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A clinical study on the effect of Aparajita churna and Jyotishmati taila on Chittodvegam ( Anxiety neurosis), JAYA LAXMI.V, Department of Kayachikitsa, PG unit Dr.BRKR Govt. Ayurvedic College, …

A clinical study on the effect of Aparajita churna and Jyotishmati taila on Chittodvegam ( Anxiety neurosis), JAYA LAXMI.V, Department of Kayachikitsa, PG unit Dr.BRKR Govt. Ayurvedic College, HYDERABAD

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  • 1. INTRODUCTION Overwhelming stress can produce psychological problems in anyone. Even stable, well adjusted person may breakdown if forced to face extensive psychological, physical, environmental or social stressors. In present conditions, human beings are living in the perpetual state of ever increasing stressful situations arising from the current lifestyle, environmental pollution highly ambitious and competitive lifestyle, over population, monotony and boredom of complex interpersonal relationships, job responsibilities and many other associated mental and emotional causes. The ever growing stress and strain in life lead to deterioration in various mental and physiological functions of body, causing psychological disorders like anxiety neurosis. Neurosis or neurotic disorder is the traditional term for those symptoms that are associated with emotional, cognitive, behavioural, and somatic symptoms, and are not due to a medical disorder or to a personality disorder. Anxiety is the primary emotion present in these disorders. Anxiety has been defined as an unpleasant emotion that is characterized by feelings of dread, worry, nervousness, or fear. The stressful life has been the major cause of prevalence of anxiety neurosis in the general population. Studies from different parts of world have found the Community Prevalence rates of neurotic symptoms, between 7and 26 per month. The most frequently reported neurotic symptoms are fatigue (27%), sleep problems (25%), irritability (22%), worry (20%), depression (10%) and anxiety (10%). The National comorbidity Survey from United States reported that almost 1 in 5 adults between 15 and 54 years suffer an anxiety disorder in a year and this rose to 1 in 4 when lifetime diagnosis was considered. On the basis of the Epidemiologic Catchment Area Survey, the prevalence of anxiety disorders in United States is 4% (Barlow, 1988), representing the single largest mental health problem in America. Chittodvega==================================================1created by of Dr.KSRPrasad
  • 2. According to the recent National Comorbidity Survey, anxiety disorders as a group are the most common kind of disorders for women, affecting approximately 30 percent of the female population at some point in their lives, and the second most common kind of disorders for men, affecting approximately 19 percent of the male population at some point (Kessler et al., 1994). The twelve month prevalence rates of anxiety for women were 23 percent and for men were 12 percent. It is very common for a person diagnosed with one anxiety disorder to be diagnosed with one or more additional anxiety disorders as well as with a mood disorder. A study appearing in the Journal of the American Medical Association (JAMA), 2004, Jan 2, indicates that anxiety disorders are the most common of mental conditions in many countries and the treatment or support is often inadequate or poorly advocated. The western medicine has not been able to crytalize its approach in the prevention and treatment of such disorders. Therefore, attempts are being made to explore the herbal resources of Ayurvedic medicine to develop suitable remedies for the management of anxiety neurosis. In the present study anxiety neurosis has been considered as the manovikara, Chittodvega, stated by Acharya Charaka. A detailed description of chittodvega is not available in classics. Though a lot of exploration is needed in understanding and in treatment of chittodvega, very few studies were conducted on this topic till now. Numbers of formulations were mentioned in classics for treatment of manasa rogas but specific medicines which are effective in chittodvega are to be evolved. In this context the present study is conducted with the objective of correlating the symptoms of Chittodvega with anxiety neurosis and an effort is made to evolve an effective treatment in the form of Aparajitha and Jyotishmati with special reference to their medhya property. Chittodvega==================================================2created by of Dr.KSRPrasad
  • 3. Statement of the problem: A clinical study on the effect of Aparajita churna and Jyotishmati taila on Chittodvegam ( Anxiety neurosis). Objectives of the study:  To study Chittodvega in comparision to anxiety neurosis.  To study the efficacy of trial drugs, Aparajitha churnum and Jyotishmati tailam, in decreasing the symptoms of anxiety.  To study the effect of trial drugs on the scores of Hamilton rating scale for anxiety and State Trait Anxiety Inventory. Hypothesis:  Null hypothesis: The trial drug doesn’t significantly decrease the signs and symptoms of chittodvega and the scores of Hamilton rating scale for anxiety and State-Trait Anxiety Inventory.  Alternate hypothesis: The trial drugs Aparajitha churnam and Jyotishmati tailam significantly decrease the signs and symptoms of Chittodvega and scores on Hamilton rating scale for anxiety and State-Trait Anxiety Inventory. Chittodvega==================================================3created by of Dr.KSRPrasad
  • 4. HISTORICAL ASPECT OF MANASA ROGAS Historical review denotes the roots of the topic in the old classics and methodical record of important events of past. Here an effort has been made to know the history of manas and manasa rogas in general from Vedic period upto 21st century. Vedic period (6000 B.C. to 1000 B.C.): Vedic era is said to be the earliest of the age or recorded history. Four Vedas with their Brahmana, Aranyaka and Upanishad part comprises the vedic scriptures. Many descriptions about mental disorders and treatments are available in these sacred texts. 1. Rigveda: Rigveda has many references about mental disorders, regarding the psychological derangements, the methods of treatment and means to prevent the psychiatric entities, which are - 1. Manas acts as a tool between Atma and Indriyas in the origin of knowledge.1 2. The Atma is supreme and the Manas as well as Indriyas surrender to it.2 3. Pisachas are blamable for mental disorganization and Agni has been worshipped for the cure of the same.3 4. Conjugation of Atma and Manas lead to Moksha.4 2.Yajurveda: A. Manas is the supreme power, which is associated for all impulses to be carried out, than to interpret it.5 B. In Shivasankalpasutra the sloka dealing with nature of mind (manas) is explained.6 Chittodvega===========================================4created by of Dr.KSRPrasad
  • 5. 3. Atharvaveda: Atharvaveda has maximum number of references related with manas and manasarogas. 7 A. Atharvani i.e psychotherapy is one among the main forms of treaties mentioned. B. Atharvani relates with the psychological aspects and includes mantra(chanting), sankalpa(decisiveness by repeated self suggestions) and vasikarana (control over self by mesmerism or hypnosis).8 9 C. Most of the hymns of Atharvaveda are directly concerned with the Atharvani. D. Devakritapapa, jwara, krimi, abhichara, rakshasa, gandharva, apsara etc., were given as the causes of mental disorders. E. Heart is considered as the seat of manas. F. Some manasa bhavas like irshya, krodha, etc., are calmed down through special treatments like Irshya Bheshaja.10 G. References of many manasa rogas like apasmara, duswapna, bibheti are found in Atharvaveda slokas. Data from Brahmanas, Upanishads and kalpasutras:-  In Aitreya brahmana, the sense organs and their functions are defined.11  Satapadha brahmana described about an important centre for dhamanis, nadis [trinabhishchakram] and shironabhi is stated as one among them.  Upanishads explained especially about Atma, Prana, Manas, Buddhi, Vividendriya vyaparas, Manonigraham, Indriyanigraham, Pranayamam, etc.  Manava grihya sutras gives an interesting description, possibly of mental derangement in the context of vinayaka prakarana.12  Taittireeya aranyakam discussed about Sristi vicharana, Pancha bhoutika shareera vicharana, Atma vicharana, Manas, Buddhi, Antahkaranas, Sattvaguna, Rajoguna, Tamoguna, Vividendriya vyaparas and Prana. Chittodvega===========================================5created by of Dr.KSRPrasad
  • 6. Post- vedic period: This period comprises of Puranas and Itihaas.  In Vayupurana sensory and motor organs are described.13  In Vishnupurana Indriyas and their functions are described in detail.14 Description about channels carrying consciousness attached to hridaya15 is given. Diseases have been grouped into two i.e.shareera and manasa and the later includes psychic aberrations like passion, wrath, greed etc.16  In Itihaasapurana, Sridhara explains virya, ojus, bala and saha as strength of mind, senses, body and heart respectively.  In Naradiyapurana sattva, rajas and tamas were mentioned as the qualities of mind.17  In Agnipurana senses along with mind were enumerated.18Heart is described like a lotus and seat of consciousness.  In Garudapurana, the role psychic state in metabolism was well emphasized.19  In Mahabharata santhi parva swaroopa of manas and sattvika gunas were described.  In Bhagavad Gita motivating talk of Krishna to treat the depression of Arjuna is a great example of psychological counselling. In eleventh skanda satvika guna vrittis were mentioned. Gnana was said to be residing in hridayam  In Ramayana, disturbed mind is stated to cause vitiation of indriyas. In yoga vashista, attempts of Vasishta, Vishwamitra and Dasaradha to elevate the depressed mood of Rama are good examples of psychotherapy.  In Brahmavaivartapurana and Manusmriti, methodology of psychological examination was explained.  In Panchatantra, a good description of psychological techniques, which can be applied in one’s life, can be seen in different stories. Chittodvega===========================================6created by of Dr.KSRPrasad
  • 7. Samhita period (1000 B.C. to 600 A.D.): In this period ancient seers like Charaka, Sushruta and Vagbhata contributed about various aspects of manas, manasa rogas and their management. Ayurveda traditionally contains Atharvani type of treatment in the form of Daiva vyapashraya chikitsa. Out of the eight specialities of Ayurveda, Bhutavidya, illumines, psychology and psychiatry in ancient times. Charaka samhita : a. A complete and detailed definition, properties and functions of manas are described.20 b. Chittodvega is mentioned as one of the vikara of manodosha.21 c. Effects of emotional factors on the body.22 d. Psychosomatic approach towards deha prakriti.23 e. Etiopathogenesis of mental disorders.24 f. Sattva pariksha i.e examination of mental status is described.25 g. Treatment of manas roga includes Gnana, Vijnana, Dhairya, Smirti, Samadhi.26 h. Complete and detailed description of major psychiatric ailments under unmada chapter.27 i. Ayuh is considered as the conjunction of Shareera(body), Indriya(senses), Sattva(mind), and Atma(soul).28 Sushruta samhita: a. Most of the manobhavas like krodha, soka, bhaya, kama are described as a part of either as iccha or dvesha.29 b. Sixteen types of manasa prakritis explained.30 c. In the definition of health, mental health is given due importance.31 d. Trigunas(sattva, rajas, tamas) are included in the Twelve pranas which chiefly regulate and control the biological functions of life.32 Chittodvega===========================================7created by of Dr.KSRPrasad
  • 8. Asthanga sangraha or hridaya: a. Introduced Dhi, Dhairya and Atmadi vijnana as the best treatment of manasa roga.33 b. Bhutavidya, unmanda, apasmara and balagraha are thoroughly discussed.34 Bhela samhita: a. Location of manas is given as sirah talvantaram.35 b. Alochaka pitta related to mental vision has been described.36 Samgraha period (600 A.D. to 1600 A.D): Detailed analysis of sattva pareeksha is given. In context of bhutavidya - Mandukaparnighrita, Saraswataghrita are indicated for the first time. Chandrata in his commentary on chikitsa kalika has explained two types of sattva– Bhiruta and Sahishnuta.37 Madhavanidana incorporated literature about mental disorders based on samhitas. Later on Sharagadhara, Bhavamishra and all the other commentators of samhitas have described manasa rogas based on samhitas. Modern period 1600 A.D onwards: In the early twentieth century, Yogendranath Sen, a renowned pupil of Gangadhar tried to elaborate some terms like moodha, alpachetas, vyakulata etc. Dr.BalakrishnaPathak, Dr.AyodhyaprasadAchal and Dr.Rajendraprasad Bhatnagar have endeavored well to interpret Ayurvedic description of psychiatry with modern literature. Chittodvega===========================================8created by of Dr.KSRPrasad
  • 9. Historical aspect of Anxiety neurosis: 1600 In the 16th century, the term hysteria is applied to anxiety and related disorders. 1678 An apparent mixture of depression and anxiety known as ‘Nostalgia’ was first described by military physicians among Swiss soldiers. It was termed as ‘Heimweh’ by German doctors. 1733 George Cheyne, in his book ‘English Malady’ and in other works launched the whole notion of ‘nervous illness’ as a malady affecting the nerves. 1751 Robert Whytt (1714-1766) worked with milder mental conditions (in effect the neuroses), categorizing them into the hysteric, the hypochondrial and those characterized by `nervous exhaustion’. 1777 The term neurosis was coined by William Cullen, replacing ‘illness of nerves’ and meaning any disease of nervous system without a known organic basis. 1818 Johann Christian Heinroth (1773-1843) developed a theory of mind involving a ‘Tripartite’ structure. He used the term-` Psychosomatic’. 1850 Heinrich Neumann (1814-1884) spoke of sexual (and other) drives which if not satisfied could generate anxiety. Otto Domrich became the first in the field of Medical Psychology to write about ‘anxiety attacks’, replacing earlier notions of neuro-circulatory neurasthenia. 1869 Chloral became the first rehearsal of the ‘Prozac’ scenario seen with drugs functioning as a hypnotic to relieve insomnia in anxious and depressed patients. 1872 Charles Darwin considered anxiety (fear) and anger (rage) to be adaptive characteristics of both human and non human animals. 1880 Charcot called hysteria as ‘ the Great Neurosis’ 1895 Sigmund Freud’s description of ‘Anxiety neurosis’ in 1895 was a wider concept that covered wilder anxiety states as well as actual panic attacks. 1937 James Papez proposed theory of the emotional brain. He speculated on neural pathways involved with emotional response in two ways- one via sensory stimulation of hypothalamus and the other via cortical stimulation and feed back of hypothalamus. Chittodvega===========================================9created by of Dr.KSRPrasad
  • 10. 1960 Patients who had unexpected anxiety attacks were deferrentiated from patients with other anxiety disorders. Chlordiazepoxide (Librium) became the first anti- anxiety medication (first benzodiazepine) to be used in psychiatry. 1980 The diagnostic category of panic disorders was first officially recognized with the publication of the American Psychiatry Association’s Diagnostic and statistical manual of mental disorders, Third edition (DSM III). 1994 DSM IV (Diagnostic and Statistical Manual of Mental disorders fourth edition, published with (listed) 297 disorders. ASAP (alternative support anxiety panic) is created, it is the first public internet forum devoted to anxiety disorders Research scholars in Ayurveda have previously studied about Chittodvega at different institutions. A brief review of the works is given below: B.H.U., VARANASI: 1. Clinical studies on chittodvega vis-à-vis anxiety neurosis and its treatment with rasayana drug Aswagandha (withania somnifera). [Dr.Malaviya P.C; 1977] 2. Role of ayurvedic drug in the management of Anxiety and Depression among elderly in relation to manasa prakriti. [Dr.Singh M.K; 2002] JAMNAGAR: 1. A study on the role of Adambu balli (Ipomea pescaprea Linn.) and Mansyadi quatha in the management of Chittodvega vis-à-vis anxiety disorders (DSM III). [Dr.Bhatt G.J; 1990] 2. Clinical study on the role of Jaladhara and Shankapushpi (Convolvulus) in the management of Chittodvega (Anxiety disorders). [Dr.Parsania Sanjay; 2001] 3. Clinico-experimental study of Kushmandadi Ghrita in GAD w.s.r. to Chittodvega.[Dr.AhirYogita; 2005] Chittodvega===========================================10created by of Dr.KSRPrasad
  • 11. STATE AYURVEDIC COLLEGE, LUCKNOW: 1. A clinical study of Shankapushpi medhya rasayana on patients of Chittodvega (anxiety neurosis).[Dr.Tripathi N.C; 1990] 2. A clinical evaluation of asvagandha choorna on manasaroga (chittodvega- Anxiety neurosis).[Dr.Saxena S.C; 1993] 3. Manasa roga Chittodvega and anxiety neurosis mein vacha choorna ka chikitsakeeya adhyayana.[Dr.Gupta R.K; 1999] GOVT.AYURVEDIC COLLEGE, THIRUVANANTHAPURAM: 1. Study on Chittodvega vis-à-vis anxiety neurosis and its treatment with three rasayana drugs. [Dr.Sarma MPE; 1987] 2. A clinical study on Anxiety neurosis with an ayurvedic compound. [Dr.Sreeja S.; 2002] VPSV AYURVEDA COLLEGE, KOTTAKKAL: 1. Management of Chittodvega (anxiety disorder) with an ayurvedic compound-A double blind study. [Dr.Autade vikas dadaso; 2003] 2. Role of Shankhapushpi (Clitorea ternate) and clinical yoga techniques in the management of general anxiety disorder. [Dr.Chavan Prashanth.J; 2004] SDM COLLEGE OF AYURVEDA, HASSAN: A study on the effect of Shankapushpi compound and Sattvavajaya chikitsa in Chittodvega. [Dr.Karla Sanjeeva; 2003-2004] GOVT.AYURVEDIC MEDICAL COLLEGE, MYSORE: A conceptual analysis of GAD and Chittodvega with a controlled clinical trial on the effect of Ksheera-Dhara. [Dr.Rajendra V; 1997] Chittodvega===========================================11created by of Dr.KSRPrasad
  • 12. SHRI AYURVEDA MAHAVIDYALAYA, NAGPUR: Chittodvega ka manovaigyanika vivechana evam us mein Medhya rasayana (yashtimadhu) ka chikitseeya adhyayana. [Dr.Thatte S.M; 1991] TILAK AYURVEDA MAHAVIDYALAYA, PUNE: To study the effect of shirodhara with Balashvagandhadi tailam in the management of anxiety neurosis. [Dr.Raut Raghunath; 2004] GOVT.AYURVEDIC MEDICAL COLLEGE, BANGALORE: Efficacy of Tagara in chittodvega w.s.r. GAD- A clinical study. [Dr.Nagendrachari.M; 2001] A.V.SAMITI’S AYURVED MAHAVIDYALAYA, BIJAPUR: A clinical evaluation of Shiro-dhara and Brahmi vati on anxiety neurosis. [Dr.Harisha.H.M; 2004] REFERENCES 1. Rg 4/1/915 2. Rg.4/5/917 3. Rg.5/29/10 4. Rg.2/243/181/1;8/4/57/1 5. Yaj.34/1-6 6. Yaj.34/3 7. Singh, 1977 8. Baloddhi&Roychoudhary, 1986 9. Baloddhi&Roychoudhary, 1986 10. Ath.veda -7/46/1; 6/28/1-3 11. Ai.Bra.5/22 12. Ma. Grh.Su, 2/14 13. Va. Pu.1/4/56-60 14. Vi.pu.3/37/19 Chittodvega===========================================12created by of Dr.KSRPrasad
  • 13. 15. Vi.Pu.1/2/46-49 16. Vi.Pu.6/5/2-6 17. Na.Pu.2/3/47-48 18. Ag.Pu.25/24 19. Ga.Pu.1/114/75 20. Ca.Sa.1/18-22 21. Ca.Vi.6/5 22. Ca Su.25/40 23. Ca.Vi.8/95-98 24. Ca.Sa.1/102,108 25. Ca.Vi.4/8 26. Ca.Su.1/54,58 27. Ca.Ni.7; Ca.Ci.9 28. Ca.Su.1/42 29. Su.Su.1/3 30. Su.Sa.4/80-96 31. Su.Su15/41 32. Su.Sa.4/2 33. As.Hr.Su.1/26 34. As.Sa.Ut.6/10;As.Hr.Ut.2/7 35. Bh.Sam.Ci.8/25 36. Bh.Sam.Sa.4/3-5 37. History of medicine in India 273p, 274p 38. http// 39. Oxford handbook of psychiatry – 340p Chittodvega===========================================13created by of Dr.KSRPrasad
  • 14. CONCEPT OF MANAS Ayurveda deals mainly with Ayu, which is life. According to Charaka Samhita, Ayu is a complex union of Sarira, Indriya, Sattva and Atma.1 The term Ayu refers to a combination of body, senses, mind and the soul.Sattva is taken as manas i.e.mind.2 The word Sattva is used not only for Manas but is also meant for cetana, citta, hridaya etc. It is called as manas when it is related to intelligence based on reception of senses and voliation.3 Manas is a Sanskrit word and is derived from the Dhatu ‘MAN’ and ‘ASAN’ the suffix following it. Etymology of Manas:- 4 The power or ability or strength that is responsible for experience of agony; Wish and will ; Inclination ; Dislike ; Repugnances ; Effort ; Endeavour ; Knowing ; Investigation ; Discussion ; Nudence. According to Sir Monier Williams Sanskrit – English dictionary: Mind ; Intellect ; Intelligence ; Understanding ; Perception ; Sense ; Conscience ; Will. Synonyms of Manas:- There are seven synonyms of Manas: “Chittam tu ceto Hridayam Swantham Hrinmanasam Manah”!5 According to Charaka Samhita there are three synonyms of Manas: “Atindriya, Sattva and Cetah.”6 Etymology of the Synonyms:- 1) Manas: A Substance that is responsible for the presence or absence of Knowledge is called Manas.7 2) Manasam: A substance which establishes the contact between the Soul and Body and which regulate the function of the Indriyas.8 Chittodvega ==========================================14created by of Dr.KSRPrasad
  • 15. 3) Sattva: The word is derived from ‘Sat’ root by adding ‘Kvta’ which gives meaning of :- Existance9 ; Mind, Intellect, Nature, Life, Conciousness10 ; Bright Knowledge, Origin of Comfort.11 4) Chittam, Cetah, Chitta: The word citta is derived from root ‘Cit’ by adding Suffix ` Kta’. It has the following meanings: - Mind12; Internal Instrument13; Awakes Provides Sense14; Thought Process, Intelligence, Heart, Soul, Spirit15 5) Hrit, Hridayam: Derived from the root ‘Hr’ meaning that which Captures or Grasps.16 All the terms represent different functional aspects of the mind. Definition of Manas:- A substance which is responsible for the presence or absence of knowledge is called manas( Ca.Sa.1/18). A substance which establishes the contact between the soul and the body and regulates the function of indriyas is called manas.17 Gunas of Manas:- Anutwam (Atomic dimention) and Ekatwam (oneness) are the basic gunas of manas.18Chakrapani while commenting in this context has given a good example to explain Anutwa and Ekatwa. When one experiences Gyana from more than one Indriya, it appears that the Manas in indulging with both of them simultaneously, it is apparently too. In fact, the Manas in indulging with the Indriyas one after another in a successive manner, the manner which is too subtle to perceive. The same is like, sudden pricking of one hundred tender lotus leaves, which are arranged one over other as a bunch, with a sharp instrument (needle). It appears that all the leaves were picked simultaneously but actually there is a subtle gap of time from one leaf to other while pricking, the subtleness is not perceivable with materialistic eye.19 Chittodvega ==========================================15created by of Dr.KSRPrasad
  • 16. Sthana of Manas:- The location of Manas in the body is a disputed question in Ayurveda. According to its functional aspects the seat of Manas has been dealt differently by Acharyas in their respective works. 1. Hridaya:- Both Caraka and Susrutacharyas have mentioned that hridaya is the seat of cetana in the body.20 Hridayam the first organ to form in garbhotpatti 21 have been mentioned by Vagbhata as the location of sattva which lies in the region of sthanayormadhya.22 Taittariyopanisad states that ‘ManomayaPurusa’ resides in Hridayakasa.23 Cakrapani also states that Manas is located in Hridaya.24 2. Sirah :- Charaka has stated that Prana is situated in Siras which is also called as uttamangam due to its control over all the Indriyas.25 3. Between Siras and Talu: - According to Bhela samhita Manas is located between siras and talu.26 4. Sarva Sarira: - Charaka stated that Manas is Atindriyam and the whole body is its adhistanam.27 5. Twak: - Twak is said to be the seat of Manas, as it is considered as the main and only Indriya distributed in all other Indriyas and without which no perception occurs.28 6. Indefinite: - Manas is considered as Achetana. It is under the control of Atma, which has the property of chetanatvam, entering different yonis. As Manas follows Atma, it dosen’t have a definite location.29 Manovaha Srotas:- These Srotas have not been separately mentioned. It is however stated in Charaka 30 samhita that the entire sentient body represents the abode of manas and therefore should be considered as the manovahasrotas.The Manovahasrotas transport either the Manas or the information related to it.31 Chittodvega ==========================================16created by of Dr.KSRPrasad
  • 17. Sajnavahasrotas are mentioned by Charaka (Ca.Su.24/25, Ca.Ni.7/3) and Sushruta (Su.Ut. 46/67) and Su.Sa 4/26). The word “Sanjan” indicates knowledge, understanding, hint, sign, mind etc.32 Since the word sajna also means Manas, Chakrapani states that the Sajnavahasrotas are the Manovahasrotas. Chestavahasrotas are not mentioned in Ayurvedic classics. But the two important functions of vata i.e. gati (movement) and gandhana (sensory perception), are conducted by these srotas. Since the direction for requisite action is from the Buddhi and those directions relay in Manas before reaching the target organs, Manas and Buddhi are considered as moolas of the chestavaha srotases. The chestavahasrotas take origin in the Buddhi and pass through the Manas to spread throughout the body. Since all organs function in accordance with the guidance and incitement of the Manas and Buddhi, the manovahasrotas are clearly associated through intercommunication with the Sajnavahasrotas which extend from the sense organs to the manas and Chestavahasrotas which extend from the manas to the motor organs. Therefore, the Manovahasrotas seem to have spread throughout the body, with Manas and Buddhi as the mula. Swarupa of Manas:- It has always been a disputable question in Ayurveda regarding the nature of manas. Theories Supporting Bhautika Nature of Manas:  Vedanta metaphysics leads to the conclusion that Manas is physical because it regards that internal organs (Manas, Buddhi, Ahamkara and Citta) are Bhautika.  In Chandagyopanishad, Manas in described as “annamayam hi saumya manah”.  Few references in Mahabharata infer that Manas may be Panchabhautika.33  Vaiseshika Darshana has accepted the Dravyatva of manas.34  Manas has been quoted as one of the nine karana Dravyas by Charaka.  Manas has been counted as one of the Sixteen Prameyas (categories or objects of right cognition).35 Chittodvega ==========================================17created by of Dr.KSRPrasad
  • 18.  Tarkasangraham has stated Manas as Indriya by quoting - “Sukhadyupalabhisadhanam Indriyam Manah”  In Bhela Samhita Manas is called ‘Sarvendriyapara’36 i.e. Super sensual and controller of all Indriyas and not identical to them. In Ayurveda, Manas and Indriyas are not regarded identical and, therefore in so many references we observe that Manas and Indriyas have been mentioned in the same phrase side by side. Theories Supporting Adhyatmika nature of Manas:-  Charaka has included Manas in the classification of Adhyatmika dravyaguna samgraha.37  In the cosmological description of evolution, Sushruta stated the origin of Manas (along with Indriyas) from Ahamkara.38 Thus Manas is Ahamkarika, and Ahamkarikas are considered as non-bhautika.  Samkhya doctrine of philosophy suggests that Manas in Ahamkarika.  In classics the Bhautikatva of dasha indriyas is stated 39but not of Manas. From these references, it can be concluded that Manas in accepted as a Dravya but belonging to the category of Adhyatmikadravyaguna Samgraha. It is Asaririka but deeply related to Sarira, Acetana but essentially related with Atma, Abhutika but depending reciprocally on the Panchabhautika Sarira in the performance of complex and integrated activities of the organic life.40 Arthas of Manas:- Whatever can be known by Manas are considered as the Mano Ardhas or Manovisayas. They do not require contact of any object, but incessantly continue to function and ultimately arrive at decision. Chittodvega ==========================================18created by of Dr.KSRPrasad
  • 19. According to Charaka Samhita Manas have five objects. They are: 41 1. Cintya – Thinking 2. Vicarya – Investigation/Inquest 3. Uhya – Imagination 4. Dhyeya – Concentration 5. Samkalpa – Intention/ Aiming While commenting in this context Chakrapani, has defined the above five objects as: 42 1) Cintya is the thing that can make a critical thinking process regarding a subject or an object. 2) Vicara is that knowledge, which directs the Manas to enquire the pros and cons of an incident or of an action. 3) Uhya is the knowledge imagining the outcome of a work (with having a high opinion). 4) Dhyeya is that knowledge which is acquired through concentration or meditation. 5) Samkalpya is that knowledge which determinesthe direction of action. All these objects of Manas are having central theme of thinking with different views. Mano karma:- The chief functions of Manas are assimilation and discrimination. According to Chakrapani the chief functions of Manas are Iccha (desire), Dvesa (hatred), Sukha (pleasure), Dukha (pain) and Prayatna (effort).43 Charaka described the Manokarmas into four categories 44 , they are: 1. Indriyabhigraha means regulation and guiding of Indriyas through supervision. 2. Controlling of one self for not indulging in noxious and hostile activities is called Swayamnigraha. 3. Grasping of knowledge through conjecture is called Uha. 4. Pondering over all facts is called Vicaraha. Chittodvega ==========================================19created by of Dr.KSRPrasad
  • 20. Charaka has stated that thinking, imagining, concentration and determination are the objects of Manas (Ca. Sa.1/21, 22). The modern Psychology also agrees about the function of mind, as the aggregate of thinking, judgement and conclusion. It directs and controls the senses to control one-self when one is getting away from right thinking, imagination and ideation. [Shukla J.P. (1966); The nature of mind] Gyanothpathi Prakriya ; Physiologial functions of Manas can be divided into three Stages: 1. Perception (cognitive or sensory) 2. Discussion and Determination 3. Stimulation or Initiation (Conative or Motor) 1. Perception: `Indriyeneindriyartho hi samanaskena grihyate!’(Ca.Sa.1/22) In this stage, Indriya receives its Artha on stimulation by Manas. Manas acts as a keyfactor in stimulation of indriyas. For the perception to occur the connection between Atma, Indriya, Manas and Arthas is essential. (Ca.Su.8/7). 2. Discussion and Determination: `Kalpayate manasa turdhvam gunato desatothva! jayate visaye tatra ya buddhi nischayatmika!!’(Ca.Sa.1/22-23) After the perception, the procedure of actual analysis starts. The Processes like Cintya, Vicharya, Uhya, Dhyeya, Samkalpa takes place. According to its capacity, it gives the determination to the perception. 3. Stimulation or Initiation (Conative/Motor): `Vyavasyati taya vaktum kartum va buddhi purvakam!’(Ca.Sa.1/23) After the determination of knowledge perceived by Gyanendriya, Buddhi takes the decision and initiates the karmendriya for desired action. Manas is called ubhayendriya because it connects Gyanendriya and Karmendriya. From the above discussion, it can be understood that Manas plays a vital role from cognition to conation. Chittodvega ==========================================20created by of Dr.KSRPrasad
  • 21. Genesis of Knowledge Buddhi Dhi, Dhriti, Smriti Uha Vichara Indriyanigraha Swanigraha MANAS Indriya Figure 1 Object Factors influencing physiology of Manas:- At Metaphysical level: Atma – gives cetanatva to the Manas At Intellectual level: The characteristics of Atma, influences Manas through its three dimensions i.e. Dhi– Proper judgment, Dhriti – contolling power; Smriti – Recall or memory. The three functional dimensions of Manas at intellectual level are – Sattva – Knowledge; Rajas- action; Tamas-Regulation At Physical level: The karmas of Manas in gross body occur through the functional faculty of body i.e. Doshas, Dhatus and Ojus. Manas activate bodily functions through the’Chala’ guna of vata; Arthagrahana, Medha and Buddhi through ‘Tikshna’ guna of pitta and stability of bodily functions through`sthira’ guna of kapha. Chittodvega ==========================================21created by of Dr.KSRPrasad
  • 22. Following are the references about doshas and dhatus in relation to sthana and karmas of Manas: Dosha: Vayu : ‘Niyanta Praneta Cha Manasah’ 46(Vayu is said to be the controller and stimulator for Manas. Prana vata: `Buddhi Hridayendriya chitta dhrik.’47Prana Vayu is present in Hridaya, Buddhi, Indriya and Chitta where its influence can be felt. Udana 48 vata:`………Smriti Kriya’ – Udana vayu is responsible for Memory. vyana vata 49 :…… `Prayah Sarvah kriyah’ – All physical and mental activities are controlled by vyanavata. Pitta : Sadhaka pitta is present in Hridayam and has functions like Buddhi, Medha Abhimanadya, intellect, liking, etc.50 Kapha : Normal mental functions like concentration, tolerance, endurance is under the control of normal function of kapha.51Avalambaka and Tarpaka kapha are very much related with Manas. Dhatus: Rasa : Rasa dhatu gets vitiated due to excessive thinking of unnecessary things.52 Rakta : Rakta dhatu heps in normal mental functions. Rakta dhatu also helps in distinct knowledge, perception and action stimulation.53 Mamsa : In Mamsakshaya,Akshaglani i.e. affliction of sense organs is observed.54 Medas : Medo dhatu causes comfort, laziness, courage.55 Asthi : Causes attachment and enthusiasm Majja : Gives strength. On vitiation causes confusion and fainting.56 Sukra : Causes happiness, courage, liking, bliss, interest.57 Ojas: It is the essence of all dhatus through which mind and body are related. Ojas and manas are seated in Hridayam. And Ojas is depleted by mental emotions such as anger, grief.58 When Ojas is depleted, the person becomes fearful, worried and his faculties will not be functioning properly. He will lack enthusiasm.59On the contrary increase of Ojas is conducive to the proper functioning of Manas.60 Chittodvega ==========================================22created by of Dr.KSRPrasad
  • 23. Satta Buddhi Rajas Atma (Dhi, dhriti, smriti) Tamas MANAS Twak (sparshanendriya Vata, adhisthana pitta, Kapha Sapta dhatu, ojas Figure 2 Significance and Importance of Manas:-  Manas is said to be the cause for binding of life or for moksha.61  Life is dependent upon the combination of Manas, Atma and Shareera.62  Manas acts as the connecting tool between Atma and Shareera which is called as the `Anusandhana kriya.’  Manas is the substratum for the diseases. (Ca.Su. 1/55)  Gyana, Buddhi and Smriti are the outcome of mental activity.  Manas is conjugated with Atma and moves from one body to another and leads to Punarjanma which is called as `aupapadika guna’.  Manas is Trigunatmaka with three types of Psychological traits or temperament formation. Trigunas (Mahagunas) of Manas: There are three major Universal attributes (Mahagunas) of Manas namely Sattva, Rajas and Tamas. The three terms can be translated as Cognition, Action and Inertia. Trigunas are the essential part of the “Samkhya” conception of Personality. Trigunas are the three potentialities which express themselves only when disturbed. The variations in the Chittodvega ==========================================23created by of Dr.KSRPrasad
  • 24. interindividual as well as intra-individual psychic behaviour are due to the relative expression at a given moment, of the above-mentioned potentialities.63 In Bhagavad Gita human beings have been classified into three types of personalities namely Satvika, Rajasika and Tamasika.64 Charaka has described three types of Sattva(manas). They are : 1. Sattvika manas 2. Rajasika manas 3. Tamasika manas Manas environd with Sattvaguna possess qualities like – Anrusahamsyam (absense of all killing or hostile propensities), Samvibhagaruchita( a judicious regimen of diet), Titikshna(forbearance), Satyam(truthfulness), Dharma(piety), Astikyam(belief in God), Jnanam( spiritual knowledge), Buddhi, Medha(intellect), smriti(a good retentive memory), Dhriti (comprehension) and Anabhishangam(performance of good deeds irrespective of consequences).65 Rajoguna yukta Manas has the qualities of Dukhabahulyam(feeling much pain and misery), Atanasheelata(a roving spirit), Adhruthi(non-comprehension), Ahamkara(vanity), Anruthikatwam(untruthfulness), Akarunyam(non clemency), Dambham(pride), Maanam(an over winning confidence in one’s own excellence), kama(lust), krodah(anger) and Harsha(hilarity).66 Tamogunayukta Manas has qualities such as Vishadam(despondency), Nastikyam(disbelief in the existence of God), Adarmasheelata(imparity), Buddhinirodham and Ajnanam, Durmedhastwam(stupification and perversity of intellect), Akarmasheelata( lethargy in action) and Nidralutwam( sleepiness).67 Chittodvega ==========================================24created by of Dr.KSRPrasad
  • 25. By critical study of the above-described qualities we can conclude that among the three Gunas, Sattva is the equilibrium state of Manas and also a state devoid of pathogencity. The chief qualities of Rajas are two – ‘Kriyasilatva’ (activeness) and ‘Uttejana’ (instigation). Due to these qualities it induces in all kinds of desires and ambitions. Tamas possess two major qualities i.e. ‘Guru’ and ‘Sthira”. The Tama because of which one can get Asatyajnana, Alasya and Nidra cause Acetana, Nishkriya and Jadata. In the process of evolution of Mind with sensory and motor faculties, the expression of ‘Sattva’ and ‘Raja’ is dominant and that of `Tamas’ is latent. From the above conceptual study of Manas we can come to the conclusion that Manas is the controller of Indriyas and the activities of Manas are the direct outcome of cerebral functions. In dictionaries, the meaning of Manas has been given as Mind. The term Mind has been used to imply the brain, especially, the cerebral cortex and cerebral processes. The cerebral cortex is, for all intents and purposes, the seat of conscious, sub-conscious and unconscious activities, usually ascribed to the different stages of the functioning of the Manas. A synonym of Manas is Buddhi. Ayurveda speaks of five Indirya Buddhis, which correspond to the areas in the cerebral cortex. Subsequent events leading to Vigyana, such as sorting out of the sensory data, their interpretation, orientation, integration and ideation are dealt with the association and silent areas of the cortex. A school of Modern Psychology makes use of the term near Mind to designate the Brain. Chittodvega ==========================================25created by of Dr.KSRPrasad
  • 26. Functional Neuroanatomy of Brain Neurons and Neuroglia: 68 Neurons or nerve cells are specialized for electrical and chemical transmission of information. Each neuron consists of a cell body with several branching dendrites and a single axon. Axons terminate in the form of branching processes, each ending with a terminal button. A synapse (gap or cleft between neurons) is formed by a terminal button presynaptically and either a dendritic spine or an area of the neuron cell body membrane post synaptically. Telencephalon (cerebral hemispheres, cerebrum): The cerebral hemispheres are composed of an outer layer of grey matter (the cerebral cortex) and inner core of white matter (the centrum semiovale) and discrete masses of subcortical grey matter or nuclei which form the basal ganglia and the amygdala. The undulating surface is made up of convulsions/gyri, grooves/sulci and deeper infoldings or fissures. The telencephalon is separated into right and left hemispheres by the longitudinal fissue. Fibre bridges or commissures, the largest of which is the corpus callosum, afford communicatin between the hemispheres. Each hemisphere is composed of four lobes: Frontal lobe, Parietal lobe, Temporal lobe and Occipital lobe. The Cortex: - There are two phylogentically distinct types of cortex: Allocortex and Neocortex. Neocortex: Is differentiated into 6 layers and is further classified into (a) Primary cortex (b) Association cortex. (a) Primary cortex is concerned with either the execution of voluntary movement or the analysis of sensory information. 1. Primary motor cortex – Located as a coronal strip anterior to the central sulcus. Parts of body represented somatotopically to form the motor homunculus. Chittodvega ==========================================26created by of Dr.KSRPrasad
  • 27. 2. Primary sensory cortex – receives input from the peripheral sense organs. (i) Somatosensory Cortex – located in the postcentral gurus of the Parietal lobe subserves touch, Pain, temperature and proprioception. (ii) Visual cortex – located around the calcarine fissure of the occipital lobe. (iii) Auditory Cortex – lies deep within the sylvian fissure in the temporal lob. (iv) Olfactory cortex – subserving taste and smell, found in the uncus and Parahippocampal gyrus of the temporal lobe. (b) Association Cortex - Forms the major portion of the neocortex (75 percent) and is concerned with higher mental function. (i) Parietal lobe association cortex – Concerned with visuospatial and tactile perception. (ii)Temporal lobe association cortex – Concerned with visual perception and memory. (iii)Frontal association cortex – Concerned with executive function. Allocortex: The edge or rim of the cerebral cortex is composed of allocortex, which is poorly differentiated in that it does not have a distinct internal structure. The edge of the cerebal cortex is infolded to form a ring of allocortex on the medial face of the hemisphere i.e. the limbic lobe. The Limbic System:- The limbic system consists of areas of allocortex, discrete subcortical structures within the telencephalon and diencephalon and interconnecting fibre pathways. Neuroanatomical Circuits formed by limbic system subserve emotional behaviour and memory.The exact components of limbic system vary according to different opinions. However, central to the concept is the ‘Papez Circuit’ formed by: Cingulate Cortex, Hippocampal formation (In the telencephalon) ; Mamillary body of the hypothalamus, anterior nucleus of the thalamus ( In the diencephalon ) ; Fornix(connecting hippocampus to mamillary bodies) ; Mamillothalamic tract (connecting mamillary body to anterior nucleus of the thalamus) ; Gyrate fornicatus (connecting anterior nucleus to cingulate gyrus) ; Cingulate fasciculus (connecting cingulate gyrus to Parahippocampal gyrus) . Chittodvega ==========================================27created by of Dr.KSRPrasad
  • 28. Other structures often included in the definition of limbic system include: Septum, Olfactory bulbs, Uncus, Entorhinal cortex (In the telencephalon); Hypothalamus, Habenular nucleus (In the diencephalon); Striamedullaris (Connecting Pathways- between several limbic structures & Habenula) Basal ganglia (corpus striatum):- Three masses of grey matter (Caudate, Putamen and Globus pallidus), congregated centrally in the midline of the hemispheres, form the basal ganglia that are concerned with the initation and performance of voluntary movements. Diencephalon: This is a midline forebrain strucuture consisting of : (i) Thalamus (ii) Hypothalamus (iii) Epithalamus (iv) Subthalamus (v) Optic chiasma (i) Thalamus: A large ovoid structure, occupying the upper half of the diencephalon, and composed of many groups if nuclei. (a) The cortical relay nuclei are situated ventrolaterally and receive the terminals of either motor or sensory fibres. The signals they convey undergo complex transformations before being tramsmitted. (b) The association nuclei have reciprocal connections to areas of association cortex, limbic structures and the hypothalamus (c) The non specific nuclei appear to be involved in arousal and form an integral part of the reticular activating system. (ii) Hypothalamus: Below the thalamus is a collection of nuclei collectively known as the hypothalamus. There are three regions – The mamillary region, the Tuberal region and the Suprachiasmatic region.The hypothalamus has two types of anatomical Chittodvega ==========================================28created by of Dr.KSRPrasad
  • 29. connections with the pituitary through the hypothalamohypophyseal tract and the pituitary portal system. Hypothalamus is poised to control homeostatic mechanisms in response to received information concerning the internal milieu and emotional state. It can detect certain properties of circulating blood, such as temperature, osmotic pressure and hormonal levels. In turn it influences autonomic nuclei in the brain stem and sends reciprocal connections to the limbic system. The brain stem:- The midbrain, Pons and Medulla oblongate constitute the brain stem. Mid-brain: – The superior part, tectum, from part of visual and auditory pathways. Substantia nigra (in peduncles) is the important source of Dopamine – containing neurons. Have nuclei of two cranial neves – occulomotor (II) and trochlear (IV). Pons and Medulla: - the important structures here are grouped as (i) Motor pathways – Corticospinal tract & the corticobulbar tracts (ii) Sensory pathways – Fibers of dorsal column of the spinal cord synapse. Nuclei of cranial nerves V – VII are in the pons and VIII- XIII are in the medulla. The reticular formation:- Throughout the medulla, pons and midbrain is a central core of group of cell bodies and fibers forming a reticular network. Within this are centres controlling vegetative functions such as the sleep/wake cycle, arousal, respiration, blood pressure and heart rate. The Cerebellum:- Located above the pons and medulla, with four pairs of central nuclei (Fastigial, Globose, Emboliform and dentate) in white matter. The cerebellum is divided into two hemispheres with a central uniting vermis. Each hemisphere has three lobes- flucculonodular, anterior and posterior. The cerebellum is a motor structure concerned with the co-ordination of movement and maintenance of equilibrium. Chittodvega ==========================================29created by of Dr.KSRPrasad
  • 30. The autonomic Nevous system (ANS):- The ANS (autonomic nervous system) is a motor system controlling involuntary activity. Its principal neurotransmitters are noradrenaline and acetylcholine. An overview of Neurotramitters:- Name Location Effects Acetylcholine Found throughout the Central nervous Involved in muscle action, system, in the Autonomic nervous learning and memory. system, and at all the neuromuscular junctions Norepinephrine Found in neurous in the Autonomic Primarily involved in nervous system(ANS). control or alertness and wakefulness. Dopamine Produced by neurous in Substantia Involved in movement, nigra attention and learning. Serotonin Found in neurons in the brain and Plays a role in the spinal cord regulation of mood and in the control of eating, sleep and arousal. GABA Found through out the brain and spinal Major inhibitory neuro cord transmitter in the brain. In general, the parasympathetic division is concerned with day-to-day vegetative function such as increased gastric acid secretion, increased intestinal motility etc. Conversely, the sympathetic division is called into action in emergency situations when the body needs to be prepared for `flight, fight or negotiation.’ Chittodvega ==========================================30created by of Dr.KSRPrasad
  • 31. REFERENCES 1. Ca.Su. 1/42 2. Chakrapani commentary on Ca.Su.1/42 3. Ca.Sa.3/13 4. Shabdakalpadrumam 5. Amarakosha 1/4/3 6. Ca.Sa. 8/4 7. Ca.Sa.1/18 8. Ca.Sa.3/13 9. Vachaspatyam, Shabdakalpadruma 10. Sir Monier Williams Sanskrit-English Dictionary 11. Vachaspatyam 12. Amarakosa 1/4/31 13. Vacaspatyam 14. Shabdakalpadruma 15. Sir Monier Williams Sanskrit – English Dictionay 16. Shabdakalpadruma 17. Ca.Sa 3/18 18. Ca.Sa.1/19 19. Chakrapani Commentary on Ca.Su.8/5 20. Ca.Su. 30/4 & Su.Sa.4/27 21. Su.Sa. 3/18 22. As.Hr.Sa.4/13 23. Tai. Up. 1/61 24. Cakrapani on Ca.In5/41 25. Ca.Sa 17/12 26. Bhe.Sam.Ci8/2 27. Ca.Vi.5/6 28. Ca.Su.11/28 29. Ca.Sa.1/76,77 Chittodvega ==========================================31created by of Dr.KSRPrasad
  • 32. 30. Ca.Vi.5/7 31. Cakrapani Commentary on Ca.In.5/41 32. Esentials of Basic Ayurvedic concepts – 8th chapter, 197-198p 33. Ma.Bha.Shanti Parva 187/12 34. Ca.Su.1/47 35. Nyaya darshana 36. Bhe.Sam.Ci.3/2 & 8/4 37. Ca.Su.8/13 38. Su.Sa.1/26 39. Su.Sa.1/20 40. Psychopathology in Indian Medicine – 2nd chapter – 105p 41. Ca.Sa.1/20 42. Cakrapani Commentary on Ca.Sa.1/20 43. Cakrapani Commentary on Ca.Su.1/49 44. Ca.Sa.1/20 45. Ca.Su.12/8 46. Ah.Su.12/4 47. Ah.Su.12/5 48. Ah.Su.12/6 49. Ah.Su.12/3 50. Ah.Su.11/3 51. Ca.Vi.5/19 52. Ca.Su.24/24 53. Ah.Su.11/18 54. Su.Su.15/5 55. Ca.Su.27/7 56. As.Sa.Su.11/4 57. Su.Su.15/23 58. Ah.Su.11/39 59. Ah.Su.11/41 Chittodvega ==========================================32created by of Dr.KSRPrasad
  • 33. 60. Patanjali yoga sutras 61. Ca.Su. 11/46 62. Ca.Su.8/5, Su.Sa.4/57 63. Gita 14/5,6,7,8 64. Su.Sa. 1/32 65. Su.Sa. 1/33 66. Su.Sa. 1/34 67.Postgraduate Psychiatry – Clinical and Scientific Foundations – 83-118p 68.Psychology-48 Chittodvega ==========================================33created by of Dr.KSRPrasad
  • 34. CHITTODVEGA Etymology And Definition: The term chittodvega comprises of two words i.e. chitta and udvega. Chitta: It is derived from root `chit’ which has the following meanings: to perceive, fix the mind upon, attend to, be attentive, to observe, take notice of, to aim at, intend, to be anxious about, care for, to resolve, to understand, comprehend, know, make attentive, remind of. (Sanskrit – English dictionary of Sir Monier Williams) Addition of “Kta” pratyaya to chit i.e. chit + kta leads to chitta, which has the following meanings according to the two Sanskrit – English dictionaries. (a) According to dictionary of P.K. Gode & C.G. karve:  Observed, perceived  Considered, reflected or mediated upon  Resolved  Intended, wished, desired  Visible, perceptible (b) According to dictionary of Sir Monier Williams:  Thinking, reflecting, imagining, thought  Intention, aim, wish  Heart, mind  Memory, intelligence, reason Chittodvega ==========================================34created by of Dr.KSRPrasad
  • 35. Udvega: It is derived from root “ud” which has following meanings:  Superiority in place, rank or power, up, upwards, upon, on, over, above  Seperation, disjunction, cut off  Motion upwards  Publicity  Wonder, Anxiety  Liberation  Blowing, expanding, opening  Acquisition, gain (Sanskrit – English Dictionary of P.K. Gode & C.G. Karve) Addition of “Vin” pratyaya to “ud” i.e. ud + vin leads to udvega, which has the following meanings.  Going swiftly, an express messenger, a runner, courier  Steady, composed, tranquil  Mounting, going up or upwards  Trembling, waving, shaking  Agitation, Anxiety  Regret, fear, distress  Admiration, astonishment (Sanskrit English Dictionary of Sir Monier Williams) Chittodvega: With the above interpretations chittodvega can be defined as – Chitta (Mind) + udvega (Anxiety) = chittodvega (Anxious state of mind). From this we can conclude that cittodvega in a perfect word for highlight the condition, anxiety neurosis. Chittodvega ==========================================35created by of Dr.KSRPrasad
  • 36. Acharya Charaka has quoted (Ca.Ni.8/27) that a single clinical feature can be considered - as a common symptom in many diseases, or as a single disease entity. The anxious state of mind or chittodvega may be considered as a separate disorder or symptom of other medical and psychological disorders. It has been described as the causative factor for apasmara, as poorvarupa of unmada, or many times it has been described as a minor psychological illness. Words related to chitta found is Ayurvedic classics are: TERMS REFERENCES ChittaVibhramsa Su.Ut.39/778,As.S.Ni.5/43, Chittavibhrama As. Ni. 6/15 Chittanasha Su.Ni. 61/3 Chittakshobha As.Hr.Ci. 7/78, As.S.Ni.8/9 Chittaviparyaya Su.Ut. 57/3 Chittavilobhana As.Hr.Ci 7/79 Chittopaplava As.Hr.Ni. 6/2 As.Ni 6/3 Asvastha Chitta Ca. Ci. 9/20, As.Hr.Ut.4/30 Anavasthita chitta Ca. Su 20/11 Tapta chitta Ca. Ni 1/38, As .Ni. 5/31 Unmatta chitta Su. Ut. 61/6, As.Ut. 10/2 Bhranta chitta Su. Ut. 61/6, As.Ut. 10/2 Chittodvega Ca. Ni. 6/5 References about udvega in Ayurvedic classics: TERMS REFERENCES Garbha lakshana Su.Sa. 3/15 Katu Rasatiyoga Su .Su. 42/9 Stambhana Atiyoga Ca.Su. 22/40 Bhutabhishanga jwara Su. Su. 39/80, Ma. Ni. 2/30 Rasagata jwara Ca .Ci. 3/76 Chittodvega ==========================================36created by of Dr.KSRPrasad
  • 37. Andhaputana graha As.Hr.Ut. 3/25 Bala graha Su.Sa. 10/51, Ma.Ni. 68/7 Mukhamandika graha Su. Ut. 27/15 Pishaca graha Su.Ut. 60/15 Putana graha Ma. Ni. 68/25 Skanda graha Su.Ut. 27/8, As.Hr.Ut. 3/8 Apasmasa Nidana Ca. Ni.8/5 Unmada purvarupa Ca. Ni. 7/6, Su. Ut. 6/62 Unmada arista lakshanas Ca. In. 5/18 Among all these terms, only chittakshobha, asvastha chitta, anavasthita chitta and chittodvega are indirectly indicating towards the meaning of anxious state of mind. However, chittodvega is more applicable term to illustrate the anxious status of mind. So in this study the term “Chittodvega” has been compared with “Anxiety Neurosis” Chittodvega ==========================================37created by of Dr.KSRPrasad
  • 38. NIDANA Multifactorial origin of psychiatric illness has been stated in modern psychology. In Ayurvedic classics also many factors are stated to be the cause of manasaroga in various contexts, which can be correlated to the Nidana aspect of chittodvega. 1. Rajas and Tamas are stated as the manasika doshas, on whose vitiation manasa roga like kama, krodha, chittodvega occur.1 2. All kinds of manasika vikaras occur due to dissociation of mind from what is desired and its association with what is undesired. 2 3. Sushruta stated that manasikavikaras, like krodha, soka, bhaya, harsha, vishada, abhasuya, dainya, matsarya, kama, loba arise due to either iccha (desire) or dvesa (aversion). 3 4. Vagbhata in his opening verse stated reference of Ragadi rogas (i.e. the emotional factors in disturbed state) as giving rise to diseases like moha, arati, autsukya.4 5. The principal cause of all saririka & manasika rogas has been stated to be (a) Prajnaparadha (volitional transgression) (b) Asatmentdriyarthasamyoga (deficient, excersive or perverted use of senses) and (c) Parinama (the deficient, excessive or perverted incidence of seasons.5 6. Prajnaparadha has been stated as the cause of manovikaras like irshya, soka, bhaya, krodha, mana, dwesha etc. 6 Prajnaparadha: In the content of manas rogas prajnaparadha has been stated as he root cause of all diseases.7 Buddhi is called `sad-asad vivekin’. The discrimination and judgement capacity of human being is related to wisdom, intelligence or understanding which is known as Prajna.8 The karma done due to dhibhramsa, dhritibhramsa and smriti bhramsa is termed as Prajnaparadha.9  Features of dhi bhramsa (derangement of understanding) - the eternal and the non- eternal, good and evil are mistaken one for the other.10 Chittodvega ==========================================38created by of Dr.KSRPrasad
  • 39.  Features of dhriti bhramsa (derangement of the will) - the mind is always reaching out for its objects, is incapable of being restrained from undesirable objects.11  Features of smriti bhramsa (derangement of memory) – the retention of true knowledge is destroyed on account of mind being clouded by rajas and tamas.12 These derangements will be responsible for atiyoga, ayoga and mithyoyoga of actions (karmas) in relation to kaya, vak and manas.13 Excessive action is the over use of speech, mind or body and their lack of action is disuse.14  Misuse (Mithyayoga) with reference to kaya (body) consists of forced suppression or forced exitation of natural urges, awkward stumbling falling or posturing of limbs, injuring the body, etc and other kinds of self mortification.  Misuse with reference to speech (vak) refers to an indulgence in language that is insulting, untrue, untimely, quarrelsome, unpleasant, harsh etc.  Misuse with reference to mind (manas) consists of giving way to fear, grief, anger, greed, infatuation, self conceit, envy, etc.15 Prajnaparadha has also been cited as the cause of adharma or purvajanmakrta papa karma, which is the ultimate cause of Janapadhodvamsa.16 Charaka, has used the term buddhi and its ayoga, atiyoga, and mithyayoga in the sense of Prajnaparadha.17 When Buddhi is defective it leads to the indulgence of man in the unwholesome qualification of the five senses.18 So Prajnaparadha is responsible for Asatmendriyarthasamyoga. Asatmendriyarthasamyoga: Indriyarthasamyoga are the cognitive processes through which a man becomes aware of both external and internal environment.19 Charaka has described the ayoga, atiyoga and mithyayoga of each indriyartha separately.20 As long as the external stimuli originating from five sense objects are within normal limits the body response is also within physiological limits that is satmya for body. But if the stimuli cross the normal range they become stressful and as soon as stressful stimuli reach the manas the imbalance in the dosas begin which may set in the disease.21 Chittodvega ==========================================39created by of Dr.KSRPrasad
  • 40. Advent of maturity of results of kala and karma is also considered as the cause of Manasarogas. Results of all misdeeds done in the past will mature in time and will afflict the persons with particular disorder.22 7. The intrinsic causes of manasaroga are mainly sariradosha and manasadosha. The saririka dosas (vata, pitta and kapha) have been indicated in causation of particular behavioural traits in individuals23 and the vitiation of these dosas cause the physical symptoms of the chittodvega. Therefore one the etiological factors for causation of chittodvega can be considered as the tridoshas. Rajas and Tamas (the two manasika dosas) have been the vitiation factors of manas.24And the rajasika and tamasika sattva subtypes explained by Charaka and Sushruta are suggestive of those prakriti persons to be easily afflicted with manasika vikaras.25 8. Sattva pariksha (mental temperament / psychiatric assessment) stated by Charaka has considered three types of manobala26 and on observing the statements of Charaka and Sushruta it can be understood that avara sattva persons are prone to manasa roga.27 9. Manasarogas mainly occur due to discharge of the controllable vegas (Dharaniya vegas) and controlling the Adharaniya vegas.28 The Adharaniya vegas like kama, krodha, lobha, harsha, bhaya, moha, udvega have been stated as the etiological factors of psychiatric illness like chittodvega and unmada.29 The presence of chronic physical illness may also cause manasa roga. And even one manasaroga may cause another manasa roga in its bhedavastha or chronicity.30 This concept has been stated by Cakrapani in his commentary stating etiology of diseases as` Sareeram manasena’ and ‘Manasam manasena’. 10. Dehabala is also a contributory factor in the manasa vikaras, as ksheenadeha bala persons are prone to psychological illness.31 11. Intake of viruddha, dushta and asuchi ahara is also the causative factor of chittodvega32 as mind is affected by the quality of diet taken by the persons. 12. Disobeying of God, Teachers and Elders also causes manasika vikaras.33 Chittodvega ==========================================40created by of Dr.KSRPrasad
  • 41. 13. Manoabhighata occurring due to bereavements like loss of wealth, loss of employment, death of partner etc results in the distortion of Manas34 resulting in chittodvega. 14. Vishamachesta i.e. abnormal motor activites like abnormal posture, excessive exercise and violation of sadvritta can also be considered as the etiological factors of chittodvega.35 The above stated factors can be considered in the nidana aspect of Chittodvega. In them one or more factors may combine and produce the disease. The etiological factors show their influence according to the individuals` personality and the circumstances. All the factors have to be taken into consideration while dealing with the disease Chittodvega. REFERENCES 1. Ca.Su.1/57 & Ca.Vi. 6/5 2. Ca .Su. 11/45 3. Su .Su .1/33 4. As. Hr.Su.1/1 5. Ca. Su.11/37 & Ca .Vi.6/6 6. Ca .Su.7/52 7. Ca .Sa.1/101 8. Psychopathology In Indian Medicine 395p 9. Ca.Sa.1/102 10. Ca.Sa.1/99 11. Ca .Sa.1/100 12. Ca. Sa .1/101 13. Ca .Su.11/38 14. Ca .Su.11/39 15. ca .su. 11/40 16. Ca .Su.3/24 17. Ca .Su.1/54 18. Ca. Ni.7/34 19. Psychopathology In Indian Medicine 393p 20. Ca. Sa.1/127 21. Science & philosophy of Indian Medicine 149,150p 22. Ca. Sa .1/113 Chittodvega ==========================================41created by of Dr.KSRPrasad
  • 42. 23. Ca.Vi. 8/98,99,100 24. Ca.Sa.4/35 25. Ca.Sa. 4/37,38,39,40 & Su.Sa.4/81-98 26. Ca .Vi.8/119 27. Ma.Ni.20/5 28. As. Su.5/25 29. Ca.Ni.7/3 30. Ca .Ni.7/3, As.Hr.Ut.6/3 31. Ma. Ni.20/4, As.Hr.Ut.6/3 32. Ma.Ni.20/4;As.Hr.Ut.6/3 33. Ma.Ni.20/4, Ca.Ni 7/3 34. Ma.Ni. 20/4, As.Hr.Ut 6/3, Ca.Ni.7/3 35. Ca.Su.8/18. Chittodvega ==========================================42created by of Dr.KSRPrasad
  • 43. SAMPRAPTI Chittodvega has been stated as one of the purvarupa of unmada by Charaka & Sushruta (Ca.Ni.7/6 & Su.Ut.62/6-7). On studying the disease entity unmada, from the classics, it can be understood that the disease indicates and includes all the manasikavyadhis. As description of Chittodvega is not available in classics samprapti of unmada is considered as the samprapti of manovikara-chittodvega. The samprapti of chittodvega can be stated as: – In the Alpa sattva individuals due to etiological factors like kama, krodha, viruddhaharavavihara, etc the doshas (both sareerika and manasika) get vitiated. The vitiated dosas goes to hridayam (the seat of buddhi) and vitiate it and spread through manovahasrotas throughout manas and sareera causing the Purvarupa and Rupa of the disease.1 1. DOSHA: (a) Manasika: Acharya Charaka stated that Rajas and Tamas are the two Manodoshas which cause manovikaras like Chittodvega.2 Rajasika prakriti play an important role in predisposing the person to chittodvega. Pajnaparadha stated as nidana of chittodvega mainly vitiates manodoshas rajas and tamas.3 Manobhighata, disobedience towards God, Teachers and Elders, discharge of dharaniya vegas are some of the causative factors for vitiation of rajas and tamas. The deranged manodoshas play major role in causation of chittodvega. (b) Sharirika: All the disorders or vikaras pertaining to the body occur only due to the tridoshas (vata, pitta and kapha).4The disease may be nija or agantuja in its origin but the involvement of the tridoshas in initial or the later stages is inevitable.5 The three causative factors (i.e. prajnaparadha, asatmendriyartha samyoga and parinama) vitiate the tridoshas and cause the symptoms of chittodvega. Chittodvega ===========================================43created by of Dr.KSRPrasad
  • 44. (i) Vata: The normal functions of vata are stated as `Niyanta praneta cha manasah, tantrayantradhara, pravartakachestanam, sarvendriyanam udyojakah’.6 Manas is under the control of vata so when vata is vitiated it leads to derangement in the functions of manas causing manovikaras. In the sub-types mainly three types of vata are concerned with the Manokarmas. They are prana, udana and vyana vayu. The etiological factors stated for chittodvega like vishama cesta, vishamasana, vegavarodha,7emotional factors like kama, bhaya, soka8 aggrevates vata which is mainly rajasika in nature. Hence vata can be considered as the main dosha involved in the pathogenesis of chittodvega. (ii) Pitta: Dalhana in his commentary has stated that sadhaka pitta dispels the kapha and tamas of the hridaya and thus enables the manas to perceive things clearly.9 Pitta is vitiated by emotional factors like krodha10and viruddhara sevana, soka, bhaya.11And this vitiation leads to buddhi & medhanasha causing chittodvega. 12 (iii) Kapha:. Vata prakopa and dhatu kshaya leads to vitiation of kapha which causes malnourishment of indriyas and bala kshaya (the vyadhikshamatvam of body is decreased by kaphakshaya).13 This in turn causes the manovikara like chittodvega. So many of the causative factors of chittodvega directly vitiate the tridoshas that in turn vitiate the dhatus and manifest the symptoms of chittodvega. 2. DUSHYA: As the disease is a manasavikara, 14 manas will be the main dushya. Dukha (also synonym of vyadhi) is stated as dhatu vaishamyam, 15 (dukham is the aspect related to manas). So, dhatus are also vitiated in causation of chittodvega. The etiological factors like krodha, viruddhasana,16madya, dharana of adharaniyavegas like chardi causes rakta dhatudushti.17Atichintana causes rasadhatu dushti.18Sukradhatu is vitiated by viruddhahara, dhatu vaishamya and dosha prakopa.19 It has been stated that basing on the vriddhi or kshaya of purvadhatu the paradhatu either gets vriddhi or kshya. So vitiation of one dhatu leads to vitiation of another and finally all the dhatus get involved in the pathogenesis of chittodvega. Chittodvega ===========================================44created by of Dr.KSRPrasad
  • 45. Dosha vaishamyam leads to dhatuvaishamyam due to the ashraya – ashrayee bhava.20 As the etiological factors vitate tridoshas they in turn cause vaishamyam of the dhatus manifesting various symptoms of chittodvega. Ojus is also a main dushya in causation of chittodvega. Ojus, which is the sarvadhatu saram21 is located in hridayam.22 Ojas is the main factor behind the vyadhikshamatva shakti of the shareera.23So any factor causing its depletion (kshaya) makes the body susceptible to diseases. The etiological factors of ojokshaya are stated as kopa, soka, dhyana, srama, dhatukshaya.24 Presence of psychological symptoms and somatic symptoms in ojokshaya25 supports the importance of ojokshaya in samprapti of chittodvega. 3. SROTAS: Manovahasrotas had been described in many classics as the srotas involved in samprapti of manasa rogas.26 Sarvashareeragata srotas are also vitiated and involved in the disease chittodvega because the etiological factors of chittodvega are also indicated as vitiating factors of many srotases. Vitiated dhatus vitiate the srotas carrying them. When the srotas are involved the vyadhi manifests its symptoms.27 Atichintana, viruddharasevana, vegavidharana, vataprakopakara ahara vihara sevana, dhatu kshaya, krisatvam, kopa, dukha, bhaya have been stated as vitiating factors of asthivahasrotas, majjavaha, rasavaha, raktavaha, sukravaha, malavaha, mutravaha and swedavaha srotas.28 4. AGNI: One of the synonyms of vyadhi is `Amaya’29and Ama is stated as the cause of all vyadhis30 due to vitiation of doshas, dushyas31 and also the srotases.32 Dhatu parinama and poshana depends on agni.33 Agni in vitiated by asuchi, viruddha annapanasevana,34 kama, krodha, lobha, moha, soka, mana, udvega leading to formation of Ama.35 Even matrahaara will not be properly digested when the person is disturbed with emotional factors like cinta, soka, bhaya, krodha, dukha.36 Vegavidharana37 and Vyadhikarsana38 also are considered as the causative factors of agnivikruti. Chittodvega ===========================================45created by of Dr.KSRPrasad
  • 46. So the etiological factors of chittodvega vitiate Agni and produce Ama which will further lead to dosha-dhatu vaishamyata and the vicious circle continues causing the somatic symptoms of chittodvega. 5. UDBHAVASTHANA: Hridayam has been stated as the udbhavasthana of chittodvega.39 As Chittodvega is a manasika vikara caused by derangement of manodoshas rajas and tamas, manas gets effected and the manifestation of the disease occurs. In the context of chittodvega hridayam indicates manas. 6. VYAKTASTHANA: First the chitta is vitiated causing vitiation of buddhi. It affects the psychological aspects of individual causing manovibhramsa, buddhivibhrama, sanjna, gyana vibhramsa.40 This leads to indulgence of individual to faulty activites (i.e sheela, chesta, achara vibhramsa) pertainignt to social aspects. The vitiation of saririka doshas, dhatus, srotas and agni leads to the manifestation of the psychological and somatic symptoms of chittodvega. So the vyaktasthana of chittodvega can be understood as manas and sarvasareera. 7. ROGAMARGA: As chittodvega is originating in hridaya it can be considered as the madhyamarogamarga janya vyadha.41 8. SADHYASADHYATHA: The samprapti of chittodvega is complicated due to the involvement of saririka-manasika doshas, sarva dhatu-mala-srotas, and presence of agnivikruti. So it is difficuit to cure the disorder. The disease is considered as kricchrasadhya as -it is marmasrita (Siras), curable by any karma, with involvement of only one marga,42 and is in purvarupa state of a major disorder. 9. UPADRAVA: Chittodvega has been stated as manovikara (i.e. minor psychiatric illness). Udvega has been stated as purvarupa of unmada,43 nidana of apasmara44 bhutabhishanga Jwara45 and rasagatajwara.46 So the major psychiatric illness like unmada,apasmara and somatic illness like Jwara can be considered as the upadrava of chittodvega. Chittodvega ===========================================46created by of Dr.KSRPrasad
  • 47. Samprapti of chittodvega Asamndriyaarthasamyoga pragnyaparadha parinama Nidana sevana Manasa dosha prakopa sarira dosha prakopa Raja Tama Vata Pitta Kapha Prakopa prakopa prakopa prakopa prakopa prana sadhaka tarpaka Udana Vyana Hridaya dushti Agnivikruit rasadidhatudushi Manodushti Manovaha srotodushti rasadisarvasrotodushti Manasalakshana uthpathi sariralakshana uthpathi Chittodvega Figure:4 Chittodvega ===========================================47created by of Dr.KSRPrasad
  • 48. From the above description the samprapti ghatakas of chittodvega can be stated as: Dosha : Manasika: Rajas, Tamas Saririka : vata : Prana, Udana, Vyana Pitta : Sadhakapitta Kapha : Avalambaka, Tarpaka Dushya : Manas, Saptadhatus, Ojas, Srotas : Manovahasrotas and Sarvasareera gata srotas Agni: Manda and Vishama Udbhava Sthana : Hridaya Vyakta Sthana: Manas, Sarvasarira SAMPRAPTI-KRIYAKALA Samprapti is described as the series of events taking place right form the beginning of the accumulation of doshas, due to indulgence in nidana, upto the complete course of the disease.The way in which the doshas are vitiated, the manner in which they spread and produce the disease by involving the dushya and ultimately manifesting the various features of the disease are described under the heading of samprapti. There is no direct description of samprapti of chittodvega in Ayurvedic texts, although it is included under Manovikara. Samprapti of chittodvega may be traced out by considering the general principles and multifactorial nidana described earlier. The positive family history,vataja prakriti,rajasika prakriti and avara sattva play an important role in predisposing the person to chittodvega.An emotion like udvega is a common response in part of life but persons having sattvasara can resist the ill-effects of such emotional disturbance as they are seen unmoved even by severe affection. On the other hand when the person having alpasattva indulges in prajnaparadha or asatmendriarthasamyoga or is under stress, it initiates the disease process by resulting in imbalance of manodoshas-rajas and tamas. At this stage the person exhibits an Chittodvega ===========================================48created by of Dr.KSRPrasad
  • 49. exaggerated response to emotional disturbance. This is the sanchayavastha of chittodvega. If chayavastha is not encountered with treatment and nidana is continued the disease lands in the next stage i.e.prakopavastha. When the imbalance of the manodoshas continues for some more time it leads to the prakopavastha of chittodvega. At this stage psychic symptoms like chinta, bhaya and soka develop. When these psychic response continue for a longer period and override the limit they start influencing the bodily doshas.At the biological level ,especially vata gets vitiated(as vata is controller of mind and is having direct relationship with rajas). At this stage bodily symptoms, predominantly of vata dosha prakopa are seen. Tarpakakapha declines resulting in undernourishment of indriyas. Derangement of sadhaka pitta also occurs due to sattvaharasa resulting in the symptoms such as bhaya, moha, krodha, etc. This stage, where both saririka and manasika doshas are involved, can be considered as prasaravastha. The vitiated manodosha and saririka doshas move to hridaya and vitiate it. Due to ashraya-ashrayi bhava manas also gets vitiated. when this vitiation persists for longer duration it results in ojoksaya. Vitiated vaatadi doshas vitiate jatharagni and later the rasadi dhatus. Hridaya, manovahasrotas, vulnerable dhatus and their srotases are vitiated resulting in the psychosomatic presentation of the disease, which is the staanasamshrayavastha of chittodvega. In chittodvega, when multiple srotas are involved with affliction of all dhatus, the full blown phase i.e.vyaktavastha occurs. When the disease is not treated properly or promptly and the nidana continues it becomes chronic and disabling. The manodosha and saririka doshas potentiate each other in a vitiated state resulting in a vicious cycle. The disease attains chronicity, becomes Chittodvega ===========================================49created by of Dr.KSRPrasad
  • 50. krichrasadhya leading to major psychiatric illness like unmada. This is the bhedavastha of chittodvega. REFERENCES 1. Ma.Ni.20/5 &Ca.Ci.9/5 2. Ca .Vi.6/5 3. Ca.Sa.1/101 4. Ca.Su.19/5 5. Ca.Su.20/7 6. Ca.Su.12/8 7. Su.Su.21/27 8. Ca.Ci.3/114 9. Dalhana commentary on Su.Su.21/10 10. Ca.Ci.3/114 11. Su.Su.15/7 12. As. Hr.Su 11/26-28 13. Su.Su.15/4 14. Ca.Vi. 6/5 15. Ca.Su.9/4 16. Su.Su. 21/24 17. Ca .Su. 25/6 18. Ca .Vi. 5/13 19. Ca .Ci. 30/135-138 20. As. Hr. Su 11/26-28 21. As. Hr.Su .11/37 22. Su.Su.15/21 23. Su.Su.15/19 24. Su.Su.15/24 25. Ca.Su.17/73 26. Ma Ni 20/5 27. Su.Su.24/10 Chittodvega ===========================================50created by of Dr.KSRPrasad
  • 51. 28. Ca .Vi .5/19 29. Bha .pra. Mad 1/59 30. Arunadatta commentary on As.Hr. Su.13/27 31 As. Hr. Su 13/27 32. Ma Ni 25/3 33. Ca.Ci.15/3-5 34. Ca. Vi 2/8 & Ca Ci 15/42, As.Hr.Su 8/31 35. Ca .Vi 2/8 36. Ca.Vi 2/9 37. Su .Su. 46/5 38. Ca .Ci .15/43, 44 39. Ma Ni .20/5;Ca.Ni.7/3 40. Ca Ni 7/4 41. Ca Su 11/49 42. Ca .Su .10/16 43. Ca Ni. 7/6 44. Ca .Ni. 8/4 45. Ma. Ni. 2/30 46. Ca .Ci .3/76 Chittodvega ===========================================51created by of Dr.KSRPrasad
  • 52. RUPA Poorvarupa: The poorvarupa or prodromal stage comprises of appearance of some of the symptoms, in a sense it is the alpavyakta stage of chittodvega. Rupa: The clinical features presenting in chittodvega are not mentioned as a separate disease entity in the texts, but basing on the etiopathogenesis, the symptomatology may be traced out in different contexts covering the symptoms of vataprakopa, pittaprakopa, kaphakshaya, ojokshaya, dhatudushti, agnivikriti and unmada purvarupa. Symptoms: Psychological: Reference 1. Udvega (Anxiety) Ca. Ni. 7/5 2. Abheekshnam dhyanam (Worrying thoughts) As .Hr. Su 11/39 3. Sammoha (Bewilderment / Confusion) Ca. Ni. 7/5 4. Bibheti (Fear complex) As.Hr. Su. 11/39 5. Durmana (Cheerlessness) As.Hr.Su.11/391 6. Ghattate (Restlessnes) Ca.Su.17/64 7. Sabda asahishnuta (Intolerance to loud sounds) As.Hr.Su.11/17 8. Svapne ca abhikshnam darshanma (Night terror) Ca. Ni. 7/5 9. Vyathitendriya (Affliction of Indriyas with pain) As .Hr. Su. 11/39 10. Deenatha (Timidity / Pervishness) As. Hr. su. 11/56 Somatic: Reference 11. Bhrama (Dizziness) As. Hr. Su. 11/58 12. Kampa (Tremors) As .Hr.Su .11/5,6 13. Toda/ Satatam lomaharsha(Prickling pain) Ca.Ni.7/5;Su.Su. 15/17 Chittodvega ===========================================52created by of Dr.KSRPrasad
  • 53. 14. Arocaka (Anorexia) Ca. Ni. 7/5 15. Avipaka (Indigestion) Ca. Ni. 7/5 16. Sakrit graha (Constipation) As. Hr. Ci. 11/5 17. Trisha (Excessive thirst) As.Hr.Su.11/6 18. Glani (Exhaustion – even without work) As.Hr.SU11/17;Ca.Su.17/66 19. Sandhivedana (Pain in the joints) As. Hr. Su.11/18 20. Bala bhramsa (Loss of strength) As .Hr. Su. 11/51 21. Nidra bhramsa (Loss of Sleep) As Hr. Su 11/51 22. Muhasosha (Dryness of mouth) Ca. Su. 17/69 23. Anaha (Excessive flatulence) As. Hr. Su 11/51 24. Kleebata (Loss of libido) Ca .Su .17/69 25. Udarditatvam (pain in upper half of body) Ca. Ni. 7/5 26. Hrit drava (Palpitations) As.Hr.Su 11/16 27. Ucchvasasadhikya (Over breathing) Ca .Ni. 7/5 28. Hrit graha (Constriction in chest) Ca .Ni. 7/5 29. Syanah Karnayo (Tinnitus) Ca. Ni. 7/5 30. Timira darshanam (Fainting) As. Hr. Su. 11/19 The above 30 symptoms were considered for as the symptoms in chittodvega. The symptoms correlating with the symptoms of anxiety states stated by Hamilton are taken into the account of the study. Chittodvega ===========================================53created by of Dr.KSRPrasad
  • 54. CLINICAL CORRELATION OF CHITTODVEGA It is very difficult to compare neurotic disorders with any disease described in Ayurveda, because of the different methods of clinical approach of Indian and Western system of medicine. In Ayurveda, all diseases and their treatments are based on the principle of tridosha, while Modern system of medicine has different etiopathological approach. As a matter of fact, no allopathic disease in its complete form can be precisely compared with any Ayurvedic description. But some practical correlations are possible. The clinical correlations of an Ayurvedic entity with the modern disease can be done on the basis of three main parameters i.e.1.Similarity of symptomatology 2.Similarity of etiopathogenesis 3.Similarity of total clinical presentation of the disease. Basing on the above view the symptoms of anxiety neurosis are correlated with a group of entities and an effort has been done to find out a precisely parallel disease in Ayurveda.They are: (i) Ojo Kshaya: The psychological and somatic symptoms stated in ojokshaya lakshanas by Charaka and Vagbhata (Ca.Su.17/33, As.Hr.Su.11/39-40) correlate with symptoms of anxiety. Psychological Symptoms:  Bibheti – fear complex  Dhyayati – worry  Durmana – restlessness, cheerlessness Somatic Symptoms:  Durbala – weakness  Vyadhitendriya – affliction of Indriyas with pain  Duscchaya – loss of complexion  Ruksha – roughness of body  Kshama – emaciated state. Chittodvega ===========================================54created by of Dr.KSRPrasad
  • 55. Ojokshaya is noticed in a variety of disorders like Madhumeha (Ca.Ni.4/37), Panduroga (Ca.Ci.6/5), Raktarsas (Ma.Ni.5/27) etc. So, it is not a single disease but only a condition occurring in samprapti of many diseases. (ii) Anavasthitachittatva: Has been mentioned by Caraka and Sharangadhara (Ca.Su. 20/11) in vataja nanatmaja vikaras. Anavastha indicates unsteady, unsettled, changed or dissoluted condition. And chitta indicates the mind. But for its meaning no other description has been given in classics. (iii) Purvarupa of unmada: In Charaka samhita (Ca.Ni. 7/6), the purvarupa (prodromal features) of unmada were described , which can be correlated with few of anxiety neurosis symptoms. Psychological Symptoms:  Asthana udvega – anxiety out of context  Asthana dhyana – attention towards unimportant objects  Unmattachittatvam – crazy mind  Asthana ayasa – fatigue  Sammoha – confusion. Somatic Symptoms:  Karnasvana – tinnitus  Uchvasasadhikya – hurried breathing  Arocaka – tastelessness  Avipaka – indigestion  Hritgraha – constriction in cardiac region  Satatamlomaharsha – prickling sensation  Udarditatvam – pain in upper part of body. (iv) Manasikadosa Vikara: Charakacharya (Ca.Ni. 6/5) stated Chittodvega as a manovikara occurring due to the vitiation of rajas and tamas. No other description is available in classics about Chittodvega. Chittodvega ===========================================55created by of Dr.KSRPrasad
  • 56. CLASSIFICATION OF PSYCHIATRIC DISORDERS Multi Axial System The DSM-IV organizes each psychiatric diagnosis into give levels (axes) relating to different aspects of disorder or disability. Axis I Clinical disorders, including major mental disorders, as well as development and learning disorders (all dental disorder except personality disorder and M.R) Axis II Underlying pervasive or personality conditions, as well as mental retardation. Axis III Acute Medical conditions and Physical disorders (Must be connected to a Mental. Axis IV Psychosocial and environmental factors contributing to the disorder. Axis V Global averment of Functioning. Common Axis I Disorders include depression, anxiety disorders, bipolar disorder, ADHD and Schizophrenia. Common Axis II Disorders include borderline personality disorder, schizotypal Personality disorder, antisocial personality disorder, narcissistic personality disorder, and mild mental retardation. DSM Group  Disorders usually first diagnosed in infancy, childhood or dolesunce. “Disorders such as autism and epilepsy have also been referred to as development disorders and developmental disabilities.  Delirium, dementia and amnesia and other cognitive disorders  Mental disorders due to a general medical condition  Substance related disorders.  Schizophrenia and other psychotic disorders  Mood disorders  Anxiety disorders Chittodvega ===========================================56created by of Dr.KSRPrasad
  • 57.  Somatoform disorders  Factitious disorders  Dissociative disorders  Sexual and gender identity disorders  Eating Disorders  Sleep disorders  Impose control disorders not elsewhere clarified  Adjustment disorders  Personality disorders  Other conditions that may be a focus of clinical attention. ICD-10 INTERNATIONAL CLASSIFICATION OF DISEASES–10 ORGANIC DISORDERS FUNCTIONAL DISORDERS 1 Dementia 1 Schizophrenia, schizotypal & delusional disorders 2 Delirium 2 Mood disorders 3 Mental & behavioural disorders due 3 Neurotic, stress-related, somatio to psychoactive substance use form disorders 4 Behavioural syndromes with psychological disturbance & physical factors 5 Disorders of adult personality & behaviour 6 Mental retardation 7 Disorders of psychological development 8 Behavioural & emotional disorders occurring in childhood & adolescence. 9 Unspecified mental disorders Chittodvega ===========================================57created by of Dr.KSRPrasad
  • 58. ANXIETY NEUROSIS Anxiety: The word anxiety is derived from the Latin word ‘Anxitas’ meaning ‘troubled in mind’.1Anxiety is a common form of reaction that every person experiences to a greater or lesser extent during his or her life time. The term anxiety is as much a part of the lay person’s vocabulary as it is the clinicians. People may describe themselves as anxious when they are anticipating an important examination, or an important job interview. Those who report an experience of fear when left alone in the dark may also describe themselves as anxious. On the other hand, anxiety may be diagnosed as pathological when general functioning is at a level below usual competence and is accompanied by physical symptoms such as tension headaches. Anxiety, in the simplest sense, is a form of response or reaction. Its existence in the individual does not necessarily denote abnormality. Anxiety can however be much more than a normal, helpful reaction in a challenging situation. Whether it is regarded as a disorder depends on the extent of its negative impact on thinking and behavior and on how much it interferes with the person’s daily life.2 Definition is particularly important with the concept of anxiety as it encompasses a range of reaction and can refer to a range of possible experiences. A precise definition is not universally agreed, presented here are the main elements that may be observed in the clinical cases of the anxiety syndrome. Anxiety may be defined as an unpleasant emotion that is characterized by feeling of dread, worry, nervousness or fear. This emotion may be experienced in response to particular events, situations, people or phenomena; or in anticipation of stimuli. This stimulus may be external (like a storm) or internal (like a negative belief accompanied by Chittodvega ===========================================58created by of Dr.KSRPrasad
  • 59. a sense of helplessness). In addition, the individual may experience physical symptoms such as sweating, over breathing, an increased heartbeat, nausea or dizziness.3 Neurosis: The term neurosis was coined by William Cullen in 1777, meaning any disease of the nervous system without a known organic basis. Clinical description of neurotic symptoms can be found in the works of Hippocrates.4 Neurosis has continued to refer to a collection of functional mental disorders that do not involve hallucinations, delusions or loss of insight, and that are not caused by organic pathology. These disorders make up the vast majority of mental disorders in the community. In most community or primary care based research, a psychiatric ‘case’ usually corresponds with a diagnosis of neurotic disorder. And several near synonymous terms have come into widespread use, such as – the common mental disorder, minor affective disorders and minor psychiatric morbidity.5 Somatic (physical) symptoms, not adequately explained by a medical disease are common in neurosis. So are easily missed in primary care and general hospitals. Neuroses are not always minor illnesses and can be chronic and disabling.6 Anxiety neurosis: It was Sigmund Freud (1895) who first suggested that cases with mainly anxiety symptoms under the name of anxiety neurosis. Freud’s original anxiety neurosis included patient with phobia’s and panic attacks, but subsequently; he divided it into two groups. The first, which retained the name anxiety neurosis, was a group of cases with mainly mental symptoms; the second group, which he called anxiety hysteria, was for cases with physical symptoms of anxiety. Freud originally proposed that the causes of anxiety neurosis and anxiety hysteria were related to sexual conflicts. Many psychiatrists considered that a very wide range of stressful problems could cause anxiety neurosis.Anxiety was in Freud’s formulation a Chittodvega ===========================================59created by of Dr.KSRPrasad
  • 60. sign of an inner battle or conflict between some primitive desire (from the id) and prohibitions against its expression (from the ego and superego). To Freud, neurosis was a psychological disorder that resulted when there was anxiety that was a sign of intrapsychic conflict.7 Freud’s ideas required inferring that anxiety some how existed in the mind and caused neurotic behavior even thought it could not be observed or measured. In recent years, Freuds views on the nature of neurosis have been criticized as too theoretical and not sufficiently tied to the real world. Since 1980, the approach of DSM has been to avoid such inferences about the causes of disorder. The DSM has separated what used to be officially called neuroses into different categories based on their symptoms, which can be observed and measured. Despite its important place in the history of psychiatry and common use by mental health professionals, the term neurosis has been gradually disappearing from the major diagnostic classifications, to be replaced by more specific diagnoses in the form of neurotic disorders. World Health Organization’s International Classification of Diseases latest revision, ICD -10, classified neurotic disorders along with stress related and somatoform disorders, owing to their common historical backgrounds and associations with psychological stress. The American psychiatric association’s Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) has been more radical in dealing with neurosis, than ICD-10. In the American Diagnostic system neurosis were grouped together on the assumption of a common etiological process of intrapsychic conflict, not on the basis of shared phenomenological characteristics. Therefore, diagnostic groups of neurosis or neurotic disorder do not appear in DSM –IV, but are superseded by anxiety disorders and dissociative disorders.8 Chittodvega ===========================================60created by of Dr.KSRPrasad
  • 61. Anxiety – the core symptom of neurotic disorders: Anxiety is the common feature of the neurotic and stress related disorders. Historically, anxiety disorders were considered to be examples of neurotic behaviour. Anxiety as a disorder: The disorder ‘anxiety’ appeared for the first time in the seventh revision of the International classification of diseases (ICD 7) in 1957. However, at sub pathological levels anxiety is a useful drive that maximizes performance. The attention and speed of response follow an inverted U-shaped curve with increasing anxiety and arousal (the Yerkes-Dodson law). Anxiety becomes destructive and warrants the description of disorder when it is prolonged, perceived by the sufferer to be out of his or her control, and when it begins to result in behaviour or symptoms that reduce normal or desired functioning. Classification of anxiety disorders: 10 ICD-10: F 40- Anxiety disorders F 40.00 – Agoraphobia without panic disorder F 40.01 – Agoraphobia with panic disorder F 40.1 – Social phobia F 40.2 – Specified (Isolated) phobia F 41 – Other anxiety disorders F 41.0 – Panic disorder F 41.1 – Generalised anxiety disorder F 41.2 – Mixed anxiety and depressive disorders F 41.3 – Other mixed anxiety disorders DSM IV: 300.22 Agoraphobia without panic disorder 300.21 Agoraphobia with panic disorder Chittodvega ===========================================61created by of Dr.KSRPrasad
  • 62. 300.23 Social phobias 300.29 Specific phobias 300.01 Panic disorder without agoraphobia 300.02 Generalised anxiety disorder 300.00 Mixed anxiety and depressive disorder DSM IV and ICD 10 adopt the same general scheme. The main differences are that in ICD 10 the disorders are divided into (a) phobic anxiety disorder (FAD) and (b) other kinds of anxiety disorder (F41). DSM IV classifies obsessive – compulsive disorder as a type of anxiety disorder while ICD 10 separates the two conditions. Epidemiology & Prevalence: 11 Anxiety disorder represents the single largest mental health problem in America. A recent British survey found that 16% of the population suffered from some form of pathological anxiety (Hale 1997; OPCS 1995). Studies from different parts of the world have found community prevalence rates between 7 to 26 percent per month. Prevalence rates of anxiety are reported to be between one-third and two-thirds higher in women than men. (Roth & Fonagy, 1996) The most common anxiety disorders are social phobia (13.3%) and simple phobia (11.3%), followed by agoraphobia (5.3%), generalized anxiety disorder (5.1%) and panic disorders (3.5%). Co-morbidity is common with depression and other anxiety disorders. Theories of anxiety acquisition: Outlined here are some of the major approaches that attempt to account for the origin and maintenance of anxiety. 1. Biological theory: It is postulated that neurotic individuals possess the characteristic of intense nervous system activity on very slow rates of habituation (i.e. poor or slow learning ability). Without the ability to habituate it will take an individual a long time to become accustomed to something and intense nervous system activity means that the individual’s response level is strong. Thus anxiety is seen as resulting largely from the Chittodvega ===========================================62created by of Dr.KSRPrasad
  • 63. interactions of individual cortical arousal level and nervous system reactivity. Anxious individuals are thought to have both high resting levels of cortical arousal and high autonomic nervous system activity. 2. Behavioural theory: Behavioral theories of acquisition and maintenance of anxiety are based on theoretical explanation of how we learn. Two concepts employed by behaviorists to describe the origin of anxiety are: a. Classical conditioning: by Ivan Pavlov b. Operant or instrumental conditioning: by Morwer It is proposed by behaviorists that the individual learns to be anxious via a number of possible procedures such as - strong association of reactions or feelings with an event or place, or reinforcement of particular behaviours or by observation of the reaction of significant others in one’s life. 3. Cognitive theory: Cognitive theorists postulate that the primary factor in the origin and maintenance of anxiety is the thinking process. Cognitions, that are one’s thoughts, determine one’s reactions (beck, 1985 a, b, c). According to cognitive theorists, one is anxious because of perceived threat. At a simple level, if we perceive a particular phenomenon in a very negative way, we are more likely to be adversely affected by it, we are more likely to worry and more likely to feel apprehension. Beck’s model of the cognitive processing proposed to be involved in the production of the anxiety syndrome may be broken down into 3 steps.  Step 1:Primary appraisal: first impression on which the individual assess the potential threat  Step 2: Secondary appraisal: individual evaluates the internal resources for protecting or deflecting damage that might result from the threat.  Step 3: Reappraisal: individual reacts with flight (due to anxiety) or fight (due to anger) depending on the level of self confidence. Chittodvega ===========================================63created by of Dr.KSRPrasad
  • 64. 4. Psychodynamic theory: This theory postulates that anxious feeling arise from internal conflicts or impulses of which the individual is not consciously aware. In this theory anxiety is related to the persistence of remembered danger situations that seemed real at an earlier stage of development. 5. Integrated theory: John Bowlby’s (1973) proposed model for the explanation of the development of anxiety state includes the notion that there is no single key. Instead he suggests that fear and anxiety are aroused in situations of many kinds. Bowlby proposes that individuals have an innate property to make emotional bonds and anxiety is seen to be related to fears of separation and insecure attachment.12 Common symptoms of anxiety: 13 Component prominent features Emotions/mood Anxiety, Irritability Cognitions Exaggerated worries and fears Behavior Avoidance of feared situations, checking, seeking reassurance Somatic symptoms Tight chest Short of breath Palpitations. Tremor Tingling of finger (due to hyperventilation) Aches and pains Poor sleep Frequent desire to pass urine and defecate Chittodvega ===========================================64created by of Dr.KSRPrasad
  • 65. Anxiety presentation: Anxiety presents itself in the consulting room in a variety of guises:-  A separate phobia may be cited as the main problem.  Inability to cope, at work or at home, may be the major difficulty experienced.  Worries about health may be reported, along with aches and pains that have been found to have no medical basis.  Recent major loss or trauma may be reported as the overwhelming difficulty.  Depression may be cited as the main problem.  Obsessive and repetitive behavior may be the main presenting problem. Secondary anxiety: 14 Before investigating psychological causes of anxiety, it is important to exclude the possibility of physical disorders in which anxiety may be a presenting complaint even before other signs of disease become evident. Cardiovascular disorders:  Atherosclerotic heart disorder  Paroxysmal tachycardia  Mitral valve prolapse  Hyper dynamic β-adrenergic circulatory state Pulmonary disorders:  Pulmonary embolism  Hypoxemia  Asthma  Chronic obstructive lung disease Disorders of the endocrine system and metabolism:  Hypoglycemia  Hyperthyroidism  Hypocalcaemia  Cushing’s syndrome  Porphyria Chittodvega ===========================================65created by of Dr.KSRPrasad
  • 66. Tumors:  Insulinoma  Carcinoid tumor  Pheochromocytoma Neurological disorders:  Multiple sclerosis  Temporal love epilepsy  Organic mental syndrome of any etiology  Meniere’s disease Infections:  Tuberculosis  Brucellosis Drug related disorders:  Abstinence syndromes  Intoxication from sympathomimetics  Akathisia  Caffeinism  Chinese restaurant syndrome Differential diagnosis: 15 Anxiety disorders are divided into three main sub types: Phobic Panic Generalised anxiety disorder anxiety Occurrence of anxiety Situational Paroxysmal Persistant Associated behavior Avoidance Escape Agitation Fear of situation Fear of symptoms Worry Associated cognitions With exposure Episodic Persistant Somatic symptoms Chittodvega ===========================================66created by of Dr.KSRPrasad
  • 67. Phobic anxiety: In a phobia, the anxiety is situational, and largely restricted to experience or anticipation of the phobic stimulus. This stimulus may be a specific concern e.g. heights, spiders or a more general one e.g. agoraphobia. As a result there is marked avoidance of those situations associated wit the stimulus. Panic disorder: Panic attacks are episodes of severe paroxysmal anxiety with prominent somatic symptoms and unpleasant feelings of depersonalization or derealization. Generalized anxiety disorder: Generalized anxiety is a syndrome of persistent anxiety associated with chronic uncontrollable and excessive worry. It may fluctuate but is not paroxysmal (as with panic), situational (as with phobia) life long (as with a personality disorder) or clearly stress related (as with a stress related disorder). Treatment: Treatment of anxiety may be broadly categorized as16 1. Psychological 2. Social 3. Biological (i) Psychotherapy: Is the most effective treatment for exogenous anxiety and anxiety due to identifiable intrapsychic conflict. Psychotherapy may be facilitated by medication and behavioral techniques. (a) Supportive psychotherapy: Psychotherapy that is primarily supportive is useful for acutely ill patients Patients under severe stress and patients with limited emotional and psychosocial resources. It is done through – 1. Development of defenses: Involving encouraging the development of defenses that are as adaptive as possible. 2. Reality testing: The continuous assessment of reality through objective evaluation of the world and one’s relationship to it should be encouraged. Chittodvega ===========================================67created by of Dr.KSRPrasad
  • 68. 3. Advice: Should be given, especially when patient attempts to avoid anxiety through destructive or self destructive behavior. 4. Adoptive behavior by the patient should be reinforced(encouraged) (b) Expressive psychotherapy: Patients whose anxiety reflects intrapsychic conflicts and who are able to and are interested in understanding themselves may gain more control of their symptoms by learning more about the psychological meaning of the anxiety. Components of expressive psychotherapy include: 1. Clarification of the patients’ statements in order to make them more comprehensible. 2. Confrontation of aspects of reality or the patients’ emotions that they are ignoring. 3. Interpretation of unconscious thoughts and feelings in order to bring them into patients’ awareness. (ii)Behavior therapy: Is a very effective for phobias, includes: (a) Systemic desensitization: Patients are taught deep muscle relaxation, which is incompatible with anxiety. Situations that cause anxieties are imagined by the patients while relaxed in this way. (b) Graduated invivo procedure: Invivo exposure is usually necessary to solidify the gains obtained in systemic desensitization. It involves the patients usually with a familymember or friend or physician for reassurance. (c) Adjunctive behavioral techniques: Includes – 1. Relaxation techniques: Patient is taught to relax at the time of tension 2. Hypnosis: Is an altered state of consciousness in which the patient is helped to concentrate on claming thoughts. 3. Bio-feed back: This method is administered for patients who prefer to learn to relax with a machine or alone. The level of muscle tension, usually in the Chittodvega ===========================================68created by of Dr.KSRPrasad
  • 69. forearm or frontalis muscle is ‘fed back’ through a visual or auditory stimulus to help patients learn to decrease motor tension. (iii)Psychopharmacology: Medication is indicated for treatment of indigenous anxiety and associated phobias that are complications of panic attacks, not responding to specific trauma or conflict. It is also indicated if a 3 months trial of psychotherapy and behavior therapy is unsuccessful. Adjunctive use of anti-anxiety medication may facilitate psychotherapy and behavior therapy in patients with active stress reactions or chronic anxiety.17 1. Benzodiazepines e.g. Diazepam, Temazepam are the most effective anti-anxiety drugs, with a rapid onset of action over a few minutes. Problems with dependence should limit their use to a maximum of 6 weeks, and the dose should be gradually reduced after the first 2 weeks. 2. Azapirones e.g. Buspirone, also is anxiolytic, but the onset of action is slow over several days and its is relatively ineffective in patients who have previously been treated with benzodiazepines 3. Somatic symptoms of anxiety e.g. tremors, palpitation are often helped by adrenoceptor antagonists. 4. Anxiety frequently co exists with depression and antidepressants provide a useful alternative in this situation. In particular, the selective 5HT-reuptake inhibitor antidepressants (SSRI’s) may by more effective than benzodiazepines, although their onset of action is delayed up to 2 weeks. 5. Cyclopyrrolones e.g. Zopiclone, is anxiolytic by its hypnotic effect. 6. Sedatives like Chloral derivatives can be useful in the elderly while sedative antihistamines are useful in children 7. Low dose Tricyclic antidepressedants e.g. Amitriphyline, Tradazone also have anxiolytic and hypnotic effects. Chittodvega ===========================================69created by of Dr.KSRPrasad
  • 70. References 1. API text book of Medicine P-1381 2. Adult Psychological problems: An introduction- P 55, 56 3. Adult Psychological problems: An introduction- P 57 4. Oxford Handbook of psychiatry P-340 5. Post Graduate Psychiatry P-209 6. Lecture Notes: Psychiatry P-101 7. Key topics in Psychiatry p-39 8. Post Graduate Psychiatry P-210 9. Adult Psychological problems: An introduction P-58 10. Oxford Handbook of Psychiatry p-932 11. Lecture notes Psychiatry P -103 12. Adult Psychological Problems: An introduction P 58-60 13. Lecture notes :Psychiatry P-103 14. Psychiatry,chapter-6;147,148p 15. Lecture notes Psychiatry P-104 16. Psychiatry-151,152p 17. Principles of medical Pharamcology-21st chapter Chittodvega ===========================================70created by of Dr.KSRPrasad
  • 71. CHIKITSA Acharya Charaka explains three types of therapies for all physical and mental disorders: 1 (1) Daivavyapashraya – Divine therapy (2) Yukthivyapashraya – Rational therapy (3) Sattvavajaya – Psycho behavioral therapy 1. Daivavyapashraya chikitsa: Deals with methods of treatement such as: 2 (i) Mantra – incantation ; (ii) Mani – wearing gems ; (iii) Mangala –propitiatory rites ; (iv) Bali – oblations ; (v) Upahara – offerings ; (vi) Homa – sacrifice ; (vii) Niyama – vows ; (viii) Prayascitta – ceremonial penitence ; (ix)Upavasa – fasts ; (x) Svastyayana – prostration ; (xi) Pranipata – surrender ; (xii) Ausadha – tying of herbs ; (xiii)Yatragamana -pilgrimage . These are recommended for treatment of mental disorders caused by invisible agents (agantufactors) or acts of past life based on theory of karma. These daivavyapasraya methods create confidence and remove the fearing and pessimistic tendencies indirectly helping the person in gathering confidence and treatment of manovikara.3 The exact mode of action of these methods is not known. Chakrapani in his commentary has stated that these methods due to its prabhava may act in mental disorders.4 2. Yuktivypashraya Cikitsa: This method of treatment depends upon reasoning out the cause of the disease and on devising suitable ways and means for its cure. It includes: Somsodhana – Antahparimarjana, Bahirparimajana, Sastrapranidhana Samsamana – Ausadha, Ahara, Vihara. Chittodvega ===========================================71created by of Dr.KSRPrasad
  • 72. In chittodvega the doshas are vitiated and also the srotodusti has occurred. So sodhana (purificatory) measures are advocated to do the cleansing of the vitiated dosha and srotas.When the sodhana is properly done, samsamana and rasayana therapies are given. Later satvavajaya measures are adopted in order to bring back the deranged manas to normalcy. The following are some of the treatment processes that are being administered in treatment of various mental disorders:- (i)Virechana (ii)Vasti (iii)Nasya (iv)Abhyanga (v)Takra/Kshira/Taila/Kashaya-dhara (vi)Mastishka/Shirolepa. Rasayana and Ausadha that are being administered in manovikaras are :- Asvagandha Rasayana, Brahmi Rasayana, Kushmanda Rasayana, Mansyadikvatha, MahakalyanaGhrita, NarasimhaGhrita, Sarasvatarista, Asvagandharista, Saravatachurna, Smritisaagara Rasa, Brahmyadiyoga, Maanasamitra Vati, Himasagara Taila, Jatamamsi, Brahmi, Tagara, Vacha are some of the aushadhas found in various classics in the context of manasaroga chikitsa. Specific mention of Medhya Rasayana is needed in the context of Manasarogas. In general, all Rasayana agents are supposed to promote medha i.e. intellect.5 Dalhana in his commentary on Sushruta Samhita has classified Rasayana and one of them is Medha kamya rasayana.6 However, Ayurvedic texts described certain Rasayanas, which specially influence the medha and promote mental competence.7 These medhaya Rasayanas promote Prajna i.e. dhi, dhriti and smriti, which is in deranged state in mental disorders like chittodvega. Many of the medhya Rasayanas have been scientifically studied in recent years and they have been reported to possess varying degree of anxiolytic activity besides restoration of intelligence and memory ( Chittodvega ===========================================72created by of Dr.KSRPrasad
  • 73. It is interesting to note that different food articles like Kshira, Ghrita, Draksha, Kapittha, Mahakushmanda, Mandukaparni, Matulunga and others are recommended as beneficial in various mental disorders. The body is the product of food and the distinction of happiness and sorrow results from the distinction of wholesome diet.8 Hence ahara plays a important role in causing mental disorders or in relieving them. 3. Sattvavajaya chikitsa: The line of treatment of mental diseases is based on the theory of normalizing the manasika doshas. Charaka defines sattvavajaya as a `mind control therapy’ in which stress has been laid on restraining the mind from unwholesome arthas.9 Acharya Charaka has included sattvavajaya and daivavyapasraya treatment methods under the category of adravyabhuta chikitsa.10 Methods employed under adravyabhuta chikitsa are: 11  Bhaya darshana – frightening  Vismapana – causing surprise  Vismarana – forgetting (engaging in other activities)  Tadana – beating  Kshobhana – administering shock  Harshana – inducing elation  Bhartsana – threatening  Vadha – thrashing  Bandhana – binding  Swapna – inducing sleep. Sushruta, while describing unmada chikitsa, narrated that in unmada and all other manasa rogas, chittaprasadana i.e. propitiation of the mind should be done.12 Dhi, Dhairya, Atmadi Vijnanam are indicated by Vagbhata as the best remedial measures of 13 manodoshas. Carakacharya has indicated that mental disorders take place due to vitiation of mind by deranged tamas and Rajas that can be reconciled by: 14  Jnana – knowledge of Atma & religion (spiritual knowledge)  Vijnana – knowledge of Shastras (scriptural knowledge)  Dhairya – fortitude (patience) Chittodvega ===========================================73created by of Dr.KSRPrasad
  • 74.  Smriti – memorizing  Samadhi – concentration (mind control) In another context, Acharya Charaka have explained the principles of management of mental disorders as: 15  Trivarga anvesana- contemplation of the three objectives of life  Tadvidyaseva – service of those who are well versed in the treatment of mental diseases  Atmajnana – self-realization  Kula – kala – bala – jnana – The knowledge about one’s own self, country, family, age, vitality and ability. As prajnaparadha has been regarded as the main cause of mental illness, true understanding is very essential for the attainment of ideal mental health and it can also be used in removing the manovikaras. Assurance and replacement of opposite emotions in also considered as a form of psychotherapy.16 Charakacharya advises that toothed snaks, tamed lions etc should produce the terror to the person. He regards that due to fear of death the insane mind becomes normal and the manararoga is cured.17 Manovikaraanutpadana (Preventive measures): Besides the above methods of treatment stress has also been laid in classics on the preservation and promotion of mental health and prevention of manovikaras. They are: i. Sadvritta ii. Acara Rasayana iii. Dharaniya vega vidharana (i) Sadvritta: Different kinds of emotions such as kama, krodha, lobha etc arise as a consequence of manodoshas (rajas and tamas). By the practice of sadvrtta, the sattvaguna prevails over rajas and tamas, thus preserves good mental health. Sadvrtta is similar to the idea of Yama and Niyama described in the context of yoga. Chittodvega ===========================================74created by of Dr.KSRPrasad
  • 75. The code of sadvrtta described in Ayurveda can summarized in the following headings: 18 A. Manasika Sadvrtta (Mental) B. Charitrika Sadvrtta (Ethical) C. Samajika Sadvrtta (Social) D. Dharmika Sadvrtta (Moral) E. Vaiyaktika Sadvrtta (Personal) (ii) Acara Rasayana: Charakacharya stated a schedule of good conduct to be observed by the man (desirous of Rasayana effects) for longevity, immunity and promotion of mental health which is called the Acara Rasayana.19 Speaking truth, Respect towards Elders,God,Teachers, having indriyanigraha, etc, are some of the schedules in Acara rasayana. It is claimed that the practice of AcaraRasayana yields in an individual all benefits of Rasayana, may it be biological or psychological. It appears easily perceivable that a peaceful happy life resulting out of good conduct will obviously be associated with a state of positive health and anabolism.20 (iii) Dharaniya vega vidharana: A number of dharaniya vegas such as sahasa, asastakarma, lobha, soka, bhaya, krodha, ahamkara, nirlajjata, irshya, raga and abhidroha has been stated in Ayurvedic classics.21 In the interest of social and personal health, it has been advocated that these urges must be restrained. These dharaniya vegas induce a variety of mental conflicts at the level of individual psyche causing mental ill- health of the individual besides their untoward impact on the society including the family and relatives.22 So the concept of dharaniya vegas is more of preventive nature and if properly followed, will lead to proper mental health. Chittodvega ===========================================75created by of Dr.KSRPrasad
  • 76. REFERENCES 1. Ca.Su.11/54 2. Ca.Su.11/54 3. Psychopathology in Indian medicine – 434p 4. Cakrapani commentary on Ca.Su. 11/54 5. Ca Ci.1/3rd pada/31 6. Dalhana commentary on Su.Chi 27/1-2 7. Histroy of medicine in India -359p 8. Ca.Su. 5/15, 28/4 9. Ca .Su. 11/54 10. Ca. Vi. 8/87 11. Ca.Ci. 9/89 12. Su .Ut. 62/34 13. As. Hr. Su. 1/26 14. Ca .Su .1/58 15. Ca. Su. 11/47 16. Ca .Ci. 9/97 17. Ca.Ci 9/94 18. Ca. Su. 8/20 19. Ca .Ci .1/31-35 20. History of medicine in India – 425p 21. Ca .Su. 7/26-30 22. History of medicine in India 425 p Chittodvega ===========================================76created by of Dr.KSRPrasad
  • 77. DRUG REVIEW Criteria for selection of drug: On account of the importance of medhya drugs stated in the chikitsa aspect of manasa rogas in Ayurvedic classics, the present study is done to assess the effect of two medhya drugs in chittodvega (anxiety neurosis) and its related symptomatology. The two single drugs choosen for the trial are taken as reference from Bhavaprakasha Nighantu, Poorva khanda, Guduchyadivarga(Aparajitha) & Hareetakyadi Varga(Jyotishmati). Aparajitha pocessess the properties of Medhya, Smriti-Buddhikara and Tridoshahara. Jyotishmati pocesses the properties of Buddhi-Smritiprada, Sarvavyadhihara and Pathya. These therapeutic properties of both the drugs are considered to correct prajna, which is deranged in chittodvega and bring back the normalcy of the deranged manasika and saririka doshas, hence relieving anxiety neurosis. APARAJITA Botanical name : Clitoria ternatea Linn. Family : Fabaceae Vernacular names :- Bengali : Aparajita English : Winged-leaved clitoria, Butterflypea, Mzerion Gujarathi : Garani Hindi : Koyala, Aparajita Kannada : Shankhapushpa, Girikarniballi, Kantisoppu Konkana : Shankapushpa, Gokarna Marathi : Gokarani, Kajali Malayalam : Aral, Samkhupuspam Tamil : Kakkanam, Shanupushpam Telugu : Dintana Chittodvega ===========================================77created by of Dr.KSRPrasad
  • 78. Manipuri : Aparajita Synonyms: Asphota, Girikarni, Vishnukranta, Sankhapuspi, Sephanda, Sveta, Mahasveta Classical categorization: Caraka: Siroverecanopaga Bhava Prakasha Nighantu : Gudichyadi varga `Sankha’ means a `conch’. The plant, which has flowers like a conch, is Sankhapushpi. So south Indian vaidyas vehemently argue that, as the flowers very nearly resemble that of a conch Clitorea is Sankhapushpi. Botanical Description: Habit: Perennial twiner Habitat: Common garden plant occurs among hedges all over India. Morphology: Leaves: pinnately 3-7 foliate Flowers: showy, white, resembling clitoris of women, petals unequal, style bearded below the stigma axillary, solitary fascicled / racemose. Fruits: pods, linear, compressed Seeds: 6-10 black Parts used: Root, bark, seeds and leaves Chemical composition:  The major ingredients are taraxerol and taraxerone in roots  Cinnamic acid, flavonol, glucosides, hexacosanol, β-sitosterol and an anthoxanthin glucoside in seeds  Aparajitin, sitosterol, stearic, palmatic, oleic, linoleic and linolenic acid, and glycosides of karempferol, stigmast – 4 – ene – 3,6 dione in leaves  Flavonoids in the petals Chittodvega ===========================================78created by of Dr.KSRPrasad
  • 79. Properties: Rasa : Katu, Tikata, Kasaya Guna : Laghu, Ruksha Virya : Sita Vipaka : Katu Karma : Tridoshahara, Medhya, Visaghna, Caksusya Karma according to various nighantus: Aparajite katu medhye site kanthye sudristide! kustha mutratridosam asothavranavishapahe !! kashaye katuke pake tikte cha smrtibuddhide!!! (Bha. Pra.) Girikarnee hima tikta pittopadravanashanee! vishanetravikaramscha hanthi kushtha rujapaha!! (Dha.Ni&Ra Ni.) Girikarnee hima tikta grahaghnee kantha dristida! tridoshashula kushthabhavrana sopha vishapaha!! (Ka. Ni.) Girikarnya swasa kasa kshaya kilasahrut! (Sh. Ni.) From the above references the action of Aparajitha can be summerised as Kanthya, Buddhiprada, Smritiprada, Medhakara, Chakshushya, Rujaapaha, Mootradoshahara, Amadoshaghna, Kushtagna, Vrangahna, Vishaghna, Sophaghna, Amapacana, Jvarghna, Daahaghna Swasa – Kasa hara and Kshaya hara. Preparation of the root powder: Roots of white flowered Aparajitha (Clitorea) were collected. The roots were cleaned and dried. The dried roots were pounded and made into powder. The powder was filtered and the fine powder obtained was packed and dispensed to the patients. Chittodvega ===========================================79created by of Dr.KSRPrasad
  • 80. Dosage: Mulachurnam – 1-3 gm Beeja churnam 1-2 gm Important Formulations:  Agasthya rasayanam, Brahmi granules, Gorochanadi gulika, Manasamithra vadakam, Smrithi granules.  In Garbhapalana Ras, Girikarni ras Bhavana is stated. Research studies: Young adult (60 day old) wistar rats of either sex were orally incubated with 50 mg/kg body weight and 100 mg / kg body weight of aqueous extract of Clitoria ternatea for 30 days along with age matched saline controls. The results showed signficant increase in dendritic intersections, branching points and dendritic processes arising from the soma of amygdaloid neurons in Clitorea treated rats especially, in the 100-ml/kg group of rats. The results suggest that Clitoria ternatea aqueous root extract enhances memory by increasing the functional growth of neurons of the amygdala. (Raj k.s, Murthy K.D, Rao M.S, Karanth K.S. Dept. of physiology KMC Manipal) Clitoria ternate root extract treatment during growth spurt period enhances learning and memory in rats. Neonatal rat pups (7 days old) were intubated with either 50 mg / kg body weight or 100 mg / kg body weight of aqueous root extract of clitoria ternatea for 30 days. Results showed improved retention and spatial learning performance, indicating the memory enhancing property of clitoria which implicates a permanent change in the brain of clitoria treated rates. (Rajk.S, Murthy K.D, Rooms, karanth K.S, Dept of Physiology, KMC, Manipal) Treatment with 100 mg / kg of Clitoria ternate aqueous roots extract, for 30 days in neonatal and young adult age groups of rat, significantly increased acetylcholine (Ach) content in their hippocampi as compared to age matched controls. Increase in Ach content in their hippocampus may be the neurochemical basis for their improved learning and memory. The study conducted on rats revealed that Clitoria ternatea root extracts Chittodvega ===========================================80created by of Dr.KSRPrasad
  • 81. increase rat brain acetylcholine content and acetylcholinesterase activity in a similar fashion to the standard cerebroprotective drug pyritinol. (Taronalli and cheeramkuzhy, 2003) In animal tests the methanolic extract of clitoria ternatea roots demonstrated nootropic, anxiolytic, antidepressant, anticonvulsant and antistress activity. JYOTISHMATI Botanical name : Celastrus paniculatus Family : Celastraceae Vernacular names English : Staff tree, Black oil tree Hindi : Malkangani Gujarati : Malakanguni Kannada : Kariganne Marathi : Kanguni Malayalam : Paluruvam Panjabi : Sankhu Tamil : Vaalulavai Telugu : Mala – erikata Sanskrit : Vahniruchi, katumbi Synonyms: Agnimasha, Amruta, Avega, Dipta, Durjara, Durmada, Gatida, Ingudi, Jyotishka, Jyotishmati, Jyotislata, Kakandi, Kanguni, Katabhi, Kinshuka, Lagana, Lava, Medha, Nishphala, Paravatanghri, Paravatapadi, Pidya, Pinya, Pitataila, Putitaila, Saraswati, Sphutabandhani, Supingala, Swarnalata, Tahnirusi, Triparni. Chittodvega ===========================================81created by of Dr.KSRPrasad
  • 82. Classical Categorization: Charaka : Sirovirecanopaga Sushruta : Arkadi, Adhobhagahara, Sirovirecana Vagbhata : Arkadi Bhava prakasha : Hareetakyadi varga Dhanvantari Nighantu : Guduchyadi Varga Botanical Description: Habit: Large perennial deciduous climbing or scrambling shrub Habitat: Found in tropical and subtropical Himalayas, Punjab, Assam, Bihar, south India and konkan Morphology: Stem - Terete branches, pendulous young shoots and branches. Leaves – Glabrous, broadly ovate, acuminate or acute Flowers – Unisexual, yellowish-green, borne in terminal pendulous panicles. Fruit – Capsule, globose, 3-valved, 3-celled, 3-6 seeded. Seeds – Angular, brownish red colour, surface wrinkled and covered with a kind of brownish powdery susbstance. Parts used: Seeds, leaves and oil Chemical composition:  Roots, bark and stem contain pristimerin.  Seeds contain celapagine, celapanigine, celapanine, celastrol, celastrine, paniculatine, malkanguniol, malkangunin, paniculatadiol, β-amyrin, β-sitosterol, acetic, benzoic, formic linoleic, linolenic, palmatic and stearic acids. Chittodvega ===========================================82created by of Dr.KSRPrasad
  • 83. Properties: Rasa : Katu, Tikta Guna : Tikshna Virya : Ushna Vipaka : Katu Karma : Kaphavatahara, Dipana, Medhya Rasayana Indications : Kustha, Vatavyadhi, udara, gulma. Preparation and properties of seed oil: The oil is obtained from the seeds by exhaustion with ether. It is thick, reddish, bitter oil, with aromatic odour. The oil of deep reddish yellow colour becomes thick like honey when kept for a time.  Oleum nigrum – an empyreumatic black oil is obtained by the destructive distillation of the seeds.  Seeds contain a bitter resinous principal, which is extracted with proof spirit or ether or by shaking the oil with alcohol. Actions / uses: The name `Jyotish – mati’ means light possessing, in allusion to its supposed property of stimulating intellectual powers and sharpening memory. Jyotismati katustikta sara kaphasamirajit! atyusna vamini tiksna vahni buddi smrtiprada!! (Bha.pra) Jyotismati teekshna medhya vyana vishotanashanee! (Sh. Ni.) Jyotishmati tikta rasa cha rukshya kinchit katur vatakaphapaha cha! daahaprada deepana krit cha medhya Prajnam cha pushanti!! (Ra. Ni.) Katu jyotishmati tailam kashayam madhuram katu! sarvavyadhi haram pathyam nana twakdoshanashnam!! (Ra. Ni.) Chittodvega ===========================================83created by of Dr.KSRPrasad
  • 84. From the above references the action of Jyotishmati can be noted as Medhya, kaphaghna, Vataghna, Pittahara, Dipana, Vedanasthapana, Vatanulomana, Gulmahara. Medicinal Properties / Therapeutics: Seeds and oil stimulated intellect and sharpen memory. Oil from seeds is a powerful stimulant, rebefacient and useful in beriberi. One part of oil and 8 parts of butter is known as “Magzsudhi” (Brain cleaner) is applied to head and believed to promote intelligence. Crude oil shows sedative and tranquiliziang effect and drug combination containing Jyotismati is useful as depressent especially in hysteria. Dosage: Powder: 1-2 gm Oil : 5-15 drops Important Formulations: Panchathiktha guggulu ghritam, Sunethri, Jyotishmati tailam Research studies: The oil obtained from the seeds of the plant produced sedation in rats in a dose of lg/kg intramuscularly. On intraperitoneal administration, the same dose of oil produced sedation but the effect was not so marked (Gaitonde et al 1957). Oil showed anti covulsant activity in rats. 50 – 100 mg/kg of oil (as emulsion) produced a gradual fall in blood pressure of cats. 20 mg/kg of the oil produced fall in cardiac output, bradycardia on isolated heart lung preparation. (Gaitonde et al 1957). An active fraction, designated, as Mal III A was isolated from the oil by using counter current distribution method. This fraction had a tranquilizing effect on rats, mice, monkeys and cats in a dose of 200 mg/kg. It potentiated the effect of hexobarbitone and produced hypothermia in mice. The fraction also decreased spontaneous motor activity, Chittodvega ===========================================84created by of Dr.KSRPrasad
  • 85. amphetamine induced hyperactivity and oxyen consumption in mice. Dimunition of carotid occlusion reflex and hypotension was observed in anaesthetized cats. Fraction Mal III and Mal III/B produced salivation, vomiting, defaecation and tremors in cats and dogs (Sheth. et. al. 1963). Polyester prepared from the oil also decreased amphetamine induced hyperactivity and group taxicity in albinorats (Joglekar & Belwani, 1967) Its therapeutic uses include treating anxiety and beriberi. It showed significant (Nervous System depressant effect and a clear synergism with Phenobarbital. Celastrin, the alkaloid in it stimulates the brain without a secondary depression. The Celastrus oil, extracted from seeds of Celastrus particulatus tested at 2 dose level (1 and 1.5 g / kg,) exhibited significant anxiolytic activity and do not produce tolerance. The non-sedative nature and reversal of buspirone induced behaviour (in open field exploration) point to the serotonergic mechanism underlying the anxiolysis. Assessment of pharmacodynamics of the drugs: Chittodvega is mainly produced due to imbalance of manasika and saririka doshas, so the drugs administered might be effective in bringing back the deranged doshas to normalcy. Aparajitha pacifies the tridoshas by its tridoshahara property. Medhya, Smriti and Buddhikara property corrects the deranged pragna (i.e dhi, dhriti and smriti) and hence anxiety and its psychic symptoms like forgetfulness, fear complex, worrying thoughts, and depression are relieved. The relief of these symptoms brings back the normal sleep pattern of the individual. Various studies have already proven the anxiolytic, antidepressant, antistress and sedative properties of Aparajitha. The properties and karmas stated in various ayurvedic texts shows the action of Aparajitha in relieving somatic symptoms associated with the anxiety states. The property like amadoshaghna, aama paachana, katu tikta kashaya rasa and katu vipaka relieve anorexia, causes angi vriddhi, relieves indigestion and constipation. Mootradoshahara Chittodvega ===========================================85created by of Dr.KSRPrasad
  • 86. property of Aparajitha shows therapeutic effect on symptoms like urgency and frequency of micturition. Pain in joints, muscularaches, pain in upper part of body are relieved by rujaapaha and shula hara property. Sita virya, daahaghna, jvaraghna gunas relieve pitta dosha and its associated features like dryness of mouth, excessive sweating. Discomfort in chest and overbreathing relieved by swasahara property. As dhatu kshaya is present in chittodvega it produces exhauation even without exertion and many somatic symptoms related to each dhatu respectively. To relieve the symptoms dhatu poshana is necessary. Aparajitha acts in two ways to cause dhatu pushti- i) by virtue of its kshayahara property and ii) indirectly by its rasa andvirya causing agnivriddhi, hence the poshana of dhatus takes place. Jyotishmati, a proven Medhya rasayana has been adviced by Sharangadhara to be taken from 41-60yrs of age (1/9/20). Jyotishmati also promotes pragna i.e dhi, driti and smriti by its buddhi smritiprada and medhya properties. So alleviates all the psychological symptoms associated with chittodvega. Vatahara and vatanulomana properties of Jyotishmati are important as majority of symptoms associated with anxiety are due to vitiation of vata, like breathlessness, tremors, prickling pain, loss of sleep etc. So by causing samana and anulomana to vayu all the symptoms associated Chittodvega are also relieved. Sara guna of Jyotishmati relieves indigestion and constipation. Aches in muscles are relieved by vedanasthapana property. Agnivriddi occurs followed by relief in anorexia by pittakara and dipana property. Jyotishmati acts as an anti-depressant due to the property vatakapahaghna. Jyotishmati relieves all the symptoms associated with chittodvega owing to its properties-sarvavyadhiharatva and pathya. Research studies conducted with Jyotishmati have proved its sedative, anti convulsant activity producing fall in blood pressure, decreased hyperactivity, anti-depressive, Chittodvega ===========================================86created by of Dr.KSRPrasad
  • 87. anxiolytic and tranquilizing effects. These properties are effective in decreasing the pulse rate, respiratory rate, systolic and diastolic blood pressures in anxiety. A criterion for this combination is to improve the efficacy and potency of the drug action in Chittodvega. REFERENCES 1. Adarsh Nighantu 2. Medicinal plants of India – by ICMR – Vol – I 3. Pharmacopoeia in Ayurveda – Part - II 4. Medicinal plants by S.G. Joshi 5. Ayurvedic Renaissance (Journal) – April- June 06 6. Indian Materia Medica by A.K. Nadkarni 7. Vasthuguna Deepika. 8. Bhavaprakasha Nighantu 9. Dhanvantari Nighantu 10. Sodhala Nighantu 11. Charaka Sutrasthanam 12. Sushruta sutra sthanam 13. Materia medica of India and their therapeutics by Rustomjee Naserwanjeekhory and Nanabhi Narosji katrak 14. Indigenous drugs of India by Dr. R.N. Chopra. 15. Dravyaguna vijnanaVol – II by Dr. J.L.N. Sastry. 16. Dravyaguna vignan by Dr. Madadi Damodar reddy. 17. Some controversial drugs in Indian medicine by Dr. Bapalal vaidya 18. Indian Medical plants Vol – I by Kirtikar & Basu 19. www. 20. 21. Chittodvega ===========================================87created by of Dr.KSRPrasad
  • 88. CLINICAL STUDY Aim: 1. To study the etiopathogenesis of chittodvega w.s.r. anxiety neurosis on ayurvedic terms. 2. To evaluate the efficacy of Aparajitha churnam and Jyotishmati tailam in the management of chittodvega. Materials and Methods: Conceptual study: All available information about the topic is collected from Ayurvedic and modern texts and other publications. A sincere effort is done to study anxiety neurosis from Ayurvedic point of view. Review on previous studies carried on anxiety neurosis is done. Clinical Study: Thirty patients attending the O.P.D of Government Ayurvedic hospital, Erragadda, are selected by following the DSM – IV criteria for anxiety disorder, with the inclusion and exclusion criteria made for the purpose. Detailed history, physical and mental examinations were done on the basis of research proforma prepared. Criteria for Diagnosis:  DSM IV (Diagnostic and Statistical Manual of mental disorders 4th edition) diagnostic criteria for various anxiety disorders were primarily adopted.  All the symptoms of chittodvega and anxiety neurosis as mentioned in Hamilton scale were taken into consideration.  Pulse, respiration and blood pressure were checked to assess the present condition of the patient.  Routine blood and urine examinations were performed to exclude other pathogenesis. Chittodvega ===========================================88created by of Dr.KSRPrasad
  • 89. Inclusion Criteria: 1. DSM – IV criteria for Anxiety disorders. 2. No discrimination of sex, caste, religion. 3. Age group 16-60 yrs. 4. Patients showing anxiety features as per clinical examination and specific psychometric scales. 5. Patients willing to give consent to participate in the trial Exclusion Criteria: 1. Patients not satisfying the inclusion criteria. 2. Patients having any other major organic disorder. 3. Patients having anxiety with psychotic disorders. 4. Patients under the use of other anti-anxiety drugs. Subject – withdrawl Criteria: 1. Patients who wished to discontinue the treatment during trial period. 2. Patients who lost follow up for two consecutive visits. Ethical Clearance: Confidentiality of the patients in maintained according to ethical code of the APA (1992, 2002). The personal information obtained is communicated only with the person’s consent. Patients who were willing to participate in the trial and signed the consent form were enrolled in the study. Plan of Study: Thirty patients of chittodvega (Anxiety neurosis) were randomly selected and both the treatment drugs were administerd as: Chittodvega ===========================================89created by of Dr.KSRPrasad
  • 90. Drug 1 : Aparajitha mula churnam Dosage: 3gm Anupana: Honey Time of intake: Early morning Drug 2 : Jyotishmati tailam Dosage : 10 drops Anupana : Milk Time of intake: Bed time Duration of treatment : 45 days Counselling: Simple counselling was given to all patients. The nature of disorder was explained and reassurance was given about any fears that symptoms of anxiety are caused by physical disease. The patients were supported to deal with or adjust to any relevant social problems. Criteria for assessment of Results: Thorough clinical assessment was done before and after the treatment by using the Ayurvedic and psychiatric criteria. Ayurvedic assessment: A qualitative assessment was carried out on the basis of the different aspects of Manas, Buddhi, Sajna, Smriti, Bhakti, Sheela, Chesta, Achara and chittodvega symptoms present in the patients as explained in Ayurvedic clasics. The assessment was carried out on a rating scale structured for this purpose. Psychiatric Assessment: was done on the basis of two anxiety rating scales (i) STAI (Y-form): Developed by C.Spielberger, is a 40–item self–report assessment that differentiates between state anxiety, a temporary condition experienced in specific situations and trait anxiety, the general chronic anxiety experienced by some individuals. The STAI has two 20 item scales. The 20 item questionnaire has equal number of Chittodvega ===========================================90created by of Dr.KSRPrasad
  • 91. anxiety present and anxiety absent items. To score the scale, 4 point response scale is used. The response scale could be assigned a numerical score. For State anxiety: Not at all = 1; some what = 2; moderately so = 3; very much so = 4; For Trait anxiety: Almost never = 1; sometimes = 2 often = 3; almost always = 4 . Combined scores from each scale can vary from a minimum of 20 to a maximum of 80. (ii) HAM – A: developed by M. Hamilton, is the most widely utilized assessment scale for anxiety symptoms, and was originally intended to be used to evaluate individuals who are already diagnosed with anxiety disorder. The HAM-A consists of 14 items and is heavily focused on somatic symptoms, with a great reliance, on the patient’s subjective report. Each item is rated on a 0 to 4 scale (0 = not present, 1= mild, 2=moderate, 3= server, 4= very severe) with a final item which rates behavior at interview. The scale is designed to evaluate anxiety symptoms at baseline and in response to treatment. Also, the vital data of all the patients (Pulse rate, Blood pressure, temperature, and respiration rate) were observed during each visit. . Research proforma: A detailed clinical record form was prepared for the purpose, by incorporating all aspects from ayurvedic and modern parlance. Follow – up: After the completion of the treatment, follow up was done for one month. The aim of the follow – up during this period, was to observe whether the changes of intervention are maintaining or not, at least for a period of one month. Overall Effect of Therapy: Overall effect of the therapy was assessed in by adopting the following criteria. 1. Very good improvement – 50-100% of relief in signs and symptoms of anxiety. 2. Good improvement – 25-50% of relief in signs and symptoms of anxiety. 3. Some improvement -less than 25% relief in signs and symptoms of anxiety. The outcome of the intervention was statistically analyzed. Chittodvega ===========================================91created by of Dr.KSRPrasad
  • 92. OBSERVATIONS Table – 1: Age wise distribution of 30 patients of Chittodvega: Age Interval Total % 16 – 26 5 16.67 27 – 36 12 40.00 37 – 46 10 33.33 47 – 56 3 10.00 Table-1 shows that distribution of 30 patients of this series according to the age groups shows that maximum i.e. 40% of patients were between 27-36 years age, 33.33% patients were in 37 – 46 years of age, 16.67% were in 16 – 26 years of age and 10% were in 47 – 56 years of age. Chart 1 Chart 2 Table – 2: Sex wise distribution of 30 patients of Chittodvega: Sex Total % Male 9 30 Female 21 70 Table-2 shows that maximum i.e. 70% of the patients were female and minimum i.e. 30% of the patients were male. Chittodvega ===========================================92created by of Dr.KSRPrasad
  • 93. Table – 3: Religion wise distribution of 30 patients of Chittodvega : Religion Total % Hindu 24 80 Muslim 5 16.67 Christian 1 3.33 Table – 3 shows that maximum i.e. 80% patients were Hindus, 16.67% were Muslims and minimum i.e. 3.33% were Christians. Chart 3 Chart 4 Table – 4: Education wise distribution of 30 patients of Chittodvega: Education Total % Uneducated 8 26.67 Primary 6 20 Secondary 7 23.33 Higher Secondary 2 6.67 Graduate 5 16.67 Post Graduate 2 6.67 Table – 4 shows that maximum i.e. 26.67% patients were uneducated, 23.33% patients were having secondary level education, 20% were having primary level education, Chittodvega ===========================================93created by of Dr.KSRPrasad
  • 94. 16.67% were having graduation, 6.67% patients were having higher secondary level education and post graduation. Table 5: Occupation wise distribution of 30 patients of Chittodvega: Occupation Total % Service 5 16.67% Business 1 3.33 House wife 11 36.67 Labour 12 40 Student 1 3.33 Table – 5 shows that maximum 40% of the patients were labours, 36.67% patients were housewives, 16.67% were in service, 3.33% were in business and student category. Chart 5 Chart 6 Table 6: Marital status wise distribution of 30 patients of Chittodvega Marital Status Total % Married 23 76.67 Unmarried 5 16.67 Widow 2 6.67 Chittodvega ===========================================94created by of Dr.KSRPrasad
  • 95. Table – 6 shows that maximum i.e. 76.67% of the patients were married, 16.67% were unmarried and 6.67% were widowed. Table 7: Socio – Economic status of 30 patients of Chittodvega: Socio Economic Total % Status Middle 12 40 Lower 18 60 Table-7 shows that in this series maximum i.e. 60% of the patients belonged to lower socio economic status, while 40% were from middle class. Chart 7 Chart 8 Table 8: Habitat wise distribution of 30 patients of Chittodvega: Habitat Total % Urban 18 60 Rural 12 40 Table-8 shows that maximum i.e. 60% of patients of the study belonged to urban habitat and minimum i.e. 40% patients belonged to rural population. Chittodvega ===========================================95created by of Dr.KSRPrasad
  • 96. Table 9: Chief complaint (psychic) reported by 30 patients of Chittodvega: Chief Complaint (Psychic) Total % Anxiety 30 100 Irritability 15 50 Inability to relax 20 66.67 Lack of concentration 7 23.33 Loss of interest 10 33.33 Disturbed sleep 20 66.67 Forgetfulness 12 40 Depression 7 23.33 Fear 12 40 Table 9 shows that maximum i.e. 100% patients reported of anxiety 66.67% patients each reported of inability to relax and disturbed sleep,50% patients reported irritability, 40% patients each reported of forgetfulness and fear, 33.33% patients reported of loss of interest, 23.33% patients reported each of lack of concentration and depression. Chart 9 Chart 9 Chittodvega ===========================================96created by of Dr.KSRPrasad
  • 97. Table 10: Chief complaint (somatic) reported by 30 patients of Chittodvega: Chief complaint (somatic) Total % Palpitation 9 30.00 Breathlessness 2 6.67 Chest pain / discomfort 5 16.67 Giddiness 5 16.67 Tremor 3 10.00 Headache 7 23.33 Muscular aches 10 33.33 Tingling extremity 8 26.67 Sweating (Excessive) 5 16.67 Dry mouth 12 40.00 Exhaustion 13 43.44 Table – 10 shows that maximum number i.e. 43.33% patients complain of easy fatiguability, 40% as dry mouth, 33.33% complain of muscular aches, 30% complain of palpitations, 26.67% of patients with tingling extremities, 23.33% of patients with headache, 16.67% patients each of sweating,giddiness,discomfort of chest, 10% complain of tremor, 6.67% complain of breathlessness as chief somatic complaints. Chittodvega ===========================================97created by of Dr.KSRPrasad
  • 98. Chittodvega ===========================================98created by of Dr.KSRPrasad
  • 99. Table 11: Chronicity of illness wise distribution of 30 patients of Chittodvega: Duration (years) Total % Upto 1 year 4 13.33 1-5 18 60.00 6-10 3 10.00 11-15 3 10.00 16-20 2 6.67 Table -11 shows that maximum i.e. 60% patients were having 1-5 years of chronicity, 13.33% patients were having upto1 year chroncity, 10% of patients each were having 6- 10 & 11-15 years of chronicity and 6.67% patients were having 16-20 years of chronicity. Table 12: Family Disturbance Reported by 30 patients of Chittodvega: Family Disturbance Total % Present 16 53.33 Absent 14 46.67 Table-12 shows that maximum i.e.53.33% of the patients were having some or other disturbance in their family and remaining having no disturbance in their family. Table 13 Marital life reported by 23 patients of Chittodvega: Marital Life Total % Satisfactory 16 69.57 Unsatisfactory 7 30.43 Table – 13 shows that maximum i.e.69.57% patients were having a satisfactory marital life and remaining i.e 30.43% patients were having an unsatisfactory marital life. Chittodvega ==========================================98created by of Dr.KSRPrasad
  • 100. Table: 14 Past History of Physical illness reported by 30 patients of Chittodvega: Physical illness Total % Reported in Patients 5 16.67 Table – 14 shows that 16.67% patients reported of having past history of physical illness. Table 15: Past history of psychiatric illness reported by 30 patients of Chittodvega: Past Psychiatric Total % History Reported in 14 46.67 Table-15 shows that 46.67% patients were having past history of psychiatric illness of anxiety for which allopathic medication was taken. Table 16: Predominant diet reported by 30 patients of Chittodvega : Predominant Diet Total % Vegetarian 6 20 Non – Vegetarian 24 80 Table-16 shows that maximum i.e. 80% of the patients were predominantly non – vegetarian and 20% were vegetarians. Table 17: Addictions Reported by 30 patients of chittodvega : Addictions Total % Tea / Coffee 15 83.33 Alcohol 4 13.33 Cigarette 3 10 Betel nut / Tobacco 2 6.67 Chittodvega ==========================================99created by of Dr.KSRPrasad
  • 101. Table-17 shows that in this series maximum i.e. 83.33% patients were addicted to tea or coffee 13.33% were addicted to alcohol intake, 10% were addicted to cigarette smoking, and 6.67% were addicted to betel nut & tobacco intake. Table – 18: precipitating factors reported by 30 patients of Chittodvega: Precipitating factor Total % Catastrophes 4 13.33 Socio – economic crisis 9 30.00 Family-centered tensions 5 16.67 Business/service tension 4 13.33 Table-18 shows that maximum i.e. 30% patient reported financial problems, 16.67% patients reported family centered tensions, 13.33% patients reported catastrophes and occupation centered tensions as the major precipitating factors. Table -19: Sleep pattern Reported by patients of Chittodvega: Sleep pattern Total % Normal 3 10.00 Difficulty failing asleep 13 43.33 Disturbed sleep 10 33.33 Early morning awakening 1 3.33 No clear pattern of disturbance 3 10.00 Table – 19 shows that maximum i.e. 43.33% patients were having difficulty in falling asleep, 33.33% were having disturbed sleep, 10% were have normal sleep and no clear pattern of disturbance, 3.33% were reported of early morning awakening. Chittodvega ==========================================100created by of Dr.KSRPrasad
  • 102. Table – 20: Appetite reported 30 patients of Chittodvega: Appetite Total % Normal 13 43.33 Decreased 16 53.33 Increased 1 3.33 Table – 20 shows that maximum i.e. 53.33% patients were having decreased appetite, 43.33% were having normal appetite, 3.33% patients were having increased appetite. Table – 21 Bowel habit reported by 30 patients of Chittodvega: Bowel habit Total % Normal 14 46.67 Constipation 16 53.33 Table-21 shows that maximum i.e. 53.33% patients were having constipation, 46.67% patients were having normal bowel habits and none of the patients reported of loose motions. Table – 22: Micturition habit reported by 30 patients of Chittodvega : Micturition habit Total % Normal 21 70.00 Increased frequency 8 26.67 Excursive and urgency 1 3.33 Table 22 shows that maximum patients i.e. 70% were having normal micturition habit, 26.67% patients were having excessive micturition. Excessive and urgency of micturition was found in 3.33% patients. Chittodvega ==========================================101created by of Dr.KSRPrasad
  • 103. Table – 23: Shariraprakriti of 30 patients of Chittodvega: Prakriti (Sarira) Total % Vata – pitta 12 40.00 Pitta – kapha 8 26.67 Kapha – vata 10 33.33 Table – 23 shows that maximum i.e. 40% of patients of the study belong to vata-pitta prakriti, 23.33% were of kapha – vata prakriti, 26.67% were of pitta-kapha prakriti. Table – 24: Manasa Prakriti of 30 patients of Chittodvega: Prakriti (Manasa) Total % Rajas 20 66.67 Tamas 10 33.33 Table-24 shows that maximum i.e. 66.67% were of Rajasika Prakriti and remaining 33.33% were of Tamasika Prakriti. Table 25: Sara wise distribution in 30 patients of Chittodvega: Saratah Total % Rasa/Twak 8 26.67 Rakta 6 20.00 Mamsa 8 26.67 Medo 3 10.00 Asthi 5 16.67 Table 25 shows that maximum i.e. 26.67% patients were of Rasa and Mamsa sara, 20% were of Rakta sara, 16.67 % were of Asthi sara, 10% were of Medo sara. Chittodvega ==========================================102created by of Dr.KSRPrasad
  • 104. Table 26: Sattva wese distribution of 30 patients of Chittodvega: Sattva Total % Pravara - - Madhyama 12 40.00 Avara 18 60.00 Table-26 shows that out of 30 patients of chittodvega 60% patients were of avara sattva and remaining 40% were of madhyama sattva and none of patients were having pravara sattva. Chittodvega ==========================================103created by of Dr.KSRPrasad
  • 105. RESULTS Outcomes of the intervention were assessed by using, signs and symptoms score, Hamilton Anxiety rating scale, State anxiety and Trait anxiety scales. Mean scores before and after the treatment were noted and relief in percentage was calculated. For analyzing the data within the group, paired students t-test was used. The details of which are given below: Table 27: Effect of treatment on psychic complaints of chittodvega : Psychi Symptoms Mean Score Std. Dev. % S.E. T- value P- BT AT BT AT Relief Value Anxiety 3.57 1.67 0.57 0.76 53.27 0.24 7.767 <0.001 Worrying thoughts 3.47 1.57 0.68 0.77 54.81 0.27 7.137 <0.001 Fear complex 2.43 1.37 1.41 1.03 43.84 0.45 2.367 <0.05 Restlessness 3.03 1.27 0.85 0.91 58.24 0.32 5.503 <0.001 Sensitivity to noise 2.23 0.80 1.30 0.76 64.18 0.39 3.675 <0.001 Depression 2.37 1.13 1.52 0.97 52.11 0.47 2.647 <0.05 Effect of Aparajitha & Jyotishmati on psychic symptoms: Table 27 exhibits that before starting the treatment mean gradation of anxiety was 3.57 and after the treatment it reduced to 1.67. This reduction of 53.27% was statistically significant (<0.001). The initial mean of worrying thoughts in this group was 3.47 and after treatment it reduced to 1.57. This 54.81% relief was statistically significant (<0.001). It was observed that before the treatment the mean of fear complex was 2.43 and after the completion of the treatment mean was 1.37. This 43.84% relief was statistically significant (<0.05). Chittodvega ==========================================104created by of Dr.KSRPrasad
  • 106. The mean score of restlessness observed before the treatment was 3.03 and after the completion of the treatment mean was 1.27. This 58.24% relief was statistically significant (<0.001). In present study, it was found that the initial mean of sensitivity to noise was 2.23 which decreased to 0.80. This 64.18% relief was statistically significant (<0.001). Before treatment mean scoring of depression was 2.37 and after treatment it was reduced to 1.13. This reduction of 52.11% was statistically significant (<0.05). Table – 28: Effect of treatment on somatic complaints of chittodvega: Somatic Complaint Mean Score Std. Dev. % S.E. T Value P. Value BT AT BT AT Relief Dizziness 2.10 0.83 1.49 0.79 60.32 0.44 2.902 <0.05 Tremors 1.23 0.53 1.36 0.73 56.76 0.40 1.760 <0.05 Prickling Pain 2.97 1.10 1.30 0.80 62.92 0.39 4.733 <0.001 Anorexia 2.87 0.60 1.50 0.72 79.07 0.43 5.264 <0.001 Indigestion 1.73 0.40 1.39 0.62 76.92 0.39 3.396 <0.05 Constipation 1.73 0.20 1.31 0.41 88.46 0.35 4.325 <0.001 Exhaustion 3.17 1.07 0.87 0.87 66.32 0.32 6.600 <0.001 Muscular aches 3.03 1.17 1.13 0.83 61.54 0.36 5.151 <0.001 Loss of sleep 3.47 0.90 1.07 0.88 74.04 0.36 7.143 <0.001 Dryness of mouth 1.27 0.47 1.17 0.68 63.16 0.35 2.285 <0.05 Flatulence 0.83 0.23 1.02 0.50 72.00 0.29 2.043 <0.05 Palpitations 2.63 1.03 1.10 0.61 60.76 0.32 4.924 <0.001 Over breathing 1.67 0.77 1.40 0.73 54.00 0.41 2.212 <0.05 Discomfort in chest 1.67 0.83 1.58 0.87 50.00 0.47 1.785 <0.05 Chittodvega ==========================================105created by of Dr.KSRPrasad
  • 107. Effect of aparajitha churnam and jyotishmati tailam on somatic symptoms of chittodvega: Table-28 showed that the initial mean of dizziness was 2.10 and after the completion of treatment it decreased to 0.83. This 60.32% relief was statistically significant (<0.05) The initial mean score of Tremors was 1.23 and after the treatment it reduced to 0.53. This reduction of 56.76% was statistically signification. (<0.05) It was found that the mean score of prickling pain before the administration of medication was 2.97, which decreased to 1.10. This reduction of 62.92% was statistically significant. (<0.001) In the present study it was seen that initial mean score of anorexia was 2.87 and after the treatment it was 0.60. This reduction 79.07% was statistically significant. (<0.001) It was observed that the mean score of indigestion before treatment was 1.73 and after the completion of the course it reduced to 0.40. This reduction of 76.92% was statistically significant (<0.05) The mean gradation of constipation before treatment was 1.73 and after the course it was 0.20. This reduction of 88.46% was statistically significant (<0.001) It was seen that the initial mean score of exhaustion was 3.17, which reduced to 1.07. This 66.32% relief was statistically significant (<0.001) The present study denoted that the mean score of muscular aches before treatment was 3.03 and after the completion of the treatment it was 1.17. This 61.54% relief was statistically significant (<0.001) Chittodvega ==========================================106created by of Dr.KSRPrasad
  • 108. The mean score of loss of sleep was 3.47 before treatment, which reduced to 0.90. This 74.04% relief was statistically significant (<0.001). It was seen that the initial mean score of dryness of mouth was 1.27, which reduced to 0.47. This 63.16% was statistically signification (<0.05). The mean gradation of flatulence before treatment was 0.83 and after the course it was 0.23. This reduction of 72% was statistically significant (<0.05) It was found that the mean score of palpitation before treatment was 2.63 and after the completion of the treatment, it decreased to 1.03. This 60.76% relief was statistically significant (<0.001). It was seen hat the initial mean of over breathing was 1.67 and after the completion of treatment it decreased to 0.77. This 54% relief was statistically significant (<0.05) The initial mean score of discomfort in chest was 1.67 and after the completion of treatment was 0.83.This 50% relief was statistically significant (<0.05). Table - 29: Effect of treatment on Hamitton scale: Scale Mean Score Std. Dev. % S.E. T value P. Value Relief BT AT BT AT HAM A 30.57 21.77 7.10 7.48 28.79 2.66 3.304 <0.05 The table –29exhibits that before treatment the mean scoring on Hamilton scale was 30.57 and after completion of course it reduced to 21.77. This reduction of 28.79% was statistically significant (<0.05). Chittodvega ==========================================107created by of Dr.KSRPrasad
  • 109. Table – 30: Effect of treatment on STAI in patients of chittodvega: Scales Mean Score Std. Dev. % Relief S.E. T value P. Value BT AT BT AT State Anxiety 51.90 43.87 13.45 14.07 15.48 5.03 1.599 >0.05 Trait Anxiety 52.37 45.23 15.17 14.60 13.62 5.44 1.312 >0.05 Table –30 detects the initial mean for state Anxiety was 51.90 and after treatment it reduced to 43.87. This 15.48% decrease in State Anxiety was not statistically significant (>0.05). It was seen that before treatment mean of Trait anxiety scale was 52.37 which reduced up to 45.23 after treatment. This reduction of 13.62% was not statistically significant (>0.05). Table-31 Effect of the Treatment on the Vital Data : Vital data Mean Score % S.D. S.E. T. P. Relief Value Value BT AT Pulse (m/n) 74.62 66.00 11.55 2.50 0.89 9.74 <0.001 Respiration (min) 20.25 16.63 17.00 3.16 1.12 3.25 <0.05 Systolic B.P. (mm-Hg) 132.50 118.25 10.75 10.39 3.67 32.19 <0.001 Diastolic BP (mm-hg) 83.25 78.50 05.70 4.40 1.56 3.05 <0.05 The table denotes that the initial mean of pulse rate in this group was 74.62/minute and after the administration of the drug it reduced up to 66.00/min. This 11.55% of reduction in pulse rate was statistically significant (<0.001). The mean of respiration rate before treatment was 20.25/min and after treatment it was 16.63/min. This reduction of 17.00% in respiration rate was statistically significant (<0.05). It was observed that initial mean of systolic blood pressure was 132.50 mm-hg which reduced to 118.25 mm-hg. This 10.75% of reduction in systolic pressure was statistically significant (<0.001). The mean Chittodvega ==========================================108created by of Dr.KSRPrasad
  • 110. of diastolic blood pressure before treatment was 83.25mm-hg which reduced to 78.50 mm-hg. This 5.70% reduction was statistically significant (<0.001). Table – 32: Overall effect of treatment in 30 patients of Chittodvega: Overall Effect Total no of Patients % Very Good Improvement 9 30 Good Improvement 11 36.66 Some Improvement 10 33.33 Overall Effect of Therapy: Table – 32 shows that out of 30 patients, 9 patients showed very good improvement (30%), 11 patients had good improvement (36.66%) and 10 patients reported of some amount of improvement (33.33%). Chittodvega ==========================================109created by of Dr.KSRPrasad
  • 111. DISCUSSION As per the World Health Organisation’s prediction, at 2020 anxiety disorders and depressive disorders will be the top in the rank order of disease burden for 18 leading countries. With the advancement in modern science, human life has become very speedy and stressful.So psychiatric disorders are broadening its sphere today, out of which anxiety disorders are most common wide spread psychiatric diseases affecting mankind all over the world and in all ethnic groups. With this view present study was undertaken to explain the description of anxiety neurosis in ayurvedic parlance and then to formulate proper management of the disease. The roots of concept of manas and mental disorders can be traced out in history. Different opinions regarding the the seat of manas has been described by various samhitas such as, an indefinite, hridaya, sirah, sarvasarira, ojas and twak etc. But, most Acharyas believe that, hridaya is the actual seat of manas, while sarvasharira is its transportation channel. The physiology of manas can be divided into three stages based on reference of Ca.Sa.1/22-23 are as follows: 1. Perception (cognitive or sensory) 2. Discussion and determination 3. Stimulation or intiation (conation or motor reflex) Chittodvega, a manasavikara described by Charaka (Ca.Vi.6/5) has been considered as a perfect word for highlighting the status of anxiety.The etymology of chittodvega clearly indicates the anxious state of mind. Ayurvedic literature has described chittodvega and its influences on body while describing other diseases. Chittodvega ==========================================110created by of Dr.KSRPrasad
  • 112. On the basis of these considerations it can be postulated that chittodvega is a minor mental disorder. In modern parlance also, the neurotic disorders, which include anxiety disorders are considered as minor mental disorders in comparision to major mental entities like schizophrenia etc. Raja and tama are the main causative manasika doshas of chittodvega. Prana, udana, vyanavayu, sadhakapitta, and tarpaka kapha are the saririka doshas involved in the causation of chittodvega.The samprapti of chittodvega involves vitiation of hridaya by doshas, sarvadhatu dushti and sroto dushti, agnidushti and ojokshaya. General principles of management of manasaroga gives an idea about the chikitsa of chittodvega.Carakacharya has especially mentioned about medhya rasayana in the management of manasaroga. By keeping all these in view, an attempt was made to study the effect of Aparajitha churnam and Jyotishmati tailam in chittodvega w.s.r. to anxiety neurosis. Thirty patients of chittodvega were administered treatment. The demographic data of all the patients of chittodvega was studied, the details of which were as follows: Age: The results of the study showed that this disease may occur in any age group but maximumi.e. 40% patients of the study were in 27-36 years of age group.The reason may be that this period of age is more stressful due to struggles for establishment in occupational and social area. Sex: Maximum i.e.70% patients of the study were female. Prevelance rates of neurotic disorders are higher in women than in men as per the modern texts. This may be because of more responsibilities for fulfilling family needs. Religion: Present study denoted that maximum i.e.80% patients belonged to hindu community. Culture specific variations of anxiety disorders have been shown in surveys of neurotic Chittodvega ==========================================111created by of Dr.KSRPrasad
  • 113. disorders in different countries.But, no relevance has been available for the higher rate of incidence of anxiety in hindu community in this study. Education: The study exhibited that maximum i.e 26.67% patients were uneducated.The reason behind this observation may be due to their non-adjustment with today`s educated and fast growing society. Occupation: Maximum i.e. 40%of the patients were labour workers and 36.67% were housewives. Job instability of these labour workers and family stressors of the house wives may be the reason for their presentation with chittodvega. Marital status: The results showed that maximum i.e.76.67% of patients presenting with chittodvega were married.The reason for this may be due to the increased family responsibilities after marriage predisposing the person to a more stressful condition leading to anxiety. Socio-economic status: In modern texts higher rates of neurotic disorders are linked with social disadvantage such as lower social class and living in poor housing environment.The present study also indicated the same as maximum i.e.60% of patients belonged to lower-socio economic status. It is commonly supposed that poor living conditions can predispose to mental disorders either directly or through their effects on family life.Increasing economical needs of the poor families in fast growing society may be the reason predisposing to anxiety neurosis. Habitat: The study denoted that maximum i.e. 60% patients were living in urban area. The mechanical and speedy life had major impact on all aspects of their life precipitating anxiety. Family disturbance: Maximum i.e. 53.33% patients of the study reported some disturbance in their family. This is the key-factor in manifestation of anxiety. Family disturbance produces a lot of Chittodvega ==========================================112created by of Dr.KSRPrasad
  • 114. stress affecting the personal, social and occupational life of the individual which further aggrevates anxiety. Marital life: The study showed that 30.43% patients were having problems with LIfe partner. It is an equally important factor in anxiety because an unsatisfactory marital life can produce various types of mental distressess. Chief complaint: All the patients of the study were having the fundamental complaint of anxiety. Other presenting complaints of patients were disturbed sleep (66.67%), inability to relax (66.67%), irritability (50%), forgetfulness (40%), fear (40%), lack of concentration (23.33%), and depression (23.33%). These symptoms may be attributed to the stressful lives of the patients. Majority of patients were having different somatic symptoms, as autonomic symptoms accompany the anxiety neurosis. So majority of patients i.e. 43.33 % complained of exhaustion even without doing any work, 40% were having muscular aches , 30% complained of palpitations, 26.67% patients reported of tingling in extremities, 23.33% patients were having tension headache, 16.67 % of patients were having complaints like chest pain or discomfort, giddiness, excessive sweating , 10% of patients had tremors. Only 6.67% patients had complaint of breathlessness. The patients suffering from palpitations, sweating, breathlessness may be due to the hyperactivity of autonomic nervous system. The symptoms like restlessness, headache, and muscular aches may be due to motor tension. Exhaustion is a common feature of generalized anxiety anxiety. Chronicity: The results of this study showed 60% of patients were having the chronicity of 1-5 years. In the remaining, 13.33% were having chronicity of less than 1 year, 10% were having chronicty between 6-15years, and only 6.67%were having 16-20 years of chronicity. It may be due to the fact that after taking some allopathic medication and finding an unsatisfactory relief, the patient comes to Ayurvedic treatment. By that time the disease Chittodvega ==========================================113created by of Dr.KSRPrasad
  • 115. attains the state of chronicity. And many patients are not able to report exact onset of complaints. Stressors: Clinical observations indicate that, anxiety neurosis often begin in relation to stressful events and become chronic when it persists. Here, in the present study many patients reported of some or the other precipitating factor involved in their intiation or progress of the disease. And the most commonly stated stressor was socio economic crisis (financial problems) reported in 30% of patients. And another major stressor was mal-relationships i.e. the family centered stressors reported in 16.67% of patients. As these are the important aspects of life, stress from these factors play a key role in causation of anxiety. Past illness: In the present study, 16.67% patients were having a positive history of physical illness. The somatic complaints presented were attributed to these illnesses by the patients. Many of the patients’ i.e.46.67% in the study reported of past history of anxiety disorders and they had taken the allopathic medication for some time the remission of symptoms after the drug withdrawl had prompted them to take the ayurvedic medication for complete and permanent cure. Diet: Majority of patients in the study were predominantly non-vegetarians i.e.80%. The dietary habits of the patients observed supports the statement of Acarya`s in the role of non vegetatian diet, which is rajasika in nature, in the manifestation of manasa vikara. Addictions: The study noted that 83.33% patients were addicted to tea/coffee. No relation has been identified between the addiction and the anxiety.13.33% patients reported of alcohol intake, 10% of cigerette smoking, and 6.67% of tobacco chewing. It has been observed that the patients initially resorted to these for the sublimation of anxious feeling, but later it lead to addiction causing more tolerance and anxiety in turn. Insight: Insight may be defined as awereness of one’s own medical condition. It is generally true that neurotic patients retain insight. Here, in this study also all the patients were retaining Chittodvega ==========================================114created by of Dr.KSRPrasad
  • 116. their insight into illness. All the patients reported to treatment on thier own will and mostly without any informat or relative. Sleep pattern: Only 10% of patients reported of normal sleep pattern. The remaining were having some or other disturbance in the sleep pattern of which the most commonly reported was difficulty in falling asleep in 43.33% of patients. 33.33% patients were having disturbed sleep, 10% could not explain the clear pattern of disturbance and 3.33% had early morning awakening. It indicates the importance of sleep stated in Ayurveda as the cause of sukha or dukha, gyana or agyana. So the sleep pattern has major role to play in chittodvega Person afflicted with anxiety due to stress gets the sleep affected, disturbing its normalcy which further predisposes the person for more anxiety and the vicious circle continues. Appetite: Maximum i.e. 53.33% patients of the study reported of decreased appetite This may be due to the minds’ preoccupation in stressful events and lack of interest in routine activities of the individual due to anxiety. Bowel habit: The study showed that maximum i.e. 53.33% patients were having constipation. This study supports the statement of Acharya Charaka in the udavarta context. (Ca. Ci 26/9) that constipation is an important factor in precipitating various mental disorders. Micturition: The study showed that 26.67% patients have reported of having excessive frequency of micturition (with no organic cause). This may be due to stimulation of Autonomic nervous system. Prakriti: Manasika: Maximum i.e. 66.67% patients in the study were belonging to rajasika prakriti. This may be due to the chalaguna of rajas causes udvega of manas predisposing the individual to anxiety. Saririka: Maximum i.e. 40% patients of the study were having vata- pittaja prakriti and next to it were vata-kaphaja prakriti persons of 33.33% incidence.Vata is the main dosha Chittodvega ==========================================115created by of Dr.KSRPrasad
  • 117. involved in vitiating the other two doshas. Vata and pitta are the two doshas involved in the causation of manovikaras, so vata pittaja prakriti persons are observed to be more prone to chittodvega. Sara: The results of study showed that maximum patients were of rasasara (26.67%) and mamsasara (26.67%). Sattva: Present study exhibited that 60% patients were of avara sattva. This study supports the statements in Ayurvedic scriptures that avara sattva persons are more prone to mental disorders. Effect of therapy: The treatment showed statistically significant percent of relief in psychic as well as somatic symptoms of chittodvega. The primary symptom of anxiety showed statistically significant i.e 53.27% of relief. Psychological symptoms like worrying thoughts, fear complex, restlessness and sensitivity to noise also showed significant relief. The deranged prajna responsible for these symptoms is corrected by effect of medhya, buddhi and smritikara properties of Aparajitha and Jyotishmati. Symptoms related to Gastro intestinal tract like indigestion, anorexia, constipation, and flatulence showed good response to treatment by major relief in percentage. Respiratory symptoms i.e. over breathing and discomfort in chest also showed significant relief. Symptoms of nervous system affliction ie.dizziness, tremors, prickling pain were showing good relief. Loss of sleep, muscular aches, and exhaustion showed good relief in percentage. Symptoms related to cardiovascular system like palpitatipns also showed good relief. Depression is relieved by 52.11% as both the drugs of the trial were effective in relieving depression along with anxiety. The vital signs like pulse, respiratory rate and blood pressure (systolic and diastolic) also showed significant relief after treatment. Chittodvega ==========================================116created by of Dr.KSRPrasad
  • 118. The results showed significant relief on Hamilton anxiety rating scale.Though there was decrease in scores on State anxiety and Trait anxiety scales the relief was not statistically significant. As the duration of therapy was short scoring might not have given statistically significant results. All the thirty patients administered with the drugs have shown improvement. The result of the present study showed that both Aparajitha and Jyotishmati relieve anxiety and the symptoms associated with it. Statistically significant relief in percentages of the symptoms are observed in the study. In the follow up patients have shown consistancy in the relief of the sympyoms. Hence the drugs used in the trial have shown long term effects on symptoms of chittodvega (anxiety neurosis). Chittodvega ==========================================117created by of Dr.KSRPrasad
  • 119. CONCLUSION The conclusions derived from the study are as follows:  Anxiety is described as a diffuse, unpleasant, vague sense of apprehension, with or without associated autonomic symptoms. Pathological anxiety is characterized by exaggerated response to stress or anxiety in absence of stress.  Chittodvega, stated as manovikara by Charaka, is a minor mental disorder occurring in alpasattva persons due to deranged manodoshas (raja and tamo).  Tridoshas, sarvadhatus, ojus and sarvasarira srotas are involved in the manifestation of chittodvega.  Hridaya is the udbhavasthanas of Chittodvega.  Treatment is mainly through correction of the deranged pragna by medhya drugs and sattvavajaya chikitsa. Sadvritta, acara rasayana are indicated in the preventive aspect of Chittodvega.  Etymology of chittodvega i.e. anxious status of mind is similar to anxiety neurosis. Psychological and somatic manifestations are also similar in both the conditions.  A study was conducted in 30 patients of chittodvega. The demographic data in these patients showed that maximum patients were females of age group 27-36 years.  Uneducated, labour workers belonging to lower socioeconomic status, with unsatisfied marital life showed prevalence of anxiety neurosis.  People belonging to urban habitat with past history of physical illness associated with some sort of family disturbance have shown more predisposure to chittodvega.  Patients of past psychiatric history of chronicity (maximum with 1-5yrs i.e. 60%) have attended the OPD with unsatisfied allopathic treatment.  Socio-economic crisis has been stated by the patients as the major stressor precipitating anxiety. Chittodvega ==========================================118created by of Dr.KSRPrasad
  • 120.  Majority of patients were non-vegetarians.  Insight is retained in all the thirty patients.  90% of patients had some or other disturbance in sleeping pattern.  The presenting complaints were anxiety (100%), restlessness (66.67%), irritability (50%), forgetfulness (40%), fear (40%), depression (23.33%), and lack of concentration (23.33%).  Somatic presentation includes exhaustion (43.33%), dryness of mouth (40%), muscular aches (33.33%), palpitations (30%), tingling in extremities (26.67%), tension headache (23.33%), giddiness, discomfort in chest, excessive sweating (16.67%), tremors (10%), overbreathing (6.67%).  The clinical study done with random selection of patients into two groups has shown viability for statistical data.  Consequent to the references available, in Ayurvedic classics about the Medhya property of Aparajitha and Jyotishmati, both the drugs have shown significant anti-anxiety effects.  Highly significant results were observed in patients of chittodvega, with oral administration of Aparajitha mula churnam and Jyotishmati bija tailam. Limitations of the study: 1. Sample size in the study was small. 2. Duration of drug intervention was only for 45 days. 3. Patients attending the OPD of Govt. ayurvedic hospital were only taken for study and the majority belonged to lower and middle socioeconomic status. 4. Only simple counselling explaining the nature of disease was given to the patients. 5. The rating scales used in the study are self-rated and observer rated, so there is a chance of errors in scoring. Chittodvega ==========================================119created by of Dr.KSRPrasad
  • 121. Recommendations for further study: 1. The sample size should be increased to get more valid statistical results. 2. Longer duration of drug intervention is needed to get a better relief percentage. 3. STAI (State Trait Anxiety Inventory) incorporated in the trial needs further study on presenting in a viable statistical data. 4. Trial drug administered along with psychotherapeutic techniques(sattvavajaya, achara rasayana) indicated in Ayurvedic literature might have given better results. 5. The drugs used in trial can be studied for their effect in other psychiatric disorders. 6. The symptomatic relief brought about by the drugs need to be studied in terms of the modern anatomical and functional bodily changes. Chittodvega ==========================================120created by of Dr.KSRPrasad
  • 122. SUMMARY The present study entitled `A clinical study on the efficacy of Aparajita churnam and Jyotishmati tailam in chittodvega with special reference to anxiety neurosis’ has been carried out with the following objectives:  To conduct a clinical study on chittodvega to understand it better in comparision with anxiety neurosis and to derive some possible correlations.  To assess the efficacy of trial drug in the management of chittodvega and its associated symptomatology. Chittodvega is described as a manasaika vikara by Charaka.Derangement of manodosha is stated to be responsible for its genesis. Todays’ fastmoving, unsteady, hard and ever changing lifestyle is causing a lot of stress to people. So, anxiety disorders are becoming the most prevelant disorders in the general community and are present in 15-20 percent of all medical clinic patients. In conceptual study, historical review of manas and anxiety disorders, along with the concept of manas are described. Chittodvega, one among the manovikaras is studiet in detail with its etiopathogenesis. Anxiety neurosis in Modern parlance is described with its etiology, pathology and treatment. In Ayurvedic management of Chittodvega, Medhya drugs are having an important role. Keeping these views in mind, it was decided to use this concept in the clinical trial. So, a clinical study was carried out on chittodvega (anxiety neurosis) on patients, by adopting a randomised single blind open trial. The demographic data and the results of the clinical trial are described in the clinical study. Meticulous discussion about demographic data and the effect of therapy was carried out with the help of available textual references. Considering the conceptual study and the observations in the clinical trial, an attempt was made to trace out the conclusions of the study. Chittodvega ==========================================121created by of Dr.KSRPrasad
  • 123. ACKNOWLEDGEMENT My salutations to Lord Vighneshwara, Goddess Gayatri and Bhagavan Dhanvantari. I bow down to my parents Sri. V.S.R. Sarma and Smt.Nirmala whose love, support and encouragement were the initiating sources which directed me towards progress and success in each and every step of my life. With immense gratitude, I acknowledge the wonderful guidance bestowed on me by honorable Dr.Prakash Chandar, M.D (Ayu), Professor and Head of the Deparmtment of Kayachikitsa, for guiding me throughout my work. I convey my gratitude to the honorable Principal Dr. M. Sadasiva Rao, honorable ex- Superintendent Dr.L.Radha Krishna murthy and present Superintendent Dr.V.L.N.Shastry, Government Ayurvedic Hospital, Erragadda, for providing necessary facilities for the study. With heartful gratitude, I acknowledge the invaluable guidance bestowed on me by honorable Dr. V. Vijaya Babu, M.D.(Ayu), Reader, Post Graduate Department of Kayachikita. The continuous support of his multidimensional wisdom gave a true sense to this work. I am very much indebted to and express my gratitude to Dr. M. Srinivasulu, M.D. (Ayu) professor, A.L GAC, warangal, for the thought provocating discussions, suggestions and support during my thesis. I am very much thankful to Dr.P.Nageshwara babu, Technical assistant & lecturer, for his co-operation and guidance. I also extend my gratitude to Dr. Ramalingeshwara Rao, and Dr. Vijayalaxmi for their precious suggestions and help throughout the study.created by of Dr.KSRPrasad
  • 124. My love and gratitude to my sister, Smt.Sudhira and brother in law, Sri.B.V.G. Raju for their co-operation and encouragement and whose moral support has boosted my spirits in needful times. I thank my loving brothers Mr. P.Diwakar, Dr. P. Radhukar and Mr. P. Srikar for their precious suggestions and help in completion of my study. My deepest gratitude to my uncle, Sri.V.Krishnamurthy and my aunt, Dr.V.P.Vardhani for their suggestions, co-operation and support during the study. I express my gratitude to all my classmates specially Dr. Sunitha, Dr. Sivaramakrishna, Dr. Kavitha Dr. Ushamadhuri, Dr. Namrata, Dr. Sirisha, Dr. Mangalakanthjha, Dr. K. Srinivas for their co-operation in completing the work. I thank my seniors and juniors especially Dr. Shivanarayana, Dr. Lavanya and Dr. Shiva Shankar for their valuable support which made this work possible. I would like to extend my thanks to Dr. Pravin, PG scholar, Jamnagar and Dr. Prasad, PG scholar, Kottakkal, for offering a helping hand in successful completion of the thesis. I thank Dr. Narapareddy for preparing and supplying of the trial drugs without which the thesis would not have been completed. I take the privilege to express my gratitude to Dr. Sharbinda Raj, HOD, Psychiatry dept, Gandhi Hospital and Dr. Sirisha, assistant Professor, Psychiatry dept, Gandhi hospital for their co-operation and support in getting a better understanding about Psychiatry. I thank Dr. Shiva Rama Prasad for his valuable suggestions. Last but not least I express my gratitude to each and every person who made this task possible. Dr. Jaya Laxmicreated by of Dr.KSRPrasad
  • 125. BIBLIOGRAPHY 1. Astangahridaya Uttarasthana – Text with English translation by K.R. Srikantha Murthy – 1st edn,1995, Krishnadas Academy, Varanasi. 2. Astanga Hridayam – Text with English translation by Prof. K. R. Srikantha Mruthy, Vol – I, Sutra & Sarirasthana, 3rd edn, 1996, Krishnadas academy, Varanasi. 3. Adult Psychological problems: An Introduction, by Lorna champion, E. Mick Power, 2nd edn, 2000, by Psychology Press Ltd., U.K. 4. Ayurvedic Renaissance – April – June 06 Monthly, P – 16. 5. Advances in Ayurvedic medicine – Mental state examination by K. Narasimha Murthy & R.H. Singh – Vol – IV, 1st edn, 2005 Haridas Ayruveda series, Chaukambha Visvabharati, Varanasi. 6. Ayurvediya Manasaroga Chikitsa (Hindi), by Acharya Govinda Prasad Upadhyaya,1st edn, 2000, Chokambha Surabharati Prakashan, Varanasi, 7. Ayurvedic Management of Unmada (Schizophrenia) – 1999 edn, published by central council for research in Ayurvedia & siddha. 8. Ayurvedic Seminar on Mental health, Research papers, 30-31 March 2006, RAV publication, 2006 March. 9. API Text book of Medicine – 7th edn, 2003, edited by Dr. Siddarth N. Shah, the Association of Physicians of India, 10. Asthangahrdayam composed by Vagbhata with the commentaries Sarvangasundara of Arunadatta and Ayurvidarasayana of Hemadri, Krishnadas Academy, Varanasi, edition reprinted 1995. 11. Astangahridaya of Vagbhata translated by a board of scholars, Vol I & IV , 1st edition 1999, shri satguru publication Delhi 12. Asthangasamgraha composed by vabhata with the commentary by Indu, edited by Vd. Anant Damodar Athavale, Ayurvidya Mudranalya, Pune. 13. Amarakosha by Amarasimha, Chaukambha Sanskrit Pratishthana, Varanasicreated by of Dr.KSRPrasad
  • 126. 14. Bhavaprakasanighantu of Sri. Bhavamisra commentary by Dr. K.L. Chunekar, Chaukhambha Bharati Academy, Varanasi. 15. Caraka Samhita by Agnivesha, text with English translation and critical exposition based on cakrapanidatta commentary by Dr. R.K. Sharma and Vd. Bhgwan Dash, 2nd edition 2001, Chaukhambha Sanskrit series varanasi. 16. Caraka Samhita by Agnivesa with the vidyotini Hindi commentary by pt. Kashinath Shastri, 5th edition, 1997, Chaukhambha Sanskrit Sansthana, Varanasi, 17. Caraka Samhita , Dridhabala commentary, vol – II –1949 edn Eng Translation by Sree Gulabkunverba Ayurvedic society, Jamnagar,. 18. Critical appraisal for psychiatry – Stephen M. Lawrie, Andre M. Mclontosh, Sanjay Rao, 1st Edn, 2000 Edn, Har court publishers Limited. 19. Darvyaguna Vijnana (Study of essential medicinal plants in Ayurveda ) Vol – II by Dr. J.L.N. Sastry. 20. Essentials of Psychiatry, by M.S. Bhatia, 2nd edition. CBS publisher and distributor. 21. Essentials of basic Ayurvedic concepts – by Dr. V. V. Subramanya Shastry 1st edn, 1999, Publication division, D.G.M. Ayurvedic Medical college, Gadag. 22. First steps in Research and statistics by Dennis Howitt and Duncan Cramer 1st Edn, 2000, tayalos & Francis Inc, Philadelphia. 23. History of medicine in India – By P. V. Sharma, Published by The Indian National Science academy, New Delhi 1stedn, 1992, oxford medical publications, Oxford University Press, New York. 24. Introduction to Kayachikita – by C. Dwarakanath 1959 edn. 25. Illustrated Sushruta Samhita : Text with English Translation – Vol – I, by Prof. K. R. Srikantha Murthy, 1st edn, 2000, Chaukamaba Orientalia, Varanasi. 26. Indian Medical Plants, Vol II by Kirtikar K.R., Basu B.D., I.C.S., 1980, , Bhishen Singh Mahendrapal Sing, Dehradun, 27. Indian Materia Medica, by Nadkarni. K.M, 1986, Popular Prakashan, Bombay. 28. Key topics in Psychiatry – by C.E. Smith, L.Sell, P. Sudbury – 1st Edn – 1996, BIOS Scientific pulishers, U.K. 29. Kaiyyadevanighantu, by P.V. Sharma Guruprasad, 1979, Choukhamba oriented, Varanasicreated by of Dr.KSRPrasad
  • 127. 30. Lecture notes, Psychiatry – By Paul Harrison John Gedder, Micheal Sharpe- 9th edn ,2005 , Blackwell publishing Ltd., U.K. 31. Materia media of India & their therapeutics: by Rustomjee Naserwanjee khory & Nanathi Navaraj Khaitani, 2nd edn 1984- 32. Medicinal Plants – by S.G. Joshi, 2000 edn, Oxford & 1st Publishing Co. Pvt. Ltd., New Delhi. 33. Madhavanidanam of Sri Madhavakara with “Madhukosa” Sanskrit commentary by Sri Vijayarakrshita and Srikantha with the “Vidyotini” Hindi: commentary and notes by SriSudarshana Sastri – Chaukhambha Sanskrit sansthana – varanasi, 27th edition. 34. Manasroga Vijnana Acarya Dr. B.A.Pathak, 1976, Sri Baidyanath Ayurveda Bhavan ltd, 1st Edition. 35. Rajanighantu of Pandit Narahari, Krishnadas Academy, Varanasi. 36. Oxford Handbook of Psychiatry ,1st Edn, 2005, by David Semple, Roger Smyth, Jonathan Burns, Rajan Drarjeendndew 1st dintosh. 37. Postgraduate Psychiatry: clinical and scientific foundations, by Lois applex, David Forshaw, Tin Amol, Helen Basher, 2nd edn, 2001 Arnold Publishers, London. 38. Principles of Medical Pharmacology – By Dereth Waller and Andrew Renwick 39. Psychathology in Indian Medicine by Satyapal Gupta – 2000 Edn, Chaukambha Sanskrit Pratisthan, Delhi. 40. Psychiatry – by James Swally, Donald W. Bechtold, Jon A. Bell, Steven L. Doboushty, Gordon L. Neligh, Janice L Peterson, 2nd edn, 1989, John Wiley & Sons (SEA) Pvt. Ltd – Singapore. 41. Psychiatry – An Illustrated colour Text 2001 edn by Lesley stevenui, Ian Rodins, Churchill living stone publication. 42. Psychological Testing – Principles, applications & Issues, 6th Edn, by Rober M. Kaplan, Dennis P. Saccuzzo, 2005, Thomson Wods worth, USA. 43. Principal of Anatomy and Physiology – Gerard J. Tortora, Sandra Reynolds Grabowshi, 8th edition, 1996, Harper Collins publishers Inc. 44. Sushruta Samhita – English Translation – Vol – III by Kaviraj Kunjalal Bhishagratna – chowkambha Sanskrit series office, varanasi, 3rd edn, 1981created by of Dr.KSRPrasad
  • 128. 45. Shabda Kalpadruma – By Raja Radha Kanta Deva – Vol – I, work No.93, chowkamba Sanskrit Series office, varanasi. 46. Sir Monier Williams Sanskrit – English dictionary by oxford at the clearodon Press, Oxford university Press, 2nd edn – 1956. 47. Science and Philosophy of Indian Medicine – By K. N. Udupa & R. H. Singh, 2nd Edn, January, 1990, Shree Bidyanatha Aurved Bhwan, Nagpur, 48. Cakradatta by Sri Chakrapanidatta, with the “ Vaidya prabha” Hindi commentary Chaukhambha Sanskrit Sanstha, Varanasi. 49. Sushruta Samhita by Sushrutha with the Nibandha samgraha commentary of Sri. Dalhanachary and Nyanachandrika Panjika of Sri Gayadasa, Krishnadas Academy, Varanasi, 1998. 50. Sarangadhara samhitha, Parashuram shastri vidyasagar, Dipika and Gudarthodipika commentary, Krishnadas series. 51. Sarangadhara Samhita, English translation, Pof. K.R. Murthy, Chaukambha Samskrit bhavan. 52. Tridosha Theory- by Dr. V. V. Subrahmanya Satri, Arya Vaidya Sab, Kottakkal. 53. The practical Sanskrit English Dictionary of P.K. Gode and C.G. Karve, edited by Prasad prakashan, Poona. 54. Vachaspathyam, A comprehensive Sanskrit Dictionary completed by Sri Taranatha Tarhavacas pathi, The chaukhambha Sanskrit series office, Varanasi. WEBSITES: 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. by of Dr.KSRPrasad
  • 129. ABBREVIATIONS Rg – Rigveda Yaj– Yajurveda Ath.Veda – Atharvaveda Ma. Grh. Su – Manava Grihya Sutras Va. Pu – Vayu Purana Vi Pu – Vishnu Purana Na. Pu – Naradiya Purana Ag. Pu – Agni Purana Ga. Pu – Garuda Purana Ca. Sa – Charaka Samhita Shareerasthana Ca. Vi – Charaka Samhita Vimana Sthana Ca. Su – Charaka Samhita Sutra Sthana Ca. Ni – Charaka Samhita Nidana Sthana Su. Su - Sushruta Samhita Sutrasthana Su. Sa – Sushruta Samhita Shareera Sthana As. Hr – Astanga Hridaya As. Sa Ut – Astanga Sangraha Uthara Sthana Bh. Sam – Bhela Samhitha Chikitasthana Ma Ni – Madhava Nidana Ka. Sam – Kashyapa Samhitha Bha. Pra Mad – Bhava Prakasha Nighantu Madhyama Khanda Sh. N – Shodhala Nighantu Ra. N – Raja Nighantu Dha. N – Dhanavanari Nighantu Ka. N – Kayyadeva Nighantu BT – Before Treatment AT – After treatment Std. Dev – Standard Deviation S.E – Standard Error HAM-A – Hamilton rating Scale for Anxiety STAI – State Trait Anxiety Inventory.created by of Dr.KSRPrasad
  • 130. HAMILTON ANXIETY SCALE Mark and score as follows: 0 – Not present; 1 – Mild; 2 – Moderate; 3 – Severe; 4 – Very severe ANXIOUS MOOD -Worries, anticipation of the worst, fearful anticipation, irritability. TENSION - Feelings of tension, fatigability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax. FEARS - Of dark, of stranger of being left alone, of animals, of traffic, of crowds INSOMNIA - Difficulty in falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares, night terrors INTELLECTUAL - Difficulty in concentration, poor memory DEPRESSED MOOD - Loss of interest, lack of pleasure in hobbies, depression, easy waking, diurnal swing. SOMATIC (Muscular) - Pains and aches, twitchings, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone SOMATIC (Sensory) - Tinnitus blurring of vision, hot and cold flushes, feelings of weakness, prickling sensation. CARDIOVASULAR SYMPTOMS - Tachycardia, palpitations, pain in chest, throbbing of vessels, fainting feelings, sighing dyspnoea. RESPIRATORY SYMPTOMS - Pressure of constriction in chest, choking feeling, sighing, dyspnoea. GASTROINTESTINAL SYMPTOMS - Difficulty in swallowing, wind, abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation GENITOURINARY SYMPTOMS - Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia development of frigidity, premature ejaculation, loss of libido impotence. AUTONOMIC SYMPTOMS - Dry mouth, flushing, pallor tendency to sweat, giddiness, tension headache, raising of hair. BEHAVIOR AT INTERVIEW - Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc.created by of Dr.KSRPrasad
  • 131. created by of Dr.KSRPrasad
  • 133. Chart 10created by of Dr.KSRPrasad
  • 134. Chart 11 Chart 12 Chart 13created by of Dr.KSRPrasad
  • 135. Figure 7 Jotismati ( Celastrus paniculatus) Plant & Seeds Figure 6 Oil extracted from seedcreated by of Dr.KSRPrasad
  • 136. Post- graduate Department of kaya chikitsa Dr.B.R.K.R.Govt.Ayurvedic Hospital,Hyderabad SPECIAL CASESHEET ON THE CLINICAL STUDY OF Name: Age: Sex: Male/FemaleReligion: Hindu/Muslim/Christian/others Economic status: Lower/Middle/UpperOccupation: Student /Service / Labour / Business / Housewife / othersHabitat: Rural/ Urban I.P/O.P NO.: Address:Chief complaint with duration:Precipitating factor:Catastrophes/ Socioeconomic crisis/ Family centered problems /Business or Service tensionAssociated complaints:History of present illness:History of past illness: Medical: Surgical: Psychiatric:Family history: created by of Dr.KSRPrasad
  • 137. Personal history: Diet : Veg/ Non-veg Appetite : Normal/ Decreased/ Increased Sleep : Normal/ Difficulty in falling asleep/ Disturbed/ Early morning awakening/ No clear pattern of disturbance Bowel : Normal/Constipation/ DiarrhoeaMicturition : Normal/ Increased frequency/Excessive and urgentSexual : Normal/ Decreased sexual urge/ Increased sexual desire/ Any otherAddictions : Tea/ Coffee/ Smoking/ Alcohol/ OthersMenstrual history: Regular/ Irregular/ Amenorrhoea/ Dysmenorrhoea/ OthersDevelopmental : HistoryAcademic history: Uneducated/ Primary/ Secondary/ Inter/ Graduate/ P.GOccupational History :Marital history : Unmarried/ Married/ Divorced/ Widow(er)General condition: Pulse: Temperature: B.p: Respiratory rate: created by of Dr.KSRPrasad
  • 138. Dasavidha pareeksha:1. Prakruti: a) Deha: Vata/ Pitta/ Kapha/ Vata-kapha/ Vata-pitta/ Kapha-pitta/Sama b) Manasa: Saatvika/ Rajasika/ Tamasika2. Vikruti: Dosha : Dushya : Srotas :3. Saratah: Twak/Rakta/Mamsa/Medo/Asthi/Majja/Sukra/Sattva/Sarva sara4. Samvahanam: Pravara/ Madhyama/ Avara5. Pramana: Adhika/ Sama/ Hina6. Sathmyam: Pravara/ Madhyama/ Avara7. Sathvam: Pravara/ Madhyama/ Avara8. Ahaara shakthi: Abhyavaharana: Jarana:9. Vyaayama shakthi: Poorvakaaleena: Adhyatana:10. Vayah: Baalya/ Madhyama/ Vriddha MENTAL STATE EXAMINATION A) Indriyabhigraha (perception and motor control) : Gnyanendriya: Normal / Hallucinations/ Illusions/ Depersonalization/ Derealisation Karmendriyas :Normal functioning/ Increased activity/ Decreased activity B) Manonigraham (Mental control) : Attention and concentration: Intact/ Impaired C) Ooha(Imagination capacity) : Intact/ Ideas of reference/ Obsessive ideas/ Delusions/ Suicidal ideas/ Ideas of worthlessness/ Hypochondrial preoccupation created by of Dr.KSRPrasad
  • 139. D) Vichara (Thought content) : Thought- Intact/ Block/ Insertion/ Withdrawal / Broadcast/ EchoE) Dhee (Decision making power) : Judgment: Intact/ Impaired Insight: I / II / III / IV / V / VI GradeF) Dhriti (Retention power) : Normal/ ImpairedG) Smriti (Memory power) : Immediate: Normal/ Impaired Recent: Normal / Impaired Remote: Normal/ ImpairedH) Bhakti (Desire) : in relation to- Aahara: Vyavaya: Vesma: Normal/ Unkempt/ Overdressed Ranjanam:I)Sila (Habits) : Temperament: Anxious/ Irritable/ Suspicious/ Depressed/ Appropriate Leisure time activity:J) Chesta (Psychomotor activity) : Speech: Too much/ Too little/ Irrelavant/ Coherent/ Incoherent/ Flight of ideas/ Circumstantiality/ Loosing/ Echolalia/ Dysphasia/ Dysarthria Body movements: Mannerisms/ Tics/ Catatonic features/ Restlessness Posture: Walking: Facial expressions: created by of Dr.KSRPrasad
  • 140. K) Acahra (Circumstantial response) : Personal standards: Dressing and taking care of self- Normal/ Impaired Going to work – Normal/ Impaired Doing household work –Normal/ Impaired Social standards: Getting along well with family members- Normal/ Impaired Getting along well with neighbors & colleagues- Normal/ Impaired L) Sangnyagnyana (Orientation & responsiveness) : Orientation to: kala (time): Intact/ Impaired Desa (Place): Intact/ Impaired Atmagnyana (person): Intact/ Impaired Response to external stimulii : Clear/ Drowsy/ Delirium/ Fluctuating stupor/ coma PSYCHOMETRIC PARAMETERS SCORESSCALE Day 1 After 15 days After 30 days After 45 daysState anxietyTrait anxietyHAM-APlan of treatment: Drug: Dosage:Time of administration: Anupana: Duration of treatment: created by of Dr.KSRPrasad
  • 141. Assessment of effect of treatment NONE = 0, MILD = 1, MODERATE = 2, SEVERE= 3, SEVERE, GROSSLY DISABLING = 4 Symptoms Day 1 After 15 After 30 After 45 days days days Udvega(anxiety) Abheekshnadhyanam (worrying thoughts) Bibheti(fear complex) Ghattate(restlessness) Shabda asahishnuta (sensitivity to noise) Visada(Depression) Bhrama(dizziness) Kampa(tremors) Toda(prickling sensation) Arochaka(anorexia) Avipaka(indigestion) Shakritgraha(constipation) Glani(exhaustion) Angamarda(aching muscles) Nidrabhramsa(insomnia) Mukhasosha(dryness of mouth) Anaha(flatulance) Hritdrava(palpitations) Uchvasasyadhikyam(over breathing) Hrit graha(constriction in chest) Total scoreRESULT: SOME GOOD VERY GOOD IMPROVEMENT IMPROVEMENT IMPROVEMENTFollow-up:Signature of PG Scholar Signature of the Guide created by of Dr.KSRPrasad
  • 142. INFORMED CONSENT I……………………………Son / Daughter / wife of ………………… am exercising my free will to participate in the above study as a subject. I have been informed to my satisfaction, by the attending physician the purpose of clinical evaluation and the nature of the drug treatment .I am also aware of my right to opt out the treatment schedule at any time during the course of the treatment. Patient’s Signature Schedule Initiation: Schedule Completion:created by of Dr.KSRPrasad