Author: Oliver The Brainy Owl

– Buddhi Clinic’s Brain and Behaviour Dialogue with the legendary Prof. Michael R Trimble of University College, London, curated and presented by Neurokrish

The Buddhi Clinic virtual programme   on 26/12/2020 was  a ‘ Brain and Behaviuor  Dialogue‘. Prof Ennapadam S Krishnamoorthy, who was Raymond Way Fellow  in Behavioural Neurology and Neuropsychiatry, UCL, from 1997, under the mentorship of Prof. Michael R. Trimble, introduced his guru of many years. He gave a brief outline of Trimble’s illustrious career and observed that there could be no better person to elucidate the Brain and Behaviour interface . 

As Chair in Behavioural Neurology and Neuropsychiatry of the Raymond Way Research unit, Institute of Neurology, Queen Square, London, and Professor in the same disciplines, Trimble established a unique system of academic mentorship over three decades. This led to neuropsychiatry worldwide remaining associated with the Raymond Way group long after the trainees and fellows left Queen Square. As a sensitive clinician, committed researcher and erudite scholar, Trimble had chosen the less trodden path, to establish neuropsychiatry as a recognised global academic and clinical discipline.

Krishnamoorthy set the ball rolling with “What made you choose Neuropsychiatry?”  Trimble observed that the term ‘Neuropsychiatry’ was always a problem, with neurologists in Europe using it vaguely to indicate psychosomatic disorders; Freud unable to give it true meaning in his attempt, through a psychoanalytic viewpoint; the Behaviourists reluctant to give up their  simplistic ‘stimulus-response paradigm’! 

Trimble observed that it was the dawn of a new era when EEG evidence of the pathophysiology in a neurological disorder, with associated psychological problems, emerged in the late 1950s. Frederic Gibbs’ pioneering EEG studies in Boston, recorded the anatomical localisation of a form of seizure  to the  temporal lobe, which was replicable over a number of patients. This established the relationship between anterior temporal lobe abnormality and the psychopathology of epilepsy. Modern Neuropsychiatry took a definitive step forward in the 1960s and 1970s, with the discovery of the structure, function and circuitry of the limbic system of the brain. Trimble recalled that as the only Behavioural Neurology consultant in UK for a long spell, he participated in the ‘neuropsychiatric awakening’ of the 1970s, and enjoyed lecturing on limbic neuroanatomy. Neuroimaging resulted in several other revelations in the brain-behavior link. The Raymond Way group, were involved in early PET studies in the 1990s that showed the volume of the hippocampus to be smaller in schizophrenia patient. 

Trimble’s dictum is that every neurologist must aim at proficiency in  neuroanatomy. This should include brain dissection and not learning through anatomical waxwork models! One wonders if every step in Trimble’s higher education and training trajectory, toward specialisation in Behavioural Neurology, was planned by him well ahead, in order to achieve the thoroughness and authority in his field, which his professional career reflects. Trimble’s first degree was in Neuroanatomy with Sir Solly Zuckerman, followed by MPhil in Psychopharmacology before he trained at Radcliffe Infirmary for MRCP, at National Hospital, Queen Square in Neurology and at Maudsley in Psychiatry. As Johns Hopkins Fellow, he was exposed to American psychiatry for the first time. Though there was demand for his expertise in new drug development, in temporal lobe epilepsy, in particular, he opted for association with the legendary Prof Lennart Heimer, in his research lab. Trimble enjoyed being in his old familiar ground of animal studies, primatology  and  neuroanatomy, but this time round with years of clinical and scientific expertise behind it. In the four-author publication on  ‘Anatomy of Neuropsychiatry’ (dealing with the latest discoveries in limbic system-basal ganglia circuitry, structure, function and pathology), with Heimer as lead author, Trimble, provided the valuable  link between  basic science sections and clinical neuropsychiatry.

Why did Prof. Trimble go into the field of Neuraesthetics?

As emeritus professor, since 2004, Prof. Trimble had the ‘leisure’ to consolidate his kaleidoscopic professional experiences and find the link to integrate them with his natural inclination towards  creativity and the Arts. This resulted in three  book publications, which go to form the subject of this online Brain and Behaviour dialogue. The rich fare presented, moved seamlessly from ‘Psychoses of Epilepsy’, championing the right brain along with other neuroscientist thinkers, to the power of the human voice in music at a Wagner opera; why Gana the gorilla at the Muenster zoo, who grieved the loss of her son  did not cry ? or why humans, on occasion, find the need to move beyond the  mundane, towards ‘a transcendental state of consciousness’?

   The Soul in the Brain: The Cerebral Basis of Language, Art, and Belief 

                                  Johns Hopkins University Press  (2007) 

This was the first book discussed. In this provocative study, Prof. Trimble alludes to the interrelationship between brain function, language, art—especially music and poetry—and religion. Inspired by the writings and reflections of his patients, Trimble was drawn into the study of their individual artistic ability, in which he observed a clear pattern. He came to the conclusion that writing effective poetry is probably incompatible with certain disorders-schizophrenia being one, and seems to be highly restricted by epilepsy. Even in the literature, there are very few acknowledged poets with schizophrenia- as the content, metre and prosody cannot be sustained by them. “To be a musician of the canon with schizophrenia seems impossible, as a compositional score, of say Wagner or Brahms, have notes that go on and on and must follow a trend to cohere with the same narrative over a long period”. However, there were patients with manic depressive psychosis (bipolar disorder) who were capable of poetry and music. Another study by the Raymond Way group showed that some patients with temporal lobe epilepsy were ‘hyperreligious’, well above the expected  range of involvement in religion. Hypergraphia was another unique temporal lobe phenomenon, but the content of the voluminous pages of writing was poor and lacked cogency.

The  ‘Soul in the Brain’ brings together poetry, music (and going back to Greek culture, which offers a third element within Greek theatre) and dancing. This  ‘total work of art’, integrating music, poetry and dancing, has  ‘movement’. Trimble referred to the German term–‘Gesamkunstwerk’ for this integration of different art forms to create a single cohesive whole. This term finds acceptance in English in the field of aesthetics. “Movement in the arts affects our brain and ourselves in a different way, and that is where neuroaesthetics comes in” Trimble explained. His own keen interest in opera, drew him deeper into the realm of Neuroaesthetics and the role of the brain and mind. 

The story of creativity started with language.  Broca localized language to a small area in the left anterior frontal region, based on the study of his stroke patients. Hughlings Jackson, a contemporary of Broca, was skeptical about his findings and maintained that a higher order brain function like language could not be confined to a small circumscribed area.  Hughlings Jackson, with his visionary understanding of the working of the human brain and mind, well ahead of his times, could be called the founder of modern Neuropsychiatry, Trimble opined. 

Scientists were preoccupied with language syntax, and if this was in place and a lesion did not involve the left hemisphere, language was assumed to be normal. It took  deeper study of patients with lesion of right anterior frontal region by experts, to spot the subtler missing elements in language,  elements which boost its richness, namely, the emotional tone and prosody, (the latter so important to poetry). There was poverty of creative expression, of metaphors and other   semantic aspects of language. Language is accompanied by gesticulation. There was slow acceptance, that it required the coordination of both hemispheres to make language. 

Going back in time to ancient Greek culture, Trimble traced it to Athens and  to the Festival of Dionysus, celebrated to this day, with much  music , dance, revelry and abandon, in the spirit of freedom, reminiscent of the romantic era. Of the arts, linking music with religion became prominent during the Renaissance period and resulted even in moving small operas into churches. Opera marked the highpoint of Western musical culture in the 19^th and 20^th century. Trimble observed that the propensity to art occupies a spectrum, and varies between individuals and also periods in history, e.g., between the Baroque  and  Romantic periods of Western culture. Ancient Greek cultural music and art forms had a profound impact in shaping European culture through the ages.Interestingly, Iain McGilchrist conceives that it is “the brain that has shaped the world”, in his  book, ‘The Master and His Emissary’!McGilchrist, neuropsychiatrist, philosopher and thinker, it was, who put creativity and art forms in the field of neuroaesthetics. 

Trimble recalled how another undisputed champion of the right brain, John Cutting and he, had long discussions on this subject, while at the Maudsley as colleagues. Cutting was a neuropsychiatrist, with special interest in schizophrenia. His vehement disagreement with the right brain being assigned ‘minor hemisphere’ status, featured in his profuse writings. Trimble had also associated with Norman Geschwind, who had published his elaborate work on the laterality of brain function.

 Why Human Like to Cry :Tragedy, Evolution and the Brain 

 Oxford University Press (2012)

The second book discussed:

What makes humans *cry?

In 2007, Gana the gorilla in the Muenster zoo, held up her son who died suddenly, and indicated her distress and grief, but did not cry, even as the humans watching her shed tears of compassion. Crying is an attribute exclusive to humans, adding to the other evolutionary attributes of  homo sapiens.

 Tears can signal pain or distress from one person to the other. When the mother sees the baby’s tears, it signals hunger or perhaps some discomfort. She cuddles and comforts the baby and each time this repeats, the bonding becomes stronger. When one looks at the large human face, and then within a short span of time, tears roll down the cheek of that face, the latter state of intense feeling creates a surge of emotion and compassion  in the beholder. 

Tears can also emerge as a result of aesthetic experience. Beauty, the art forms, and relating to memories of the past can evoke strong emotions. Proust describes 

*Crying’  involves shedding of tears. It may be in the form of sobbing, weeping, etc

the archaeologist who bursts into tears on beholding an ancient Assyrian sculpture. It was a spontaneous mark of reverence for an artifact of the past. Trimble expressed concern that the Western world seems to be moving away from the past – be it from parents and family, a historical monument, or even the four walls of the house where one spent one’s childhood. This is a great pity, as these memories and emotions form the core of aesthetic values and in its absence, one may not be moved by a strain of music or a beautiful face – and  probably be the loser!

Crying may follow a deep religious experience or listening to music or while at an opera. “Music appears to be the art form most likely to make us cry”, says Trimble. A study by his team, interviewing participants of the study, revealed that 80% cried to music, and 60% to poetry. Reading a novel, with continuity of the narrative almost equaled music in its impact on the reader. Another study of lottery participants left the team puzzled over why the winner cried. It came about that the ‘tears of joy’ made their appearance when the winner shared the news and bonded with the family and dear ones. Trimble confessed that tears well up in his eyes when he is at a Wagner opera, where the power of the human voice in music can raise the emotional response to its heights. It was acceptable to cry at the opera or in church, especially for men !   

Greek tragedy explored many themes around human nature and it heavily influenced the theatre of the Renaissance.In the Renaissance period, in church, every member of the congregation was expected to cry, especially the men.  If they failed to concur, they could be severely reprimanded, as crying was  considered  part of  the religious experience, sacred and symbolic of grieving for the loss. He referred to the practice of lamentation,the passionate expression of grief or sorrow, from the Book of Lamentations of the Old Testament. He made a biblical reference to ‘Lacrima Christi’, which literally means ‘Tears of Christ’. William James, the modern psychologist and great thinker elaborated on a variety of religious experiences. He observed that the human mind is in search of a transcendental idea. A deep religious experience can provide this. William James on  consciousness : “Consciousness, does not appear to itself chopped up in bits”. There is a continuous flow of thought in our minds, one leading to the other, which he referred to as ‘stream of consciousness’.

Trimble observed that our emotional response to tragedy and crying for emotional reasons have evolved over several millions of years. Then, why are people ashamed of crying ?  

 One of the more recent major discoveries of highest significance to neuropsychiatry is the mirror neuron. It goes beyond the scope of functional neuroimaging in some areas, as the presence of mirror neurons in the human brain allows identification with the other. This could be through the other person’s facial expression. But tears are an even surer signal from one person to another of emotional feelings; it arouses  ‘with’= ‘com’- passion and feeling  ‘in’= ‘em’ -pathy.  Though the appearance of tears may be physical, put in the metaphysical context, it is a link from one person to the other, by what is termed empathy. ‘Theory of Mind’ is a complex human ability of social cognition, which is required to empathise and must have evolved towards fulfilling emotional reaction; chimpanzees do not have this highly evolved ability of  social cognition,  though they may imitate an action, like picking  up a banana, due to the presence of some mirror  neurons, but not beyond this.  

Though the human brain circuitry for emotional tears is widespread, it links the cerebral cortex, especially anteriorly, with those areas associated with the representation of emotion-the limbic system and to the autonomic nervous system for the release of emotional tears. This highly evolved circuitry is not present  in primates, again pointing to the hand of evolution.

 The Intentional Brain: Motion, Emotion  and the Development of Modern Neuropsychiatry  Johns Hopkins University Press  (2016 )                    

This was the third book discussed:

 ‘The Intentional brain’ puts together information it has accumulated over several hundred years-over 2000 years. Trimble’s purpose of the book may be conveyed briefly, by quoting from the preface to the book. “The book is not simply about Neuropsychiatry as a medical discipline, but it is in many ways much more a reflection on the way the brain and its functions have been viewed over the centuries, as well as the huge change in orientation, germinating within romanticism, which has given us an understanding of our dynamic, active, creative brain”. This was in stark contrast to the Baroque period, which was restrictive and had some strict formulations for literature, music, and other art forms. 

Modern research has focused on the brain as a predictive organ. Trimble’s view of the dynamism of the brain and how we receive the world, borders on the transcendental!  “The way we greet the world and the way the world greets us and the world is embodied within us and our need to control it”, he says and goes on to “ We go out in the world expecting something, greet the world with hope of fulfillment, moment by moment. If not fulfilled, there has to be some reconciliation.” If this does not happen, an alternative path is taken, as each situation demands, laying down a novel brain circuitry. The belief that the brain is a passive organ with a stimulus evoking a response, assumes that with repetition of this pattern, neural tracks are laid down, which subsequently guide the automatic response which has been preset.

Trimble spoke about the Baroque period, which was restrictive. The Age of Enlightenment brought further strictures in the belief that science offered the solution to everything. Almost as a reaction to the progressively tightening fetters, both political and social, imposed by earlier periods, there  arose an intellectual movement, and with it an explosion of art, music, literature, and the glorification of nature and the past in poetry by the romantics  of the 19^th century. We enjoy much of this freedom, culture and art forms even today, but  some nations show signs of repression, curbing freedom of speech and of the press and increasing inequity which could be possibly labelled the post-post modern age! McGilchrist puts the blame of all the unsavoury components of modernity squarely on people paying less heed to the right brain.

Iain McGilchrist, in his voluminous book, “The Master and His Emissary’,  describes the evolution of Western culture, as influenced by specialised hemispheric functioning. He designates the right brain, with its greater contributionto creativity and the arts, (and perhaps to humanity) as the Master, and the left brain as the emissary in the “divided brain”. He is wary of the Western world today becoming increasingly dominated by the left brain which he believes may be to our detriment. 

Prof Trimble concluded with “The Intentional Brain is how the brain works and we have got it wrong for 2000 years!”  His appeal to appreciate the art forms in order to live life fully continues into his  next book, from which he shared a sentence – “ A world without music is not human”.

Dr. Subbulakshmy Natarajan MBBS, DCN (Lond.), PhD, FRCP (Edin.)

Research Consultant, Neuroscience India Group (NSIG)

Adjunct Faculty Public Health Foundation of India

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Prof. Michael Trimble is no stranger to the Chennai audience as he has visited at our invitation on several occasions.  He came first  at the invitation of Prof. Krishnamoorthy Srinivas  as the TS Srinivasan orator for 1998. It is of interest to note that in the topic of his oration ‘Towards a Neuropsychiatric Theory of Literary Creativity’, the central neuroaesthetic theme of the books discussed here was already taking shape, to be consolidated in his retirement days. At several points of the dialogue  Prof. Trimble, in a chatty way,  would stop to address Prof. Ennapadam S Krishnamoorthy to revive the memories of the significant clinical and research work done together in the Raymond Way unit.

The programme saw good audience participation. During question time there was reference to Indian art forms and some thought-provoking questions, which Prof. Trimble answered at length.

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 Every decade of TS Srinivasan orations, marks yet another significant milestone in the global neuroscience arena.

Prof. Ralph L. Sacco

Ralph L. Sacco, MD, MS, is the Chairman of Neurology, Olemberg Family Chair in Neurological Disorders, Miller Professor of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Executive Director of the Evelyn McKnight Brain Institute, Senior Associate Dean for Clinical and Translational Science, Director of the Clinical and Translational Science Institute at the Miller School of Medicine, University of Miami, and Chief of the Neurology Service at Jackson Memorial Hospital.  He was previously Professor of Neurology, Chief of Stroke and Critical Care Division, and Associate Chairman at Columbia University before taking his current position.

Prof. Sacco has been a member of the World Stroke Organization since 2008 and past chair of the WSO Research Committee, and is on the Board of Directors. He has published extensively with over 600 peer-reviewed articles and 250 invited articles in the areas of stroke prevention, disparities, treatment, epidemiology, risk factors, vascular cognitive impairment, and human genetics. He has been the recipient of numerous awards including the AAN Wartenberg Lecture.  He is the founding Principal Investigator of the NINDS-funded Northern Manhattan Study among several other NIH – funded research projects. He is the immediate past-President of the American Academy of Neurology and was the first neurologist to serve as the President of the American Heart Association, 2010-2011. Fifty years ago, the American Heart Association’s journal Stroke was conceived, and now it is the premier journal in the field. Ralph L. Sacco, will take the reins as Stroke’s editor-in-chief beginning with the July 2020 issue.

 Preventing Stroke and Maintaining Brain Health in 2020

Prof. Ralph L. Sacco, the 40^th TS Srinivasan orator observed that the impact of the Srinivasan lectures was felt not only in India but the world over. Looking at the impressive list of 39 orators before him, he elaborated on how nine among them had touched his life in varied capacities. To mention the role of two, Prof JP Mohr (the 2004 orator) was his mentor in Stroke, and he took over as the third Chair in Neurology at University of Miami from WG Bradley (the 1996 orator). He acknowledged the vision of the TS Srinivasan family, the significant contribution of the programme distinguished mentors and the amazing hospitality and  meticulous organisation that went into the success of the mammoth event that marked the neuroscientific calendar year after year.  

Prof. Sacco outlined the global burden of stroke and dementia, and the alarming projected figures for 1. Stroke, a major cause of mortality and the second highest cause of disability and for 2. cognitive  decline and dementia with the progressive increase in the greying population. The urgency to deal with ‘Brain Health’ globally and to adopt preventive strategies was the focus of Prof. Sacco’s oration. He dwelt on the interplay between vascular disease, stroke and dementia and on the convergence of the pathogenic mechanisms in vascular and neurodegenerative processes. He had devoted much effort and thought to this concept and as the first neurologist to be elected President of the American Heart Association (AHA) 2010-2011, his Presidential address was ‘Achieving Ideal Cardiovascular and Brain Health – Opportunity Amid Crisis’ bringing the two vital organs under a common lens to establish the link between factors leading to carotid artery stenosis due to atheromatous plaques, atrial fibrillation releasing embedded clots, and heart failure with brain health and cerebrovascular events. 

The multidimensional stroke disability burden (Global Burden of Disability 2016) risk factors for stroke are hypertension, high blood sugar and cholesterol levels, and kidney disease- 72% ; smoking, poor diet control and poor physical activity – 66.3 % and  air pollution 28.1 %, risk factors total – near 90%. Stroke and cognitive decline/dementia being life–course illnesses, preventive steps must be taken before midlife and not later, when adverse consequences result. A Presidential Advisory from ASA/American Stroke Association, 2017, is ‘AHA’s Life simple 7 ‘ (which the professor believes are not so simple and the average score falls short by 2-3  of the ideal ). The 7 metrics to define optimal brain health in adults are ideal health behaviors (nonsmoking, physical activity at goal levels, healthy diet consistent with current guideline levels, and body mass index <25 kg/m²) and 3 ideal health factors (untreated blood pressure <120/<80 mm Hg, untreated total cholesterol <200 mg/dL, and fasting blood glucose <100 mg/dL).  The professor shared the large cohort study stretching over 27 years -the Northern Manhattan Study (NOMAS), where his team established that timely intervention in behaviours and control of other health factors could prevent stroke and slow cognitive decline when compared with those in the study who did not adhere to lifestyle modifications in diet, physical activity, etc. NOMAS studies moved on to include baseline values of cognitive performance with follow up records after 5 years, conducted subtle cognitive neuropsychiatric test based on executive function, semantic memory, episodic memory and processing speed, where the cognitive decline was less in those who took preventive measures early to alter the course. The study of novel determinants, namely inflammatory and infectious markers,  MRI  markers of subclinical brain ageing –small vessel disease, white matter hyperintensities, microbleeds, silent infarcts and brain atrophy, and predisposing candidate genes were other advanced aspects of the study, yielding promising research data, toward  speeding up early risk prediction and prevention.

The professor discussed the ethnic variations, and socio-economic factors influencing the course of stroke and cognitive decline. There was an urgent need for setting population health goals and policies towards preventive measures for non-communicable diseases, lifestyle changes, healthcare of the elderly, and government advocacy measures to improve these areas of health policy, more so for LMIC countries with mounting public health concerns. He stressed the need for effective communication to the public on preventive measures and on recognition of early symptom of stroke to hasten hospitalization within the stipulated golden  period. The scope of research in the branches of this field are phenomenal and must be exploited effectively with adequate funding. Moving closer to equitable global healthcare should be the goal and  national and international collaboration is the key, he observed 

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A Report by Dr. Subbulakshmi Natarajan, MBBS, DCN (Lond), FRCP (Edin), Clinical Neuroscientist & Science Writer.

December brings the promise of pleasant, cool days to Chennai, south India, along with the annual Indian classical music and dance festivals and church choral music, to mark a month-long atmosphere of peace, joy and festivity.  It was in this part of the year, in the serenity of the colonial era milieu of Madras Club, that an international cast of experts discussed the brain, mind and their rich interface, sharing the global trends in the field and their individual and team experiences at the exclusive closed door meeting (by invitation) of the International Neuropsychiatric Association. The theme of the INA Colloquium 2019 was “New Horizons in Neuropsychiatry’ 

Prof. Ennapadam S Krishnamoorthy, the INA President, extended a warm welcome. It was an honour to have the inaugural President of INA , Prof. Colin Shapiro (1998-2002) and INA’s third President , Prof. Perminder Sachdev (2004-2006)  as colloquium faculty. Other eminent, senior members of INA also comprised the colloquium faculty.

Prof. Krishnamoorthy called upon faculty members to light the ‘Lamp of Knowledge’ , to the background chant to Saraswathi, the Goddess of Learning. “The overall  theme ‘Brain and Behaviour’ belongs to all present,” he said and announced that those attending the colloquium could register free for a year to become members of INA, and receive ‘the INA pin’ In the hands of the experts and over several decades, the complexities of  mind, brain and behaviour captured separately by the specialities of  Neurology and Psychiatry, have been brought together in a holistic manner under the INA banner, much to the benefit of Neuroscience, the clinician and the patient. It was keenly felt that this knowledge deserved to be shared by a wider medical fraternity towards global excellence in brain and mind healthcare and research. 

The colloquium was sponsored by the ever-flowing generosity of the TS Srinivasan family. The handsome endowment towards this was in honour of the philanthropist industrialist, TS Srinivasan.

Inaugural Address

Prof ES Krishnamoorthy opened the scientific session with  ‘Innovation: An Integrated Care Model in Neuropsychiatry’  as  practiced in the Buddhi Clinic, Chennai,  founded by him in 2010. The Integrated Brain and Mind care at Buddhi Clinic , towards ‘Restoration, Rehabilitation and Rejuvenation ‘ has over the years  developed protocols and procedures which make them sustainable, replicable and measurable. More gratifying is the qualitative measure of patient response. Here, CAM enjoys a common platform with Modern Neuropsychiatry and Neurorehabilitation.

Presidential Session

Perminder Sachdev, Professor of Neuropsychiatry at UNSW, Co-Director of the Centre for Healthy Brain Ageing (CHeBA), UNSW, Australia, took us through the exciting present day ‘Biomarker Approach to the Diagnosis of Dementia’, and the dilemmas in this unrelenting quest for the Holy Grail. The heterogeneous presentation of person-specific contribution of neuropathologies to cognitive loss  (more so in  old age), makes the search for an AD biomarker elusive.  It is only with pooling of multiple data that we can hope to arrive at a biomarker complex to detect at the pre-AD phase. NIA AA has proposed an effective Research Framework for AD biomarker grouping AT(N)  (Jack C et al, 2018). He touched on the consensus study (VICCCS) on the vascular causes of dementia, for which he was an international collaborator along with two other speakers, Prof. Ingmar Skoog and Prof. Raj Kalaria.

Raj Kalaria , Professor of Neuropathology, Newcastle University, UK shared with us his twenty- year experience and  heading the Neurovascular Group at the Institute of Neuroscience, Newcastle,  in ‘the Cognitive Function after Stroke’ ( CogFAST) study. Being a strong proponent of the concept of cognitive decline due to vascular causes, he observed that the understanding of lifestyle diseases and the preventable nature of the risk factors led to a renewed interest in refinement and classification of vascular dementias (VaD). It resulted in ‘Vascular Impairment of Cognition Classification Consensus Study (VICCCS)’, with international collaborators, on sensitive and specific clinical and research criteria to diagnose the earliest phase of Vascular Cognitive Impairment (VCI). He went on to say that cerebral vessel disease may be an under-recognised risk factor for AD dementia-the vascular pathology in AD is arteriosclerosis and capillary degeneration. Changes in vessel wall causes chronic hypoperfusive state (oligaemia) and the white matter changes and may result in either stroke or degeneration (to AD) or in a mixed type which includes both. 

Epilepsy and Behaviour  – Learning through case studies

This session saw four interesting presentations by leading Indian experts.

The Many Ramifications of Post-ictal Psychosis

 Bindu Menon, Professor and Head of Dept. of Neurology, Apollo Specialty Hospital, Nellore, south India, was a case based presentation.  A 38 year lady, single, living with her parents, diagnosed as complex partial seizures with secondary generalization, based on clinical, EEG and imaging parameters. She was on optimum dose of levetiracetem, with a history of poor drug adherence and with recurrent episodes. She presented  in a confused, agitated state, with auditory and visual hallucinations and with persecutory delusions and aggressive behaviour. Her mother reported a cluster of seizures two days prior to this admission and reported that she had had two similar bizarre episodes earlier. Dr. Menon took us through the differential diagnosis of such a presentation and elegantly argued her opting for Post-ictal Psychosis (PIP), based on Logsdail and Toone criteria.  

Epilepsy and Neurodisability

Prof. Nirmal Surya, Consultant Neurophysician, Bombay Hospital Institute of Medical Sciences, shared his experience in neurorehabilitation of  young patients with neurodevelopmental disabilities (NDD)  with associated epilepsy at the Epilepsy Foundation Centre and his rural community-based outreach programmes. His multidisciplinary team offers management of the physical, cognitive, language, psychosocial and behavioural problems of these patients.  He presented video clips of 4 cases, with various levels and types of disability. The lack of awareness, the continuing stigma attached to epilepsy and all forms of disability, poor availability and accessibility of rehabilitation centres, and the out-of-pocket expenditure are major concerns in India

Paediatric Psychogenic Non-epileptic Seizures

Dr.  Praveen Kumar Jakati,  Consultant Child and  Adolescent Psychiatrist, Institute of Neuroscience, Kolkata, India-spoke on Paediatric Psychogenic Non-epileptic Seizures PNES, and showed video- EEGs of typical episodes in a few patients. Comprehensive psychiatric assessment points to a conversion disorder or occasionally a dissociative disorder. Gold standard for diagnosis is a prolonged video EEG. Early recognition of PNES and early intervention offers the best results

Epilepsy and Behaviour: the gentle overlap

Prof Manjari Tripati, Head of Dept. of Neurology, AIIMS, Delhi  outlined  the ‘Good, Bad and the Ugly’ in surgical intervention for  intractable epilepsy in her study of over 200 cases in the dedicated epilepsy neurosurgical dept. of AIIMS, Delhi.  The ‘good’ was the 10-fold improvement in the seizure episodes and significant improvement clinically and on the Child Behaviour Checklist, and Paediatric Quality of Life Measure The ‘ugly’ were two patients, both teenage boys, who underwent posterior temporo-parietal resections; one became seizure- free following surgery, the other continued to have about 4 seizures a month.  In both cases, post operative ASD was diagnosed, with severe behavioural  problems. There was  little improvement  after therapies over several years.

Why is ASD in such cases underreported in world literature? The posterior brain location of both these lesions could perhaps account for the post-op ASD, as the parieto-occipital region represents ‘autistic functionality’ and ‘theory of mind’.   

Stand ups:

‘If you have anything interesting to say, you must be able to convey it within eight minutes- these are what these stand ups are about, following which they will be open  for discussion’. The 4  Buddhi team members were game for the challenge !

Mr. Vivek Misra, Neuroscientist & Neuromodulation consultant of the Buddhi team spoke on Integrating Neuromodulation in a Multidisciplinary Care Paradigm. He contributes to the neuromodulation with brain  stimulation with repetitive Transcranial Magnetic Stimulation (rTMS) and Transcranial Direct Current Stimulation (tDCS). He outlined  the beneficial effects of rTMS on the Parkinson’s disease patients at Buddhi Clinic and discussed future plans for brain stimulation in the lab.  rTMS not only improves the motor performance but also the cognitive and behavioural outcomes- 20 sessions bilateral motor area stimulated  following the standard protocol  showed benefit  not only on the UPDRS scale but also showed progressive improvement on MoCA and NPI assessment at baseline, mid treatment and end of brain stimulation, WHOQOL BREF showed positive scores on the social domain. The audience suggested more cases in the series under controlled conditions are required to launch the study on a research basis.

Dr. VG Srivatsa, Neuropsychiatrist presented on  intractable behavioural difficulties, anxiety, aggression, below average intelligence  in a 14 year old treated with a multidisciplinary  integrated approach including neurodevelopmental therapy, behavioural therapy , family focused therapy and  rTMS.  It was a diagnostic dilemma. The Buddhi clinic team came to a diagnosis of ASD with intellectual disability and severe anxiety state.  Rapidly escalating anxiety and panic in the wake of below average intelligence, with the added effect of early life trauma was  suggested by two experts reviewing the case who ruled out autism.

Indhu Rajagopal, Clinical Psychologist, Buddhi clinic 

Case presentation was of  a 17 year old girl Treatment-resistant  depression following a single seizure – found with LOC, vomited once, aggressive on admission, EEG normal initially, subsequent prolonged  EEG showed bilateral temporo-parietal and occipital epileptiform activity . CT brain normal, stressors at school and home with maladaptive responses. History of recurrent attacks of migraine.Patient was treated  as a case of seizure disorder with Levetiracetam and Clobazam. Subsequently, Levetiracetam was tapered and Lamotrigine introduced, with some improvement all round. Paroxetime CR was continued.

The final diagnosis was  AED –induced mood and anxiety disorder with accompanying insomnia.

Dr. Krishnaswamy Viswanathan, Senior Neurosurgeon – is Director of the Buddhi Clinic at Porur. He operates at Sri Ramachandra Medical College and Research Centre- He is an MRCS Edinburgh, and received special training in DBS at the Sai Baba Hospital at Whitefield, Bengaluru. 

He explained the procedure for DBS electrode implantation in the brain,   in some detail and the brain stimulation. The videograph, of his patient, an elderly male with dystonia, pre and post operative, and following three months of therapy, was impressive. 

Clinical Neuropsychiatry- The Child

Prof. Valsa Eapen, Chair, Infant, Child and Adolescent Psychiatry, University of New South Wales, Australia elaborated on ‘The Burden of Neurodevelopmental Disability- Call for Action’ Globally NDD affects 52.9 million children, accounting for 29.3 million years lived in disability; and 23% of 2-9year olds.  She outlined ‘A New- to- World Integrated Approach’ to Child Development covering the first 2000 days. Each stage of integrated service delivery needs to build on to the next a form of ‘cumulative buffering’ to counter cumulative risks. New South Wales Child Development Study is ‘A Longitudinal, Multiagency, Trans-generational Record Linkage Study’ in which 77, 062 children and their parents are under review- Carr et al 2019. The message of hope is that advances in Neuroscience, molecular biology, genomics and the Behavioural and Social Sciences could be leveraged to catalyse innovative policies and practices across sectors.

KP Vinayan  Prof. and Head, Dept. of  Paediatric Neurology, Amritha Advanced Centre for Epilepsy,  Amrita Institute of Medical Sciences, Kochi, Kerala demystified ‘Developmental Encephalopathies: A New Terminology or a Conceptual Progress?’ He broke down the elements in the most recent International League Against Epilepsy (ILAE) Commission Report definition of Epileptic Encephalopathies. There is an underlying brain pathology, either congenital or acquired. The epileptic activity itself contributes to severe cognitive and behavioural deficits which is well beyond what might be expected from the underlying brain pathology and these impairments can worsen over time. Treatment of the seizures or EEG abnormalities, a herculean task in this group, would be expected to improve the cognitive and behavioural deficits and also reduce the seizures. He discussed Lennox- Gastaut syndrome and Davert syndrome as examples.

Keynote Address:

Mustafa M. Hussain, Prof. of Neurology, Psychiatry and Internal Medicine , Director Neuromodulation and Therapeutics, UT Southwestern Medical Centre, Dallas, USA, recounted his over twenty years experience in neuromodulation procedures in ‘Dawn of a New Era in Depression’ The remarkable value of ECT in depression cannot be underestimated, he said. However, the more modern Magnetic Seizure Therapy enters the brain unimpeded, the seizure is focal, mild and only on the targeted regions, there is better control over the induced seizure, it does not affect cortical regions responsible for cognitive side effects, and the recovery after a session is quick.  The induced seizure modulates the neuronal activity within the brain to effect change. He confessed that Neuromodulation is  expensive therapy, and if Fluoxetine could do the job, he would go for it. 

Clinical Neuropsychiatry : The Adult 

Colin Shapiro, Professor, Dept of Psychiatry and Ophthalmology, University of Toronto, Canada Director, International Sleep Clinic spoke on ‘Sleep and the Expansion of Neuropsychiatry’ with conviction that “Every psychiatrist must be doing a sleep study on every patient they see!” There may be an underlying history of sexual abuse or PTSD. Sleep deprivation can have  its impact on many psychiatric conditions, depression in particular, and anxiety, and lead to excessive dependence on sleeping dose medication, and to drug and alcohol abuse. Sleep apnoea is more common than estimated. Non-communicable diseases may be exacerbated due to sleep deprivation.    Polysomnography   provides the critical information on sleep disorders. The factors to be studied in a sleep EEG record are

• 1. Sleep continuity disturbances
• 2. Slow wave sleep deficit
• 3. REM sleep disorder
• 4. Short sleep duration. 

Prof Niruj Agrawal, Consultant Neuropsychiatrist and Hon. Senior Lecturer, St George’s Hospital, London, dealt with the topic Dementia following Traumatic Brain Injury (TBI) – a reality. After TBI or repetitive injury as in contact sports, a gap of several decades, may be followed by aggressive behaviour, cognitive decline and  memory deficit. The inflammation following TBI, the white matter changes, brain atrophy and subsequent ‘immunotoxicity’, can trigger a progressive neurological degeneration, a condition called chronic traumatic encephalopathy. There is a progressive increase primarily of phosphorylated tau, and also of amyloid beta and alpha synuclein associated with a clinical presentation of  Alzheimer’s  disease, fronto-temporal dementia or Parkinson’s disease.

Neurotheology- A Thought Leadership Session

Dr Sudhir Shah, Neurologist, Ahmedabad,   has a regular consulting clinic, but his unique research interest borders on Neurotheology, dipping into the neural correlates of religious and spiritual belief. He elaborated on ‘Happiness, Meditation and the Brain’ – the merits of positive emotions and the role of gratitude, compassion, forgiveness, appreciation of others and acceptance of what cannot be changed, the ancient day wisdom for physical, mental and psychological well-being.  “We are our own enemies when negative emotions take over” he emphasized. The four paths of yoga of karma, gnana, bhakthi and the classical raja yoga help in control of the mind.  He presented functional neuroimaging scans of studies (in some of which he was part of the study group) where meditation activates the neural structures  involved in attention and control of the autonomic nervous system and emotions positive or negative show  response in the limbic areas. 

Biological Psychiatry:

Prathima Murthy Prof. and Head, Dept.of Psychiatry- Chief of De-addiction Services, NIMHANS, Benguluru, when faced with the question Neurostimulation for Addictive Disorders, Fad or Fact? started her talk by confessing “I am a clinician and a ‘mechanistic agnostic’, but if it helps my patient, I am willing to go along with it”. She went on to describe the various stimulation modalities used on her patients, and the human research studies conducted in her lab on  some newer modalities.  Addictive drugs cause activation of reward pathways. Biological, sociological and psychological factors influence the vulnerable. Transcranial direct current stimulation (tDCS) is safe , employs low intensity current, is non-invasive, and achieves neuronal sensitivity through weak intensity current stimulation. Modulation of prefrontal cortical excitability with tDCS may reduce alcohol craving and cue-reactivity. Periodic follow up is required as the effect of the neuromodulation wanes over time.

Dr. Adith Mohan, CheBA, Sydney, Australia elaborated on the ‘Psychosis of Suspected Autoimmune Origin- proposed model for co-ordinated clinical care at the Neuropsychiatric Institute, Sydney’. He opened his talk quoting  Susannah Cahalan  who describes her experience of the condition and recovery  in her book  ‘Brain on Fire’ (2018) where she agonises  on  “How many people currently are in psychiatric wards and nursing homes denied the relatively simple cure of steroids, plasma exchange, (or) more intense immunotherapy?”. What is important is to pick these patients early clinically, and treat, the red flags being- 1^st week of viral prodrome ;1-2 weeks of psychotic symptoms, delusions, hallucinations, mania, agitation, speech changes, disorganized thinking, catatonia , insomnia,  and often seizures; weeks to months of neurological complications, movement abnormalities, dysautonomia, hypoventilation and seizures, coma. This is the inflammatory phase and tapers, followed by months to years of prolonged deficits- executive dysfunction, impulsivity, disinhibition, and sleep abnormalities. The pathomechanism: Antibodies of IgG class targeting  NMDAR subunits on dendritic clusters. 40 % triggers are paraneoplastic (ovarian teratoma)-  As NMS is a major risk, one  must be  wary of use of antipsychotics.

Prof.Krishnamoorthy quoted the example of the 13 year female patient in his  Buddhi clinic  in 2013, with  bizarre,  acquired, acute behavioural psychosis and cognitive deficit. Under the guidance of Prof. Angela Vincent, the patient tested positive for NMDA receptor antibodies and recovered well with a course of Methylprednisolone, with a relapse after a few years. It is  important to create awareness among Psychiatrists  when to suspect autoimmune psychosis, a reversible condition.

Dr Mohan suggested the latest  article underlining the red flags –  ‘Autoimmune Psychosis – an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin’ – Thomas Pollak,  Lancet Psychiatry,  Nov 2019 . 

John P John, Prof of Psychiatry, NIMHANS , has a special research interest in  ‘Multimodal brain imaging in Schizophrenia and Dementia’. The Multi- modal Brain Imaging Analytic Lab (MBIAL) of NIMHANS has state of the art equipment, funded by Department of Biotechnology, Government of India. The research is conducted with the collaboration of the DST-sponsored clinical group at NIMHANS. One test for the schizophrenia participant in the research was the semantic word fluency test (word generation) against repeating  what is produced on the screen. In this task, activation is as important as is deactivation. In normal subject, anterior prefrontal activation is accompanied by posterior brain deactivation.  In the patient of schizophrenia, there is less deactivation of posterior brain. There is hyperconnectivity in Default mode network (DMN) in schizophrenia and  a positive relation between DMN connectivity and the psychotic symptoms. (Whitfield Gabrieli et al, PNAS, 2009). The reason why the  DMN is  of particular relevance in the study of dementia is because these areas are where AB amyloid is deposited even in early MCI. The DMN shows less connectivity.

Dementia:

Ingmar Skoog, Prof of Psychiatry, University of Gothenburg, Director, Centre for Health and Ageing and  Leader for the Neuroepidemiology Unit, Gothenburg,  Sweden stressed  that  the first biomarker appearance and preclinical AD can have a gap of 20 years,  the order  being CSF abeta , PET amyloid, CSF tau, PET tau, MRI atrophy, memory symptoms, MCI, Dementia – ( ‘Temporal ordering of the pathological processes of AD’. Jack et al, Lancet, 2013.)  Prof. Skoog has a large series  of CSF studies,  as the study participants give consent for lumbar puncture and even for a follow up study. Other concomitant  pathological markers in CSF he has  studied in 85 year olds: total tau a biomarker for neuronal damage; neurogranin a marker for synaptic degeneration, a post synaptic protein, CSF levels of which increase significantly in MCI and AD; phospho tau 18, a marker for tangle pathology, phosphorylation of tau appearing to be  specific to AD, showing a 2-3-fold increase in CSF; YKL -40, a marker for reactive astrocytosis, increase of which coccurs in the CSF in AD and FTD.

Mathew Varghese, Prof. of Psychiatry, Geriatric Dept., NIMHANS spoke on the ‘Psychosocial Interventions in Dementia’ with particular reference to the Indian scenario and as practiced in his department. He emphasised that in India it is mainly informal caregiving at home. Education of the caregivers with the ABC symptoms of dementia, namely problems with activities of daily living (ADL) and the behavioural  and cognitive symptoms, which require attention is provided in the clinic through family counseling. The need for progressive coping is underlined. The care recommended is a whole -day structured activity schedule, simple, tasks, keeping the general health, nutrition and exercise of the patient in mind, in a safe environment, preserving the dignity of the patient and avoiding confrontation. Prof. Varghese has been involved in modules for dementia healthcare from 2003. Agencies and Societies  providing service are ARDSI (the Indian chapter of ADI),  HelpAge India and Senior Citizens Forum. The Mental Healthcare Act- has outlined some positive steps towards a national level preparedness.  National Health Mission, the flagship programme of GoI, is in the process of preparing district clinic manuals for rehabilitation centres.

Amithaba  Ghosh, Consultant Neurologist from Kolkata, spoke about Frontotemporal dementia in the Indian setting presenting unique biological, cognitive, behavioural and psychosocial data from this setting. 

The impressive cast of Indian chairpersons for the colloquium included Professors :

• Lakshminarasimhan R, Chennai
• Mehndiratta MM, Delhi
• Bharat Srikala, Bangalore
• Bhattacharya Kalyan, Kolkata,  
• Padmavathi R, Chennai, 
• Lakshminarayanan R, Chennai, 
• Sudhakar TP, Tirupathi, 
• Thara R, Chennai,
• Vijayakumar Lakshmi, Chennai.  

Chennai being a hub of Indian Neuroscience, it does not stop with the advantage of inviting local experts, but for opting for among the best in the field.

In all the INA Colloquium was a meeting of minds, Western & Eastern, modern scientific and ancient integrative, discussing many aspects of the brain and mind interface.   Truly a feast for the brain, mind & soul, with the wonderful fusion cuisine of Madras Club satisfying also the palate. 

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!

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”.

Sad but true! One in five children, in a developing nation like India, emerge into this world with their innate human capital compromised. A range of neurodevelopmental disorders (NDD) are the outcome of such compromise: learning disability, childhood epilepsy, cerebral palsy, mental retardation, attention deficit and hyperactivity disorder, autistic spectrum disorder; conditions that strike early and leave lasting impact on the child. On the occasion of the International Day of People with Disabilities (3rd December) we delve further.

What is neurodevelopmental disability?A range of conditions that follow abnormal brain development and impact on motor function (strength, dexterity, coordination); or cognitive function (intelligence, learning, aptitude); or emotions & behavior (temperament, mood swings, emotionality, aggression, hyperactive-impulsive behaviours, socialization issues etc.). In all these instances, there are demonstrable changes in the brain and its development, either structural or in it’s functioning.

Why NDD? While some humans have NDD imprinted in their biological code (through genetic, hormonal, and other neurobiological factors), for many others, the causes lie in critical stages of development, with a range of factors causing compromise. Factors that affect maternal health around conception and through pregnancy; trauma through injury, drugs (both prescription and non-prescription), alcohol, smoking; exposure of the pregnant mother to infections or toxins; and maternal malnutrition, commonly compromise this desired state of “optimality”. Factors affecting the child include birth trauma and infection through poorly planned and executed deliveries, neonatal compromise (asphyxia, jaundice, early trauma through accidents or abuse, infections, malnutrition); untreated epilepsy; other progressive neuropsychiatric disorders etc. Contributory factors include late recognition of the problem, failure to be evaluated in formal medical settings, and the failure to seek and secure early interventions.

Who is at risk?The global lesson from the “Human Genome Project” was that about 10% of all neurological conditions are explained by abnormalities in a single gene. The majority of disorders were thus deemed to be multifactorial- more than one genetic abnormality being responsible, with strong contributions from environmental events that have impact. This probably holds good for NDD as well. In general, having a parent or first degree relative affected by a neuropsychiatric or developmental condition, may double the risk of NDD.

When should we suspect NDD?At the one end of the spectrum are children with overtly manifested disability with severe problems that are apparent early and demand medical interventions. They only form the tip of the iceberg. The larger group who go undetected, are children with minimal brain dysfunction. Typically, they are slow-learners in school, who find academic progress challenging; may be clumsy and lack dexterity, with poor handwriting; or indeed demonstrate a range of emotional and behavioral patterns.

Why should we take action early? These children are often the poor performers and/or perceived troublemakers in school. Rather than receiving special attention, they are at worst punished and at best ignored, in many mainstream schools. Without adequate help and support, these children will slowly and surely slide down the educational scale, out of mainstream schooling, into special schooling systems that cannot really tap their potential. Further, children who do not receive support are likely to feel stigmatized and lose their self-confidence.

Where should I take my child, when in doubt?Your pediatrician should be the first port of call. The class teacher may also have valuable inputs. When either pediatrician or class teacher (or both) suspect a problem, more specialized inputs become necessary. Problems in learning and intelligence are best assessed by a clinical psychologist; problems in motor or other brain function (like epilepsy) by a neurologist, sometimes with the assistance of an occupational therapist; problems in behavior by psychiatrists, often with the assistance of a counselor. When language development is affected, ENT doctors supported by speech and language therapists may need to be consulted. In many instances, comprehensive assessment requires a team approach. Depending on the problem the specialists consulted may require a range of laboratory tests- brain scans, brain wave (EEG) and other electrophysiological tests; blood and urine tests including hormonal assays and so on.

How should I progress once diagnosed?

• Your pediatrician should be your primary support
• Your child’s school needs to be briefed transparently and kept in the loop. Don’t worry about being asked to leave. If the school cannot accept the problem and work with you, it may not be the best place for your child.
• Identify a team of professionals; be consistent in your interactions and regular in follow up. Make sustainable plans and set realistic goals. Prepare for the marathon, not a sprint.
• Don’t focus only on the disability; your child may also have special interests and abilities. Put focus on them too.
• Don’t be preoccupied by academic results; focus on overall development.
• Caregiving is challenging and tiring; share the care as a family, develop your own support networks with other parents and keep your spirit up.

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.

On the threshold of a new academic year, parents and students are again confronted by the dilemma of career choices. But insights from neurological and behavioural sciences can help you make an appropriate choice.As schools and colleges reopen, those of us with an interest in brain development and behaviour are witness to, yet again, a stream of anxious parents and their wards seeking advice and support. Course and career choices that young people are about to embark on challenge the best equipped families and provoke considerable debate (and conflict). What is clearly apparent is that both parents and their wards have not, in most cases, prepared themselves adequately for these unique milestones.

We live in an aspirational society, where higher standards of achievement are generally, constantly, being set as the norm. Also one where success has acquired many new connotations! This has its effect on both parents and their wards. Many people set as targets for their children all those goals they wanted to achieve (or wish they had achieved) but couldn’t. Others are keen to ensure their wards follow in their own footsteps, in the belief that this will give them “a leg up” in their careers. What gets forgotten amidst these parental aspirations is that the child may not share these parental goals, nor have the aptitude and ability to see them to fruition. Youngsters too, influenced as they are by a changing society, sometimes set unreasonable targets for themselves; targets for which they may not necessarily have the ability, aptitude or at a pragmatic level, wherewithal. Peer pressure also plays on both parents and their wards. One often encounters otherwise relaxed parents degenerating into a state of panic at the thought of admissions and career choices. There is no doubt therefore that this scenario causes much distress to all concerned.

Help at Hand : A question that is not asked often enough is whether there is a science that will help us approach career and course choices logically. Today, neurological and behavioural scientists have a sophisticated understanding of human brain development and behaviour. Application of even working knowledge in these fields can help both parents and their wards. The concept of hemispheric dominance, i.e. which side of the brain has a more dominant effect in the concerned individual, is one example of how brain function may influence aptitude, learning, behaviour and consequently success.From a cognition perspective, people who are left brain dominant have a better verbal memory, better linguistic abilities, reasoning and logical skills and better vocabulary! From a behavioural perspective, these left brain dominant individuals tend to be more ideological and philosophical in their approach; more motivated by social and pragmatic, rather than emotional concerns; more diligent, purposeful, capable of greater tenacity and driven more often by a sense of duty. On the other hand, people with right brain dominance have a better visual memory, better perception of space, better appreciation of the fine arts, and greater creative ability. They also tend to be more mood and emotion driven in making their choices. As a consequence, they may work with inspirational bursts of energy, not for reasons of purpose, duty, outcome or workplace ethic alone. Those in the creative professions are commonly observed to have such predilections. Put simply, left brain dominant individuals think with their heads; those who are right brain dominant, with their hearts!

Plenty of Options Can these concepts be useful in making course and career choices? Courses and careers that leverage on a person’s natural aptitude and ability are most likely to be enjoyed and to result in successful outcomes. Pre-eminent among these for the left brain dominant individual are careers that demand literary learning, verbal memory, logical reasoning and diligence; medicine, law, business studies, accounting and finance, computing, research, some humanity disciplines (philosophy, psychology, sociology, history, economics etc.), teaching conventional subjects, to name a few important choices. On the other hand a right brain dominant person may choose the fine arts, theatre, cinema, music, architecture, design, advertising and media, and a range of other careers that demand creative endeavour. Indeed, it may not be just in the choice of careers that brain dominance plays a role. Even within these professions, brain dominance may help define specialisation, role functioning and ability.Parents and their wards may therefore do well to consider these factors in making decisions about courses, careers ands the future. The rapid strides that we have made in economic and social development in urban India have engendered a certain egalitarian ethos in our work places and across professions. No longer does one have to be a doctor, lawyer, accountant, bureaucrat or manager in order to “succeed”. While these career choices remain rather more secure and acceptable across social strata, the career buffet that the young person is presented with today accommodates a range of aptitudes and abilities, with differences in qualification or educational endowment not really being reflected in the pay cheque, in the grossly discriminatory manner so familiar even a decade ago. Young people today have the option of starting work relatively early in life, with fewer formal qualifications, often being paid better for their efforts than older, more experienced and perhaps better qualified individuals in their own families. When such glasnost has percolated into the workplace, then pray why the angst and obsession about traditional and safe career choices? Why not just allow young people to make the choices their brains are dominant for; accepting thereby the predominance of brain dominance!

Facts:

• Courses and careers that leverage on a person’s natural aptitude and ability are most likely to be enjoyed and to result in successful outcomes.
• Reading the brain Put simply, left brain dominant individuals think with their heads; the right brain dominant, with their hearts! Why not just allow young people to make the choices their brains are dominant for? Both parents and wards are not prepared adequately to tackle these unique milestones.

Life with my pet canines is not just joyful and entertaining; it reveals to me each day, profound neuro-scientific insights. Carlo, my German Shepherd, is a classic example of his breed; in looks and temperament. A “Master’s” dog, his life revolves around my routines. A glance in his direction, slight change in tone, low whistle, all will ensure his immediate compliance with “his Master’s” desires. Obedient and devoted to a fault, Carlo is also extremely high strung and anxious, alert to every change in his environment, and protective of it; so much so that I rarely catch him in fitful slumber. Blessed with an uncanny sixth sense for “his Master”, a trait that his breed is famous for, Carlo actually heads for the gate, minutes before my arrival at home from work. Not one to break rules, he will not enter a room or defile a piece of furniture, once forbidden. Natty and fastidious about his appearance, he remains shiny coated through the week, not an ounce of dirt on him, nor a doggy odour.

Unpredictable and WilfulContrast this with my later acquisition Coco, a Basset Hound. A handsome specimen with the classic sad and droopy face, jowls et al, Coco suffers from both occasional seizures and frequent mood swings. An approach in his direction, with best intentions, can evoke dramatically different responses: from a friendly, excited, tail-wagging welcome, to total loss of control; sometimes a resentful, even angry growl, bark or snap in the general direction of approach. Unpredictable mood swings from hypomania and hyperactivity to depression and profound apathy characterise his eventful existence. Disobedient, wilful and obstinate, he can be depended on to do exactly the opposite of what is intended, oblivious to “his Master’s” pleas, commands and threats. Indeed so agnostic is Coco of his surroundings that he can collapse like a sac, his numerous folds spread around him, in fitful slumber, no matter what the circumstances are. House rules mean little to this brat! Stride he will into any room at will, climb on any piece of furniture that strikes his fancy; and somehow manage at least once in each week to manifest for our benefit the pinnacle of filth; no part of the garden, however muddy, having been spared during his meanderings.

Not surprisingly, he emits a profound doggy odour so striking that dog lovers claim it should be bottled and sold (Chanel by Coco is our private joke). Guests without a fondness for canines, beat a hasty retreat from our abode when he decides to bless our company with his presence.

The contrasts in doggy behaviour become most apparent in our morning walk together. Carlo, the German Shepherd, needs no leash, walking three to four kilometres on the footpath that runs alongside arterial roads near our home. Rarely straying more than 10 feet from “his Master”, purposeful in his stride, nary a glance asunder, whatever the provocation, Carlo is the epitome of walking propriety, even his ablutions being timed for completion at a certain discreet spot.

Coco, the Basset Hound, on the other hand, treats the walk as a grand exploration of sorts; an opportunity to experience for himself this beautiful world that the good God has created. Constantly tugging at his leash in an angle perpendicular to the general direction of travel; sparing no human, animal or plant form en route from his nasal excursions, Coco is anything but purposeful about his morning constitutional, his ablutions being intermittent and erratic, intruding into the well directed journey of his fellow canine and Master, much to their combined annoyance. No order is heard, let alone obeyed; no single purpose complied with, other than that, which his doggie mind is set on.

My clinical experience in brain and mind matters has led me to conclude that Carlo, my German Shepherd, is left-brained and Coco, my Basset Hound, right-brained. The concept of hemispheric dominance, i.e. which side of the brain has a more dominant effect in the concerned individual, is one example of how brain function may influence behaviour and temperament.

Left brain dominant individuals tend to be more ideological and philosophical in their approach; more motivated by social and pragmatic, rather than emotional concerns; more diligent, purposeful, capable of greater tenacity and driven more often by a sense of duty.

On the other hand, right brain dominant people have a better appreciation of the world around them, greater creative ability; a proclivity for the finer aspects of life; and tend to be more mood and emotion driven in making their choices; both day to day ones and those that are life-defining. Put simply, left brained individuals think with their heads, the right brained with their hearts; and can be quite a study in contrasts, experiencing great difficulty understanding one another. Little wonder then that many professional and personal relationships run into rough weather; the two parties failing to understand each other’s contrasting preferences and predilections.

Unique Temperamental Attributes

Carlo and Coco have taught me that brain dominance is not an exclusive prerogative of the human race. And love them as I do, equally, I have learnt through them to celebrate rather than despair in these unique temperamental attributes conferred on us by our brain, that marvellous wonder of creation. To understand my family and friends better by observing their brain dominance. To choose correctly my activity companions: left brained for the purposeful and right brained, the hedonistic; and to tailor my expectations of them, appropriately. Carlo and Coco have enhanced my understanding of human nature; and thanks in part to them, I find myself at peace with my fellow men; well most of the time. It is a dog’s life, indeed!

The word stress, used loosely today in society, has many connotations and can imply a range of circumstances from ordinary workplace or familial dissonance to serious mental disturbance. Crucially, what starts off as a minimal disturbance in one sphere of activity can have significant ramifications that affect many life spheres, if left unattended.

Life and society in the 21st century are profoundly stress generating. While a range of reasons may be held responsible, central to all manner of stress genesis is “the yawning gap between expectation and reality”. Modern lives have spiralled unthinkingly into a vortex, driven by predominantly Western economic models: of unremitting desire, relentless aspiration, pursuit of material gain, needless and thoughtless consumption, transient and elusive fulfilment, and unfettered hedonism. Stress is a natural accompaniment, a constant companion, as new desires replace the old, and the gap between expectation and reality remains constant, if not ever-widening.

Can we escape this vortex? Reduce, even remove, the negative factors that perpetuate stress in our lives? Transform ourselves into that epitome of self-management that others look up to?

Sources of stressThe Psychological Conflict Hypothesis: The concept of a psychological conflict comes from Freudian thought and is believed to underlie emotional stress. Freud proposed that we have both an unconscious and a conscious mind and that there were inherent conflicts between the primitive urges (Id), the unconscious (ego, current awareness) and the feedback from the moral agency (super-ego). While Freud emphasised sexual urges, psychological conflicts are generally believed to have their genesis in the dissonance that can arise between our inner urges and socially permissible actions; a dissonance that may defy resolution.

The Self Actualisation Hypothesis: Proposed by Maslow, it assumes that each individual has to ascend different steps of the self-actualisation pyramid. At the very bottom of the pyramid are the person’s survival needs; after which appear, progressively, security needs, social needs and ego needs in that order (see box). When all these needs are addressed to a significant extent, the person achieves a state of self actualisation, of fulfilment and being content with one’s lot. Stress is a constant companion at various points on the self-actualisation pyramid and disappears when self actualisation is achieved. However, Maslow’s rather utopian view of the lasting self-actualised state of being may not hold true in the fast-paced modern world, where events often outpace individual development in most unexpected ways.

The Locus of Control Hypothesis: An important psychological construct used to explain the development of depression, an important consequence of stress is the locus of control hypothesis. It has been observed that rats placed in connected cages soon learn to avoid the cage that habitually gives them an adverse stimulus such as an electric shock. However, when the rat receives shocks in an unpredictable manner, it becomes listless, withdrawn and inactive, a state of “learned helplessness”. This has led to the understanding that internal locus of control (where the person feels in control of his circumstances) is protective from emotional stress; while an external locus of control (being controlled by one’s circumstances), makes one vulnerable to it. In the years of post-war industrialisation this phenomenon was recognised in “assembly line workers” who had little control over the nature or pace of their work and were expected to perform a repetitive task for hours on end. Interestingly, our much vaunted IT revolution has ushered in a new generation of “assembly line workers” who operate on international time and in response to international demands, often with little control over their workspace destiny.

The Coping Hypothesis: One point which eludes us when we are in a stressful situation is that there are, usually, only two ways out. Take for instance the example of a very short-tempered boss who reacts without provocation. One can either attempt to modify the situation (i.e. bring about a change in the boss so that he loses his temper less); or one can modify one’s own expectations (i.e. accept that boss with his short temper and learn to work around it). No prizes for guessing which is the easier pathway here. It is often said for this reason “when you cannot modify the situation, modify your expectations”.

Coping strategies are of two kinds: i. Problem-focused coping where the attempt is to short-circuit negative emotions by modifying, avoiding or changing the threatening situation and; ii. Emotion-focused coping where the attempt to moderate or eliminate unpleasant emotions by rethinking in a positive way. Some strategies employed include relaxation, denial and wishful thinking.

In many circumstances, both approaches are combined in the effort to overcome stress.

Preventing StressThe prevention of stress is achieved through good self management. The key to self management lies in being mindful: of oneself and the world around. Inexorably linked with this mindfulness is developing a better understanding of oneself and one’s fellowmen. Caught as one is in the vortex of modern existence, mindfulness can often be elusive, as the roller coaster of life takes us from one event to the next.

The famous Tibetan Buddhist teacher and philosopher Sogyal Rimpoche differentiates the active laziness of the West whereby unimportant tasks become responsibilities, part of a rigid schedule, and begin to dictate one’s existence (appointments, schedules, waiting times); from the passive laziness of the East, hanging out in front of the roadside stall with film music blaring, watching the world go by.

Neither, he contends, is ideal; instead, he highlights the importance of spirituality and contemplation and the need for us to devote some time in each day to examining the deeper meaning of life. In his view “Our task is to strike a balance, to find a middle way, to learn not to overstretch ourselves with extraneous activities and preoccupations, but to simplify our lives more and more. The key to finding a happy balance in modern lives is simplicity.”

It must be noted that stress clearly has its benefits. Imagine if you did not feel stressed out in advance of an interview or exam; your preparation and performance are both likely to be sub-optimal. Some stress is therefore necessary in order for human beings to “survive”. Too much stress, on the other hand, can be unproductive, even wasteful; resulting in much negative energy being expended. What we must try and achieve, therefore, is a fine balance between ambition and motivation on one hand and equanimity of mind on the other. And, while we strive to control our own destinies, by being in control of our lives and circumstances, our destiny may have other plans, that we cannot fathom; plans that we must learn to accept and live with. Perhaps, therein lies the key to effective stress management.

Heart Facts:

• Stress impacts on the heart: it can cause myocardial infarction (heart attacks) and sudden death. It can affect the regulation of your heart beat by the central nervous system.
• The INTERHEART study investigated the relationship between chronic stressors and Myocardial Infarction in about 25,000 people from 52 countries. After adjusting for other risk factors, those who reported “permanent stress” at work or at home had double the risk for developing a heart attack (MI).
• The broken heart syndrome , sudden ballooning of the heart apex (left ventricle) follows acute stress. Often there is no evidence of obstructive blood vessel disease. Episodes of intense emotional or physiological stress are reported prior to presentation and maybe the triggering factor. Even when intense bouts of emotion don’t kill, they may cause long-lasting heart damage.
• The Whitehall II study found over a two-fold increased risk for new coronary heart disease in men who experienced a mismatch between effort and reward at work. High-risk subjects were those who were competitive, hostile, and overcommitted at work, in the face of poor promotion prospects and blocked careers.
• Cardiac syndrome X affects women more; there is angina-like chest pain and a positive response to the treadmill test with normal heart circulation. Cardiac syndrome X patients report more depression, anxiety and somatic (physical) concerns; they also have better prognosis.
• Depression is a primary risk factor for Ischemic Heart Disease and an independent secondary risk factor for Heart Attacks. Depression also has a direct impact on cardiac risk factors such as diabetes, hypertension and obesity. Depression after myocardial infarction more than doubles the risk of death and of another heart attack. People who suffer chronic anxiety are more likely than others to suffer heart attack. Emotional trauma such as the death of a spouse, mental or physical abuse, or post-traumatic stress disorder (PTSD) increases risk of heart attack.
• People with Type D personalities (characterised by pessimistic emotions and inability to share emotions with others) and Type A personalities (characterised by anxiety directed outward as aggressive, irritable, or hostile behaviours) are more likely than others to suffer heart attacks.
• Freud said that happiness comes when one has pleasure in love and work. Research shows that marital stress in women and both marital and work stress in men greatly increase the risk of death due to a cardiac event. A famous doctor has observed “where can he go if he is unhappy at work and at home?” The implied, if somewhat flamboyant, answer was always “to an early grave.”