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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 31-39

Kaphaja unmada: Myxedema psychosis?


Department of Kaya Chikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat, India

Date of Web Publication2-May-2017

Correspondence Address:
Kshama Gupta
Department of Kaya Chikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijny.ijoyppp_10_16

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  Abstract 

Unmada (a broad term which denotes various psychiatric problems under one umbrella) is a major psychiatric illness described in all Ayurvedic classics which is characterized by deranged mental functions. The etymological meaning of Unmada is “a state of disturbed mental functions.” Kaphaja Unmada is one among the five types of Unmada, which is caused by the aggravation of Kapha dosha. The description of Kaphaja Unmada is available in all classical texts of Ayurveda along with its symptomatology. Previous works have correlated ”Kaphaja Unmada” with “depressive disorder”/“depression”/“major depressive disorder.” The symptomatology of Kaphaja Unmada and depressive disorder is 70% similar, but some of the signs and symptoms of Kaphaja Unmada such as laala sighanaka sravanam, swapna nityata, svayathuranane, shukla stimita malopadigdha akshata, naari priyata, chhardi, balam cha bhukte, ushnasevi, nakhadi shauklyam, kasa, and raatrau bhrisham are not seen in depressive disorders and they denote hypersomnia, puffiness of face, pernicious or megaloblastic anemia, hypersexual behavior, vomiting, nocturnal and postprandial aggravation, cold intolerance, depression, and dementia conditions which are due to the underlying hypothyroidism instead of depression only. These signs and symptoms can be explained in a better way when Kaphaja Unmada is compared with myxedema/hypothyroidism with depression. The present study considers that Kaphaja Unmada is more similar with hypothyroidism with depression/myxedema madness/myxedema psychosis than primary depression/typical depression alone.

Keywords: Kaphaja Unmada, Ayurveda, Hypothyroidism, Depression, Myxedema psychosis, dementia


How to cite this article:
Gupta K, Mamidi P. Kaphaja unmada: Myxedema psychosis?. Int J Yoga - Philosop Psychol Parapsychol 2015;3:31-9

How to cite this URL:
Gupta K, Mamidi P. Kaphaja unmada: Myxedema psychosis?. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2015 [cited 2017 Aug 21];3:31-9. Available from: http://www.ijoyppp.org/text.asp?2015/3/2/31/205521


  Introduction Top


Unmada (a broad term which denotes various psychiatric problems under one umbrella) is a major psychiatric illness described in all Ayurvedic classics which is characterized by deranged mental functions. The etymological meaning of Unmada is “a state of disturbed mental functions.” According to AcharyaCharka, deviation of manas (mind), buddhi (decision), smriti (memory), sangyagyanam (orientation and responsiveness), bhakti (desire), sheela (habit), cheshta (activity), and achaara (conduct) like eight factors (either all of them or some) is the characteristic pathological feature of Unmada.[1]

Classification of Unmada is done by different authors of Ayurvedic classical texts in different ways. According to CharakaSamhita, Unmada is classified into five major types – vataja, pittaja, kaphaja, sannipatika (due to vata, pitta, and kapha together) and agantuja (due to idiopathic/unknown causes).[1]SushrutaSamhita[2] and AshtangaSamgraha[3] as well as Ashtangahridaya[4] divide Unmada into six types - three doshika types (vataja,pittaja, and kaphaja), one sannipatika type, vishaja (due to poisonous substances) and aadhija or dukhaja (due to acute stress/bereavement). Madhavanidana and Bhavamishra[5],[6] have also classified in the same way as Sushruta [Table 1].
Table 1: Classification of Unmada according to various Ayurvedic classical texts

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KaphajaUnmada is one among the five types of Unmada, which is caused by the aggravation of Kaphadosha. The description of KaphajaUnmada is available in all classical texts of Ayurveda along with its symptomatology. The causative factors and pathogenesis of KaphajaUnmada are mentioned in Charakasamhita clearly. Excessive eating and sedentary life style are the causative factors for the aggravation of Kapha. This aggravated Kapha along with Pitta gets lodged in vital place Hridaya (heart/brain), which impairs the functions of Buddhi (decision taking capacity/cognition) and Smriti (memory) leading to Moha (confusion) and ultimately produce KaphajaUnmada.[7]

Previous works have correlated “KaphajaUnmada” with “depressive disorder” or “depression”/“major depressive disorder.”[8],[9],[10],[11],[12],[13],[14] The symptomatology of KaphajaUnmada and depressive disorder is 70% similar. The signs and symptoms of KaphajaUnmada such as mandavaak/manda cheshta (psychomotor retardation), sthaanamekadeshe (prefers solitude), rahakaamata (social withdrawal), anannabhilasha (anorexia), arochaka (tastelessness/loss of interest in food), sadana (fatigue/lassitude), alpamati (decreased concentration/decreased higher mental functions), shauchadvesha (ignoring personal hygiene), and tushneebhava (mutism) are similar to depression, and various authors have compared KaphajaUnmada with depression based on this similarity.[8],[9],[10],[11],[12],[13],[14] However, some other signs and symptoms of KaphajaUnmada are dissimilar with depression such as laalasighanakasravanam (excessive discharge of saliva and nasal secretions), swapnanityata (hypersomnia), svayathuranane (puffiness of face), shuklastimitamalopadigdhaakshata (white and timid eyes with excreta adherent to them), naaripriyata (hypersexuality/prefers to stay along with women), chhardi (vomiting), balamchabhukte (postprandial aggravation), ushnasevi (longing for heat), nakhadishauklyam (pallor of face, nails etc.), kasa (cough), and raatraubhrisham (aggravation during night); the previous scholars were unable to answer for this dissimilarity between some of the KaphajaUnmada signs and symptoms with depression.

The present study is aimed to sort out this dissimilarity in between some of the signs and symptoms of KaphajaUnmada and depression and also to arrive/to find a more suitable/similar/relevant condition with KaphajaUnmada.


  Review Methodology Top


Ayurvedic material related to “Kaphaja Unmada” collected from major Ayurvedic texts with their commentaries such as Charaka samhita, Sushruta samhita, Ashtanga sangraha, Ashtanga hridaya, Madhava nidaana, and Bhela samhita. Electronic databases such as “Google scholar search” and “Google search” were searched for relevant studies and reviews published till November 2016, irrespective of their appearance/publication year. The key words used for search were, “Kaphaja Unmada,” “Myxedema madness,” “Hypothyroidism and depression,” “Vomiting in hypothyroidism,” “Hypersexuality in hypothyroidism,” “Biological symptoms of depression,” “Hypersexuality in depression,” “Symptomatology of hypothyroidism with depression,” “Hypothyroidism and negative symptoms of schizophrenia” and “Hypothyroidism.” Abstracts and full-text articles which are freely downloadable in English language were only included. Relevant Ayurvedic material collected from the textbooks available at “Parul Institute of Ayurveda” library has been referred.


  Similarity between Kaphaja Unmadaand Depression Top


AcharyaCharaka has given a detailed description of etiopathology of KaphajaUnmada. The kapha gets vitiated because of sampoorana (excessive food intake/over nourishment) and mandacheshta (sedentary lifestyle). The aggravated kapha along with pitta afflicts the vital organs (heart) adversely and affects the Buddhi (intellect) and Smriti (memory) by vitiating the Manas (mind) and leads to KaphajaUnmada. Here, the two etiological factors described are excessive eating or overnourishment and sedentary lifestyle.[7] Preeminent Kaphaja constitution persons are more prone to get KaphajaUnmada along with the above-mentioned etiological factors. Different Acharyas have mentioned the lakshanas (signs and symptoms) of KaphajaUnmada more or less in the same manner [Table 2].[1],[2],[3],[4],[5],[6] There is profound similarity between KaphajaUnamadalakshanas and signs and symptoms of depression [Table 3].
Table 2: Kaphaja Unmada lakshanas according to various Ayurvedic classical texts

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Table 3: Similarity between Kaphaja Unmada and depression

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Depression refers to a range of mental problems characterized by loss of interest and enjoyment in ordinary experiences, low mood and associated emotional, cognitive, physical, and behavioral symptoms. The current Diagnostic and Statistical Manual of Mental Disorders classification includes three specifiers of symptom characteristics during depressive episodes: catatonic, melancholic, and atypical features. Atypical depression is characterized by hypersomnia, fatigue, increased appetite, weight gain, mood reactivity, and interpersonal rejection sensitivity. It is present in 15%–30% of depressed cases (approximately). Melancholic depression is marked by anhedonia, nonreactive mood, psychomotor disturbances, vegetative and cognitive symptoms of insomnia, loss of weight and appetite, diurnal mood variation, and impaired concentration. Approximately 25%–30% of depressed individuals display melancholic features. Recent data-driven techniques examining a wide range of depressive symptoms have confirmed that depressed population can generally be divided into a melancholic (sometimes termed “typical”) and an “atypical” subtype which are not very different in overall severity but differ mainly in terms of appetite, weight, and sleep symptoms (more in atypical less in melancholic depression).[15]

The signs and symptoms of KaphajaUnmada such as manda cheshta/alpa chankramana (psychomotor retardation), vaak manda/alpa kathanam (slowness of speech/mutism), sthaanamekadeshe, rahakaamata, anannabhilasha, arochaka, sadana, alpamati, smritivibhrama (disturbance of memory), shauchadvesha, and tushneebhava are similar to the characteristic features of depression such as decreased activity, pervasive sadness, social withdrawal, reduced psychomotor activity, complete anhedonia (inability to experience pleasure), difficulty in thinking, concentrating, indecisiveness, poor memory, lack of initiative and energy, body pains, easy fatigability, decreased ability to function in occupational and inter-personal areas, nihilistic delusions (in severe depression), and depressive stupor.[16]


  Dissimilarity between Kaphaja Unmadaand Depression Top


Some of the signs and symptoms of KaphajaUnmada such as laalasighanakasravanam, swapnanityata, svayathuranane, shuklastimitamalopadigdhaakshata, naaripriyata, chhardi, balamchabhukte, ushnasevi, nakhadishauklyam, kasa, and raatraubhrisham are not seen in depressive disorders. These signs and symptoms are biological in nature and they manifest due to the aggravation of Kaphadosha. Previous studies have correlated KaphajaUnmada with depression based on the 70% similarity in the signs and symptoms of these two conditions, but they were unable to explain the other 30% dissimilarity between KaphajaUnmada and depression.[8],[9],[10],[11],[12],[13],[14]

Vamanakarma (therapeutic emesis/therapeutically induced vomiting) is indicated for the management of KaphajaUnmada. Vamanakarma is desirable only when Kaphajalakshanas such as Laalasighanakasravanam, swapnanityata, svayathuranane, shuklastimitamalopadigdhaakshata, naaripriyata, chhardi, balamchabhukte, ushnasevi, nakhadishauklyam, kasa, and raatraubhrisham are present in a case of Unmada (whether it may be depression or may not be).[17] By considering all these facts, it seems that, either KaphajaUnmada is not depression (may be some other psychiatric condition) or KaphajaUnmada is depression associated with/comorbid with some other organic pathology (secondary depression/depression due to systemic disease or pathology). The present study considers that KaphajaUnmada can be correlated with hypothyroidism with depression/myxedema madness/myxedema psychosis in a better way rather than primary depression/typical depression.


  Hypothyroidism Top


Sluggishness of all functions, decreased muscular activity, intolerance of cold, decreased metabolic rate, easy fatigability, facial puffiness, periorbital edema, and aching muscles are the signs and symptoms of hypothyroidism.[18] Mild thyroid failure patients significantly more often reported dry skin, poor memory, slow thinking, muscle weakness, fatigue, muscle cramps, cold intolerance, puffy eyes, constipation, and cognitive impairment in a survey than did euthyroid patients.[19] The onset of naturally occurring hypothyroidism is insidious. The patient is often unaware of it as may be friends and relatives. The first symptom may be decrease in sweating and dislike of cold. Marked hypersensitivity to cold and demand for a warmer room or more clothing are common.[20] It has long been recognized that frank hypothyroidism can cause depressive symptoms and it almost always does so in severe cases. There is a prevalence of major depressive disorder 36.67%, in hypothyroid patients. There is a significant correlation between major depressive disorder and hypothyroidism.[21]


  Association between Hypothyroidism and Depression Top


An association between hypothyroidism and depression has been accepted and taught in medicine for many years.[22] The diagnosis of subclinical or overt hypothyroidism must be considered in every patient with depression. In fact, a small proportion of all patients with depression have primary hypothyroidism, either overt or subclinical.[23] The similarity and overlapping between symptoms of depression and thyroid disorders has been the theoretical base for the hypothesis regarding a possible relationship between both entities. Hypothyroidism could induce cognitive dysfunction and depressive symptoms besides psychological distress in a very similar way to primary depression.[24] In 63% of the patients of hypothyroidism, comorbid depression is found. Psychiatric presentations are often the first sign of hypothyroidism, occurring as the initial symptoms in approximately 2%–12% of cases. Anxiety, progressive mental slowing associated with diminished recent memory, speech deficits, and diminished learning ability are the characteristic initial progression of symptoms.[25]

The line between thyroid function and psychiatric disorders, particularly mood disorders, has long been recognized. Hypothyroidism patients frequently demonstrate features of depression, cognitive dysfunction, apathy, and psychomotor slowing. In severe forms of hypothyroidism, clinical symptoms may mimic that of melancholic depression and dementia. Among the various neuropsychiatric manifestations of thyroid disorders, depression remains the most common.[26] Abnormalities in thyroid hormonal status are common in major psychiatric disorders. Thyroid dysfunction is present in patients with schizophrenic spectrum disorder as well as mood disorders. The association between thyroid dysfunction and mood disorders is well recognized. Thyroid hormone receptors are localized to limbic structures which are implicated in regulation of mood.[27] Psychomotor retardation, fatigue, lethargy, diminished volition, and depressed mood are often observed in both major depression and hypothyroidism. Hypothyroidism and major depressive disorder share neuropsychiatric features.[28]


  Myxedema Madness/myxedema Psychosis Top


According to previous works, 5%–15% of myxedematous patients have shown some form of psychosis. Some studies have provided the classical manifestations of hypothyroid induced psychosis. A study on 14 patients of myxedema madness has been often cited as a typical example of psychosis secondary to hypothyroidism; subsequent case reports have revealed considerable variation in clinical psychotic presentation induced by hypothyroidism. One of the consequences of chronic hypothyroidism is what is now termed as “myxedematous psychosis” and it includes progressive dementia, delirium, hallucinations, and delusions. Hypothyroidism may manifest with a variety of physical signs and symptoms mostly related to slowing of the metabolic processes secondary to lack of thyroid hormone. Fatigue, intolerance to cold, slow speech, weight gain, delayed deep tendon reflexes, and bradycardia are all the results due to slowing metabolic processes. In severe disease, nonpitting edema (myxedema) can occur and may reveal broad spectrum of dysfunction, ranging from mild attention impairment to significant agitated delirium or psychosis.

Myxedema madness/psychosis is characterized by the signs and symptoms such as withdrawn behavior, poor communication, maintaining one posture for hours, mutism, decreased social activities, remains asleep almost whole day, not taking self-care, laughing without reason, and facial puffiness The patient is completely mute with no speech at all, marked psychomotor retardation, blunt affect, remains withdrawn, poor eye-to-eye contact, sleep disturbance, hypothyroidism, facial puffiness, and nonpitting leg edema. Impaired attention, concentration, and poor recent memory may also present.[29] Cognitive impairment (decreased attention, motor speed, memory, and visual/spatial organization) and psychotic disorders (e.g., depression, dementia) are the manifestations of myxedema.[30]


  Similarity between Kaphaja Unmadaand Myxedema Psychosis Top


The signs and symptoms of KaphajaUnmada are strikingly similar to myxedema psychosis [20] [Table 3]. KaphajaUnmada can be understood in a better way when it is compared with hypothyroidism with depression or myxedema psychosis. The lakshanas of KaphajaUnmada such as Laalasighanakasravanam, swapnanityata, svayathuranane, shuklastimitamalopadigdhaakshata, naaripriyata, chhardi, balamchabhukte, ushnasevi, nakhadishauklyam, kasa, and raatraubhrisham can also be explained in a better way when KaphajaUnmada is correlated with myxedema psychosis/hypothyroidism with depression rather than typical depression alone. Here, various KaphajaUnmadalakshanas are compared with hypothyroidism with depression/myxedema madness in detail.

Arochaka/Alpahara/Agnimandya (anorexia/anhedonia)

Loss of interest in taking food or tastelessness or decreased digestive capacity, etc., in KaphajaUnmadalakshnas resemble various gastrointestinal disturbances caused by hypothyroidism. The symptoms from the digestive system are essentially the expression of the slow rate at which the living machinery is turning over. Anorexia, which is common, can reasonably interpret as the reflection of a lowered food requirement, and constipation, which is frequently present in hypothyroidism, is the result of a lowered food intake and decreased peristaltic activity.[20]

Alpa cheshtha/Alpa chankramana/Alpa vaak/Sthaanamekadeshe/Rehapreeti (psychomotor retardation/social withdrawal)

Some of the features of hypothyroidism with depression such as retarded locomotor ability, apathy,[31] decreased motor speed,[30] psychomotor retardation,[32] loneliness, presence of interpersonal problems,[33] decreased muscular activity, sluggishness of all functions,[18] social withdrawal, poor communication, mutism, decreased social activities, rarely initiating eye-to-eye contact, blunt effect and slow speech,[29] and speech deficits [25] resemble the signs and symptoms of KaphajaUnmada such as alpacheshtha,alpachankramana,alpavaak,sthaanamekadeshe,andrehapreeti.

Chhardi (vomiting)

Anorexia and nausea are the most common gastrointestinal presentations of hypothyroidism.[30] Prolonged gastric emptying, prolonged intestinal transit time, and slowed intestinal absorption are the gastrointestinal manifestations of hypothyroidism. Dysphagia or heartburn may be due to disordered esophageal motility. Dyspepsia, nausea, or vomiting may be due to delayed gastric emptying. Abdominal discomfort, flatulence, and bloating occur in patients with small intestinal bacterial overgrowth.[20] One case report has mentioned recurrent nausea, vomiting, and abdominal pain due to hypothyroidism. This may be due to severe intestinal hypomotility. Congenital hypothyroidism may present with recurrent vomiting in pediatric population.[34]Chhardi explained as one of the KaphajaUnmadalakshanas is similar to nausea or vomiting in a patient of hypothyroidism.

Kasa (cough)

Myxedematous patients are more subject to respiratory infections. Kasa (cough) explained as one of the clinical features of KaphajaUnmada may be due to secondary infection in a hypothyroid patient. Dyspnea is a frequent complaint of myxedematous patients. Congestive heart failure, pleural effusion, anemia, obesity, or pulmonary disease may be responsible for dyspnea. Decreased maximal breathing capacity, decreased diffusion capacity, and decreased ventilator response to carbon dioxide may induce dyspnea. The severity of hypothyroidism parallels the incidence of impaired ventilator drive. Weakness of the respiratory muscles has also been implicated as a cause of alveolar hypoventilation. Radiologic pulmonary abnormalities suggestive of fibrotic disease are associated with severe hypothyroidism. Myxedematous patients are more subject to respiratory infections.[20]

Sadana (fatigue)

Easy fatigability, aching muscles,[18] lack of initiation and energy,[35] muscle weakness, muscle cramps,[19] myasthenia gravis, delayed relaxation phase, and myopathy [32] are the muscular symptoms seen in hypothyroidism patients. Muscular symptoms such as myalgia, muscle weakness, stiffness, cramps, and easy fatigability are very prevalent in hypothyroidism patients.[20]Sadana denotes the above muscular symptoms induced by hypothyroidism.

Sauchadvesha/Bhibhatsyam (lack of personal hygiene)

This lakshana denotes lack of hygiene either in major depressive disorder or hypothyroidism (due to muscle weakness or fatigue) or nihilistic delusions or dementia induced by myxedema. This lack of hygiene may be due to the lack of interest to maintain personal hygiene (depression), lack of energy to maintain personal hygiene (lethargy or fatigue in hypothyroidism), lack of memory to maintain personal hygiene (dementia due to hypothyroidism), or due to delusions/negative symptoms of schizophrenia/psychosis.

Nidra (hypersomnia)

Hypersomnia is one of the features of atypical depression.[35] Somnolence [31]/excessive somnolence [34]/sleep disturbance [29] of the hypothyroidism is similar to “Nidra” (one of the KaphajaUnmadalakshanas). The typical somnolence of severe hypothyroidism may suggest the psychiatric diagnosis of depression or dementia.[20] Depression has been linked to various endogenous circadian rhythms abnormalities, and one among them is disturbance of sleep-wake cycle.[26]

Ushnasevi (fond of warm things/cold intolerance)

The first symptom of hypothyroidism may be decrease in sweating and dislike of/intolerance to cold. Marked hypersensitivity to cold and demand for a warmer room or more clothing is common in hypothyroid patients. Thyroid hormone deficiency slows metabolism, resulting in a decrease of resting energy expenditure, oxygen consumption, and utilization of substrates. Reduced thermogenesis is related to the characteristic cold intolerance of hypothyroid patients.[20] Severe hypothermia can be precipitated in myxedema patients.[32]Ushnasevi” denotes the underlying hypothyroidism in a depression patient.

Shvayathuranane (puffiness of face)

In the report on myxedema, there is a detailed analysis of the symptoms of 109 patients described as “cretinoid,” “expressionless,” “heavy,” “apathetic,” “mask like,” “vacant,” “stolid,” “blunted,” and “large featured.” The face is expressionless at rest, puffy, pale, and often with a yellowish or old ivory tint in myxedema patients. Face is seldom as puffy as the classic facies of chronic renal failure.[20] Puffiness of the face/periorbital edema is one of the characteristic features of hypothyroidism/myxedema.[18]

Balavaan raatrau (nocturnal aggravation)

“Balavaanraatrau” denotes aggravation of signs and symptoms during night time. In hypothyroid patients, fall of environmental temperature during nights may aggravate the signs and symptoms (intolerance to cold/unable to maintain body temperature during night time cold). Depression has been linked to various endogenous circadian rhythms abnormalities such as diurnal mood variation, abnormalities in core body temperature, cortisol secretion, and sleep-wake cycle. In addition to these circadian dysfunctions, depression has been linked to an abnormal diurnal thyroid-stimulating hormone (TSH) rhythm as well. An absent TSH nocturnal surge has been noted in depression and a lower basal TSH has been reported in major depression.[26] Central hypothyroidism is also associated with a decreased nocturnal TSH surge (due to loss of the nocturnal increase in TSH pulse amplitude under preservation of the night time increase in TSH pulse frequency) which further hampers the maintenance of a normal thyroid function.[20] Nocturnal aggravation of symptoms mentioned in KaphajaUnmada denotes underlying hypothyroidism.

Bhukta maatre balavaan (postprandial aggravation)

This symptom denotes aggravation after intake of food. After intake of food, due to extra load on metabolism may aggravate the symptoms in hypothyroid patients. Glucose is absorbed from the intestine at a slower rate than normal. Slow gastric motility and delayed absorption of glucose are common. Data suggest insulin resistance might be present in some patients in the fasting state, but more frequently in the postprandial state. Hypothyroid patients have lower postprandial glucose uptake in muscles and adipose tissue.[20]

Nakhadi shauklyam (pallor of nails, face, eyes, etc.)

“Nakhadishauklyam” denotes pallor of nails, face, and other body parts. This pallor suggests underlying anemia which is commonly seen in hypothyroid patients. In hypothyroidism, plasma volume and red blood cell mass both are diminished and blood volume is lowered. Anemia is common and its incidence ranges from 32% to 84%. The anemia may be a result of a specific depression of bone marrow that lacks thyroid hormone, or may be due to decreased absorption because of gastric achlorhydria or decreased absorption of Vitamin B12 (which has been found to occur in certain patients with myxedema as a result of diminished intrinsic factor) or due to diminished production of erythropoietin by the kidney. The incidence of pernicious anemia is higher than normal in myxedematous persons. Megaloblastic anemia due to folic acid deficiency has also been demonstrated in hypothyroidism. Reduced intestinal absorption secondary to hypothyroidism may be responsible for this deficiency. Complete achlorhydria occurs in more than half of myxedematous patients. Around 25% of patients with myxedema have circulating antibodies against the gastric-parietal cells. These findings, at least in part, are suggestive of the frequency of achlorhydria and impaired absorption of Vitamin B12. Fourteen percent of patients of idiopathic myxedema have coincident pernicious anemia.[20] This anemia may cause pallor of nails, eyes, and face.

Laalasinghanaka sruti and Malopadigdha akshata (excessive saliva, nasal secretions, etc.)

Excessive discharge of saliva, nasal secretion, and excreta of eyes may suggest some underlying inflammation/infection of those organs due to decreased immunity/decreased metabolism in hypothyroid/myxedema patients.

Naari priyata (hypersexual behavior)

Though hypersexuality is commonly seen in mania, it can also be seen in depression. One study reported major depression or dysthymia in almost 14 out of 36 patients reporting compulsive sexual behavior. Loneliness, presence of interpersonal problems, and increased vulnerability to stress have also been observed in association with hypersexual behavior.[33] There is a positive and moderate relation between nonparaphiliac hypersexual behavior and depression. Nonparaphiliac hypersexual behavior is associated with depressive symptoms.[36] This hypersexual or stay with women suggests “reactivity of mood” of “atypical depression.”

Alpamati (dementia/impairment of cognitive functions)

The word “Alpamati” denotes diminished cognitive functions or poor memory or indecisiveness or dementia or progressive intellectual deterioration. Cognitive neurological symptoms are common in myxedema in particular a general slowing of cognitive functions with memory impairment and apathy. This may progress insidiously to a global cognitive impairment of dementia. Memory and learning impairment, depression, psychotic behavior, and progressive intellectual deterioration are seen in hypothyroidism patients.[31] Anxiety, progressive mental slowing, diminished recent memory, speech deficits, and diminished learning ability are the characteristic initial progression of symptoms in hypothyroidism with psychosis or depression. Patients may become delusional, paranoid, and may complain of auditory or visual hallucinations.[25]

Extreme complacency, impaired memory, impaired attention, loss of enthusiasm, decreased attention span, and slow reaction time are the psychiatric signs and symptoms due to hypothyroidism. Hypothyroidism may also give rise to reversible dementia, associated with reversible cerebral hypoperfusion.[20] Hypothyroidism may cause chronic dementia. Hypothyroidism will frequently present with depressive symptoms. The symptoms of dementia in hypothyroidism are strikingly similar to those of primary degenerative dementia.[37] Cognitive impairment (decreased attention, motor speed, memory, and visual/spatial organization) and psychotic disorders (e.g., depression, dementia) are the manifestations of myxedema. There is a decrease in cerebral blood flow and cerebral glucose metabolism in hypothyroid patients.[30]Alpamati” denotes the pathology of central nervous system and its consequences due to underlying hypothyroidism.

On considering all the above facts, it seems that there is profound similarity between KaphajaUnmada and myxedema psychosis/hypothyroidism with depression [Table 4].
Table 4: Similarity between Kaphaja Unmada and myxedema psychosis/hypothyroidism with depression

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  Management of Kaphaja Unmada Top


Vamanakarma (therapeutic emesis/vomiting) is one of the panchakarmas (five major body cleansing therapies) which is used in treating kaphaja disorders.[38] Some clinical trials have used vamana in the treatment of depressive disorders.[13] The treatment protocol for KaphajaUnmada includes shodhana (body cleansing therapies), shamana (internal medicines to pacify the disease), and rasayana (general health tonics) followed by satvavajayachikitsa (psychotherapy) which varies according to the condition of the patient and disease. Nasya (nasal medication) with teekshna (strong) drugs are also indicated in KaphajaUnmada as the principal dosha is kapha.[12] This treatment protocol which is indicated for KaphajaUnmada is also suitable for hypothyroidism with clinical presentation of depression and also for myxedema.


  Conclusion Top


KaphajaUnmada is one among the five types of Unmada, which is caused by the aggravation of Kaphadosha. The description of KaphajaUnmada is available in all classical texts of Ayurveda along with its symptomatology. Previous works have correlated ”KaphajaUnmada” with “depressive disorder”/“depression”/“major depressive disorder.” The symptomatology of KaphajaUnmada and depressive disorder is 70% similar, but some of the signs and symptoms of KaphajaUnmada such as laalasighanakasravanam, swapnanityata, svayathuranane, shuklastimitamalopadigdhaakshata, naaripriyata, chhardi, balamchabhukte, ushnasevi, nakhadishauklyam, kasa, and raatraubhrisham are not seen in depression. These signs and symptoms can be explained in a better way when KaphajaUnmada is compared with myxedema/hypothyroidism with depression. The present study considers that KaphajaUnmada is more similar with hypothyroidism with depression/myxedema madness/myxedema psychosis than primary depression/typical depression alone.

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Conflicts of interest

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  References Top

1.
Acharya VJ, editor. Agnivesha, Elaborated by Charaka and Dridhabala Commentary by Chakrapani. Charaka Samhita, Nidana Sthana, Unmada Nidanam Adhyaya, 7/1-10. Varanasi: Chaukhamba Surbharati Prakashan; 2008. p. 222-4.  Back to cited text no. 1
    
2.
Acharya VJ, Sushruta NR, editors. Sushruta Samhita, Commentary by Dalhana. Uttara Tantra, Unmada Pratishedha Adhyaya, 62/1-10. Varanasi: Chaukhamba Orientalia; 2009. p. 803-4.  Back to cited text no. 2
    
3.
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   Abstract
  Introduction
  Review Methodology
   Similarity betwe...
   Dissimilarity be...
  Hypothyroidism
   Association betw...
   Myxedema Madness...
   Similarity betwe...
   Management of Ka...
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