Categories
Buddhi Stories Epilepsy & Seizures Featured Memory Problems

Rare illness, caught on time

Seizures, memory loss, aggression: symptoms that left a television news editor unfit to work. Until a providential diagnosis helped him make a remarkable recovery.

When R, a television news editor in his 40s, came to us a couple of years ago, he was suffering from seizures, poor short-term memory, mood swings, irritability, suspiciousness and aggression. Although he had a great track record at work, his condition had left him unfit to return to his job at a well-known television company. We found that his symptoms were provoked by limbic encephalitis, an antibody syndrome where the body’s immune system attacks rather than defends it. Apart from repeated seizures, the condition, which affects parts of the brain that control memory and emotion (the temporal lobes), had left him with a set of neurobehavioral symptoms.

While treating him for this, a timely visit from Oxford by Angela Vincent, a world renowned expert on antibody syndromes, in 2014, helped us diagnose R with a second, hitherto undiagnosed — and rare — antibody-mediated syndrome called NMDAR 1. We gave him a second course of intravenous steroids (the first having been given during initial presentation) following this discovery, and saw a distinct improvement in his memory and behaviour.

Evaluating R in some detail, we found he had severe deficits in cognition, with very poor ability to remember any new information. Indeed, he took quite a while to even become familiar with our team that was meeting him each day.

Our integrative rehabilitation programme for him was, therefore, focused on memory retraining and behavioural management, but included shirodhara (an Ayurveda treatment with brain-behaviour focus), acupressure, reflexology and physiotherapy. He was also given a combination of drugs to control seizures, enhance memory and modulate behaviour.

Counselling the family, helping them understand his predicament — that his symptoms were not deliberate or put on but an outcome of brain injury — was also part of the treatment. Working with his employer, who was concerned about R’s inability to do even some simple crucial functions, and prescribing a time-frame for our continued efforts, was also essential, helping R retain his job. Indeed, his immediate boss, a popular media personality, visited the centre to discuss R’s condition.

R’s recovery over two years was stormy. Seizure clusters, poorly controlled (pre-existing) diabetes, and an extraordinary reaction to a drug prescribed for seizures resulted in three emergency hospital admissions.

Also, R had great difficulty in accepting changes at home, such as his wife taking on decision-making and financial management roles. Paranoia and disturbed sleep taxed him and his interpersonal relationships greatly. At work, a change in the software platform magnified R’s difficulties. No longer could he work on auto-pilot; skills learnt over two decades were suddenly obsolete.

Supported by a caregiving trinity — family, employer and medical team — working in tandem, R managed to overcome these multifaceted problems.

Two years on, the transformation in R is remarkable. He is seizure-free, composed, communicates clearly, manages well at work having learnt to use the new software platform effectively, and enjoys a close trusting relationship with his family. He still has some residual memory and cognitive dysfunction and attends our centre for weekly cognitive retraining sessions. He continues to take some medication to control seizures and improve his memory.

This father of two, the sole breadwinner of a young family, managed to retain his job and win back his life because of a providential and timely diagnosis.

Categories
Buddhi Stories Featured Unexplained Medical Symptoms

What’s up, doc?

When symptoms defy explanation, an interdisciplinary approach works best.

When I first met Mrs. A, the wife of a practising physician, she had been clinically symptomatic for over two years. Her main complaints were an uncontrolled appetite (she was eating every two hours and in large quantities), weight gain (over 10 kilograms), irritable bowels (she was visiting the loo every two hours as well), vague aches and pains, fatigue and excessive sleep. She had consulted an army of specialists of every conceivable description, undergone (often repeatedly) a battery of investigations, no specific abnormalities being identified and consequently no diagnosis having been made.

Each person who saw her had given her a diagnosis: the gastroenterologist called it “irritable bowel syndrome”, the orthopaedic surgeon “fibromyalgia” and psychiatrist “atypical depression”. None of these diagnosis or treatments thereof had resulted in symptom reduction. Mrs. A was thus at her wits end when we met, desperate for a diagnosis and a cure.

Mrs. A is one of many people who suffer from a distinctly peculiar condition: unexplained medical symptoms. Clinical studies have shown that over 30 per cent of people attending out-patient clinics and emergency rooms have medical symptoms without ostensible cause. Indeed, a plethora of examinations and investigations done in these individuals fail to reveal any specific clinical abnormality, or diagnostic entity.

Shuttling between doctors, hospitals and diagnostic facilities, they often remain clueless about the real cause of their symptoms. Over time they develop a cynicism about the healthcare environment and proceed to explore alternative options. Meanwhile, healthcare professionals also become cynical toward such individuals, labelling them “neurotic”, “anxious”, “hysterical” and other potentially disparaging terms.

A famous study by Dr. Eliot Slater — an eminent psychiatrist in the National Hospital for Neurology, Queen Square, London — followed up over a decade, all those diagnosed with “hysteria” in this pre-eminent institution and showed that a very large proportion (about half) went on to develop “real” medical illnesses. The results of that medical study published many years ago, warned physicians about the dangers of writing off unexplained medical symptoms as being “hysterical” or “in the mind”.

A repeat study in the same hospital in the 1990s, under the guidance of Prof. Maria Ron, an eminent neuropsychiatrist, showed that the rate of erroneous labelling as “non-organic” had fallen to about 10 per cent, aided no doubt by advances in medical technology. It must be noted however, that mis-diagnosis as “non-organic” or “in the mind” continues to occur even in pre-eminent medical institutions staffed by experts with access to best medical technology. Having said that, a number of people with unexplained medical symptoms do have “non-organic” causality.

So why do people have unexplained medical symptoms? A proportion, perhaps, have a genuine medical cause or complaint that has remained undetected. Examples include inflammatory, infectious and metabolic conditions, and rare forms of cancer that may take time to manifest their full avatar. A proportion may have true hysteria — deep psychological trauma that is finding its outlet in physical symptomatology with secondary gain being the attention derived thereof.

A proportion may be addicted to the hospital environment — “Munchausen’s” hospital addiction syndrome — leading them to repeatedly seek contact and reassurance from healthcare professionals. A proportion may have health-related anxiety and engage in so called “abnormal illness behaviour”, with their reactions being out of proportion to the symptoms they are experiencing. A proportion may be engaging in conscious malingering, presenting a medical symptom in order to avoid a social problem, for example, an arrest or a court appearance.

In all people with unexplained medical symptoms, the bogey of an “organic” cause that has hitherto gone undetected, needs to be kept in mind. Repeated and detailed history-taking and clinical examinations are necessary, as is a close and empathetic follow up, with neither the physician nor the patient’s family succumbing to the proverbial “crying wolf” syndrome. In patients in whom an organic cause has been excluded beyond reasonable doubt, hysteria, somatisation (multiple physical symptoms without a physical cause), Munchausen’s syndrome, Abnormal Illness Behaviour and malingering may all be considered and form part of a psychological continuum.

What varies across this continuum is the level of conscious awareness, considered low (hence unconscious) in hysteria and somatisation, and high (hence conscious, deliberate and wilful projection of symptoms) in malingering. What varies also is the motive or intent; preference for the hospital environment in Munchausen’s syndrome, avoidance of a social problem in malingering, or indeed the more fuzzy and less easy to diagnose “secondary gain” of hysteria and somatisation. In all these instances, an empathetic approach, with deep understanding of the client’s background (developmental, familial, social, occupational and marital) is necessary, as is a strong therapeutic relationship rooted in mutual respect and trust.

All the above seem a tall order when demanded from a solitary physician doing her/his best with the constraints of time and resources. Patients with unexplained medical symptoms do well when managed by an interdisciplinary team. Such a team usually is lead by an astute clinically focussed physician, supported by nurse practitioners, physical therapists, psychological therapists and counsellors, nutritionists, and other caregiving professionals.

In the emerging space of integrative medicine, physicians from a host of alternative disciplines like Naturopathy & Yoga, Ayurveda, Homeopathy, Acupuncture etc. participate in care delivery. For the person with unexplained medical symptoms interdisciplinary care provides the opportunity to both understand and manage various symptoms, physical and psychological, better. Learning to live with what cannot be cured, maintaining one’s activities of daily living and quality of life often become reasonable and acceptable goals.

Mrs. A was diagnosed by an interdisciplinary team, after a detailed evaluation, to have clinically significant autonomic dysfunction, a difficult to diagnose problem with myriad physical and psychological manifestations. Combined with this was an element of “Abnormal Illness Behaviour”. Her medical management was suitably augmented to address these complaints and she committed herself to a care program that integrated physical, psychological and nutritional therapy with ayurvedic treatments, mud therapy and yoga therapy.

Over a span of three months her symptoms improved considerably: normalization of appetite, regulated bowel movements, improved energy and enhanced activities of daily living and considerably reduced health related anxiety. Her success story underlines the challenges of interpreting unexplained maladies, the crucial role of personalised clinical medicine, the need for interdisciplinary care for chronic medical conditions, and for our intellectual glasnost as a society towards the wealth of clinical wisdom that resides in our ancient medical traditions.

As Hans Berger, the inventor of the Electroencephalogram (EEG) an instrument that studies brain waves, said, “A machine can replace neither common sense nor intelligence”.

Categories
Attention Deficit and Hyperactivity Disorder (ADHD) Autistic Spectrum Disorder (ASD) Buddhi Stories Featured

From Tasmanian Devil to Mathematical Whiz

Master S first met the Neurokrish team (later to become the Trimed-Neurokrish team) about 6 years ago. Aged three years at the time, he was brought to us by his grandfather who had recovered fully from a stroke, under our care. S demonstrated clearly to us the features of both Autistic Spectrum Disorder (ASD) and Attention Deficit and Hyperactivity Disorder (ADHD). He refused to maintain eye-contact, engaged in fleeting social contact which was very poorly sustained and was yet to develop any language skills of note. More disturbingly, S was profoundly hyperactive and disruptive, so much so, that he could in a few moments literally tear apart a consulting or therapy room, when left alone. Needless to say, his mother was distraught, and his extended family members were dismayed. In our minds, S bore a striking resemblance to “Taz” the adorable but disruptive “Tasmanian Devil”, then a beloved cartoon character, much loved by the kids.

Taz was offered a combination of behaviour therapy, Neurodevelopmental therapy and family counselling. He was also prescribed medication to improve attention, stabilise his volatile moods and cut down his very disruptive behaviours. Over a 3 year period, our therapeutic relationship with Taz’s family evolved; together we walked many a milestone; his first words, his play school, kindergarden, and primary school. Therapeutic holidays from drugs during summer and winter vacations; the role of extended families, maternal and paternal; expectations of the many stakeholders, parents, both sets of grandparents, uncles and aunts; teacher and school interactions; our therapeutic relationship weathered these many storms. His GI problems responded to our Naturotherapy approaches; his limbs became dexterous and his fine motor skills including handwriting skills improved with Neurodevelopmental therapy and Ayurvedic massages. Thanks to sustained behaviour

therapy and parental counselling he became less disruptive, could follow parental instructions and began to sit for longer periods of time. His attendance and participation at school improved dramatically; his intuitive mathematical abilities started to shine; he learned to interact better with peers and teachers. Indeed, not only did he survive primary school, he had even topped his class in mathematics. Clearly Taz was endowed with “mathematical intelligence” that outstripped other “emotional and social” domains (see A Vital & Alternative Perspective To Enabling Potential).

Taz, with a combination of ADHD and ASD, was one of our most challenging child clients ever! Recently we met our “Taz” one final time, before he migrated with his family abroad. His evolved parents had declared his condition in the immigration visa application form and sought special assistance for him aided by a detailed summary from Trimed-Neurokrish.

Taz is still a little disruptive and impulsive, butts into conversations, slightly stilted in his speech, but we know he has come a long way. Our Trimed-Neurokrish Integrated approach judiciously combined medication and behavioural and neurodevelopmental therapy, with Naturopathy and Ayurveda, empowered the family with counselling, and awakened his “mathematical intelligence”, with progressive increase in his self-esteem. With this, his social interactions exude warmth and willingness to communicate. His onward life’s journey while abroad must follow the same trajectory.

We must admit that S’s remarkable progress was made possible by the wonderful therapeutic relationship our team had with his family. From S and his family we have learnt the importance of looking beyond terminology and the diagnostic label. Sustained therapy with vigilant monitoring and family and special school support, carry their own reward and hold hope for children, affected just like S. Prof. Dr. Ennapadam S. Krishnamoorthy

Categories
Autistic Spectrum Disorder (ASD) Buddhi Stories Epilepsy & Seizures Featured

Bharath – Emerging From The Shell

Biography

By 9 months of age the infant showed regression in eye-contact and response to call. By the time the child was 1 year old, the father left home, never to return, but provided financial support from afar. Was he shirking his paternal role towards his child with developmental disability? But the well-educated mother took matters in hand, moved in with her parents for logistical and emotional support for the whole family, and devoted her time to Bharath, to quell his hyperactivity at two years and to push his delayed language acquisition to the next level. Paediatric consultations for guidance, regular speech therapy and early Montessori schooling saw Bharath settle comfortably in a mainstream school, with

age-appropriate range of receptive and expressive language, with reading and writing in place by 6 years of age. He continued to be a slow learner.

Was he shirking his paternal role towards his child with developmental disability?

However, the challenge for the family has been the inevitable behaviour problem of ASD – (differently wired!) which is often traced to poor sensory integration, resultant poor holistic perception, hyperactive emotional network with weak frontal lobe inhibitory commands to suppress the eruptions of uncontrolled energy. Bharath’s unprovoked emotional outbursts, with violence directed mainly against his mother (or in destroying objects), is partly an expression of internal hurt, as he is not amnestic of the event, and shows remorse for the behaviour in recent times. He insists on his mother’s undivided attention and spares her little time to devote to his elder sister. These outbursts are fewer over the past 1.6 years since he joined Vidya Sagar, as he receives multimodal therapy, is on regular anticonvulsant, antipsychotic medication and SSRI, and his energies have been channelled, with the focus on academics. He has cleared the Open School Board Examinations in Home Science, English and Computer Data entry, without scribe assistance, and is preparing for the Business Studies examination in October 2017. He will complete all five subjects required for the Board’s 10th Std. Secondary School Certificate in April 2018, when he does the bakery/painting examination – truly a most commendable effort!

With his self-esteem and self-confidence rising, we find Bharath come out of his shell and mingle socially with his peer group at school and with relatives and friends who visit their home. He is Secretary of the local Interact Club, has joined NCC as a cadet and follows cricket and movies on TV with keen interest. He tends to talk excessively, lacks discrimination and even reveals close family concerns to outsiders. The client had seizure disorder which is moderately controlled on medication. Currently he is on the following medication: Syrup Sodium Valproate Extended Release, Zolpidem (Non Benzodiazepine hypnotic), Aripiprazole (Aripiprazole is an antipsychotic preparation and helps control irritable behavior such as aggression, temper tantrums, and frequent mood changes in ASD).

Assessment Reports

The Clinical Specialists Observations –

An intact systemic examination. Neuropsychiatric Inventory reveals intact Higher Mental Function (HMF), reactive affect, normal intelligence and no focal deficit.

EEG Report :

Awake and resting EEG conducted on a standard 10-20 system. Background activity is alpha at 9-10 Hz, with bilateral, generalized paroxysmal sharp wave activity. The EEG is suggestive of seizure disorder.

DST:

Age of 12 years was attained, based on parameters of functioning.

ISAA SCORE:

71- indicating mild autism

CBCL:

Mainly overeating and talking excessively and indiscriminately.

VSMS:

Obtained a social age of 8 years and 9 months, with a social quotient of 58, indicating mild deficits in social adaptive functioning.

ICF Neurodevelopmental Disability Assessment

No structural deficits observed and no limitation of function, minimal activity limitation. Mother and Institution proved to be facilitators.

Response To Therapy

As he developed chicken pox, a break in therapy had to be instituted. Improvement in sleep and behavioural problems were reported at the end of the sessions.

Reviewed One Month After The End Of Therapy

His aggressiveness which was already on the mend, was helped by the therapy to calm him down further. He was advised to continue the medication regimen as before.

Categories
Autistic Spectrum Disorder (ASD) Buddhi Stories Epilepsy & Seizures Featured Obsessive Compulsive Disorder

Shanthi – The Time Keeper

Biography

The antenatal period was moderately smooth. Shanthi was born at full term by natural delivery with a birth weight of 3.45 kgs. The birth cry was delayed, with hypoxia and neonatal seizures, and the neonate required oxygen and ventilatory support for a week. By 21 days of birth, she was re-admitted with high fever and respiratory distress with a diagnosis of pneumonia. Bouts of diarrhoea continued till the third year. There was delay in cognitive, language and motor developmental milestones and she uttered the first meaningful word and walked unsupported only at the age of 4. To add to this, she showed autistic-like symptoms of bizarre behaviours and auditory hypersensitivity. Covering both ears, which she repeats often – even while watching a movie on TV – is in all probability a learned behavior linked to anxiety. Children with ASD are known to become fearful of potential unpleasant noises.

Shanthi’s anxiety repertoire extends to strong separation anxiety of a pathological nature, and that may account for her daily ritualistic morning tantrum when she has to attend school. She watches the clock every moment and believes in an obsessive-compulsive manner that her life and the life of her family members revolve around the ticking of the clock. OCD traits are not uncommon in adolescent females with ASD. She awaits her father and elder brother’s return from the day’s work at the expected hour. With even a 10 minute delay, she paces the floor and shortly after, all hell breaks loose! Curiously, she throws a lesser tantrum even if they return from work early, as this disturbs her need for ‘sameness’ and routine.

Shanthi is selectively aggressive and violent at home, beating her mother, the primary caregiver, even without provocation, pinching the elder brother if he switches on the TV without her permission, and breaking objects. While at home, she opposes the figure of authority with screams, when she does not wish to satisfy a demand, bordering on oppositional defiant behaviour but shows remorse when the mother cries.

Attention-seeking, access to preferred items/activities and elimination of demands may be the likely reasons for her to maintain this aberrant behaviour cluster. She has poor self-care skills and is partially dependent on the mother for ADL, especially in areas of personal hygiene.

At school she is a near gem, except for occasionally kicking a classmate for ‘not falling in line’. Then there is the familiar, prolonged holler between class sessions in which she indulges. Her expressive language is poor, but she receives, comprehends and has good retentive power. Immersed in academics, while at school, she has completed two subjects (Science and English) of the Open School Examination with scribe assistance.

With even a 10 minute delay, she paces the floor and shortly after, all hell breaks loose!

Buddhi Notes : Prodigiously Particular

There is little disposition to generalise from these particulars or to integrate them with each other, causally or historically, or with the self. In such a memory there tends to be an immovable connection of scene and time, of content and context (a so-called concrete-situational or episodic memory)-hence the astounding powers of literal recall so common in autistic savants, along with difficulty extracting the salient features from these particular memories, in order to build a general sense and memory. It is characteristic of the savant memory (in whatever spher-visual, musical, lexical) that it is prodigiously retentive of particulars.

Oliver Sacks, Neurologist & Writer on the Savant Brain

Assessment Reports

The Clinical Specialists Observations –

Intact systemic examination. Flaccid tone of all muscles, muscle power 4+, diminished deep tendon reflexes and plantars bilaterally flexor.

EEG Report :

The sleep EEG shows bilaterally symmetrical tall sharp waves in stage 2 sleep. This is an abnormal record.

DST:

Age of 7 years was attained based on parameters of functioning

ISAA SCORE:

73 – indicating mild autism

CBCL:

Externalizing syndrome – aggressive behaviours with co-morbid. Internalizing syndrome – withdrawn/depressed and anxious.

VSMS:

Social age of 8 years and 9 months, and a social quotient of 19, indicating profound deficit in social adaptive functioning.

ICF Neurodevelopmental Disability Assessment

Issues present in mental, neuromuscular and movement areas. No major structural deficits. Significant issues present in the subdomains of learning, applying knowledge, communication, general tasks and demands.

Response To Therapy

Shanthi co-operated for the therapy. Though there was no significant benefit, her mother was pleased with the procedure and requested a longer period of therapy.

Prof. Dr. ESK and the Vidya Sagar team felt that the physical disability status required review, and the Trimed-Neurokrish senior physiotherapist was called in to assess the client. The report reads as follows:

“Normal muscle tone, muscle power 4+, with low endurance. Flat feet with externally rotated lower limb while walking. Atypical gait. Decreased fine motor skills but good gross motor activity.”

The unacceptable behaviours may be explained by the biopsychosocial model of multifactorial risk factors. Structured behavioural modification sessions along with parental skill training may benefit Shanthi and reduce parental stress.

Categories
Autistic Spectrum Disorder (ASD) Buddhi Stories Featured

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.

Categories
Autistic Spectrum Disorder (ASD) Buddhi Stories Featured

David – Comfort in Monotony

Biography

At full term, uterine dystocia and prolonged labour were the indications for birth by caesarean section. The post-natal period was uneventful, except for mild physiological jaundice. It was around the end of the second year, that the parents’ mounting concern about their son not uttering even one meaningful word, took them to the specialist.

David did not respond when called by his name. However, even as a 2 year old, he would run to the TV to hear the familiar TV jingles, which he still seems to relate to every time with the same joy and zest. David was preoccupied with himself, muttered and showed poor eye contact. He was hyperactive and indulged in lone play. BERA (to rule out hearing deficit) and brain MRI (to look for any structural lesions) were done and reported normal. A diagnosis of ASD was arrived at by the specialists.

Special schooling was initiated right away, with emphasis on speech therapy and occupational therapy, and soon he could write numbers and solve basic-level jigsaw puzzles. He has been with Vidya Sagar for the past 2 years. Initially he kept moving around the classroom, with strong intolerance to sitting in one place. He showed no inclination towards academics, except scribbling on paper and favouring the letter ‘H’ and the digit ‘7’ in the letter/number picking exercise. With lack of meaningful words and phrases, David’s self-learning is mainly visual and through observation. He repeatedly grabs a Fevistick with its attractive yellow label or a crayon – preferably green in colour, objects to which he has an ‘inappropriate attachment’ (as tenned in ASD clinical jargon). ‘Sameness’ seems to be his comfort zone. When asked to return the object – being of easy and flexible temperament -he returns it without a whimper, only to grab it the next moment. Occasionally he has to resort to tantrums to get his way, when caregivers seem unreasonable!

With physical exertion in the dance class, his restlessness has been brought under a semblance of control and with this his attention span has shown improvement. Attention is the first step towards learning and the child shows some progress in activity-based learning, as he sits through longer sessions with undivided attention. His restlessness continues to manifest as hand flicking and whistling intermittently.

Assessment Reports

The Clinical Specialists Observations –

A general clinical examination showed an intact systemic examination. The Neuropsychiatric Inventory revealed increased motor activity in the classroom, unintelligible sounds by way of speech, grossly intact higher mental functions and no focal deficits.

EEG Report :

Bilateral Epileptiform Dysfunction

DST:

DST age of 3 years attained

ISAA SCORE:

94 – indicating mild autism

CBCL:

Internalising Syndrome Criteria for withdrawn/depressed, social problem and attention deficit.

VSMS:

Social age of 5 years, 4 months and 8 days obtained with a social quotient of 70, indicating borderline deficits in social adaptive functioning.

ICF Neurodevelopmental Disability Assessment shows minor problems in mental function, and no structural deficit. Under activity and limitation, significant problems in subdomains of learning and application of the gained knowledge, general tasks and demands, self-care, major life areas and community, social and civic life. Considering environmental factors, both parents and institution prove to be facilitators.

Buddhi Notes : A Curious Attachment

One of the most outstonding symptoms of the autism spectrum is a curious attachment to objects. Perhaps part of a tendency to over-invest in certain activities, at the expense of other “more normal” pursuits, such attachment can traverse the gamut of inanimate objects. On occasion, such attachment can be to a particular activity or even a particular person. I recall an interesting article by a doctor in the Journal of the American Medical Association titled “Phantom of the Opera” in which she described her son’s attachment to a particular piece of music and need to hear the same, over and over again. Curiously, attachment to certain objects (such as a teddy bear, even one that is moth eaten or mangled) is a transcultural childhood trait. Remember Mr. Bean and his companion bear, anyone?

Prof. Dr. Ennapadam S. Krishnamoorthy

Response To Therapy

David co-operated overall for the therapy except for some restlessness in the second session. At the end of therapy, the overall improvement was significant. His mother wished to continue therapy.

Reviewed one month after the end of therapy, his motor movement and co-ordination were better, and his repetitive movements reduced. His attention span has improved and he responds better to classroom activity. David has anger outbursts when pushed by his brother, which was considered a natural response to the provoking stimulus and was viewed as a positive sign, both by the Trimed-Neurokrish team and the senior faculty of the institution.

Prof. Dr. ESK suggested introducing AED medication with the consent of the parents.

Categories
Attention Deficit and Hyperactivity Disorder (ADHD) Buddhi Stories Dystonia Featured Neurodevelopmental Disability (NDD)

Deepak – Precious Child

Biography

Everything seemed against the birth, growth and development of Deepak, as if nature and nurture were conspiring against his very survival at every stage. However, he got past the onslaught of the catastrophic events around his birth, was diagnosed with Neurodevelopmental Disability (NDD) in his infancy, and associated conditions, namely ADHD in his childhood and Seizure Disorder in the adolescent phase. As a young adult he developed Dystonia (involuntary muscle spasm).

Deepak’s mother was an elderly primi at 32 years of age and conceiving for the first time 7 years after marriage and he was ‘a precious baby’. She was hypothyroid, on thyroid supplements, and was on psychiatric medication for 4 years prior to the delivery. The child was delivered by elective Caesarian section, and the mother suffered Post-Partum Haemorrhage (PPH) while the newborn had an Apgar score of 9, with some breathing difficulty.

Exploring the Condition

It was a non-consanguineous marriage. The father had a chronic health condition and his career never took off. It was thus a dysfunctional family, with an overanxious mother coping with a hyperkinetic child with NDD, the father shirking the responsibilities of fatherhood. Deepak’s father died when he was barely 6 years of age and the mother moved in with her parents with the child. There was a history of dementia on Deepak’s maternal side but no family history of suggestive of neurological, psychiatric or other general medical (including liver) condition to indicate Wilson’s disease (see box).

Motor milestones were delayed, and the child walked at 2 years. Unthinking TV viewing by the family saw Deepak at the same age jumping and clapping hands at every violent scene on the screen as if to cheer the hero and villain along! Language was delayed and he started saying a few meaningful words around 2½ years.  At school at age 4 years, he had poor attention span, would not sit in one place, and his learning ability was average. He did not mingle with his peer group in school, and this awkwardness in social interaction continued, into adolescence and adulthood. It is around 5-6 years that Deepak started showing significant aggression, especially aimed at his mother.

He had fears and phobias, and was reluctant to board the public bus to school with his mother, resulting in frequent tantrums. The mother sought a psychiatric consultation for Deepak and he was prescribed a mild tranquiliser. He managed to get through mainstream school (with only one change of school in the 5th grade). While in middle school, he was seen by a Neurologist and diagnosed to have ADHD  and was prescribed Dicorate ER (Divalproex) 250 mg – 1-0-1 and Modafinil (a stimulant drug) 100 mg – 1-0-0. In the 9th grade, he had difficulty coping with studies but managed to pass the 10th grade Board examination.

Before completing 12th grade examination, in 2009, Deepak had seizures manifesting as momentary loss of consciousness and stare. He had memory deficit following the seizure onset and could not cope with his studies.  He dropped out of school as a consequence and subsequently developed frequent minor involuntary movements of the limbs, later dystonic turning of head/neck to the right, with facial grimacing.  Lifting the arm spontaneously, without voluntary control, also followed. At this stage a Neurology Consultant  put him on Tab.Trihexiphenidyl 2mg – 1-0-1.

Our Healing Approach

After comprehensive assessment at TriMed-Neurokrish, at the age of 22 years, a diagnosis was arrived at of Neurodevelopmental Disability with Neurobehavioural Syndrome, borderline intelligence and Movement Disorder (MD). The management of the patient was planned carefully taking into account the multiple challenges that had to be dealt with effectively. The patient was on polypharmacy, and the first step was modification of the drug regimen to optimize benefit. He was on Tab.Divalproex ER 250 mg – 1-0-1 and Lamotrigine 50mg – 0-0-1 was added to this regimen, as effective mood stabilizing combinations in such conditions. Along with this, a novel antipsychotic, Clozapine 25 mg – 0-0-1½ was prescribed; later Atomoxetine 25 mg – 1 -0-0 was started to control ADHD features; to improve attention and concentration and to reduce hyperkinetic behaviour. Modifinil was eventually tapered and stopped as was Dicorate.

The patient did well on this new drug regimen with no further seizures and reduction in the frequency of involuntary motor disturbances. Multivitamin, Calcium Piracetam were added on at various stages of treatment. Deepak had severe musculo-skeletal pain all over the body with spasm of the limb muscles, and the trapezius muuscles in particular, bilaterally. Tab.Trigabantin (Gabapentin 300mg + Methylcobalamin 0.5 mg), Alpha Lipoic Acid 100 mg was added to the drug regimen, and with physiotherapy aimed at relaxing the muscle groups involved there was relief of spasms and with it, pain relief. He also received Podikizhi, an Ayurvedic massage therapy technique with dry herbal powder which is efficacious in the treatment of complaints associated with joints, musculoskeletal and neuromuscular pains in addition to rejuvenating, relaxing and strengthening the joints, muscles and soft tissues and as a result providing remarkable pain relief.

The integrated therapies of Neurorehabilitation and Cognitive Retraining sessions, combined Yogasana, Pranayama, Meditation 22 sessions, Acupuncture 10 sessions, Reflexology 20 sessions, ran parallel to the physiotherapy exercises and TENS 22 sessions. Following a few sessions of therapy, there was improvement in gait, involuntary movements were significantly reduced and ADL performance was returning to normal. The beneficial response to cognitive retraining was noteworthy, as his power of concentration and with it his retentive power and memory had stepped up remarkably with goal-directed cognitive activity. Behavioural problems were brought under control.

The NDD at birth with neurobehavioural problems, exaggerated neuropsychiatric symptoms with onset of the movement disorders/dystonia, the raised Aminotransferase, on LFT testing (indicative of disturbed liver function), the chronic constipation, and a high serum copper (196.4 micrograms/dL), suggested to the Neurokrish Consultant a drug challenge with Penicillamine (a chelating agent), even though the clinical and lab findings were atypical for Wilson’s disease. There was no KF ring, and serum caeruloplasmin and 24 hour urinary copper were normal. Penicillamine (250mg) was slowly increased from one to 2 tablets and was successful over weeks in     reducing dystonia considerably. Subsequently serum copper levels improved and LFT became normal. At the end of 6 months, the Penicillamine was tapered over a month and then stopped, with no return of the dystonia at monthly follow up, even at the end of 7 months.

Wilson’s Disease

Wilson’s disease is an autosomal recessive disorder of copper metabolism, characterised by excessive accumulation of copper in the brain, liver, kidney, cornea and other organs. The clinical manifestation of WD is due to the toxic accumulation of copper in these organs.

Copper is an essential metal that is an important cofactor for many proteins. The average diet contains adequate amounts of copper. The absorbed copper from the duodenum and small intestines enters the portal circulation and reaches the liver.  The liver utilizes some copper for its metabolic needs, synthesizes and secretes the copper-containing protein Ceruloplasmin, and excretes the excess copper via bile secretion. Defective excretion of copper (Roberts 2008)1, results in its deposition especially in the liver and brain.

Ceruloplasmin is the major carrier for copper in the blood, accounting for 90% of the circulating copper in normal individuals. In one series (Steindl 1997)2, 12 of 55 patients with WD and mainly liver involvement, had normal ceruloplasmin and no Kayser-Fleischer rings, though subjects in the same study with predominantly  neurological manifestation had  lowered serum caeruloplasmin and the presence of KF ring.

The gene for Wilson’s Disease ATP 7B, has been mapped to chromosome 13. There are multiple disease mutations of the gene described in proband with the disorder. Further, there are significant Indian studies (Mukherjee, 2014)3 on the genetics of WD, highlighting that some of the more frequently occurring mutations in Indians are different from those reported by  the West.

First-degree relatives of any patient newly diagnosed with WD must be screened. Serum aminotransferase activities are generally abnormal in WD except at a very early age. In many individuals, the degree of elevation of aminotransferase activity may be mild and does not reflect the severity of the liver disease. D-penicillamine (demethylcysteine) is an effective chelator of copper, well absorbed when taken orally , and it promotes the  urinary excretion of copper.

D-penicillamine – induced status dystonicus (Paliwal, 2010)4 is a unique but serious drug related complication in a subset of patients with Wilson disease  with good response to Gabapentin, but failing to respond to other antidystonia drugs.

References

  • Roberts E.A., Schilsky M.L. Diagnosis and Treatment of Wilson’s Disease: An Update (AASLD Guidelines) Hepatology, June (2008),47,(6)  : 2089-2111
  • Steindl P., Ferenci P., Dienes H.P., Grimm G., Pabinger I., Madl C., et al. Wilson’s disease in patients presenting with liver disease: a diagnostic challenge. Gastroenterology 1997;113:
  • Mukherjee S., Dutta S., Majumdar S., Biswas T. et al Genetic defects in Indian Wilson disease patients and genotype- phenotype correlation. Parkinsonism Relat Disord. 2014 Jan;20(1):75-81.
  • Paliwal V.K., Gupta P.K., Pradhan S. Gabapentin as a rescue drug in D-penicillamine-induced status dystonicus in patients with Wilson disease. Neurol India 2010;58:761-3.

Looking Ahead

Deepak has progressed well all round, much to the delight of the TriMed-Neurokrish team. The mother is thankful and has no words to express it. Deepak continues his follow up at Trimed-Neurokrish, is regular with his medication, and is advised short course of therapies if indicated. He continues his exercise regimen at home. He went through a short three-month computer course and is now employed for a computer data entry job, which he carries out efficiently, with all the concentration required. The  occasional flicker of involuntary movement is almost negligible. Behaviour problems have receded to the background, and he is less awkward socially though he continues to be introverted. Above all, there is an inner calm and peace that Deepak radiates, which tells the long story of pain and hardship of the past, and of the future which he knows will offer better hope and cheer. Life is good!

Categories
Buddhi Stories Dementia & Memory Loss Featured Memory Problems

Jayaram – The Decline

Biography

It was six years into retirement, in 2009 when the early signs of mental illness surfaced in a subtle manner in Mr. Jayaram. Where had he kept the house keys? How could he forget to buy the cooking oil from the shop round the corner? He had never missed even one of ten items for routine household purchase that his wife verbally listed to him and so she spared herself the trouble of writing it down. Jayaram brushed aside his occasional memory lapses, and went on to read the day’s news, reclining comfortably in his planter cane-and-wood ‘easy chair’, while his wife brought him fresh south Indian filter coffee, even as the television audio sounded the Suprabhatham, the gentle daily chant to wake up the Lord of the Seven Hills.

The wife began to register concern as the memory lapses occurred more frequently. Jayaram appeared agitated at times as if he was experiencing an inner turmoil. Soon he showed signs of social withdrawal.

Exploring the Condition

When the family physician was approached for a routine check up of his hypertensive and diabetic status, for which he was on regular medication for several years, the wife shared her concerns with the doctor. A specialist consultation was advised, but at the very heel of the neurological consultation, Jayaram had lost his way home along his oft trodden path and had to be escorted to his house by tense family members and neighbours. A repeat of this behaviour resulted in GPS tagging and going out on his own became a taboo. A diagnosis of Alzheimer’s Disease was made and T2 Hyperintensities (with his history of long-term diabetes and hypertension) on MRI brain suggested an added vascular element to the dementia.

Following a successful career in a position of authority in Central Government, Jayaram had returned to his hometown near Chennai with his wife to settle to a peaceful retired life. His son and daughter having been married a couple of years earlier, had settled abroad with their respective families. They visited the parents once a year. Jayaram and his wife travelled to USA to be with the children and grandchildren for a few months, as was the practice with many Indian parents with children abroad. Life seemed to offer the best of both worlds. However, this state of well-being was not to last forever.

In early 2015, Jayaram’s condition took a marked downhill course. He developed global insomnia, decreasing appetite, weight loss, and refusal to extend his cooperation in simple activities of daily living, leaving the wife, the principal caregiver, in a desperate state and with increasing inability to cope with the situation. She was in a near ‘burn-out’ phase and that is what  brought her to the doors of TriMed-Neurokrish. He was bed bound, with double incontinence, expressive aphasia (inability to express language through speech or writing), and probable unexpressed pain and discomfort, resultant behavioural and psychological dysfunction. He became stubborn, refusing to follow any instruction. However, formal psychological testing revealed that he had retained several of his cognitive abilities. Repeated and staggered assessments had to be carried out, deriving maximum diagnostic leads during the lucid phases of orientation and patient co-operation.

Our Healing Approach

From the start, the patient management by our team had to be home-care based, since transporting him to the clinic would prove to be a great ordeal all round and would cause exacerbation of behavioural symptoms. A global assessment of the patient was the first step. Jayaram was clearly heading towards Stage 3 Dementia, in the absence of stimulation and positive hand-holding.

The patient was already on multiple drugs for Dementia, Behavioural and Psychological Symptoms of Dememtia (BPSD) and comorbid conditions, prescribed by his regular Neurologist and Diabetologist  over the years. He was on Escitalopam 10 mg – 0-0-1 (a mood elevator), along with Tab.Donamem 10 mg – 0-0-1  (a combination drug of Donapezil and Memantine and specific for dementia), Tab.Oleanz 2.5 mg – 0-0-1, Olanzipine (an antipsychotic), Tab.Ativan 1 mg – 1/2-0-1, Lorazepam (for a tranquillising effect) and follow up with a Diabetologist and General Physician, who had prescribed regular Tab.Glyciphage 1-0-1, Tab.Telista (Telmisartan) 40mg – 1-0-0,  Tab.Ecosprin 150 mg – 0-0-1 and Tab.Tonact TG (Atorvastatin)  0-0-1 towards control of diabetes and hypertension and blood thinning and cholesterol-lowering  actions,  respectively.

The team decision was to cash in on the patient’s cognitive reserve after reshuffling the regular medicine regimen and introducing add-on medication to tame the BPS.  In short, the focus was on pharmacotherapy to control the BPS, and cognitive therapy to encourage re-establishing basal activities of daily living to start with. He was treated with Dicorate ER 1 g a day and Tab. Escitalopam 10 mg was stepped up to 1-0-1, in addition to Donamem and his other regular medication. The physiotherapist encouraged gait training in a graded manner till the patient was able to walk around the house with support. With this the BPSD symptoms decreased. Remission or reduction of BPSD is known to produce remarkable improvement in the functional and even cognitive  abilities of the patient, which it did in the case of Jayaram. He became more responsive in interpersonal relations, responded to questions, showed some improvement in memory in terms of alphabets, numbers and was able to indulge in meaningful physical activities like throwing a ball.

Glycemic control was one of the foremost challenges at this point, with an erratic dietary pattern, at the patient’s bidding, often ending with poor intake followed by binging on carbohydrates and sweets of his preference. His regular diabetologist reviewed his diabetic status. Jayaam needed a short period of hospitalization as his blood sugar levels were high. On Tab.Galvus Met 50/500 – 1-0-1  and Tab.Diamicron 80 mg 1/2-0-0, the most recent prescription, good control of blood sugar levels and  hypertension was established. A lipids review showed a high level of triglycerides and cholesterol. With titration of the drug dosage during his period in hospital, his medication was lowered subsequently to Escitalopram  10 mg – 0-0-1 and Tab.Dicorate to 750 mg – 0-0-1, and the significant control of the BPS remained. However, the occasional lack of overnight sleep would bring on the screaming, which started as a whimper, built up to a crescendo, staying high-pitched for prolonged stretches into the morning hours.

Meanwhile Jayaram developed an intermittent headache, which he indicated by constantly holding his head with his hands, and tucked between his folded knees. As BPS can increase with pain or other discomfort, a detailed investigation for headache was done and diagnosed to be an exacerbation of the migraine which was recorded in his past history. He was treated with Tab.Sibelium 5 mg, 1 at bedtime which effectively controlled the headache.

Initial hand-holding of the spouse to reduce caregiver fatigue and hopelessness was an essential part of the treatment plan, as much to safeguard her health status as to encourage her active participation in the management of the patient. She had meanwhile learnt to cope with his illness, having reached the acceptance stage. However, episodic exacerbation of caregiver distress was inevitable in spite of formal caregivers employed.

“Initial hand-holding of the spouse to reduce caregiver fatigue and hopelessness was an essential part of the treatment plan…”

Dementia

Behavioral and Psychological Symptoms of Dementia (BPSD), represent a heterogeneous group of non-cognitive symptoms and behaviors which occur in subjects with dementia. BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. BPSD constitute a major component of the dementia syndrome irrespective of its subtype and it has been estimated that it affects up to 90% of all dementia subjects over the course of their illness (Lyketsos, 2015). BPSD is probably the result of a complex interplay of psychological, social, and biological factors. Recent studies have emphasized the role of neurochemical, neuropathological, and genetic factors underlying the clinical manifestations of BPSD.

BPSD also have a profound physical and psychological impact on both the formal and informal caregivers. A considerable part of caregiver distress relates directly to the manifestation of BPSD. Caregiver burden refers to the presence of problems, difficulties or adverse events which affect the life of significant other(s) of the patient (Platt, S., 1985). It is the extent to which caregivers perceive their emotional, physical health, social life, and financial status to be affected as a result of caregiving (Zarit et al., 1986). A qualitative quote from an Indian study reflects the Indian ethos and culture of caring for a near relative:  ‘‘Why are you using the word ‘Burden’? My father is not a burden to me. It is my duty to care for my parent and doing so makes me a little tired but gives me great satisfaction.”  (R.D. Pattanayak, 2010). Regarding BPSD, these symptoms are stressful for the co-resident caregivers, who lack support and guidance from the health care delivery system which service is poor in developing nations (Shaji K.S., 2009). Prince observes “Our findings underline the global impact of caring for a person with dementia and support the need for scaling up carer support, education and training.. Carer benefits, disability benefits for people with dementia and respite care should all be considered” (Prince, M., 2012).

References

  • Helen C. Kales , Laura N. Gitlin, Constantine G. Lyketsos Assessment and management of behavioral and psychological symptoms of dementia, State of the Art Review BMJ 2015;350:h369
  • Platt, S., 1985. Measuring the burden of psychiatric illness on the family: an evaluation of some rating scales. Psychol. Med. 15, 383–393. Zarit, S.H., Todd, P.A., Zarit, J.M., 1986. Subjective burden of husbands and wives as caregivers: a longitudinal study. Gerontologist 26, 260–270
  • R.D. Pattanayak , R. Jena , M. Tripathi , S.K. Khandelwal ,  Asian Journal of Psychiatry 3 (2010) 112–116 Shaji, K.S., George, R.K., Prince, M.J., Jacob, K.S., 2009. Behavioral symptoms and caregiver burden in dementia. Indian J. Psychiatry 51, 45–49.
  • Prince M., Brodaty H., Uwakwe R., Acosta D., Ferri C.P., Guerra M., Huang Y., Jacob K.S., Llibre Rodriguez J.J., Salas A., Sosa A.L., Williams J.D., Jotheeswaran A.T.,Liu Z. Strain and its correlates among carers of people with dementia in low-income and middle-income countries. A 10/66 Dementia Research Group population-based survey Int J Geriatr Psychiatry. 2012 Jul;27(7):670-82.

Looking Ahead

The merciless progression of the degenerative process cannot be halted or reversed at this stage of medical knowledge. However, reducing the BPSD significantly, encouraging some physical and mental activity in the patient and allowing some calm to prevail is in itself noteworthy.

The spouse’s understanding has changed from vacillating between anger, fear and panic, to one of acceptance and the need for pursuing individual activities to the extent possible within the circumstances. She is in better control of her emotions. She is aware that with progression of the degenerative process, the cognitive, language and motor decline will be steep and that the character of the BPS often can change from one of positive symptoms of aggression, night-wandering to a predomi-nant negative symptom cluster, characterized by apathy. She is thankful for being able to give some quality of life to her husband, and to have achieved some peace of mind and calm, having reposed faith in the treating team and managing reasonably with formal caregivers to share the work.She shudders at the thought of the day’s prior to TriMed-Neurokrish intervention when each day was a nightmare. Knowl-edge is power, and with it, if you have extended your resources-physical, mental, emotional, financial to the utmost, you know you have done your best.

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

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!