Friday, March 6, 2020

Schizophrenia—Evolution of Humanness

brain diagram showing distortions in language and perception
Is schizophrenia bound to human evolution? Schizophrenia is a neuro-developmental disorder characterised by delusions, hallucinations, and bizarre behaviours. No other animal displays these symptoms. Depression, addiction, anxiety are all found in other animal species, but not schizophrenia. Schizophrenia is not even found in chimpanzees our most recent evolutionary ancestors. It is inheritable, and highly disadvantageous to survival of the affected person. Given this, schizophrenia should be almost non-existent. Yet it continues to affect a massive 1% of the global population. Something is pushing for the persistence of this disorder and its spontaneous manifestation in humans.

Human evolution separated from the chimpanzees 5.5 million years ago when we walked upright and then acquired language abilities. Language ability developed after 'lateralisation', the separation of brain functions into the left (sequential) and right (parallel processing) hemispheres. The peculiar delusions and hallucinations of schizophrenia can be understood as failure of the complex brain mechanism that enables the speaker to distinguish his thoughts from his speech or that of others. This brain mechanism evolved with lateralisation of brain functions. Loss of brain laterality in schizophrenia has been demonstrated.

Comparison of the gene sequences of early humans and their close evolutionary relatives, the Neanderthals have shown that regions of the human genome that underwent positive selection are enriched by association with schizophrenia. This suggests that schizophrenia susceptibility factors may be a "side effect" of human achievements like language and creative thinking. 

Recent evolutionary modifications in brain wiring and connections may have played a role in the development of schizophrenia in humans. Compared to our closest living relative the chimpanzee, brain connections present only in humans show a higher involvement in schizophrenia. Evolutionary changes in the human brain related to supporting more complex brain functions are paralleled with a higher risk for brain dysfunctions that can manifest as schizophrenia.

However, this genetic susceptibility is actually reducing. A study comparing modern-human-specific gene sites with archaic ones has shown that schizophrenia-risk related genes in modern humans are much less than those in Neanderthals and Denisovans (archaic humans). So negative selection of schizophrenia risk-related genes are probably being gradually removed from the modern human genome.

References

  1. https://en.wikipedia.org/wiki/Human_evolution
  2. Crow TJ. Is schizophrenia the price that Homo sapiens pays for language? Schizophr Res. 1997;28(2-3):127–141. doi:10.1016/s0920-9964(97)00110-2
  3. Crow TJ. Schizophrenia as the price that homo sapiens pays for language: a resolution of the central paradox in the origin of the species. Brain Res Brain Res Rev. 2000;31(2-3):118–129. doi:10.1016/s0165-0173(99)00029-6
  4. Srinivasan S, Bettella F, Mattingsdal M, et al. Genetic Markers of Human Evolution Are Enriched in Schizophrenia. Biol Psychiatry. 2016;80(4):284–292. doi:10.1016/j.biopsych.2015.10.009
  5. van den Heuvel MP, Scholtens LH, de Lange SC, et al. Evolutionary modifications in human brain connectivity associated with schizophrenia. Brain. 2019;142(12):3991–4002. doi:10.1093/brain/awz330
  6. Liu C, Everall I, Pantelis C, Bousman C. Interrogating the Evolutionary Paradox of Schizophrenia: A Novel Framework and Evidence Supporting Recent Negative Selection of Schizophrenia Risk Alleles. Front Genet. 2019;10:389. Published 2019 Apr 30. doi:10.3389/fgene.2019.00389

Wednesday, January 29, 2020

Creativity

How do we define creativity?

Creativity is the ability of individuals to develop novel and useful products. Novelty, originality, innovation, ingenuity are some of the words often used to define creativity. But originality is just one component of creativity. There is another essential aspect of creativity – the idea should be effective, useful or productive. 

Creativity exists in many domains and is not just limited to the arts, as most people seem to think. Creativity is at work behind most scientific inventions, innovative gadgets, health technologies and economic theories which have changed the world.

Individuals differ in their propensity and capacity to be creative. Many of us are creative in small ways - in ways we find solutions to problems of everyday life. Only a few are highly creative and leave their mark on the world.

What does it take to be creative?

Creative individuals tend to possess some qualities or traits that may contribute to or are associated with their original thinking:
  • Excellence: creative people are usually masters in their particular domains.
  • Interests: they tend to be interested and curious about many things outside their main subject. This probably enables them to combine ideas or techniques from other disciplines in unusual ways to come up with novel, workable solutions to problems.
  • Exploratory: They tend to be open to new experiences, ideas and ways of doing things.
  • Motivation: most creative individuals are passionate about their interests and internally motivated.
Creativity is not about sitting and waiting for a sudden flash of insight or inspiration. This insight usually comes after much time spent in gaining knowledge and working hard at the task on hand. Discipline and perseverance are an essential part of the creative process.

As Edison famously said
Genius is 1% inspiration and 99% perspiration
High intelligence does not equate with creativity, however, creative people tend to have an above average IQ.

Can creativity be taught?

The generally accepted view is that creativity is not a set of skills which can be taught or learnt. However, certain habits, tools or strategies can be taught, and an environment that encourages and fosters creativity can be provided in our homes, schools and workplaces.
  • Building basic skills and domain-specific knowledge
  • Stimulating and rewarding curiosity and exploration
  • Encouraging internal motivation, mastery and self-competition
  • Providing opportunities and resources
  • Promoting a willingness to take risks

Creativity and mental health

Those in creative, artistic professions tend to have a higher than average correlation with mental illnesses including schizophrenia, bipolar illness, substance abuse and suicide risk. 

Conversely, creative activities such as music, dance, art, journaling and poetry writing have been known to promote psychological well-being.

Does treatment of mental illness reduce creativity?

Treatment of mental illness could both help or hurt creativity. When treatment reduces fearfulness and avoidance it helps creativity. When it reduces motivation and flexibility it can hurt creativity. In practice there is usually a delicate balance that needs to be monitored. Some treatments are more effective at preserving creativity than others. Treatment that preserves goal-driven motivation helps all people, not only those in the arts field. As with most other aspect of health, physical exercise and adequate sleep help creativity.

Creativity is not all good nor all beneficial to society. A quick survey of the daily newspaper is enough to demonstrate how people resort to extremely creative ways to cheat, defraud or harm others.

References

  1. Flaherty AW. Brain illness and creativity: mechanisms and treatment risks. Can J Psychiatry. 2011;56(3):132–143. doi:10.1177/070674371105600303
  2. MacCabe JH, Sariaslan A, Almqvist C, Lichtenstein P, Larsson H, Kyaga S. Artistic creativity and risk for schizophrenia, bipolar disorder and unipolar depression: a Swedish population-based case-control study and sib-pair analysis. Br J Psychiatry. 2018;212(6):370–376. doi:10.1192/bjp.2018.23

Image

Children vector created by freepik - www.freepik.com


Wednesday, October 30, 2019

Humanity and Psychiatry | Prehistory to Pinel

Prehistoric human skull with trepanations (Monte Albán, Mexico)

Six to seven millenia ago in the Neolithic age it was understood that abnormal behaviours originated in the brain. However, the cause was ascribed to 'confined demons' and holes were drilled in the skull (trepanation) to let them out (Faria 2015). Later, the ancient Greeks and Egyptians developed an illness model of abnormal moods and behaviours, though they believed it was the heart and not the brain that controlled them. Texts that survive indicate formal psychiatric history taking and evaluation, prescription physical therapies like sleep, fever, and music alongside what would fit in with present day supportive and lifestyle and stress management therapies (Lambrini K, 2018). This care was confined to religious temple complexes some of which specialised in treatment of mental health disorders.

The 1st Millennium

Organised medical care in hospitals originated in the near and middle eastern regions. They were the first purely medical centres that developed outside of religious influence. Mental illness was also treated at these centers. The peak of this phase was in the academic medical centre (bimaristan) at Jundi-Shapur, Iran in the 6th century (Miller, 2006). Evidence based medicine may owe its first tentative roots to this centre. The crusaders, most notably the knights of St John brought back this model of aid to the ill and wounded on their return to Europe. Their legacy persists in the St John's Ambulance Brigade. 'Asylums for the Fearful' were maintained by Jain ascetic scholars during the medieval Chola period (848-1279) in Tamil Nadu, India as evidenced by stone inscriptions from that time.

In the 'Dark Ages' 

The 'dark' ages are considered as symbolizing everything malign about mental health treatments. However, medieval authors were mostly aware that diet, alcohol, overwork, and grief contributed to mental illness. The association with sin and punishment was probably propaganda that was used in a minority of cases (Kroll J, Bachrach B 1984). In 1487 Heinrich Kramer published the Malleus Malleficarum that became a paradigm for the treatment of  'witchcraft' and by extension of social and mental deviations from the norm of the time. The invention of the printing press and religious turmoil that occurred at the same time may have served to preserve what may otherwise have been an obscure book. Treatment of the 'insane' then became confined to asylums typified by the descent of Bethlehem Hospital into Bedlam by the early 15th century. In June 1816 Thomas Monro, Principal Physician, resigned as a result of scandal when he was accused of 'wanting in humanity' towards his patients.

Pinel in the age of reason

Philippe Pinel (1745–1826) initiated humanitarian reforms in the treatment of the mentally ill at the Pitié-Salpêtrière Hospital for women in Paris. He observed a strict nonviolent management of mental patients that came to be called moral treatment. He was dramatised in portraits as liberating the insane from their chains. His psychological approach was well thought out, behavioural, and tailored to the individual rather than the diagnosis. He assembled detailed case histories and a natural history of the progress of his cases. Pinel is seen as the physician who established the field that would come to be called psychiatry.

The empirical age

We are now in the age of evidence based medicine. Fortunately there is a mountain of evidence to support a humane, individualised approach to treatment of mental health disorders (Knoll 2013). The benefits of a pollution-free environment, nurturing homes, and safe schools and workplaces has a positive impact on mental health. Individual factors like regular exercise, moderation in diet, adequate rest, and recreation are still shown to improve mental health outcomes. Physical treatments and humanity still go hand in hand for the management of mental illness.


References:
  1. Faria MA. Violence, mental illness, and the brain - A brief history of psychosurgery: Part 1 - From trephination to lobotomy. Surg Neurol Int. 2013 Apr 5;4:49. doi: 10.4103/2152-7806.110146. Print 2013. Accessed 03-Aug-2019
  2. Lambrini K et al. Care for Patients with Mental Illness inAncient Greece. Top 10 Contributions on Nursing & Health Care: 2nd Edition. Chapter 1. 2018. Accessed 03-Aug-2019
  3. Miller A. Jundi-Shapur, bimaristans, and the rise of academic medical centres. 2006. Accessed 20-Aug-2019
  4. Kroll JBachrach Bhttps://www.ncbi.nlm.nih.gov/pubmed/6387755 1984. Accessed 13-Sep-2019
  5. Wikipedia. https://en.wikipedia.org/wiki/Bethlem_Royal_Hospital . Accessed 02-Oct-2019
  6. Wikipedia. https://en.wikipedia.org/wiki/Philippe_Pinel . Accessed 08-Oct-2019
  7. Knoll JL. The Humanities and Psychiatry: The Rebirth of Mind. 2013-03-05. Accessed 2019-10-19
  8. Somasundaram O, Raghavan V. Asylum for the fearful: A Jain innovation of the early Tamil land. Indian J Psychiatry [serial online] 2020 [cited 2020 Feb 3];62:107-8.

Tuesday, July 30, 2019

Parenting After Divorce

Almost half of all couples divorcing have a child under the age of 16 years. Parental separation results in a major upheaval in the life of a child. Apart from the loss created by the absence of one parent, there are usually major changes in living conditions, home, neighbourhood and school. Added to this are the psychological hazards of insecurity, loss of trust, anxiety, guilt and fear.

Psychological impact of divorce on the child

The psychological impact of divorce on the child is a complex issue. Several factors such as the manner in which the parents separated; the age and maturity of the child, socio-economic factors and support of family members determine the effect of the separation on the child.

Emotional and behavioural problems in children have been found to occur more often when the separation has been hostile and accompanied by much unpleasantness. A little sensitivity, a great deal of love and understanding and reassurance goes a long way in preventing emotional and behavioural disorders in the child.

Child’s Emotional Experience

Irrespective of their age, the child may feel
  • A sense of loss.
  • Sudden unwelcome changes in his life – change of school, neighbourhood and friends.
  • Fearful (Who will look after me? What will happen if my mom leaves me?)
  • Angry – at one or both parents for failing to look after him.
  • Guilt and confusion – (Has this happened because of me? Am I responsible in some way?)
  • Insecure and rejected – their world has fallen apart.
  • Torn between feelings for both parents

Developmental Stage Reactions

A young child (less than 8-9 years) is more dependent on the parents for love, protection and security, and is likely to respond with more fearfulness and anxiety. There is also a greater tendency towards wishful thinking and hoping that the parents get back together. He/she may become more ‘clingy’ and dependent; and may have nightmares, stomach-aches, or may regress to bed-wetting. Attention-seeking behaviours may be aimed at getting the parents back may result in childish behaviours and tantrums. It is important to reassure the child, and establish a predictable routine to give him a sense of security and stability.

An older child or adolescent tends to respond with greater anger and may become oppositional or withdrawn. He may feel that his parents have failed to look after him, and start relying more on himself; and may retaliate by being more self-centred, independent and deliberately hurtful.
‘They don’t care about me, why should I care about them’
It may help to talk things over with an adolescent, and channelize his need for independence by giving him some responsibilities.

Strategies to Help Your Child

DOs

  • Be open. The child has the right to know what is going on and what to expect. It should be explained in simple terms why the parents are separating and who he he/she is going to stay with (without giving specific unpleasant details) and he/she should be given age appropriate answers to any questions they may have.
  • Reassure the child that he/she will always be loved and looked after by both parents.
  • Protect the child from the unpleasantness, conflicts and arguments which may arise between you and your spouse.
  • Take responsibility for the situation, and be careful not to blame the child.
  • Make as few changes as possible to the child’s daily routine and caregiving, though some changes are inevitable.
  • Get help from family members, friends and teachers. Social support gives a sense of security and belonging to your child and is equally important for you.

DON’Ts

  • Don’t pull your child into the conflict – do not use him as a weapon, messenger or spy. It only serves to build up resentment in the child.
  • Don’t ask your child to take sides.
  • Don’t criticise, abuse or argue with your ex in front of your child.
  • Don’t share your anger and frustration about your spouse with your child. If you need to vent your feelings, do it with a friend, family member or counsellor.
  • Don’t discuss mutual pending matters (e.g financial or legal issues) with your child.
Remember, your child has the right to be loved, cared for and protected. He has the right to know about changes which affect him. Above all, your child has the right to grow up like other children his age. Create an atmosphere of trust, where he/she can talk about his/her feelings, ask questions and expect truthful answers. A supportive and caring parent-child relationship has been found to greatly reduce the negative impact of divorce.

Ref:
  1. https://www.justice.gc.ca/eng/rp-pr/fl-lf/divorce/wd98_2-dt98_2/wd98_2.pdf
  2. https://link.springer.com/chapter/10.1007/978-1-4613-9811-0_7
  3. https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/divorce-or-separation-of-parents---the-impact-on-children-and-adolescents-for-parents-and-carers

Friday, December 21, 2018

Multiple Illnesses and Multiple Prescriptions—Clarify safety with prescribing doctor

People with a serious psychiatric ailment fall ill, just like anyone else does. They develop colds and coughs, fevers and stomach ailments. They may sprain their ankles, have headaches, develop indigestion after having too good a meal, rashes after trying a new cosmetic and food poisoning after eating some unhygienic street food. Like anyone else, they do one of two things: they buy an OTC medicine; or they consult a general physician.

Precautions with other prescriptions

Be careful with OTC preparations. Not all OTC medications are benign or free from side effects. Avoid drug combinations. Cough syrups (even ‘safe’ herbal ones) usually have a combination of many ingredients, including substances which are highly addictive.

It is usually better and safer to go for option two – visit your GP. It is a good idea to establish a trusted professional relationship with one particular GP who knows your medical history thoroughly. However, this may not always be possible.

Very often, the distress of the current ailment takes precedence in the mind of both the patient and the doctor; because of immediate discomfort, pain or distress involved.  It is all too common for a busy GP, to misguidedly tell you to stop your psychiatric medication, attribute your symptoms to your medication or to simply waive the responsibility - ‘tell your psychiatrist to change your medication.’ Also, don't stop any long term medication on the advice of a person who is not a qualified medical practitioner.

Many psychiatric illnesses are serious, long-term, and may be life-threatening; just like chronic medical illnesses like hypertension, diabetes, epilepsy or heart disease are. No doctor will ever ask you to stop the medications for these illnesses abruptly while he treats your fever or loose motions. He will prescribe a medicine which will not react adversely with those you are already taking. Insist that your illness be treated similarly.

Medications for psychiatric illnesses are relatively few, as compared to the number of antibiotics, pain relievers or cough medicines available in the market. They also have to be started at low doses and built up gradually until you have the most benefits with the least side-effects. It is a slow process, for which you have had to follow-up regularly with your psychiatrist usually over months. It is important that this process should not be derailed without due consideration.

Stopping your psychiatric medication abruptly
  1. May cause the distressing symptoms to return i.e you may relapse.
  2. More seriously, you may find that the original medication, on which you were stable and symptom-free has now become ineffective, and you may require stronger medicines and/or multiple drugs to treat your illness.
  3. Even more seriously, you may wrongly attempt to restart your psychiatry medication at its full strength when you recover from your viral fever after a week. Do not do so. Serious side-effects may follow.

What to do when consulting another doctor

  • Always take your previous prescription with you when you need to consult another doctor. The prescription from our clinic has the dose and generic name of the medicine you are taking (as best practices worldwide demand and as mandated by the govt).
  • Check with your doctor that he has prescribed a medicine which does not react with what you are already taking. Numerous apps are available to check drug interactions, which most doctors are conversant with. It takes only a couple of minutes to do so and prescribe a suitable drug. It can take months to find a new psychiatric medication that suits you and is as effective as the one you are on presently.
  • In case, there is still a doubt, ask him to speak to your psychiatrist. Professional courtesy demands so.
  • If you have stopped your medication, do not resume it without guidance. Seek an early appointment with your psychiatrist.