Out of the blues: Lessons learnt from the past

People look forward for weekends, but Saturday evenings used to spell horror for me. Saturdays are the days when I remain awake till late, almost 1 am, giving time to myself.
I know there are a lot of areas in life I have to work on, many mistakes I can't help but repeat and many events that make me feel I have emerged as an imperfect but a strong warrior in the battle of life.

With a plethora of thoughts flooding my mind, my eyes stay fixed into nothingness. Everything seems meaningful and meaningless at the same time and my head finds itself too powerless to contain a bagful of contrasting beliefs and emotions. And then comes the dark, murky, morbid past that once threatened to ruin every bit of emotion I had. I almost felt myself slipping away into a depression which would be refractory. It is not easy to self-prescribe anti-depressants being a psychologist, because you know they might just be supportive therapy and you might end up taking them for a lifetime.

There was a time when I could not do my patient work, take rounds or attend meetings at workplace. I just used to manage enough energy to drag myself to work place. Being at the work place made things worse. Many of my regular colleagues were surprised to see a person like me dragging along in a depressive stupor, but all I could tell them was ''I need time for myself''. It is great to have a ''Doctor's Room'' in the Premier ICU where one can sit peacefully in an air conditioned room on a sofa. However, people would still come and with that fear, perhaps, tears would not!

Not being pessimistic, one hard truth of life is that no one wants a lousy soul around, especially when one in in the medical profession- All the more when that lousy soul is a psychologist. Psychologists are psychologists only when it comes to 8 hours of profession. I guess we are humans and we do have the right to experience emotions and feel weak from time to time. It is not self pampering. It is liberty.

A life incident shook me up to the very core and I began questioning my self identity. However, when the hot molten lava froze down a bit and my vision was not so clouded, I began to see that the incident of pain was not only meant to teach me a lesson but also make me a better professional. A 24 year old student taking hasty case histories, aiming to make perfect diagnoses and looking for every opportunity to chart out a perfect treatment plan, medically and therapeutically, turns into a 25 year old psychologist with tons of patience to listen and feel the gravity of the patient's problems. Suddenly, the ''symptoms'' turn into ''Bothering issues'', ''Complaints'' turn into ''problems'', ''perfect diagnoses'' turns into ''Arbitrary diagnoses'' and ''chasing perfection'' turns into ''living with imperfection''.


Four months later, my clinical practice has undergone an absolute change. It used to rely on knowledge earlier.....now it combines knowledge with experience and empathy: two quintessential qualities that make a clinician worth remembering. In the entire heart wrenching journey, I can never forget those who managed to make me laugh when I did not even want to smile: my colleagues, Dr. Khushbu Thakkar and Dr. Minal Patel. I'd like to share 10 basic tenets that life forced me to look at after this storm passed by.

10. Youngsters have the knowledge but lack the experience. Energy makes you apply, experience gives you wisdom and inspires you to learn more.

09. Every human being has the right to express emotionally. You cry, doesn't mean you are weak. It means you have been strong enough for too long and need to break down once before rebuilding yourself

08. Keep yourself open to learning options

07. No knowledge goes waste

06. We are stronger than we think we are.

05. Pain is a must: not only to teach lessons, but also to make you a refined version of yourself

04. The easiest seeming things must undergo a solid test to prove how solid it is

03. In the end what matters is how much you lived, how much you loved and how much you helped someone who cannot return you the favour.

02. There is a supernatural force: Call it God or something else, it is there

01. YOU NEED A BUNCH OF CRAZY, WHACKED OUT FRIENDS WHO CAN MAKE YOU KICK EVERY PROBLEM OUT OF THE WINDOW IN LESS THAN A SECOND!!!

That's a snapshot from my real life!

Psychoses: A new angle to Parkinsonism

Parkinson’s disease affects millions over the world and is not a pleasant experience for the patients and their families. Parkinson’s disease (PD) is one of the most debilitating neuro-degenerative disorders which occur because of gradual death of dopamine generating cells in substantia niagra (an area of the mid brain responsible in formation of dopamine neurotransmitter).

Initially, PD presents itself with some obvious, movement related deficits which include muscle rigidity, shaking and trembling, slowness in movement and drooping eyelids. Later on, as the disease progresses, it causes cognitive deficits (problems related to thinking, memory, judgement). Dementia is a dangerous psychiatric by-product of PD whereas Depression is one of the most common co-morbidities which is obviously related to the debilitation and loss of dopamine.

Neuro-cognitive deficits can be seen in early phases of PD which relate to difficulties in making judgment, slurred speech, strange thoughts and impaired mood. Patients often experience apathy and an inability to experience normal range of emotions. As the disease progresses, one can also not the visuo-spatial difficulties, memory impairments, impulse control disorders, hypersexuality and psychotic symptoms.

Medicines for PD include Levodopamine, the aim of which is to replace the lost dopamine in the brain. Co-adjunct treatment alongside Dopamine agonists are antidepressants and Pacitane. However, Pacitane in some cases is known to trigger delirium. An anti-depressant is also started alongside.

However, despite these medications, as PD advances, an individual may become more vulnerable to environmental stressors and these stressors combined with dopamine deficiency may cause psychotic reactions.

One of my patients with old ischemic heart disease was admitted for Angiography when I saw him. He maintained a good conversation despite the obviously visible tremors and mild hyperexcitability. Since he was already 82, I thought it was a normal reaction to hospitalization. The medical chart hadn’t mentioned anything about him being on Levodopamine or Pacitane.

He inquired about the procedure of angiography as any other patient would. However, after the angiography, his reaction changed markedly. He started showing irritability, became extra-sensitive to bodily symptoms and showed increased drowsiness. I still treated it as a normal, transient psychiatric reaction to hospitalization and the pain in the radial area to angiography.

However, on the third day, he developed severe psychosis. He started experiencing visual hallucinations and began responding to them. He saw his friends and people who weren’t present in the room inquiring after his health and started answering them.

Since he was in the ICU, I was left with no other option but to communicate with his grandson. The young boy then told me that his grandfather had been diagnosed with PD about one and a half months back but hadn’t adhered to medication which is the reason why the tremors still persisted.

I could suddenly see the block fitting in and the clouds suddenly started to disappear giving way to light. I could see that the old man’s psychotism was directly related to PD. He was shifted to the general ward from the ICU as he became haemodynamically more stable. The foley’s catheter, IV cannula and the monitor leads were removed. He felt much better and the presentation of psychoticism gradually decreased but not to the desired level.

His newly acquired psychiatric reaction was a matter of concern for his family members too. The only plan I, along with the admitting cardiologist could devise was to restart him on PD medications and revisit his neurophysician.

The possible prognosis is that we can expect the tremors, gait and psychiatric reactions to improve once the patient restarts on PD medications. The only way to know about his current state of well-being is nto wait until his next follow-up. 

The turmoil inside my head

When did life ever come out as a fair game?

When did life ever show it is just?

Does poetic justice exist only in books and films? Or is it just a creation of a hopeful mind?

A million thoughts cross my messed up head as soft guitar chords are heard setting up a painful tune. I just realize the sound comes from my Laptop's super advanced Altec Lansing speakers and I realize that I am being drawn away by my own thoughts. I find it difficult to focus on the tangible items lying in front of me. I find it difficult to orient myself t time and space despite a mug of strong black coffee.

Perceptual splitting and eventual schizophrenia?

Naaah.....My mind is used to making diagnosis and trying to prevent the occurences before treatment is left as the only option.

More thoughts......Not one of them is positive. 


Only my heart and my God know how I have managed work and studies for such a long time. But the speech of God is not audible and to my heart, no one listens---not even me! Who's to give the testimony?

Wow! My sense of humor may not be good, but my sense of sarcasm is improving incredibly!

Now was that a display of sarcasm??????!

The mug of coffee is still lying here, untouched and I am staring at the laptop screen without a single expression on my face. I could've been dead!
I need to get up and force myself to get oriented to the real world. I need to shake myself of the emotional unreality and put my legs into the freezing waters of the Arctic reality. 

More thoughts, I'll meet you in the shower. That's how I take 30 minutes to complete my bath! Ohhhhh the world here in my head gives me so much more pleasure than the real world. I don't mind splitting my brain in a million pieces. I'll take the responsibility to hold those pieces together.

Migration & Pruning in brain cells: Ever heard of it?

Neuropsychology has gained an entirely new perspective with extremely detailed research done through MRI, FMRI and PET scans. However, from the viewpoint of clinical psychology, one question will always remain: ‘Is it in the brain or in the mind?’’

One of the most difficult questions in neuroscience and medicine, isn’t it?

The answer remains equally ambivalent. It is a double-edged sword. It depends on the intensity and type of a disorder with which the person is afflicted. However, one thing is absolutely clear: Just as human beings are ‘’social’’, so is the human brain. 

By the eighth week of conception, the zygote experiences 250,000 neuroblasts (nerve cells per minute). Cells in brain show a particular behaviour. They all perform different functions. Cells that perform similar function, gather together in a place. For example, cells that are to perform verbal functions would gather in a place and relate to that function only.

Cells migrate all the time. Even after birth. However, the process of moving of cells from one place to another is called migration. Visual neurons become visual neurons, not because they are born visual, but because they migrate to a particular part of the brain to perform that activity.

Psychological disorders like schizophrenia, autism, dyslexia and many more are caused mostly because of some defect in migration.

And then comes the time to talk about behaviour. 

These cells, while migrating, and otherwise too, come in contact with genes and when this happens, behaviour (response) activates. Over a period of time, if the neurons are not medicated or trained to change response, that behaviour becomes ingrained and thus, as a result, you get many complaints!!!

‘’He’s got an anger issue, right since his childhood!!!!!’’

‘’She always gets anxious, no matter what the situation is. She has always been like this’’.

Whose gone inside her head would know what took to make her ‘anxious’’ since ‘forever’?

And there, when research so clearly proves that there are lots of substances that inhibit the healthy migration process. Mothers who smoke are shown of have children who suffer ADD. Alcohol also inhibits healthy migration causing FAS (Fetal Alcohol Syndrome).

Let us come to the second part. Pruning.

Before that, let’s make it clear. The world and ‘life’ (each organism) lives and dies in a state of ‘competition’. Charles Darwin’s term ‘Survival of the fittest’ strikes me first as I think about Pruning.

Think of an office where you’ve got nothing but utter competition. Employees who do not perform are thrown out and those who become incapable to perform because of old age, they retire. Same is the case with neurons.

Why does an 83 year old woman face so much of difficulty in seeing? One reason is that the speed with which neurons regenerate in her occipital lobe is very slow. More and more neurons lose their capacity to function; this problem as a result!

Life, movement, regeneration, organization, destruction is more than just a part of nature. It inhabits every cell!

Please let me know if this explanation answers the question:

‘Brain or mind?’ sufficiently

With many clients, I don’t buy into their talk when they use the term ‘’hereditary’’ so loosely. That’s layman talk. Except a very few cases of Huntington’s disease or color blindness or phenylketoneuria, very few disorders are completely governed by one single ‘gene’. It’s so easy to blame ‘genes’.

One epic joke: ‘Sorry darling, I misbehaved. My dad did it this way. It’s in genes!!’

The darling is going to understand the shit behind sophisticated neuropsychology.

Now let’s take the example of diabetes. It is highly genetic, but if the person who is pre-disposed to it takes care not to become over-weight, it can be avoided. Never blame genes fully for anxiety, depression or schizophrenia. It’s always a dual process.

I am not sitting on the fence by speaking on both sides, but I do feel the complexities leave us with no other option.

Eternity.........................: About GAD (Generalized anxiety disorder)

Eternity.........................: About GAD (Generalized anxiety disorder): GAD (Generalized anxiety disorder) is perhaps the most misunderstood clinical condition. It becomes dangerous when used loosely by laymen a...

About GAD (Generalized anxiety disorder)

GAD (Generalized anxiety disorder) is perhaps the most misunderstood clinical condition. It becomes dangerous when used loosely by laymen and professionals without adequate clinical knowledge and training. My purpose of writing this blog is not to write ''about'' GAD but ''for'' it.

Last year, a colleague from the department of Egyptology approached me and said: 

''I have cigarettes. They kick up the system and now I feel I got GAD. You know, I am crazy.''

I felt like clutching my head. I groaned ''Oh God! Not one more, please!!''

First of all, this person was a 100% sure he had GAD.

Secondly, he thought he was an expert and knew what moderated his so-labelled GAD because according to him, feeling anxious about everything defined GAD. Well, GAD isn't that simple.

I asked him, ''Do you know what GAD is?''

He fumbled. He knew he'd been caught on the wrong side but he was quick to reply, ''I think it's just feeling anxious about everything.''

''And what is that everything?'', questioned I.

''I can't clinically define it but this is what I feel''

''It seems you aren't sure what GAD is, are you?''

''No''

''And yet you, so confidently diagnosed yourself''

Most of us think we know ourselves the best, so we can give labels and having a psychological label sounds like a cool new thing on the block. You may know yourself the best, but you don't know the disorder itself. So think a hundred times before self-diagnosing.

Coming back to GAD, I won't defy everything my Egyptologist friend had said. 

GAD does comprise of anxiety, but anxiety's second level, which is called meta-worry is the main driver for GAD. It's not the worry. It's worry about worry. Adrian Wells speaks of these cognitive levels in depth.

Borkovec and Newman (1992) have given another explanation stating that worrying is an attempt to avoid more acute distress. Confrontation with real life situations can be a real ''pain in the arse'' and worrying about them gives a sense of ''solving the problem in head'' (though they are never really solved). But you get the idea how it keeps going.

The third explanation is given by Quebec who says GAD develops with the habit of ''intolerance of uncertainty''. It is not good to remain uncertain. 

Let me speak about my own self to elaborate Quebec's weird but true explanation. 

Autumn 2009. 
I was called in to see our neuropsychology professor, Dr. Tree.
I had read a lot of his work in journals and in books. I respected him and I still do.
However, I did not know why he had called me in his office. I couldn't stand that uncertainty. I was supposed to see him on Monday and the entire Sunday night was spent tossing in bed. Before some light sleep came over to me, I thought I must have failed my Neuropsychology assignment or must have done a project badly. Failing was bad, but was still better than uncertainty.

The next day I enter Dr. Tree's cabin with the conclusion that I must have failed. All I get to know was I had scored the second highest in the entire masters' batch in Neuropsychology Module.


So you see how important it is to be certain all the time?????!!!

That's how brains work!

And mind it, I wasn't diagnosed with GAD because again, we must bear in mind that clinical diagnosis does not depend on 1-2 such events.


GAD presents clinically in a million different ways, but in your case histories, it is very important to understand what events in their lives have precipitated their GAD. There may be many events, but some are crucial. Plus, there is one major philosophy behind GAD and it is:

''Over-estimation of the situation and under-estimation of their own coping resources''

Apart from that, ''Cognitive distortions'' or ''UTH'' (Thinking habits) as described by Burns (2000) must be outlined.With GAD patients, they know they are thinking shit and they don't want to hear it from  their doctor. 

As a psychotherapist, never focus on telling them what's right and what's wrong. Try using Beck's Anxiety Inventory, HADS or GHQ (in general) and GAD-7, which is a specific GAD inventory to know the crucial potholes in their clinical condition and how it impacts their health. 

Never underestimate the ''topics'' about which your GAD clients worry or say, seek internal safety. They might worry about a possible storm and their property getting destroyed, but that cannot be stamped as ''illogical''. If you try to explain the ''truth'' or ''logic'' of the thinking, you'll only involve in an argument. They are not wrong because an unlikely storm is absolutely possible......but why do they worry about it and we don't?

Statistics are alarming.....I don't buy into them, nor would I advise anyone to remember and buy into statistics. They are not perfect and so are researchers (they are more than imperfect)

There is a little more for those who are interested:

There is one more aspect which is good only to rely on when reading; it is Neurobiology of GAD (or any other condition for that matter)
What I present here may not necessarily be the truth, so it is important to be objective.

Just as any clinical condition is bound to cause alterations in chemical, hormonal and neuronal features of the body/ brain, there's one sure universal fact; the brain is affected. You cannot have just a few areas of brain getting affected in isolation.

I would bring into picture Amygdala (the old brain emotional centre), peri-amygdala regions (for the same emotions) as well as Pre-frontal cortex (for cognitive processing).
I might be saying this because I am CBT therapy oriented where cognitions and emotional reaction is the key behind understanding any disorder. 

Biologists and neuropsychology may rely more on Hippocampal regions to understand the impact of ''narrative events'' from case histories.

Most studies are based on activities shown in MRI and PET-scans, but even these and FMRI scans can only speak about the glucose activity going on in these regions at that point of time and since this is extremely fickle, it is hard to put a stamp of 100% objectivity here as well.

The answer to this and many other questions leads us to the topic of GAD treatment which is not the purpose of today's blog. 

I have tried clarifying clinical GAD in a simple manner. I have tried my best to avoid technical terms and jargons and stick to examples from real life events. I just thought this wouldn't make the blog look like an academic lesson.  Your feedback is very important to me.

Thank you very much.


Phoram Trivedi.

First things first: Before CBT or Neuroscience

1. Buy and sell: The knowledge game.

Going to U.K for masters is not a part of sophistication any longer. With India's development and progress in the 21st century, it's a matter of pride that every Indian from financially stable family can afford foreign education if he saves wise and earns smart. I am definitely speaking under the influence of David Cameron's recent visit to India & catching up with students.

However, the point is not this. The point it doing an MSc in Abnormal and Clinical psychology.

As a 16-17 year old passionate kid, I was always keen on studying clinical psychology (Paper 4 as Gujarat University put it) because the processes in the disorders, symptoms, diagnosis looked very appealing. I went to University of Wales, Swansea with the same passion.

ALAS! Only if passion could solve all the problems. Unfortunately, it doesn't.

In clinical psychology, what matters the most is not having diagnostic criteria at the tips of your fingers. I do not remember how many criteria need to be fulfilled in order to be diagnosable for GAD or MDD.

Secondly, it is always necessary to remember that the nature of the disorder has to be explored in depth through research. And rule of thumb, there is nothing right or wrong in research, because no research is perfect. Every research has it's limitations. So, you must learn 'NOT TO BUY INTO' any research, but just read it to be aware. The moment you start relying and buying on already existing researches, you lose focus and critical analysis.

Researchers just try to be objective in their viewpoints, which many, at least in India mistake for lack of knowledge, being diplomatic or sitting on the fence. It is my belief that as students, aiming to launch careers, it is very important to develop critical reasoning as a part of your personality and not just limiting it to academics.


2. Statistics, Mathematics, is that Lucifer, the devil?
Statistics and mathematics is the nemesis for so many students. I won't exclude myself from the category.

As a teenager, I landed up in this completely different world with high class statistical terms like Multiple regression analysis, running an SPSS, Kendall tests, Mann Whitney U-Tests and much more. I cried on the first day, I won't lie about it. However, what I learnt was that conceptual knowledge is more important than results. Indian system needs to learn that.

You are allowed to use calculators, and if you get a wrong answer through calculator, you lose only half a mark. But if your answer is right and you got the wrong procedure, you will be marked down.
You learn a very important lesson.

''Journey is important, not the destination''.

If we all tried to work like this, we'd be literate, quick and educated rather than being literate, quick and uneducated (just informed).

Mathematics and statistics is logic after all........as simple as that. In India, I believed and was really bad at basic school mathematics, but now I don't. The meta concept is that mathematics should be delivered in the right manner. India is the country in which ''0'' was invented, a country that did great stuff in geometry and trigonometry and sadly enough today we are complicating mathematics so much instead of understanding the basics. Is this how you prove that you're into the competition?

(PS: I don't even remember the procedures now, but if I re-acquaint myself, these procedures should come easy).

3. Research and practice are different but same.

''Go and start your practice now'' is the typical advice.

The student becomes happy. I don't have to study any longer......I am the all knowledgeable person in this area because now, I can practice.

Dear Pappas and mummys, your child has started practising, it doesn't mean he/she is an expert. Most of us don't even look back to books once.



This is my view after I finished my Post masters dip degree in CBT Therapy from University of Wales, Newport. I am not a CBT expert. I finished 100 hours of clinical training under supervision and even after all this, there's still improvement.

I almost swore at what I learnt back home about 'Open ended and close ended questions' and 'Settings of a clinical counselling// therapy room''. What the fuck!!! It does not matter.....I never wore any formal clothes to the clinical centre, and still managed to complete a degree accredited by BACP (British Association of Clinical Psychotherapy).

Practice in Clinical psychology is about remaining open to the diagnosis. Giving a label is not enough. A patient comes to me, I talk over and diagnose him with OCD, or GAD. The process through which the vicious cycle of formation is made and how the clinical collaboration works to make this change is the core of practice.

Practice brings you back to research.......How many  clients did you see? How did it work with each one of them? Are there any repetitive patterns you marked in them? A tiring frame of reference to build indeed!

4. At the end, it is application and thinking that matter.

One evening I was feeling quite stressed out and said this to my colleague who's into Marine Science.

He instinctively turned towards me and spoke ''Use psychology here.....''

I did not speak any further. I was shocked as to how loosely terms are perceived.

I may have my own views are are not compatible with a healthy thinking style, but until and unless I don't let them interfere my professional and academic life, how does it matter whether I am obsessive or depressive?

It may matter to some, though.

If you have a critical thinking you should be able to hear crap from others and not arguing back in a loud voice. That is my simple perception, non academic and non clinical.

5. A dream

Based on all the aforementioned crap and some useful stuff I might have written above, I dream of a new education system, at least in my field of clinical science and clinical psychology/ neuropsychology: A system that is not governed by the state, a system that is based on unbiased approaches and a system that makes citizens and responsible professionals out of students.

I do not day dream or fantasize about this, but having this at the back of my mind keeps me grounded and motivated. All I know is that passion and dreams can give you a direction but a proper pathway ensures that you are on the right track.

My dream is to make knowledge primary and information secondary.

My dream is to help promote conceptual thinking and avoid biased thinking.

I want it to be a win-win situation for all.

If I could have your feedback on this, I'd be more than pleased.


Please do not think this blog is written by an expert. It is written by a common student.......a student for lifetime.

The next blog shall be about Neuroscience and CBT.