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krishna – A Quest of the Mind

School days had been fun, playing team games at school and with the neighbours’ children in the sprawling campus all evening and on weekends. This did not deter him from achieving 90% and above in all the subjects in school and in the 10th standard Board Examination. 11th and 12th were in one of those cram schools, with 10-hour teaching schedules, which prepare children for the IIT entrance examination. IIT proved elusive and Krishna joined a reputed private engineering college and stayed in the hostel attached to the institution.

Biography

It is not clear whether it was the initial ragging, or the continuous teasing by the seniors in the hostel that made Krishna progressively more anxious and to withdraw socially; or indeed whether these were early manifestations of his mental health condition; whatever it was, seemed to viciously erode his self confidence in stages. He had been at the butt end of jokes even at school, as he was prone to get some facts wrong in areas of common knowledge, which he would blurt out impulsively. The inherent social awkwardness became magnified into loss of self-esteem and social withdrawal in the new environment, away from home and away from his childhood friends. Class grades plummeted by end of 2nd year at Engineering College and he had accumulated arrears in a few subjects. Clearing them seemed insurmountable even as his mental turmoil increased. By the 3rd year, he had to take a break from studies and later returned to the college, commuting from the home of his paternal grandparents (who lived in the same city where he attended college), for a period of six months, after which he opted to brave the hostel milieu, cleared the arrears and completed the course effectively, receiving a choice of campus placement.

Exploring the Condition

Krishna had thus been through a four year period of waxing and waning symptoms of social anxiety, with significantly reduced social interaction from about 17 years of age. He had a once in three month follow up with a psychiatrist over the previous couple of years and was on antidepressant medication, a low maintenance dose of Fluoxetine. On this medication and some counseling, Krishna was managing his daily activities and work performance satisfactorily, till 6 months prior to his consultation with us, when his condition turned for the worse.

In the competitive job scenario, Krishna found the IT project job very stressful as he could not grasp the concept of project ideas conveyed to him over the phone, often within a brief communication and consequently could not reply relevantly to suit the demands of the foreign clients. Being inherently a high achiever and wanting to please, he found this situation beyond his coping ability. An acute phase of illness set in, with marked loss of appetite, insomnia, loss of weight, fatigue, poor self-care, poor concentration, total inability to attend office, social isolation and subsequently led  to a state of almost catatonic mutism  During this period he had delusions of reference (others are talking and commenting about me) and experienced mental confusion. He appeared to be out of touch with reality and in a state of acute psychosis. Krishna was forced to go on medical leave.

It is at this point that the highly concerned, well educated, discerning parents made inquiries for a place that could offer sustained therapies and close follow up. He was admitted for a few days for comprehensive assessment and investigations and management of the acute psychotic state by the TriMed-Neurokrish team.

The case called for elaborate psychological testing. These assessment scores are touched upon here, without too much explanation, for the lay reader to appreciate the need for a scientific and evidence-based approach to a neuropsychiatric case which depends not only on the clinical acumen of the Neuropsychiatric Consultant as Head of the Group, but that clinical judgement is dependent on inputs from other team members, to estimate the degree of mental disturbance and to guide the course of management. 

Our Healing Approach

During assessment at Trimed-Neurokrish, Krishna admitted to have gone through similar, but less alarming phases of physical limitation and mental turmoil which he had not expressed clearly to anybody. Self perception and perception of the environment became progressively maladaptive in a range of social and personal contexts, and the subjective distress kept mounting. He had experienced suicidal ideation 2 years earlier.

He also described vividly ‘catastrophic scenarios that he had witnessed in his mind’ (possibly delusional) for e.g., an unknown person to the patient, whose tongue had been lengthened infinitely to be placed with precision under a running truck and  the vivid, gruesome picture of the resultant trauma and bleeding. On further questioning, there is no history of manic or hypomanic phase or of drug abuse; no clear family history of major depression.

On medical leave, out of the stress-inducing situation in his work space and on integrated therapy and medication at Trimed-Neurokrish, Krishna soon came out of his acute psychotic state dramatically and settled to a preparedness to face the real world. In this phase, he was reported to have improved insight and judgment, understood he had a problem which impaired his capacity to cope with workplace stress and to engage in social interaction with his peers. He wanted to overcome this state, and be able to get back to his routine in better shape. 

The patient was cooperative for the psychological testing. The 42 responses to the Rorschach test met the criteria for the Coping Deficit Index. Thematic Aperception Testing pointed to the need for achievement, security, nurture, the conflict arising out of lack of ego strength and fear of rejection. The Neuropsychiatric Inventory score was 4-5 on anxiety, delusion, night time behaviour and appetite, and low on the depression scale.  A diagnosis of late onset Persistent Depressive Disorder (dysthymic disorder) was arrived at.

Krishna was on regular medication for over 2  months:

  •  Dicorate ER 750mg ( Divalproex)
  • Olanzipine  (10mg + 2.5mg) at bedtime and (20 mg + 10mg) in the morning
  • Vitamin  and Calcium supplements

He responded well to the integrated therapy with a total of 15 sessions of Reflexology, Acupuncture and Yoga and over 10 hours of Cognitive Behaviour Therapy and some sessions of parental counselling.

An individualised short course CBT was initiated, setting attainable goals which helps in  bringing the  them back to their normal level of functioning.

In PERSISTENT DEPRESSIVE DISORDER, the patient suffers  a pervasive sad mood for over 4 years with barely any symptom-free period. The symptoms cause significant distress or impairment in social, occupational, educational, employment and other important areas of functioning.

Dysthymics however, may be pushed into major depression and subsequent acute psychosis Often this occurs at times of high stress and is linked to strong emotions and feelings, for example worry, anxiety, fear, depression or feeling overwhelmed by events. Lack of appetite, difficulty sleeping, lack of energy, poor self-esteem, difficulty with concentration or decision making,and a feeling of hopelessness, peaking to result in a phase of acute psychosis. It has been suggested that in dysthymic disorder, to compensate for the lack of social and real life interaction, the patient can create elaborate and complex fantasy inner worlds within their minds. According to DSM V criteria, individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.

Our Focus:

Cognitive Rehabilitation

A person who suffers from dysthymic disorder has generally learned to live with a fair amount of chronic unhappiness in their lives and so the therapist cannot go by the mood on a particular dayl He must first identify the thoughts associated with the patient’s distress. In dysthymia, these thoughts may concern the patient’s self-view, his or her representation of a significant relationship, or a meaningful situation.

Goals will vary according to type of therapy. The emphasis in Cognitive Therapy is to effect changes in one’s faulty or distorted way of thinking and perceiving the world. Interpersonal therapy focuses on an individual’s relationships with others and how to improve and strengthen existing relationships and an attempt to accommodate new ones. Solution-focused therapy looks at specific problems affecting the person’s life in the present and examines how to best go about changing the person’s behavior to solve these difficulties. Social skills training focuses on teaching the client new skills on how to become more effective in social and work relationships.

REFERENCES

Dean Schuyler Evidence–based Review Short-term cognitive therapy shows promise for dysthymia Vol. 1, No. 5 / May 2002

Looking Ahead

Krishna continued to suffer from low self-esteem and a pervasive sad mood, with occasional congruent delusions of reference and delusional exaggerated fantasy, when assessed midway  from onset of the integrated therapy. By the end of the intensive integrated therapy sessions at TriMed-Neurokrish, he was much more stable, and was on the bench at his IT job, preparing with a greater level of confidence for active work to be initiated with the clients.

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The Quintessential Rational Mind

The day of Vaisakh Purnima (May 27 this year), is significant for three reasons. It was on this day that Gautama Buddha was born as Prince Siddhartha at Lumbini in Nepal in 560 B.C; the day when he attained enlightenment at Gaya in India; and the day he attained Nirvana (Unity with the Absolute) in 480 B.C. It is, therefore, observed as Buddha Purnima, worldwide. To mark this day in 2010, we examine the rational mind, as conceived by Buddha.

It has become fashionable and commonplace to associate Buddhism with the metaphysical. This is in stark contrast with Buddha’s emphasis on rational thought and insistence on empirical verification. He encouraged the development of theories that were verifiable and was strongly opposed to dogma, which he viewed as an impediment to the truth. To him the truth was supreme, and ideas that hinder the discovery of truth best avoided. He believed in full freedom in thought and action; “the gates of freedom will cease to be gates, if people start clinging to the gates.”

Buddha also had very interesting, remarkably contemporary views on the mind and some of these are enumerated below.

On Thoughts and Ideas: The very first verse of the Dhammapada translates as“you are nothing but your mind”, based on which, “Sarvam Buddhimayam Jagat” has been proposed. The word used by Buddha ‘ mana’ translates both as thoughts and as mind, and can be interpreted to mean the brain. Buddha’s emphasis is on the flow of thoughts and the continuous change in the thinking process. In his concept, ideas are not constant, they change all the time. Ideas have no independent origination; they have ideas preceding and following them. Consequently, all ideas are interrelated and there are no stand alone or absolute ideas. The thinker, the thought and the concepts therein cannot be separated. Interestingly, this concept has parallels in modern psychiatry. A primary delusion, a first rank symptom of Schizophrenia is said to arise when the person, following a “delusional mood” has a thought “out of the blue” and “without antecedents”. To have such a thought that has no thoughts preceding it, and possibly therefore no basis in fact, was abnormal to the Buddha, and remains so in modern concept.

On Perception: Both the Surangama Sutra and the Lankavatra Sutra attribute perception, physical and emotional, to the mind. “Both delusion and enlightenment originate within the mind and every existence or phenomenon arise from the functions of the mind.” The Surangama Sutra poses an interesting question: “A man opens his hand and the mind perceives it; but what is it that moves? Is it the mind, or is it the hand? Or is it neither of them? If the hand moves then the mind moves accordingly, and vice versa; but the moving mind is only a superficial appearance of mind”. According to the Buddha, all perception had basis within oneself. This concept of the Buddha has neuro-scientific underpinnings. If one were to replace the “mind” as Buddha called it, with “brain” as he probably meant, and is contemporary concept; that all our perception and action has basis in the brain, is truism. Prof. VS Ramachandran has described in his book Phantoms in the Brain, novel representation areas for human body parts that have been amputated, developing in the brain.

This illustration leads to another important question, namely, what is ‘me’ and what is ‘mine’? Buddha, through fables, encourages us to think about this existential dilemma. The parable is about a man who takes shelter in an abandoned structure on a stormy night. Sitting in a corner of a dilapidated room he sees around midnight, a demon enter, with a corpse. The demon leaves the corpse on the floor; suddenly another demon appears and claims the corpse. Both demons turn to the man and ask him to decide on the ownership of the corpse. Being truthful, he indicates he saw the first demon bring in the corpse. On hearing this, the second demon is enraged, tears away and eats the hand of the unfortunate man, which the first demon, immediately replaces with the one taken from the corpse. After the demons leave, the man wonders and thinks aloud, “the replaced hand is ‘mine’ but is it ‘me’?

Again, the questions raised have neuro-scientific relevance. After damaging physical trauma, and transplants, it is well reported that people sometimes feel dissociated from their new organs. Indeed, having an organ replaced can be a life-changing experience. At another level, damage to the brain, the parietal lobe in particular, can result in the sufferer neglecting his body parts, as he does not recognise them as his own. The phenomenon of anosognosia, leading to neglect of one half of the body (hemi-neglect), is a well described phenomenon after a stroke. Here, the person sees the paralysed limb lying beside him on the bed, but is unable to recognise it as his own.

Buddha did, therefore, begin the mind-matter debate much before it became fashionable in contemporary philosophy. He placed human emotion firmly within the organ he referred to as the mind, which we now understand to be the brain. His statement – “If we learn that there is no world of delusion outside the mind, the bewildered mind becomes clear” – is remarkably accurate.

On Perception and Memory

Buddha made a distinction between the flow of thoughts and the stock of memory influencing our perception. In his view our perceptions are influenced by our memory. Thus we view the present through the coloured glass of past experience and do not see things as they exist or as they are constituted. When a person perceives an object, both the memory of the same or similar object and the feelings the person had on the earlier occasion are rekindled. Moreover, comparisons are made between imaginary constructions of the object and the object itself. However, this distinction between stock and flow is more analytical than exclusive. Indeed, stock and flow interact all the time.

This view mirrors our current understanding of how the limbic system in the brain works. It has been proposed that the hippocampus is the storehouse of memories. Adjacent and connected to it by a chemical rich neural network is the amygdala, an organ deeply concerned with human emotion.

Any external stimulus results in activation of both organs; thus when a person sees a snake, his memory (and learning) tell him that it could be dangerous, and he experiences fear as a consequence. Memory and emotion are therefore in continuous interplay, as conceived by Buddha.

The Rational Mind

Buddha’s understanding of the human mind (and brain) was unique; both rational and contemporary. He encouraged debate and discourse; raised questions more often than he provided answers; encouraging his followers to think like him, with freedom. He recognised the pitfalls of blind faith, unquestioning belief and intolerance of contradictory ideas. He laid emphasis on empirical verification and on understanding the world, as it is and as it is constituted. Indeed, through his radical empiricism, he laid the foundations of scientific spirit and enquiry 2500 years ago. His was the quintessential rational mind.

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