the bhavana case – or should it be called the sunil case?

On the night of February 17th a young actor from Kerala, Bhavana, was raped by six men. She was in her car, being driven from Kochi to Thrissur. It was a planned attack by her driver, Martin, and her former driver, Sunil, whose services she had terminated as she had come to know that he was a suspect in a murder case.

Why did Martin agree to Sunil’s plan instead of warning his employer? What is the equation between these two men apart from the fact that Sunil got Martin his job?

People trust their drivers. To the best of my knowledge, such horrendous incidents are not commonplace, though in clinical practice I have seen a significant number of women who have been abused by drivers and servants as children. Now, mothers often go along when drivers drop off and pick up their kids from school. This practice has been prevalent for many years now.

There was no way Bhavana could have suspected Martin, not even when he got out of the car to investigate the staged accident. How can we run background checks on our employees before hiring them, because nearly everyone can produce a fake good reference? And how reliable are our instincts, especially when dealing with experienced conmen?

Is this case about Bhavana or about Sunil? Bhavana was the unfortunate victim. She didn’t do anything wrong. Is Sunil a case of antisocial personality disorder – otherwise known as psychopathy?

  • police say he’s a rowdy sheeter
  • is a suspect in another murder case
  • has planned and executed this incident
  • no remorse, no empathy

Sunil’s sister has said to the media that “he doesn’t share good relations with the family since he turned 17.” Further information is not available, but it seems unlikely that they had only minor disagreements.

Psychopaths make up about 1% of the general population and as much as 25 % of male offenders in correctional settings. Dr. Robert Hare, the psychologist who came up with the 20-item test called the Hare Psychopathy checklist, says psychopaths may be a result of an evolutionary survival mechanism. This article appeared in ‘The Independent’ in 2012.

http://www.independent.co.uk/news/science/psychopathy-may-be-a-result-of-adaptive-evolution-rather-than-a-disorder-says-inventor-of-the-a7025706.html

Is he right? Are people’s aspirations, ambitions and need to survive in an increasingly expensive and competitive world generating adaptive mechanisms that belong in the *psychopathy checklist? Maybe not the full-blown psychopath personality, but just traits getting exaggerated?

Dr. Liane Leedom, a psychiatrist, and Linda Hartoonian Almas, an educator with criminal justice experience, who has worked as a police officer, have explained psychopathy from a behavioural sciences perspective. They say it is not an adaptation but an aberration. This is how they explain it.

There are four social behaviour systems involved in adaptation:

  • attachment system
  • caregiving system
  • dominance system
  • sexual systems.

Psychopathy is associated with excessive sexual responses, lack of caregiving, and aberrant dominance responses. ‘Caregiving’ behaviour, however, may be used to gain power and dominance, so the recipient of the ‘care’ may be fooled until the psychopath’s objective is achieved.

Here’s the link to their article:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3573869/

In 2006, during a genetic imaging study in which he was a control subject, Dr. James Fallon, professor of psychiatry at UC Irvine, discovered that his brain was similar to the brains of psychopaths!

https://www.theguardian.com/commentisfree/2014/jun/03/how-i-discovered-i-have-the-brain-of-a-psychopath

In 2013 he gave a TED talk on exploring the mind of a killer. He mentioned the interaction of risk genes, brain damage and the environment, that result in psychopathic behaviour.

https://www.ted.com/talks/jim_fallon_exploring_the_mind_of_a_killer

This is his conclusion regarding why he became a successful neuroscientist and family man instead of a psychopath.

“But why, in the light of the fact I have all of the biological markers for psychopathy, including a turned off limbic system, the high risk genetic alleles, and the attendant behaviours, including well over half of those listed in the psychopathy tests and low emotional empathy, did I turn out to be a successful professor and family man? One most likely reason is that although I have the genetic makeup of a “born” psychopath, some of those very same “risk” genes in someone showered with love (versus abuse or abandonment), from childbirth through the critical first few years of life, appear to offset the psychopathy-inducing effects of the other “risk” genes.”

As I’ve said in an earlier blog post, being born with the risk genes for psychopathy doesn’t mean the condition has to manifest.

https://drshyamalavatsa.wordpress.com/2013/03/17/teenagers-and-crime/

To think that one man’s warped mind came up with a callous, inhuman and remorseless plan that needlessly devastated an innocent young woman. There are strong rumours that Sunil was paid to do this, but the fact remains that he had no qualms about going ahead with it.

*Psychopathy Checklist:

Arrogant and Deceitful Interpersonal Style

Glibness/Superficial charm

Grandiose sense of self-worth

Pathological lying

Conning/Manipulative

Deficient Affective Experience

Lack of remorse or guilt

Shallow affect

Callous/Lack of empathy

Failure to accept responsibility

Lack of realistic long-term goals

Impulsive and Irresponsible Behavioural Style

Need for stimulation/Proneness to boredom

Parasitic lifestyle

Impulsivity

Irresponsibility

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A little about taking medicines for depression and anxiety

‘Depression’ and ‘anxiety’ are two problems for which people often seek help. Help from family physicians, counsellors, psychologists, therapists, psychiatrists, reiki experts, yoga teachers, NLP practitioners, astrologers and a host of other possibly helpful people.

Very depressed people don’t much care what happens to their lives, and very anxious people can barely listen to anyone, even if they try. It’s difficult to reach them. Medicines can bring down depression or anxiety enough to help the patient think a little more clearly, and listen to what people concerned about his wellbeing are telling him.

Many antidepressants reduce both anxiety and depression. Extremely anxious people may need an additional dose of an anti-anxiety medicine for a week or two.

  • Antidepressants are not addictive and are usually given as a course for a few months.
  • Side effects usually appear at the beginning of treatment, last just a couple of weeks or so, and get lesser day by day. In case they don’t go away, there are other options.
  • Side effects cause some discomfort, but don’t affect work – and life in general – enough to discontinue their use. You don’t have to throw the baby out with the bathwater.
  • Therapeutic effects are seen in less than a fortnight with some antidepressants, although some can take up to 1½ months to make a difference.
  • The choice of medicine depends on what side effects you are trying to avoid.

These medicines are like an umbrella. Under their calming influence a patient can sort out his life. He can do this either on his own – by coming up with better ways of coping, or by talking things over with his psychiatrist, a psychologist or a therapist. And really, if the depressive episode or anxiety attack was brought on by a situation, talking things through with a friend may be enough!

He can explore meditation, yoga or any other lifestyle changes that he finds useful, and make them a part of his life from then on. If he can figure out what triggers anxiety or depression in him, that’s useful too.

More medicines to combat side effects of psychiatric medicines – isn’t that unfair?

This seems like the ultimate injustice, if I go by people’s blogposts.

Actually, there are very few situations where this needs to be done. It usually happens with antipsychotics, the strong medicines used to treat severe conditions like schizophrenia.

We can’t inject medicines directly into thousands of those tiny synapses (the little spaces where two nerve cells in the brain meet and communicate through chemicals) that are defective in schizophrenia. Orally administered medicines go all over the body and affect other systems.

Even then, it is possible to switch to a medicine that does not cause the particular side effect that the patient finds distressing. For example, one antipsychotic causes restlessness and a need to keep moving. Changing to another equally effective antipsychotic gets rid of this side effect. Since every patient does not get every side effect listed in the books, we can be optimistic about finding a fit, a medicine to match the patient’s needs.

Agreed, we are sometimes in a situation where we have to prescribe more medicines to control side effects of medicines used for treatment. Research is underway to find better molecules that will be as free of side effects as possible. Until then we have to titrate doses of medicines to minimize side effects, without compromising on effectiveness.

I can say with certainty that the medicines being prescribed today are far superior to those that were available 25 years ago, mainly in terms of side effects. And a preview of those in the pipeline tells me better medicines are on their way.

Using psychiatric medicines

Even as I wrote the first paragraph of my last post I realized there was room for disagreement.

Firstly, not everybody believes that mental illnesses like schizophrenia have a scientific basis. Not everybody believes in allopathic medicines either. For people who haven’t had much to do with science, believing in psychiatry may be a stretch. So, when I wrote the blogpost about side effects of medicines used in psychiatry, I was only addressing the concerns of people using them.

Some patients believe that medicines are only for physical illness. They look completely unconvinced when you tell them their odd symptoms (hearing threatening voices, fear that someone’s tapping their phone, etc.) can be controlled by these little pills, tablets that aren’t even the substantial size of a Crocin or the awe-inspiring size of Brufen 400!

There seem to be all sorts of remedies available – herbal, ayurvedic and homeopathic. I find that a lot of patients and, more often caregivers of people with severe mental illnesses like schizophrenia, reach out for help on sites that offer alternatives to allopathic medicines. Their main concerns:

  • How long do I have to take the medicine? I want to stop.
  • Is there a treatment that doesn’t give me side effects?

These medicines need to be seen as making up for a tiny but important part of the brain not working. It’s not very different from getting diabetes because one tiny but important part of the pancreas is not working. Isn’t treatment for diabetes lifelong?

Virtually everything that goes into your body has ‘side effects’. Like the coffee you drink as a beverage, and the food you eat for nourishment. Spinach has the good ‘side effect’ of giving you fibre along with nutrients, while fried chicken has the ‘side effect’ of raising your cholesterol.

Nobody has a perfect life. Everybody has some cross to bear, and sometimes it is a heavy one. Having to swallow a couple of pills every night before going to bed is yours. Thanks to those pills you can live a fairly normal life with a few ‘side effects’ that are better – much better – than what the illness was doing to you.

I also need to add that there are many, many patients who have their medicines regularly, come for a review every three months, and have practically no side effects because they are on optimum doses of their medicines. Occasionally I find one of them responding to a post discussing alternative medicines, earnestly telling people how they have benefitted from allopathic medicines. I do feel glad when this happens.

 

Side effects of psychiatric medicines

I am often surprised by blogposts where someone declares that he will never see a psychiatrist. I wonder what else can be done for illnesses that are a result of neural circuits that don’t work, because connections between some nerve cells are lost and need to be reestablished. This is how medicines work. And they DO work.

Psychiatry is about biology.

Psychiatry is mainly about behaviour disturbances caused by biology. Psychological factors are relevant only where, for example, too many stressful experiences can impact ‘risk genes’ and cause mental illness. Or being stressed for a long time can prevent brain cells from growing. Things like that.

IMG_1445

The brain is an organ. The ‘mind’ is a process. This process happens because cells in the brain connect environmental cues, thoughts and feelings, and generate actions. Mental illnesses are a result of this process being interrupted at different points.

Going by what I’ve come across on the net, most people seem upset by side effects of psychiatric medicines. If the rule ‘start low and go slow’ is followed there should be practically no side effects. At least, no more than what you get when you take an antihistaminic for a cold.

Medicines are not magic potions. They are not going to make your longstanding problems disappear overnight. They need to reach a certain level in the body before they show the effects you want to see. This can take a few days. If you start with a high dose, or raise the dose too fast, there will certainly be side effects.

Starting low introduces the medicine to your body and lets you know what sort of side effects you can expect. For example, if you are likely to react with stomach acidity, you’ll get a mild attack with a small dose, and something can be done about it.

Despair

I first heard the word anomie when I was a postgraduate student. A little French word that described a profound feeling of disconnect that people experience when life goes so out of control that it starts to feel meaningless.

I remembered the ‘meaning of Life’ discussions with friends at undergrad college. None of us had read the philosophers; nobody did anything but study science in the years leading up to medical college those days. Some of us had heard of nihilism, but we didn’t subscribe to that. We had been brought up to believe that God watched over us, and there was a reason for everything that happened. For that reason we didn’t despair; we soldiered on with a ‘que sera, sera’ attitude.

Newspapers now frequently carry stories of teenagers taking their lives out of ‘despair’. And readers anxiously wonder why this is happening to our kids.

In the nineteenth century a French sociologist, Emile Durkheim, used the word anomie to describe the feeling of alienation, the disconnectedness that one feels when there is a mismatch between a personal goal and a social one. There is a breakdown of social bonds between the individual and his community.

This, I suppose, is what those youngsters feel: expectations from parents and society are either different or higher than their own, filling them with despair and a sense of failure, with no inner strength to deal with it.

If a kid who wants to be a pilot is forced to take up a course in Medicine, what happens to his personal goal? Won’t he feel isolated from his classmates who are obviously passionate about Medicine? Won’t he feel a disconnect with himself, his own identity, and ask “Who am I, really?” How does the future look to him?

If a kid growing up in poverty wants to get rich but can’t get admission into a college to fulfill his dream, won’t he feel a lack of meaning and direction? Won’t he feel lonely, desperate and angry? One can quite imagine why some youngsters get talked into get-rich-quick schemes and have run-ins with the police. Strain Theory, based on anomie, explains it as a discrepancy between common social goals and legitimate means to attain those goals.

In recent years norms have changed. There was a time when it was usual for a child to pray before leaving for school. No one does that anymore. Most city children don’t anyway. A child never gets a chance to learn how to connect with his innermost self every day, for that’s what prayer is partly about: connecting with and learning to believe in ourselves, deriving strength from a benevolent God who we imagine is watching out for us. Over the years a source of strength is lost, leaving . . . what? When a teenager encounters a setback in school or college and ends his life because he can’t deal with it, we are shocked. How did he become so fragile? Shouldn’t he have been more resilient? Shouldn’t he have been stronger?

The German philosopher Frieidrich Nietzsche said that belief in God acts as an antidote against nihilism, against despair, against meaninglessness. Why is Moral Science no longer taught in schools? In our country we have never had difficulty dealing with dichotomies; though we give science its due, we believe in a force beyond science too. We start scientific seminars with five dignitaries lighting a lamp, and having someone sing an invocation to God to ensure the seminar’s success!

Emile Durkheim also said that traditional religions provide the basis for the shared values that an anomic person lacks. These values give him a sense of rootedness, a connection with his community, and a faith in God, so he has both people and God to reach out to in a crisis. He doesn’t sink into the terrifying emptiness that is anomie.

Over the years I have received phone calls, mostly in the middle of the night, from young patients on the verge of giving up on life. Each time I’ve sensed that they are in a place beyond depression, an empty place where nothing seems to matter. They cry in such anguish that I know it must be very, very frightening. I imagine anomie feels like being all alone in a rudderless boat on a rough sea, in complete darkness, the oars already yanked out of your hands by the wind long ago.

The American philosopher, George Santayana described faith as that ‘splendid error, which conforms better to the impulses of the soul’. He apparently wrote this when he mourned his loss of faith. Faith may be unscientific, but so what? As long as it works when a kid needs it. . .

Encouraging a child to have faith in God may help him through the tender adolescent years when he needs support. As I’ve said elsewhere in my blog, religion can be seen as a scaffold to stand on while he’s building his value system brick by brick; he may discard it when the stronger structure of his adult personality is firmly in place, if he wants to.

Note: The paintings in this post were made by two young patients of mine to express their sense of isolation, despair and inability to control what they were going through.

 

Teenagers and crime

Clipping from the Times of India, dated 15th March, 2013.
Clipping from the Times of India, dated 15th March, 2013.

Juvenile delinquency is a legal term for an act by a young person (usually below 18), which would be considered a crime if committed by an adult. That makes it a legal problem.

Or is it?

The offender has disobeyed social rules and infringed on the rights of others. There is apparently nothing wrong with his mental state. Shouldn’t people involved in his socialization – parents, teachers and law-makers – be the ones dealing with him? Is this a social problem?

Psychoanalytic theories have linked aspects of parenting to the development of conduct disorder in childhood, which is carried forward into adolescence as juvenile delinquency. Is this, then, a psychological problem?

For any behavior to develop, something has to happen in the child’s brain at the level of brain cells. How do brain cells process information received from a child’s experience? Is this a medical problem then?

In juvenile delinquents it has been noted that there is often a history of

  • complications during birth (and possible brain damage)
  • restlessness, impulsivity, difficulty concentrating and other symptoms of ADHD, deficits in language-based skills, low IQ in many (again, minimal brain damage is said to be the cause)
  • school work being neither enjoyable nor rewarding because of the above, and all the consequences of being a ‘bad’ student (problems with peers and teachers) including low self-esteem, and aggressiveness to cope with the constant sense of failure and helplessness
  • impaired coordination, or clumsiness
  • abnormal EEGs in >50% (general population 5-15%) indicating abnormality in parts of the brain
  • psychotic symptoms like misperceiving what is said, episodic paranoia, and occasional visual and auditory hallucinations

All these deficits are subtle – very subtle – and linked to minimal brain damage that cannot be seen on a CT scan or MRI. If any of them were just that bit more, a diagnosis of epilepsy, schizophrenia, or mental retardation would have been made.

Admittedly no single factor – social, psychological or neurological – accounts for a child turning into a juvenile delinquent.

BUT. . .

growing up with violence, coupled with an intrinsic vulnerability (like conditions listed above), predisposes a child to delinquency.

AND. . .

the path from behavior problems in childhood to delinquency is not inevitable. There are things that can be done to prevent such an outcome.

  • Recognize child’s needs and respond sensitively, without hostility, gain the child’s trust and respect, and make him feel secure.
  • Make rules and instructions clear, e.g. instead of saying “Stop that noise!” tell him something he can do.
  • Respond firmly and calmly to defiance and aggression.
  • Help the child with his interpersonal skills.
  • Deal with problems at school, for e.g. assessment and remedial education for learning disabilities.
  • Steer the child away from deviant peers.
  • Treat hyperactivity with medications, if present.

Psychologists say aggression is worst around the age of two. Attachment, or bonding, enables the child to control his aggression as he begins to understand others’ feelings. The part of the brain called the prefrontal cortex is involved in this process.

If the way we bond with our children when they are little can cause changes in their brains that can affect the rest of their lives, shouldn’t we be a lot more careful? Shouldn’t we as a society be using television channels that are watched by the maximum number of people to propagate the fact that children are quite plastic, literally putty in our hands? That we should be aware of the effects our actions have on them?

We know as little of the intricacies of the human brain as we do of the workings of galaxies in the universe. How homeostasis is maintained is mind-boggling; every hormone level, blood cell count, electrolyte has to be within a narrow range. Any change in one has far-reaching effects on multiple systems.

So just imagine the kind of damage a birth complication that cuts off oxygen for a few seconds can cause to the brain. Since every part of the brain controls some function, the damaged part is going to produce some ‘symptom’ in the form of a ‘behavior’ as the child grows. Lack of control over aggressive impulses leading to juvenile delinquency could be one, so more effort has to go into teaching the child how to deal with aggression.

This is the responsibility of all the significant adults in his life, and of society as a whole.