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A CLINICAL STUDY ON THE EFFECT OF AN AYURVEDIC COMPOUND DRUG IN ATATTWABHINIVESHA W.S.R. to OBSESSIVE, COMPULSIVE DISORDER (OCD)." Sivaramakrishna, Department of Kayachikitsa, PG unit Dr.BRKR Govt. …

A CLINICAL STUDY ON THE EFFECT OF AN AYURVEDIC COMPOUND DRUG IN ATATTWABHINIVESHA W.S.R. to OBSESSIVE, COMPULSIVE DISORDER (OCD)." Sivaramakrishna, Department of Kayachikitsa, PG unit Dr.BRKR Govt. Ayurvedic College, HYDERABAD

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  • 1. A CLINICAL STUDY ON THE EFFECT OF AN AYURVEDIC COMPOUND DRUG IN ATATTWABHINIVESHA W.S.R. to OBSESSIVE, COMPULSIVE DISORDER (OCD)." Sivaramakrishna CONTENTINTRODUCTIONPART - I CONCEPTUAL STUDYHistorical AspectConcept of manasEtymologyHetuRupaSampraptiVyavachhedaka NidanaSadyaasadhyathaPART - II PRINCIPLES OF TREATMENTAND DRUG STUDYPrinciples of TreatmentMedhya RasayanaDrugs ReviewPART - III CLINICAL STUDYMaterials and methodsObservations and ResultsPART - IV DISCUSSIONPART V SUMMARY & CONCLUSIONANNEXUREBibliographyCasesheetConsent formY-BOCS Check list 1
  • 2. ABBREVIATIONSCh. Ni.S = Charaka Samhita Nidana SthanaCh. Vi.S = Charaka samhita Vimana SthanaCh. Sha.S = Charaka samhita Sharira SthanaCh.Chi.S = Charaka Samhita Chikitsa SthanaSu. Su.S = Sushruta Samhita Sutra SthanaSu. Sha.S = Sushruta Samhita Sharira SthanaSu. Utt.t = Sushruta Samhita Uttara TantraSu. Chi.S = Sushruta Samhita Chikitsa SthanaA.S.Utt.t = Asthanga Sangraha Uttara TantraA.H.Su.S = Ashtanga Hridaya Sutra SthanaA.H. Sha.S = Asthanga Hridaya Sharira SthanaA.H.Utt.t = Asthanga Hridaya Uttara TantraMa.Ni. = Madhava NidanaBhai.Ra. = Bhaisajya Ratnavali.Ri. = RigvedaY-BOCS = Yale Brown Obsessive Conpulsive Scale 2
  • 3. ACKNOWLEDGE I humbly owe every successful endeavour of my life to my beloved Parents. I express my greatfulness with a deep admiration to my guide Dr. PrakashChander, M.D. (Ayu.) professor and H.O.D., post graduate department ofkayachikitsa, Dr. B.R.K.R. Govt. Ayurvedic college and hospital, Hyderabad for hisconstant and valuable guidance, encouragement through out the dissertation work.Undoubtedly the correct, affectionate and untiring guidance of my guide has beena great asset in the completion of this thesis work. I express my heartful gratitude to Dr. V. Viajya Babu, M.D. (Ay), Reader,post Graduate Department of kayachikitsa, Dr. B.R.K.R. Govt. Ayurvedic collegeand hospital, Hyderabad for his thought provoking lecture and his constant support,guidance, encouragement and kind co-operation in all aspects. Iam highly indebted to my co-guide Dr. P-Nageswar Babu M.D. (Ay) for hisvaluable guidance and suggestion through out the study. I pay me sincere respect to Dr. M. Sadashiva Rao, Principal, Dr.B.R.K.R.Govt. Ayurvedic college, Hyderabad for providing facilities during my study. I am highly thankful to Dr. M. Srinivasulu M.D. (Ayu), former GazettedLecturer, PG Deportment of K.C. for suggesting me in selecting such a good topicand further valuable suggestions. I am also thankful to Dr. Ramalingeshwar Rao M.D. (Ayu) And Dr. K.Vijayalakshmi M.D. (Ay) for their constant support for the completion of the thesiswork. I convey my whole hearted thanks and sincere respect to Dr. Sharband Rajprofessor and HOD, Department of psychiatry, Gandhi Hospital, Secunderabad. 3
  • 4. Dr. Sireesha Asst. Professor, Department of psychiatry, Gandhi HospitalSecunderabad. I am also highly thankful to Dr. V. Ananta Shayanachari Professor & H.O.D.,P.G. Department of SSP and Dr. M. Philip Anand kumar, Reader & H.O.D. PGDepartment of Dravyaguna and Dr. Jeeva Ratnam Reader, P.G. department ofShalya and Dr. S. Sharangapani, Gaz. lecturer P.G. Department of Shalya for thekind co-operation during the study. I am thankful to P.G. Schollers Dr. Sivanarayan, Dr. G. Lavanya M.D. (Ay.),Dr. J. Sivanarayana M.D. (Ay), Dr. K. Nanda Kumar M.D. (Ay), Dr. T. Srrenivasulu,Dr. Ali Basha, Dr. V. Jayalakshmi, Dr. R.T.S. Lakshmi Kumari, Dr. P. Jyotsnafor giving valuable suggestions and support in completion of my thesis. I am thankful to my loving brothers and sisters for their precious suggestionsand help in completion my study. I cordially acknowledge my collegues Dr. V. Jayalakshmi, Dr. B. UshnaMadhuri, Dr. Dr. G. Kavitha, D. K. Suneetha, Dr. D. Nageswara Rao, Dr. NagaRaju, Dr. Mangala Kantajha, Dr. B. Ravi, Dr. B. Padmaja, Dr. G. RanganathDr. K. Namrata, Dr. K. Srinviasulu, Dr. T. Sireetha, and Dr. N. Geetha who havehelped me a lot in one way are the other in the successful completion of this task. I thank to V. Mamatha DTP operator for completing this work. I am thankful to all my patients of trial drug and all these persons, who havehelped me directly or indirectly for this project work. Date: Place: (Dr. Sivaramakrishna) 4
  • 5. INTRODUCTION In present days, psychological disroders are scaling high due to stressful lifestyles, thought of global village, maladjustments and changes in human relationsout of all these psychological disorders 10% are of neurotic disorders, in whichObsessive Compulsive Disorders (OCD) has got a major share. Charaka has explained a disease entity as Atattwabhinivesha, which is alsonamed as mahagada in Sutra & Chikitsa sthanas. In this context, Vishama Buddhi isthe prime factor for Atattwabhinivesha i.e. loss of nischayatmaka Jnana of buddhi.This is similar to the case of Obsessive Compulsive Disorder (OCD) where vishamabuddhi is the basic thing. It is a type of psychological disorder having maincharacteristics as obsessive thoughts and ideas which are sometimes accompaniedby compulsive behaviours and actions, often designed togetherly as Obsessive -Compulsive Disorder. Majority of the drugs employed in the modern medical system are limited toalmost suppressing the present symptoms. A repeated and long term use of suchmedicines is likely to harm the patients and tendency for addiction is also possible.Therefore a safer drug regimen from the Ayurvedic materia medica is very muchnecessary. The texts of Ayurveda provide ample references regarding medicine andtreatment lines for such psychiatric problems. I have selected Atattwabhinivesha for the present study, and selected someAyurvedic drugs for its treatment. The drugs selected are from Samhitas the referencesof which are as fallows Susruta has mentioned some drugs as Manasarogaharagana in uttara tantra- Amanushopasarga adhyaya.Where in Vacha, Sarpagandha,Jatamamsi, Aparajita are mentioned. Charaka has described yastimadhu asmedhyarasana in Ch.Chi. 1st Chapter. Keeping in veiw, a composition preparedfrom aparajita, vacha, sarpagandha, yasti churna, which suits the samprapti vighatanaof Atattwabhinivesha condition was selected for the present study. 5
  • 6. The present study is divided into 5 partsPart I - Conceptual StudyPart II - Principles of Treatment and Drug studyPart III - Clinical StudyPart - IV - DiscussionsPart - V - Summary & Conclusions 6
  • 7. HISTORICAL ASPECTVedic period (1500 BC to 500 BC ): It is well known that the ancient Indian thought is not only rich in metaphysicalapproach but also in the psychological approach. Vedic era is said to be the earliestof the age of recorded history. In Rigveda many references regarding the psychological derangements, themethods of treatment and the mean to prevent the psychiatric entities are mentioned.Ri. 6.47.1, Ri 9.113.4 Yajurveda and Atharva. Vedas are also having reference ofpsychology and psychiatry. Whitney (1962) tried to interpret and classify the mental disorders inAthrvaveda, which have been presented in the tabular form (Table -1) The main form of treatises mentioned in Atharuvaveda are: 1. Atharvani i.e. Psychotherapy 2. Daivya i.e. Naturotherapy 3. Manushyaja i.e. herbal medicines prepared by human being and amulet (Singh: 1977) Among them, Atharvani relates with the psychical and psychological aspectsand includes 1. Mantras i.e. chanting 2. Sankalpa i.e. decisiveness by repeated self suggestions 3. Vasheekarana i.e. control over self by mesmerism / Asypnosis (Baloddhi & Toychow dhary, 1986) Some scholors noted atharvaveda, hold two parts, one with offensive measuresand the other with beneficial ones. The former was called ‘Angirasi’ and the latteras ‘Atharvani’ (Vayupurana 47.27) 7
  • 8. Table – 1 Table showing glimpses of mental disorders in atharva veda (Whitney, 1962) S.No Vedic term Subject covered Ref. of atharvavedic Hymns 1 Gatudhana Sorcery and witches 1,7: 8,28 and 8.3 2 Gandharva Sex disorders 2. 2.5; 6.130.4; 6.130.1 &Apsaras 3 Bibheeti Fear with it four 2.15.1; 6.40.1; 7.3.22; type 4.10;4.19; 4.33 4 Rakshashagraha Possession 8.319; 8.3.15 5 Moha Erocism 3.21.4; 3.25.6; 6.130. 1.4 6 Shapa Curse 2.7; 6.37, 59, 61 and 6.67 7 Manya Fury 6.42 9 Unmada Insanity 8.3.3; 6.3 1-2 10 Grahi Hysteria 2.9.1; 4.37, 1-12;8.2-12; 12.3, 18; 2.1-2 11 Enas, Aparadha Guilt 6.117.1; 6.118.12, 6.119. 1-3 dutitani 12 Irshya Jealousy 6.18.1-3; 7.74.3, 8.45-47: 13 Krodha Agession 6.42.1-3; 6.43.1 14 Manaspapa Schizophenia 6.45. 1-3 Paranoid type 15 Uttaram Superiority 6.45.1 16 Ahamsa Distress 6.96.12-13 17 Duhsovapna Evil dream 6.46.1-3; 6.100.1; 16.7.8. 18 Apasmara Epilepsy 8.1.16; 8.13 8
  • 9. Most of the hymns of atharvaveda are directly concerned with the atharvani orpsychotherapy and thus have influenced the majority or psychotherapy and thushave influenced the majority of Indians to believe in ‘Mantras’ for the cure of mentaldisorders (Baloddhi & Roychovadary, 1986) However, there is no obvious reference of Atattwabhinivesha obtainable invedas. Apasmara is an illustrate of epilepsy and unmade enlighten distinctive majorpsychotic disorder.Samhita Period (1500 BC to 600 A.D.) Around 7th to 8th century B.C. Ayurveda established itself as a seperate systemof rational and scientific medicine. In it, mental disorders are attributed to both theexogenous and endogenous causes, which includes sorcery, withchery etc. andManasika Doshas i.e. Raja, Tama, Sharirika Doshas i.e. Vata, Pitta, Kapharespectively. Being upaveda of Atharvaveda, Ayurveda traditionally containsAtharvani type of treatment in the form of Daiva Vypashraya Chikitsa andSatvavajaya Chikitsa. Out of the eight specialities of Ayurveda one termed as Grahabadha orBhutavidya Tantra, which illumine psychology and Psychiatry in ancient times.Bhutavidya Tantra deals with an omen arises from the Deva, Asura, Gandharva,Yaksha, Raksha, Pitru, Pishacha, Naga like evil spirits i.e. Grahas and its managementlike Shantikarma, Bali etc. (Su.Su.1:8). It also includes Amanush Nishedha,Apasmara, Unmada etc. (Su.Su.3:41). On the basis of above classical references, we can interpret and correlate mostof the psychiatric disorders with the entities described under Bhutavidya Tantra.Amanushopasarga means devoured by evil spirits, which inverse ones nature andilluminate different major as well as minor psychological disorders. Apasmara is anillustrate of epilepsy and Unmada enlighten distinctive major psychotic meladies. I have tried to highlight some glimpses of mental health and mental disordersaccording to samhitas. 9
  • 10. Charaka samhita A complete recital of psyche and psychological disorders is available in thistext, which is summarized as follows: 1. An exhausitive physiology of manas i.e. mind, which contains its definition properties, functions, indications etc. (Cha.sha. 1:75-76; cha.sha:1:17-22) 2. Examination and determination of manasika bhava i.e. emotional factors. (Cha.Vi.4:8) 3. Investigations for mental status i.e. satva parikshana (Ch.Vi. 8:94) 4. Manas i.e. mind as a seat of various diseases. (Cha.Su.1:55) 5. Manas doshas i.e. Rajas and Tamas and minor psychological disorders produced by vitiation of these two doshas (Cha.Su.1:57; Cha. Vi. 6:6) 6. Effects of emotional factors on the body (Cha.Su.25:40) 7. Psychosomatic approach towards deha prakriti i.e. body constitution (Ch.Vi.8:95-98) 8. Somatic presentation of mental disorders (Ch.Chi.3:114-115) 9. Etipathogenesis of mental disorders (Ch.Sha.1:120,108) 10. Role of psychological factors in the causation of all diseases (Ch.Vi.6:6; Ch.Su. 11:43) 11. Treatment of mental disorders in general (Ch.Su. 1:58; Ch.Su.11:47; Ch.Chi. 1-3:30,31; Ch.Su.1-4; 30-35) 12. Inclusion of psychological factors in the types of therapeutics of all diseases i.e. daivavyapashraya and sattvavajaya (Ch.Su.11:54) 13. Complete and detailed description of major psychiatric ailments under ‘unmada’ chapter (Ch.Ni.7; Ch.Chi.9) 10
  • 11. 14. An idealistic literature regarding etiology, pathogenesis and treatment of apasmara i.e. epilepsy (Ch.Ni.8; Ch.Chi.10) 15. Atattvabhinivesha: The entity only described by charaka (Ch.Chi. 10:54- 63) 16. In addition many selected references are also available pertaining to manas i.e. mind and manosika vyadhi i.e. mental disorders.Sushruta samhita In the very first chapter susruta has narrated most of the minor psychiatricentities like kama i.e. passion, krodha i.e. anger, shoka i.e. grief, bhaya i.e. fear,vishada i.e. depression etc. as either a part of Ichha i.e. desire or Dvesha i.e. aversion(su.su.1:25). An elegant literature regarding manas prakriti i.e. mental constitutionis described in 4th chapter of sharira sthana (Su.sha.4: 81-95). He has also narratedthe description of Bala grahas i.e. psychiatric disorders of child andAmanushopasarga in Uttara tantra. Major disorders like unmade Apasmara are reported in detail in uttara tantra(su.ut.27-37); su.ut.60-62). Susruta has not mentioned as such the atattvabhiniveshaany where in the samhita.Ashtanga sangraha & Hridaya: The both texts follow charaka and susruta in the sphere of psychiatric disorders(A.S. ut. 6-10; A.H.Ut 2-7), but kept quite regarding atattvabhinivesha. Medieval period (600 A.D. to 1600 A.D) This period is described as sangraha kala. Modhava nidana is an eminent bookof diagnosis from this period and incorporates literature of mental illhealth basedon samhitas. Later on, sharangadhar, bhavamishra and all the commentators ofsamhitas followed the same trend. No author or the commentator of this periodthought in the direction of Atattvabhivinesha chakrapani, the renowned commentatorof charaka samhita described that the atattvabhinivesha is a mental disorder, hencebeing the course for all wordly distress, it is called mahagada (chakrapani on 11
  • 12. cha.su.19:8), but elsewhere, he denied the description of Atattvabhinivesha in thesamhita by saying that it is an adulteration and not described by the sages. Above facts exposes our view to the decline of psychiatry in medieval period.Dominance of Tantrikas in bhutavidya tantra produced fear towards psychiatricdisorders among laymen and it created inattention of our scientists towards psychiatry. The western people kept distance of thinking in the field of mental disorders,possession of the mind of the mentally ill person by an evil spirit, with or withoutthe will of subject, resulting in all sorts of verbal manifestations and abnormalbehaviour, came to be accepted as common cause of mental disorders by them. Theexorcising of persons allegedly possessed by harmful intorders became a frequentpractice in the middle ages of western world. This short account shows that mental disorders were recognized in India asmedical conditions. The community accepted and tolerated the mentally sick. Suchattitude in India was sharp contract to the situation existing in the west, where patientswere considered evil and dangerous and the society had to be protected from them.Moderen period (1600 A.D. on words) In the early 20th century, yogin dranath sen, a renowned people of Gangadharand commentator of charaka samhita tried to elaborate some terms like mudha,alpachetana, vyakula etc. While commenting on atattvabhinivesha. Also, shrisudarshan shastri has described the Atattvabhinivesha as mahagada with its synonymsin the appendages of Madhava nidana. Dr. Balakrishna pathak, Dr. Ayo dhyaprashad achol and Dr. Rajendra Prasad Bhatnagar have endeavoured well to interpretayurvedic description of psychiatry with moderen literature. In India, as far as ayurveda is concerned, a lot of work regarding the psychiatricdisorders has already been carried out in IPGT & RA Jamnagar and faculty ofAyurveda, IMS, BHU Varanasi. 12
  • 13. HISTORY OF OCD Although psychiatric discussions of obsessional and compulsive phenomenadata is available from 1833, literary descriptions of such behavior may be foundmuch earlier. Euripides (480-406 B.C.) and Shakespeare (1564-1610) both providedequalent descriptions of obsessional / Jealousy in the plays meda and Othello.Shakeshpear also provided an illustrative description of obsessional guilt coupledwith compulsive ritualistic behaviour in his portrayal of lady Macbeth after violentmurder of king Donlan. Current understanding of the obsessive compulsive disorder has evolved fromthe gradual integration of clinical observations made over the past 150 years (black,1974). Compulsive symptoms have historically been dealt with as a subject ofobsessional symptoms. A French psychiatrist, Enquirol, first reported a clinical caseof obsessional doubting in 1838. Fabret (cited in Gray, 1978) later, named this condition. “La maladie du doute”or “The illness of doubt” The term obsession was coined by morel, a Frenchpsychiatrist in 1866. Griesenger (lifted in Gray, 1978) employed the term in 1870 todescribe recorrect thought patterns that assumed the form of questions, were notrational, and were beyond the control of the individual, In 1867, Krafft, Ebing (citedin Gray, 1978) introduced the term obsessinal to German psychiatry and hypothesizedthat obsessions were related to depression. Westphal first defined obsessions as“Ideas which come to consciousness in spite of and contravy to, the will of thepatient – ideas which he is unable to suppress) although be recognized them to beabnormal and not characteristic of himself” (cited in Black, 1974, P.20) The twentieth century introduced intensified efforts to define and describethis psychiatric condition. Janet (1903) developed the classification of psychasthenia,a category that included obsessions, phobias, and other neurotic disorders, whileexcluding hysterias. According to Jonet (1903), the obsessional ideas were thenmet with doubts, hesitations, and feelings of uneasiness, which, were caused byweakness in the reflective and decision making abilities. 13
  • 14. Lewis (1936) proposed that the sensible, senseless dimension is not primaryimportance in the obsessional disorder. He consider the content of many obsessionsplausible and atimes, even appropriate. Carr (1974) synthesized the definitions of previous clinicians and consideredthe use of separate terms, obsessive and compulsive, misleading. He defined thecompulsion, not the obsession, as “a recurrent or persistent thought, impulse, imageor action that is accompanied by a sense of compulsion and a desire to resist it”. (P-311). In the fourth edition of Diagnostic and statistical manual (DSM-IV) Americanpsychiatric association, 1980). Ref: Asberg M.Montgomercy S. perris C, et al. A comprehensivepsychopathological rating scale. Acta psychiatrica Scandinavia 1978. 271 (suppl):5. 14
  • 15. CONCEPT OF MANAS Human birth is a very rare privilege, for only man has the possibility of livinga conscious, wide-awake, controlled life. Human being only possess extra abilitieslike intelligence and languages development. All these things may not happen withoutpresence of Manas (psyche) and Atma (soul). But, sitting amidst the mountain ofwealth and prosperity man lives a life of worry, anxiety and discontentment, whichis a sad paradox. This state can be overcome by understanding MANAS, which ismainly responsible for pleasure – pain perception. Therefore, for understanding theabnormal mind and psychopathology, knowledge about the normal state of mind isessential. Ayurveda, the science of life, effectively explains about Manas and its functionsand lays emphasis on the need of overcoming the impediments like, Kama (Desire),Krodha (Anger), etc. which are reflected in the form of psychological illness andprescribes methods toward off them effectively. Our ancient legend of health – Ayurveda, defines Ayu (life) as the combinedstate of Sharira (body), Indriya (senses), Sattva (psyche) and Atma (soul). "Sharirendriyasattvatmasamyogo Dhari Jivitam" (Ch. Su. 1/42) The first two are greater entities and easy to understand. The latter two aresubtle and beyond the sensory experience, hence difficult to understand. As perAyurveda, Dharma (Righteousness), Artha (Wealth), Kama (Desire), and Moksa(Salvation) are the prime aims of life, and for attaining these goals Arogya (Health)is essential and important. "Dharmarthakama moksanam arogyamoolottamam " I (Ch. Su. I) 15
  • 16. Healthy life, according to Ayurveda is defined as, "Samadosha Samagnisca SamadhatumalakriahI Prasannatmendriya Manah Svastha Ityabhidhiyate" II (Su. Su. 15/80) A person is healthy one, whose humors (Dosa) and metabolic state (Agni) isin equilibrium, whose functional activities of the tissues and excretory systems arein balance, and the soul, senses and mind are clear. Therefore, cheerful state ofmind is necessary for the good healthy life. In today’s metaphysical society, human life has become speedy, mechanized,less effectious and more centered, which contribute to more production of Kama(Desire), Krodha (anger), Lobha (greed), Bhaya (fear), Shoka (Greif), Cinta (Worry)and Irsa (envy) etc. Like Manas Vikara. In this way, accurate knowledge of Manas is necessary to understand aboutnature of life and health.Etymology of Manas: The word “Manah” is derived from root “Mana” adding the suffix “Asuna”with the following meanings: q Which perceives q Which leads to knowledge (Shabda Kalpadruma) q Which analyses by special knowledge (Maha Bharata)Synonyms of manas: According to seat : Hridayam, Hrnmanasama According to function: Prajna (accommodator of super senses) Smriti (restores knowledge) Mahamati (super-most analyzer) Sattvam (Express the presence of Atma) 16
  • 17. According to relation : Svantam (closely related to Atma) According to shape : Anangakam (non-morphological entity) According to action : Chitta (thought process) Purvabdhikhyatih (Carrier of previous deeds) Others : Eswarah (god, owner) Brahma (the soul)Definition of Manas: q A substance, which is responsible for the presence or absence of the knowledge, is called Manas (Ca.Sa. 1/18) q An instrument for perception of happiness or miseries. (Ca.Sa.1/18) q A substance which established the contact between the soul and body and which regulates the functions of the indriyas is defined as Manas (Ca.Sa.3/13) q Which yokes the spirit with sentient organism on the immense, of whose departure virtually leaves the body, the inclination changes, all the sense organs distraught, strength wanes, diseases get aggravated, and finally on whose departure the organism is benefit of life and which holds the senses together is called as Manasa. (Ca.Sa.3/13)STHANAS OF MANAS: In Ayurvedic literature, various references are available regarding the seat ofmanas, which are being discussed, as here.1. Indifinite: Mind is continuously active i.e. cancala (Ca.Sa.3/21), so it cannot stay at oneparticular place. Hence it is very difficult to say about the seat of manas. 17
  • 18. 2. Hridaya: Many references are available in charaka and susruta regarding the seat ofmanas in Hridaya. Both acarya have mentioned that only hridaya is the seat ofcetana in the body. It indicates that Hridaya is the actual seat of manas. (Ca.sa.7/8, Su.Sa. 4/34), Ah.Sa.4/21)3. Shiras: In caraka (su.17/12), it has been explained that, prana and whole Indriyas aresituated in uttamanga i.e. shiras. Among the whole Indriyas, manas is the supremebecause it is the controller of them. So, it illustrates that manas is situated in uttamangai.e. shira. Bhela considers space between shiras and Talu as seat of manas. (Bhe.Ci.8/25)4. Sarva sharira: Acarya caraka states that sarva sharira is adhisthana of atindriya i.e. mind(Ca.Vi.5/7)5. Ojas: Ojas is said to be the seat of manas (Ca.Ci.24/34)6. Twak: Twak is considered to be the seat of manas (Ca.Su11/38, Sa 11/133-135) All the reference regarding the seat of manas, which are mentioned aboveindicate various places, but majority of Acarya believe that the actual seat of manasis hridaya and its transportation channel is sarva sharira.Characteristics of Manas: "Anutvamatha Caikatvam Dvau Gunau Manasah Smrtau I" (Ca.Sa.1/19) Anutvam (atomic dimension) and Ekatavam (uniqueness) are considered tobe the two characteristics of the Manas. 18
  • 19. These are very basic characters of the mind, if it were not so, all kinds ofperceptions would have occured at a time.Other characteristics or properties of manas are: q Manas is Dravya (Ca.Su.1) It is Karana or instrument of Atma It is one of the 24 or 25 tattvas from which Purusa is derived. (Ca.S.a1) It is one among the Adhyatma dravya samgraha (Ca.Su.8/13) q The three Mahaguna Sattva, Rajas, Tamas are said to be the guna of manas or they are imposed on Manas (Matsya Purana) q It is acetana but does functions by getting Cetana from Atma (Ca.Sa.1/ 75) q It is dual faculty i.e. Ubhayendriya - both sensory and motor q Manas is considered as one of the Antahkarana Catustaya (Sharirikopnisada) q Manas is considered as Atindriya, as it is subtle than Indirya and is considered to be superior than Indriya (Ca.Sa. 9/4, Kathopnisada 1/3/ 10) q Cancalatva (unstability) is a characteristic of Manas (Bahopanisada)Objects of Manas: "Cintyam Vicaryam Uhyam Ca Dhyeyam Samkalpyame Ca l Yatkincinmanaso Jneyam Tatsarvam Hyarthasamjnakam" ll (Ca.Sa.1/20) Cintya (things requiring thought), Vicarya (consideration), Uhya (hypothesis),Dhyeya (emotional thinking), Sankalpa (determination) or whatever can be knownby mind, are regarded as its objects. 19
  • 20. 1. Cintya: Things requiring thought, to think about to do or not to do with purposeful or purposeless manner. 2. Vicarya: It is a distinct analysis, which is enough to direct the mind to accept or reject a thing. 3. Uhyam: It is a speculation, hypothetical self-discussions and logical thinking about a thing. 4. Dheyeya: It is an emotional thinking about distinct thing. 5. Samkalpya: It is consideration, determination of mind about a thing. 6. Yatkincit Jneyam: Any of the emotions like Sukha, Dukha, etc. perceived by Manas are called as objects of mind.Functions of Manas: "Indriyabhigrahah Karma Manasah Svasyanigrahah l Uho Vicarasca...........................................................ll" (Ca.Sa.1/20) Indiryabhigraha (control of sense organs), Svasyanigraha (self restraint), Uha(hypothesis) and Vicara (consideration) represent the functions of mind.1. Indriyabhigraha: Manas sends the impulses and inspirations to the cognitive senses and facilitatethem for the perception of objects.2. Svsyanigraha: Controlling of own functions of self-restrain is another functin of Manas. AsManasa is called Cancala (Ca.Sa.3/21) it is necessary to have Svasyanigraha for theperception of desired objects and retraction from those after the purpose is fulfilledand from those unwanted.3. Uha: Cakrapani explained that Uha means, knowledge of perceived objects, whichis produced by complete analysis by mind. 20
  • 21. 4. Vicara: Carkrapani stated that thinking upon perceived object for its reception(Upadeya) or rejection (Heya) is Vicara.Relationship between the manas and body: As manas originated from Ahamkara due to which it is called Ahamkarika, itsnourishment continues according to the different types of consombale articles andhence manas is also said to be Bhautika on the basis of its Bhautikatva, it can besaid that manas is related to the body. As far as the knowledge production phenomenais concerned it can be very easily concluded that the manas has got relationshipwith the living body. In the pathological condition it is seen that if the mind is affected by someetiological factors the psychological disorders will be produced, which will exhibitsome disturbance in the bodily functions also. Similarly if any bodily disease isproduced, some psychological symptoms will also be produced. Charaka has alsoaccepted this fact, and on the basis of this realization he tole that the mind followsthe body and vice versa (Ca.Sa.4/36)Relationship between the mind and Indriyas: As the manas is related to the body it is also related to the sense organs. Thisrelationship can be explained by one example regarding the process of knowledgeproduction. It has been stated that for the production of knowledge. Four components are required viz Atma, manas, Indriyas and Arthas (Ca.S1/32-34) If and only when they are interrelated with one another, the knowledge isproduced. This relation is called Sannikarsa. First of all, the Atma unites with themanas. By the union of Atma, manas assumes cetanata and its motility will beinspired. Then it will unite with the Indriyas, which will get the activation of manasand cetana of Atma. Finally the Indriyas will be united with the Arthas and theknowledge will be produced. Here in this example, though the direct contact between 21
  • 22. the Indriyas and Arthas take place, the contact of manas and Atma is also necessarythought, not apparent.Relation between ATMA And MANAS: According to charaka atma is nirvikara (uneffected by physical andpsychological oilments, cause for conscioussness nitya (perpetual and ever lasting),Drasta (objerver of all activities). Through atma is nirvikara, only when mind comesin contact with atma one can experience pleasure or misery. (Ca.Su. 1.50)Manasa Prakruti: Since living being is a subtle representation of the universe, the mind in livingorganism is also having the three major attributes i.e. satva, rajas and tamas. Eachindividual has different temperament and mental personality based on thepredominance of these universal attributes.Satvika Prakriti: "Anrusamsyam samvibhagaruchita titikshna satyam dharma Asthikyam Jnanam Buddhirmedha smiriti dhritiranabhishangascha" (Su.Sha.4) Kindness, Discretion in the use of articles, Forgivness, Truthfulness,Righteousness, faith in god, knowledge, wisdom, Intelligence, memory, Firmnessnon-attachment.Rajasika prakriti: "Dhunkhabahulata Atanaseelata Adhrutirahamkaara Anrutikatvamakarunyam dambho maanah harsha kama Krodhasya" (Su.Sha.4) Excessive miseries, Roaming spirit, unsteady nature, pride, falseness,unkindness, havghtiness, vanity, pleasure, lust. 22
  • 23. tamasika prakriti: "Vishaditvam nastikyam adharmaseelana buddhernirodho Ajnanam durmedhasthavam akarmaseelata Nidraluptam cheti" Dispondency or sorrowfulness, Atheism, unrighteousness, pervertedintelligence, ignorance, lethargy, sleepyness. These three main prakritis are subdivided into 16 kayas or satvas both bycharaka and susruta.SATVIKAYAS: Caraka Susruta1. Brahma Sattva: Purity, love for Brahma-Kaya: Cleanliness of person truth, self controlled; Power of and conduct, belief in existence of discrimination, material and God, a constant reader of Vedas a spiritual knowledge, power of worship and reverence of elders and exposition, reply and memory, preceptors, hospitality and celebration freedom from passion, anger, gree, of religious sacrifice. ignorance, Jealousy, dejection and intolerance; and Favourable disposition equally for all creatures.2. Arsa Sattva: Devotion to sacred Rishi-Kaya: Divine contemplation, rituals, sacred vos oblations, observance of vows, complete sexual hospitable disposition, freedom abstinence, performance of Homas from pride, ego, attachment, greed celebration of divine of spiritual and anger, intellectual excellence science. and eloquence and power of understanding and retention 23
  • 24. 3. Aindra Sattva: Lord-ship and aut- Mehendra-Kaya: Valour, command horitative speech, performance of constant discussion of sastra sacred rituals, Bravery, strength, maintance of servants and dependents freedom from means acts, for and magnanimity. sightedness and devotion to virtuous acts, earning for wealth and proper satisfaction of desire.4. Yamya sattva: Observance of Yamya-Kaya: Sense of duty. correctness in actions, initiation of Promptness, firmness of action action, non-violability, readi-ness courage, purity and absence of anger, for initiating action, memory and illusion, fear and malice. lordship, freedom from attachment, envy, hatred and ignorance.5. Varuna Sattva: Bravery, patience, Varuna-Kaya: Liking for exposure to purity and dislike for impurity: cold, forbearance, a brown hue of observance of religious rites pupils, golden color of the hair and fondness for aquatic sports, a sweet speech. version for mean-acts, and exhibition of anger and pleasure in proper place.6. Kaubera Sattva: Possession of Kaubera-kaya: Arbitration of disputes, station, honors, luxuries and capacity of bearing hardships, earning attendant, constant liking of and accumulation propagation of virtuous acts, wealth and fertility. satisfaction of desire, purity and liking for pleasure of recreation.7. Gandharva Sattva: Fondness for Gandharva - Kaya: Love for garlands dancing, Singing, music and and perfumes, fondness for songs and praise, expertness in poetry, music and rover. singing, stories, historic narration and epics, constant fondness, for scents, garlands, unguents appares, association of women and men and passion. 24
  • 25. RAJASA KAYAS1. Asura Satva: bravery, cruelty, envy, Asura kaaya: Affluent in circumstances, lordship, movement in disguise, dreadful, fearless, jealous of others terrifying appearance, truthlessness, excellence, greedy, hot-tempered, fond indulge in self praise. of eating, eats without sharing.2. Rakshasa satva: Intolerance constant Rakshasa kaaya: solitary in his habits, anger, violence at weak points, fierce, jealous of others excellence, cruelty, greedy, fond ness for non externally pious, extremely ignorant. vegetarian food, excessive sleep and laziness, envious disposition.3. Paisacha satva: greedy, fondness for Paisacha kaya: eats food left by others, women, liking for staying with irritable temper, rashness shamelessness, women in lonely place, unclean materialism, liking towards women. habbits, disliking for cleanliness, cowardice and terrifying disposition, resorting to abnormal diet and regimens.4. Sarpa satva: bravery in furious Sarpa kaya: irritable, labourious, mental state, cowardice when he is cowardly, angry, double dealing, hasty not angry. Sharp reaction, excessive in eating, unsteadyness lethargy, experiencing fear while walking, taking food and other vihaaraas.5. Preta satva: Excessive desire for Preta kaya: will not share his things with food, excessively sorrowful nature others, lazyness miserableness, jealous, (aachaara, upachaara), enviou-sness, greedy, never gives daana. actions without discrimi-nation, excessive greediness and inactivity.6. Sakuna satva: attachment with Sakuna kaya: excessive indulgence in passion, excessive food and sexual act, eats incessantly, intolerance, regimens, unsteadiness, ruthless- unsteady mind. ness, un acquisitiveness. 25
  • 26. TAAMASA KAYAS1. Pasu satva: unable to solve his Pasu kaya: perversion of intellect, problems, lack of intelligence, tightfistedness, frequent sexual embarrassing food intake and life dreams, indecisive. style, always indulges in sex, excessive sleep.2. Matsya satva: cowardice, lack of Matsya kaya: unsteadyness stupidity, intelligence greediness for food, cowardice, fond of quarrel, liking unsteadyness, excessive kaama towards water. krodha, always moves from here to there liking towards water:3. Vanaspatya satva: lazyness, Matsya kaya: fondness towards indulgence in food, dificiency of staying at a same place, constant all intellecutal faculties. eating absence of dharma artha kaama. This concept of classifying people into number of groups and groubs is very uniquein nature. Lot of study is required in this field for understanding the depth of manasavignyana in Ayurveda. 26
  • 27. PHYSIOLOGY OF MANAS Physiological functions of manas can be divided into three stages/ 1. Perception (congnitive or sensory) 2. Discussion and determination 3. Stimulation or Intiation (conative or motor) Though many references regarding this topic are mentioned in the texts, theprime reference is explained in caraka samhita sharirasthana 1/22-23, the details ofwhich is as follows:1. Perception (Congnitive or sensory) "Indriyeneindriyartho Hi samanasken Grihyate" (Ca.Sa.1/22) In this stage, Indriya receives Artha if it is stimulated by manas. Caraka alsoexplains that manas is a key factor of Indriyas, if it wants to perceive Artha (Ca.Su.8/7) if perception has to occur the connection between Atma, Indriya, manas andArtha is very essential. (Ca.Su.11/12, Ca.Sa 1/33)2. Discussions and Determination: "Kalpyate manosa turdhvam gunato dosatothva l Jayate visaye tatra ya buddhi nischayatmika ll" (Ca.Sa.1/22-23) After perception, the procedure of actual analysis start these processes i.e.cintya, vicasya, uhya, dhyeya, samkalpyam etc. highlight the various objects ofmind. According to its capacity, it gives the determination to the perception. 3. Stimulation or Initiation (Conative or motor) "Vyavasyati tayavaktum kartum va buddhipurvakam" (Ca.Sa.1/23) This part of physiology of manas is related with karmendriya manas is calledubhayendriya because it connects Jnanedriya and Karmendriya. After the 27
  • 28. determination of knowledge perceived by Jnanendriya, Buddhi (intellect) takes thedecision and initiates karmendriya for desired action. In this way, beginning from congnitive and sensory, perception up to stimulationof motor reflexes, manas is playing a key role. GENESIS OF KNOWLEDGE BUDDHI DHEE DHRITI SMRITI III UHA VICARA INDRIYANIGRAHA SWANIGRAHA MANAS INDRIYA OBJECT Fig1: Phenomenon of knowledge production I. Indriyabhibhigraha karma manasah svasyanigrahah II. Uho vicarasca III. Tatah param Buddhi pravartate 28
  • 29. FACTORS INFLUENCING PHYSIOLOGY OF MANASAt metaphysical level: ATMA: It is Atma, which gives cetanatva to the manas, by which manas can attain its kartritva.At Intellectual level: BUDDHI: The characteristic of Atma, influences manas through its three dimensions viz. Dhee: Proper judgement Dhriti: Controlling power Smriti: Recall or memory (Ca.Sa.1)At physical level: Vayu: "Niyanta praneta ca Manasah l" (Ca.Su. 12/8) i.e. controller and stimulator for manas. Pranavayu is present in hridaya, indriya, buddhi & citta where its influence can be felt. Prana: "Buddhi Hridayendriya cittadhrik l" (Ah.Su.12/4) Udana: -------------Smriti kriya (Ah.Su.12/5) Udana vata is responsible for memory and action Vyana: "Prayah sarvah kriyah"l (Ah.Su,.12/6) All physical and mental activities are controlled by vyanavata. Pitta: Sadhaka: "Sadhaka hridgatam pittam l Buddhi medha Abhimanadyai " (Ah.Su.12/3) Sadhaka pittam is present in hridaya. Intellect living are controlled by sadhaka pittam. KAPHA: Normal mental functions like, concentration, tolerance, endurance are among the normal fuctions of kapha (Ah.Su.11/3). Avalambaka kapha and Tarpaka kapha are very much related with manas. 29
  • 30. DHATU: Many dhatu have functions related to manas and also some mental factors directly vitiate some dhatu. RASA: "Cintyanam ca aticintanat" (CA.Vi.5) Rasa dhatu gets vitiated due to excessive thinking of unnecessary things. RAKTA: "Kriyanam Apatighatam" (Normal mental functions) Amoham Buddhi karmanam (Distrinct knowledge) Perception and action stimulation. MAMSA: "Akshaglani" (Ah.Su.11) MEDAS: Sukhabhisanga, Alasya, Dhirata (Su.Su.15/5) Medo dhatu causes comfort, laziness, courage. ASTHI: Srama (Ca.Su17/67), Toda (Su.Su.17/9), Mohotsaha Vitiation of Asthi dhatu causes tiredness. Mohotsaha, Asthi dhatu causes attachment and enthusiasm. MAJJA: Bala (Ca.Su.13/17), Bhrama, Murcha, Tamodarshana (Ca.Su.27/7) Majja dhatu gives strength, Bhrama, Murcha. Vitiation of Majja dhatu causes confusion and fainting. SHUKRA: Harsa, Dhairya, Peeti, Ananda, Kama Shukra dhatu causes happiness, courage, liking, bliss, interest.Ojas and Manas: It is the essence of all dhatu through which mind and body are related. Bothmind and ojas are seated in Heart. Ojas is depleted by mental emotions such asAnger, Grief (Su.Su.15/23). When ojas is depleted, the person becomes fearful, worried, and his facultieswill not be functioning properly. He will lack enthusiasm (Ah.su.11/39) and contary,to this increase of ojas is conductive to the proper functioning of mind (Ah.su.11/41) The description of the influencing factors on the physiology of manas andparticularly influence between manas and sharira can be easily understood throughthis shloka: "Shaviram hi api Sattvamanuvidheeyate, Sattvam ca shariram l" (Ca.Sa.3/19) 30
  • 31. Both body and mind interact with one another in all spheres of life. Subtlemind required some factors for its activity in the gross body. Manas seated in pancabhavtic body is according to "padmapatramivambhasanyaya" water drop on lotus leaf never adheres to it, but its root is always in water. Inthe same way, manas is seated in the body even though it has got its own identityand speciality. The karmas of manas in gross body occur through the functional faculty ofbody i.e. Tridosa. Manas activate bodily functions through the calaguna of vata,Artha Grahana medha, and Buddhi all these activities of manas occur throughTikshna guna of pitta. manas influence the stability of bodily functions throughsthira guna of kapha. Caraka gives much importance to sparsanendriya. According to him, "Thesense of touch alone pervades all the senses. It is permently associated with mind.The mind again pervades the sense of touch. The latter, in form pervades all thesenses. (Ca.Su.11/33). This clearly indicates the importance of sparsanendriya. Nosensation occurs without the sense of touch. For perception of their artha all Indiryasrequire the sense of touch. Hence, the relation of manas with twak, the adhisthanaof sparsanendriya is explained in scientific manner, by caraka ATMA VATA PITTA KAPHA BUDDHI DHEE DHRITI MANAS TWAK SMRITI (sparsanendriya Adhisthana) RASADI SATTVA DHATUs RAJAS TAMAS OJAS Fig: 2- Factors Influencing Psysiology of Manas 31
  • 32. MANOVAHA SROTAS The detailed description of Manovahasrotas is not seen in the Srotovimana,i.e. along with other srotases, even though 13 channels are enumerated for humors.It is however said that vata, pitta and Sleshma traverse the entire body throughkinds of Srotamsi along with the Manasika dosas, which are beyond sense perception.Hence the entire sentient body is their vehicle and field of the operation. Classical literature regarding the channels does not directly enumerate thechannels of mind in the context of Unmada and Apasmara, Caraka has mentionedabout Manovaha Srotas, but also in other contexts like Mada, Murccha, and Sanyasadifferent other terms like "Cetanavahi srotas," "Samjnavahi Srotas" are used. Theseterms can be taken as synonyms for Manovaha Srotas. (Ca.su.24/25, Ca.Ni.7/4, and Ca.ci.9/5, Su.U.61/10) UNDERSTANDING HUMAN BRAIN To interpret the manasa vignyana to this modern era we need a detailedknowledge of brain, its functions and the factors that influence brain. Neuroanatomyis the branch of anatomy that studies the anatomial organization of the nervoussystem. The human nervous system is divided into the central and peripheral nervoussystems. The central nervous system consists of the brain and spinal cord, and playsa key role in controlling behavior. The peripheral nervous system is made of all theneurons in the body outside of the central nervous system, and is further subdividedinto the somatic and autonomic nervous systems. The somatic nervous system ismade up of afferent neurons that convey sensory information from the sense organsto the brain and spinal cord, and efferent neurons that carry motor instructions tothe muscles. The autonomic nervous system also has two subdivisions. The sympatheticnervous system is a set of nerves that activate what has been called the "fight-or-flight" response that prepares the body for action. The parasympathetic nervoussystem instead prepares the body to rest and conserve energy. 32
  • 33. Following are the parts of brain and their functions Brain Function Structure Cerebral The outermost layer of the cerebral hemisphere which Cortex is composed of gray matter. Cortices are asymmetrical. Both hemispheres are able to analyze sensory data, perform memory fuctnions, learn new information, form thoughts and make decisions. Left Sequential Analysis: Systematic, logical interpretation of Hemisphere information. Interpretation and production of symbolic information: language, mathematics, abstraction and reasoning. Memory stored in a language format. Right Holistic Functioning: Processing multi-sensory input Hemisphere simultaneously to provide "holistic" picture of ones environment. Visual spatial skills. Holistic functions such as dancing and gymnastics are corrdinated by the right hemisphere. Memory is stored in auditory, visual and spatial modalities. Corpus Connects right and left hemisphere to allow for Callosum communication between the hemispheres. Forms roof of the lateral and third ventricles. Frontal Lobe Front part of the brain; involved in planning, organizing, problem solving, selective attention, personality and a variety of "higher cognitive functions" including behavior and emotions. The anterior (front of the frontal lobe is called the prefrontal cortex. It is very important for the "higher cognitive functions" and the determination of the personality. The posterior (back) of the frontal lobe consists of the premotor and motor areas. Nerve cells that produce movement are located in the motor areas. The premotor areas serve to modify movements. 33
  • 34. Partial Lobe The frontal lobe is divided from the parietal lobe by the central culcus. One of the two parietal lobes of the brain located behind the frontal lobe at thetop of the brain. parietal Lobe, Right-Damage to this area can cause visuo- spatial deficits (e.g.the patient may have difficulty finding their way around new, or even familiarplaces). Parietal Lobe, Left-Damage to this area may disrupt a patients ability to understand spoken and / or written language. The parietal lobes contain the primary sensory cortex which controls sensation (touch, pressure). Behind the primary sensory cortex is a large associatio area that controls fine sensation (judgment of texture, weight, size, shape).Occipital Lobe Region in the back of the brain which processes visual information. Not only is the occipital lobe mainly responsible for visual reception, it also contains association areas that help in the visual recognition of shapes and colors. Damage to this lobe can cause visual deficits.Temporal Lobe There are two temporal lobes, one on each side of the brain located at about the level of the ears. These lobes allow a person to tell one smell from another and one sound from another. They also help in sorting new information and are believed to be responsible for short- term memory. Right lobe-mainly involved in visual memory (i.e. memory for pictures and faces). Left lobe- Mainly involved in verbal memory (i.e. memory for words and names). The limbic system includes the structures in the human brain involved in emotion, motivation, and emotional association with memory. The limbic system influences 34
  • 35. Limbic system the formation of memory by integrating emotional states with stored memories of physical and subcortical brain structures. Amygdala: Involved in signaling the cortex of motivationally significant stimuli such as those that are reward and fear related; Hippocampus: Required for the formation of long- term memories Cingulata gyrus: Autonomic functions regulating heart rate and blood pressure as well as cognitive and attentional processing; Fornicate gyrus: Region encompassing the cingulate, hippocampus, and parahippocampal gyrus; Hypocampus, and parahippocampal gyrus; Hypothalamus: Regulates the autonomic nervous system via hormone production and release. Affects and regulates blood pressure, heart rate, hunger, thirst, sexual arousal, and the sleep/wake cycle; Mammillary body: Important for the formation of memory; Nucleus accumbens: Involved in reward, pleasure, and addictio; Orbitofrontal cortex: Required for decision making; Parahippocampal gyrus: Plays a role in the formation of spatial memory and is part of the hippocampus; Subcortical gray matter nuclei. Processing link between thalamus and motor cortex. Initiation andBasal Ganglia direction of voluntary movement. Balance (inhibitory), Postural reflexes. Part of extrapyramidal system: regulation of automatic movement 35
  • 36. STRUCTURES OF DIENCEPHALON(with in the cerebrum & continues with the midbrain) Brain Function Structure Thalamus Processing center of the cerebral cortex. Coordinates and regulates all functional activity of the cortex via the integration of the afferent input to the cortex (except olfaction). Contributes to affectual expression. Hypothalamus Integration center of Autonomic Nervous System (ANS): Regulation of body temperature and endocrine function Anterior Hypothalamus: Parasyampathtic activity (maintenance fuction) Posterior Hypothalamus: Sumpathetic activity ("Fight" or "Flight", stress response. Behavioral patterns: Physical expression of behavior appestat: Feeding center Pleasure center. Internal Capsule Motor tracts Reticular Activating Responsible for arousal from sleep, wakefulness, System attention.THE CEREBELLUM AND THE BRAIN STEM Brain Structure Function Cerebellum The portion of the brain (located at the back) which helps coordinate movement (balance and muscle coordination). Damage may result in ataxia which is problem of muscle coordination. This can interfere with a persons ability to walk, talk, eat, and to perform other self care tasks. 36
  • 37. Midbrain Nerve pathway of cerebral hemispheres. Auditory and Visual reflex centers. Cranial Nerves: CN III - Occulomotor (Related to eye movement), (motor), CN IV - Trochlear (Superior oblique muscle of the eye which rotates the eye down and out), (motor)Pons Respiratory Center. Cranial Nerves: CN V - Trigeminal (Skin of face, tongue, teeth; muscle of mastication), (motor and sensory) CN VI - Abducens (Lateral rectus muscle of eye which rotates eye outward), (motor) CN VII - Facial (MUscles of expression), (motor and sensory) CN VIII - Acoustic (Internal auditory passage), sensory)Medulla Crossing of motor tracts takes place hereOblongata Cardiac Center Respiratory Center Vasomotor (nerves having muscular control of the blood vessel walls) Center Centers for cough, gag, swallow, and vomit. Cranial Nerves: CN IX - Glossopharyneal (Muscles and mucuous membranes of pharynx, the constricted openings from the mouth and the oral pharynx and the posterior third of tontue.), (mixed) CN X - Vagus (Pharynx, larynx, heart, lungs, stomach), (Mixed) CN XI - Accessory (Rotation of the head and shoulder), (motor). CN XII - Hypoglossal (Intrinsic muscles of the tongue), (motor) 37
  • 38. ETIMOLOGY OF ATATTVABHINIVESHA Atattvabhinivesha has been included under the group of manasa rogas anddescribed within the chapter of Apasmara in charaka samhita no other scholars ofAyurveda described it in their text. The name of disease carries specific meaning, soit is necessary to go through the composition of the word Atattvabhinivesha and itsvarious meanings. Atattvabhinivesha consists of two terms viz. Atattva and Abhinivesha Atattva: A When used as a prefix with the word Tattva, menas an absence ofTattva. Vyutpati i.e. Derivation of the word Tattva (faminine gender). It has beensynthesized from the root words tan and krip by applying Tuk as termination, whichmeans Tasya Bhavah i.e. nature of the thing (shabda kalpa-druma, 1961 orvachaspathyam, 1961) Shabdastoma mahanidhi follows the same in explaining the word: Explanation: According to gode and kurve (1958), the world Tattva menasthe true state or condition, fact, reality. Another sanskrit english dictionary by monier williams (1981) gives themeanings of Tattva as true or real state, truth, reality etc. On the basis of above meanings of Tattva, we can state clearly that Atattvameans an absence of the real - state, truth or reality.Abhinevesha: Vyutpati i.e. derivation: The composition of the word Abhinivesha ( masculinegender) is based on the root words Ni, Vish and Bhave with prefix Abhi by applyingDhanj as termination which means "MANAH SAMYOGA VISHESHA i.e. anattachment with mind (Shabdakalpadrama 1961) 38
  • 39. In vachaspatyam (1962), slight different synthesis of the word "Abhinivesha"is given. According to it, the root words Ni and vish with prefix Abhi and Dhanyas termination compose the word Abhinivesha. Abhinivesha as devotion firm attachment, intentness being occupied with,adherence to, close application etc. Study affection, devotion, determination i.e. toeffect a purpose or attain on object, adherence to etc. Thus Atattwabhinivesha means Above substratum helps us to conclude the exact meaning of the wordAtatvabhinivesha i.e. being occupied with or with a firm attachment with mind ofwhich is not true or in real state. 39
  • 40. SAMANYA NIDANA OF MANASA ROGAS1. All kinds of manasika vikaras occurs due to non-attainment of what is desired and attainment of what is non-desired.2. Charaka has mentioned the principle causes of all saririka and manasika rogas as a) prajnaparadha b) asatmendriyartha samyogam c)Parinamam.. (Cha.sa.1:102)a. Prajanaparadha: The state at which Dhee, Dhriti and smirit are detoriated, there by whatever activities the person does is called prajnaparadha. Acharya charaka had classified prajnaparadha as 3 types namely a) vak b) manah c) sarira, and each one again subdivided into hinayoga, mithyayoga, atiyoga. (Cha.su,.11:42) Udirnavegavidharana is one of the nidanas of Atattvabhinivesha, which can be taken under mithya. yoga of sharirika karma, type of prajnaparadha.b. Asatmendriyartha samyogam: The state of compatability between Indiryas and Indriyarthas as Ayoga, Atiyoga, Mithya yoga is termed as Asatmendri yartha samyogani. (Cha.su.11)c. Parinamam: The state of atiyoga, Ayoga, mithya yoga of kala (seasons) is termed as parinama.3) Rajas and tamas are stated as the manasika doshas of whose vitiation manasa rogas like kama, krodha, Bhayo etc. are generated. (Che.vi:8).Hetu of Atattvabhinivesha (one of manasika roga): Ayurvedic description of the etiology of this disease is available in charakasamhita which are as follows: It has been cleared that Raja and moha or tama are manas doshas and these canproduce the features like Kama, Krodha, Moha, Bhaya, Chinta, Udvega, Shoka etc. 40
  • 41. When ones mind or spirit are covered by raja and tama, susceptibility towardsatattvabhinivesha occurs.2. Malina Ahara Shilata: Continuous use of impure diet is cause of poor nutrition. As we know that poornutritional status may provoke several somatic as well as prychic disorders, likewise,it may produce atattvabhinivesha also.3. Udirna vega vidharana: Supression of the natural urges is a mithya yoga of sharirika karma and it issimply one type of prajnaparadha i.e. volitional trangression (Ch.su.11:41) charakahas narrated that budhdhya vishama vijnana i.e. misconception of intellect is to beonders as prajnaparadha (Cha.sha.1:109).4. Excessive use of shita, ushna, ruksha, snigdha etc. Excessive use of shita, ushna, ruksha, snigdha etc: These are the causes for thevitiation of Tridosha. ETIOLOGY OF OCD In modern medicine the following etiological factors are described (Ref: KAPLAN & SADOCKS synopsis of psychiatry)Neurotransmitters: Serotonin: Research evidence supports the possibility that there is dysregulationin serotonin (5-hydroxytryptomine function) q 5-hydroxy indoleacetic acid (5-HIAA) levels in the C.S.F. may be reduced q Mcpp (a 5-HT agonist) may exacerbate symptoms q Meterogline (a 5-HT agonist) may ameliovate symtpoms Other neurotransmitters, nor-adrenaline and dopamine, have been implicated inthe etiology of OCD.Brain Imaging: Functional brain imaging: PET (Positron emission tomography shows increasedactivity in the frontal lobes, basal ganglia (especially caudate) and lingulum of patientwith OCD.Structural brain imaging: CT, MRI shows smaller caudates bilaterally. 41
  • 42. Genetics: These is a significant genetic component and family studies shown an increasein OCD in relatives of sufferers. In twin studies, monozygotic (MZ) concordance isslightly higher than dizygotic (DZ.)Behavioral factors: According to learning theorists, obsessions are conditioned stimuli. A relativelyneutral stimulus becomes associated with fear or anxiety through a process ofrespondent conditioning by being paired with events that are noxious or anxietyproducing. Thus, previously neutral objects and thoughts become conditioned stimulicapable of provoking anxiety or discomfort. Compulsions are established in a different way. When a person discovers thata certain action reduces anxiety attached to an obserssional thought and developsactive avoidance strate in the forms of compulsions or ritualistic behaviours to controlthe anxiety. Gradually, because of their efficacy in reducing a painful secondarydrive (anxiety, the avoidance strategies become fixed as learned patterns ofcompulsive behaviors.Psychological factors: a) Personality factors: The majority of patients with OCD do not havepremorbid obsessional personality triats. Only about 15 to 35 percent of patientswith OCD have permorhid obsessional triats. b) Psychodynamic factors: Three major mechanisms are said to be operatingin OCD.Isolation: Under ordinary circumstances, a person is conscious both of the affect and theimagery of an emotion largen idea. When isolation occurs the affect is seperatedfrom the idea. When isolation occurs the affect is seperated from the idea and ispushed out of consciousness, and the person is aware only of the affectless idea.Undoing: A compulsive act that is performed in an attempt to prevent or undo theconsequences that the patient irrationally fears from the frightening obsessionalthought or impulsive.Reaction formation: Involves behaviour and consciously experienced attitudes that are exactly theopposite of the underlying impulses. 42
  • 43. SAMPRAPTI OF ATATTVABHINIVESHA (Cha.chi. 10: 51-56) Samprapti is described as the series of events taking place right from thebegining of the accumilation of doshas due to indulgence in NIdana upto completemanifestation of the disease. The way by which the doshas are vitiated and themanner in which they spread and produce the disease by involving dushyas andultimately manifesting the various features of the disease are described undersamprapti. Describing the samprapti of Attattvabhinivesha, Charaka observes, "In a person,in whom the Atma is enveloped by Raja, and Tama and who is addicted to theingestion of malinahara i.e. spoild food and is habituated with vegavarodha and thedoshas become prakupita due to excessive shita, ushna, snigdha and ruksha sevaraand get localised in Hridaya, impair the pathways of the manas and buddhi. In thiscondition, the mana and Buddhi become enveloped by Raja and Tama and Hridayadisturbed by rampant doshas. The individual (thus affected) becomes mudha andalpachetana he tends to formulate vishama buddhi relating to the true and false, andwholesome and unwholesome. Authorities entitled to an opinion to such a conditionas atattvabhinivesha. From this above mentioned samprapti the following conclusion can be drawn. 1. In this disease, Rajomohavritta atmana i.e. enveloped mana or Atma by Raja and Tama, is to be taken as a condition of vitiated manasika doshas. Malinahara shilata and vegavarodha are to be treated as vitiation shariraka doshas. 2. The vitiation of manas and shariraka doshas due to the above causitive factors remains in leenavastha. 3. When a person is having the leenavastha of sharirika and manasika doshas, indulges excessive and promiscuous shita, ushna and snigdha, ruksha etc., the doshas becomes prakupita. 4. Then they lodged in the Hridaya and impair the strotas of mana and buddhi. 43
  • 44. 5. In this condition, two processes are continued side by side. a) Further vitiated manasika doshas envelops buddhi and mana b) Hridaya is disturbed by the rampant doshas.6. A person thus, affected becomes mudha and Alpachetana.7. Due to envelop mana and Buddhi by Raja and Tama and vyakula Hridaya, Vishama Buddhi relating to the true and false and the wholesome and unwholesome.Thus, a person becomes affected by the disease Attattvabhinivesha. SAMPRAPTI OF ATATTVABHINIVESHARajomohavritta Malinahara Sevana VegavarodhaAtmana Leenavasthna of Doshas Excessive use of Shita, Ushna and ruksha, snigdha Sevama etc. Tridosha prakopaImpairment of the Lodging inSrotas of Buddhi Hridayaand Mana Mudha Hridaya Vyakula Alpachetana (Disturbance of condition Hridaya by Rampant Doshas) Vishama Buddhihi Nityanitye Hitahite ATATTWABHINIVESHA 44
  • 45. SAMPRAPTI GHATAKA In the pathogenesis of Atattvabhinivesha, both sharirika and manasika doshasare involved.Three sharirika doshas: Caraka, while describing in the samprapti of Atattvabhinivesha has used theword Doshas. This plural world Doshas indicated involvement of Tridosha. Furtherthis condition is also supported by the fact that in nidana, excessive use of shita,ushna and ruksha, snigdha have been mentioned here, shita is responsible for vataand kapha; ruksha for vata; ushna for pitta and snigdha for kapha provocations.Further, malinahara may also be taken one of the cause for the vitiation of Tridosha.In this way, it may be concluded that, in Atattvabhinivesha all the three doshas areinvolved.Manasika doshas: The involvement of raja and tama has been clearly mentioned in the sampraptiof atattvabhinivesha. Dushya: In Atattvabhinives buddhi is intact, judgement becomes vishamaand the patient is unable to judge the difference between Nitya and Anitya, Hita andAhita. Here Dushya is Buddhi.SROTAS: The involvement of manovaha and buddhivaha srotas is a basic featurein this disease.MARGA: Involvement of hridaya indicates that this disease is of madhyama marga. On the basis of above discussion, the samprapti Ghataka of Atatvabhiniveshaare as follows: Dosha Three sharirika doshas and two manasika doshas Dushya Sapthadhatus specially Rasa Dhatu Srotas Manovaha, Buddhivaha Adhisthana Hridaya, mana Marg Madhyama marga 45
  • 46. RUPA OF ATATTVABHINIVESHA (Cha.chi.10:56) Charaka has not mentioned detailed symptomatology of atattvabhinivesha butoccurance of vishama buddhi for the judgement of nitya, anitya and hita, ahita, hasbeen noted in these patients.Vishama Buddhi: According to charaka, the Indriyas along with mana when come in contactwith their subject, that particular object is cognised and it may be taken as first partof Buddhi (Cha.sah.1:21) Thereafter, this object is analysed by mana taking into consideration itsproperties or merits ordemerits, the object is interpreted or understood, and it isknown as nischayatmaka buddhi (cha.sa.1:22) There after proper action or reaction take place. As evident from Pathogenesis of Atattwabhinivesha the first part of buddhii.e. cognitions remains intact and only nischayatmaka buddhi i.e. judgement becomesvishama and the patient is unable to judge the difference between nitya, anitya andhita, ahita on this basis it may also be said that due this error of buddhi, the patientmay feel Hita in Ahita and Nitya in Anitya. In additon to this Hridaya vyakulata, mudha and Alpachetana have also beennarrated in the samprapti of this disease. Moreover, in this disease, vishama buddhi is the main feature and other facultieslike mana, sanjna, Jnana, smriti, Bhakti, shila, chesta and achara are not affect. Sohe understands his suffering from this discase and wants to get rid of it, hence hecomes to the physician for treatment. Thus the following is the symptomatology of Atattwabhinivesha 1. Occurence of Vishamabuddhi for the judgement of Nitya, Anitya and Hita, Ahita 2. Hridaya Vyakulata, mudha and Alpachatana 3. Avarana of Atmana by Raja and Tama The modern views follows: 46
  • 47. DIAGNOSIS AND CLINICAL FEATURES OF OCD (KAPLAN & SADOCKS synopsis of psychiatry) As part of the diagnostic criteria for OCD, the text revison of the fourth editionof diagnostic and statistical manual of mental disorders (DSM. IV-TR) DSM - IV - TR Diagnostic criteria for OCD. A. Either obsessions or compulsions: Obsessions as defined by (1) (2) (3) and (4)1. Recurrent and peristant thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.2. The thoughts, impulses, or images are not simply excesive worries about real - life problems.3. The person attempt to ignore or supress such thoughts, impulses, or imgages or to neutralize them with some other thought or action.4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind.Compulsions as defined by (1) and (2)1. Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. Praying, Counting, repeating words silently) that the person feels driven to perform in response to an obsession or accoding to rules that must be applied regidly.2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to mentralize or prevent or are clearly excessive.B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.C. The obsessions or compulsions are marked distress, time comsuming (take more than 1 hour a day); or significantly interfere with the persons normal 47
  • 48. routine, occupational (or academic) functioning, or usual social activities or relationships.D. If another axis 1 disorder is present, the content of the obsessions or compulsins is not restricted to it. (e.g. hair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder).E. The distrubance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) Symptom patterns The presentation of obsessions and compulsions is heterogenous is adults. Obsessions Compulsions Contamination - 45% Checking - 63% Doubts - 42% Washing - 50% Somatic - 36% Counting - 36% Need for symmetry - 31% Symmetry and precision - 28% Aggressive - 28% Hoarding - 18% Sexual - 26% Multiple comparisons - 48% Other - 13%Multiple obsession - 60% Contamination: The most common pattern is an obsession of contamination,followed by washing or accompanied by compulsive avoidance of the ontaminatedobject. The feard object is often hard to avoid (e.g. feces, urine, dust, or geru).Patients may literally rub the skin of their hands by excessive hand washing or maybe unable to leave their homes because of fear of germs, patients with contaminationobsessions usually believe that contamination is spread from object to object orperson to person by the slightest contact. Doubts: The second most common pattern is an objession of doubts, followedby a compulsion of checking, the doubt the gas knob is not turned off properly and 48
  • 49. an a result gas may leak and cause a fire accident. The checking may involve multipletrips back into the house to check the stove. Intrusive thoughts: In the third most common pattern, there are intrusiveobsessional thoughts without a compulsion. Such obsessions are usually repetitiousthoughts of a sexual or aggressive act that is reprehensible to the patient. Patientsobsessed with thoughts of aggressive or sexual act may report themselves to policeor confess to a priest. Symmetry: The foorth most common pattern is the need for symmetry orprecision. Which can lead to a compulsion of slowness. Patients can literally takehours to eat a meal or shave their faces. Other symptam patterns: Religious obsessions and compulsive hoardingare common in patients with OCD. 49
  • 50. DIAGNOSIS AND CLINICAL FEATURES OF OCD (kaplan & sadocks synopsis of psyche) As part of the diagnostic criteria for OCD, the Text revision of the fourthedition of Diagnostic and Statistical Manual of mental disorders (DSM.IV.TR) DSM - IV-TR Diagnostic criteria for OCD.A. Either obsessions or compulsions:Obsessions as defined by (1) (2) (3) and (4):1. Recurrent and peristant thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.2. The thoughts, impulses, or images are not simply excessive worries about real - life problems.3. The person attempts to ignore or supress such thoughts, impulses, or images or to neutralize them with some other thought or action.4. The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind.Compulsions as defined by (1) and (2)1. Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly.2. The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. 50
  • 51. B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.C. The obsessions or compulsions are marked distress, time comsuming (take more than 1 hour a day); or significantly interfere with the persons normal routine, occupational (or academic) functioning, or usual social activities or relationships.D. If another axis 1 disorder is present, the content of the obsessions or compulsions is not restricted to it. (e.g. hair pulling in the presence of trichotillomania; concern with apeparance in the presence of body dysmorphic disorders)E. The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, amedication). Symptom patterns The presentation of obsessions and compulsions is heterogenous is adults. Obsessions Compulsions Contamination - 45% Checking - 63% Doubts - 42% Washing - 50% Somatic - 36% Counting - 36% Need for symmetry - 31% Symmetry and precision - 28% Aggressive - 28% Hoarding - 18% Sexual - 26% Multiple comparisons - 48% Other - 13% Multiple obsession - 60% Contamination Obsession: The most common pattern is an obsession ofcontamination, followed by washing or accompanied by compulsive avoidance of 51
  • 52. the contaminated object. The feard object is often hard to avoid (e.g. faeces, urine,dust, or geru). Patients may literally rub the skin of their hands by excessive handwashing or may be unable to leave their homes because of fear of germs, patientswith contamination obsessions usually believe that contamination is spread fromobject to object or person to person by the slightest contact. Doubts: The second most common pattern is an objession of doubts, followedby a compulsion of checking, the doubt the gas knob is not turned off properly andan a result gas may leak and cause a fire accident. The checking may involve multipletrips back into the house to check the stove. Intrusive thoughts: In the third most common pattern, there are intrusiveobsessional thoughts without a compulsion. Such obsessions are usually repetitiousthoughts of a sexual or aggressive act that is reprehensible to the patient. Patientsobsessed with thoughts of aggressive or sexual act may report themselves to policeor confess to a priest. Symmetry: The fourth most common pattern is the need for symmetry orprecision. Which can lead to a compulsion of slowness. Patients can literally takehours to eat a meal or shave their faces. Other Symptom patterns: Religious obsessions and compulsive hoardingare common in patients with OCD. 52
  • 53. VYAVACHHEDAKA NIDANA OF ATATTVABHINIVESHA Vyavachhedaka Nidana of Atattvabhinivesha should be done with Unmada. The Differential Diagnosis of Atattvabhinivesha and UnmadaIn context Atattvabhinivesha UnmadatoHetu No specific indications Specifically Bhiru and regarding susceptibility of Utklista Sattva persons are this disease susceptible for this disease. Mild form of etiological Gravity of the etiological factors factors of Unmada is so much that they cause severe mental trauma (upahata Mana) in the patientsRupa Not described in detail, The person who is suffering but Hridaya Vyakulata, from Unmada is said to have Mudha, Alpachetana, hallucinations, illusions etc. Vishama Buddhi etc. which differs in contrast to suggest disabling symptoms Atattvabhinivesha. with relatively intact psychic functionsSamprapti In etiopathology of Vibhrama, a comparatively Attattvabhinivesha, severe condition of Buddhi, Vishama Buddhi has alongwith Vibhrama of smriti, been considered. Bhakti, Shila, Chesta, Achara, Sanjna, Jnana, play an important role in manifestation of Unmada. Only the vishamatva i.e. Vibhrama i.e. confusional derangement of Buddhi state of Buddhi along with is noted Vibhrama of other eight factors are noted. Ref: Cha. Chi.9, 10 53
  • 54. DIFFERENTIAL DIAGNOSIS OF OCD1. Depressivedisorder: Obsessional symptoms and depressive symptoms often occurtogether. Depression often occurs secondary to long-standing OCD. conversely 30%of severe depressives develop obsessional symptoms. The two conditions are bestdistinguished by their courses. Depressives developed obsession, in this condition obsessions are found inthe depression state only remaining period obsessions are not found. Depression, secondary to long standing OCD, in this conditions obsessionsare not only found in the depression state but also in remaining period also.2. Generalized anxiety disorder (GAD): The comorbidity of OCD with GAD isof inferest because of the seeming similarity between obsessions in OCD and worriesin GAD. GAD is characterized by chronic, uncontrollable excessive worry about everyday or real life problems, such as work, finances, job responsibilities, saftey offamily members or even minor matters such as household chores, car repairs orbeing late to offices. Obsessions are not simply excessive worries about everyday or real lifeproblems, but rather are unwanted, irrational and onreasonable infrusions. In addition,must obsessions are accompanied by compulsions that reduce the anxiety.3. Phobias: Phobias are characterized by recurrent, excessive, irrational fear of aspecific object or situation. Phobias and OCD have similarities in that the fears are recognized by thepateint to be irrational. Phobics tend to have a direct fear of the object or situation, whereas OCDsufferes tend to fear the imagined consequencies. 54
  • 55. 4. Body dysmorphic disorder.BDD is an obsessive preoccupation with a perceiveddefect in ones physical appearance. A relatively high comorbidity exists between BDD and OCD. The symptomsof the two disorders are similar: They are characterized by obsessive preoccupationsand checking. The characteristic difference between these disorders is insight. Insight ofpatients with BDD seems to be significantly more impaired than that of patient withOCD. This lack of insight can lead to a delay in seeking psychiatric treatment.Instead, because they consider their perceived defects to be real.5. Hypochondriasis: The fear or belief that one has a severe illness characterizeshypochondriasis. This fear is based on an individuals misinterpretation of signs and symptoms,and results in multiple doctor visits and medical tests. Patients tend to indulge inripetitive checking of the body for symptoms of an alleged medical condition, andinternet searching for information about illness and their symptoms this behaviourpersists despite medical reassurance that the individual does not have a disease orillness. Hypochondriasis and OCD are common comorbid condition both theconditions have similar clinical picture. However, there are some differences, whichhelp in differentiating OCD from hypochondriasis. (1) In OCD there is a fear of getting an illness whereas in hypochondrians there is a fear of having an illness. (2) Insight is fairly well preserved in OCD, but in hypochondriasis there is a high degree of conviction that they have a disease. 55
  • 56. SADHYASADHYATA Detailed description regarding sadhyasadhyata is not mentioned in our classics,however Charaka was mentioned Atattwabhiniesha as the synomy of Mahagada. Clincal correlation of Atattwabhinivesha in this study has been considered asObsessive Compulsive Disorder (OCD), and in modern psychiatric texts, OCD hasbeen mentioned as having prognosis of about 20 to 30 percent of patients will havesignificant improvement in their symptoms, and 40 to 50 percent have moderateimprovement. The remaining 20 to 40 percent of patients either remain ill or theirsymptoms worsen. In the absence of prognosis of Atattwabhinivesha in Ayurvedic texts, and thisdiesase is compared with OCD. The modern description of prognosis of OCD maybe considered fit for Atattwabhinivesha also. 56
  • 57. PRINCIPLES OF TREATMENT The involvement of both sharirika and Manasika Doshas has clearly been mentionedin the Samprapti of Atattvabhinivesha. It is observed that the psychic as well as somaticfactors have equal importance in the causation of this disease. So, when we are dealingwith the treatment, the importance of the psyche as well as the Soma are necessary to beconsidered.Management of Manasika Rogas in General: Various factors have been taken for consideration while planing for the treatment ofManasika Rogas, and can be divided into several divisions as per classics. They aredescribed below:1. Acharya Charaka emphasized the general line of treatment for all the diseases under the title Trividha Aushadham. Under this category: a) Daiva Vyapashraya b) Yukti Vyapashraya and c) Sattvavajaya have been explained (Ch.Su.11:54). Out of the above three, DaivaVyapashraya and Sattvavajaya are taken as the major line of treatment in the managementof Manasika Rogas. Daivavyapashraya like Mantras, Manidharana etc. is a sort of faith treatment derivedmainly from Atharvaveda; whereas Sattvavajaya advocates Ahitebhyo ArthebhyoManonigraha i.e. control of mind from unwholesome objects. It may be considered as thepsychotherapy of modern psychiartry (Singh R. 1987)2. Further, while describing the principles of treatment of manasika rogas, charaka prescribes the following methods of treatment (Ch.Su.1:58). Jnana - Knowledge of Atma and religion Vijnana - Knowledge of Shastra 57
  • 58. Dhairya - Fortitude Smriti - Memory Samadhi - Concentraiton Vagbhata also has described the same matter in other words (A.H.Su.1:26). Dhee,Dhairya and Atmadi Vijnana are indicated by him as the best remedial measures of ManoDosha. The specific note on Dhee or Buddhi is of importance in reference toAtattvabhinivesha, where Buddhi Vaishamya is considered to be vital element in pathology.3. In other reference, Charaka mentions a few more methods of treatment (Ch.Su. 11:47) viz. Trivarga Anvavekshanam - Contempleting of the three objectives of life. Tadvidyaseva - Service of those who are well versed in the knowledge. Atmadinam cha - The knowledge of ones own self etc. in Sarvashaha Vijnanam all respects.4. In context to Achara Rasayanha, more stress has been emphasized to perform the regimens in the classics (Ch.Chi, 1-4: 30-35); which has a direct effect in potentiation of the Sattva property of Mana. It is considered as the vitalization process through good conduct, thus the same may proves as a preventive factor of Manasika Rogas.5. Besides these, assurance and replacement of opposite emotions (viz. Kama for Krodha etc.) are also deemed a part of Manasa Roga Chikitsa. Incase, when the disease is caused by the emotional disturbances like Kama, Krodha, Shoka etc., such the above emotional factors should be replaced by the opposite side (Ch.Chi.9:6). The same principle has been advocated in treating fevers caused by Kama and Krodha (Ch.chi. 3:322).6. The another glimpse for the treatment of mental disorders may be accepted from Charaka Samhita, where he has depicted two types of therapies viz.: 58
  • 59. 1. Dravyabhoota Chikitsa 2. Adravyabhoota Chikitsa In context to Adravyabhoota Chikitsa, he has narrated following remedies: Bhaya Darshana- Frightening Vis-mapana - Causing surprise Vis-marana - Obliterating memory Kshobhana - Administering shock Harshana - Inducing elation Vadha - Thrasing Bandhana - Binding Swapna - Inducing sleep (Ch.Vi. 8:87) Above mentioned Adravyabhoota therapies may be followed for the treatment ofmanasika rogas.7. Sushruta, while describing Unmada Chikitsa, narrated that in Unmada and all other Manasika Rogas, Chittaprasadana i.e. propitiation of the mind should be done (Su.Ut. 62:34). Here, Chittaprasadana may be taken as a motto for the treatment of all Manasika Rogas. Besides the above methods of the treatment, stress has also been laid on the avoidanceof Prajnaparadha and Asatmyendriyartha Samyoga, observance of Sadvritta and DharaniyaManasika Vegas (Ch.su. 7:26-27; Ch.Su. 8:17); Ch.Su. 7:53). 59
  • 60. NON-DRUG THERAPY OF ATATTVABHINIVESHA Above mentioned regimens are the principle line of treatment for all theManasika Rogas. But, When we are dealing with specific therapy ofAtattvabhinivesha, it has been stated that, as a non drug therapy, the propitiousfriends of the patients and trusted mentors, who can expound to him both his moraland material good should instill into his Vijnana. Dhairya, Smriti and Samadhai(Ch.Chi.10:63). These measures are similar to that, which are described for allManasika Rogas. In this direction, the author of Bhaishajya Ratnavali has narrated that,reassurance, friendly behaviour, encouragement, palliation and good service to thepatient may help in relieving this disease. (Bhai.Ra. 78:5)DRUGS USED IN THE MANAGEMENT OF ATATTVABHI-NIVESHA: Even though, the disease is not explained in very detail in Charaka Samhita,still its specific treatment is given (Ch.Chi. 10:61-62). Further, in BhaishajyaRatnavali also, the specific management of Atattvabhinivesha is indicated underthe chapter of Gadovega Chikitsa.a) Drug therapy mentioned in Charaka Samhita: The patient of this disorder should first be subjected to Snehana and Swedanafollowed by Shodhana. Thenafter the Sansarjana Karma - rehabilitation of strength- is to be followed. When the patient regains the strength, he should be administeredMedhya Anna and Pana. Further, patient should be given the Panchagavya Ghritaalongwith Brahmi Swarasa, Shankapushpi etc. Medhya Rasayana Dravyas.b) Drug therapy mentioned in Bhaishajya Ratnavali: Drugs which have the Vatanulomana, Deepana, Pachana, Pittahara andKaphahara property are indicated for the management of Atattvabhinivesha. The treatment mentioned in Vatavyadhi chapter like Ghrita, Taila,Rasaushadham and Rasayana should also be provided to the patients of 60
  • 61. Atattvabhinivesha. In addition to the above therapeutics, he prescribed the compoundpreparations like Yamanyadi Churnam, Kshirodadhi Rasa and Gandharaja Tailam. It is worth mentioned here that Charaka has emphasized on Medhya Rasayanaswhile delineating the drug therapy of Atattvabhinivesha. So, the detailed descriptionsof Medhya Rasayana are being described hereafter.MEDHYA RASAYANA The word Medhya Rasayana consists of two terms viz. Medhya and Rasayana. Medhya: The word Medhya is derived from the word Medha adding Yatsuffix means which is beneficial to Medha - Medha Hitam Medhyam." The Medhyais concerned with Prabhava i.e. Achintya Shakti (Rasavaisheshika Sutra 4:27) Here,it is necessary to describe the relative word Medha. MEDHA: The word Medha is originated from the root Medhr Sangame -Medhati Te - (Amarkosha). Vagbhata has quoted Medha as a property of Sadhaka Pitta (As.Hr. Su. 12:13).Arundatta, while commenting on it, has mentioned "Buddhi Vishesha Medha" inthe sense of prerogate to Buddhi (Arunadatta on As. Hr. Su. 12:13). Dalhana hascommented the Medha as "Sarvato Avyahata Sukshmatama Pragadha BuddhihiShrutadharini (Dalhana on Su. Chi. 28:1-2), means it is an unobstructed, minuteand very deep Buddhi, which is possessing learning; elsewhere he has narrated theMedha as Grantha Avadharana Shakti in the meaning of perception and retentionpower of knowledge (Dalhana on Su. Su. 1:1 18-19). The Monnier Williams (1981)has translated it as mental vigour and mental power etc. RASAYANA: Rasayana is concerned with the promotion of physical andmental health according to Charaka. Rasayana is a mean by which one gets RasaRakta etc. Dhatus of optimum quality (Ch.Chi. 1-1:8). Further, on the basis of various 61
  • 62. definitions described in classics (Su.Su. 1:16, As.Hr. Utt. 39:1; Sha.Pu. 4:14, Bha.Utt.79:1) it may be stated that Rasayana is a therapy which provides optimum qualityof the bodily tissues due to which it promotes both physical and mental health,prevents ageing and diseases and thus enables to live for a longer period ofyouthfullness. In conclusion, it may be stated that Medhya Rasayana means, a therapy ordrugs which promotes Medha i.e. mental vigour. Moreover, in general, every Rasayana drug is supposed to be Medhya butquite a few of such drugs have been described to possess a predominance of mentaleffects. Such drugs have been described as Medhya Rasayana (Ch.Chi. 1-3:30)Such as Shankhapushpi, Mandukparni, Guduchi, Yasti etc. This fact has been furtherclarified and is given greater emphasis by Sushruta and his commentator Dalhana(Su.Chi. 28:2), who puts Medha Kamyam Rasayana as a seperate class whileclassifying the Rasayana as a separate class while classifying the Rasayana (KamyamRasayana) drugs. 62
  • 63. DRUGS REVIEWCriteria for selection of Medhyadrugs Acharya Charaka has explained a disease entity as Atattwabhinivesha, whichis also named as mahagada in sutra and chikitsa sthanas (Cha.chi.10/56). In thiscontext, vishama buddhi is the prime factor for Atattwabhinivesha i.e. nischayatmakaJnana of buddhi has lost, which is similar to the case of Obsessive CompulsiveDisorder (OCD) here vishama buddhi is the basic. It is a type psychological disorderhaving main characteristics as obsessive thougths and ideas, which are sometimesaccompained by compulsive behaviours and actions, often designed together asobsessive compulsive disorder. Susruta has mentioned some drugs as manasarogahara gana in uttar tantra.Amanushopasarga adhyaya (su.sa. utt 60/46-53). These are vacha, sarpagnadha,Jatamamsi, aparajita. Charaka described yastimadhu as medhyarasayana. Keeping the above mentioned views in mind, I have prepared an Ayurvediccompound medicine comprising four medhya Rasayana drugs which are as follows. 1. Aparajita moola choornam - 4 gms 2. Sarpaganda moola choornam - 1 gm 3. Vacha choornam - 1 gm 4. Yasti choornam - 4 gms In addition, Jatamamsi was administered in qvatha form. These compound drugs suits the samprapti vighatana of Atattwabhinivesacondition and comprise of best nidrajanaka, akshepaka samaka chittodvegahara andmedhyakara dravyas. Further Jatamamsi qvatha anupana will fortify this compound. Since no data is recorded of these drugs clinical efficacy, this study has beenunder taken to put the effects of these drugs on staistically records. This study hasbeen undertaken with special reference to obsessive compulsive disorder, since 63
  • 64. atattwabhinivesha is eqvated with it. (Professor: R.H. Singh - Ayurvedamanasavignanam Pg. no. 156).Method of Preparations: An Ayurvedic compound drug is made up of 4 medhya rasayana drugs, namelyAparajita, Sarpagandha, Vacha, and Yasti. Sarpagandha, Vacha, Yasti, Jatamansi are collected from Govt. AyurvedicPharmacy, Hyderabad. Aparajita is collected from the market. All these drugs are powdered coarsely, later on finely powdered and of those,aparajita moola churna as 4 gms. Sarpaganda moola churna 1 gms, Vacha churnam1 grm, Yasthi churnam 4 gms are taken, mixed thoroughly until an uniform mixtureof compound drug is obtained. For clinical trials, the compound drug was packed 150gms each packet whichis suitable for 15 days dosage, where the patients is advised to take 5 gms twice aday.Preparation of Jatamansi kvatham: The kvatha of jatamansi was prepared by adding eight times (80 ml) of waterto 10 gms of powder of Jatamansi and boiled till one fourth part of total liquid(20ml) remained. The fresh kvatha of jatamansi was prepared in morning and eveningand was administered to the patients. 64
  • 65. VACHABotanical Name : Acorus calamusFamily : ARACEAEGanas : Sirovirecana, Sanjnasthapana, sitaprasamana, Lekhaniya, Arsoghna, Triptighna, (Charaka) Pippalyadi, mustadi, Vacadi (Susruta)Synonyms : Ugragandha, Golomi, Sataparvika, SadgrandhaVernacular Names : Hindi - Vacha Telugu - Vasa English - Sweet flag Tamil - Vasambu Malayalam - BavambuProperties : Rasa - Katu, tikta Guna - Laghu, tikshna Virya - Usna Vipaka - KatuKarma : Kapha - vata hara, lekhaniya, medhyaIndications : Unmada, apasmara, jvaraPart used : RhizomeDosage : Powder 125 - 500 mg 65
  • 66. Research : 1. Asarone antagonised the hyper-activity and hallucinogenic effect of mescaline in and offered protection to aggregated mice treated with dextroamphetamine (Dandiya and menon, 1965) 2. It was found that the sedative effect of asarone was dependent of the depression of the ergotropic division of the hypothalamus (menon and dandiya 1967) 3. Asarone reduced spontaneous motor activity and caused reduction in anxiety without dulling the perception in rats. It produced calming effect in monkeys. Asarone failed to cause release of 5-HT from the brain. It also prevented the depletion of adrenal ascorbic acid in rats subjected to cold stress (Dandiya and menon 1964 a & b) 66
  • 67. SARPAGANDHABotanical Name : Rauwalfiya serpentinaFamily : ApocyanaceaeGanas : Aparajita gana (uttaratantra susruta)Synonyms : Gandramara, Dhavala vitapa, nakuli, sugandha nakulesta.Vernacular Names : Hindi - Chota chand Telugu - Patala garuda English - Serpentina root Malayalam - Civan amalpodiProperties : Rasa - Tikta Guna - Ruksa Virya - usna Vipaka - KatuKarma : Kapha - vata hara, nidrajanakaIndications : Apasmara, Unmada, Siragatavata, Anidra, BhramaPart used : RootDosage : 3-6 gr.Chemical constituents : Reserpine (an indole alkoloid) is the antihypertensive principle having tranquilizing property also. 67
  • 68. YASHTI MADHUBotanical Name : Glycyrrhiza glabraFamily : FABACEAEGanas : Charaka-Jivaniya, Sandhaniya, Varnya, Kanthya, Kandughna, Chardinigrahana, Sonitasthapana, Mutraviranjaniya, Snehopaga, Vamanopaga, Asthapanapaga. Susruta - Kakolyadi, Sarivadi, Anjanadi Vagbhata - Sarivadi, AnjanadiSynonyms : Madhuka, Madhuyasti, Madhulika, JalajayastiVernacular Names : Hindi - Mulethi English - Liquorice Telugu - Atimadhuram Tamil - Atimadhuram Gujarat - JethimadhuProperties : Rasa - Madhura Guna - Guru, Snigdha Virya - Sita Vipaka - MadhuraKarma : Tridoshahara, Rasayana, Vrisya, Caksusya, MedhyaIndications : Vranasotha, Chardi, Trisna, Visavoga, Daha, Raktapitta, Hridroga, VranaPart used : RootDosage : Powder 3-5 grmResearch : Glycyrrhetic acid protected guineaping against bronchospasm induced by histamine or 5-HT. It significantly lowered plasma corticosterone concentration although adrenal weight remained unaltered (tangriet al, 1960) 68
  • 69. APARAJITABotanical Name : Clitoria ternataFamily : FABACEAEGanas : Sirovirecanopaga (Charaka)Synonyms : Asphota, Girikarni, Visnukranta, Sankhapuspi, Sephanda, Sveta, Maha svetaVernacular Names : Hindi - Koyala Telugu - DintenaProperties : Rasa - Katu, tikta, kasaya Guna - Laghu, ruksa Virya - Sita Vipaka - KatuKarma : Tridosahara, medhya, visaghna, chaksusyaIndications : Kustha, Sotha, Unmada, Vrana, SulaPart used : Root, seedsDosage : Root powder 1-3g, seed powder 1-2 gr.Therapeutic uses : Manasaroga: Root of white flowered aparajita is pounded with rice water and used as nasya by mixing with ghee. (R.M.) 69
  • 70. JATAMANSIBotanical Name : Nardostachys JatamansiFamily : ValerianaceaeGanas : Sanjaasthapana, Kandughna, Tikta skandha (charaka) Elajanadigana, Eladigana (susruta)Synonyms : Tapasvini, Nalada, Pisita, Bhutajata, vilomasaVernacular Names : Hindi - Jatamansi Telugu - Jatamanis English - Spikenard Malayalam - JatamansiChemical constituents :Properties : Rasa - Tikta, kasaya, madhura Guna - Laghu, snigdha Virya - Sita Vipaka - KatuKarma : Tridosahara, Medhya, Kustaghna, BalyaIndications : Visaroga, asmari, apasmara, unmada, vatarakto etc.Part used : RhizomeDosage : Powder 1-3 grResearch : 1. The essential oil from the rhizomes had a depressant action on the CNS of guinea pigs, rats (Chopra et al . 1954) 2. Root powder (60g) showed a sedative action in a clinical study on 24 medical students as evidnece by prolongation of the visual reaction time (Anin et al, 1961) 70
  • 71. MATERIALS AND METHODSMaterials: Drug PatientsDrugs: Susruta has mentioned some drugs as manasarogahara gana in uttara tantra,amanushopasarga adhyaya. These are Vacha, Sarpagandha, Jatamansi, Aparajita.Charaka has described yastimadhu as medhyarasana. Keeping in view a compositionprepared from Aparajita, vacha, sarpagandha, yasti churna which suits the sampraptivighatana of atattwabhinivesha condition. An Ayurvedic compound churna wasformulated consisting of:1. Ayurvedic Compound: 1. Aprajita moola choornam 4 gms 2. Sarpa ganda moola choornam 1 gm Mix well to make the medicine 3. Vacha choornam 1 gm 4. Yasti choornam 4 gms2. Jatamansi Kwatha: Symptoms like insomnia are very troublesome to the patients. Jatamansikwatha was also given simultaneously. It should be noted here, that Jatamansi isalso a medhya rasayana drug and it is more effective in the form of kashaya onManasarogas and insomnia.Sample / Patients: Total 41 patients were screened and among them 11 discontinued treatment.The present study deals with 30 patients of diagnosed Atattwabhinivesha.Source: From OPD of Kayachikitsa of the G.A.H. Erragadda, Hyderabad, and OPD ofPsychiatry, Gandhi Medical College/ Hospital, Hyderabad. 71
  • 72. Design of the study: Open trialDiagnosis: The patients were registered. The physical and psychological examination wereperformed. Based on the symptomatology of Atattwabhinivesha discribed in calssicaltext and Text revision of the fourth edition of Diagnostic and Statistitical manual ofmental disorders (DSM IV TR) criteria, the patients were finally diagnosed. Target symptoms such as contamination obsessions, sexual obsessions,pathological doubts, agressive obsessions, religious obsessions, washingcompulsions, checking compulsions, repeating rituals, counting compulsions,miscellaneous compulsions, of each patients were identified basing on the YaleBrown Obsessive Compulsive scale (Y-BOCS) check list. The severity of OCD was assessed basing on Yale Brown ObsessiveCompulsive scale (Y-BOCS).Inclusive criteria 1. Symptomatology of Atattwabhinivesha and obsessive compulsive disorder (OCD) as described in the text. 2. Patient with a score of above 7 points in obsession and compulsive rating scale 3. Age group in between 15-50 yrs 4. No discrimination of Sex, Caste, and ReligionExclusive criteria 1. Patients with a score of above 30 points in obsession and compulsive rating scale 2. Below 15 yrs and above 50 yrs. 3. Patients with other psychological disorders 72
  • 73. Administration of the drug Method of preparation: Described under drug review Dosage: 5 grm. BID Time of administration - 1/2 an hour after meals Anupana - 20 ml of Jatamansi qvatham Duration - 45 daysCriteria for assessment: Clinical assessment was done before and after the treatment using Yale-BrownObsessive Compulsive Scale (Y-BOCS) Y-BOCS SYMPTOM CHECKLIST (9/89)Aggressive Obsessions Current PastFear might harm selfFear might harm othersViolent or horrific imagesFear will act on unwanted impulsesFear will steal thingsFear will harm others because not careful enoughFear will be responsible for something elseterrible happening 73
  • 74. CONTAMINATION OBSESSIONSContamination obsessions Current PastConcerns of disgust with bodily waste orsecrectionsConcenr with dirt or germsExcessive concern with environmentalContaminantsExcessive concern with household itemsExcessive concern with animalsBothered by sticky substances or residuesConcerned will get ill because of contaminantConcerned will get others ill by spreadingcontaminantSEXUAL OBSESSIONS Current PastForbidden or perverse sexual thoughts,images, or impulsesContent involves children or incestOtherRELIGIOUS OBSESSIONS Current PastScrupulosity) Concerned with sacrilege andblasphemyExcess concern with right/wrong, moralityOther 74
  • 75. OBSESSION WITH NEED FOR Current PastSYMMETRY OR EXACTNESS(Accompanied by magical thinking (concernedthe mother will have accident unless things and inthe right place)Not accompanied by magical thinkingMISCELLANEOUS OBSESSIONS Current PastNeed to know or rememberFear of saying certain thingsFear of not saying just the right thingFear of losing thingsFear of losing thingsIntrusive (non-violent) imagesLucky/unlucky numbersColors with special significance Superstitious fearsCLEANING/WASHING COMPULSIONS Current PastExcessive or ritualized handwashingExcessive or ritualized showering, bathing,toothbrushing, grooming, or toilet routine.Involves cleaning of household items or otherinanimate objectsOther measures to prevent or remove contactwith contaminantsOtherREPEATING RITUALS Current PastRe-reading or re-writingNeed to repeat routine activitiesOthers 75
  • 76. COUNTING COMPULSIONS Current PastORDERING/ARRANGING COMPULSIONS Current PastMISCELLANEOUS COMPULSIONS Current PastMental rituals (other than checking/counting)Excessive listmakingNeed to tell, ask, or confessharm to self, harm to others, terrible consequencesOther TARGET SYMPTOM LIST OBESESSIONS: 1. 2. 3. COMPULSIONS: 1. 2. 3. 76
  • 77. Obsession Rating Scale -Item- - Range of severity -1. Time spent 0 hrs/day 0-1hrs/day 1-3hrs/day 3-8hrs/day 8+hrs/day Score 0 1 2 3 42 Interference None Mild Definite Substantial Incapacitating from but manag- Incapacitating obsessions eable Impairment Score 0 1 2 3 43. Distress None Little Moderate Severe Near constang, from but manag- Disabling Obsessions eable Score 0 1 2 3 44. Resistance Always Much Some Often Completely to Obsessions resists Resistance Resistance Yields Yields Score 0 1 2 3 45. Control Over Complete Much Some Little No Obsessions Control Control Control Control Control Score 0 1 2 3 4Compulsion Rating Scale -Item- - Range of severity -1. Time spent 0 hrs/day 0-1hrs/day 1-3hrs/day 3-8hrs/day 8+hrs/day Score 0 1 2 3 42 Interference None Mild Definite Substantial Incapacitating from but manag- Incapacitating obsessions eable Impairment Score 0 1 2 3 43. Distress None Little Moderate Severe Near constang, from but manag- Disabling Obsessions eable Score 0 1 2 3 44. Resistance Always Much Some Often Completely to Obsessions resists Resistance Resistance Yields Yields Score 0 1 2 3 45. Control Over Complete Much Some Little No Obsessions Control Control Control Control Control Score 0 1 2 3 4 77
  • 78. Total Y-BOCS score: Range of severity for patients who have both obsessionsand compulsions 0-7 Subclinical 8-15 Mild 16-23 Moderate 24-31 Severe 32-40 ExtremeGradation of Results: At the end of the treatment the total effect of the therapy was assessed in theterms of Complete remission, Marked imrovement; Moderate improvement, Mildimprovement and Unchanged with the following criteria.Complete cure : 100% relief in symptomsMarked Improvement : Above 50% below 75% relief in symptomsModerate Improvement : Above 25% below 50% relief in symptomsMild Improvement : Below 25% relief in symptomsUnchanged : No relief in symptoms 78
  • 79. OBSERVATIONS & RESULTS 41 patients of Atattvabhinivesha were registered, out of which 11 patientswere discontinued the treatment, their results were not included in this series. Theresults of remaining 30 patients of Atattvabhinivesha (obsessive compulsive disorder)who have completed the full course are being presented here in detail. The age, sex, religion, occupation etc. along with the findings of dasavidhapariksha of all the 30 patients of Atattvabhinivesha (obsessive compulsive disorder)studied in this series were as follows:According to Age:Table No. 1S.No. Age No. of patients Percentage1 20-30 18 602 31-40 11 36.63 41-50 1 3.4 All the patients of this series were between the age of 20- 50 yrs. The maximum(60%) were from the age group of 20-30 years followed by the group 31-40 yearswhich had 36.6% of patients. 41-50 years age group contained 3.3% of the patients. 18 16 14 12 10 No. of Patients 8 6 4 2 0 20-30 31-40 41-50 79
  • 80. Table No.2: According to Sex: S.No. Sex No. of patients Percentage 1 Male 13 43.33 2 Female 17 56.67 56.66% patients of this study were females and remaining 43.44% were males 43.33% 56.67%Table No.3: According to Religion: S.No. Religion No. of patients Percentage 1 Hindu 22 73.33 Male Female 2 Muslim 7 23.33 3 Christian 1 3.34 In this study most of the patients (73.33%) were Hindus. 23.33% patients aremuslim and only 1 patient (3.3%) is christian. (Table 3) 25 20 15 Series1 10 5 0 Hindu Muslim Christian 80
  • 81. Table No.4: According to Occupation: S.No. Occupation No. of patients Percentage 1 Household workers 10 33.33 2 Employee 9 30 3 Business 2 6.67 4 Students 6 20 5 Labour 3 10 Maximum number of the patients (33.33%) were coming from house hold workersfollowed by employs (30%). Out of the remaining 20% patients were students, 10% patientswere labour and 2 patients were belonging to business respectively 10 9 8 7 6 5 No. of patients 4 3 2 1 0 House hold Employee Business Students 81
  • 82. Table No.5 According to Economical status: S.No. Economical status No. of patients Percentage 1 Poor 9 30 2 Low middle 8 26.66 3 Middle 10 33.34 4 Upper middle 3 10 An attempt was made to find out monthly income of the patients andaccordingly they were clasifed into poor, lower middle, middle and uper middle.(poor = below Rs.5,000, Lower middle = Rs.5000-10000, Middle = Rs.10000-20000,Upper middle=Above Rs.20000)Accordingly the classification of the patientsshowed that the maximum patients (33.33%) of the study were from poor class. The30% patients were from middle class followed by 26.6%. Patients from low middleclass. Remaining 10% patients were from upper middle class (Table 5) 10 9 8 7 6 5 4 3 2 1 0 Poor Low Middle Upper middle Middle 82
  • 83. Table No.6: According to Educational status: S.No. Educational status No. of patients Percentage 1 Un-educated 0 0 2 Primary 10 33.33 3 Secondary 5 16.67 4 Graduate 15 50 In this study, the maximum (50%) patients had graduation followed by 33.3%of patients educated upto primary level. 16.6% were secondary level. 33.33% 50% 16.67%Table No. 7: According to Habitat: S.No. Habitat No. of patients Percentage Un-Educated Primary 1 Urban 24 80 Urban Secondary Rural Graduate 2 Rural 6 20 In this study majority of patients (80%) were belonged to urban area, andremaining 20% of patients were belonged to rural area. 20% 80% 83
  • 84. Table No.8: According to Addiction:S.No. Addiction No. of patients Percentage1 Tea 10 33.32 Tobaco chewing 1 3.33 Pan 3 104 Alcoholic+smoker 3 105 Only smoker 4 13.36 Chating 1 3.37 Nil 8 26.8 In this study majority (33.3%) patients had Tea addiction followed by 26.6%of patients had no addiction. 10% patients had pan chewing. 3 patients are alcoholic+ smokers. 1 patients had tobaco chewing and another 1 patient was addicted tochotting. 10 9 8 7 6 5 4 3 2 1 0 Tea Alcoholic+Smoker Nil 84
  • 85. Table No.9: According to Dehaprakriti: S.No. Dehaprakriti No. of patients Percentage 1 Vata pitta 12 40 2 Vata kapha 12 40 3 Pitta kapha 6 20 In this study majority of the patients were of vata pitta and vata kapha prakriti(both are 40%). The remaining 20% patients were pitta kapha prakriti. 20% 40% 40%Table No.10: According to Manasaprakriti: S.No. Manasaprakriti No. of patients Percentage Raja Tam 1 Rajas 15 50 2 Tamas 15 50 All the patients belonging to rajas and tamas prakriti in this study they are inequal number (both are 50%) 50% 50% 85
  • 86. Table No. 11: According to Sara: S.No. Sara No. of patients Percentage 1 Twak 0 0 2 Rakta 4 13.4 3 Mamsa 11 36.6 4 Medo 5 16.6 5 Asthi 10 33.3 6 Majja 0 0 7 Sukra 0 0 Most of the patients of this series had mamsa sara (36.6) and Asthisara (33.3%).16.6% patients were medudara and remaing 13.3% patients were rakta sara patients. 12 10 8 6 4 2 0 Twak Mamsa Asthi Sukra 86
  • 87. Table No. 12: According to Samhana: S.No. Samahana No. of patients Percentage 1 Madhya 15 50 2 Avara 12 40 3 Pravara 3 10 In this study most of the patients were belonging to madhyama samhana (50%).40% of patients were Avara samhana and 10% of patients were pravara samhana.Table No. 13: According to Sattva: S.No. Sattva No. of patients Percentage 1 Pravara 0 2 Madyama 8 26.4 3 Avara 22 73.6 In this study 73.6% of pateints were Avara satva and remaining 26.4% ofpatients were belonging to Madhyama satva. No patient was having Pravara sattva. Madyama Pravara 0 5 10 15 87
  • 88. Table No. 14: According to Chronicity: S.No. Chronicity No. of patients Percentage 1 up to 1 year 5 16.7 2 1 - 3 year 15 50 3 3 to 6 year 5 16.7 4 6 to 9 year 3 10 5 9 to 12 year 2 6.6 In this study, 16.7% of the patients were suffering from this disease since 1year, 50% patients were having the chronicity of 1-3 years. Out of the remaining16.7% patients were 3-6 years. 10% having 6 to 9 years chronicity and 6.6% patientswere suffering from this disease move than 9 years. 9-12 years 6-9 years 3-6 years 1-3 years Up to 1 year 0 5 10 88
  • 89. Table No. 15: According to Marital status: S.No. Marital status No. of patients Percentage 1 Un-married 9 30 2 Married 21 70 In this study 70% patients were married and 30% patients were un married.Table No. 16: According to Marital life: S.No. Marital life No. of patients Percentage 1 Un-Satisfactory 15 50 2 Satisfactory 6 20 3. Un-Married 9 30 Out of the 30 patients of this series 21 patients are married. Among them 50%were belonged to Un-satisfactory marital life. 20% were belonged to Satisfactorymarital life, remaining 30% patients belonged to Un-married catogery.Table No. 17: According to Occupational life: S.No. Occupational life No. of patients Percentage 1 Satisfactory 9 30 2 Unsatisfactory 21 70 In this study 70% were belonged to unsatisfactor occupational life, remaining30% were belonged to satisfactory occupational life. Marital Status Occupational Life 89
  • 90. Table No. 18: According to Type of obsessions: Types of obsessions reported by the 30 patients of obsessive compulsivedisorder of this series have been shown in table - among the type of obsessions,60% of patient having contamination obsession. Pathological doubts and sexualobsessions are found in equal percentage (40%) of patients 23.3% of patients havingagressive obsessions, need for symmetry is 20% of patients having and 13.3% ofpatients having religious obsessions. S.No. Type of obsessions No. of patients Percentage 1 Contaminations 18 60 2 Doubts 12 40 3 Sexual 12 40 4. Savings 5 16.6 5 Agressive 7 23.3 6 Religious 4 13.3 7 Need for symmetry 6 18 20 8 Miscellaneous 0 16 0 14 12 10 8 No. of Pa 6 4 2 0 1 2 3 4 5 6 7 8 Contaminations Sexual symmetry Agressive Doubts Savings Miscellaneous Religious Need for 90
  • 91. Table No. 19: According to Type of compulsions: S.No. Type of compulsion No. of patients Percentage 1 Washing compuls 15 50 2 Checking 10 33.3 3 Repeating rituals 4 13.3 4 Counting 5 16.6 5 Ordering 4 13.3 6 Hoarding 3 10 7 Miscelleneous 0 0 Types of compulsions reported by the 30 patients of obsessive compulsive ofdisorder of this series have been show in table - Among the types of compulsions50% of patients were having washing compulsions. Checking copulsions are foundin 33.3% of patients. Repeating rituals and ordering compulsion are found in equalpatients with the 13.3%. 16.6% of patients were having counting compulsion and10% of patients having hoarding compulsions. 16 14 12 10 8 No. of Patients 6 4 2 0 1 2 3 4 5 6 7 Ordering Washing compuls Miscellaneous Checking Counting Repeating rituals Hoarding 91
  • 92. RESULTS Yale Brown obsessive compulsive scale (Y-BOCS) has been considered asthe assessment creteria for the present study conducted in 30 patients. Result wereassessed basing on the score obtained, which are as follows:Table showing the relief percentage. Item Rang of severity BT AT Relief % 1. Time spent on obsessions 75 60 37.5 2 Interference from on obsessions 64 49 37.5 3. Distress from on obsessions 56 43 32.5 4. Resistance to on obsessions 52 45 17.5 5. Control Over on obsessions 34 28 15 6. Time spent on Compulsions 59 49 25 7 Interference from on Compulsions 53 35 45 8. Distress from on Compulsions 44 41 75 9. Resistance to on Compulsions 41 35 15 10.Control Over on Compulsions 29 23 15 The above table shows the relief percentage obtained in decreased in range ofseveority of both obsessions and compulsions. Table showing the statistical parameters. Mean SD SE t P 3.26 2.46 0.45 7.1 <0.001 92
  • 93. Table showing the total outcome of the treatment: S.No. No.of patients Percentage 1. Complete Cure 0 0 2. Morked improvement 0 0 3. Moderate improvement 16 53.8 4. Mild improvement 12 39.6 5. Un-changed 2 6.6 Out of 30 patients no one reported to have either complete or marked improvement16 patients (53.8%) were reported moderate improvement, 12 patients (39.6) werereported mild improvement. 2 Patients were found in the unchanged category. 6.6% 53.8% 39.6% 93
  • 94. DISCUSSION Atattwabhinivesha is a disease described only by charaka at the end ofApasmara chikitsa chapter. Literally the word Atattvabhinivesha consists of two parts i.e. Atattva andAbhinivesha, it refers to a firm attachment of being occupied with the mind whichis not true or in real state. The Vishma Buddhi in Nitya - Anitya and Hita-Ahita is the major. Feature ofAtattvabhinivesha. In comparison to unmada this is a minor disease as all the ninefaculties are not involved. Vishamatva denotes lesser degree of involvement. So,lesser degree of errand activities of Buddhi leading to continuous disturbed thoughtscompelling to perceive Hita as Ahita. There are many types of obsessions and compulsions, which can be understoodin accordance to the description of Atattwabhinivesham. Obsessive - compulsive disorder is an anxiety disorder characterized byobsessions or compulsions - having one or both. Obsessions are a recurring and presistent idea, thoughts or images that areoften experienced as senseless, intrusive and difficult to control. The person realizesthat these thoughts, images or ideas are the product of his or her own mind. Compulsions are repetitive, intentional and often stereotyped behaviorperformed in response to an obsession or according to certain rules. Although thebehavior is intended to neutralize or prevent some deaded event or situation, it isclearly not connected in a realistic way with what it is designed to prevent or isexcessive. (e.g. repetitive hand washing in order to prevent death). There are many types of obsessions and compulsions, which can be understoodby the description of Atattwabhinivesha. 94
  • 95. Vishama Buddhi leads to perceiving Anitya i.e. non occuring / false as Nityai.e. occuring / true. Which further leads to perceiving and or doing the activitiesAhita i.e. un-wholesome as Hita i.e. wholesome. Here patients mind is occupied with which is not true or in real state. Theword meaning of Atattwabhinivesha also refers the same meaning. considering the samprapti of Atattwabhinivesha and for better therapeuticefficacy, it is necessary to administer the medhya rasayana in a compound form,hence I have choosen an Ayurvedic compound, that contains Sarpagandha, Aparajita,Vacha, and Yastimadhu along with Jatamamsi kwatha. As Sarangadhara has mentioned Karsha is the dose for the choornas, so thepresent compound drug taken as 10gms per day. The results obtained in the study are being discussed hereunder. Majority of affected patients belong to the age group of 20-30 years, due toinsecurity, Maladaptability to conditions, stressful life style to cope up the competitiveworld, there by Vishamatva of Satva and are more suseptable to Psychologicaldisorder, particularly Atattwabhinivesha (OCD). Out of 30 patients study 16 patients are Females and 14 are that of Males.Where it shows Males and Females are nearly equally affected, which supportswith the description of Kaplan Saddock synopsis of Psycheiatry. Most of the patients of this study were Hindus. This fact is only a reflection ofgeographical predominance of particular area that Hindus being dominant in thisarea. Highest number of patients of this series came from Middle class category,may have more strain and stressfull lives, causing Alpasatva and are leading tomore prone to Atattwabhinivesha (OCD). The study denoted that maximum i.e. 80% patients were living in urban area.The mechanical and speedy life has major impact on all aspects of their lifeprecipitating Atattwabhinivesha (OCD). 95
  • 96. The study showed that 50% patients were having problem with life partner.Un-satisfactory marital life can produced various type of Psychological disorders.Particularly Atattwabhinivesha (OCD). In this study most of the patients were having Graduation, may have morestress for settlement, thus susceptibility towards the OCD. In this study most of the patients are seffering with OCD from 1-3 yearschronicity. All the patients of this series were having dvandraja deha prakriti, highestnumber of patients were belonged to vatapitta and vatakapha deha prakriti. All the patients of this series were of Raja and tama prakriti. In this study most of the patients are suffering with OCD from Avara Sattvapatients. Basing to Yale-Brown obsessive compulsive scale (Y-BOCS). The time spenton obsessions were relieved by 37.5%. Where as interference obsessions was alsoso relieved by 37.5% only. Distress from obsession was relieved only by 32.5%,least releaf i.e. 17.5% and 15% was noticed in resistnace and control over obsessionsrespectively. Compulsions range of seviority is found to be relieved only to some extent.Time spent on compulsions was relieved by 25%. Interference from compulsionswas relieved by 45%. Where as marked releaf that is 75% was noticed in distressfrom compulsions. Last releaf i.e. 15% was found in resistance and control overcompulsions. Out of 30 patients no one reported to have either complete or markedimprovement 16 patients (53.8%) were reported moderate improvement, 12 patients(39.6%) were reported mild improvement. 2 patients were recorded in the unchangedcategory. Though the results are not curative, but they are Satisfactory. 96
  • 97. In this study I have observed few patients experianced Gastritis, headache,nausia and diarrhoea during the treatment. This cannot be differentiated whether itis due to the drug given or patients psycholgoical feeling.Probable mode of Action: Medhya Rasayana yoga selected for this study contains Aparajita, Sarpagandha,Vacha, Yasti madhu in powdar form and Jatamansi in kwatha form Orally. Accordingto the pharmaco therapaetic analysis on the basis of the Rasapanchaka. It containsKatu, Tikta rasa, Katu vipaka and ushnaveerya, Jatamamsi kwatha is having Tikta,Madhura and Kashaya rasa, Katu vipaka and Sita veerya. This combination is having Tridoshahara property passifying the Vata, Pittaand Kapha involved in the manifestation of the disease. Saririka Dosha prasamanaminturn influence the manasika doshas, the doshaharatva property of the combinationalong with medhya parabhava has synerzitic action in counteracting the diseasepathogenisis. Medhya prabhava can be interpreted as having nootropic effect along withsubtle action at the neurotransmitter levels. Rationally the action of the drug can be expected at the neurotransmitter levelsince the pathology occurs there. Scientifically the action can be explained on further technical study of thepharmacodynamic and therapeutic properties.Scope for further study. 1. To generalize the out come of the treatment sample size should be increased along with increased duration of the study. 2. Placebo controled study should be taken up for still more accurate results. 3. Increasing palatability along with effective administration of the drug in either Ghrita or capsules can be taken up. 4. For the better management of the disease other therapies such as Sirodhara, Yoga etc may be included for further studies taken up along with internal medications. 97
  • 98. SUMMARY Thes is entitled "A CLINICAL STUDY ON THE EFFECT OF ANAYURVEDIC COMPOUND DRUG IN ATATTWABHINIVESHA W.S.R. toOBSESSIVE, COMPULSIVE DISORDER (OCD)." is broadly classified into 1. Conceptual study, 2. Clinical study The first part of the thesis termed as conceptual study mainly deals with theliterary aspects of the disease. In this part, at the outset, history of Manas Rogas ingeneral and Atattvabhinivesha in particular has been traced from the Vedic periodupto the 20th centruy. Thereafter an attempt has been made to define the diseaseAtattwabhinivesha on the basis of its etymology. Other main topics covered in thispart are concept of Manas, Hetu, Rupa, Samprapti and Vyavachhedaka Nidana ofAtattwabhinivesha are described. The principles of treatment of Manasa Roga ingeneral and Atattvabhinivesha in particular has been discussed. Thereafter thereasoning behind selecting the Medhya Rasayana drugs. Method of preparation anddetailed description of the properties of the drugs has been discussed in the endingof the first part. The second part of this thesis deals with the results of clinical study. In thebeginning the detailed criteria of diagnosis, administration of drugs and criteria ofassessment have been mentioned. It follows the description of the observationsrecorded pertaining to demographic aspects of 30 patients of Atattwabhinivesha(OCD) registered for the study. Thereafter the results obtained. The various aspects of the result of clinical studies have been discussed andthe conclusion are drawn. 98
  • 99. CONCLUSSION AND SUMMARY1. Atattwabhinivesha, is a psychological disorder is only vishama buddhi is involved.2. OCD is a neurotic disorder with increasing prevalance due to present stressful life style.3. Females are more prone when compare to males.4. The present study of an Ayurvedic compound along with Jatamamsi kwatha has not shown significant effect in the management of Atattwabhinivesha.5. Though symptoms are not completely releaved, but the seveority of the symptoms is reduced.6. Among all the items of the Yale - Brown obsessive, compulsive scale (Y- BOCS) distress from compulsions and obsessions showed marked releaf.7. Due to the small smaple size and short duration of the study results cannot be generalized.8. The poor prognosis observed in this study is also in accordance with in the Mahagada discription given by our Acharyas. 99
  • 100. BIBLIOGRAPHY1. Charaka samhita: With Ayurvediadipika commentry of chakrapani, Chavkhambha sanskrit Santhan, Varamasi2. Charaka Samhita:With Jalpakalpataru commentry of Gangadhara and Ayurvedadipika commentry of chakrapani Duh;Edi I.C.K.Seh & Co.Calcutta.3. Charaka samhita:Charakopaskar commentry by yogindranath sep, pub by J.N. Sen, Calcutta4. Charaka samhita: Edi. and pub Gulabkuvarba, Ayurveda society, Jamnagar.5. AP.I. Text Book of : Association of physicions of India, medicine (1979) III Edi. Bombay6. Davidsons principles & Practice of medicine (1986): J. John macleod, XIV Edi. E.L.B.S.7. KAPLAN & SADDACKS 1943, Synopsis of Psychiatry/clinical psychiatry. tenth edition, B.I. waverlop Pvt Ltd., New Delhi.8. Sushruta samhita with Nibandha sangraha comm. by Dalhana Nidanasthana Nyayachandrika comm. of Gayadas) Edited by Y.T. Achavya, edi., IV. 1980. Choukamba orientalia, varanasi.9. Asthanga Hridayans with savranga sundara commentry of A. Shashtri (1969) chavkambha sanskrit series office, Varanasi.10. Bhaishajya Ratnawali with Hindi commentry of A. Shanshtri (1969) chavkambha sanskrit series office, Varanasi11. Bhava Mishra: Bhava prakasha, Vidyottini Hindi commentry by H.P, Pandeyan: Vidya vilas press, Varanasi.12. Bibiography on Ravwolfina serpentina: Medicinal and Aromatic plants Abstr. Vol. 4 No.1 Feb 1982. 100
  • 101. 13. Ayurvediya Manasa vijnan: Prof. R.H. Singh. Chaukhanbha Ayurveda Granthamala.14. Key topics in psychiatry CE Smith P. Sudbury Bios Scientific L. BIOS publication, UK.15. How to over come mental tension. Swami gokulananda Ramakrishna missioninstitute of culture.16. Management of Unmada CCRAS17. Dwarakanath C. 1959, Intorduction to kayachikitsa popular Book Depot, Bombay.18. Sharma P.V. (1931): Dravya Guna vijnana Vol. III, Edi V. Chavkhambha Bharati Academy, Varanasi.19. Sharma P.V. (9171): Indian medicine in the classical Age. Edi. I, Chaukhambha publication Varanasi.20. Yoga Darshana by patanyali, Chavkchambha sanskrit series. Varanasi.21. Kirtikar & Basu (1975): Indian Medicinal Plants: Vol. I, II, III.22. Asberg M. Montgomercy S, perris C, et al. A. Comprehensive psychopathological rating scale. Acta psychiatrica Scandinavia 1978: 271 (suppl):5.23. Cooper J. The leyton obsessional Inventory: Psychiatric medicine 1970:1: 48- 54.24. Rachman SJ. Hodgson RH obsessions and compulsions. Prentice Hall, Engle wood elifs (1980).25. World health organization. The ICD-10 classification of mental and behavioral disorders.26. Ayurveda and mind vamadeva sastry motilala bahavasidar 101
  • 102. 27. Acharya Dr. B.A. Pathak, 1976, manasa roga vijmona, Sri Baidyanath ayurveda bhavan, Lt. Ist28. Diagnostic and statistical manual of mental disorders, 4th edition, published by American Psychiatric association 1995.29. Dorland: Pocket medical distionary, oxford and IBH pulishing Co. Pvt. Ltd. 25th edition.30. Dr. P.V. Sharma, Indian medicine in the classical age, chavkambha sanskrit series office, Varanasi.31. Indian clinical epidermiology network, Chennai,32. K.N. Udopa, stress and its management by yoga.33. Kaplan and saddocks comprehensive text book of psychiatry, 7th ed. Vol. I & II.34. M.S. Bhatiya, essentials of psychiatry. CBS publisher and distribator, 2nd ed.35. Madhavanidam of Sri Madhavakara with the "Madhukosa" Sanskrit commentary by Sri Vijaya raksita and Sri Kanthadatta with the "Vidyotini" Hindi commentory.36. Mangal S.K. Abnormal psychology, sterling publication Pvt. Ltd., Banglore.37. P.K. Gode and C.G. Karve, the practical sanskrit English dictionary edited by prasad prakashan, poora.38. Niraj Ahuja & J.N. Vyas (1999). Text book of post graduate psychiatry, 2nd edition, Jayp5ee Brothers, New Delhi.39. Nadkarni K.M., 1986, Indian Materia Medica, popular Prakashan, Bombay, vol. II: 354, Vol. III: 1291, 1808.40. Niraj Ahuja & J.N. Vyas (1999): Textbook of Postgraduate Psychiatry, 2nd edition, Jaypee Brothers, New Delhi.41. P.K. Gode and C.G. Karve, The Practical Sanskrit - English Dictionary edited by Prasad Prakashan, Poona. 102
  • 103. 42. Pandit Hemaraja Sharma, Kasypa samhita, vidyotini commentary, Chaukhamba series.43. Ramgopal Shastri, Vedon Men Ayurveda, 1956, Madan Mohanlal Ayurvedic, New Delhi.44. Sarangadhara samhita, English translation, Prof K.R. Murthy, Caukhamba.45. Shabdakalpadurama by Raja Radha Kanta Deva, The Chaukhambha sanskrit series office, Varanasi.46. Prof. D.A. kulkarni Rasaratnasamucaya, Meherchand Lachamandas, New Delhi.47. Sharma P.V., Sharma Guruprasad, 1979, Kaiyyadevnighntu, Choukhamba Orientalia, Varanasi48. Sir Monier Williams, Sanskrit - Entlish Dictionary, Etymologically and Phiologically Arranged, Oxford University Press - London.49. Sri Cakrapanidatta, Cakradatta with the "Vaidyaprabha", Hindi commentary, Chaukhambha Sanskrit Sansthana, Varanasi.50. Vachaspathyam, A Comprehensive Sanskrit Dictionary completed by Sri Tarantha Tarkavacaspati, The Chaukhambha Sanskrit Series Office.51. www.thehimalayadrugco.com of Himalaya Drugs company, Banglore.52. www.medlineplus. Depression.htm53. www.medscape.com Information about Depression54. www.nbc12.com55. www.nimh.nih.gov56. www.rpeurifoy.com/index.html57. www.loaj.com/index.html58. www.ayurvedainsrilanka.com/59. my.webmd.com/content/dmk/dmk_article_146096760. www.vedamsbooks.com/ayurveda.htm * * * 103
  • 104. Y-BOCS SYMPTOM CHECKLIST (9/89)Aggressive Obsessions Current PastFear might harm selfFear might harm othersViolent or horrific imagesFear will act on unwanted impulsesFear will steal thingsFear will harm others because not careful enoughFear will be responsible for something elseterrible happening CONTAMINATION OBSESSIONSContamination obsessions Current PastConcerns of disgust with bodily waste orsecrectionsConcenr with dirt or germsExcessive concern with environmentalContaminantsExcessive concern with household itemsExcessive concern with animalsBothered by sticky substances or residuesConcerned will get ill because of contaminantConcerned will get others ill by spreadingcontaminant 104
  • 105. SEXUAL OBSESSIONS Current PastForbidden or perverse sexual thoughts,images, or impulsesContent involves children or incestOtherRELIGIOUS OBSESSIONS Current PastScrupulosity) Concerned with sacrilege andblasphemyExcess concern with right/wrong, moralityOtherOBSESSION WITH NEED FOR Current PastSYMMETRY OR EXACTNESS(Accompanied by magical thinking (concernedthe mother will have accident unless things and inthe right place)Not accompanied by magical thinkingMISCELLANEOUS OBSESSIONS Current PastNeed to know or rememberFear of saying certain thingsFear of not saying just the right thingFear of losing thingsFear of losing thingsIntrusive (non-violent) imagesLucky/unlucky numbersColors with special significance Superstitious fears 105
  • 106. CLEANING/WASHING COMPULSIONS Current PastExcessive or ritualized handwashingExcessive or ritualized showering, bathing,toothbrushing, grooming, or toilet routine.Involves cleaning of household items or otherinanimate objectsOther measures to prevent or remove contactwith contaminantsOtherCHECKING COMPULSIONS Current PastChecking locks, stove, appliances, etc.Checking that did not/will not harm othersChecking that did not/will not harm selfChecking that nothing terrible did/will happenChecking that did not make mistakeChecking tied to somatic obsessionsOthersREPEATING RITUALS Current PastRe-reading or re-writingNeed to repeat routine activitiesOthersCOUNTING COMPULSIONS Current PastORDERING/ARRANGING COMPULSIONS Current Past 106
  • 107. MISCELLANEOUS COMPULSIONS Current PastMental rituals (other than checking/counting)Excessive listmakingNeed to tell, ask, or confessharm to self, harm to others, terrible consequencesOther TARGET SYMPTOM LIST OBESESSIONS: 1. 2. 3. COMPULSIONS: 1. 2. 3. 107
  • 108. Obsession Rating Scale -Item- - Range of severity -1. Time spent 0 hrs/day 0-1hrs/day 1-3hrs/day 3-8hrs/day 8+hrs/day Score 0 1 2 3 42 Interference None Mild Definite Substantial Incapacitating from but manag- Incapacitating obsessions eable Impairment Score 0 1 2 3 43. Distress None Little Moderate Severe Near constang, from but manag- Disabling Obsessions eable Score 0 1 2 3 44. Resistance Always Much Some Often Completely to Obsessions resists Resistance Resistance Yields Yields Score 0 1 2 3 45. Control Over Complete Much Some Little No Obsessions Control Control Control Control Control Score 0 1 2 3 4Compulsion Rating Scale -Item- - Range of severity -1. Time spent 0 hrs/day 0-1hrs/day 1-3hrs/day 3-8hrs/day 8+hrs/day Score 0 1 2 3 42 Interference None Mild Definite Substantial Incapacitating from but manag- Incapacitating obsessions eable Impairment Score 0 1 2 3 43. Distress None Little Moderate Severe Near constang, from but manag- Disabling Obsessions eable Score 0 1 2 3 44. Resistance Always Much Some Often Completely to Obsessions resists Resistance Resistance Yields Yields Score 0 1 2 3 45. Control Over Complete Much Some Little No Obsessions Control Control Control Control Control Score 0 1 2 3 4 108
  • 109. My commitment increases my level of energy. My energy increases my level of action. Myaction increases my level of success. My success increases my level of commitment.Research in any field is the most important section of development. Ayurveda is inservice is for ages to the needy mankind to relieve their ailments and recording the factsfor the future generations. At present the Ayurveda research scholar, developing theAyurveda and understanding under the limelight of contemporary scientific backgrounds.The plagiarism is more and more now a day in the scientific community. This ishappening as the researches of the various institutions are not available for the commonresearcher. We wish to control this plagiarism by contributing the dissertations forscientific community. If you find any thesis is a copy of the previous publication, we takethis issue to the university authorities for proper action. The solution to prevent copy catsis … http://ayurvedaresearch.wordpress.com/ Dr. Shiva Rama Prasad Kethamakka technoayurveda@gmail.com,