Categories
Alzhimers Featured Memory Problems

Of menopause & memory

A is a generally healthy and active woman professional of about 48 summers. I know her socially, well, and was curious when she sought an urgent appointment to see me professionally. “I am losing my memory doc”, was A’s first statement as she walked into my office. Probing further I found A was complaining of much more that absent mindedness. Word finding difficulties, struggling with routine skills like driving, becoming disoriented on arriving in a hitherto familiar location, not precisely remembering why she was there anyway, the list seemed endless. “Am I getting Alzheimer’s doc” was her genuine concern, expressed more than once as our interview progressed. 

Different Strokes

I asked her about her general health- whether she had any of the four key lifestyle risk factors which predispose to memory loss: Hypertension, Obesity, Lipid (high cholesterol) or Diabetes. While she did not have high blood pressure, blood sugar or cholesterol, she had been overweight until 2 years ago when she went ahead and elected to have bariatric surgery abroad. Following this she has lost considerable weight and had been on a rather severe diet that was recommended for about 18 months after. “I am slowly resuming a normal diet, but the quantities I eat remain small”, said A. On questioning she reported normal thyroid function, no lupus or other such inflammatory condition, both of which can also predispose to memory problems in younger people. Her heart and kidneys had been declared “fit and well” by her physician, during her last master health evaluation. What about your monthly periods, I demurred? “Menopause finally set in doc, about 2 years ago”, said A. When did the memory problems start, I wondered? A thought for a few moments before responding; “about the same time as my periods started tapering off” she responded. A clarified to leading questions that she was not under any significant emotional stress, nor were there any stressful life events in recent times. Indeed, with both children off to college and her husband having come into considerable wealth recently, A felt life could not be better, especially as they now had the time, resources and freedom to travel, something they both enjoyed. I asked her about neurological events or symptoms during her lifetime: head injury, seizures, fainting episodes, strokes, to all of which she replied in the negative. 

On physical evaluation A was completely well and there were no signs of concern. On the bedside evaluation of memory and cognition, though, I found A struggled a little with tasks of attention (focus), recent memory (recall) & executive function (ability to perform tasks in sequence), resulting in her working memory being somewhat affected. She did manage to remember and perform most tasks: however, she was a little less efficient and speedy than I expected her to be, considering that she was a smart & efficient professional. The obligatory brain scan (as a measure of safety) was normal, but her blood tests revealed that she was deficient in vitamin B12 (an outcome of her dietary restrictions following bariatric surgery) with elevated homocysteine, a brain chemical that is associated with memory problems. I concluded therefore that A had two reversible causes of memory impairment: vitamin B12 deficiency & menopause. 

The Menopause Effect

The World Health Organization defines the perimenopause as the time immediately preceding the menopause, beginning with endocrine, biologic, and clinical changes, and ending a year after the final menstrual period. The Study of Women’s Health Across the Nation (SWAN) published in the American Journal of Epidemiology (2000) showed that of 12425 women aged 45-55 years across sociodemographic categories who participated, between 31 and 44 % of perimenopausal women, endorsed forgetfulness. Overall perimenopausal women were 1.4 times more likely than premenopausal women to be forgetful, this finding not being just due to emotional stress. Indeed, there is considerable research today to show that in the year after the final menstrual period, women do demonstrate deficits in attention, working memory, visual & verbal memory and motor speed. Interestingly, studies like the “Harvard Study of Moods & Cycles” show that in the perimenopausal period, women are twice as likely to be depressed, and while this is not related to negative life events, it is associated with vasomotor symptoms (hot flushes). This links up with the theory that the brain hormone cortisol (which exercises an influence on the reproductive hormones) may be associated with both memory and mood; that higher cortisol levels and/or greater cortisol reactivity may be the biological link between hot flashes, depressive or anxiety symptoms and perimenopausal decrements in memory. Indeed, research has shown that young women have lower reactivity to cortisol than older (perimenopausal) women. This of course brings up the inevitable question, which A asked me “doc, should I be on Hormone Replacement Therapy”? HRT has been both praised and vilified (like many medical procedures) in equal measure. The summary evidence suggests that HRT commenced during the perimenopausal period has the potential to help symptoms of mood, anxiety and perhaps importantly, memory. However, HRT started outside these time periods does not appear to have a similarly beneficial effect, indeed may even be detrimental. 

Prevention & Cure

I had identified in A, apart from menopausal transition, a reversible cause of memory impairment, vit B12 deficiency with elevated homocysteine; which has an impact on memory and makes one vulnerable to having strokes. Other reasons why middle aged individuals like A have problems with memory include depression, infections, inflammations and metabolic (including thyroid) problems (all reversible); cancer, strokes & brain tumours (potentially reversible, at least in part); and  brain degeneration (non- reversible but can be slowed, partly arrested). It is for this reason that people with memory complaints in middle life like A, need to be thoroughly evaluated for a range of causes. A did go through such an evaluation before we concluded that her problems were due to menopausal transition and B12 deficiency, both of which we proceeded to address. We recommended to her, all those things that can help a person stave off memory loss (and indeed lifestyle disease): a healthy and predictable life, an antioxidant rich diet, adequate rest and sleep; regular aerobic exercise (walking, jogging, gymming); yoga, pilates or tai chi as mind-body interventions; moderation in all that one does, including and especially social consumption of alcohol. Turmeric is today in advanced trials and extra virgin coconut oil in early phase trials as a memory protecting agent. The former is adequately present in Indian diets generally; the latter easy to add, admixed with rice etc. We recommended both to A. 

We learnt from her too, as we do from all patients; the links between mood, memory & menopause, preventive health and the importance of holistic evaluation and care. All memory loss is not dementia and women like A in menopausal transition would do well to consider and address that aspect of their health.

Categories
Featured

The four legged stool

Mr. A is one of our “happy stories”. One who has been helped by the four legged stool: self-motivation, a supportive family, a supportive boss and adherence to the therapeutic relationship with the Neurokrish-Trimed team. He found and stayed with TRIMED and in him we find the raison d’être for our professional existence. 

When we first met Mr. A 8 years ago, he was doing his Masters in a prestigious American university. Rather devastatingly for him and his family he was diagnosed with Paranoid Schizophrenia, which had in the previous year impacted severely on his life and academic performance. Confused by his hallucinations and delusions, fearful for his safety and struggling to live alone, Mr. A was brought back to Chennai by his family. We treated his acute illness with psychotropic drugs, relaxation exercises, individual and family counselling and nutritional counselling (for his obesity, in part a consequence of his drug treatment). Within a month, Mr. A was able to return to his university and continue his course. He did of course have a few stable paranoid ideas and occasional mood swings.

Mr. A managed to stay on in university and graduate with a Master’s degree with ample family support. He progressed to secure a suitable technical position in a major multi-national computer manufacturing firm. Here, he was fortunate to be placed under a humane and empathetic boss. Over the past 8 years he has continued to visit Chennai annually for a course of multi-disciplinary therapy with our team. He also remains on fortnightly-monthly skype sessions with our clinical psychologist. He has had periodic exacerbations of mood changes with racing thoughts and paranoid ideas. He has wondered about the intentions of his fellow employees and become agitated in his interactions with them. He has had to take time off work to go and stay with his sister, in another part of the US, for a few days. He has on occasion, especially close to major life events (exams, role transfers) needed his parents to travel to the US and stay with him.

However, thanks to his own efforts, his uniquely supportive parents and sibling, a very supportive boss and mentor at work, and (in our belief) TRIMED therapy, he has managed not only to keep his symptoms under control, but to hold on to a job and climb the ranks at work. Back in India for his review and booster therapy sessions, Mr. A reported that his symptoms have almost remitted over the last year. This, despite his move to a new job at another respected multinational technology major. He is proud to share his weight loss efforts and to seek TRIMED’s assistance in meeting these goals. He has been diligent about his medicines, and has practiced the TRIMED way (relaxation, yoga and ergonomics) diligently, through the past year.

Mr. A is one of our “happy stories”. One who has been helped by the four legged stool: self-motivation, a supportive family, a supportive boss and adherence to the therapeutic relationship with the Neurokrish-Trimed team. He found and stayed with TRIMED and in him we find the raison d’être for our professional existence.

Categories
Depression Dystonia Featured Obsessive Compulsive Disorder

Stimulation for the brain!

What is deep brain stimulation?

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

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

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

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

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

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

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

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

Categories
COVID-19 Epilepsy & Seizures Featured

Managing epilepsy during COVID-19

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

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

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

Can COVID-19 cause epilepsy?

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

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

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

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

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

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

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

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

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

Are there special precautions?

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

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.