients’ preference for alternative forms of healing, I observed a deficit of innovation in therapies that are based on integrative medicine. This is where Buddhi Clinic’s genesis and my entrepreneurial journey can be traced.
I realised there was no other healthcare outfit in the world that provides a unique 360° evaluation of body, brain and mind through an integrated approach. At Buddhi, we take a holistic approach to diagnose a medical condition that combines the scientific rigour of modern medicine’s diagnosis and drug treatments with the therapeutic benefits of ancient healing traditions.
In essence, my long-term vision for our healthcare startup that was founded as a project in 2009 and company in 2013, is to make complementary and alternative medicine (CAM) gain acceptance as mainstream therapies. From my experience, I realised this would be possible only by seamlessly integrating them with modern medicine.
Let me tell you how this is done at Buddhi Clinic.
A Game-Changer in Brain and Mind Integrated Therapy
We are the pioneers and innovators of integrated care for the brain and mind. What sets Buddhi Clinic apart from the rest is that we don’t follow a cookie-cutter approach to diagnosis and treatment. Our raison d’être lies in being able to provide unique personalised treatment strategies for patients that is managed by interdisciplinary process-driven programmes.
Since several neurological and mental health disorders and disability are longstanding issues, patients need continuous and comprehensive care. Thus, we strive to offer a better quality of daily life to our patients by curating a range of therapeutic solutions based on considerable clinical and empirical research, and our team’s extensive experience.
Buddhi Clinic’s focus is on neurology and mental health rehabilitation and therapy. We have also created a range of interventions for pain, mental health, lifestyle and disablement conditions.
While our diagnostic approach and internal treatments are allopathic, we also rely on traditional healing therapies to restore the equilibrium of your brain and mind interface. Buddhi Clinic’s seamlessly integrated approach offers 14 non-pharmacological treatment modalities that are an amalgamation of modern science and ancient wisdom.
We offer treatment programmes for each condition customised for children, adults and the elderly. These include: Ayurveda, Acupuncture, Acupressure, Naturopathy- water, mud, aroma and magnet treatments; Reflexology and Yoga; and Rehabilitation therapies – speech, neurodevelopmental, physiotherapy and a range of specialized psychological therapies. We have also curated treatment combinations for Psychology – CBT, CRT, Behavioural, JPMR, ERP, EMDR; and Neuromodulation or brain stimulation (a full house of treatments).
Empowering the Patient Based on the “McDonald’s Model”
One of the guiding principles behind founding Buddhi is respecting and understanding patient preferences and engaging patients in shared decision-making. Towards this end, we perceive our startup to be the McDonald’s of “Brain and Mind Care and Rehabilitation”.
Similar to how a customer can curate his meal in a McDonald’s outlet, Buddhi Clinic, too, offers patients the choice to curate integrated treatment programmes tailored to their specific needs. This is called the “choice model” and is better suited for mild impairment and chronic or progressive health conditions. In such situations, we give patients the choice and flexibility to select a combination of modern and ancient interventions rather than rely on a single medical treatment, procedure and therapy. It is our belief that for best treatment outcomes, the patient should be in control of his own decisions regarding his healthcare options.
That said, our team also draws up a “prescription model” when the patient suffers from a chronic condition and requires continuous restoration and rehabilitation.
Crucially, at Buddhi Clinic, we adopt a holistic approach to healing our patients and focus on their overall wellness and recovery that goes beyond cure. We think different—not just about illness or disablement but also about ability and enablement.
Research and Innovation Led Approach
Nothing fulfils me more than making sustained efforts to give our patients a better quality of life. Our patient-focused approach includes continuously monitoring their progress and offering them quality pre-treatment, mid-treatment and end-of-treatment assessments.
Over the years, we have delivered quality healthcare to over 10,000 patients who have received an excess of 1,00,000 interventions. Our success stories that cover conditions such as autism, epilepsy, depression, Parkinson’s disease and dementia, among others, are documented as detailed case studies in ‘Buddhi Books’. The books are aimed at fostering the spirit of research and continuous learning to enable children, adults and elders achieve a better quality of daily life.
Buddhi Clinic also endeavors to offer innovative products and services to enhance the integrated approach to long-term brain and mind care. For instance, we use Transcranial Magnetic Stimulation (TMS) to treat neurological and psychiatric disorders. Transcranial Direct Current Stimulation (tDCS) and transcutaneous auricular Vagus Nerve Stimulation (taVNS) are also the Neuromodulation innovations we bring in. While the former two, rTMS and tDCS stimulate specific brain pathways for specific conditions and outcomes, the latter tAVNS stimulates the auricular (ear lobe) branch of the vagus nerve (ABVN), an easily accessible target that innervates the human autonomic nervous system. Like this, there are other innovations in the pipeline that we hope will lead to paradigm disruption in this space.
Building a Service-Oriented Approach
In order to create a healing environment based on holistic principles, we aim to continue to provide personalised and meaningful patient experiences at competitive rates. Since today’s patients have greater discernment, patient satisfaction is paramount to us. Our service-oriented approach helps us deliver, on an average, 10-20% more therapy to each paying client, apart from serving the disadvantaged at low cost or free of cost.
In the coming years, it is our goal to collaborate with doctors and diverse talents in the healthcare sector to serve populations beyond Chennai and India. Our objective is to demonstrate our capability as pioneers and leaders in integrated care with a brain and mind focus.
One of my key learnings as a healthcare entrepreneur has been that it’s not enough to achieve a robust bottom line growth. It is equally important to sustain it by creating impact at scale through a committed patient-focused approach.