“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.
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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.
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.
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.
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.
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.
