Lecture Note: Ayurvedic Management of Psychiatric Disorders (Part-5)

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Ayurvedic Management of Psychiatric Disorders
Part-5

Prof. Muralidhara Sharma

Transcript by
Dr. Swati Sharma
Senior resident, Dept of Kriya Sharir, IMS BHU
and Dr. Varsha More

based on the lecture available at-Ayurvedic Management of Psychiatric Disorders

 

Alcohol related psychological and physical disorders  

Another common group of disorders that physicians commonly face daily in clinical practices is Alcohol related psychological and physical disorders. Now we can see that both psychological and physical disorders are related. So we are discussing them here together.

Consumption of regular alcohol is now considered as a psychological condition. In DSM-5classification alcohol and other substance induced psychotic disorders are included and explained. Substance that causes prominent hallucinations or delusions are considered under substance- induced psychotic disorders and given under DSM-5 classification. The persons who is unable to resist alcohol intake by himself/ herself is included under psychiatric condition as such which needs to be intervene. Delusions and false ideas also  could be a psychological condition as per the DSM-5 classification. Alcohol consumption according to Ayurveda is not considered as psychological illness as such. Alcohol in Ayurveda is compared to Visha (poison) while at the same time alcohol consumption in controlled quantity and quality is also suggested good for health aspect. According to current scenario, the consumption of alcohol in India is increasing rapidly based upon the market statistics. By, 2020 6.53 billion liters of alcohol is consumed in India. And majority of them are strong drinks. State wise distribution of alcohol consumption on market basis is as given below

Now, let us look at the global situation. Globally, the number of people who never consumed alcohol in India are higher than other countries as this we can see in the above figure. But at the same time consumption of alcohol is the major cause of illness in India compared to other countries.

According to Charak Samhita Madya (alcohol) is compared to Anna but at the same time if it is consumed irresponsibly considering dose and other things then it can be a poison to same human being.

किन्तु मद्यं स्वभावेन यथैवान्नं तथा स्मृतम्|
अयुक्तियुक्तं रोगाय युक्तियुक्तं यथाऽमृतम्||५९||
प्राणाः प्राणभृतामन्नं तदयुक्त्या निहन्त्यसून्|
विषं प्राणहरं तच्च युक्तियुक्तं रसायनम्||
Ch.Chi24/59,60

But contrary to the above data when it comes to consumption of strong alcohol unlike bear etc, India occupies the upper rank as shown below.

The majority of people who consumes alcohol in India, they consume stronger alcohol. This is a very paradoxical situation. Hence, when it comes to people suffering from diseases or deaths due to alcohol Indian population occupies the larger number.

Breath analysis testDe addiction

Clinically important thing is that whether the person would be helped to skip the alcohol or not. There are many medications or de addiction drugs. A few of them are Disulfiram (unpleasant feeling after consumption), Acamprostate (reduces the urge), Naltrexone (blocks the kick) etc.

So first thing to avoid alcohol is to make the person ready to leave it unless it would be quite difficult. The best of the motivation is by counselling and group motivation. Many programs of government are active these days where earlier alcoholic addicted persons are running counselling sessions for avoiding alcohol intake now. Alcoholics anonymous is one such platform available online. Family atmosphere is another important factor.

Stages of alcohol

  1. Sobriety
  2. Euphoria
  3. Excitement
  4. Confusion
  5. Stupor
  6. Coma
  7. Death

Here, first three conditions do not require any medical intervention as such. Clinically next three conditions are important to deal i.e. confusion, stupor and coma. Intravenous  fluid, glucose and vitamins, thiamine can be given for managing these three stages. No other medical intervention is needed for acute alcoholism.

Ayurveda has given four stages of alcoholism.

बुद्धिस्मृतिप्रीतिकरः सुखश्च पानान्ननिद्रारतिवर्धनश्च |
सम्पाठगीतस्वरवर्धनश्च प्रोक्तोऽतिरम्यः प्रथमो मदो हि

अव्यक्तबुद्धिस्मृतिवाग्विचेष्टः सोन्मत्तलीलाकृतिरप्रशान्तः |
आलस्यनिद्राभिहतो मुहुश्च मध्येन मत्तः पुरुषो मदेन ||८||

गच्छेदगम्यान्न गुरूंश्च मन्येत् खादेदभक्ष्याणि च नष्टसञ्ज्ञः |
ब्रूयाच्च गुह्यानि हृदि स्थितानि मदे तृतीये पुरुषोऽस्वतन्त्रः ||९||

चतुर्थे तु मदे मूढो भग्नदार्विव निष्क्रियः |
कार्याकार्यविभागज्ञो मृतादप्यपरो मृतः ||१०||

को मदं तादृशं गच्छेदुन्मादमिव चापरम् |
बहुदोषमिवामूढः कान्तारं स्ववशः कृती ||११||
Ch.chi 24/8,9,10,11

Key point :Hydration with glucose is only means of treating a patient with severe alcoholism.

Hangover symptoms

The other group of symptoms with alcohol consuming people are hangover symptoms. These includes

  1. Fatigue and weakness
  2. Excessive thirst and dry mouth
  3. Headaches and muscle aches
  4. Nausea vomiting or stomachache
  5. Poor or decreased sleep
  6. Increased sensitivity to light and sound
  7. Dizziness
  8. Shakiness

For such symptoms my prescription is Sootshekhar rasa, Kamdugha and Avipathikara choorna considering Pitta vitiation. Charak categorized this symptoms as Pitta  Prakopa Lakshana.

आध्मानमुद्गिरणमम्लरसो विदाहोऽजीर्णस्य पानजनितस्य वदन्ति लिङ्गम् ||२०||
ज्ञेयानि तत्र भिषजा सुविनिश्चितानि पित्तप्रकोपजनितानि च कारणानि |
Ch.chi 24/20,21

 For signs and symptoms of alcohol withdrawal like nausea vomiting, diaphoresis, agitation, anxiety, headache, tremor, seizures and visual & auditory hallucinations. And my prescription for this would be Smritisagara rasa, Kamdugha and Saraswatarishta. Taila dhara and Matrabasti are procedures to be adopted.

Alcoholic ketoacidosis

Alcoholic ketoacidosis is a rare but serious medical emergency that can occur when an individual has been drinking heavily for an extended period of time and suddenly stops. This condition can cause nausea, vomiting, severe abdominal pain, tachypnoea, hypothermia, and hematemesis, among other complications. Treatment typically involves maintaining the body’s arterial pH less than 7.3 and bicarbonate levels less than 75 meq/l through intravenous fluids, such as ringers’ lactate or bicarbonate, and thiamine supplementation. I don’t think that we can   manage this by ayurvedic prescription alone. If at all ayurvedic prescription has to be given then my prescription would be Arogya vardhini, Kamadugha and Kumari Asava once after stabilizing the patient’s  general condition.

 This condition in Ayurveda text has been described as Madatyaya.

हिक्काश्वासशिरःकम्पपार्श्वशूलप्रजागरैः |
विद्याद्बहुप्रलापस्य वातप्रायं मदात्ययम् ||१६||

तृष्णादाहज्वरस्वेदमोहातीसारविभ्रमैः |
विद्याद्धरितवर्णस्य पित्तप्रायं मदात्ययम्
||
Ch.chi 24/16,17

छर्द्यरोचकहृल्लासतन्द्रास्तैमित्यगौरवैः |
विद्याच्छीतपरीतस्य कफप्रायं मदात्ययम् |
ज्ञेयस्त्रिदोषजश्चापि सर्वलिङ्गैर्मदात्ययः
||
Ch.chi 24/18

 Madatyaya is another condition that can result from chronic alcohol abuse and presents with symptoms such as bahu pralapa, hikka shwasa, chardi, arochak, and murccha. This condition is considered to be incurable without using intravenous fluids. Intravenous fluids mandatory in this condition otherwise patient may land up into ketoacidosis.

Alcohol withdrawal [Paramada]

Ketoacidosis is acute medical emergency condition while alcohol withdrawal is relatively milder condition. Paramada on the other hand, refers to alcohol withdrawal symptoms, which are relatively mild and include nausea, vomiting, typhoid, sweating, agitation, headache, and tremens delirium in prolonged cases. Delirium tremens can cause tachycardia, hypertension, and raised body temperature.

Signs and symptoms of alcohol withdrawal [Paramada]

  • Nausea and vomiting
  • Diaphoresis
  • Agitation and anxiety
  • Headache
  • Tremor
  • Seizures
  • Visual and auditory hallucinations:
  • Delirium tremens: tachycardia and hypertension, temperature elevation, delirium

श्लेष्मोच्छ्रयोऽङ्गगुरुता विरसास्यता विण्मूत्रसक्तिरथ तन्द्रिररोचकश्च |
लिङ्गं परस्य मदस्य वदन्ति तज्ज्ञास्तृष्णा रुजा शिरसि सन्धिषु चापि भेदः
||
Su Ut 47/20

 Sushruta  has been described Paramada as  Kapha- pittaja vyadhi.

My prescription would be

Smritisagara asa

Kamadugha

Saraswatarishta

Taila dhara and matrabasti- occasional use

 These chronic conditions require long-term intervention, and response would be good if patient stopped consuming alcohol. But all these patients need to be watched and investigated for hepatic damage.

Signs of Chronic alcoholism

When a person consumes more than 100ml per day every day and becomes dependent on it is considered as chronic alcoholism. Chronic alcoholism can have various consequences, such as hepatic damage, gynecomastia, chronic hepatic failure, testicular atrophy, cirrhosis of the liver, and foetal alcohol syndrome (FAS) in pregnant women. FAS can cause severe damage to the foetus and new-born, with characteristic facial expressions such as small eyes, wide phylum, thick upper lips, and no nasal bridges.

foetal alcohol syndrome (FAS)

In conclusion, alcoholic ketoacidosis, Madatyaya, and Paramada are serious conditions that require immediate medical attention. Chronic alcoholism can cause severe damage to the body and can even be fatal if left untreated. Therefore, seeking help and support is essential for individuals struggling with alcohol addiction.

Management of cirrhosis in detail we have discussed in other context but in general the prescription

unless the patient has established cirrhosis, a chronic hepatic pathology might description would be

My prescriptions

Arogyavardhini

Kamadugha

Kumari asava

Shirodhara Rajayapana basti

 Shirodhara Rajayapana basti also is prescribed usually in such conditions which can help in at least

pulling on the status. I don’t consider that once there is a hepatic damage it would be possible to reverse the condition. Most of the time it becomes irreversible once there is a fatty degeneration and the other complications of the alcoholism where it could be all that patients can present with other severe diseases of the alcoholism, gas ingestion like establishes cirrhosis of the liver, peptic ulcer disorders, gastritis, pancreatitis, even carcinoma, cardiovascular conditions, hypertension, cardiomyopathy, atrial fibrillation. I am not going to deal with those issues because we have already dealt with these issues in another context. Important is a patient presenting with any of these disorders like a cardiovascular, neurological, immunological. Before you make a final diagnosis.

Complications of alcoholism

  • Gastrointestinal –Cirrhosis of the liver, peptic ulcer disease, gastritis, pancreatitis, and carcinoma
  • Cardiovascular – Hypertension, cardiomyopathy, atrial fibrillation (” holiday heart syndrome “)
  • Neurological – Peripheral neuropathy leading to ataxia, Wernicke encephalopathy, Korsakoff psychosis, and structural changes in the brain leading to dementia
  • Immunologic – Suppression of neutrophil function and cell-mediated immunity
  • Endocrine – In males, increase in estrogen and decrease in testosterone, leading to impotence, testicular atrophy, and gynecomastia
  • Obstetric –Fetal alcohol syndrome (i.e. mental retardation, facial deformity, other neurologic problems)

It is quite important that you need to take a detailed history of the alcoholism and keep one option of the possibility that the disease could be triggered due to alcoholism. And of course the approach of the management will be based upon that primary important disease condition like a peptic ulcer, you have a specific management but at the same time something has to be done with the alcoholism, withdrawal of the alcoholism where possible is one of the basic approaches.

Avoidant personality disorder [Chronic alcoholism]

One condition where the person becomes totally addicted to alcohol and virtually it will never

be possible to reverse the condition would be when it becomes avoidant personality disorder. It’s also classified by DSM condition where a person exhibits more than four of these set of the symptoms where patient would be avoiding his occupational activities, doesn’t go for the job, is unable to get involved with the people unless he is certain of being like. So, he will not mix up with every person, he will be just mixing with only a few of the persons as such and doesn’t have an intimate relationship with any of the people and has yet all social situations he will be either rejecting or will be criticized and he has inhibited interpersonal situations. So there will be a established personality disorder and in that condition virtually the treatment would be impossible, it becomes irreversible. So, in my practice I avoid those patients. Of course, the contemporary psychiatric treatment of course many of the psychoactive drugs are often prescribed and I have though I do not prescribe any of those medicines but I have seen the patients where these drugs are prescribed and virtually with very minimal or no advantages as such. So that’s about the as such conditions. If the patient is insisting on the treatment I would be prescribing Chandraprabha vati ,Saraswatarishta,Takradhara ,Rajayapana basti but I don’t ensure that the results would be very satisfied.

So once the patient has a chronic alcoholism which results in a personality disorder it becomes virtually difficult or impossible to treat that condition.

 Premenopausal syndrome

  • Menstrual irregularities
  • Prolonged and heavy menstruation
  • Intermittent amenorrhea
  • Vasomotor symptoms
  • Insomnia

 Post-menopausal syndrome

  • Hot flashes
  • Cold sweats
  • Irregular menstrual bleeding
  • Urogenital atrophy
  • Dyspareunia
  • incontinence
  • Cognitive and affective disturbance

 Premenopausal and post-menopausal syndrome is another psychiatric related condition to be managed.

आर्तवक्षये यथोचितकालादर्शनमल्पता वा योनिवेदना च;
तत्र संशोधनमाग्नेयानां द्रव्याणां
विधिवदुपयोगः |
Su. Su 15/11

 

रसक्षये हृत्पीडाकम्पशून्यतास्तृष्णा च,
शोणितक्षये त्वक्पारुष्यमम्लशीतप्रार्थना सिराशैथिल्यं
च,
Su Su 15/9

Chandraprabha vati, Punarnava mandoora, Draksharishta/ Usheerasava and Shatavari rasayana is my prescription for such conditions considering Rasakshaya or Rajakshaya. This prescription is not for psychiatric illness rather it is for physical illness presented with psychiatric symptoms.

Schizophrenia

Schizophrenia is another disease that we come across. There is a legal issue that we come up with when it comes to treating schizophrenia as treating it as a general physician is not advisable as such. It is categorized in 4 categories i) Positive symptoms ii) Negative symptoms iii) Cognitive symptoms iv) Mood symptoms. For this I would refer the Unmaada roga.

एकैकशः सर्वशश्च दोषैरत्यर्थमूर्छितैः |
मानसेन च दुःखेन स च पञ्चविधो मतः ||

विषाद्भवति षष्ठश्च यथास्वं तत्र भेषजम् |
स चाप्रवृद्धस्तरुणो मदसञ्ज्ञां बिभर्ति च ||
Su.Ut 62/2,3

Sushrut has been described six types Unmada i.e Vataja, Pittaj, Kaphaja, Tridoshaja,Manogata,and  Vishaja.

 Positive symptoms: Psychotic symptoms, such as hallucinations, which are usually auditory; delusions; and disorganized speech and behavior. These symptoms are near to Pittaja Unmaada where the person would have agitated behavior.

अमर्षसंरम्भविनग्नभावाः सन्तर्जनातिद्रवणौष्ण्यरोषाः |
प्रच्छायशीतान्नजलाभिलाषः पीता च भाः पित्तकृतस्य लिङ्गम् ||
Ch. Chi. 9/12

Negative Symptoms

Negative symptoms are seen in Kaphaja unmaada.

Decrease in emotional range, poverty of speech, and loss of interests and drive; the person with schizophrenia has tremendous inertia. These features can be   seen in Kaphaja Unmaad.

बुद्धिं स्मृतिं चाप्युपहत्य चित्तं प्रमोहयन् सञ्जनयेद्विकारम् ||११||
वाक्चेष्टितं मन्दमरोचकश्च नारीविविक्तप्रियताऽतिनिद्रा |
छर्दिश्च लाला च बलं च भुक्ते नखादिशौक्ल्यं च कफात्मके स्यात्
Ch. Chi. 9/13,14

Cognitive symptoms are related to Manogata unmaada . Previous specific psychological illness triggers Unmaada

गाढं क्षते मनसि च प्रियया रिरंसोर्जायेत चोत्कटतमो मनसो विकारः ||
चित्रं ब्रवीति च मनोऽनुगतं विसञ्ज्ञो गायत्यथो हसति चापि मूढः
Su.Ut.62/12,13

The mood symptoms

The mood symptoms are related to  Vataja unmaada where person would have unstable  mood condition.

अस्थानहासस्मितनृत्यगीतवागङ्गविक्षेपणरोदनानि |
पारुष्यकार्श्यारुणवर्णताश्च जीर्णे बलं चानिलजस्य रूपम्
Ch. Chi. 9/10

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), to meet the criteria for diagnosis of schizophrenia, the patient must have experienced at least 2 of the following symptoms

  • Delusions
  • Hallucinations
  • Disorganized speech
  • Disorganized or catatonic behavior
  • Negative symptoms

After DSM-5 criteria it should be treated. Ayurveda described it as physical and psychological derangement.  It is physical illness presented as psychiatric symptoms. Though it is categorized as Manas there is scope for treatment. According to our texts, the basic treatment to be given is Shodhana. Shoka shalya has to be removed by proper counselling.

There you have all those philosophical approaches; these are the suggested treatment. But practically from the clinical point of view, as I have told already, I tried to avoid those conditions for a primary treatment because one, the legal issues and another is the results are not very consistent. And one of the important issues is a patient who is already on an antipsychotic drug. To withdraw the drug is quite dangerous, many times there could be severe aggravations. So psychoactive drugs particularly used in schizophrenia,it will be quite difficult. A patient is already on the antipsychotic drugs and then they prefer

some Ayurvedic treatment usually I prescribe Smritisagar rasa and Saraswatarishta,Takradhara, and Virechan karma can be given along with the existing treatment which can help in to a certain extent to minimize the issues as such. But as the other way, the adverse effects of these drugs also are quite significant and commonly used drugs are these primary groups of the drugs, chlorponazine and so on, which are relatively less prescribed now. Whereas most of the prescriptions are the second-generation drugs,where it could be Clozapine and so on. These would have quite significant adverse effects and

 it will be quite difficult to withdraw those drugs and the adverse effects are mainly of different drugs now.

Anticholinergic effects and dyslipidemia, extra-pyramidal symptoms are commonly seen. Extra-pyramidal symptoms, they occur quite frequently in a high potency drug. Most of the high potency of primary generation drugs, this would be the most common. Patients with the anticholinergic effects, they would be presenting with the tachycardia and so on. Along with the pre-existing drug, I would be prescribing Draksharishta, Sootashekhara which can reduce these adverse effects significantly. Patients with dyslipidemia, where the cholesterol level would be quite high, particularly even lower density lipids also tend to become quite high. I do not think that it is an issue treatment, but it can reduce symptoms. And in case of the extra-pyramidal tract symptoms, which are most common, as a person would have tremors and these abnormal lip movements, so on, and gait is altered. My description would be Smritisagara rasa, Ekangaveera, Tailadhara, Matrabasti which gives more dependable results. And again, I highlight on that part, like I would not try to withdraw those drugs.  Then in hyperprolactinemia, patients who have a reduced libido infertility as a clinical symptom, usually my description would be Makaradwaja but the results are not predictable, not very reliable, but certain of the patients will feel better with that prescription.

 And the patients would have a related neuro malignant disorder rarely seen. Theperson would have a high fever, rigidity, altered consciousness. It is a life-threatening emergency and virtually very little scope for any analytic treatment. It is an emergency condition where you need to have life support treatment as such. In case of postural hypertension, my prescription would be Ashvagandharishta Chandraprabha.Then a patient with the cardiac abnormality, where the ECG shows a prolonged QT interval, my prescription would be Prabhakara vati which is primarily a cardiac problem. Having seizures,patients having seizures with the schizophrenic drugs and the schizophrenic drugs, it is a verycomplex situation. It needs evaluation and maybe a change of prescription, the drug may have to

be changed. So, it is a very complex issue dealing with the person who is an anti-psychotic drug presenting the seizure to give a simple prescription would be quite dangerous. Then ofcourse, patients who have sedation, feeling sleepy, usually the prescription would be Makaradwaja. Type 2 diabetes mellitus, weight gain, I do not suggest any other specific management. It is as we treat diabetes mellitus.

Anticholinergic effects – Draksharishta, Sootshekhara

Dyslipidemia – Arogyavardhini, Kumari aasava

Extra pyramidal symptoms – Smriti Sagara rasa, Ekangaveera ,Taildhara and Matrabasti

Hyperprolactinemia – Makaradwaja

Neuroleptic malignant syndrome

Postural hypotension – Ashwaganadha, Chandraprabhavati

Prolonged QT interval – Prabhakar vati

Sedation – Makardhwaja

Seizures – need evaluation

Sexual dysfunction

Type II diabetes mellitus

Weight gain

Key points

  • Concept of Manas in Ayurveda has a strong foothold.
  • Self-awareness is the best method to prevent and manage psychological disorders.
  • Physicians should be aware of the legal provisions related to mental health.
  • Over prescription of anxiolytics and antipsychotics is a clinical problem.
  • Majority of the adverse effects of psychoactive prescriptions can be effectively managed with Ayurvedic protocol.

So description of Manas in Ayurveda is much better than what the present psychiatrists or physiologists have understood. Self-awareness is the best method to prevent and manage psychological disorder. So Dhi,Dhairya, Atma Vidyana, these are the best methods.

So those who have that would not develop psychological disorder. And the other important issues which I have tried to make sense would be the legal provisions related to mental health, we need to be aware of that. Overprescription of anxiolytics and antipsychotics is a practical, critical problem where definitely from Ayurvedic practice point of view, we have some area where we can produce a significant change. Majority of adverse effects of psychiatric prescriptions can be effectively managed with the Ayurvedic protocol.

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