Dr. E.S. Krishnamoorthy , Behavioural Neurologist & Neuropsychiatrist, Founder of Buddhi Clinic in conversation with Dr. Prabha Chandra, Professor of Psychiatry & Incharge of NIMHANS centre of well being & Ms. Sunena Gupta who was then a student at UC Berkeley and some one who has turned around her self-image, overcome chronic illness & mental health issues through art.
Sunena is a disciple of the esteemed Guru, Mulla Afsar Khan at the Singapore Fine Arts Society and her production in 2020 “Colours of Hope” exhibits her passion for using dance for creating awareness around social issues. What has been commendable is her willingness and ability to share her personal journey.
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.
Our brain is a wonderful organ. Designed by the chief architect, this is the most complex CPU ever built. Like our computer’s CPU, this CPU in our body can also be thought of a bundle of electrical wires criss-crossing in a highly complex fashion. Every once in a while, there can be something that happens to cause some malfunction in this circuit. DBS can be thought of as an operation to set right this malfunction by inserting a pacemaker into the brain.
Miss J, a 22 year old girl had been diagnosed with a brain tumour as a child and had undergone radiation for that. While the tumour was successfully treated, this radiation to the brain had a nasty side-effect. Some of the circuitry in her midbrain had been altered, leaving her with a permanent tremor in the right hand and leg.
She was suffering silently for more than 10 years, not knowing that this problem has a solution in the form of DBS! While the damage to the brain that is an inevitable consequence of radiation cant be undone, by placing a pacemaker into the brain, the imbalance in her movement circuitry could be modulated.
The result is almost instantaneous since the operation is done with the patient awake in the operating room. Once the electrode reaches the correct area in the brain and electrical current is sent through it, the tremor reduces immediately and her slow movements become rapid.
DBS is helpful in a wide variety of conditions apart from tremors. It is very useful to improve the symptoms of Parkinson’s disease, Dystonia, drug resistant Epilepsy, Obsessive compulsive disorder, major depression and Chronic Pain syndromes.
The deep area in the brain which is stimulated varies according to the condition treated. However, in all conditions the patient is awake during surgery and is being tested with stimulation and a wide variety of observations are done as and when surgery is in progress. Therefore, the success of surgery involves the active co-operation of the patient.
Before surgery is considered, all patients undergo a detailed assessment to look for factors in favour and against surgery.
Each patient and family are thoroughly counselled about what to expect before, during and after surgery. After successful surgery, they need to be followed up for programming sessions where the stimulator is turned on and tuned in order to achieve the best clinical benefit with the least side-effects.
Varadarajan was on a pilgrimage to Badrinath in the company of extended family members in late 2010. Little did he imagine that he would be the victim of a fall, which proved disastrous and would alter the course of his life so abruptly. The initial 3-4 months of dramatic progress in his health condition reached a plateau, with minimal further improvement. It was at this point of standstill that the helplessness and hopelessness of a dependent status descended on him. The loss of self-esteem and of self-confidence built up, till the depression peaked in early 2013. All this in spite of a supportive family.
Mr. Varadarajan an engineering graduate, worked in a company for a few years before he decided to establish his own business. This he pursued in a committed manner and with enterprise, travelled a great deal on business, kept his family comfortable, educated his two children well, arranged & conducted his daughter’s marriage, an important milestone for any middle aged Indian couple. The daughter is settled abroad and visits with family every year. The trip to Badrinath, fulfilled Varadarajan’s religious inclinations as much as his urge to travel and seek adventure in the ‘mountainous Himalayan escape’!
Of Holy Shrines and Landslides The organised Char Dham pilgrimage is to the holy shrines of Lord Vishnu, Siva, Gangotri and Yamunotri, dotting the celestial Himalayan heights of Uttarakhand. The shrines are open to devotees in May and closed in early October, with the onset of the heavy snowfall. Roadblocks occur due to landslides, especially during the monsoon months of July-August, when the south-westerly winds bring with it rain, which lashes in all her fury on the slopes of the mountain ranges. Thousands of pilgrims may be stranded for a few days to a week for the roads to be cleared following a landslide. Natural disasters caused by the landslides and flash floods (the latter as in 2012 which claimed many lives) are no deterrent to the pilgrims, and year after year over 20 million pilgrims visit these holy temples in groups. The Border Road Organisation, Uttarakhand Government and the Badrinath-Kedarnath Temple Committee have their hands full during the pilgrimage season, not only to cater to basic amenities, which are sparse, but also to ensure the safety of vehicles on the winding, hazardous roads leading to the shrines. The Army is called upon to help in clearing heavy roadblocks and emergency helicopter service has to be sometimes deployed for medical emergencies and in disaster situations. The State Disaster Response Force has been established following the flash floods in 2013, to regulate the flow of pilgrims and towards better preparedness in the face of natural or man-made disaster situations. All these arrangements fall short of ideal organization, which the sheer enormity of the pilgrim population defeats.
The bus with the pilgrims had wound its way through the mountainous terrain until the driver was alerted of landslides ahead, and he knew by force of habit that he must halt the vehicle and warn the passengers to stay put. They had reached Pandukeshwar, a small town, 1829 metres above sea level, which lies about 20 km from the Vishnu temple at Badrinath. The bus crew took control of the situation, which was familiar to them, and made sure that there was no sign of panic among the busload of devotees. Their common mission was to reach Badrinath and that they would.
Exploring the Condition
Peace and calm prevailed and the long wait for the onward journey was taken as the ‘Will of God’. It was in the late evening that Varadarajan having just stepped out of the bus, perhaps to answer the call of nature, slipped on the slope, which sent him hurtling down 40 feet to land on his forehead. The bus crew and a few passengers rushed to the rescue. The wound was sutured and other first aid measures employed by the special team of healthcare providers. There was no immediate sequelae of loss of consciousness or seizures.
Varadarajan, within a few hours of the event, showed the foreboding signs of irritability and restlessness, pacing the floor of the shelter, becoming disoriented at times. He was transferred to the primary health centre at Joshi matt the following morning. In the next 3 days he progressed to semi-coma and was slipping into coma, and required specialized care. He was air-lifted by the Army helicopter and admitted to the ICU of a premier hospital in Dehradun, (the capital of Uttarakhand) which offered Neurosurgery as a superspeciality. The MRI reported ‘Subarachnoid haemorrhage and Subdural haematoma, with contusion on the right side’. His progress was monitored closely to minimize secondary brain injury following Traumatic Brain Injury (TBI), and the condition was managed conservatively with the patient on heavy medication. He regained consciousness after 21 days, was disoriented initially and did not recognize his immediate family members, who had rushed down on receiving the news. At discharge he was able to sit up, was on oral feeds and was continent and off the Foley’s catheter.
Back in Chennai, followed by a neurologist, and on home care, in familiar surroundings, stimulated by the presence of family and friends and with minimum therapies, the patient made slow progress. Over a few months, his memory improved, and he recovered his gross cognitive ability and other faculties, including to some extent language and writing skills. There was a residual right-sided weakness, but the patient could walk with a little support. He had impaired hearing in the right ear. Repeat MRI confirmed resolution of the blood clots over large brain areas, which correlated with return of efficient brain functioning.
Traumatic Brain Injury
Moderate to severe Traumatic Brain Injury (TBI) is a major Public Health concern in India, as it is globally. 1.5 to 2 million persons are injured and 1 million succumb to death every year in India due to accidents. A comprehensive report in 2002 of the Dept. of Epidemiology, WHO Collaborating Centre for Injury Prevention and Safety Promotion, Rehabilitation, Policies and Programmes, at NIMHANS, Bangalore, India, headed by Prof. Gururaj, states that road traffic injuries are the leading cause (60%) of TBIs, followed by falls (20%-25%) and violence (10%). Since then, road traffic accidents have increased exponentially, and with an ageing population, falls in the elderly must add significantly to that category as well.
Of all TBIs, 63% affect persons aged 15 to 64 and these represent the primary working population. These persons often have severe problems resuming a productive life and maintaining satisfactory interpersonal relations, despite the significant physical recovery within the first 6 months of injury. Depression can occur at any stage following an acquired brain injury, from the acute hospital stage to many years later. Post-injury depression may range from mild, (where a person may still be able to function in day to day life, but generally feel ‘low’), to severe depression and debilitation. Like in other forms of depression, the mood may be of sadness, despair, flat emotional reaction, increased frustration, irritability and anger. The thinking pattern may include a sense of hopelessness, pessimistic beliefs, and behaviour patterns may be of reduced attention to physical appearance, social withdrawal, loss of motivation to participate in activities the subject enjoyed premorbidly, accompanied by fatigue, sleep disturbances and poor appetite. There may be inability to return to previous employment and the subject may become dependent and progressively isolated, with a gradual decline in ability to perform everyday tasks and progressive disability to cope with everyday stressors. Most of the patients with these disturbances are unable to identify the cause of their inner mental state or report their social functioning accurately and the family may be at an equal loss to fathom the reason. Researchers have consistently suggested that the psychosocial problems associated with TBI may be the major challenge facing rehabilitation. This is where a specialist integrative therapy team can step in to achieve what seems impossible, patiently holding the hands of the patient and family members, guiding them through the assessments followed by the therapies in a graded manner and coaxing stepwise positive advancement in the patient’s condition. This is the ‘Art of Medicine’.
Recognition of pituitary hormonal insufficiencies after head injury and Aneurysmal Subarachnoid Hemorrhage (SAH) may be important, especially given that hypopituitarism-related neurobehavioral problems are typically alleviated by hormone replacement.
Gururaj G. Epidemiology of Traumatic Brain Injuries: Indian scenario. Neurol Res. 2002 Jan;24(1):24-8.
Rafael Gomez-Hernandez, Jeffrey E. Max, Todd Kosier, BS, Sergio Paradiso, Sergio Paradiso, Robert G. Robinson, Social Impairment and Depression After Traumatic Brain Injury Archives of Physical Medicine Rehabilitation 1997; 78: 1321-1326
Daniel F.Kelly, Irene T, Gaw Gonzalo, Pejman Cohan, Nancy Berman, Ronald Werdloff, Christina Wang Hypopituatarism Following Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage: a preliminary report J Neurosurg; 93: 743–752, 2000
The Prolonged, Gloomy, Negative Phase
The rehabilitation progress seemed to have reached a plateau within the next few months . The realization of the problems related to recovery from TBI dawned on Mr. Varadarajan. He was no longer the independent, vigorous, frequent-traveller, successful businessman, to whom the whole family looked up and others marveled. He was dependent, even for some physical help, could no longer travel alone on business, and with the financial stress and poor back up of human resource for his private enterprise, he was in the verge of closing down his business, which he had nurtured with a certain nonchalant air of confidence through these years. Life seemed to be slipping away from his control, and he was home bound, sleeping much of the time, with poor appetite, poor socializing and full of all the negative thoughts which sheer hopelessness can bring with it.
At this juncture, Varadarajan’s son’s marriage was fixed and the wife was forced to take up single-handedly, the elaborate arrangements and formalities which go with an arranged south Indian marriage. The daughter, who arrived early from abroad for her brother’s marriage, was alarmed at the father’s state of health, with weight loss, socially withdrawn, curled up in bed and sleeping long hours and finding it difficult to participate spiritedly in the wedding activities, which was very unlike the father she knew. She realised that something had to be done to pull him out of this state and to instill in him some positive energy. It was at this point that she came across information of the novel and holistic TriMed-Neurokrish approach to healthcare and decided to pursue it.
Our Healing Approach
After putting the marriage celebrations behind her, Varadarajan’s daughter arrived at the Trimed-Neurokrish reception counter and made enquiries and met Dr. E. S. Krishnamoorthy. She knew right away that that ray of hope to give her father some quality of life lay in this setting. She did not delay by even a day to arrive with her father to initiate the comprehensive assessment, integrated therapy and counselling offered here.
The Neuropsychiatric diagnosis was Post-Traumatic Brain Injury Depression, and Gait Disability. The residual neurological deficit was minimal on clinical examination, with some gait dysfunction and right sided weakness. Blood examination was unremarkable except for D3 deficit. A careful endocrinal screening was done to rule out neurobehavioural problems secondary to hypopituitarism, which can occur in TBI with subarachnoid haemorrhage.
Varadarajan’s blood pressure was under control on regular medication with Amlodipine taken twice daily. He was also on regular Phenytoin Sodium twice daily, Clinidipine for heart function, started on admission soon after the TBI and these continued. Other medication introduced at Trimed-Neurokrish included antioxidants, piracetam, ginseng (all for brain health), pregabalin (for anxiety and seizure prophylaxis) once a day, Donepezil (for memory) and Paroxetine (for mood). Vitamin D3 and B12 supplementation was initiated as well.
On neuropsychological evaluation, deficits in certain subtler areas of cognition were noted, which could hinder efficient performance. When questioned, Varadarajan said he felt hopeless, worthless, and had a sense of guilt for not being able to support his family. Cognitive Behaviour Therapy for depression and Cognitive Retraining were introduced and continued for over months, with a definite positive trend in his outlook. Family counseling and psychoeducation added to the improvement. The physiotherapist noted severe hamstring spasm, with restricted SLR bilaterally – basic exercises to make the limbs more flexible were given with Yoga and mud therapy. His gait disabilities were addressed specifically and over time he began to ambulate with greater ease. Yoga therapy helped his posture and balance, apart from reducing anxiety. Ayurvedic medicated oil massage for muscle spasm and joint flexibility, Shirodhara for cognition and mood and sessions of acupuncture were all spread over 3 months. Patient and family members were extremely pleased with the personal participation in the recovery process, the positive waves from the team enhancing the results of the long term therapies.
The focus of the TriMed-Neurokrish challenge was not just to improve the physical independent activity of the patient, but to modify behaviour (with the negative feelings of hopelessness and helplessness of the patient, leading to severe depression), to positive waves in slow but sure stages through cognitive behaviour therapy for the patient and through family counseling. Gaining the trust of the patient and family as the first step made them go along with the therapies with a sense of total dynamic participation in the process of rehabilitation and it even became a ‘fun game’ as marked improvement was noted. Recognising the patient’s often warped ‘thoughts and beliefs’, the altered life situations and the loss of self-esteem that contribute to the maladaptive and social withdrawal behaviours and the immediate triggers that set it off, are part of the sensitive professional assessments. These can be remedied by cognitive behaviour therapy, (when followed with diligence), towards placing the patient back in his original zone of comfort and self confidence in the home and in the community. A supportive network in this process includes health care providers, family, old friends, new friends, and persons who have had similar experiences.
The yoga sessions, massages, and other integrative therapies reinforce the wellness of the person through their general and specific actions, ensure continuity with the treatment team, and motivate the patient and family to participate willingly in the path to patient recovery.
“She knew right away that that ray of hope to give her father some quality of life lay in this setting.”
Over months, Varadarajan has made a steady recovery. His cognitive difficulties have largely remitted, his walking has improved, so much so, that he now does 5 kms on his own and walks his dog as well; his mood has improved, anxiety reduced and confidence levels have been boosted considerably. He is attending to his business again and has started to strike new deals, possibly saving his factory from closure; he is even planning a visit to the USA to spend time with his daughter, rekindling too an old desire for travel. Mr. Varadarajan continues to attend his medical reviews and booster therapy sessions regularly as scheduled and is gregarious in his interactions with the treating team, often sharing a hearty laugh.
For us, Varadarajan and scores of courageous patients like him, are our true inspiration. His family are beside themselves with joy to have him well and truly back in their midst, for his has truly been “A Himalayan Odyssey”. The Longman’s Dictionary of Contemporary English which defines the word ‘odyssey’ (with its roots in the Homer’s epic poem by that name) “as a series of experiences that teach you something about yourself or about life – a spiritual odyssey”, suits the theme of this TriMed-Neurokrish story best.
School days had been fun, playing team games at school and with the neighbours’ children in the sprawling campus all evening and on weekends. This did not deter him from achieving 90% and above in all the subjects in school and in the 10th standard Board Examination. 11th and 12th were in one of those cram schools, with 10-hour teaching schedules, which prepare children for the IIT entrance examination. IIT proved elusive and Krishna joined a reputed private engineering college and stayed in the hostel attached to the institution.
It is not clear whether it was the initial ragging, or the continuous teasing by the seniors in the hostel that made Krishna progressively more anxious and to withdraw socially; or indeed whether these were early manifestations of his mental health condition; whatever it was, seemed to viciously erode his self confidence in stages. He had been at the butt end of jokes even at school, as he was prone to get some facts wrong in areas of common knowledge, which he would blurt out impulsively. The inherent social awkwardness became magnified into loss of self-esteem and social withdrawal in the new environment, away from home and away from his childhood friends. Class grades plummeted by end of 2nd year at Engineering College and he had accumulated arrears in a few subjects. Clearing them seemed insurmountable even as his mental turmoil increased. By the 3rd year, he had to take a break from studies and later returned to the college, commuting from the home of his paternal grandparents (who lived in the same city where he attended college), for a period of six months, after which he opted to brave the hostel milieu, cleared the arrears and completed the course effectively, receiving a choice of campus placement.
Exploring the Condition
Krishna had thus been through a four year period of waxing and waning symptoms of social anxiety, with significantly reduced social interaction from about 17 years of age. He had a once in three month follow up with a psychiatrist over the previous couple of years and was on antidepressant medication, a low maintenance dose of Fluoxetine. On this medication and some counseling, Krishna was managing his daily activities and work performance satisfactorily, till 6 months prior to his consultation with us, when his condition turned for the worse.
In the competitive job scenario, Krishna found the IT project job very stressful as he could not grasp the concept of project ideas conveyed to him over the phone, often within a brief communication and consequently could not reply relevantly to suit the demands of the foreign clients. Being inherently a high achiever and wanting to please, he found this situation beyond his coping ability. An acute phase of illness set in, with marked loss of appetite, insomnia, loss of weight, fatigue, poor self-care, poor concentration, total inability to attend office, social isolation and subsequently led to a state of almost catatonic mutism During this period he had delusions of reference (others are talking and commenting about me) and experienced mental confusion. He appeared to be out of touch with reality and in a state of acute psychosis. Krishna was forced to go on medical leave.
It is at this point that the highly concerned, well educated, discerning parents made inquiries for a place that could offer sustained therapies and close follow up. He was admitted for a few days for comprehensive assessment and investigations and management of the acute psychotic state by the TriMed-Neurokrish team.
The case called for elaborate psychological testing. These assessment scores are touched upon here, without too much explanation, for the lay reader to appreciate the need for a scientific and evidence-based approach to a neuropsychiatric case which depends not only on the clinical acumen of the Neuropsychiatric Consultant as Head of the Group, but that clinical judgement is dependent on inputs from other team members, to estimate the degree of mental disturbance and to guide the course of management.
Our Healing Approach
During assessment at Trimed-Neurokrish, Krishna admitted to have gone through similar, but less alarming phases of physical limitation and mental turmoil which he had not expressed clearly to anybody. Self perception and perception of the environment became progressively maladaptive in a range of social and personal contexts, and the subjective distress kept mounting. He had experienced suicidal ideation 2 years earlier.
He also described vividly ‘catastrophic scenarios that he had witnessed in his mind’ (possibly delusional) for e.g., an unknown person to the patient, whose tongue had been lengthened infinitely to be placed with precision under a running truck and the vivid, gruesome picture of the resultant trauma and bleeding. On further questioning, there is no history of manic or hypomanic phase or of drug abuse; no clear family history of major depression.
On medical leave, out of the stress-inducing situation in his work space and on integrated therapy and medication at Trimed-Neurokrish, Krishna soon came out of his acute psychotic state dramatically and settled to a preparedness to face the real world. In this phase, he was reported to have improved insight and judgment, understood he had a problem which impaired his capacity to cope with workplace stress and to engage in social interaction with his peers. He wanted to overcome this state, and be able to get back to his routine in better shape.
The patient was cooperative for the psychological testing. The 42 responses to the Rorschach test met the criteria for the Coping Deficit Index. Thematic Aperception Testing pointed to the need for achievement, security, nurture, the conflict arising out of lack of ego strength and fear of rejection. The Neuropsychiatric Inventory score was 4-5 on anxiety, delusion, night time behaviour and appetite, and low on the depression scale. A diagnosis of late onset Persistent Depressive Disorder (dysthymic disorder) was arrived at.
Krishna was on regular medication for over 2 months:
Dicorate ER 750mg ( Divalproex)
Olanzipine (10mg + 2.5mg) at bedtime and (20 mg + 10mg) in the morning
Vitamin and Calcium supplements
He responded well to the integrated therapy with a total of 15 sessions of Reflexology, Acupuncture and Yoga and over 10 hours of Cognitive Behaviour Therapy and some sessions of parental counselling.
An individualised short course CBT was initiated, setting attainable goals which helps in bringing the them back to their normal level of functioning.
In PERSISTENT DEPRESSIVE DISORDER, the patient suffers a pervasive sad mood for over 4 years with barely any symptom-free period. The symptoms cause significant distress or impairment in social, occupational, educational, employment and other important areas of functioning.
Dysthymics however, may be pushed into major depression and subsequent acute psychosis Often this occurs at times of high stress and is linked to strong emotions and feelings, for example worry, anxiety, fear, depression or feeling overwhelmed by events. Lack of appetite, difficulty sleeping, lack of energy, poor self-esteem, difficulty with concentration or decision making,and a feeling of hopelessness, peaking to result in a phase of acute psychosis. It has been suggested that in dysthymic disorder, to compensate for the lack of social and real life interaction, the patient can create elaborate and complex fantasy inner worlds within their minds. According to DSM V criteria, individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.
A person who suffers from dysthymic disorder has generally learned to live with a fair amount of chronic unhappiness in their lives and so the therapist cannot go by the mood on a particular dayl He must first identify the thoughts associated with the patient’s distress. In dysthymia, these thoughts may concern the patient’s self-view, his or her representation of a significant relationship, or a meaningful situation.
Goals will vary according to type of therapy. The emphasis in Cognitive Therapy is to effect changes in one’s faulty or distorted way of thinking and perceiving the world. Interpersonal therapy focuses on an individual’s relationships with others and how to improve and strengthen existing relationships and an attempt to accommodate new ones. Solution-focused therapy looks at specific problems affecting the person’s life in the present and examines how to best go about changing the person’s behavior to solve these difficulties. Social skills training focuses on teaching the client new skills on how to become more effective in social and work relationships.
Dean Schuyler Evidence–based Review Short-term cognitive therapy shows promise for dysthymia Vol. 1, No. 5 / May 2002
Krishna continued to suffer from low self-esteem and a pervasive sad mood, with occasional congruent delusions of reference and delusional exaggerated fantasy, when assessed midway from onset of the integrated therapy. By the end of the intensive integrated therapy sessions at TriMed-Neurokrish, he was much more stable, and was on the bench at his IT job, preparing with a greater level of confidence for active work to be initiated with the clients.
It was a full term natural delivery. The newborn was small at 2.7 kgs. There was no complication of pregnancy and mother and infant were well. Motor milestones followed a normal curve, but language was delayed till the age of five years. Strangely, musical expression preceded language and by 2 years 6 months, Ragini lisped in melodic sequences, as melody with lyrics came with ease. She belonged to yet another traditional south Indian family where music occupies the whole day, from the TV devotional music broadcast at the break of dawn, the bathroom singing by the father relaxing through an evening lukewarm shower after the day’s work, till into the night, when the mother sings the infant to sleep – that ‘soporific lullaby’ which never fails! However, nurture alone cannot explain the child’s musical ability, which advantage she carried without losing ground, into adolescence and adult life with formal vocal classical music instruction. The family being resident in the West, she received higher grade training in Western classical music as well and got into the stride of it with no extra effort.
Exploring the Condition
Ragini had poor communication skills, sub-average intelligence on the Wechsler Intelligence Scale for Children (WISC), language processing difficulty, perceptual thinking deficit and social fears and phobias when examined in childhood. She became irritable and frustrated, as coping with routine stresses, given her condition, became increasingly difficult over the years, and she showed significant disruptive behaviour at about 10 years of age by way of aggression. Following a psychiatric assessment, she was started on Tab. Risperidone, an atypical antipsychotic to control the irritability of the Autistic Spectrum Disorder (ASD) and to reduce her depression. She continued Risperidone till the age of 19 years, went through mainstream schooling, as she was a high functioning ASD, and successfully completed a Certificate Course in Vocational training.
In 2013, Risperidone had to be withdrawn, due to tardive dyskinesia, and Clonazepam SOS was prescribed. Two years passed peacefully, off medication. With the support of her well educated, discerning parents empathetic to her needs, Ragini established her own space in her music studio, where she could listen to music, catalogue the music videos in her collection in the studio library, and even give musical training to groups. All this was encouraged by her parents, mindful of her problems as it also represented an attempt to organize herself into some self employed music-related career, in an area closest to her heart. However, largely alone in the studio also left her isolated and socially withdrawn. Perhaps due to this a feeling of helplessness, hopelessness and worthlessness descended upon her, and she had suicidal ideation. She was emotionally sensitive, eager to please, but did not have the ability to take criticism. Symptoms that started insidiously, reached a peak within 6 months, in mid-2015. She became severely depressed.
Escitalopram (antidepressant) and Quitiepine (an atypical antipsychotic) prescribed by the psychiatrist could not bring about any control. After a further 5 months of rapid mood swings, crying, shouting, explosive episodes of dyscontrol and threats of leaving home, the mother brought Ragini to India, hoping that a change of environment would help in some way to ease mounting family tensions. She had information about the multidisciplinary approach and integrated therapy offered by TriMed-Neurokrish and fixed an appointment for Ragini.
Our Healing Approach
It was not easy for the team at TriMed-Neurokrish to thaw the ice and make Ragini accept that the specialist team was there to help her. Once this was achieved even partially, with gentle persuasion, the flow of the assessments became smoother, with cooperation from the patient. The diagnosis and plan of management fell in place with the detailed clinical history of events that led up to the mental state at the time of assessments and clinical examination.
Her Rorschach Inkblot test produced 22 responses, meeting the perceptual thinking and coping deficit index. She had severe depression and a feeling of worthlessness. EEG showed significant epileptiform activity without localization or lateralisation. She had a past history of episodes of stare with momentary loss of consciousness. Blood test and MRI/MRA brain were unremarkable.
The Diagnosis was Autistic Spectrum Disorder (High Functioning) with Rapid Cycling Affective Disorder and Episodic Dyscontrol Syndrome. Arriving at a suitable drug regimen was more difficult and prolonged, with loss of precious time, as 2 anticonvulsants used as thymoleptic agents had to be rejected as Oxcabamazepine produced a moderate allergic response, and even worse, Lamotragine produced a Steven Johnson’s type adverse drug reaction. After allowing time for recovery from these drug reactions, the patient was stabilised on a drug regimen which she tolerated well, along with an extended program of therapies running parallel.
The regular medication was
Lithium (sustained release) 400mg – 1/2-0-1
Olanzapine 10mg – 1/2-0-1
Lorazepam 2mg – 0-0-1
The mood stabilising, antidepressant and anxiolytic effect of this drug combination was reinforced with 24 sessions of CBT, individual psychotherapy and family education, 11 of physiotherapy (grade 2), 34 of Acupuncture, 20 of Reflexology, 34 sessions of Shirodhara and whole body massage and 24 sessions of Yogasana, intensive and daily over the initial phase and then spaced out to 3-4 days a week.
“There is considerable evidence suggesting that a subset of Pervasive Developmental Disorder (PDD), youth with extreme disturbance of mood suffer from a symptom cluster that is phenomenologically consistent with the syndrome of Bipolar Disorder (BPD)”
Longitudinal studies are essential for observing the onset and progression of co-morbid condition of Bipolar disorder in ASD.
“It is of importance to recognise both the psychiatric diagnoses of ASD and overlapping BPD in order to plan the drug regimen, therapies and set realistic treatment goals.”
Following the extended therapy program and after being stabilized on the drug regimen, there is a definite return of Ragini’s lost self esteem, which had been shattered during the downhill phase. Her mood swings are minimal, and there is no episodic dyscontrol. The mother admits that she came with the hope of some relief of Ragini’s symptoms of aggression and dyscontrol. She got much more from the team at TriMed-Neurokrish, she confessed, and feels that the situation is under control and has the hopes to settle her daughter’s future plans of home and career within reasonable goals.