A CLINICAL STUDY ON THE EFFECT OF AN AYURVEDIC COMPOUND DRUG IN ATATTWABHINIVESHA W.S.R. to OBSESSIVE, COMPULSIVE DISORDER...
ABBREVIATIONSCh. Ni.S     =   Charaka Samhita Nidana SthanaCh. Vi.S     =   Charaka samhita Vimana SthanaCh. Sha.S    =   ...
ACKNOWLEDGE     I humbly owe every successful endeavour of my life to my beloved Parents.     I express my greatfulness wi...
Dr. Sireesha Asst. Professor, Department of psychiatry, Gandhi HospitalSecunderabad.     I am also highly thankful to Dr. ...
INTRODUCTION     In present days, psychological disroders are scaling high due to stressful lifestyles, thought of global ...
The present study is divided into 5 partsPart I - Conceptual StudyPart II - Principles of Treatment and Drug studyPart III...
HISTORICAL ASPECTVedic period (1500 BC to 500 BC ):     It is well known that the ancient Indian thought is not only rich ...
Table – 1      Table showing glimpses of mental disorders in atharva veda (Whitney, 1962) S.No    Vedic term         Subje...
Most of the hymns of atharvaveda are directly concerned with the atharvani orpsychotherapy and thus have influenced the ma...
Charaka samhita     A complete recital of psyche and psychological disorders is available in thistext, which is summarized...
14. An idealistic literature regarding etiology, pathogenesis and treatment of           apasmara i.e. epilepsy (Ch.Ni.8; ...
cha.su.19:8), but elsewhere, he denied the description of Atattvabhinivesha in thesamhita by saying that it is an adultera...
HISTORY OF OCD     Although psychiatric discussions of obsessional and compulsive phenomenadata is available from 1833, li...
Lewis (1936) proposed that the sensible, senseless dimension is not primaryimportance in the obsessional disorder. He cons...
CONCEPT OF MANAS     Human birth is a very rare privilege, for only man has the possibility of livinga conscious, wide-awa...
Healthy life, according to Ayurveda is defined as,                       "Samadosha Samagnisca SamadhatumalakriahI        ...
According to relation : Svantam (closely related to Atma)     According to shape      : Anangakam (non-morphological entit...
2. Hridaya:      Many references are available in charaka and susruta regarding the seat ofmanas in Hridaya. Both acarya h...
These are very basic characters of the mind, if it were not so, all kinds ofperceptions would have occured at a time.Other...
1. Cintya: Things requiring thought, to think about to do or not to do with               purposeful or purposeless manner...
4. Vicara:     Carkrapani stated that thinking upon perceived object for its reception(Upadeya) or rejection (Heya) is Vic...
the Indriyas and Arthas take place, the contact of manas and Atma is also necessarythought, not apparent.Relation between ...
tamasika prakriti:            "Vishaditvam nastikyam adharmaseelana buddhernirodho         Ajnanam durmedhasthavam akarmas...
3. Aindra Sattva: Lord-ship and aut-       Mehendra-Kaya: Valour, command   horitative speech, performance of       consta...
RAJASA KAYAS1. Asura Satva: bravery, cruelty, envy,    Asura kaaya: Affluent in circumstances,   lordship, movement in dis...
TAAMASA KAYAS1. Pasu satva: unable to solve his          Pasu kaya: perversion of intellect,    problems, lack of intellig...
PHYSIOLOGY OF MANAS     Physiological functions of manas can be divided into three stages/     1. Perception (congnitive o...
determination of knowledge perceived by Jnanendriya, Buddhi (intellect) takes thedecision and initiates karmendriya for de...
FACTORS INFLUENCING PHYSIOLOGY OF MANASAt metaphysical level:     ATMA:          It is Atma, which gives cetanatva to the ...
DHATU:     Many dhatu have functions related to manas and also some mental                 factors directly vitiate some d...
Both body and mind interact with one another in all spheres of life. Subtlemind required some factors for its activity in ...
MANOVAHA SROTAS     The detailed description of Manovahasrotas is not seen in the Srotovimana,i.e. along with other srotas...
Following are the parts of brain and their functions Brain              Function Structure Cerebral         The outermost ...
Partial Lobe     The frontal lobe is divided from the parietal lobe by the                 central culcus.                ...
Limbic system   the formation of memory by integrating emotional                states with stored memories of physical an...
STRUCTURES OF DIENCEPHALON(with in the cerebrum & continues with the midbrain) Brain                  Function Structure T...
Midbrain    Nerve pathway of cerebral hemispheres.            Auditory and Visual reflex centers.            Cranial Nerve...
ETIMOLOGY OF ATATTVABHINIVESHA      Atattvabhinivesha has been included under the group of manasa rogas anddescribed withi...
In vachaspatyam (1962), slight different synthesis of the word "Abhinivesha"is given. According to it, the root words Ni a...
SAMANYA NIDANA OF MANASA ROGAS1.       All kinds of manasika vikaras occurs due to non-attainment of what is         desir...
When ones mind or spirit are covered by raja and tama, susceptibility towardsatattvabhinivesha occurs.2. Malina Ahara Shil...
Genetics:     These is a significant genetic component and family studies shown an increasein OCD in relatives of sufferer...
SAMPRAPTI OF ATATTVABHINIVESHA                                                                (Cha.chi. 10: 51-56)     Sam...
5.    In this condition, two processes are continued side by side.      a) Further vitiated manasika doshas envelops buddh...
SAMPRAPTI GHATAKA     In the pathogenesis of Atattvabhinivesha, both sharirika and manasika doshasare involved.Three shari...
RUPA OF ATATTVABHINIVESHA                                                                       (Cha.chi.10:56)     Charak...
DIAGNOSIS AND CLINICAL FEATURES OF OCD                                   (KAPLAN & SADOCKS synopsis of psychiatry)     As ...
routine, occupational (or academic) functioning, or usual social activities or       relationships.D.     If another axis ...
an a result gas may leak and cause a fire accident. The checking may involve multipletrips back into the house to check th...
DIAGNOSIS AND CLINICAL FEATURES OF OCD                                           (kaplan & sadocks synopsis of psyche)    ...
B.     At some point during the course of the disorder, the person has recognized       that the obsessions or compulsions...
the contaminated object. The feard object is often hard to avoid (e.g. faeces, urine,dust, or geru). Patients may literall...
VYAVACHHEDAKA NIDANA OF ATATTVABHINIVESHA    Vyavachhedaka Nidana of Atattvabhinivesha should be done with Unmada.    The ...
DIFFERENTIAL DIAGNOSIS OF OCD1. Depressivedisorder: Obsessional symptoms and depressive symptoms often occurtogether. Depr...
4. Body dysmorphic disorder.BDD is an obsessive preoccupation with a perceiveddefect in ones physical appearance.      A r...
SADHYASADHYATA     Detailed description regarding sadhyasadhyata is not mentioned in our classics,however Charaka was ment...
PRINCIPLES OF TREATMENT     The involvement of both sharirika and Manasika Doshas has clearly been mentionedin the Samprap...
Dhairya          -       Fortitude     Smriti           -       Memory     Samadhi -        Concentraiton     Vagbhata als...
1. Dravyabhoota Chikitsa     2. Adravyabhoota Chikitsa     In context to Adravyabhoota Chikitsa, he has narrated following...
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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. Ayurvedic College, HYDERABAD

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  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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