Here is something on your personality type and the music you like

Music exists in different types and forms. We are also of different types. Is there any correlation between our personality type and the kind of music we like? There have been many speculations on this, but very few empirical studies. Here is a study which I came across. But there is a caveat. Do not take it too seriously.

http://www.scribd.com/doc/5573359/Music-tastes-link-to-personality-Press-release

What motivates the suicide squads?

Hi readers,

Manu has asked "What motivates a terrorist ?" in response to one of my earlier posts. In fact most of us would be having the same thought in our minds, post the recent events in Mumbai. Why do they do this?

Recently there has been reports of youth from even the southern most state of India - Kerala, where nobody speaks Hindi, leave alone Urdu - being recruited for terrorist activities in Kashmir. Most of these were either unemployed youth desperate to get a job or people with past criminal record who came into contact with the recruiting agents. Money would be a very powerful factor to lure such people. Obviously, there is huge money involved in this business. It is not fully convincing to think that Pakistan alone is behind all this. Can the government of a poor nation like Pakistan alone fund such large scale activities? May be, Pakistan is only a transit point in the whole affair. Funding may be being done outside that country by some agency with real money power. Revealing the whole truth needs concerted efforts of all nations. Such issues are not my subject in any case.

Mental health professionals will be more interested in uncovering the factors motivating one to join the ranks of such outifts involved in inhuman activities. It is very difficult to think that a pious person -of any faith - will involve in such activities.

I am quoting from an email send to the e-group of psychiatrists by Dr Abhay Matkar practising psychiatrist at Hubli, Karnataka. He describes findings from his study by interviewing some militants captured by army from Kashmir.

Dr. Matkar writes...."I am reminded of the study which was conducted by me & few others to know the psychodynamics of militancy.I pen down a few thoughts picked during the study on over 500 militants captured by the Indian army: Economic deprivation & deep sense of hurt(alienation) was the major cause of militancy in Kashmir.Coercion was the next major cause to take up to arms.Contrary to the popular belief,religion was not the primary motivational factor for Kashmir militants. What was striking was the strong motivation to sacrifice oneself for Jihad--the holy war.The indoctrination of ethnic & religious identity,political insecurity &deep sense of personal deprivation entrapped the virgin mind into taking to the 'gun culture'.The weak ego,a low self esteem & low frustration made matters worse. Militants seen by me showed no warmth in their relationship with family members nor a keen desire to be reunited with their dear ones.Three-fourths of these are between 15 to 30 years of age;most of them school dropouts.A significant youngsters had painfully tattooed the organisation they belonged to. Militants showed no personal involvement; killing was dehumanised- the victim was faceless,unknown to him.Often the militant was ordered or nominated to carry out the killing-killing was institutionalised. Suicide for a cause was rational & was called martyrdom. A group seen by me reacted with pride when chosen for a 'mission'.Those not selected reacted with bitter & sometimes hysterical resentment.The chosen ones were given a 'dining out' by the Commander.The farewell speech super-charged them mentally. These militants could not be categorised as "fanatics" or "mad men","psychopaths" or "mentally abnormal".They are normal people with a different psycho-logic of their own. It pains to see that time has not removed the veil of cruelty.Political answers are far from soothing. A real introspection & EARLY INTERVENTION are the only way we can have a safe tomorrow. LETS RISE.Regards. Abhay Matkar Hubli"

I am posting this for wider circulation among mental health professionals, other experts, social / political leaders and the public. Comments are welcome.

Bye

Dr Harish M Tharayil

Sleep and your mood.

As said earlier mood disorders are closely associated with sleep disturbances.
What is the relationship between sleep and mood?
Studies have shown that transient sleep deprivation can lead to an elevation of mood. A depressed person feels much better after overnight sleep deprivation.
Sleep deprivation can increase the risk of precipitating an attack of mania in a person predisposed to Bipolar disorder. Many persons develop their first manic episodes during festival seasons. They go to the temple yards to watch the late night celebration and fireworks. This is repeated frequently as most of the festivals are clustered in the same period. The resultant sleep deprivation triggers a manic episode.

Another condition that can be worsened by sleep deprivation is epilepsy. Sleep deprivation can precipitate an attack of seizure in a person predispose to it or in whom the disease is under control using drugs.

Management of sleep problems.

Non pharmacological treatment of insomnia

1) Maintain regular hours for going to bed and waking up. Try to wake up at a fixed time every day, even if you find it difficult to fall asleep at a fixed time. Even though you feel sleepy, do not sleep again. Within a few days the time of sleep onset advances to an earlier time.
2) Avoid heavy meals closer to bed time. Early dinner is better, especially if it is heavy.
3) Avoid day time naps.
4) Engage in some physical exercises. Avoid doing it or any other vigorous physical activity during late evenings.
5) Avoid tea, coffee and tobacco at least 6 hours prior to bed time.
6) Avoid bright light before sleep time. It is better for the bedroom to be dimly lit and slightly cool to promote sleep.
7) Clean up your mind before going to sleep. Avoid pondering over issues while lying on the bed. If you suddenly remember something urgent or important, jot it on a piece of paper to look into it next morning.
8) Avoid gazing at the clock repeatedly if you are lying in the bed awake. It is better to sit up and do something that is dull, boring and non stimulating.
9) If you find it difficult to get sleep even after 15 to 20 minutes in bed, get up and sit down. Get something that is not very stimulating or interesting to read. Read it sitting on a chair beside the bed using a reading lamp or in dim light. If you feel sleepy after sometime again try to sleep. Repeat this till you sleep.
10) If you feel tensed up while in bed, engage in deep, slow, abdominal (diaphragmatic) breathing. Take slow deep breaths ensuring that your abdomen lifts up with each breath. Avoid laboring with your chest. When the breath is fully in and your abdomen is protuberant, start slow exhalation by slowing tucking in the abdomen. Repeating this for a few minutes will make you feel relaxed. Thinking some positive thoughts or soothing imagery during this deep breathing may be helpful to some.
11) Use the bed exclusively for sex and sleeping. Avoid reading on the bed even during daytime.
12) Keep away from the tendency to use alcohol as a hypnotic.
These measures can be tried by any one who has difficulty to get sleep. There is no risk involved with any of this.
Insomnia can be transient or continuous.
Transient insomnia is due to mental tension or some minor problems. Continuous insomnia may be due to medical or psychiatric disorders.
Depression, anxiety, psychosis, substance abuse etc are the psychiatric illnesses leading to insomnia.

Using drugs for the treatment of insomnia is not always advocated. First of all the medical and psychiatric disorders have to be ruled out. Next an agent with minimum chances of abuse has to be selected which does not cause daytime sleepiness. Unfortunately, not many drugs are available which satisfies the above criteria. Hence it is better to consult a doctor for choosing a drug and for appropriate instructions.

Some sleep problems....

Delayed sleep phase syndrome is a mismatch between a person’s sleep-wake cycle to that of the general population. Most of us sleep between 10 pm to 12 midnight and wake up between 5 am to 7am.
But a person with this condition is not able to sleep till 2 am or 3 am. He is awake and mentally active till this time, showing no signs of exhaustion or sleepiness. He is able get up without feeling sleepy only bi 11 am or 12 noon.
There are many explanations for the development of this condition. One is that the sufferer’s brain is unable to respond to the most important regulator of our sleep – wake cycle i.e. light. The brain areas controlling the sleep – wakefulness cycle do not respond to the diminishing daylight to induce sleepiness. In majority of us this is why we feel sleepy when the lights are dimmed.
Need for sleep varies between individuals, and within the individual at different points in life. People with need for longer sleep may be dissatisfied even after sleeping for 9 to 10 hours. People with mood disorders – both unipolar depression and bipolar disorder – show abnormalities of sleep. Many of the bipolar patients in depressed phase, and those with a subtype of unipolar depression called atypical depression sleep for long hours.

Sleep duration, quality, dreaming......

Misconceptions about many aspects of sleep, including its duration are highly prevalent in the community. Sleeping for lesser duration is equated with evidence of hard work. There is no fact in this. An adolescent aged 14 or 15 years has to sleep at least 9 hours a day according to most experts. But will any child who is to appear for CBSE / SSLC be permitted to sleep this much ?
In reality, there is wide variation in the sleep requirement of individuals. Some can function without any problem even by sleeping for 4 or 5 hours. But generalizing this to the whole population will only lead to unnecessary conflicts. Advancing age reduces the need for sleep as well as results in fragmented and poor quality sleep.
Among the stages of sleep about 25% of time is spent in REM sleep and 75% in Non REM sleep. About 25 to 30% of the Non REM sleep is spent in superficial stages I and II. Usually this portion of sleep can be dispensed off without much adverse consequences. This is what is done by most short sleepers. They enter in to the deeper stages of Non REM III and IV within few minutes of sleep onset. The minimum time of sleep needed may vary from 4.5 to 5.5 hours. This is roughly the time spent in Non REM Stages III, IV and REM together. Reducing the time spent in these stages can lead to sleepiness, poor concentration, impaired work performance, accident proneness etc. If such a deprivation is prolonged mental or physical disorders can occur.
Dreams mostly occur during REM sleep. Dreams may occur in SWS also, but these are less likely to be remembered. It is usual for the sleep to be disturbed by dreams after being deprived of proper sleep the previous night. This is due to rebound of REM sleep. The body tries to compensate for the lost REM sleep by more frequent bursts in the succeeding night.

Dreams were thought to have symbolic meaning. This idea attained maximum scientific attention after Sigmund Freud's book 'The interpretation of dreams'. But now, neuroscientists and psychologists do not give much importance to the content of dreams in understanding the mental life of a person.

Sleep......

Sleep is a behavior seen in almost all animals. We spend around one third of our life time asleep. Prolonged sleep deprivation can lead to severe mental and physical problems and result in death. Lack of proper sleep can lead to reduced immunity, impairment in memory, reduced alertness and clarity if thinking. Disturbances of sleep are commonly found in majority of psychiatric disorders.
Generally people think of sleep as a uniform state. But studies using electrophysiological equipments have shown that sleep can be divided into distinct stages which occur in a predictable sequence. This pattern is referred to as sleep architecture.
Sleep can be defined as a state of rest with reduced awareness about the environment that is easily reversible. Thus it is different from other superficially similar states like coma.
Human sleep is subdivided into 2 types based on certain electrophysiological parameters and other phenomena. These are the REM (rapid eye movement) and Non REM sleep. REM sleep gets this name as there are rapid movements of the eye balls during this phase. This phase is associated with vivid dreams.
As one falls asleep the first stage occurring is called Stage I of NREM sleep. Then we successively pass through stages II, III and IV. Each stage has characteristic features on the Electro encephalogram (EEG). Slowing of EEG activity is noted from stages I through IV. Stages III and IV are together called Slow wave sleep (SWS) because the EEG record show considerable slowing during these stages. The EEG of REM sleep shows fast activity resembling the waking record.
REM sleep appears in bursts. At the end of approximately 90 to 110 minutes the first burst occurs. By this time the subject would have progressed to the SWS stages.
Subsequently, the subject moves back to SWS in around 20 minutes. Thereafter the sleep alternates between SWS and REM bouts every 60 to 90 minutes. The person enters the stages I and II of NREM only if wakes up again. Otherwise the rest of night is spent in SWS and REM sleep only.
Sleep is essential for growth and repair of the body, consolidation of memory and many other unknown functions. The secretion of growth hormone is maximal during sleep in babies, showing the important role of sleep in their growth.

Is addiction a moral weakness?

The only reason to make the distinction [between habit and addiction] is to persecute somebody’ (Szasz, 1973).
The terms addiction, abuse, dependence etc have been used in an imprecise manner by many and this has created some confusion. Lay people still use the term 'addict, addiction' as these are easily understood. But professionals, especially mental health professionals, prefer to avoid these terms for various reasons. One reason is from the angle of political correctness - these terms have pejorative connotations. The other reason is the lack of precise definition, even though these terms have been in use for quite long time. Yet another issue is the trivialized usage. This is when we refer to 'cross word puzzle addicts or exercise addict'. Using the term this way creates a wrong impression that substance use is a problem of similar nature.
Both DSM - TR and ICD - 10 (these are the classification systems used by psychiatrists for diagnosing and classifying mental disorders) use the terms 'substance use disorders' and substance induced disorders'. Substance use disorders include 'substance abuse' and 'substance dependence'. Substance induced disorders include intoxication, withdrawal and other more serious psychiatric conditions.
There are two aspects to dependence - physiological and behavioral. Physiological dependence has two aspects. One is the development of tolerance to the drug necessitating the use of increased quantity over time. The other is the development of a specific withdrawal syndrome on cessation of use.
Behavioral aspects include 1) strong desire or craving for the substance, 2) inability to control the onset, duration, termination or quantity of use, 3) spending lot of time to procure, use or get over from the effects and neglecting other avenues of pleasure due to excessive preoccupation with the substance
and 4) continued despite having adverse consequence (e.g: drinking despite having liver impairment)
It has been argued that it is better to use the term 'neuro adaptation' to the physiological phenomena of tolerance and withdrawal. Therefore, the term dependence is better reserved for the psychological and behavioral consequences.
But this is not strictly adhered to by most authorities. Thus the term 'dependence' continues to include both the physiological phenomena and the behavioral aspects.
The quote given at the beginning is not acceptable to mental health professionals. Dependence is a maladaptive state. It is a significant problem affecting millions all over the world - both the users, their families, employers and the society as a whole. A problem of such magnitude should not be trivialized by comparing with use of common things like food, music, clothes, water or oxygen.
Dependence to substances need not always be thought of from the moralistic angle. A person who is dependent on a psychoactive substance is in a pathological state. It is not like excessive time being spent on music or cross word puzzles. There are no serious physical, mental or social consequences for them. But the serious consequences of substance dependence can be proved with ample evidence. There is no need to be value neutral when one is dealing with a disease condition.
There is definite vulnerability underlying development of dependence. When such a vulnerable person is exposed to the substance, he is at risk for dependence. Social, cultural and psychological factors are also important in shaping the final picture. There may be several others who can have controlled usage. Dependence on substance is not a sign of moral weakness. It is a pathological condition which develops in persons with biological, psychological or social vulnerability, needing proper evaluation and treatment. If untreated, it will lead to serious individual and social consequences. Substance abuse in most cases, is just a prelude to development of dependence. It is always better to intervene at this stage without waiting for development of a full blown dependence syndrome or serious health consequences.

Dr. Vilayanur S Ramachandran talks on the Mind

An excellent talk on 'Brain and Mind' by noted neuroscientist Dr. Vilayanur S Ramachandran is available at this link.

http://www.ted.com/index.php/talks/vilayanur_ramachandran_on_your_mind.html

He disucsses the Capgras delusion, Phantom limb pain and synesthesia in this talk. The 'mirror box' used to relieve phantom limb pain is also shown.

OCEAN of personality

Study of personality based on psychological traits has a quite interesting history. It started with Gordon Allport and Henry Odbert in 1936 who used a very innovative method. They searched an unabridged dictionary for words that could be used to describe persons. They identified around 35000 words. Further analysis was done to eliminate mere evaluative terms (e.g:awful) resulting in 4000 genuine words that can be called words describing genuine traits.
Raymond Cattell identified 35 personality variables from this list of 4000 words. Further empirical testing and analysis (using statistical technique of factor analysis) resulted in 12 personality factors. He could identify a further 4 factors using self report questionnaire. Thus he came up with the 16 personality factors. He also devised test for measuring these 16 factors (16 PF test).
Later the highly influential British psychologist Eysenck argued that only 2 factors are needed to describe the personality These were extraversion - introversion and neuroticism - emotional stability. Though this was widely accepted, there was a feeling that this is not the whole story.
In 1961, Ernest Tupes and Raymond Christal did studies using the 35 factors of Cattell. They produced evidence that a 5 five factor model could fit in well with empirical data and could explain personality. Thus this model was better than Eysenck's 2 factor model.
The utility of this model was confirmed by Norman and Goldberg 20 years later creating renewed interest in this model.
The 5 factors involved are
Openness to experience, Conscientiousness, Extraversion, Agreeableness and Neuroticism. (can be abbreviated as OCEAN)
Each factor has around 5 or 6 underlying traits. These traits have a strong correlation to the adjectives used to describe a person in the natural languages. Studies have been done in Chinese, hebrew, Filipino and several Indo-European languages.
The personality disorders described in DSM - IV can be understood based on the levels of the underlying traits of these 5 factors.

Internet and computer addiction

These are new terms coined to describe 'addiction to internet and computers'. But as expected, there are controversies about these terms and the concepts. Please read the article at the url below for a discussion
http://apt.rcpsych.org/cgi/content/full/13/1/31
There are also reports from China confirming that they have already recognized this as a disorder. They have even started to treat! Read on.....

http://www.wired.com/culture/lifestyle/news/2005/07/68081

http://www.breitbart.com/article.php?id=081110072129.dnm63sjd&show_article=1
The risk factors for developing internet addiction have been studued, The following are some of the important variable
1) Persons who have poor self esteem, especially as children.
2) Anxious, shy individuals
3) Depressed persons.
4) Persons with high degree of impulsivity.
Looks like it is affects people prone to develop other types of addictions as well.
Learning theorists think that the development of addiction is related to reward pathways of the brain.

Unholy Alliance

Please read about an instance of the nexus between pharma companies and opinion leaders of the medical profession in this url
http://www.emorywheel.com/detail.php?n=25943

Who will take over Psychiatry?

I was thinking of writing about the future of Psychiatry. Surprisingly, Ajeesh has raised this issue in his reply to the post on "Many face of love". (It should have been Many faces). He writes that Psyhcology and psychiatry may be taken over by neurology in future. I have heard the same arguments from many other doctors, mostly neurologists and internal medicine specialists. Theoretically it sounds natural as neurology is THE medical speciality dealing with brain. But there are a few issues in practice.
The incidence of major psychiatric disorders are much higher compared to the pure 'neurological' disorders.The most common neurological condition is epilepsy. This is being treated by psychiatrists, internists, pediatricians and the GP without much problem. The skill sets needed to practice hard core neurology is different from those needed to practise psychiatry. In neurology things are more concrete and precise. In the field of mental health, most of the disorder are still vague and abstract. Enormous verbal skills are needed to listen to the patient, and offer psychological treatments. A neurologist may consider all this including the time spent for establishment of rapport as a waste. Of course, a neurologist or any other doctor with the right inclination can practice psychiatry well. Psychiatrists will outnumber neurologists in most countries.
I view things in a different light. The psychotic disorders need mostly drugs, some education about how to handle the illness (for the patient) and education about how to handle the patient (for the relative). To some extent this can be done by any willing doctor with reasonable expertise in psycho pharmacology, if there is a good social worker to help him with the education part. Usually most doctors are uncomfortable with these patients as they are prone to violence and cause disruption in their respectable consultation rooms. This is why they avoid seeing such patients.
The most common mental disorders belong to the category of neurotic disorders (anxiety, somatization and minor depressions). Here more intensive psychotherapy is needed. Hence a mental health professional is needed. My view is that these disorders are best handled by a good G P with adequate training.
If psychiatry is going to be taken over by another speciality, I wish this will be by the speciality of General Practice. This is more beneficial for the persons with the most common forms of mental illnesses. They can approach the GP without fear of stigma. If the GP has some training and is willing to spend some time, he can manage such cases properly. Thus a G P who is willing, can be trained to manage most mental illnesses and reduce the stigma. Only the most difficult cases and those with multiple diagnoses, need to be send to Psychiatrists. In fact this is true of most specialities. A good G P with adequate training can at least rule out serious conditions and refer only those cases needing real specialist care. It is sad that the speciality of G P is not developed in our country. I do not know why this is so. But I am sure this is one important step towards reducing health care costs. The general practitioners should outnumber the total of all the specialists together in a country.
I hope at least some of my friends and colleagues will respond to my arguments.

Many face of love.....

This is a news item reported in the press from Kochi 2 weeks ago. A boy and a girl who were in love got their marriage registered and proceeded to a jeweller to buy ornaments. They quarrelled over the request made by the girl to the salesperson (to give a good purse as compliment). The groom hit the bride on the cheek in public. She ran out lamenting "if you dare to beat me on the day of registration, you may kill me on the day of marriage". (The families had planned a wedding function after a month). The boy was furious and threw the bag containing jewels and cash to the nearby sewage canal. Later some of this were recovered with the help of police.
Many who read this might have wondered 'Were they truly in love?'. I think love is very much misunderstood in our society. Several sex scandals in Kerala started with a boy (who acts as an agent of a sex racket) abducts a girl in the name of love.
I think it is worthwhile to explore the psychological aspects of love. Earlier I had written about love. This time I shall attempt to go a bit deeper. What I write is based on the work of a psychologist called Robert Sternberg. He has divided companionate love into 2 - intimacy and commitment. So we get three dimensions including 'passionate love'(which was discussed in the earlier post).
Sternberg speaks of nine types of love based on the permutations and combinations of these three dimensions.
If passion (erotic or sexual attraction) alone is present it is only infatuation.
If intimacy (warmth, closeness and sharing in a relationship) alone is present it is just called liking.
If both passion and intimacy are present it can be called Romantic love.
Combination of passion and commitment is called fatuous love.
Combination of intimacy and commitment is called companionate love.
If only commitment (intention to maintain a relationship in spite of difficulties and costs that may arise) is there it may be called empty love, devoid of any intimacy and passion.
True or consummate love only occurs if all the three ingredients - passion, intimacy and commitment - are present.
In the early phase of any relationship, it is passion or erotic attraction that dominates. Later on feelings of intimacy and need to be together arises. But it is only after some time the third factor emerges. This is very important for long term stability of the relationship. Of course some level of maturity and interpersonal familiarity is needed to take a decision to stay together forever.
If people who fall in love are willing to take some time to understand these underlying dimensions that can influence their behaviors, many later disappointments can be avoided. Frequently young people equate erotic attraction with consummate love and commit themselves. This can lead to disappointment later. Before proceeding with any relationship some degree of intimacy is needed. This can later pave the way to development of commitment to maintain the relationship. True, satisfying relationships that last can only be built on such firm foundations.

Doctors dilemma

Dear Dr Vijayan and others,
Any establishment tries to hide some fundamental facts from people to attain their selfish gains or hidden agenda. This is true of religion, political parties and other social movements. That is how movements which started as genuine mass movements become another establishment later on. Rarely only one can see a mass movement without any hidden agenda. I do not share the view that doctors are the most greedy, wicked villains in our society. I repeat my earlier statement that there are good, fair and bad individual in any organization or community. There are few popular myths held by malayalis regarding doctors. One is that doctor is next to god. The other is that one should not lie to a doctor or lawyer. Many people repeat this parrot fashion. This could be one reason why doctors are manhandled when a patient dies. If we think we are next to Gods we have to be infallible. But we enjoy the first as it glorifies us and pampers our egos. But we do not want to be beaten up, so we resort to the defence "We are not Gods". I think both these are wrong. A doctor is like a glorified technician. Like the difference between an ordinary cab driver and an aircraft pilot. It is better to be realistic and popularize this view. Obviously humane approach is very important for a doctor.

Regarding government's role: Landlords never willingly gave their excess land to farmers. It was the government who enacted laws and took over the land. Why our Governments are not regulating the drug industry is because the political parties also stand to gain from the mess. That is why whatever Dr Ekbal or others did has not changed anything in our country. Dr Vijayan sounds like a Christian missionary appealing to sinners to repent and return to God with his appeal to the conscience of doctors. What I say is that no such appeal is needed. If one is sure that offences will be booked, nobody (doctor or politician or God men) will dare to violate laws. This is what happened in UK, Australia, USA, New Zealand etc. Everywhere the Governments enacted rules to regulate the practice of medicine. This is their duty, just like the doctors duty to their patients. Why they do not do this is because of their hidden agenda. Dr Vijayan is silent on this and blames individuals for the evils due to failure of the system.
Let me put in another argument, just for arguing. Dr Ekbal and many others were dead enemies of computerization. All of them used to repeat that computerization is a hidden agenda of capitalism etc. But now none of them travel without their laptops. They cannot think of a day without access to Internet. Clearly they were wrong and had missed the bus. Are you sure that they won't swallow their words again ? Will they later realize that private firms are needed to pump in money for drug research ? History of drug research shows that it was a few original workers who contributed to humanity by developing the wonderful drugs we have now. The issue is not to drive away all private participation. The need is for regulatory authority. Only the government can do this. That too only at the national level, by seeking participation and support of the ethically minded minority in the profession. But only honest politicians will dare to do this. There is no point in speaking like religious preachers appealing to conscience.
In conclusion, let me add that I have no intention of defending unethical practices of doctors. Those who are good will regulate themselves, those who are not good, hell is thy abode! I too have started to preach!

What motivates us.......?

We are motivated to do things by our needs. But all needs do not have the same power to motivate us. The best theory to explain human motivation was put forward by a prominent humanistic theorist called Abraham Maslow.

Maslow has conceptualized that human needs can be arranged into a hierarchy. The most basic needs (usually based on satisfaction of biological needs and drives) have to be satisfied to a reasonable extent for a person to become concerned about the needs at higher levels.
Tier 1 - Physiological needs like hunger, thirst etc.
Tier 2 – Safety and security needs.
Tier 3 – Belongingness, love and affiliation.
Tier 4 – Achievement, recognition and self esteem needs
Tier 5 – Cognitive needs, that is knowledge and understanding.
Tier 6 – Aesthetic needs, that is for order and beauty.
Tier 6 – Need for self actualization. A person can be fully happy if he is able to fulfill his real potential.
This theory has been highly influential in the fields of psychology, behavioral sciences and management studies. The strength is that it integrates the biological needs of a person with his social and emotional needs, thus achieving a synthetic or holistic perspective.
Maslow says “What a man can be, he must be” (or he should rather attempt to become).

Basic health care at affordabkle costs....Who should ensure this ?

Ajeesh may be surprised to know that there is no proper course to train a GP in our country. Except the Dip NB (Family medicine) course of the National Board which is not very popular among doctors. What we do is to shout from rooftops about the importance of primary care service. It may be having commercial interests as well. Specialist practice is concentrated around towns / cities in huge capital intensive multi speciality hospitals. Providing basic health care at affordable costs to the public is a very important duty of the government. It is not something that doctors or private health care providers should be entrusted with. It is not correct to depend on the committment or compassion of a few doctors alone for this.
Experts and medical teachers all over the world are now speaking of providing medical education in community settings to reduce the overemphasis on technology and equipments. Majority of health problems can be solved by the good old village doctor. What he does is to rule out serious illnesses and comfort the poor man. This helps to reduce the cost of health care. Those who need expert care are referred to specialist settings. But this arrangement may not be welcomed by the hospital promoters and some drug companies. It is true that private companies are the most active players in the development of new drugs. How to regulate them without hindering research is another major challenge.

Hotch-potch medicine

Dear friends,
Thanks for the comments. The history of medical practice in India is quite complex as suggested by Dr Vijayan, We had a totally unregulated system till the British entered. Thereafter the western scientific medicine started receiving support of the governments. It was eminently successful in controlling infectious diseases. After independence, there was no proper strategy. the British medicine continued to receive state patronage. Instead of developing suitable methods of teaching and developing indigenous systems like Ayurveda, Unani, Siddha etc, they decided to blindly ape the western systems and similar colleges were started.The duration of the course was artificially fixed as 4 and half years in line with that of MBBS. The German system of homeopathy was also treated at par with our indigenous systems. The importance of research was not realized at all. The importance of research in to the merits of traditional systems was highlighted by our former president A P J Abdul kalam.
The development of modern medicine did not follow any proper plan or design either. More on this later

Health care delivery has to be revamped

Some concerns raised by Ajeesh in his comment to my post on Malingering needs to be taken seriously. Being a non medical person, he has observed how doctors do wrong things to patients. But the situation is much more complex in reality. It has to be analyzed in the context of the way medical care is provided in our society. There are various models for providing health care. One is the U K kind of situation in which the general practitioner acts as the point of primary contact for all ill persons, except in an emergency. The G P is also the gate keeper, who decides which patients need to be referred to specialist services. Another style is followed in the U S A and some other countries, where the G P has no specific role.

In our country there is no such strict criterion or demarcation. It is the sick person who decides which doctor he will consult. Often this choice is based on many factors. Proximity, his judgment about the gravity of the illness, cost, accessibility etc are important. For a problem which he thinks is minor, a local non specialist will be consulted. For a more serious problem, he may see a specialist in the nearby town. For a serious complaint, he may choose to consult a large hospital or medical college hospital.

Studies have shown that only about 20 to 30% of symptoms seen in general practice have an organic basis. The G P is actually trying to rule out serious diseases by examination or tests. This is done with a desire to keep the costs as low as possible. The risk-benefit ratio has to be carefully understood in this decision. Sometimes the G P may miss serious illness. This will ruin his reputation and worsen the patients' outcome. Hence, to be on the safer side, he may over treat or over do investigations. The public is ignorant of the complexities involved in taking such decisions. The doctor is actually doing this on their behalf, but he is penalised for errors of omission. Committing errors of commission is a different matter altogether.
The situation is further complicated by kickbacks some drug companies or labs offer. Competition from other doctors is also a concern for a G P whose livelihood depends on his practice income. Another complicating issue is the presence of alternate systems and hostile media who tend to blame the doctor for any negative outcome.
It is the job of the government to come out with clear guidelines of duties and responsibilities of different categories of doctors. One way out may be to follow the U K system and ensure that patients contact specialists only through G P referrals. But this also can lead to problems in some situations, though it can reduce health care costs. The role of the specialist will be to confirm the suspicion of the referring G P or to rule out the suspected serious illness. If serious illness is detected, the patient is treated by the specialist. But the present system of administration in our country may not be able to bring about such a drastic change in the pattern of service delivery. The process of conversion from one system to another can bring up crisis situations which will result in antagonism of the public and media. I do not think our political leadership in any state or at the Center has the will or vision to think about major changes. The way drug industry is regulated in our country is another source for problems. This also need drastic measures.
I am stopping here. Comments from the readers are welcome.

Brain and Mind

“The brain, and the brain alone, is the source of our pleasures, joys, laughter, and amusement, as well as our sorrow, pain, grief, and tears. It is especially the organ we use to think and learn, see and hear, to distinguish the ugly from the beautiful, the bad from the good, and the pleasant from the unpleasant. The brain is also the seat of madness and delirium, of the fears and terrors which assail by night or by day, of sleeplessness, awkward mistakes and thoughts that will not come, of pointless anxieties, forgetfulness and eccentricities”. —Hippocrates, ca. 400
I need not add any more to this vivid statement made more than 2500 years ago. If the father of Modern Medicine could make this statement just by using his powers of observation and deductive reasoning, why many of us still find it difficult to accept this fact?

They ask “What is the evidence for this?”
Fair enough! I shall try to give some simple examples to ponder over.
.
1) Epilepsy is a disorder of brain causing loss of consciousness. There is enough evidence to conclude that excessive uncontrollable firing of nerve cells (neurons) is causing epilepsy. An electro encephalogram (EEG) can show these discharges on a graph paper.
2) Drugs causing altered mental states cannot act if they do not reach the brain.
3) Mentally retarded children have smaller brains leading to their lower IQ.
4) In dementia loss of intellect results from damage to the nerve cells (neurons). This can be seen by taking brain scans.
5) Sleep - only the brain sleeps. The other vital organs like liver, heart, lungs etc continue to function while ‘we’ sleep. Who is this ‘we’? It is our brain.
6) Again heart, liver, kidneys etc can be transplanted. But nobody speaks of brain transplant.
Why?
If brain is transplanted, the person becomes another person.
Sever blow on the head causes almost unconsciousness


What about heart?

Why do people believe that heart is responsible for mind?
People generally equate mind with emotions. It is a common observation that hart beats faster when one is emotionally stimulated. For example when we are afraid, anxious or sexually stimulated heart beats faster. This might have given rise to the belief.

Brain

Cerebral cortex – is the outermost and bulkiest part – responsible for perception, thinking, conscious activity.
Middle part is responsible for emotions and unconscious actions.
Lowest parts are responsible for control of visceral functions. These are almost completely out of voluntary control

Basic functions of the brain / mind

Consciousness
Attention and concentration
Memory and orientation to time, place, self, and others (ability to be aware of who am I, where am I, what time is it now, who are these other people around me etc)
Perception
Language and speech
Thinking
Emotions and mood
Intelligence
Insight and judgment
Behavior and actions

How do we know about external world?
It is through our sense organs and the neurons which receive information from them.
Sensory systems which help us (or our brains) to understand about external world are listed below. This understanding is the basis of our ability to respond to events outside.
Visual, Auditory, Smell, Taste, Touch, Vibration, Joint and muscle sensations


Registration of incoming information about external world is called sensation.
Primary analysis helps to understand what is received.
Giving meaning to sensation based on past experience – perception and apperception.
Secondary analysis
Comparison with existing stored information – this is called memory
Language and second signaling
Control of attention and memory – this is called thinking
It is mostly under conscious control



Processing of emotions

This type of processing is mostly at unconscious level – unconscious mind of Freud. These are mostly under conscious control. Pathways for emotional expressions are not under voluntary control
Complex entities like human health or behavior cannot be understood or explained by a single theory or approach.

The bio-psycho-social model of brain / mind.

Bio-psycho-social model gives due consideration for all the factors.
Social factors operate in the social/interpersonal space.
Psychological mechanisms operate within the individual mind – thoughts, emotions, moods and subjective experiences and their interpretations. The final common pathway for all these factors to operate and affect us is the brain of the individual with its complex electro-chemical processes. Proper understanding of all these factors and their interplay is vital for proper understanding of human health and disease.

Malingering

This is not a medical or psychiatric diagnosis. It refers to willful production of a physical or psychological symptom with the intent of deceiving others and gaining some privileges. The difference from factitious disorder is that here the malingerer is after material gain or escape from punishment. Usually this occurs in forensic settings (when some public figure is arrested!) and in prisoners. The doctor has to examine the patient at different times to check for consistency if the symptoms. If the symptoms are changing in an inconsistent manner it is conclusive proof. The patient’s behavior has to be observed when he is unaware of this. A person with limping may be found to walk normally when alone in his room. Subjective complaint like insomnia may be reported to get hypnotic drugs. Here also observation is important.
It is not correct to ill-treat or insult a malingerer. He has no valid reason to be in the hospital. But he may be having other difficulties. After ensuring that this is ‘genuine’ malingering, the doctor has to report this to concerned authorities. He has to be handled by appropriate social, legal or government agencies.

Usual situations for MUPS

1) Physical illness in the early stages. It takes time for a disease to manifest its pathognomonic signs. Before this the sufferer may have sub threshold symptoms without any objective evidence. Hence it is mandatory that the patients’ symptoms are treated as real and adequate evaluation is done.

2) Subjective exaggeration of mild discomforts by a person who has excessive traits of anxiety or depression.

3) Anxiety and Depressive disorders

4) Somatoform disorders.
i. Somatization disorder.
ii. Conversion disorder.
iii. Persistent pain disorder.
iv. Hypochondriasis.
v. Factitious disorders

5) Malingering.

Each of these are unique situations. They need diferent skills and approaches. In most situations close collaborationb between the treating doctor and mental health professional is needed for proper evaluation and management.

Some underlying concepts..

There is wide variation in our ability to perceive sensations. This is important in our ability to perceive pain and other sensations arising from within our body. Some people are able to perceive peristalsis and other internal movements at a very low threshold. Ability to endure pain also shows wide variation. It also depends on our subjective mental state and contextual factors (e.g.: being lonely in a strange hospital or being surrounded by one’s close kith and kin).

Illness behavior: A person’s belief about presence or absence of illness in him. It can be abnormal when an ill person denies having illness or a healthy person misperceives himself as ill.

Sick Role: It is the privilege given by the society to a person found to be sick by appropriate specialists. The sick person is temporarily exempted from work and other responsibilities. In turn he is expected to subject himself to medical examinations and comply with treatments prescribed. When he is declared as relieved he is expected to abandon sick role and return back.
Clinical picture
14 symptoms are the cause of 50% of medical attendance in general practice. Only 10 to 15% of these are found to be having an organic basis over a period of one year follow up. The rest of them continue to seek medical help without benefit. They sometimes frustrate and irritate the doctors and give rise to arguments. They are a potential source for legal battles. A lot of money is squandered by them and they are at risk of iatrogenic complications from medical investigations and surgical procedures.

The common symptoms are
1) Abdominal pain.
2) Headache.
3) Chest pain / tightness in chest
4) Palpitations
5) Breathing difficulty
6) Low back ache.
7) Vague aches and pains / fibromyalgia.
8) Dyspepsia
9) Dizziness / tinnitus.
10) Vaginal discharge
11) Pelvic pain / premenstrual syndrome.
12) Alterations in bowel habits.
13) Fatigue
14) Sleep disturbance.

Symptoms are usually of prolonged duration with a waxing and waning course. Multiple consultations including specialist work ups would have drawn a blank.

Medically Unexplained Physical symptoms (MUPS)

Patients commonly present to doctors with symptoms or complaints. Complaints are usually of pain and alterations in structure or function of body organs or regions. Doctors are like Sherlock Holmes. Their aim is find out what is wrong with the patient. This exercise is based on the data he is able to collect by history (accurate description of the difficulty including its location, factors associated with onset and termination, duration, nature or quality, other accompanying symptoms etc) and physical examination (aimed to uncover objective evidence to support the symptom – findings like swelling, warmth, restriction of movements or altered sounds during heart beats, breathing etc).

Usually the doctor rules out serious conditions by the above methods, makes an informed guess (provisional diagnosis) about the likely cause of the symptom and prescribes treatment like drugs, dietary changes or other advice. He may order additional tests to confirm or rule out other causative conditions. All this looks fairly simple and straight forward.

Sometimes the doctor senses that the patients’ complaints and objective evidence (obtained by physical examination or tests) do not match. Some patients do not show concern even when they are told that they have serious diseases. Others are not relieved by such pronunciations by the doctor and appear unconvinced, tense and worried.

Both these situations need special attention. Many of the patients who fail to get relief from modern medicine later seek help in alternative systems of medicine as there is no conflict between them and experts in these fields. Practitioners of alternate systems have a very ill defined concept about basic anatomy, physiology and pathology. They are not worried about the mismatch between subjective report and objective evidence like experts in modern medicine. They are in a primitive state (or post modern state with contextual interpretation of reality) and happily listen to long narration of bizarre symptoms uncritically.
The emotional relief obtained from this ventilation may be partly responsible for the therapeutic gains obtained. Some who fail to get relief even from them, flock to faith healers or quacks and demigods out of desperation.

Doctors of modern medicine need to rethink why they are helpless or driven to desperation by such patients. We need to be tuned in to the cues of emotional distress voiced by the patients, and hone up our skills as counselors and emotional healers.

World Mental Health Day 2008 at Kozhikode (Calicut)

My earlier post on the same program on 11th October gives the details of the program. The last photos show Drawing competiton ans Quiz program on Mental Health conducted for school student as part of the WMH Day.

More on delusions ---Form and content.

Another distinction made by psychiatrists is between 'form' and 'content' of the symptom. A person believes that neighbors are plotting to harm or kill him. He may have some reasons for this, as there were some disputes between them and his family over boundary of the plot or something else. But of all the family, only this person believes that there is a plot against him. The other family members might say "It is true that we are not on good terms with them. But that was because our father had a case against them in the court over the boundary. Now that is over, but we are not very cordial to them. Our children play and talk with each other. We do not see any reason why they should conspire to harm or kill us. They are ordinary people without such malicious intent". Now what can the psychiatrist do. He looks at the form and the content.

Content is explainable (explaining and understandability are term used in phenomenological psychology) from the antecedent event of previous conflict. It means that you can reasonably explain the circumstances and the logic behind the belief. But the form (the false unshakable belief, which is not shared by his family members - that is a delusion) is not understandable (understandability is the ability to empathize with him based on the person's situation). Why does he believe so, when even his father (who filed the case) does not believe so ? This is how the belief is labelled as a delusion. Presence of a delusion is conclusive proof of a psychotic illness. Now this is done by looking at other parameters. The person may get one of the psychotic diagnosis - Delusions (paranoid)psychosis, paranoid schizophrenia, or mood disorder (either mania or depression) with psychotic features.
There are two aspects in analyzing any symptom. The Dynamic psychology, which explains the content of the symptom - Why this person is showing this particular symptom now ?. This is based on psychological theories - psychoanalysis or others.
The other is the phenomenological school. The task of Phenomenology is to describe any phenomena that is manifesting in a person's mind by making him to describe it in as much detail and accuracy as possible. This helps to explain the belief baesd on cause and effect logic. Ability to understand and empathize will help to form the therapeutic alliance. In the case of delusions, explanation may be possible based on antecedents, but the form, that is, how a man could be convinced of a patenlty false ideas is not understandable.

Freud and psychoanalysts stressed on the dynamic line of thinking. Emil Kraepelin (the father of psychiatric classification) stressed on accurate description and labelling of the symptom. It was Karl Jaspers (psychiatrist who later turned a philosopher) who highlighted the importance of the use of Phenomenology (a branch of existential philosophy) in Psychiatry.
The dynamic approaches were very popular as everybody wanted an explanation for the errant behavior. But this approach met with only limited success as a therapeutic tool. Later most of the underlying psychological theories used to explain behaviors fell into the category of pseudoscience, as empirical evidence for support was lacking. The current classification systems (both DSM - IV TR and ICD - 10) give more emphasis to accurate descriptions of symptoms. This is why their manuals become a list of symptoms. Used sensibly, this helps to increase objective agreement between different clinicians seeing the same patient. But superficial approaches can do more harm than good.
One more issue is the role of insight. A person with a delusion does not have the insight that his belief is false, or that it does not hold up on objective scrutiny. This is why Esquirol (is it not him ?) remarked "Delusions are the hallmark of insanity". Hence presence of a delusion merits the diagnosis of psychosis (Insight is lost in psychosis, contrary to neurosis). So Sashi's fond hope that a person with a delusion will voluntarily seek treatment does not happen usually. On the contrary they turn hostile to anybody who attempts to correct their belief. Yesterday I Happened to see a lady send by the CJM court Thalassey, who was abusing even the accompanying police constables alleging that they are also a party to the big conspiracy against her.

On Delusions....

It is indeed heartening to follow the discussions on the basis of psychiatric diagnosis, and the relationship between creativity and mental illnesses. Let me go into a little more details on delusions. A delusion is defined as a false and unshakable belief that is not explainable by the persona's socio cultural factors. It can be explained
1) False belief - the belief in question can be shown to be false by objective methods or verification by others.
2) Unshakable - The person refuses to accept any proof contrary to his belief and holds on to it.
3) Not explained by socio cultural factors - This criterion may have been added for social or political reasons than based on science. The most difficult issue at that time may have been 'how to keep religious belief out of the domain of psychopathology'. Without this criterion it will be difficult to do this. Cultural beliefs (for example, a local belief that God resides on top of a nearby mountain) may have to be labelled as psychopathology.

Richard Dawkins explains why he chose the title of his book as 'The God delusion'. He admits that delusion is a technical word used by psychiatrists, but justifies his title seeing no reason not to call belief in God as a delusion. We need not discuss this further. What I am trying to convey is that psychiatric diagnosis have a social/ political/ cultural angle to it and safeguards should be there to prevent abuse of psychiatry by totalitarian regimes.

World Mental Health Day observed at Calicut

Every year the 10th of October is observed as the World Mental Health Day as called for by the World Federation of Mental Health and the World health Organization. This years theme is "Making mental health a global priority; Scaling up services through citizen advocacy and action " The World Mental Health Day was observed at Calicut on 10tth October 2008 in a grand function organized at I M A Hall Calicut jointly by Institute of Mental Health and Neuroscience (IMHANS) Calicut, Kerala State branch of the Indian Psychiatric Society ()IPS) and Arogyakeralam (National Rural Health Mission). The function was inaugurated by Worshipful Mayor of Calicut Shri M Bhaskaran in a function presided over by Mr A Pradeep Kumar, MLA. Shri Radhakrishnan Master, Chairman of the Health Standing Committee, Kozhikode District Panchayat, Dr A Baburaj District Medical Officer and District Program Manager of NRHM, and Dr Mathew Nambeli, Coordinator of Pain and Palliative Care Society Malappuram felicitated on the occasion. Dr. Harish M T Assistant Professor of Psychiaatry and Editor of Kerlaa Journal of Psychiatry of IPS welcomed the gathering. Dr Roshan Bijlee, Research Officer at IMHANS proposed vote of thanks. Dr K S Shaji President of Indian Psychiatric Society, Kerala state branch delivered the keynote address focusing on reducing the burden of care givers by using community volunteers of the Pain and Palliative Care Initiative. He stated that IPS Kerala is willing to associate with this project and also in the long term community care of geriatric persons. Different models of community care were presented in the seminar that followed. Shri Johny from Jyoti Nivas at Vazhavatta, Wayanad presented his efforts in organizing long stay and rehab facilities by individual effort alone with little charity contribution later. The Malappuram and Balussery models were presented next. Here community care and rehab are being organized by collective efforts of Local Self Governance bodies with technical support of the Pain and Palliative Care Society. The District Mental Health Program model of Wayanad and Kannur was presented by Dr Krishnakumar next. Both of these are top down models implemented with financial assistance of Central Government by tertiary care institutions. Department of Psychiatry, Medical College Calicut is implementing the program at Kannur (Dr Harish M T is the nodal officer) and IMHANS is implemnenting it in Wayanad. Dr Krishnakumar, Director of IMHANS is the nodal officer. Mr. Baby from IMHANS presented the story of how the note book manufacturing unit was started as part of the rehab initiative by IMHANS from 1989 onwards.

Buddha, Gandhiji and Spillberg

A famous Professor of Psychiatry in Bombay used to narrate the story of Siddhartha Gautama to his fresh post graduates in Psychiatry (of course without revealing the name) and ask them "What will be your advice if such a parson is brought to you by his parents ?" Obviously it is difficult to give an accurate answer.
The concept of normality is based on statistical norms or conventions etc. A person whose thoughts and behaviors run contrary to these standards is at risk of being labelled abnormal.
I had read in 'Readers' Digest' long ago that the famous Hollywood director Steven Spillberg showed unusual behaviors as a child. He had a huge parakeet living in his room. Nobody except his grandma used to enter his room for cleaning or collecting dirty clothes. All of them were afraid that the bird will fly away. The room was untidy most of the time.
This and many other peculiarities might have given him several unusual experiences in childhood. All these might have contributed to his later creative work. (Later he was diagnosed as having Asperger's syndrome).

His grandma also remembers that the family was advised to consult a psychiatrist by many relatives and friends. She never allowed the parents to do this. She thinks this way she helped to protect his creativity. Is she right ? I have no answer. Is this why Americans use the term Headshrinker (shrinks !) for psychiatrists ?

Creativity and mood disorders.

The present understanding is that Type II bipolar disorder is the underlying disorder in creative persons. When depressed people tend to look back at life and the world with a philosophical outlook. Mind goes into an introspective attitude, analyzing everything with detachment. Such mental state may give rise to profound insight about everything. Later when they become hypomanic, there is increased energy and activity, thoughts race through the mind with extreme clarity and pace. Such state helps the writer to complete the creative work. It has to be emphasized that the severe form of mania is not compatible with this ability to control one's mind and produce works of art. This is why Type II Bipolar disorder is found to be more prevalent. Alcoholism could also be related to this. When depressed they may self medicate with this to improve mood state. During the hypomania it may be used to curb the excess energy and obtain sleep. Other than this, excess use of alcohol may occur as a hazard of being a celebrity. Many of these creative persons are as vulnerable to vices as any of us, if not more. Some think they have a licence to get away with any sort of behaviors, like some of our professional politicians.

Mood disorders

This is the second most serious mental illness after schizophrenia. There are two prototypes of mood syndromes. Mania is characterized by extreme and unreasonable cheerfulness. The person's mood is described as euphoric or elated. He has fat racing thoughts, fast and pressured speech. His activity level increases. In some cases the patient develops grandiose ideas, which reaches delusional conviction in some cases. The person may believe that he is of superior birth, has higher purpose and is chosen by God, or he may believe that he is wealthy and spend recklessly. This cheerfulness may suddenly shift to irritability, anger and assaulting tendency at times. Usually this occurs when relatives try to control the behavior by advice or other means. A milder version of the same condition is called hypomania.
Depression is the opposite extreme. I have already discussed about depression in an earlier post (The black cloud of depression - 09/03/08). Bipolar disorder is a condition which a person shows symptoms of mania (or hypomania) and depression at different times.
Depression can occur as a single episode or as Recurrent depression with multiple episodes. If such a patient develops mania or hypomania later, the diagnosis of recurrent depression changes to bipolar disorder. This condition is subdivided in to several subtypes. If the person get s episodes of both Mania and depression it is called Bipolar Disorder Type I. If he gets depression and hypomanic episodes only it is called Type II. There are many other subtypes but we need not go in to these at present.

Creativity and mental illnesses....

Rather than engaging in side wise discussion (by posting replies), I thought I will write another post. I thank Ajeesh for bringing up the most appropriate reference on the topic. There has been a paradigm shift in understanding the relationship between mental illness and creativity. Earlier most psychiatrists were of the opinion that schizophrenia and related conditions would be the underlying condition in creative people. The perceptual distortions and oddities made them think this way. Van Gogh is one such case in point. It was thought that he suffered from schizophrenia. This could also be due to the lack of proper diagnostic criteria and definitions for the major mental illnesses. The psychological theories dominant at that time may also contributed to this. I am speaking about the 19th century and first half of the 20th century.
Now all this have changed. Mental disorders are now diagnosed by fairly objective criteria and the age of impressionism in diagnosis is over. Most of the psychological theories have now receded to the realm of pseudo science (Thanks to Karl Popper et al and the behaviorists). Now there is fairly good consensus among psychiatrists that mood disorders, especially bipolar disorder is the most common condition found in creative writers and mass leaders. Alcoholism is another common diagnosis. Earnest Hemingway suffered from both. Tolstoy, Abraham Lincoln, Issac Newton etc suffered from depression. Winston Churchill, Beethoven etc suffered from Bipolar disorder. Our own Vaikom Muhamed Basheer also suffered from severe manic episodes with paranoid delusion.

Thinking. mentall illness...and creativity...

The most important events in our waking time are - maintaining alertness and choosing what to pay attention to, processing these inputs and associated feelings etc, thinking and planning, and finally responding by appropriate verbal or behavioral means. We are continuously preoccupied with one thought or another throughout our waking hours. But what is thinking ?
According to one definition It is a flow of ideas, symbols (words are symbols for objects or concepts) or associations (refers to connection between one idea and the next). Thought is usually initiated by a problem or a task, proceeds in a logical manner and results in a reality oriented conclusion. This type of thinking is called rational thinking which is the most usual mode of thinking employed by us. Such thought can also use the medium of combinations of sounds or colors as when a musician or painter makes his creations. But usually most of our thought uses the medium of language.
But we are also capable of many other types of thought. In fantasy there is no clear use of logic. Contact with reality may also be abandoned to some extent when one is in the mode of fantasy thinking. Creative writers use this mode for creating their tales or poems. But if fantasy thinking becomes excessive, or uncontrolled, or if it becomes the predominant mode, the person may have crossed over to the other side of the Line of control. Psychotics are unable to distinguish between these modes of thinking. A person with schizophrenia may be believing the irrational or subjective reality created by his mind and taking this as objective fact. (It has to be conceded that his genetic and environmental vulnerabilty also contributes to this state).
This may be one reason why madness and creativity were thought of as 2 sides of the same coin. In psychosis, the person is unable to perform reality checks to put his subjective world in order. A creative writer is able to utilise this gift of imagination in a controlled manner.In addition he also has good linguistic skills, vocabulary, the insight and empathy to understand the emotional world of others. Many of them have an open attitude and are bold to experiment with life and entertain unconventional ideas. I think it is this combination of many facets that makes a creative writer. It has to highlighted that emotional skills are as much important as cognitive skill for an artist.

Am I 'mentally normal' ?

Well, it is one of the most difficult questions to answer. Psychiatrists have to face this question frequently. We happen to see grossly abnormal, psychotic person asserting that he is normal; on the other hand many apparently normal persons approach us with the above question. The truth is that there is no absolute yardstick to measure whether one is normal or not. But this is so even in the most branches of biology.
We can define an average Indian male citizen as a person with X cms of height, Y kg of weight, Z color of skin, M color of eyes etc. But such a person may never exist in real world !. This normality is based on statistical calculations.
We may also define normality by other methods. All are presumed to be healthy unless found to have an abnormality or a symptom. This is a presumptive criterion used in community health.
Normality can also be thought of as an ideal or utopia. It can also be viewed as a dynamic state or as a process.
I am stressing this difficulty as I think it is important that we are aware of the limitations in judging others. With this background only we can start the discussion on mental health, illness, creativity and psychopathology.
We have to accpet that even the most normal of us can have certain queer or abnormal behaviors in some situations.

On lagging behind....

In continuation of the post on "We" lagging behind our brains, I am quoiting Dr. Vilayanur S Ramachandran's words on this subject. Please read on ....

"Now let's go back to normals and do a PET scan when you're voluntarily moving your finger using your free will. A second to three-fourths of a second prior to moving your finger, I get the EEG potential and it's called the Readiness Potential. It's as though the brain events are kicking in a second prior to your actual finger movement, even though your conscious intention of moving the finger coincides almost exactly with the wiggle of the finger. Why? Why is the mental sensation of willing the finger delayed by a second, coming a second after the brain events kick in as monitored by the EEG? What might the evolutionary rationale be?
The answer is, I think, that there is an inevitable neural delay before the signal arising in the brain cascades through the brain and the message arrives to wiggle you finger. There's going to be a delay because of neural processing - just like the satellite interviews on TV which you've all been watching. So natural selection has ensured that the subjective sensation of wiling is delayed deliberately to coincide not with the onset of the brain commands but with the actual execution of the command by your finger, so that you feel you're moving it.
And this in turn is telling you something important. It's telling you that the subjective sensations that accompany brain events must have an evolutionary purpose, for if it had no purpose and merely accompanied brain events - like so many philosophers believe (this is called epiphenomenalism) - in other words the subjective sensation of willing is like a shadow that moves with you as you walk but is not causal in making you move, if that's correct then why would evolution bother delaying the signal so that it coincides with your finger movement?
So you see the amazing paradox is that on the one hand the experiment shows that free will is illusory, right? It can't be causing the brain events because the events kick in a second earlier. But on the other hand it has to have some function because if it didn't have a function, why would evolution bother delaying it? But if it does have a function, what could it be other than moving the finger? So may be our very notion of causation requires a radical revision here as happened in quantum physics. OK, enough of free will. It's all philosophy!"
Splendid !.
But I salute the great Lord Buddha, who declared 2500 years ago. that the notion of our 'self' is an illusion (though he could not tell us the process behind this). In fact there is only moment to moment existence.

The Self

To start a discussion on self I am quoting from Dr V S Ramachandran, from his BBC Lectures. He says the sense of slf has 4 elements -

Emodiment or ownership - we experience our self as embodied in our body.
Continuity We experience ourselves as having continuity is time - past present and future.
Unity - Though undegoing diverse sensory and other experiences and doing many things, we experience a sense of unity. The 'me' doing all this is experienced as the same.
Agency - We experience ourselves as masters of our own actions, experiences and our destiny.

Please read on ......
V S Ramachandran.....
"But what about the self? The last remaining great mystery in science,it's something that everybody's interested in - and especially ifyou're from India, like me. Now obviously self and qualia are twosides of the same coin. You can't have free-floating sensations or qualia with no-one to experience it and you can't have a self completely devoid of sensory experiences, memories or emotions.
What exactly do people mean when they speak of the self? Its defining characteristics are fourfold. First of all, continuity. You've a sense of time, a sense of past, a sense of future. There seems to be a thread running through your personality, through your mind. Second,closely related is the idea of unity or coherence of self. In spite ofthe diversity of sensory experiences, memories, beliefs and thoughts,you experience yourself as one person, as a unity.
So there's continuity, there's unity. And then there's the sense of embodiment or ownership - yourself as anchored to your body. And fourth is a sense of agency, what we call free will, your sense of being in charge of your own destiny. I moved my finger. Now as we've seen in my lectures so far, these different aspects of self can be differentially disturbed in brain disease, which leads me to believe that the self really isn't one thing, but many. Just like love or happiness, we have one word but it's actually lumping together many different phenomena. For example, if I stimulate your right parietal cortex with an electrode (you're conscious and awake) you will momentarily feel that you are floating near the ceiling watchingyour own body down below. You have an out-of-the-body experience. The embodiment of self is abandoned. One of the axiomatic foundations ofyour Self is temporarily abandoned. And this is true of each of those aspects of self I was talking about. They can be selectively affected in brain disease".

We lag by 0.3 sec !

According to Benjamin Libet, there is a delay of 0.3 sec between the arrival of a sensory stimulus in our brain and its conscious recognition. There is a similar delay between initiation of action and its awareness.

Yes ! Its true "We" are 0.3 sec behind our brains, both in apprehending external world and responding to it !

This may be the time taken for the neurons and synapses to complete the underlying electrical and chemical processes. Please follow the link below for reading a discussion.
http://serendip.brynmawr.edu/exchange/node/231

Free will and Brain

I am writing this post to throw some more light on the issue of free will and its basis in the brain. The brain has many subdivisions - lobes, nuclei, fibers and tracts connecting these areas etc. The most evolved portion of the brain dealing with - choosing actions based on goals, planning things in advance, taking steps to execute these etc is the prefrontal lobes. Anything that the brain encounters the first time is passed on to the these lobes to evaluation.This is because this area is specialized in handling any novel situation (cognitive novelty). For example, when you are learning to drive a car, each of your actions originate in and are monitored and controlled by the prefrontal cortex. Later when you are an expert driver, this task becomes a routine thing for the brain, and hence the prefrontal areas are spared from this routine to do important things like handling newer situations. Routinized tasks need not be under the control of this highly specialized neurons.
To sum up, the most developed area is let free to handle complex things and the older and less sophisticated areas take care of routine things. Division of labour. Just like your mom tries to supervise her newly recruited household help; later she alone manages the routine tasks. Mom is free to take up newer challenges.
This division of labor is for saving time and energy. Conditioning is also a similar method to save time and energy. There is nothing wrong in assuming that a bell will be followed by food, if this has been the case on several past occasions.
Such methods used by the brain should not be taken to be running contrary to free will.

Observance of the World Schizophrenia Day on 24th May 2008,

The District Mental Health Program Kannur, observed the World Schizophrenia Day on 24th May 2008 by conducting a Mental Health Awareness program at Government Hospital Mattannur in collaboration with Mattannur Municipality.