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

The Curious Case of Vincent van Gogh

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

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

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

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

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

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

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

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Adults Cerebral Musings Children Expert Blogs

The Inside Man

Personality is a term with many varying connotations, depending on the context of usage. It is a term that may be used to denote a celebrity (a public personality of figure), one’s character and temperament, or the way one comes across to others (he or she has a good personality). In medical and psychological parlance, however, personality is used to denote “those characteristics of a person that account for consistent patterns of feeling, thinking and behaving”; unique and enduring patterns of behavior and emotional response, which make us distinct individuals.

It seems rational to assume that one’s personality is a product of one’s upbringing and experience. We often cluck our tongues disapprovingly and say “Poor boy, with a disturbed background like that, how else would you expect him to behave” or indeed to warmly suggest, “One would expect no less from her; after all she comes from such a good family”. Psychological research seems to support these social assumptions that we regularly make. There is little doubt in the notion that our personalities are in good measure a product of our upbringing, the positive and negative experiences we have in our lives, the human interactions that influence us, and the patterns of emotional response we consequently develop.But is that all? Can every aspect of the human personality be explained on the basis of upbringing and experience? Do disturbed families yield disturbed children who may then grow up into disturbed adults only because of environment? Or are there genetic and other biological factors that influence these developments? Indeed, why do some people from very disturbed backgrounds remain stable and productive, while others from seemingly stable backgrounds display enduring disturbances in their ways of thinking, feeling and behaving? These are questions that continue to befuddle us.

Localising Mind and Brain Interactions: Given the mind does not exist as a physical entity and is widely regarded as the software (the Brain being the hardware), it seems self evident that disturbances in brain function would have an impact on our mind (and possibly vice-versa). Surely, any affectation of these brain systems is likely to have an influence on our personality? Surely, also, our personalities are likely to result from biological imprints in our brain, imprints that lead to the very consistent patterns of thinking, feeling, and behaving, making us the individuals we are?Perhaps the earliest attempt to link human temperament with the brain was “Phrenology”, the study of the human skull, its characteristics, and the correlation of these with various aspects of behavior, emotion and temperament. From this time emerged also what has become an enduring tradition in clinical neurology practice; repetitive and careful observation and documentation of patients: the symptoms they described, and the signs that were manifest during the clinical examination, an approach that yielded excellent descriptions of emotions, behavior and temperament in brain disorders. Correlating these with studies of brain biology using brain scans, genetic, chemical and hormonal studies etc., and autopsy data, has improved our understanding of mind-brain interactions. The personality in neurological disorders such as epilepsy is now relatively well documented, and we are able to build models linking different brain structures with typical behavioral patterns that are observed in these disorders.

A Tale of Two Personalities: While there are several striking descriptions in the literature of personality changes associated with brain disease, the illness in which classic personality features are well described is epilepsy, providing a template to understand the neurological contributions to human personality. Epilepsy is a paroxysmal disorder that often begins in childhood or adolescence, and may continue throughout a person’s life. Epilepsy is characterised by recurrent seizures or fits, usually involving loss of consciousness, fall, jerking of the limbs, clenching of the jaws, injury (often tongue bite), and incontinence (involuntarily urination and/or defecation). Epilepsy may, however, also manifest in partial or minor forms as involuntary movements or repetitive behaviors of which the person is unaware or partially aware. The illness which begins as short circuit in normal brain activity is commonly characterised as primary or secondary generalised: primary generalised epilepsy arises from a central pacemaker in the brain and secondary generalised from a distinct part of the brain (usually a lesion or scar) later spreading to involve other parts (generalising). Distinct personality types are described in the two different forms of epilepsy: the obsessive-emotive personality of temporal lobe epilepsy and the labile-disinhibited personality of juvenile myoclonic epilepsy.

The Obsessive Neurotic: One of the most striking descriptions of personality in neurology is in patients with epilepsy that arises from the temporal lobes. The temporal lobes are located on either side of the brain, roughly in the area beneath the ears and are the seat of human memory and emotion. It has been shown in a number of studies that disturbances in this region can result in striking behavioral or cognitive (memory, attention etc.) change.An American neurologist, Normal Geschwind, widely regarded as the father of behavioral neurology, described specific personality features in people with temporal lobe epilepsy. These include:

  • A tendency to write copiously (but not necessarily in a creative way) and to keep voluminous diaries (Hypergraphia)
  • A tendency to be overly religious, often in a ritualistic manner, out of keeping with the person’s family/ cultural background (Hyper-religiosity)
  • A tendency to have a decreased interest in sexual matters (Hypo-sexuality)
  • A tendency for anxiety and obsessionality; to dwell on minor matters and to experience difficulty in terminating social intercourse (emotional viscosity or stickiness)
  • An increased interest in spiritual or ideational issues in the absence of pragmatic interests
  • Turbulent emotions — irritability, agitation, anxiety, restlessness, paranoia etc.
  • Mood swings, commonly spells of depression with occasional elation
  • Psychotic and quasi-psychotic phenomena; transient hallucinations, delusional thinking etc. occurring on and off

These personality traits have been described mainly in people with chronic temporal lobe epilepsy that failed to respond to anti-epileptic drug therapy. We must remember the vast majority of people with temporal lobe epilepsy are honest, conscientious, sincere and upright members of the community they live in, these positive qualities being aided perhaps by the personality traits described. Only in a small proportion of people, usually those with severe epilepsy, do these traits become severe and/or disabling. In some way therefore, these are probably the behavioral manifestations of the pathology in the brain that most often underlies temporal lobe epilepsy, sclerosis of a part of the temporal lobe called the hippocampus. The hippocampus is a small organ, no larger than a finger joint, which is the storehouse of memory and is located on either side, deep within the brain. Adjacent to it is the amygdala, a multinucleated structure that is believed to play a substantive role in human emotion. There is evolving literature that suggests a role for these structures in various disorders of the mind, schizophrenia and depression for example. One may argue that both behavioural and brain dysfunction are varying manifestations of a common underlying abnormality in brain biology. In disorders like temporal lobe epilepsy the patterns appear to be surfacing early providing the basis for enduring behaviour patterns i.e. the personality.

The Eternal Adolescent: In contrast to the person with Temporal Lobe Epilepsy, the person with Juvenile Myoclonic Epilepsy (JME) has been described as the eternal adolescent by Dieter Janz, the legendary German neurologist who first described the condition in the 1950s. Juvenile Myoclonic Epilepsy is characterised by myoclonic jerks; sudden jerky spasms of the limbs, even the whole body, which might even result in objects flying out of the person’s hand. These myoclonic jerks also have potential to generalise and manifest as a full blown seizure. Further, people with JME also suffer from “absence” periods, when they appear out of touch, albeit briefly, and “photosensitivity”, the sensitivity to flashing lights, these provoking myoclonic jerks or even a seizure episode.Describing the personality of people with JME, Janz and Christian found them to be of average intellectual ability with a tendency to “promise more than they can deliver”. They went on to describe the personality of people with JME as follows. “They often appeared self assured and bragging, the girls and women coquettish, but they only act decidedly mistruthfully and are timid, frightened and inhibited. Their labile feelings of self worth lead them to be both eager to help, to invite, to give, on the one hand and to be able to act in an exaggeratedly sensitive way on the other hand. Their mood changes rapidly and frequently. This makes their contact both charming and difficult. They are easy to encourage and discourage, they are gullible and unreliable. Their suggestibility makes contacts easily but makes trust difficult. This personality profile plays along a scale from likeable nonchalance or timidity, through a psychasthenic syndrome to the extremes represented by sensitive or reckless psychopathy.”In the clinic setting, treating the person with JME can often be an exasperating experience. They seldom follow through on instructions; often break rules willfully; for example, despite knowing that lack of sleep may provoke seizures, they favour late nights. They may be irregular with their epilepsy medication to the point of recklessness. They may show disinhibition in their patterns of interaction, political correctness not being their strength. Indeed, the person with JME demonstrates many features of frontal lobe dysfunction, emphasising the importance of this part of the brain in social behavior.

From Brain Circuits to Personality Traits: This tale of two personalities in epilepsy indicates clearly the differential role of frontal and temporal brain circuits in human personality development and change. Temporal lobe dysfunction underlies dominant obsessional neurotic personality traits and frontal lobe dysfunction, immature eternal adolescence. To assume, however, a direct impact of these brain circuits on behavioral patterns may be simplistic, as today, the brain is conceived as working in circuits (a sum of parts). However, these observations help establish a general principle that the brain has considerable impact, not only on the behavioral state of a person (current or ongoing dysfunction), but also on behavioral traits (enduring temperamental patterns).What is striking about the personality features in epilepsy is that they become established rather early in the person’s life (much like the illness, which often begins in childhood or in adolescence), and are not only personality changes consequent to progressive brain disease or brain injury as in Stroke, Multiple Sclerosis and Parkinson’s disease. They do therefore reflect to a large extent, the natural history of personality development in the human being, and are probably a product of both brain biology and life experience.

The Inside Man!: In highlighting the epilepsy example, it must be borne in mind that the severe personality changes in epilepsy are an exception rather than the norm; and are confined to a small proportion of people with difficult-to-treat epilepsy. Importantly, however, the changes in epilepsy described herein help us understand the biological underpinnings of the human personality, clarifying for us a role for nature, beyond nurture.One wonders if all personality traits have their biological imprints in the brain; that dominant personality trait patterns in each one of us merely reflect the pre-dominance of brain circuits? One may argue that both the behavioral and brain dysfunction in epilepsy are varying manifestations of a common underlying abnormality in brain biology. If that were true, then pray what role doth life experience have in shaping our personalities, you may well ask. Would not a lifetime of coping with the trials and tribulations of illness have an impact on the personality? Would the disability, physical, psychosocial and pragmatic that chronic illness confers on a person, not influence the personality, towards neurotic obsessionality or carefree adolescence? And pray, what lessons do these models have for understanding the personality of people without neurological illness? A plethora of questions assails us and begs for answers; answers that current medical and scientific knowledge do not possess.As medical technology evolves and we begin to visualise brain circuits in action, using techniques like Functional MRI, MRI Tractography and Positron Emission Tomography (PET), we expect to see the links between brain biology and human behavior unravel further. Perhaps, in time, we will all understand this “inside man (or woman)”; the personality that resides in our brains. In the interim, conditions like epilepsy are windows through which we can view the brain and mind. And view the brain and mind we must with compassion and understanding; without stigmatisation; combining science with medicine; cleverness with common sense; knowledge of medicine and the art of clinical practice; all the while thanking people with epilepsy for enhancing our understanding of the brain and mind.

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Adults Bipolar Disorder Elders Expert Blogs

From Elusive Cure to Enabling Comfort

We must consider quality of life and wellness as treatment outcomes and ask ourselves whether the treatment we opt for will help us achieve these outcomes.

Quality of life is a relatively novel concept that dominates both medical science and health policy today and is widely accepted as the best indicator of outcome of treatment. The focus among practitioners of modern medicine, and indeed, in social consciousness, however, remains firmly on the elusive concept of “cure.” The adage among medical practitioners of yore: “to cure sometimes, control often; but comfort always,” hints at the importance of life quality, one that is forgotten, however, in the quest for miracle cures.That the majority of chronic conditions defy cure is something doctors know, but often choose to be agnostic of. Thus apart from infections, inflammations, metabolic disturbances and transient visitations of their ilk, that respond well to drugs designed to terminate them; and indeed abnormalities of structure (organs that have lost structural integrity) that are amenable to surgical intervention, the vast majority of medical conditions while potentially controllable, are not curable. Diabetes, hypertension, high cholesterol levels, ischaemic heart disease, stroke, epilepsy, dementia and a host of other conditions while “treatable” and/or “modifiable” (relief from clinical symptoms and attendant complications) are not “curable.” The promise of a “cure” for many chronic diseases thus remains wishful; that rainbow with its elusive pot of gold, at the end of the dark, illness cloud.There is no doubt we are living longer as a society, and this longevity is attributable, in great part, to advances in modern medicine; cardiac bypass procedures, joint replacements, organ transplants and such like. There is ample evidence to support our collective social longevity, the average Indian lifespan having increased by over a third, since the time of independence, the increase being greater in “advanced” societies like Japan. However, whether such longevity leads automatically to enhanced quality of life remains a conjecture. For example, the follow-up data after a cardiac bypass surgery, arguably the best known lifespan enhancing procedure, shows in many studies high rates of depression and cognitive dysfunction (memory and higher order brain function problems) 5-10 years after the procedure. It would be fallacious to blame the bypass procedure for these complications in the brain and mind; after all, had the person with ischaemic heart disease lived long enough, without the procedure, he might have developed these anyway. However, in evaluating the overall “success” of such procedures or advocating their widespread application through policy implementation, these factors must be considered carefully. In this instance, the question that begs our attention is: “while the procedure enhances lifespan, does it enhance the quality of life?” And if it does not for a select group, who constitutes the group? Why not for it? When does it enhance the quality of life, and when doesn’t it? What determines the outcome in a given individual? Where and how is this outcome determined? These questions need clear answers and we do not always have them.It is striking how both modern medicine and society are obsessed with the concept of “cure,” the quest for magic pills (or, indeed, magic procedures) that will help achieve the longevity goal, being never ending. The energy, enterprise and expense invested in this quest, by affected individuals, their families, and governments are, unfortunately, not always rewarded with a good quality of life after the procedure. Our obsession with “cure” probably comes from two very different directions. The first is idealistic; the tantalising possibility that we will, through advancements in science and technology, “fix” the vast majority of problems concerning the human body. When mankind has learnt to fly, build tunnels through mountains and under the sea, and transport itself into space at will, this aspiration of curing chronic diseases and enhancing longevity does not really seem that distant a frontier.The second, however, probably has more sinister origins that merit careful consideration. The business of curative medicine is enormously lucrative and demands the constant creation of markets that will utilise the goods and services it develops. What could interest the human race more than the possibility of a cure for illness and life-enhancement (with or without quality)? A degree of scepticism of novel, potentially curative treatments is, therefore, warranted in the modern social context, and we must examine carefully whether the promise of “a magic cure” for any chronic condition guarantees alongside an improvement in the quality of life. Thus, while we share a collective belief that people not only live longer due to advances in medical science but also live well, the presumption of a better quality of life, is sadly, in many instances, just that — a presumption!Scientifically viewed, the proof that many modern medical treatments enhance the life quality remains tenuous, to say the least. At a recent lecture in VHS, Chennai, Shah Ebrahim, Professor at the London School of Hygiene and Tropical Medicine and Chair of the South Asian Chronic Diseases Network, a renowned international expert on chronic disease epidemiology, rued our societal predilection for magic bullets (The Hindu, January 9, 2010). Talking about the “polypill” — a combination of aspirin (blood thinner), a Statin (to lower cholesterol levels), and antihypertensive agents (to lower blood pressure) — that is intended to enhance cardiovascular health, he pointed out that simple health promotion measures such as changing over to rock salt from processed salt (high in sodium) and using soya oil as opposed to palm oil (which strangely attracts a lower tax probably due to anomalies in trade policy) were just as likely to improve cardiovascular health. These are far cheaper for governments to implement, and relevant to developing nations.Prescribing the widespread use of the polypill for the middle-aged, as opposed to implementing these simple public health interventions through changes in policy, both health and trade, will be deleterious in many ways, he opined. It will be costly to the nation and poorly sustainable, will have low penetration in society and perhaps, most importantly, take away the responsibility for our health from us, placing it firmly in the hands of the pharmaceutical industry. Further, the former approach, of making people assume responsibility for their lifestyle and diet, alongside the implementation of a complementary government lead policy, is far more likely to enhance other desirable health behaviours in society and, indeed, global health outcomes.Why do we then as a society look to the “polypill” with such enthusiasm or consider it with such seriousness? The answer probably lies in our preference for “cure” as opposed to comfort and life quality. Happily for us, improved quality of life and “wellness,” a concept that has traditionally dominated eastern thought and traditional medical systems, is today receiving much global attention. Wellness encompasses both physical and mental well-being, the latter being a dynamic state of optimal functioning referring to the individual’s ability to develop his or her potential, work productively, build strong and positive relationships with others and contribute to the community. We must recognise that the prevention and management of diabetes extend far beyond the popular notion of blood sugar control; that cardiac health cannot be achieved merely by unblocking blood vessels and enhancing circulation through a stent or bypass; and indeed that the drugs for dementia available today do not even guarantee slowing of disease progression, let alone cure or reversal.Given this scenario, we as a nation and society must consider quality of life and wellness as treatment outcomes, quite seriously, and ask ourselves whether the treatments we are considering, however technologically advanced and seductive, will likely help us achieve these outcomes. We would also do well to examine closely the role of traditional and indigenous medical systems that have for centuries retained this focus on wellness and life quality through health promotion, prevention of illness, care and comfort for those affected with chronic illness; not merely curative treatments.

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Children Epilepsy & Seizures Expert Blogs Featured

The Whole Picture – Epilepsy Care and Management

A therapeutic alliance and an interdisciplinary approach work well for patients with epilepsy.

In over 85 per cent of cases,
epilepsy can be treated successfully.

Epilepsy was once considered a manifestation of gods, demons, spirits and their disaffection with humankind. Its treatment in ancient times involved a range of rituals and exorcisms. In the 19th century, as medical science evolved, epilepsy came to be regarded as a disease of the brain but continued to be associated closely with the mind and was often treated in asylums by doctors, who were as concerned with mental illness as they were with epilepsy.In the first part of the 20th century, clear associations between the mind and epilepsy began to emerge from patient settings. That behaviours could be a manifestation of underlying epilepsy (epileptic equivalents), precede a seizure (aura or warning), and follow seizures (post-ictal states) all became part of neurological lore. That psychological states (hysteria) could manifest with seizure-like episodes, ‘psychogenic seizures’, or ‘pseudoseizures’ also were described. Anxiety, depression, psychosis, obsessions, hysteria… a wide range of mental states being a prelude to seizures, accompanying silent seizures, or following seizures were described by European neuro-psychiatrists. However, despite this rich medical literature of over two centuries, the relationship between epilepsy and the mind remains much misunderstood as also the treatment of disorders thereof.Fourteen-year-old Miss V, with a childhood history of febrile seizures, suffered from repeated episodes of jerking and being ‘absent’ that tended to cluster around her menstrual periods. She also had falling academic grades, mood swings, anxiety, disturbed digestion and poor sleep. A good student whose childhood epilepsy had been well controlled, she was bemused by the sudden outbreak of symptoms around menarche that had over a year substantially reduced her quality of life.Consultations with an array of specialists and close observation by her intelligent and attentive parents led to the understanding that the problem was not easily responsive to conventional medication; was closely linked to stress, both academic and familial; clustered around her menstrual periods; was unpredictable and at times subtle (a jerk or two while on the dining table that could otherwise pass off as a teenage mannerism); could affect her on several days in a month. Indeed, her father, a diligent record keeper, could identify as many as 50 to 60 events in a given month occurring in five to six clusters.A comprehensive care approach for such a patient would comprise:A detailed interdisciplinary history: general medical, menstrual, neurological, psychiatric, developmental, social, familial and nutritionalA detailed treatment history: drugs, doses, side-effects, impact of treatment. Investigations to exclude co-morbidities and complications.Establishment of a therapeutic alliance with the family: A firm commitment to work together with transparency, mutual respect and common goals.An interdisciplinary therapeutic programme: nutritional and medical, psychological counselling, yoga therapy, naturopathic and Ayurveda therapies for digestion, sleep and peri-menstrual symptoms.A carefully graded approach to drug treatment of epilepsy with commitment to identify the ideal drug combination and the therapeutic window thereof.After a similar approach for Miss V, one year later it was found:Episodes diminished from 50 to two to three a month.Attacks were brief and had limited impact (a couple of hours at best).Peri-menstrual periods were bearable.Mood swings and anxiety had remitted; sleep and appetite improved greatly; stress levels fallen.Is compliant with medication and regular; tolerated her drug doses well.A therapeutic alliance and interdisciplinary approach (a recommended global best practice model of epilepsy care*) appear to have worked. Miss V is firmly on the road to recovery.FAQsWhat is epilepsy? A short circuit in the brain’s electrochemical activity is a seizure. A tendency to have unprovoked seizures is epilepsy.What causes epilepsy? About 10 per cent of all patients have clear genetic causes. In others, brain trauma (in pregnancy or later life), infections (cysticercosis and tuberculosis), inflammations, tumours; brain scarring due to poor blood supply (ischemia) and degeneration contribute.Can epilepsy be treated? In over 85 per cent of cases, epilepsy can be treated successfully (either complete absence of seizures or a substantial reduction). A range of drugs, surgical treatments and brain stimulation procedures are available.Can a person with epilepsy lead a normal life? Certainly! People with epilepsy can study, hold responsible jobs, get married, have children, play sport and engage in social, cultural activities. Limitations if any are related to driving a motorised vehicle (law varies across countries), taking part in adventure sports, swimming without supervision etc.Can epilepsy be prevented? Epilepsy is not contagious. Prevention starts at conception with good maternal health and antenatal care. Good care of the newborn, appropriate nutrition, prevention of infections, head injuries especially road traffic accidents, early diagnosis and treatment of seizures are the cornerstones of prevention.What to do when a person has a seizure? Put them on their side comfortably (the recovery position), remove all dangerous objects (those that are sharp, emit heat etc.), provide a soft head rest; hold them gently until the event is over (seconds to minutes). Do not try and insert your hands into their mouth; do not hold them forcefully or try to interrupt the seizure. Giving them keys or metal to hold has no medical impact. If a seizure is prolonged, call an ambulance immediately.

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