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Beyond Feeling Featured

The Godfather Paradox

Over four decades ago, Mario Puzo gave us, through his The Godfather, an insight into the mind of the socially enabled psychopath. Born in Corleone, a small village in Sicily, that troubled, deprived and violent part of Italy we have learnt to associate closely with the “mafia”, Vito Corleone earned his stripes as a young boy, learning to use the Sicilian gun “the Lupara” with finesse and precision. His flight from Sicily, early years in New York as a humble immigrant, barely managing to make ends meet, and struggling to provide for his young family during the great depression, and his eventual entry into the grey belly of the New York “underworld” after his shrewd murder of a local don, were brought to life most brilliantly by Puzo. Incredibly, the “Godfather” who emerged from these violent beginnings metamorphosed over time into “a reasonable man”, a fact the author takes pain to reiterate several times during the course of the complex tale.

The Mind of the PsychopathVito Corleone, the Godfather who emerged from these humble beginnings in Puzo’s novel and went on to occupy a pre-eminent position in the underworld, makes a fascinating case study, one of the finest descriptions of psychopathic personality in popular fiction. The prototypical psychopath has deficits or deviances in some core areas: interpersonal relationships, emotion, and self-control. Psychopaths gain satisfaction through antisocial (or socially deviant) behaviour, and do not experience shame, guilt, or remorse for their actions. A classic trait among psychopaths is the lack of a sense of guilt or remorse for any harm they may have caused others. Instead, the psychopath rationalises his behaviour, blames it on others, or denies it outright. Psychopaths also lack empathy towards others in general, resulting in tactlessness, insensitivity, and contemptuousness. All of this belies their tendency to make a good, likable first impression. Psychopaths have a superficial charm about them, enabled by a willingness to say anything without concern for accuracy or truth. Shallow affect also describes the psychopath’s tendency for genuine emotion to be short lived and egocentric with an overall cold demeanour. Their behaviour is impulsive and irresponsible, often failing to keep a job or defaulting on debts. Psychopaths also have a markedly distorted sense of the potential consequences of their actions, not only for others, but also for themselves. They do not, for example, recognise the inherent risk of being caught, disbelieved or injured as a result of their behaviour.Emotionally, the fundamental traits underlying this personality are an inability to empathise with others, to feel their emotions, to share their love, joy, pain and sorrow in a deep way. Indeed, the emotions that this personality experiences are distinctly shallow and poorly sustained. It is not that the psychopath does not feel emotions; he feels them so fleetingly and his being carried away by them is so transient (albeit intense) that those feelings fail to have any impact on how he perceives and reacts to the emotions of others. In other words, his emotional experience probably has little impact on his emotional learning and development as a human being.Research has shown that psychopaths have poor perception of the facial emotions others express, and experience difficulties in affect recognition (i.e. gauging the other person’s mood). They also seem to have difficulty in integrating contextual cues in their environment; their perception of an environmental cue is linked to how it relates to goal-relevant environmental information. Put simply, the psychopath fails to perceive environmental cues in the context they are and may thus react inappropriately. As a consequence, psychopathic personalities may fail to perceive fear in the object of their aggression; fail to recognise his abject submission; and therefore perhaps, fail to tailor their aggression to that which will merely provoke a desired response. In the process, their aggressive reactions may be far in excess of that needed to achieve their ends.Psychopaths also often do not sense right and wrong in conventional ways accepted by society: in other words, they often choose to operate from their own reality framework and do not necessarily fit within the moral and legal framework that we accept as a society. From Al Pacino to Veerappan, Real life examples of “Godfathers”, like Veerappan, have been (with few exceptions) intensely proud men, who are not afraid to write their own rule books; judge right and wrong in their unique ways; seldom appearing to feel, certainly not expressing remorse for their actions, however impactful, including the ending of human life, both of perceived opponents and of their own kith and kin. For example, Puzo’s godfather, in mourning the violent death of his favourite older son, focuses more on his (son’s) inability to control his impulses rather than on his own contribution to the sadness that has visited his family. Curiously, the Godfather’s wife, a devout Christian, is described as fervently praying for his (the Godfather’s) soul and presumably its salvation.

A Reasonable ManWhat is fascinating about Puzo’s Godfather is his quality of “reasonableness”, so important for a leader, yet so unusual for a psychopath. Indeed, Vito Corleone is almost statesmanlike in his responses. Highly moralistic in his personal values, he is portrayed as having very strong views about appropriate public behaviour, family honour and sexuality in particular, and is seen to frown on social inappropriateness of any kind. Indeed his second son’s fondness for company with the opposite sex becomes the major reason for the Godfather to summarily reject him, despite having lost his older son to the ravages of his profession. Particular about language and its usage, he reserves his strongest rebuke, “infamita”, to markedly inoffensive situations; even so, it conveys squarely to those around him his displeasure about a person, his statements or actions. That someone so moralistic does not see it amiss to eliminate a rival through murder in cold blood, or indeed coerce a recalcitrant and arrogant movie producer by decapitating his favourite, priceless race horse, leaving the (race horse’s) head in his bedroom for him to wake up beside, experiencing untold terror in the process, exemplifies for us the paradox the Godfather is. Strangely also, throughout the book, the Godfather stands out for his willingness to negotiate; “I will reason with them” is his favourite refrain when confronted with a difficult situation.

The Godfather ParadoxSo if Puzo’s Godfather is a psychopath, what manner of psychopathy does he represent? The primary quality of psychopathy that the Godfather possesses to a great extent appears to be the ability to be ruthless in achieving his own ends. A second psychopathic quality the Godfather exudes is a distorted reality of the impact of his actions; not quite consonant with traditional expectations or social beliefs, nor indeed particularly empathetic. A third, perhaps most striking psychopathic quality the Godfather possesses is his ability to manipulate people and situations rather skilfully. His dispensation of favours is usually with a caveat; that one day, at an appropriate time, the favours will have to be returned. Hesitation to accept or return the Godfather’s favour is viewed with open contempt, suspicion, even derision.There are, however, several differences. Quite contrary to the typical psychopathic personality, the Godfather’s is a slow to warm, even phlegmatic, temperament, and he does not exude a superficial charm. Nor does he lose control over his emotions at any point in time, whatever the provocation; indeed, he regards the inability to control one’s emotions as being an “animal” quality, unbecoming of a sensible human being. His is also a remarkably sensitive personality; quick to take offence and very perceptive of the moods, emotions and reactions of those around him. His ability to perceive social and emotional cues is highly developed, quite unlike the conventional psychopath who appears oblivious to these. Finally, his almost statesman-like willingness to reason makes him stand out from the conventional image we have of the psychopath as a society. Puzo’s Godfather does, therefore, present us with a paradox; cruel psychopath to some, beloved friend and protector to others; a unique combination of sense and sensibility on the one hand, balanced against latent potential for ruthless violence. Does he then represent the socially enabled psychopath?

Are effective leaders socially enabled psychopaths?While “goodness” and “greatness” within organisations is determined in large part by their in-built value systems, leaders often have potential to change value systems, goals, performance and outcomes both positively and negatively. In traditional professions and businesses, leadership is often either supervisory or strategic: the former focussing on getting the organisation (or a group within it) to perform effectively; the latter on managing change and uncertainty effectively, positioning the organisation for future growth. While many forms of leadership have been described, “inspirational leadership” has as its focus “the emotional connect” with people’s energies and goals, converting them into effective followers under all circumstances. This form is perhaps predominant in the leader who is a socially enabled psychopath.Effective leadership is often about helping people and organisations achieve the goals they have set for themselves. Engagement in such goal-oriented activity does call for a certain focus; where the goals set achieve primacy over other concerns, for example, those of the ethical or moral kind. In the competitive world of business, for example, the most effective leader is often perceived as the one who “delivers” whatever the means he employs. It is in this environment that the socially enabled psychopath with his unique perceptions of reality, willingness to shift societal norms and expectations to suit his agenda, and most importantly “willingness to reason with his fellow men” using a range of strategies from charming persuasion to latent threat, comes into his own. His “killer instinct”, lack of empathy and inability to experience and empathise excessively with the pathos of his fellow men consequent to his actions, serve him well here. His actions may hurt his fellow men, or be distasteful; but in the rough and tumble modern world we inhabit, the ability to achieve tangible and productive goals profitable to his organisation and to him, without twinges of conscience or feelings of regret, is often advantageous. The modern-day CEO is, therefore, in many cases, a socially enabled psychopath, effective leaders in business, science, technology, medicine, politics, and religion all exemplifying this “Godfather Paradox”.To label all effective leaders as “socially enabled psychopaths” would clearly be uncharitable to society at large and too much of a generalisation. However, empirical observation does highlight the predominance of aforementioned qualities in various permutations and combinations, among leaders in society, which is curious, to say the least. One may even argue that a certain amount of “social psychopathy” is necessary in order for leaders to succeed, as excessive empathy towards different stakeholders, lack of a personal reality orientation, and inability to “reason” can in many situations be detrimental to the larger cause one represents. Perhaps modern society would eventually deem acceptable a breed of leaders with such “benevolent positive psychopathic traits” without an iota of physical or emotional violence in them. Perhaps, we will as a society, one day, celebrate rather than vilify, “the Godfather Paradox”. Perhaps!

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Autism & ADHD Beyond Feeling Featured

Overcoming Autism with Growing Brain Lab

Disorders of brain and nervous system development are among the most disabling disorders that  affect young children and their families. These include several forms of mental   retardation and learning disability, cerebral palsy, dyslexia, autism, attention   deficit and hyperactivity disorder and a spectrum of motor, cognitive, behavioral and emotional   disorders including those due to family and school stress.

Autism is one of the most important disorders that affects young children. Autism is known as a ‘spectrum disorder,’ because the severity of symptoms ranges from a mild disabilities in learning, language development and social interactions to a severe impairment, with multiple problems and highly unusual behavior. The disorder may occur alone, or with accompanying problems such as mental retardation or seizures. Autism is not a rare disorder, being the third most common developmental disorder, more common than Down’s Syndrome. Typically, about 20 in a population of 10,000 people will be autistic or have autistic symptoms. 80% of those affected by autism are boys.

Children with Autism need the care and attention of a multi-disciplinary team, including the paediatrician, neurologist, psychiatrist, physical, occupational and speech therapists,   psychologists with special training and interest in education and development,   special educators, social workers, speech therapists and nurses.  At present, there is no pharmacological therapy which can cure autism. The only consistently effective treatment for autism is a structured training program; therefore, a combination of a good school and parent training is the best known treatment. Autistic children can make significant progress if the intervention is appropriate and consistent.

Growing Brain Lab (GBL) is an innovative project at Neurokrish-Trimed.  Over a decade GBL has evolved as multidisciplinary model of assessment that addresses Learning,   Aptitude and Behaviour across motor, cognitive, emotional, and psychosocial   domains. GBL has also perfected in this timeframe a model of after-school   therapy incorporating behavioral management and Neurodevelopmental therapy.   With the advent of TRIMED and it’s integrative approach, GBL now incorporates seamlessly a range of holistic interventions targeting symptoms of various developmental disorders including Autism. Play Yoga, Mud Therapy, Reflexology, Ayurvedic Therapies all blend seamlessly into a whole in the TRIMED-GBL program. Inspired by excellence and Success Stories, GBL is today making accessible to families, modern healthcare with ancient wisdom, which is the TRIMED mantra.

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Beyond Medication Dementia & Memory Loss Featured

Dementia: A Looming Threat

Photo Credit: The Hindu: N Sridharan

A low level of awareness about dementia is most often why diagnosis is delayed and public health consciousness remains poor.World Alzheimer’s Day (September 21) was marked this year, in India, by the release of a comprehensive Dementia India Report. Prepared by national experts, converging under the Alzheimer’s and Related Disorders Society of India (ARDSI) umbrella, it estimates that there are 3.7 million elderly currently living with dementia in India, each spending Rs. 43,000 per annum on medical care. Dementia mainly affects older people, although about two per cent of cases start before the age of 65 years. After this, the prevalence doubles every five years with over a third of all people aged 90+ years being affected. With the exponential increase in the population of the elderly (60+ years) in India, an estimated 100 million today, expected to rise 198 million in 2030 and 326 million in 2050, dementia poses a looming public health challenge, the enormity of which cannot be underscored. The report thus addresses a felt need among professionals, policy makers, dementia sufferers and their families.

What it is ?Dementia is a neuropsychiatric disorder in which memory and other cognitive functions like thought, comprehension, language, arithmetic, judgment and insight deteriorate progressively. While it increases in prevalence with advancing age, it is not a normal feature of ageing, a common misconception. Further, dementia is a clinical syndrome, one with many underlying causes, some potentially treatable. Of the many conditions that cause dementia, Alzheimer’s disease (AD) associated with neuro-chemical decline and waste product accumulation in the brain; vascular dementia (VaD) associated with strokes; dementia with Lewy bodies (DLB), a condition associated with Parkinson’s disease; and frontotemporal dementia (FTD), are most common. The treatable conditions that cause dementia include infections such as syphilis, HIV and tuberculosis; hypothyroidism and other endocrinal problems; vitamin B12 and folic acid deficiency; toxic conditions of various kinds and so on. As they are potentially reversible they need to be addressed swiftly.

What the report highlights ?The report highlights two areas of great import for dementia sufferers and their families: activities of daily living (ADL) an important measure of the human condition, and behavioural and psychological symptoms associated with dementia (BPSD), an important predictor of health related quality of life (HRQoL). Problem behaviours in dementia include agitation, aggression, calling out repeatedly, sleep disturbance, wandering and apathy. Common psychological symptoms include anxiety, depression, delusions and hallucinations. BPSD occur most commonly in the middle stage of dementia and are an important cause of caregiver strain. They appear to be just as common in low and middle income countries as in developed ones.The report outlines the current evidence based pharmacological treatments for dementia, especially AD and VaD: cholinesterase inhibitors (donepezil, rivastigmine, galantamine); NMDA agonists (memantine); drugs for BPSD (SSRI’s for depression and anxiety; new antipsychotics for psychotic symptoms like agitation, aggression, hallucinations; antiepileptic drugs that serve as mood stabilising agents); addressing also their cost-benefit in low-middle income countries. It also lays stress on the importance of structured caregiver interventions as part of standard treatment including psycho-educational interventions for dementia; psychological therapies such as cognitive behaviour therapy, cognitive retraining and family and caregiver counselling; as also caregiver support and respite care. Highlighting that caregiver interventions have been conclusively shown to delay institutionalisation of the person with dementia in the developed world; it observes that many new treatments in advanced stages of research hold promise for persons with dementia and their families.The report differentiates risk factors into those that are non-modifiable (genetic factors for example) and those that are potentially modifiable. It highlights the extensive and evolving medical literature on the role of lifestyle diseases: diabetes and insulin resistance; high cholesterol levels; high blood pressure; increased fat intake and obesity; together the so-called metabolic syndrome as a modifiable risk factor for dementia. It is important that policy makers recognise these factors as targets for both primary (early) and secondary (after the onset) risk factor prevention. It points to the low level of awareness about dementia as an important reason why diagnosis is delayed and public health consciousness remains poor. Worryingly, it observes that the lack of awareness extends to health professionals, formal training in dementia diagnosis and care not being a part of most medical, nursing and paramedical curricula; a matter of great concern needing immediate remediation. That stigmatisation of persons with dementia is rampant and that there is a need for raising awareness about the condition across segments of society is explicitly stated.

In India…Assuming incremental life expectancy and a stable incidence of dementia, the report attempts to estimate the future burden of dementia both nationally and State-wise. A twofold increase in dementia prevalence to 7.6 million by 2030 and a threefold increase to over 14 million by 2050 are thus estimated. Interestingly in the State-wise estimation, Delhi, Bihar and Jharkhand are all estimated to witness a 200 per cent or greater increment in dementia cases. These figures have of course been calculated based on certain assumptions. When one factors in the significant disability that dementia confers on the affected person, estimated as being greater than any other health condition except severe developmental disability, the impact of this exponential rise in prevalence, even put mildly, is staggering. The report addresses the need for services to be developed: memory clinics, day care, residential care, support groups and helplines, pointing out the paucity that currently exists. Also highlighted is the severe paucity of human resources for dementia care. A number of short-term and long-term focus goals, to improve resources; as well as scope, scale and quality of care are proposed.The report concludes with several key recommendations. The most important of these are:

  • Make dementia a national priority
  • Increase funding for dementia research
  • Increase awareness about dementia
  • Improve dementia identification and care skills
  • Develop community support mechanisms
  • Guarantee caregiver support packages
  • Develop comprehensive dementia care models
  • Develop new national policies and legislation for people with dementia

While these recommendations do address the need for dementia to be integrated into the National Policy for Older Persons (NPOP), they predominantly highlight the specific needs of dementia as a disabling and common condition among the elderly; one that can and will challenge Indian public health systems. However, the report acknowledges that dementia must be viewed in the context of other elder health problems, and within the framework of the NPOP.

Sets a gold-standardPerhaps the greatest contribution of this Dementia India Report is in its setting a gold-standard for other disorders of ageing: quantifying the prevalence and burden of the condition; its impact on the sufferer, caregiver and society as a whole; the framework of services required in order to give succour and solace to sufferers and their families; the causes, risk factors, treatments and management models; and the State-wise national impact. One fervently hopes that it will facilitate a powerful and futuristic policy response from the powers that be. In a country where the average age of the parliamentarian clearly falls in the “elder” category, one can only hope that it will be welcomed and adopted with the enthusiasm it richly deserves.Acknowledgements: Dr. K Jacob Roy, National Chairman of Alzheimer’s and Related Disorders Society of India (ARDSI) for permission to present this summary of the report and the use of figures.

Facts: 

  • There are 3.7 million elderly currently living with dementia in India, each spending Rs. 43,000 per annum on medical care
  • A twofold increase in dementia prevalence to 7.6 million by 2030 and a threefold increase to over 14 million by 2050 are thus estimated
  • Many new treatments in advanced stages of research hold promise for persons with dementia and their families

With the exponential increase in the population of the elderly in India, the disorder poses a challenge to public health systems.

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Beyond Medication Dementia & Memory Loss Featured

Perspectives in Dementia Care and Health Policy

A health policy for dementia should be comprehensive, especially spelling out the role of family, community and government.A brainstorming session on future perspectives in dementia care and health policy, at the National Dementia Summit held recently in New Delhi, is most insightful. The key prompts for this interactive session are simple and follow a 5W1H management model — who, what, why, when, where and how, in Rudyard Kipling’s “six friendly men” mould. We begin by asking who should take part in developing public policy. The large number of stakeholders becomes apparent: apart from Government, civil society agencies, medical, nursing, paramedical and other professionals, university faculty and researchers and those engaged in the care of dementia; the person affected (if able), their caregivers and families, clearly should all have a say in health policy development. Other stakeholders include the insurance sector, private care providers and agencies rendering dementia related services — pharmaceutical, nutraceutical, medical instrumentation industries; hospitals, hospices and homes. There is unanimity on whom health policy should target; everyone affected by the condition regardless of their economic or social

Photo Credit: The Hindu : N. Sridharan

circumstances.Prevention of Risk FactorsWhen should dementia health policy become operational (at what point of time in the lifespan) we ask. The discussion among experts is animated. They point out that primary prevention i.e. the prevention of risk factors that increase the likelihood of dementia development: hypertension, obesity, high lipid factor levels and diabetes; smoking and alcohol consumption; should begin young, perhaps even in teenaged years. These being the risk factors for many chronic and lifestyle diseases, the benefits of such primary prevention will undoubtedly go far beyond dementia, to a host of other chronic and lifestyle diseases. Secondary prevention, the optimal management of risk factors once they have developed, usually begins in middle age, when risk factors surface and are first detected in individuals. Tertiary prevention, early diagnosis of dementia, even in the mild cognitive impairment stage, often mistaken to be part of normal ageing; the early treatment with drugs that can slow down the disease; and supportive interventions for the caregiver, is universally believed to be mandatory. The group is unanimous that the time for a well defined national health policy is now, when there are an estimated 100 million elders in India, 3.7 million of whom are believed to have dementia.Participants believe that a health policy for dementia should be comprehensive and cover standards for diagnosis, treatment, clinical management; spelling out clearly the role of the family, community and government. Aside from this, dementia requires considerable care, which goes far beyond cure: rehabilitation care, respite care and palliative care, all of which must be clearly outlined. Dementia is a condition with many ethical, legal and financial implications that need to be addressed; and is also the focus of much research. Participants feel strongly that such health policy development should be inclusive and bottom-up, assimilating inclusively the views of all stakeholders; not top-down, based on the views of a minority who have access to the corridors of power. International delegates point out that there is evidence today that the bottom up approach to policy making is far more likely to work that the top down one. In this context participants express their regret that much of health policy development in India remains top down, with stakeholders being seldom consulted.Discussing the focus of a health policy, there is general agreement that all essential domains of dementia care need to be addressed: thus the person, family especially the principal caregiver and community health resources all need importance. However, given dementia’s inherent nature, a disabling condition with complex medical and social needs, secondary care, even tertiary care, cannot be avoided at times of diagnosis; for management, both drugs and non-drug therapies; and complications. At the same time rehabilitation care, both in-patient and out-patient, needs emphasis. When asked to choose between these different domains of care, putting focus on one, participating experts and stakeholders are unanimous; the person, his family and the community resources they can leverage upon are a paramount focus of health policy development.We proceed to ask “who should do what?” for the person with dementia. Interestingly, the need for co-operation and partnership between government, civil society, private providers and affected families becomes immediately apparent. The government clearly has to lead on making dementia a national priority, guaranteeing support for the caregiver and developing new dementia policy and legislation, all of which need immediate and timely action. On the other hand civil society support groups and care providers clearly have their work cut out for them taking ownership for tasks like increasing awareness in the community, improving dementia identification and care skills, and developing community support systems. The development of comprehensive care-giving models will require the involvement of experts: universities and tertiary facilities, working in tandem with affected families. Research is seen as one area where all parties need to take part. The government must increase funding for dementia research; pharmaceutical agencies and industry must contribute their mite; as must universities and other academic agencies; civil society supporting and enhancing the process; families participating with enthusiasm and altruism.The development of dementia health policy, as it has unfolded here, is by no means unique to that condition. The majority of chronic diseases, a rising burden in India today, will require a similar approach: paradigms that address long term care (when cure is not an option); participation and co-operation among a range of agencies, often as different from one another as chalk is from cheese; and inclusive, bottom up health policy development. While a nodal national agency charged with this responsibility will probably be part of the answer, this discussion on dementia brings to the fore, an urgent felt need in this country, for health policy paradigms that will address the emerging epidemic of chronic and lifestyle diseases. Isn’t it time our policy makers and Kipling’s six friendly men, met?

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Beyond Medication Featured

Food for Thought

A healthy diet and lifestyle can stave off memory loss.Dementia is a disorder of brain aging caused by a range of factors: degeneration of chemical systems in the brain; accumulation of waste products; diminishing blood perfusion leading to many small areas of damage (microvascular infarction); and several other causative factors.Prevention assumes great significance in this era of chronic and lifestyle diseases; with hypertension, obesity, lipid disorders (high cholesterol) and diabetes (HOLD) being rampant in society. Nutrition underpins both HOLD and dementia.It is well known that sub-clinical deficiency in essential nutrients can lead to dementia. Research has shown memory deficits in people with low plasma levels of vitamin B 12, folic acid, lycopene, a-carotene, b-carotene, total carotene, b-cryptoxanthin, a-tocopherol etc.

There is mounting evidence for the Mediterranean diet — high consumption of olive oil and fish, hence elevated intakes of monounsaturated fatty acids and v–3 polyunsaturated fatty acids — being protective against age-related cognitive decline. The antioxidant compounds in olive oil (tocopherols and polyphenols), and fatty acids may help maintain the structural integrity of nerve membranes. The naturopathy food pyramid is a good indicator of what we should eat in order to remain healthy and prevent dementia.There is no doubt that red wine consumed in moderation may be beneficial, reducing bad cholesterol, preventing blood clots and protecting the heart. The protection may come from the constituents of red wine made from tannin grapes, which include procyanidins, a class of flavonoids also found in plants, fruits and cocoa beans. Thus moderate red wine consumption maybe good, but only when accompanied by a “healthy” lifestyle.There is growing evidence that vitamin supplementation has a significant role to play in lowering the risk of dementia. Evidence for vit C, E, B12 and folic acid — as supplements in higher doses — is particularly strong. Indeed, the US FDA has recommended folic acid fortification of foods, for example flour and bread. High vitamin levels due to inappropriate supplementation can, however, be problematic and must be guarded against.It has long been known that certain plant formulations — Brahmi (Bacopa Monnieri), Tulsi (Basil), Ashwagandha (Withania Somnifera), Curcumin (in turmeric), extra virgin coconut oil — may enhance memory function and these are subjects of active research. Evidence to support over-the-counter plant formulations is, however, not available.A well-preserved memory is the cornerstone of a good life; good nutrition and a healthy lifestyle will help us achieve this milestone. To paraphrase the great bard, do we not desire to avoid or at least postpone our “sans everything” years?

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Epilepsy & Seizures Featured

The Whole Picture – Epilepsy Care and Management

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

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

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

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Beyond Medication Featured

Beyond Medication

Modern medicine cannot, on its own, address the care needs of several hundred thousand people confined to their beds and to wheelchairs, due to illness and injury.

Nothing strikes greater fear in our hearts than the prospect of permanent medical disability. Sadly, with humans living longer (but not necessarily healthier) lives, multi-morbidity and chronic medical disability have become common. When struck down by disability, the prevailing medical model provides both for surgical correction and symptom relief through drugs and procedures. However, with a large proportion of patients either failing to respond adequately, or indeed rejecting those conventional options, there is a need to look beyond.Mrs. L, an 80-year-old housewife, was rushed to the hospital after suffering a brain haemorrhage. Unconscious, paralysed on the left side, unable to speak and swallow, she needed ICU care with the ventilator (and tracheostomy) to help her breathe and a feeding tube to receive fair nutrition. Three weeks later, when she was transferred to rehabilitation care, Mrs. L was barely conscious; still had a tracheostomy tube, feeding tube and catheter in place, remained severely paralysed on the left side (not even a flicker of muscle contraction), and suffered from excessive throat secretions and severe chest congestion.After a comprehensive assessment by the rehabilitation physician, with inputs from the chest and ENT physician, her medication was optimised and intravenous steroids to kick-start brain function were introduced. She also received an integrative therapy programme, including twice daily sessions of physiotherapy in the form of nerve and muscle stimulation, graded passive and active exercises, combined with manual interventions such as acupressure, acupuncture and reflexology. Over two weeks, Mrs. L responded well to this treatment. Her consciousness and comprehension improved, and she began to respond to and obey simple commands. She began to sit with support, and then her chest secretions reduced. She regained urinary sensation and gradually her catheter was removed. She started to show response in the paralysed limbs; she stood with support; even walked a few steps. However, there was persistent left vocal cord palsy and the tracheostomy removal failed. So the feeding tube had to be left in place. We started work with her family, helping them cope with her condition and setting graded, realistic goals.She was discharged to home care and nursing and continued to undergo integrative therapy. Sessions of Ayurveda therapy in the form of oil massages and medicated foments were now introduced to improve limb power and movement along with continued physical and manual therapy procedures. The psychological therapist engaged her in cognitive therapy and motivational enhancement, apart from helping her caregivers deal with their distress. Over six weeks, she began to walk with support, express herself with gestures and swallow small amounts of soft solids. Apart from a minor bout of aspiration pneumonia in the interim, requiring brief hospitalisation, she made good progress.When Mrs. L returned to the hospital for a team review, her tracheostomy tube and feeding tube were removed. She regained her ability to speak, albeit hoarsely. Her chest was clear and she was progressively able to swallow more each day. Her gait had improved and she walked well with support. She appeared bright, sprightly and ready to engage with the world, even presiding over her family’s “harvest festival” celebration. Today, this determined lady continues weekly sessions in the pursuit of complete wellness.Mrs. L’s is an inspirational story. While modern medicine saved her life, it could not possibly, on its own, give her back “quality of life”. The integration of several medical therapies, as a rehabilitation model, succeeded in doing just that. Involving the use of trained personnel and a range of techniques and therapies — both ancient and modern — have great relevance in our culture. Modern medicine at the fountainhead of such treatment is crucial, not least because people with medical disability are especially vulnerable and need close scientific supervision. However, modern medicine cannot, on its own, address the care needs of several hundred thousand people confined to their beds and to wheelchairs, due to illness and injury. With an estimated 125 million elderly in India, slated to grow to 176 million by 2026, 30 per cent of whom have chronic medical conditions, we must clearly look beyond, at holistic care.

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Beyond Medication Featured

Falling men, Failing Neurons

Clinical Autonomic Dysfunction with a plethora of systemic complaints often goes unrecognised. But the right diagnosis and treatment can help speed up the recovery process.

Most of us take standing up for granted. Only when we cannot stand for some reason are we reminded of its importance. Oliver Sacks, the legendary neurologist and author, addressed this rather poignantly in his story On standing on one leg, which documented his experiences after a fall in the Alps. The human species started ‘standing on two legs’ rather late in its evolution. As a consequence, body mechanisms that enable standing — for example ‘preventing all the blood from pooling in our feet, thanks to gravity’ — developed rather late. A complex neural network rich in chemicals and hormones controls postural changes in blood pressure, as it does heart rate, body temperature, digestion, urinary and sexual function… a host of human activities performed, often unthinkingly. This complex network — the autonomic nervous system or ANS — is ‘autonomic’ i.e. ‘independent’ of our conscious control, yet to some extent modifiable. For example, we can hold our urine until we reach the bathroom, well, most of the time!V, a 64-year-old retired headmaster, came to us with a rather peculiar problem. For almost a year, he had been unable to stand up. He would collapse and transiently lose consciousness. Starting with giddiness on standing up, the problem had progressed to intolerable vertigo and eventually episodes of syncope (fainting), leaving him most comfortable when flat on his back. Not surprisingly, V had taken himself to bed, occupying supine repose, in which he was most comfortable. Not surprisingly also, this rendered him severely disabled, dependant on his wife of almost four decades, for all activities of daily life.

When we first met V, he was petrified of standing up, even with our persuasive encouragement and promise of medical support. We had to, therefore, admit him to a partner hospital, and begin attending to him there. Our detailed 360° evaluation confirmed that he had a rare but disabling condition — progressive autonomic failure — with the background of long-standing depression, under treatment with psychotropic medication and a history of generalised seizures (in remission). He had many symptoms of clinical autonomic dysfunction: his blood pressure when taken lying down was 90/50 mmHg; when he stood up, however, his blood pressure plummeted to 50/? — the diastolic so low that it was unrecordable. His postural vertigo, variable heart rate, altered patterns of sweating, pain in the neck and shoulders (coat hanger distribution), unpredictable bowel movements were all symptomatic of his underlying condition: Clinical Autonomic Dysfunction. In addition V had slurred speech and diminished swallowing ability without apparent neuromuscular weakness.

Following diagnosis, V was started on one of the few drugs that can help prevent postural fall in blood pressure. He also was enrolled into our interdisciplinary and integrative rehabilitation programme for autonomic dysfunction. Extended physiotherapy sessions including passive mobilisation, electrotherapy for pain, postural exercise paradigms, gait and balance training, and active exercise protocols delivered over three weeks. He also received acupuncture targeting his neurological symptoms and therapeutic mud for his gastro-intestinal symptoms. Sessions of Jacobson’s Progressive Muscle Relaxation as well as supportive counselling to build confidence and motivation and address caregiver distress were included. At the end of the treatment period, aided no doubt by both drug and alternative therapy approaches, V was back on his feet.

Clinical Autonomic Dysfunction with a plethora of systemic complaints often goes unrecognised as a medical diagnosis; so little being known about ANS and it being difficult to test. Many patients with autonomic symptoms are labelled as ‘psychosomatic’ and do not receive necessary medical attention, leading to avoidable delays in treatment. Indeed the ANS is perhaps one of the last frontiers of neuroscience, requiring significant research focus, as concluded in the recent TS Srinivasan-NIMHANS Conclave on the subject. Not just neurological and psychiatric, ANS symptoms can present with vertigo (ENT), cardiac (heart), respiratory (lungs), gastroenterological (abdomen), genitourinary (urinary and sexual), orthopaedic and rheumatology (bones, joints, musculoskeletal) complaints. A clinical diversity that can test the most accomplished physicians. While falling men like V could well have failing neurons, we also learn from him that people with a plethora of unexplained medical symptoms do deserve an ‘autonomic’ approach and may well benefit from therapy and rehabilitation.