Detangle by Kinjal
Detangle is a podcast created by health psychologist and writer, Dr Kinjal Goyal. Each episode is a conversation with an expert in their field, as they dive deep into their journerys and experiences. The conversations are full of insight and a great way to hear, first hand, how the mind plays a pivotal role in almost everything that we do. The guests range from doctors, to writers, to those in entertainment and of course, those from mental health fields.
Detangle by Kinjal
Detangle with Dr. Sudhir Kothari
Discover the nuanced world of neurology and psychology with Dr. Sudhir Kothari, one of India's leading neurologists. What sparked his journey into neurology? A book recommendation, interestingly enough. In this episode, Dr. Kothari shares his expertise on diagnosing dizziness—a term that can mean a lot of different things to different people—and the analytical rigor required to differentiate between conditions like benign paroxysmal positional vertigo (BPPV) and vestibular migraines. Through compelling anecdotes and case studies, including one where excessive screen time was the root cause of dizziness, we uncover the critical role of effective communication and patient history in diagnosis and treatment.
Dive deeper into the mental health challenges faced by medical professionals. Dr. Kothari sheds light on how doctors often avoid seeking help for psychological issues, opting instead for activities like playing chess or multitasking. Discussing the financial and professional pressures, particularly on younger doctors, Dr. Kothari compares the strengths and weaknesses of the Indian medical system to that of the USA. This episode also clarifies the different types of vertigo, including Persistent Postural-Perceptual Dizziness (PPPD), and distinguishes between vertigo, dizziness, and imbalance, offering listeners a clearer understanding of these often misunderstood conditions.
We then talk about the enriching experience of co-authoring a book with Dr. Kothari. We delve into the collaboration process, the balancing act of agreements and disagreements, and the continuous learning journey it fosters. We conclude with a glimpse into future episodes, specifically mentioning an upcoming focus on headaches. Don't miss this insightful episode on neurology, psychology eand the complexities of diagnosing and treating dizziness.
Welcome to Detangle, where we untangle the complexities of life one conversation at a time. I am your host, Dr Kinjal Goel, a psychologist and a writer. Our guest today is Dr Sudhir Kothari, one of India's leading neurologists and also a dear friend. Welcome, Doc. Thank you for joining me on Detangle today. For those who don't know, you tell us a little bit about your scope of work, please. Detangle today For those who don't know.
Speaker 2:You tell us a little bit about your scope of work, please? Hello everyone. I am a neurologist. I have been in practice now for almost 40 years. After my MD done in Pune, I went to Bombay and did my DM Neurology under a famous neurologist, Dr Singhal. After that I have gradually got interested more and more in headache and now even more vertigo. So I have become a member of the esteemed Barani Society, which is a world society for doctors dealing with vertigo, and I'm also keenly interested in neurology education. So we have started a trust called the Forum for Indian Neurology Education through which we have been conducting lots of lectures and training for Indian neurologists.
Speaker 1:Super Well, Doc. We've had so many conversations in the last decade and a half. I can't wait to get these conversations out there, because I've learned so much of neurology from you and the overlap in neurology and psychology is just beautiful. I mean, it's a piece of art.
Speaker 2:I have learned psychology and how to talk with patients from you.
Speaker 1:Well, so let's get started. Doc, how did neurology come about for you? Was it something you always wanted to do as a child, or did it happen eventually?
Speaker 2:As a child, I was never interested in biology. I was much more interested in chemistry and physics.
Speaker 1:Really.
Speaker 2:And I never thought until one friend, his brother, gave me a book called the intelligentigent Layman's Guide to the Biological Sciences by a very famous author called Isaac Asimo, and he said that this will ensure that I'll get interested in biology. And sure enough, you know, it took me from biochemistry up to how molecules, how proteins, how things you know, dna, and then finally to living. But so I got interested in biology and then I went into medicine. Neurology was different because when I went into medicine I was exposed to a very famous and senior neurologist, dr RS Wadia, who was a gem in neurology andI the first time I attended his courses. After that, each of his clinics I would attend right from MBBS. So I was very keenly interested.
Speaker 2:I've always been interested in chess and in, you know, thinking and trying to predict what something is or what. So neurology is the ultimate sort of game for us diagnostically, where we have to figure out from the patient's symptoms and signs. Sometimes we scratch the foot, sometimes we look in the patient's eyes, sometimes we tap his reflex and from the history we make a diagnosis. And it is a lot of fun. I would say that when everybody else has been struggling with the diagnosis, the neurologist I used to see dr badia. He would be referred a case and he would just walk in and five minutes later he'll declare this is the diagnosis, and everybody would be flabbergasted. You know how did he make this that?
Speaker 1:so, now that all of us neurologists love to make diagnosis of course we also love to treat, but diagnosis is the first step so, instead of you going out there and finding your inspiration, the inspiration found you in the form of a book, and then you took it forward Fabulous. So, doc, you deal with a lot of segments on a daily basis, two of the major ones being headache and dizziness. Now, how common are these and how many of these kind of patients do you see on a daily basis?
Speaker 2:Both are extremely common and I must be seeing at least three to four patients of headache every day and maybe another three to five, maybe five of each dizziness. My practice has become more and more specialized in vertigo and dizziness so I get patients from across the country and therefore a big chunk of my patients is a dizzy and patients with vertigo now.
Speaker 1:So let's focus on dizziness then. So chakkar, as it is fondly called in India, is a word that we've all used at some point in various degrees to describe some symptom that we are feeling. So tell us about the different kinds of chakkar, the different kinds of dizziness, and how do they you, you know kind of lead to a different diagnosis.
Speaker 2:So the first, problem with the word chakkar is it is used so loosely by patients to describe multiple different types of symptoms. So somebody who feels he might pass out and faint, he also calls it chakkar. Somebody who just feels everything spinning around, he calls it chakkar. Somebody who just feels everything spinning around, he calls that chakkar another person you know he's sitting at work and looking, staring at his laptop and see some complicated stuff that he has to work out. His mind goes dizzy and boozy. He calls it. He calls it chakkar another person sees.
Speaker 2:You know a lady sees a mother-in-law walking and she feels dizzy. So everything is called dizzy. Even when they lose balance and feel they might fall, that is called dizzy. So now, unfortunately, when the patient says I am feeling chakkar, the doctor just assumes often that he is meaning spinning type of vertigo. He may be actually feeling faint, he might be feeling imbalanced, but if the patient calls it chakkar, he is diagnosed as vertigo by the doctor and given a medicine which works for vertigo, rather than something to improve his balance or something to prevent his. It can be as simple as his blood pressure becoming low. So somebody who's's taking antihypertensive BP medicine and suddenly gets up to you know he's lying down and gets up suddenly he might feel faint because the BP transiently falls, becomes low. So these patients are also called themselves chakkar and they may wrongly receive therapy for vertigo when all they need is reducing the BP medicine.
Speaker 1:Right. So in many ways dizziness can really mess with the mind. I mean, a person who has been perpetually dizzy for whatever reason can start feeling a little uncomfortable, even emotionally. But tell me from the other side, can an emotionally unstable mind lead to dizziness?
Speaker 2:Absolutely so, dizziness. I look at it as it's a feeling of when you are not unsure, when you are yourself unsure about your place in space or into a sand, when it could be physical, it could be emotional. So when somebody is not sure where his head is, if he's feeling everything spinning, of course that is called dizziness. Somebody who feels he might fall is called dizziness. Somebody who feels he might fall is called dizziness. But somebody who suddenly lands up with a big responsibility let's say he is suddenly elevated from a teacher to a principal or something these patients often start feeling dizzy and they feel, because they feel unsure about can I handle this? Will I be able to handle it? And that also also makes them start feeling unsteady. They feel they call it dizzy, so they call it chakkar.
Speaker 1:So this brings me to my next question. I have seen you personally identify patients with psychosomatic symptoms and encourage them to seek psychotherapy. Sometimes I know that you have no idea what is actually wrong with them emotionally, but you have still picked the right patient for this kind of therapy. How do you identify them? Have you had any formal training in this?
Speaker 2:No, this is being something like you jump into the water and start swimming. So initially it was very awkward trying to ask somebody directly that is there some stress? Are you stressed? And I realized that that was not something taken well by a patient. Nobody likes to accept that they are stressed out or there is tension.
Speaker 2:In fact, if I ask a lady who's come with dizziness and where I am, I have, of course the first step is to rule out something organic. When I check and I find that it is not fitting in with something like benign positional vertigo or a viral infection, and if the history sounds as if it is not consistent, then I start thinking that could this be stressful? In the earlier days I would ask them kuch tension ho gaya kya? And before the lady could answer, the husband on his side would say no, no, no, usko kya tension? There is no tension. So they often feel responsible and they want to say there is no tension, everything is fine. How can she be tense? How can there be any stress? So gradually I realized that this was not the way to ask.
Speaker 2:Now, if I ask somebody how has your last two weeks been? Was it particularly different than your usual time? What has it been hectic? Then they say say yes, yes, yes, it was hectic, there were a lot of guests, we had a family function, there was a marriage coming up Then they accept it. So maybe maybe you correct me here, but I have the feeling that when somebody says I am stressed, I am under tension, he is accepting the blame, so to say, for being sad. But when somebody says it is hectic, it was overworked, you are accepting the blame, so to say, for being sad. But when somebody says it is hectic, it was over, you are putting the blame outside and therefore it's more acceptable. Do you think that is right?
Speaker 1:so sometimes overthinking is taken as a blame. People say, oh, you overthink and hence you must be feeling these symptoms, and it's a sign of weakness that my mind is playing games with my body. So people always want to feel strong and in control and say, oh, the environment caused it, a traffic jam caused palpitations, or I was late because of this and so I was so stressed.
Speaker 2:So once the blame goes outside, they can deal with it better because they're more objective I have seen that I mean like, uh, these patients heal now rather than stop coming to me if I ask them are you stressed or tensioned? Sure enough, next time they will not come to me because they feel blamed. The husband and the wife will go back and they will start. Why did you say you were stressed? And you know it does not heal the whole situation. But now, when we say about it hectic, everybody understands yes, it was. There was this thing. You didn't sleep well, you didn't get to eat time. So now I can advise them about lifestyle issues and they improve so I have seen this progression with you over the years.
Speaker 1:Initially maybe you would have told a patient that, look, you need to see a psychologist. It's nothing, it's just stress. But you don't say that anymore.
Speaker 2:Yes, you inform them that actually saying yesterday only some patient. When I examined her and she said, oh so it's just, it is just stress, I said don't say just stress, read my book there. I have written a whole book on how the mind and just stress is wrong. The mind has a huge role to play in various illnesses and every day at least half the patients who come to my clinic have some problem related to stress and their mind. But therefore don't call it just stress. So that girl was very happy and I gave her a book and I said you must read it and come back oh, so we're talking about blind to the mind now.
Speaker 1:Well, for the audience, that's a book that we've written together and it has been a great resource material for us to share with patients.
Speaker 2:Even I've been able to give a lot of simple psychoeducative tips just by handing over the book, so I'm glad we did that at some point it was difficult for me to you know, all along in our training we were sort of made to believe that somebody who has a functional problem, somebody who has a problem related to stress, is actually wasting our time and so neurologists would want to deal with something exotic, some proper, you know neurological illness, and locate where the problem is.
Speaker 2:So we would feel this patient is wasting my time and we would actually be sort of angry with the patient that the patient is having a functional symptom, wasting my time, wasting the resources of the country, so to say. So now, over the years I have come to realize how being functional is not something that is being done purposely. They are not faking it, they are suffering and we need to help them also.
Speaker 1:True, and they do get better.
Speaker 2:A lot of patients do improve with psychotherapy.
Speaker 1:Let me ask you this question, which is extremely common. I'm sure you've heard it, answered it, thought about it, but every time I ask this question, I realize that we have changed in the level of the question. For example, a few years ago, google doctors were an in thing I'm sure you've spoken about it. That people went on, google got their diagnosis, came to you, irritating yes, now we have AI. Now people are getting used to asking, let's say, chat, gpt or meta AI, something coming up with a more articulate answer, answer having a more fixed diagnosis in their head, which may or may not be right, and then they come to you. So do you feel these patients insist on a quicker cure or a shortcut healing?
Speaker 2:yes. So first of all, luckily, I have still not had people in front of me opening out the chat GPT and telling me this is what chat gpt said, but I'm sure that is going to happen. I recently gave a talk on ai and we have to be ready for this because patients are going to see it is useful and it will be useful. It will at least make the doctor think that, okay, this then. Then he has to think why is it not what you are saying? Why am I saying this is the diagnosis and not that? So you have to explain your diagnosis, which, as of now, most doctors are not in the habit of explaining.
Speaker 2:They just like to declare the diagnosis and tell the patient yeh goli khao and come back after two weeks. So this will make them also think. I do not think it is wrong for patients to look it up. But when patients start trying to look up chat, gpt or Google to get a diagnosis, that is very fallacious because it is always going to throw up the more exotic, the more dangerous diagnosis. And somebody with a minor tension headache would say oh, my symptoms are fitting in with the brain tumor, so you have to be careful there. So a proper mix of that would be useful, I think so I like the idea of anything which is artificial intelligence.
Speaker 1:Opening up a conversation with a doctor, yes, if everybody thinks about it.
Speaker 2:The name itself is chat. It is not google, it's not a search engine, it is a conversation. And if you have really used chat gpt, you'll see how well you can converse it. It tells something you say no, I don't understand it. Can you explain? I have recently done some talk so I told it okay, explain what is a transformer? Gpt is a generative transformer, pre-trained transformer. So I didn't know all these words. I told him explain as if I am a 10 year old and it explained it so nicely.
Speaker 1:True, so it is useful so, instead of fighting it, we need to become allies absolutely, I think you have to use it. So now, Doc, tell me, over these years, you have entered the zone where you're spending a lot more time giving second and even third opinions. Where do you see and what area are you correcting the mistakes of others the most? I mean, what is the most common mistake other physicians are making in terms of dizziness?
Speaker 2:The commonest mistake is not listening to what the patient has or just getting carried away by the words or the description that the patient. The patient calls it dizzy, but I have realized that, rather than just ask what do you feel when you are dizzy? If I've asked them what brings on that feeling of dizziness? Does it happen when you lie down? Does it happen when you turn in bed? Does it happen when you get up? Does it happen when you're staring at the computer or doing some work? All these give me clues. If it is when the patient lies down and turns in bed and just feels dizzy for less than two or three minutes, in 80% of these patients it is a disease called benign paroxysmal positional vertigo, or BPPV. Okay, that is, we'll go about it over that later, but that's a very simple and easy way to diagnose. If your dizziness is triggered by head movement and it lasts less than three minutes, make sure it is not BPPV. It's so easily treatable. It's almost magical therapy for it. If the patient says that his dizziness comes when he has a late night, when he does traveling, when he has missed a meal or when there's some lot of stress, and if there is also a history of migraine as headaches in the past, even if the patient does not have headache during the attack of dizziness, most likely that is vertiginous migraine or vestibular migraine, a form of migraine. See, most people know that migraine causes headache.
Speaker 2:Many people don people know that migraine causes headache. Many people don't know that migraine is the commonest cause of spontaneous attacks of vertigo. Spontaneous means, not positional. If you are sitting in a room and you are doing, if I am having a podcast and suddenly the room starts spinning, for me that is most likely vestibular migraine. Of course, at my age you also have to think about a TIA or transient ischemic attack. That means, is the blood supply to my brain getting compromised? Is it a warning for stroke? So if somebody is diabetic, hypertensive, old and he gets such an attack of vertigo lasting for a few minutes without any reason, without position change, you have to think of the rare but dangerous possibility of a TI. But then most common is migraine.
Speaker 1:I had a very interesting case recently where I had a patient who was 28 years old and she said I had been feeling dizzy in the evenings, so this was timed dizziness Every day. By 6.30, 7, she would start feeling dizzy. She went to a neurologist in her city. She was from a small town and she was prescribed some I think it was Vertin or some one of those vertigo medicines which she took very religiously. She did not skip a single dose, but she said it just made things worse. Now the neurologist said look, I've treated you the best I can, so maybe this is all in your mind. You know, figure this out.
Speaker 1:After we started therapy it took us only 30 minutes to realize that she was using her phone for 7 to 8 hours a day. By the time it was 6.37, she had seen so much screen at such short distance that her head was spinning. The medicines only made her sleepier and made her worse, because now her brain was not even active enough to do that and she was battling on two fronts. It was when she went off social media and took a break from the devices that she started feeling better. So now these things are so easy to miss because the neurologist doesn't have the time to sit and listen to a whole day.
Speaker 2:I think the crucial step was her coming to you. So it's, like you know, getting. The biggest challenge I used to find in earlier times was to tell a patient that you need to go and see a counselor. And now, in the last two or three years, I have learned that the first step has to be done by me. I cannot just tell a patient okay, you don't have anything neurological. Go and see this person and let that I have to explain to the patient, get them to understand how the mind is playing a role. So that first step is very important. If they then at that time accept that, yes, this is due to the mind then telling a role, so that first step is very important. If they then at that time accept that, yes, this is due to the mind, then telling them to a counselor, they are willing to accept. But if I tell them that for diagnosis you go to the counselor, then it's not accepted fair.
Speaker 1:So, doc, with the sort of life that you live, the busy schedule that you have, the patient load that you deal with, how do you manage your own physical and mental health any mantra that you've been swearing by all these years?
Speaker 2:well, I, I exercise. I exercise quite religiously. I used to do running earlier. Now I do a gym thrice a week. I do yoga once in a week at least, and I am learning now how to swim because I am not. I'm a pretty poor swimmer, I used to gasp for breath, so now I'm learning. I want to. So, basically, you need to be physically active. I like to be active on social media, particularly neurology related stuff.
Speaker 2:We exchange cases and we like because it's nice to have. We keep getting these spot diagnosis and this is a patient coming with this what is your diagnosis? I love it when in between there was a patient. A friend of mine from another town posted a case of a young boy with a stroke and something one side paralysis and he was saying that he wanted to give blood thinner and I said, no, ask the surgeon to burr. You know, make a hole in the skull. There is pus there and nobody was believing it, but I convinced him to do hole in the skull. There is pus there and nobody was believing it, but I convinced him to do it and, sure enough, there was pus. So that boy was saved and it's this.
Speaker 2:Sort of things are rewarding we have a very active group in our maharashtra neurologist where we exchange cases and we learn from each other yes, the famous man manA-N.
Speaker 1:Yeah, m-a-n, m-a-n.
Speaker 2:Maharashtra Association of Neurology.
Speaker 1:Yes. So, Doc, if you were to give any advice to your 16-year-old self, what would you say?
Speaker 2:16-year-old. Well, that 16-year-old I was very different. I had stood first in SSE at that time, so that time I was in the, you know, my head was very high. Now, if I was 16, what would I do differently? I don't think I would do anything different.
Speaker 1:So no advice to your 16 year old self do exactly what you did.
Speaker 2:I'm happy with whatever I have done.
Speaker 1:Fantastic Dr. Mental health of medical professionals is at a very high risk, especially in this ecosystem. That we are now A highq doesn't mean that a doctor can't suffer just like everyone else, but doctors are very adept at hiding this. Do you see more colleagues reaching out for help with psychologists now, or are things still the same?
Speaker 2:no, they don't like to reach out, they don't like to accept that they are having problems. I think most of the neurologists probably like me, like, just like to keep themselves busy and running so that they don't have time to think about problems. At least, that probably is my coping mechanism.
Speaker 2:I don't like to think, In the spare time that I have, I will play chess. I play at least one or two hours of chess online every day and I do a lot of work on the computer, so keeping yourself busy and doing some things. I like to multitask. There are multiple things going on at the same time. I think most neurologists do that and I have not seen a neurologist saying he's going and taking. Maybe they are, but nobody will admit that they are taking psychological help. They don't think they need.
Speaker 1:Well, I have a fair share of patients who are doctors, but I think there are a lot more who are suffering because you do find out from them about their colleagues and you wish that more people saw them.
Speaker 2:See, it's a very difficult thing, just not to be a doctor there's no question, and particularly now see, at my age, probably it's easier because we've done all the hard work but somebody who's now struggling, who has taken a loan for a family, who has to buy a house, buy a car and then make still make things work, working in a corporate hospital which has a lot of pressure on them bring patients, do this, do that. So there's a lot of pressure and I think they must be having problems dealing with it.
Speaker 1:True. So if you could change that one thing about medical practice in India, what is that one thing you would change?
Speaker 2:See there are some things good in uh medical practice and I have been to usa and recently my daughter is there and I find medical system there is in some ways better, but in most ways our system is better. You know you cannot approach a medical care help, you cannot get something here. You can get a neurologist in one day. I mean just three, four phones and I have to see a patient or there. You'll not get a neurologist for two, three months. So what could we change? Maybe the working hours, maybe the, the respect. I think we do get respect. All said and done. There are places, I mean problems when doctors are mashed up and things like, but, but in general people respect doctors and most doctors are doing a good job. Everywhere there is some problem, but in general I think the Indian system is good and despite our huge population and the scarcity of doctors, we are, I think, doing a good job.
Speaker 2:Fair, our only problem is, I think, think, the cost and the problem that most people are not insured and medical therapy is becoming more and more expensive. So if one doesn't have insurance it is a big problem. So I think if there's one thing I would change is encourage everybody to go in for medical insurance before they get ill, of course.
Speaker 1:I think that's a very important step. It's a very important step. It's a simple thing, but something which people always say we'll do it later.
Speaker 2:Once you get ill then you don't get insurance. So it's better to always do it before. And the insurance companies are very clever. They are all the time trying to find out whether this is pre-existing or something and try to deny your claim. So if you start early something and try to deny your claim.
Speaker 1:So if you start early, they can't do that. This brings me back to your game of chess, where you're trying to preempt the next move and do something which you can do right now rather than later, before you have a checkmate. So, doc, tell me now about the different kinds of vertigo. We've covered a lot of things in the conversation so far. One of the most common things people use is vertigo. Right, people will stand on top of a building Mujhe vertigo hai, I can't look down or people will you know, just look downstairs and say, oh, I have vertigo. There is also PPPD, there is vertiginous migraine. So tell us about these different sorts of chakkar.
Speaker 2:Okay, so there are not too many actual conditions. The most common and most important one you should know. First, most important one you should know First of all what is vertigo. When you get a sensation of spinning, it's not always spinning, it can just be feeling that you are tilted or you're moving, you're bobbing, some sensation of movement which is not really there, but you feel the movement. So it's a hallucination of movement that you get. That is called vertigo. Dizziness is when you just feel unsteady, unsure about your position, but without this false sensation of movement. And then the third one which you should know is imbalance, where you feel no spinning but you feel you might lose balance and fall. So, very simply, if the person feels spinning or some sensation of movement when it lies down, when he gets up, when he turns in bed or when he looks up or looks down, that is typically vertigo.
Speaker 2:Dizziness is often along with that imbalance on the other hand, you will never get when you're lying in bed or you're sitting on a chair. Vertigo you can get, and very often you get, but imbalance is mainly when you stand up and are about to walk. You feel as if you might fall. That is so it makes sense to ask the patient what brings on your feeling of dizziness. Use any word apart from vertigo. Most people are so used to calling everything vertigo. So they come to me and they say I'm getting this and that, and then I ask them what did your doctor tell you? After four or five, typically, various studies have shown all over the world that for a patient of dizziness to get a diagnosis they need to go to at least around four to five doctors on an average.
Speaker 1:Really yes.
Speaker 2:So because nobody is comfortable including the doctors with a patient who's saying I'm feeling dizzy because it's so vague and you have to spend time trying to learn what he is seeing. With practice now I can get it within two or three minutes what the patient means, but many people get confused when they're not, so you have to first clarify, is it?
Speaker 2:really vertigo. Once you have vertigo, the commonest cause is benign position vertigo. Now, that's a very simple and again, I like it because of my I like physics and maths. So essentially, we have to remember that your ears constantly send information to the brain about hearing, about sound, but they also send information about head position, head movement, which way it is going, is it going up or down? Is it going straight or backwards in a car, or are you spinning or turning backwards, forwards, whatever? So this information is constantly being sent. Just as you have your gyro in your phone, when you tilt it, the image changes. Same way this there's this sensor in the inner ear which you can't see, but that is constantly sending information. Now, this sensor has small calcium crystals inside which should be in a particular place. If they are in the proper place, they give the proper information. Sometimes they get loose, for example with age. Sometimes you fall down and bump your head. Or even if you don't bump your head, just a fall, the particles can get loose and go into a wrong position. Now, when you move your head, they said, the particle moves and for a few seconds or maybe a minute, it gives the wrong information to the brain that everything is turning these patients. It can be very scary because it is unpredictable. Sometimes you look up, it spins, sometimes it doesn't. Sometimes you go down, you lie down to sleep and suddenly the room goes spinning. They may. I have had patients screaming and shouting when they come to me. When I ask them to lie down, some have even drawn blood because they grip you so hard. So this is a very scary vertigo, especially in a elderly person who's going out independently earlier and now doesn't know when it will spin, when it will fall. So they get their whole life gets that.
Speaker 2:It is very easy to treat this. Unfortunately, most doctors only give a tablet to suppress this vertigo. What the tablet does is the particles remain in the wrong position but the wrong message gets suppressed. So you do feel better. But when you stop the tablet, very often the particle is there and the vertigo will return. So the treatment is very simple the particle has gone in the wrong place, locate where it is and move it back. So we used to play this game in childhood with those small metallic spheres and try to guide them inside. This is something like that. We guide the patient. We have a special goggle which, when the particles move. Not only does the patient feel spinning, but his eyes rotate in a particular way and so we see the eyes. And with a special goggle I see the eyes and I know how the particle is moving. Is it moving in the proper way that I wanted to? And I turn the patient from one position to another and the vertigo stops. So such patients, it can be magical. Within five minutes the patient who has been having repeated vertigo for months, it's just gone. They often cannot believe it. So this is one the sort of place where we can do magic for the patients and we should not miss it.
Speaker 2:Second one I would say is vestibular migraine. So that is again very common. Some people say it might be more common than BPPV. So patients who may have headaches at times you know, migraine, as you know, is a tendency to get headaches when you have a late night, when you are stressed out, when you don't eat in time, when you conduct too many podcasts, whatever. You know that. So migraine patients can get dizzy, they can get attacks of vertigo, which can be quite severe, and that is once you realize what it is. If you advise proper lifestyle, if you give them certain drugs, you can get that migraine under control.
Speaker 2:Then there's one very common disease, very often diagnosed but it's not so common really. I said commonly diagnosed and that is something called Meniere's disease. Now the problem is that Meniere's disease has to have attacks of vertigo more than 20 minutes. It should have hearing loss and it should have ringing noises in the ear. Everybody has been taught about manias as a doctor. So what happens is when a patient goes to a doctor and says the first doctor asks him, patient says it's fine. Then he goes to a second one because the first one has not been able to solve his problems. He goes to a second one. Again the same question. Now the patient, after two or three doctors, starts becoming looks like this is important. He goes home at night and focuses carefully and says, yes, there is some ringing noise in the left ear. And then he puts his mobile to both ears and says, yes, left side is slightly less.
Speaker 2:So the fourth doctor. He says, yes, I have ringing noises in the ear, I have little hearing loss, and he gets the label of Meniere's disease. So this is not Meniere's. You have to have proper progressive hearing loss, you have to have loud noise and the attack of vertigo has to be more than 20. So actual Meniere's is quite rare. I see maybe once in a month or once in two months, but I see much more migraine. I see much, much, much more BPP. Then fourth cause I would say is something called vestibular neuritis. It's a viral infection of the ear, of the inner ear, and then it suddenly it strikes out of the blue. There may or may not be any fever or anything and then you get persistent vertigo, going round and round for days.
Speaker 2:This is not just few seconds or minutes like bppv, not uh minutes or hours like migraine, but days days and there's no hearing loss, there's no pain in the ear.
Speaker 2:So often these patients land up in ICU because of vomiting, sweating, and they are thought to be cardiac. Only when the patient tries to get up later and walk he notices that he's losing balance, he has vertigo and then the neurology reference comes and we know it is vestibular neuritis. Last one probably is before we go to PPPD is stroke. You have to remember that somebody who gets vertigo attack for the first time in life, most of these patients are vestibular neuritis, but a significant number, maybe one in four, can be stroke. And so if an elderly person, diabetic, hypertensive, comes for the first time, first attack of vertigo which is not stopping in hours, be careful, it could be a stroke.
Speaker 1:Now the elephant in the room. Yes, pppd, let's talk about it.
Speaker 2:So what is PPPD? It's persistent, so more than three months. Perceptual. So the person perceives dizziness I don't see anything. So the doctors earlier used to call this subjective dizziness. I don't see anything, so the doctors earlier used to call this subjective dizziness. This is like saying you are feeling dizzy, I don't see anything. It's like I don't believe you. You are saying it, so I'm giving you the label subjective. It's like saying you have got subjective headache. I can't see headache. When you get headache, every symptom is subjective. That doesn't mean the person is not having headache, so you don't label it subjective headache. So, similarly, the subjective dizziness name has been removed. Some people earlier used to call it psychogenic dizziness, type 4 dizziness, trying to you know, not tell the patient that I'm thinking this is psychological, but I won't say it on your face, so I call it type 4 dizziness. Now we all call it triple PD, and just the change in the name has changed my approach to it. So it's persistent, perceptual, positional dizziness. There's no vertigo. Now what is this?
Speaker 2:This is a sort of person who keeps feeling unsteady and dizzy all the time, even when sitting. Sometimes he's okay when he's driving a car, but when the car stops at the signal and he sees other cars whizzing past, he feels dizzy. Sometimes just looking at a curtain moving may make him feel dizzy, or walking in a mall can make them dizzy. So a lot of complex visual stimulation can cause them to feel dizzy. This, I feel, is essentially an iatrogenic condition. Iatrogenic means caused by the doctor. Why do I say that? When a person has, let's say, bppv, the person wants an answer. Why am I getting this vertigo? If he goes to the doctor and the first one says I think it is your cervical spine which is the problem, which very often they are told. Or another says no, no, I think this is the ear. The third person says no, no, I think this is the year. The third person says no, probably there's less blood supply to the patient, feels that nobody's understanding what. And then they start feeling insecure and, in a person who's a little analytical and who likes to have answers for everything, this is the setting for getting triple pd. Then they start feeling will this cause dizziness? They start holding their neck stiffly because they are worried it might cause. So all these secondary changes happen.
Speaker 2:This balance, as you know, is something. If you are confident about your balance it is good. But the minute you start doubting your balance you feel more unsteady. So you know I always give the example that if I put a line on the floor, say maybe half two inches wide, and tell you to walk on it, you'll walk very easily. But if I put that same stick on top, about 10 feet above and I tell you now walk on it, you will lose balance because you are now scared, will I lose balance and your balance worsens. So same thing happens in triple PD.
Speaker 2:So it could be the trigger is not necessarily vertigo. Trigger can be something. Just yesterday I saw a patient. The patient woke up in the morning 6 am or so, went to the washroom and was standing and passing urine and suddenly felt dizzy and fell down. He was admitted to the hospital, sent to the ICU because they were sweating and he had lost consciousness for a minute or so. So ECG, eco, this that brain MRI, ngo, multiple tests done, finally told nothing, maybe nothing much, don't worry and given some medicine and sent back, but not given a diagnosis that this was micturition syncope, that this was fainting because of suddenly relieving. When patients suddenly, if their bladder is full and it is relieved, the BP can fall and patients can pass out. So not getting a diagnosis can itself trigger all this.
Speaker 1:Right. So PVPD actually presents in a very complicated way. Even when patients reach me, they are so sure of the organic cause of this dizziness me, they are so sure of the organic cause of this dizziness it takes me at least two to three sessions to make them understand that we can treat it from the other side. It's almost like crossing over to the dark side. Tell them welcome to psychology, let's deal with it, let's discuss it, and afterwards, when they start seeing a remission of symptoms, do they start believing that, okay, this might have been? This is the only one condition which goes the other way.
Speaker 2:You have to give them relief for them to believe one more thing I have realized over time is now patients with bppv. Let's say, I treat the patient's particles, it is stopped, but he keeps feeling unsteady. He now, why does that happen? Earlier we used to get angry and frustrated with this patient that see, when I first put you down there was so much nystagmus, that abnormal eye moment. It's all gone. You have no right now to complain and this is not fair.
Speaker 2:I used to feel that you know I have treated you and you are still saying you are feeling dizzy. Now I know what it is. So now I explain the patients very nicely. I say that for the last six months your ear was sending wrong messages to your brain that things are spinning when they are not. Now, in these six months your brain has got confused. It doesn't know what to trust and what not to trust and therefore it is not paying attention properly to the ear signals. So we'll have to retrain it, we'll have to reduce your anxiety. So for retraining, I give them some vestibular exercises For reducing anxiety, I send them to you and I may give them a small SSri like drug and antidepressant for a few weeks and these patients now improve dramatically. They do very well just telling them what it is, when they understand why this is happening. Often it helps I completely agree.
Speaker 1:Well, that has been extremely enlightening, because chakkar for everybody was just chakkar, but hopefully after listening to this, they understand that there are different kinds of chakkar. Which which brings me to the most interesting question in my podcast, something I love asking all my patients. So, as a doctor, you of course have a first aid kit in your home. You keep all your band-aids and antiseptic painkillers, you know, for those days where you have minor cuts or bruises. But what if you were to keep a mental first aid box in your house, something which you could just open on a day when you're emotionally run down?
Speaker 2:What would make you happy? Personally, for me, music. So I like to sing or I like to listen to some type of music, so particularly classical music. And when I was myself ill, that was one of the things that I asked for one particular raga by Ali Akbar Khan, and that would always soothe me. So certain pieces of music I like my dog, who's a dachshund. He never fails to cheer me up Because just seeing him you know if you are down the way he'll wag his tail and he'll come and lick you. I think that's more than enough. And, of course, a game of chess on the computer. That is enough to and some dark chocolate.
Speaker 1:I know there is chocolate in that box. I'm not.
Speaker 2:I was a little guilty over telling about that it's okay, guilty pleasures work.
Speaker 1:So, doc, I'm going to leave the floor open to you now. Is there any question you would like to ask me as a psychologist?
Speaker 2:okay. So in the last maybe 15 or what odd years that we know each other, I want to ask you how do you think I have progressed in understanding, in dealing, in developing empathy, Because you used to say I had that typical snigger when I was describing a functional patient. Do you think that snigger has gone and if it hasn't, what can help me get rid of it?
Speaker 1:well, I think a lot has changed and I can see this from the simple attrition that has changed between your patients coming to me. Initially, if you were sending 10 patients, hardly one would turn up. Now, if you tell me that x, y, z, three patients are coming, all three will take an appointment. So that's a very large leap. Also, this snigger which you talk about, the giggle as I used to call, it every time you would find a patient with functional symptoms.
Speaker 1:It would be like you have solved the case. You know you've cracked the code and you would use words like PSY to define this as a psychosomatic patient. And empathy is something which initially you were trying to show and not trying to feel, and you always asked how can I show more empathy? But over the years you don't need to show that empathy anymore. I know you feel it and I know you're feeling that this patient is suffering, no matter what it is organic, mental, emotional.
Speaker 1:Also, now you have stopped trying to crack the code, you have stopped trying to solve a puzzle and you have stopped trying to crack the code. You have stopped trying to solve a puzzle and you have stopped trying to be the psychologist. So I know initially there were years when you would find out it is stress, tell them look, it is stress, stop fretting about it and you will feel better. But now, when you don't do that, the patient always feels that they can come back to you and they know that, okay, this is one process they need to go through and they feel more confident. So I see a lot of patients reporting this confidence also.
Speaker 2:Yeah, so I no longer tell them, I no longer banish them to you, correct? I tell them go to her and come back and let me know how you're feeling after six weeks.
Speaker 1:So that makes a lot of difference, so I don't give them up.
Speaker 2:They have to come back and report to me that they are better or not, or how they are feeling, and that makes them feel that I am not giving up on them. I am still sort of treating them.
Speaker 1:It's a matter of being seen, it's a matter of knowing that this is not a dustbin diagnosis.
Speaker 2:Yes.
Speaker 1:And you've also started now looking at psychosomatics as a positive diagnosis.
Speaker 2:Yes.
Speaker 1:It's earlier for you. It was just a negative.
Speaker 2:I can't find anything else, the patient looks nice and happy and on the face, must be psychological. That is what my earlier thing. Now I look for positive ways that this, this, this and therefore it is very likely at the same time. Earlier I used to think that functional was a sort of, or very akin to malingering, where the person is purposely faking illness, or I used to call think of them as system cheats. Now I do not. I have myself had some issues and I know that, how functional or stress can trigger real physical symptoms.
Speaker 1:I think we came a long way while writing our book, because when we were both trying to understand from the other person's perspective, we delved into the depths of the mind and the body in a very, very different way, which was great fun, because we fought over the book, we agreed, we disagreed and the whole point was not to write with somebody who either agrees with something all the time or disagrees with something all the time.
Speaker 2:So we found that balance some, some things in the book I would now change I'm sure we will rethink it.
Speaker 1:Yes, and that's the whole point. Maybe we'll come up with another version soon, but well, doc, this has been tremendous. I mean, there are so many things we talk about on a daily basis, that we discuss and that we learn from each other. I'm so glad we could bring this out to the audience. It has been an amazing conversation. I hope people listen to this. We will come up with another season, another episode, purely on headaches.
Speaker 2:But this time it's for all the chakkar out there. So thank you so much for your time, thank you. Thank you, I enjoyed too. Thank you.
