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Adolescents Buddhi Stories Children Epilepsy & Seizures Featured Patient Stories

Asma – Building Rapport

Asma – Building Rapport
Asma – Building Rapport

Biography

Asma was the second born of two daughters to parents who were both working professionals and of a middle class background. Since the mother had some minor complication in the first delivery and as there was an eight-year gap between the two pregnancies with maternal age at 30 years, a planned, elective Cesarean was carried out. The delivery was conducted at term and the developmental milestones of infancy and early childhood were normal.

The maternal grandparents lived close to Asma’s home and looked after the two grandchildren when the parents were at work. In the Indian grandparenting context, this was carried out diligently, with focus on every aspect of traditional child development, covering the spectra of nutritional requirements, discipline, academic performance and physical, mental and spiritual growth. Asma’s attention-seeking behavior, temper tantrums and need to win every event she took part in might have been influenced by the environmental situation, but it was distinctly excessive on any account.

Exploring the Condition

Premorbidly, Asma was described as being intelligent, cheerful, sociable, enthusiastic about participation in extracurricular events like dance and music, and though a slow learner at school, she was keen on overcoming her academic deficiencies with added effort, which the teachers recognized and were lenient when marking her.

Asma’s clinical problems manifested at the age of six years, with two types of bizarre episodes of a repetitive, stereotypic nature. The first involved jumping up and down 10-20 times, in a seated position, clapping hands and bursting into unprovoked laughter, which could not be described as totally mirthless. She was aware and able to answer questions during the episodes, which were associated with sweating and terminated, after a couple of minutes in a cough, as if she was choking. These episodes occurred frequently.

The second type, 15-20 episodes in 24 hours, occurred both while awake and in sleep initially, and later was confined to the sleep stage. The attack was of arousal, stare, movement of hips  up and down 5-10 times rhythmically (pelvic thrust), followed by a smile, hyperventilation and incomprehensible muttering for a few minutes and back to sleep. Initially she was responding to call during these episodes, but later she became unresponsive right through the episode. After basic seizure screening, in a city Epilepsy Clinic, which included neurological assessment, EEG and MRI neuroimaging, anticonvulsant therapy had been initiated, with some control of the frequency of seizures. Meanwhile, behavioural patterns, which were a clear departure from the norm for Asma had peaked, which caused great alarm to the family and school teachers at the mainstream school where she had studied from lower kindergarten class. The Principal of the school, who had known many childhood neuropsychiatric problems sorted out for them by the TriMed and Neurokrish team, referred the child to the medical facility, with a word of encouragement to the dispirited parents.

Our Healing Approach

When Asma presented to our service, accompanied by her parents, a month after the initial symptoms, she had clusters of 5-6 one-minute seizure episodes packed into 1 hour of daytime sleep and 3-4 two-minute nocturnal episodes. Bedwetting occurred once in two days, and only at night. The abnormal behaviours ranged from hyperactivity, aggression, abusive behaviour, biting, spitting, excessive and disorderly eating, to bullying other children, lying and employing overtly manipulative behaviours and defiant behaviour towards figures of authority. This was reported after detailed assessment by the Child Behaviour Therapist of Neurokrish.

The TriMed-Neurokrish team was alerted to gear up to fulfil their individual and collective roles in remedying the enormous challenge posed by Asma’s health problems. They had to bring into action (with mild variations, to suit the individual and the situation) the protocol for ‘Comprehensive Care for Epilepsy’- a best practice model for a resource-poor country like India, developed by Dr. E. S. Krishnamoorthy, to suit the sociocultural milieu and fine-tuned over the years of its use by him and his team members.

The basic requirement is a multidisciplinary team, which provides treatment, therapies, counselling and hand-holding for the patient and parents to get over the worst initial phase and to participate with hope even as they witness a palpable shift towards the positive phase of patient management.

Detailed medical and neurological examination of Asma revealed no overt clinical markers – neurological, endocrinal or genetic, suggesting a developmental disability or heritable trait. Repeated electroencephalograms (EEG’s) were abnormal with bilateral spike and wave dysfunction but failed to reveal any localization or lateralization of epileptiform activity. There was no suggestion of any syndromic epileptic disorder. Detailed testing of hematological, biochemical, endocrinal and metabolic, infectious and inflammatory parameters was non-contributory. Repeated MRI scans were taken, including  a 3 Tesla MRI scan, the last, to define even a minute lesion if present It failed to reveal any neurodevelopmental markers of significance. We looked for hippocampal sclerosis, cortical dysplasia and hypothalamic hamartomas in particular and these were eliminated.

It was the turn of the clinical psychologist to assess the patient using standard assessment scales; Binet-Kamat Test for general mental ability, screening test for specific learning disability, NIMHANS Neuropsychological Battery for Children for profiling the neuropsychological component and Raven’s Control Projection Test, to assess the child’s attitude towards parents, friends, likes, dislikes, fears and worries.  On these tests, she was found to have bright normal intellectual ability with an IQ of 119, mild difficulty in (the ‘three R’s’ as they were referred to in the colonial days! – ‘a’ being silent in arithmetic in its verbal rendering) reading, writing and arithmetic. She fell behind what was expected at her age. She also had problems in the areas of working or online memory, comprehension, attention (more frontal lobe related), visuospatial ability and mild memory deficit.

The projection test revealed “fighting with friends, problems at school and fear of ghosts”. While the child was cooperative and it was possible for the psychologist to establish rapport with her easily, she had a tendency to stray into phases of inattention, verbosity, playfulness and gnosis. This resulted in tests being incomplete. Given her general levels of comprehension, her ‘show of indifference’ to the overall predicament struck one as being altogether incongruous.  

“The basic requirement is a multidisciplinary team, which provides treatment, therapies, counselling and hand-holding for the patient and parents to get over the worst initial phase…”

The Diagnosis

Asma was diagnosed to have epilepsy with complex partial seizures originating from frontal lobe. Behavioural problems are known to occur in complex partial seizures of frontal origin, as are the selective areas of learning disability. Her inability to keep up with the class, further aggravated the abnormal behaviour, as she was obsessed with being a winner every time.

The child was started on Levetiracetam and Clobazam, two of the anticonvulsants in the list of drugs of choice for this type of seizure disorder, in a girl child of pre-pubescent age. Risperidone in small doses was introduced in an attempt to control difficult behaviours. Multidisciplinary interventions included behavioural therapy, neurodevelopmental and task-based occupational therapy (specifically with focus on attention, fine motor skills and handwriting) and remedial educational support after school for dysgraphia and dyscalculia. With family counselling, it was possible to persuade the family to cooperate even more, as they developed awareness of the child’s genuine health problem and the basis of the multidisciplinary approach. The management protocol was complimented by working with the school, counselling the Head and the teachers, developing a joint statement of special needs and building a therapeutic alliance with her concerned but informed and enthusiastic parents and grandparents. Developing a process of continued and consistent communication between the family, school and treatment team was well established, and continued over several years.

Over weeks, with titration of anticonvulsant drug dosage, her episodes remitted. With optimal use of risperidone and the therapies, her behavior pattern also became more manageable. Her problems with inattention, learning and academic performance did however continue. Although through the six-year period of comprehensive care, Asma had managed to remain in mainstream education, and continued to work with her behavioral therapist and special educator, she was advised by Dr. Krishnamoorthy to drop a year and to consider more flexible educational streams in order to cope and with less tension all round, as stress of studies, a board exam to face, failures etc., could exacerbate the seizures and the behavioural problems. Following this  advice and guidance, her parents sought admission for Asma in a city special school offering the National Open School stream. This stream allows choice of subjects with which the candidate is comfortable and he/she can take the school leaving examination, covering 2 or 3 subjects at a time at a hassle-free pace.

Epilepsy

The onset of any form of epilepsy can be devastating to the patient and family. It may repeat frequently or be moderate to severe, and persist through the lifespan, affecting education, employment, marriage and even independent living. Early diagnosis and treatment with anticonvulsants is essential. What is equally important is to have continued specialized and comprehensive epilepsy care to give the person with epilepsy a quality of life. Complex partial epilepsy of frontal origin are very uncommon, and can pose a diagnostic dilemma, unless the clinician has a clear knowledge of the condition. This is where a health care provider can draw from literature on the subject and know what others have said about it. A much cited author Williamson (1985), described “the complex partial attacks of frontal origin as brief, frequent attacks, complex motor automatisms, kicking, thrashing, pelvic thrusting, vocalization, while consciousness is maintained”, pretty much what our patient presented with.

Braakman (2012) undertook a comprehensive neuropsychological study of 71 children with cryptogenic (with no detectable lesion) frontal lobe epilepsy  (FLE) to report that,  “Across measures, the patients demonstrated a host of cognitive and behavioral impairments”, which again goes with Asma’s clinical picture and further confirmed by the presence of gelastic epilepsy.  Gelastic epilepsy (‘laughing epilepsy’- Gelastikos in Greek meaning laughter) is a very rare epilepsy form, and is most frequently due to a benign tumour in the hypothalamus, but may also originate from the frontal or temporal lobe. Unnwongse (2010) recorded the symptomatic zone of laughter in the frontal lobe of a patient with gelastic epilepsy, employing intracranial video EEG. Benge (2014) observed that Executive Functioning, which is the ability to initiate volitional responses, plan, decide, and monitor performance is one of the most frequently impaired cognitive constructs in FLE. The frontal lobes have a critical role to play in memory functions as well, including organization and encoding of information to be learned, memory retrieval, and prospective memory. Attention and working memory difficulties may add to the cognitive deficit.

With all these areas of deficit, it is not surprising that the patient manifest learning disability. The clinical psychological assessment at baseline with performance score recording, when the patient started the treatment regimen, followed once in 3-6 months, will give a clinical evaluation of the progress, status quo or even regressive tendency, correlating with the real world patient’s all round performance, and carry with it projection and prognostication value. 

  • Braakman HM, Ijff DM, Vaessen MJ, Debeij-van Hall MH, Hofman PA, Backes WH, et al. Cognitive and behavioural findings in children with frontal lobe epilepsy. Eur J Paediatr Neurol. 2012; 16: 707-715.
  • Williamson PD, Spencer DD Complex partial seizures of frontal origin Ann Neurol 1985 Oct.; 18,(4), 497-504
  • K. Unnwongse,  Wehner T,  Singaman W Gelastic Epilepsy and the anteromesial superior frontal gyrus Epilepsia Vol 51, issue 10, 19th March 2010
  • Jared F Benge, J Michael Therwhanger, Batool Kirmani The Neuropsychology of Frontal Lobe Epilepsy: A Selective Review of 5 Years of Progress. J. of Neurological Disorders and Stroke, Special issue on Epilepsy, May 2014, 2 (3), 1057

Our Focus:

Comprehensive Epilepsy Care

Comprehensive Epilepsy Care is about targeting patients, caregivers, healthcare professionals and society at large with focus on helping the person with epilepsy minimize stigma, achieve optimal activities of daily living (ADL), health related quality of life (HRQoL); social, educational and occupational milestones. It enquires into the goal of each treatment or therapy employed within a time frame, while including the patient’s (and their relatives) subjective evaluations and perspectives. There is considerable evidence to suggest that information, education and understanding help people deal with their condition better, as ‘knowledge is power’. There is also evidence in epilepsy that psychosocial interventions improve outcome. For the team to plan the intervention effectively, it is imperative that the problems diagnosed in the clinical or lab setting is converted to understanding their real world correlates and this derived knowledge is applied towards holistic and individualized patient care.

Looking Ahead

Asma has remained seizure free, has not shown any further behavioral decompensation and remains aligned with the therapeutic team and school. The parents express their heartfelt thanks everytime they come to TriMed for follow up. The Child Behaviour Therapist, in her inimitable way says that she will take Asma’s self confidence and self esteem to the next level as she enjoys total rapport with Asma (as with other children), teases and chides her and in turn hugs her to show appreciation. The Trimed-Neurokrish team is happy to deliver patient-centred, holistic healthcare with patience and diligence as a team in the midst of a modern consumerist healthcare environment.

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Adolescents Adults Cerebral Musings Children Elders Expert Blogs

Why Humans Like to Cry? Tragedy, Evolution & The Brain

Professor Michael Trimble the renowned British Neuropsychiatrist begins this,  his second popular science work, by stating affirmatively that emotional crying is unique to the human species. He goes on to dismiss as myths reports about apes, elephants and dolphins being capable of crying for emotional reasons. Not only is emotional crying unique to us, says the good professor, we have through our tradition of “tragedies” converted it over centuries, into an fine art form.

Music, gave rise to the birth of tragedy, which according to Nietzsche contains a fusion of Apollonian beauty with Dionysian creative energy and art.

Many other philosophers have taken up this two god theme- Mann, Hesse & Ibsen to name a few. “Apollo is the cold hard separatism of Western personality and categorical thought. Dionysius, is energy, ecstasy, hysteria, promiscuity, emotionalism, heedless indiscriminateness of idea or practice….Complete harmony is impossible, our brains are split and the brain is split from body. The quarrel between Apollo and Dionysius is the quarrel between the cortex and the older reptilian limbic brain”.

And thus does Trimble set the stage for his dissertation. From why and how we humans cry, through the neuroanatomy of the limbic system and it’s association areas, its neurobiological links with the lacrimal gland which causes us to tear (both in joy and sorrow); through the power of aesthetics- art, poetry, literature, painting, archeology, but most of all and most significantly so, according to the author, music!

What follows is a smorgasbord of philosophical, neurobiological, cultural and literary information; pearls of wisdom in every page. The “cutaneous shiver” of William James, and Shelley’s verse on the power of music, all find a place in the author’s evocative descriptions.

“I pant for the music which is divine
My heart in its thirst is a dying flower;
Pour forth the sound like enchanted wine,
Loosen the notes in a silver shower;
Like a herb less plain for the gentle rain,
I gasp, I faint, till they wake again.”

Using the theory of mind as the centrepiece of his dissertation, the author delves into the role of altruism and empathy in the development of the human social brain, which a number of studies of emotional-facial recognition using MRI scans have pointed to. “The evolution of cognitive empathy with corresponding increase in the size of the human pre-frontal cortex, provides experimental and neuroanatomical evidence explaining, from a neurobiological perspective, the human ability to feel the sadness of others, and cry emotional tears”. From an anthropological perspective, he also links empathy and tears to an awareness of the self: which according to Clive Finlayson “produced an animal capable of locating itself in space and time, an animal that became aware of the consequences of its own behaviour and mortality”.

The importance of language and linguistic processing is well brought out in the book. “Linguistic representations can influence how emotional states are represented and thus experienced”. Trimble points to the right hemisphere of the brain, quoting Norman Cook “At every level of linguistic processing that has been investigated experimentally, the right hemisphere has been found to make characteristic contributions, from the processing of affective effects of intonation, through the appreciation of word connotations, the decoding of metaphors and figures of speech, to the understanding of the overall coherency of verbal humour, paragraphs and short stories”. Trimble also points to the amygdala as a central organ that modulates human emotion, alluding to the elegant work of Zeki and colleagues who have used functional imaging to extensively study emotion.

Of music, Trimble points to, apart from linguistic impact, the triadic quality of the tonal Western harmonic system, whereby the tonic pitch on which harmonies are built, by means of progression from chord to chord, using such musical techniques of composition such as repetition, modulation and transformation, move away from these centres only to return with harmonic resolution. Through this “acousamatic” quality, calm and tension are developed, discord requiring a return to concord, provoking restlessness, suspensions and anticipation all requiring resolution. At these moments of “chills” or “shivers down the spine”, scientists have described changes in brain imaging (MRI and PET) involving the amygdala, insula, cingulate, per-frontal cortex and limbic association areas. Further, music has been demonstrated to elicit autobiographical memories, thus underlining its power to influence human emotion.

The author concludes that “Tears are an accompaniment of tragedy as an art form, and they reflect the tears of everyday human tragedy, which is linked to loss and mourning. These feelings have arisen in the course of our long evolutionary history, notably with the rise of self-consciousness, the development of small communities, the growing potential of love and hence an even greater sense of loss”.  As Semir Zeki, Professor of Neuroesthetics, University College of London has elegantly put: “This book is not a page turner. It is much better than that, one that is full of insights and of material for reflection on almost every page”.

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Adults Cerebral Musings Expert Blogs Featured

The Almighty Within

Most dictionaries describe religion as “a way of life”. Religious beliefs, practices and experiences of individuals in our society, appear to have a strong cultural basis in their evolution and have been described as part of every ancient civilisation discovered and studied by modern man. On the face of it, therefore, it seems inconceivable that religious experiences may have biological basis in our brains.Several questions remain unanswered in our quest to understand how religious experiences occur.

Why are some people intense in their religious beliefs and practices and others considerably less enthusiastic? Or indeed, why do one’s religious attitudes, beliefs and practices change during a life span, progressing sometimes: from atheism to agnosia to intense religiosity (or indeed in the converse direction)? Can socio-cultural factors alone have such influence on our lives, or are there more inherent biological determinants of these experiences and behaviours? Empirical observation suggests that a simple sociocultural explanation may be inadequate. There are for example considerable differences in religious attitudes and practices between siblings born of the same set of parents. The socio-cultural ethos in this situation is a virtual constant. Yet variations in the quality, frequency and intensity of religious experiences are observed and it’s not uncommon to witness the entire spectrum, from intense religiosity to a strong atheistic tendency within the same family. While psychological experiences and social factors unique to each individual may have a significant role in determining these variations, they are often conjectures that arise from social and clinical observation.

Insights from NeuropsychiatryNeurology, psychiatry and their interface discipline neuropsychiatry provide many interesting models for the study of religiosity. Religious phenomena vary tremendously across brain and mind disorders. The religious ecstasy of the person in a bipolar mania is qualitatively different from the prophetic fervour of the person with paranoid schizophrenia. The depressed, anxious or avoidant individual is almost desperate in his pleas for religious salvation, rather different from the intense ritualism of the person with OCD or indeed the magical beliefs of the schizotypal individual.

There are also variations in quality and intensity of religious experience across psychiatric disorders; for example, the acute hyper-religiosity of mania is rather different from the grumbling, slowly evolving, almost prophet-like religious fervour of the person with a schizophrenia-like illness. Are these variations in phenomenology, quality and intensity of religious experience governed by psychological and socio-cultural determinants alone? Or indeed do different brain mechanisms have a role to play in determining these variations?Neurology too has its share of religiosity models. The Geschwind syndrome is a personality syndrome that has been described in people with poorly controlled temporal lobe epilepsy. While a well defined cluster of behavioural symptoms characterise this personality type (see “The Inside Man”, The Hindu Magazinedated November 29, 2009), intense hyper-religiosity with intensified preoccupations related to moral, philosophical, religious, or ethical themes are a core feature of this syndrome (see also box on Kumagusu Minakata). Bear and Fedio (1977) provided a biological explanation for this syndrome (the sensory-limbic hyperconnection” hypothesis). They proposed that ongoing electrical activity in the temporal lobe (in the person with temporal lobe epilepsy or TLE) resulted in all sensory experience (seeing, hearing, feeling, smelling, tasting etc.) being suffused with a strong emotional coloration. This resulted in relatively ordinary experiences being viewed with a certain emotional intensity by the person with TLE. Hyper-connection of critical brain structures for emotion, specifically the limbic system comprising the amygdala, hippocampus and other critical structures, was therefore thought to be the biological underpinning that determined hyper-religiosity and other personality features in TLE.

A God Module in the Brain?Perhaps the most dramatic recent description of hyper-religiosity in epilepsy is that of V.S. Ramachandran in his book “Phantoms in the Brain”. In a chapter provocatively titled “God and the Limbic System”, Ramachandran draws on his clinical experience to give the reader an evocative description of a hyper-religious patient with temporal lobe epilepsy. He describes the dramatis persona complete with religious symbols and a prophetic fervour, accompanied by a firm belief (in that individual) that his life had special meaning and his existence a special purpose for the world we live in. While Ramachandran’s subject had symptoms that were decidedly exaggerated (a caricature rather than the norm), hyper-religiosity in people with TLE evolves over time (a trait phenomenon), not just appearing suddenly (as in a state phenomenon).

Ramachandran poses the interesting question “is religiosity a pre-determined biological trait”; paraphrased, this could read “is there a god module in the human brain?” Research using MRI volumetry and functional MRI (fMRI) techniques have demonstrated rather interestingly, links between structures in the limbic brain, especially the hippocampus and religiosity. Indeed, one paper that I co-authored (Wuerfel et al, 2004) demonstrated links between a small right hippocampus and hyper-religiosity in epilepsy.

Unanswered QuestionsWhile putative associations between religious experiences and the limbic system have been demonstrated, a number of questions remain unanswered. First, what exactly is normal religiosity and what is hyper-religiosity? One suspects that this in itself is subject to transcultural influences. Western studies report about a third of people surveyed as being “religious” or “very religious”. We surveyed over 500 people using a suburban railway booking counter in Chennai and found almost 70 per cent of all individuals qualified as being “religious” or “very religious”. In the Indian social context, where religious expressions and beliefs are common place, the phenomenon of hyper-religiosity can be difficult to define.

For example, in our Chennai survey, when we described hyper-religiosity as being two standard deviations from the median score in our questionnaire, we found only a small proportion of people qualified. Social norms of “normal religiosity” will therefore have a significant impact on what we perceive in each culture as hyper-religiosity.Second, are religious experiences a trait or state phenomenon? It seems clear that religiosity can be both a state and trait phenomenon when observed across the spectrum of neuropsychiatric disorders. Contrary to popular perception, trait behaviours do not stop developing with the onset of adulthood and continue to evolve subtly over many years. It is conceivable that religiosity as a trait behaviour in people with neuropsychiatric disorders may exist from early on, but become very much more apparent during the course of the lifespan, periods of acute emotional distress being particularly prone for religious expression. On the other hand, hyper-religiosity may also be a pure state phenomenon, as observed in mania or acute psychotic episodes, with the person reverting to baseline levels of religious expression, post-episode. In a person without neuropsychiatric illness the religiosity trait may evolve over a lifespan, and depending on life experience may enhance or become muted.

Our religiosity may also periodically achieve enhancement during times of adversity, sorrow and grief or indeed euphoria; times when we instinctively reach out to powers beyond.Third, is religiosity a natural consequence of adversity rather than a pathological process? It seems entirely plausible, when viewed from a psychological perspective, that individuals meet adversity in their lives with an increase in religious interest and or experience. Indeed, society encourages and endorses such reactive religiosity and acute emotional breakdown states are often described as spiritual experience or transformation. The flight into hyper-religiosity in the context of a neuropsychiatric disorder may well be a helpful, socially endorsed coping mechanism; spiritual excess being better accepted in society than emotional distress. Why hyper-religiosity disappears in many disorders with the resolution of neuropsychiatric symptoms, and persists in others even after their resolution, does of course beg answers.Fourth, is hyper-religiosity a pathological phenomenon? With the finding of a small right hippocampus being associated with hyper-religiosity and other descriptions of altered limbic physiology in this state, it seems conceivable that biological influences may in some way affect the development or maintenance of hyper-religiosity. Is hyper-religiosity as behaviour pathological? To decide this, one would typically have to refer to the individual’s previous background (personal and socio-cultural) in the religiosity context. Religious behaviours especially those with sudden onset and not in keeping with the person’s background may well be, from a behavioural perspective, pathological.Finally, are the changes in limbic system structure and activity identified in brain imaging of hyper-religious individuals, a cause or consequence of this behavioural predilection? Changes in limbic system structure and function are thought to accompany the longitudinal course of many neuropsychiatric disorders: epilepsy, schizophrenia and depression to name a few conditions. Clarity about what precedes (structural change or behaviour) remains elusive and the changes observed in the brain may thus be both cause and consequence, the brain being a remarkably plastic organ.

Final analysis: So is there a god module in our brain? The evidence available seems to indicate that our emotional brain, the limbic system, the hippocampus in particular, perhaps more on the right side, plays a significant role in determining the nature and quality of one’s religious experience and expression. It is very likely, the rich neuro-chemical networks that populate this region, including dopamine and serotonin, have considerable influence on our religiosity, notwithstanding the alteration of brain structure, right hippocampal atrophy. Religiosity may thus be viewed as a trait, which can undergo both physiological and pathological evolution during the course of a person’s lifetime. The nature of the underlying biological framework in an individual is likely to determine the form, quantum and nature of religious experience and expression that psychosocial adversity and emotional illness provoke.

The bio-psychosocial model of mental health and illness dictates that both the physiological and pathological manifestations of this trait marker are likely to be influenced strongly by the sociocultural ethos of the individual, as well as his psychological evolution during the course of a lifespan.We must acknowledge here, the very significant role that religion and spirituality play, in helping human beings maintain optimal emotional well being or indeed achieve restoration of emotional health after a breakdown. One must also acknowledge our collective ignorance, as a society, about the biological, neuropsychiatric and psychological effects and virtues of theism, atheism and their many-splendored, much-debated, interface. Whether our religious predilections have a role in protecting and preserving or indeed enhancing our emotional state, remains thus, a matter of conjecture. The influence of this god module in our brain, “The Almighty Within”, is however probably omnipresent, just as our ancients conceived the almighty himself to be. Strange then, indeed, are his ways!

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