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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 24-31

Rakshasa grahonmada: Antisocial personality disorder with psychotic mania?


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

Date of Web Publication31-May-2018

Correspondence Address:
Dr. Prasad Mamidi
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_12_17

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  Abstract 


“Bhuta vidya”/“Graha chikitsa” is one among the eight specialties of Ayurveda. This specialty deals with the mode of affl iction by evil spirits and making offerings to various grahas (supernatural powers/extraterrestrial forces/evil spirits) such as deva, pishacha, gandharva, yaksha, rakshasa, etc., for cure of diseases originating from their malignant infl uence. Acharya Vagbhata has described 18 types of bhootonmada (psychosis caused by affl iction of grahas). “Rakshasa grahonmada” (RG) is one among those 18 types. In Ayurveda, till date, the concept of grahnomada as a whole or individually is under explored. The present study aims at better understanding of RG in particular with modern research and literature support. RG is characterized by krodha drishti, bhairavaasya, bhrukuti udvahantam (anger, aggression, violent), tvaritam abhidhavantam, ruvantam, sambhramam, praharantam (agitation, impulsiveness, restlessness, hyperactivity), nashta nidra (sleeplessness), nisha vihaari (wandering at nights), anna dveshinam (aversion to food), shooram (grandiosity, violent, aggressive), nirlajja (disinhibition), ati balinam (excessive energy levels), stree priyam (hypersexuality), madya priyam (alcoholic/substance abuse), rakta, amisha priyam (food cravings to nonvegetarian items), deenam (depressed), shankitam (suspicious/paranoid), akasmaat rudantam, hasantam and gaayantam (inappropriate behavior) and nirarthakam paribhashanam (irrelevant speech) etc., features. These features of RG are similar to the condition of “antisocial personality disorder” (ASPD) comorbid with “psychotic mania.”RG is similar to ASPD comorbid with other conditions such as mania, schizophrenia, and substance abuse.

Keywords: Antisocial personality disorder, Ayurveda, mania, Rakshasa grahonmada, schizophrenia, substance abuse


How to cite this article:
Mamidi P, Gupta K. Rakshasa grahonmada: Antisocial personality disorder with psychotic mania?. Int J Yoga - Philosop Psychol Parapsychol 2018;6:24-31

How to cite this URL:
Mamidi P, Gupta K. Rakshasa grahonmada: Antisocial personality disorder with psychotic mania?. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2018 [cited 2018 Dec 18];6:24-31. Available from: http://www.ijoyppp.org/text.asp?2018/6/1/24/233605




  Introduction Top


Bhootonmada (psychosis caused by evil spirits/extraterrestrial forces/supernatural powers) in general characterized by abnormal behavior in terms of exhibition of strength, energy, manliness and enthusiasm, defects in perception, retention and memory, abnormality in speech, abnormality in perceiving self and environment. Sushruta has described 8 types of bhootonmadadeva, asura, gandharva, yaksha, pitru, naga, rakshasa and pishacha. According to Acharya Charaka, 11 types of bhootonmada are described. They are deva, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, brahma rakshasa, and pishacha. However, in Ashtanga hridaya, 18 types of grahonmadas are explained. They are deva, asura, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala.[1]Rakshasa grahonmada (RG) is one among the bhootonmadas or garhonmadas.

In Bhootonmada, the symptoms occur suddenly without visible reason or triggered by chidra kaala (stressful factors) and the course of the disease is also unpredictable. The occurrence or aggravation of symptoms in bhootonmada is not specific. As bhootonmada is an agantuja type of unmada, it is not related with shareeraka doshas (bodily humors) and the prognosis is unpredictable. The purpose of graha seizing a person may be due to himsa (violence/aggression) or rati (attachment/desire) or abhyarchanam (for worship). The unmada with the intention to inflict injury to self or to others (himsatmaka) is said to be asadhya (untreatable) and remaining two (rati, abhyarchana) are considered as sadhya (treatable).[1]

Rakshasa grahnomada (RG) is explained in all the major texts of Ayurveda but each text has explained the lakshanas (signs and symptoms) of RG differently. The lakshanas of RG include krodha drishti, bhairavaasya, bhrukuti udvahantam (aggressiveness, violence, impulsivity), tvaritam abhidhavantam, ruvantam, sambhramam, praharantam (agitation, impulsiveness, restlessness, hyperactivity), nashta nidra (sleeplessness/decreased need for sleep), nisha vihaari (wandering at nights), anna dveshinam (aversion to food/refusal to food), shooram (grandiosity, violent, aggressive), nirlajja (disinhibition), ati balinam (excessive energy levels/increased psychomotor activity/agitation), stree priyam (hyper sexuality), madya priyam (alcoholic/substance abuse), rakta, amisha priyam (food cravings to nonvegetarian items), deenam (depressed), shankitam (suspicious/paranoid), akasmaat rudantam, hasantam, and gaayantam (inappropriate or disorganized behavior), and nirarthakam paribhashanam (irrelevant or disorganized speech).[2],[3],[4],[5],[6] Till date, no studies have been conducted and the concept of RG is under explored. The present study is aimed at better understanding of RG and its similarity with various psychiatric conditions.

Etiology, pathogenesis, and prognosis of Rakshasa grahnomada

Pragnaaparaadha (intellectual blasphemy) and karma (idiopathic) plays an important role in the pathogenesis of bhootonmada and causative factors are untraceable.Grahas seize the persons only at certain specifi c times only. The reasons explained for grahavesha (affl iction by evil spirit/extraterrestrial force/supernatural power) are prgnaaparaadha in present life or previous life.[1] There is no specific etiology, pathogenesis, and prognosis explained for RG. The common etiology, pathogenesis, and prognosis explained for all bhootonmadas are applicable for RG also.


  Rakshasa Grahonmada Lakshanas Top


Compared to other Ayurvedic texts, Vriddha Vagbhata in “Ashtanga samgraha” has described RG lakshanas in a detailed way.[4] Various psychiatric conditions such as antisocial personality disorder (ASPD), conduct disorder (CD), substance use disorder (SUD), bipolar disorder (BPD), attention deficit hyperactivity disorder (ADHD), Schizophrenia, etc., resemble with RG in signs and symptoms. All the lakshana's of RG are correlated with similar modern psychiatric condition explored in following sections.

Krodham/Krooram/Krodha drishtim/Bhairavaananam/Bhrutkutim udvahantam/Shooram/Ati nishtooram (aggressiveness/violence/impulsivity/cruelty/harshness)

Various lakshanas (signs and symptoms) of RG such as “krodhaalu” (angry/hostile), “krodha drishtim” (angry looks), “bhrukuti udvahantam” (anger/hostility), “bhairavaananam” (terrible face), “roshanam” (furious), “ati shooram/shooram (recklessness/risky behavior), “krooram” (cruelty), “shastra abhilashinam” (using weapons/violent), “samtarjakarm” (threatening others), “ati nishtooram” (ruthless, harsh, cruel, rough), praharanam (beating, attacking, striking with weapons), etc., denotes aggressiveness, impulsivity, irritability, violence and anger which are commonly seen in ASPD, CD, SUD, ADHD, Mania, and Psychosis. Aggressiveness can be defined as “the generation of a behavior that aims at causing physical or psychic harm to somebody else.” The prefrontal region is associated with the control and regulation of emotions, reactions, and impulses generated by the limbic system. Lesions to the prefrontal areas enhance negative emotional reactions and violent behavior. Lesions of the medial temporal lobe including limbic system are associated with intermittent impulse control disorders characterized by episodes of extreme unprovoked anger. Impulsive aggressive behavior is associated with an imbalance between various neurotransmitter systems of the prefrontal cortex. Reduced serotoninergic activity and increased dopaminergic activity are associated with higher risk of violent behavior. High cortisol levels may be associated with persistent aggressive behavior in men.[7]

Irritability and disruptive aggressive behavior are the characteristic features of “irritable mania.”[8] Aggressive behavior generally has a target which is described as anger, rage, or hostility. The content of aggressive behavior consists of objection, fear, anger, impulsiveness, and violence. Lesions in the medial and frontal areas cause psychiatric symptoms including aggressive behavior and social incompatibility. Aggressiveness is an important issue commonly seen in personality disorders, particularly in ASPD. Individuals with ASPD display a low frustration tolerance.[9] Outbursts or aggressive states are associated with rapidly executed, impulsive acts of unexpected violence, occurring in response to minimal provocation or, on occasion, for no discernable reason. During these outbursts, a great deal of pathological tension is relieved. Violent behavior is relatively common in BPD and usually occurs during acute manic episodes. It has been observed that manic patients with incongruent psychotic symptoms have showed agitated, aggressive behavior. The tendency to engage in risky and aggressive behaviors is a core feature of the manic episodes of BPD.[10]

Cruelty toward animals is also one of the features of RG (”rakta and amisha priyam,” “shastra abhilashinam,” “krooram”). Earlier prospective, longitudinal studies systematically examined other antisocial behaviors such as stealing, impulsivity, aggressive actions, disobedience, cheating, defiance, profanity, destruction of school materials, and general cruelty and bullying, but not animal cruelty. Research suggests the importance of serotonergic systems in aggressive behavior and impulsivity, including cruelty toward animals. There is significant association of animal cruelty with antisocial personality traits and polysubstance abuse. Typically, animal cruelty is one of the several antisocial behaviors related to CD in childhood.[11] Characteristic features of ASPD include a pervasive pattern of disregard for and violation of the rights of others, a failure to conform social norms, irresponsibility, deceitfulness, indifference to the welfare of others, recklessness, irritability, a failure to plan ahead, and aggressiveness. ASPD patients even exhibit traits of impulsivity, high negative emotionality, low conscientiousness, and wide range of interpersonal as well as social disturbances.[12]

Tvaritam abhidhavantam/Pradhaavantam/Ruvantam/Sasambhramam (Running/attacking/assault/shouting/agitation/restlessness/hyperactivity/impulsivity)

Distractibility and increased motor activity are the characteristic features of mania.[9] Individuals with SUD are relatively more likely to have or have had ADHD. The cardinal features of ADHD, restlessness, inattention, and impulsivity are highly nonspecific and occur in numerous conditions. As a result, disorders may be comorbid due to lack of symptomatic specificity across various diagnoses. With regard to ADHD, problems of symptomatic overlap appear likely for depression and BPD since they explicitly include similar features, such as poor concentration, restlessness, and in the case of BPD, impulsivity. Among substance abusers, ASPD is also related to adult ADHD. There is clearly a strong association between substance abuse and dependence with adult ADHD. The evidence for comorbidity between ADHD and SUD is considerable. The few controlled studies of BPD have reported that ADHD adults have an excess of BPD.[13] Features of ADHD such as hyperactivity with impulsivity and features of mania such as psychomotor agitation, restlessness, impulsivity, irritability, and increased goal-directed activity [14] resemble with the features of RG such as “pradhaavantam,” “sambhramam” and “abhidhaavantam.”

Nashta nidram (sleeplessness) and Nisha vihaari (wandering at nights)

Decreased need for sleep is one of the important features of manic episode. The person with manic episode usually awakens several hours earlier than usual, feeling full of energy. Even a person with manic episode may go for days without sleep when the sleep disturbance is severe and yet not feel tired. The person with mania feels rested after only 3 h of sleep.[14] Decreased sleep is found in almost 90% of the cases suffering with mania and it is also one of the most common initial presentations of mania.[15] “Psychotic mania” is conceptualized as a more severe form of mania and it is associated with poorer levels of social functioning. Poor sleep is found in “psychotic mania.”[9] Alcohol abuse (madya priyata as explained in RG) causes deficiency of vitamins B2, B6, A, and C, essential fatty acids, and methionine. Malnutrition with folate deficiency is frequently found among alcoholics. Vitamins are important for mental health including iron, folate, and vitamins B6 and B12. Deficiencies of any of these nutrients can mimic mental health problems such as depression, fatigue, poor attention, and altered sleep. Alcohol abuse leads to decreased appetite (anna dveshinam as explained in RG) and hampers the absorption of vital nutrients which ultimately results in deficiency of various vitamins and minerals.[16] Dysphoric mood which is one of the features of schizophrenia may take the form of depression, anxiety, or anger along with disturbances of sleep pattern such as sleeping during day and nighttime activity or restlessness.[17] Along with decreased need for sleep, other features of mania such as psychomotor agitation, unceasing as well as indiscriminate enthusiasm, elevated mood, feeling full of energy, increase in goal-directed activities, expansiveness, grandiosity, poor judgment, and hyperactivity [14] together may be the reasons for “nisha vihaari” of RG. “Nashta nidra” of RG is similar to “decreased need for sleep” of mania or it might be caused by alcohol abuse.

Anna dveshinam (aversion to food)

Patients with a primary psychotic illness (e.g., schizophrenia or delusional depression) can stop eating due to delusions related to food, for example, the food is poisoned; the food is contaminated and subsequently develop an eating disorder. Control of food intake provides a sense of mastery, achievement, and self-control to individuals whose sense of self-efficacy is low, as is the case of individuals who are at risk for psychosis. Patients with schizophrenia develop delusions about food which may subsequently lead to food refusal. It is also the case that the delusions of a primary psychotic condition can lead to food aversions.[18]Shankitam” (suspicious/paranoid delusion) is one of the features of RG which may subsequently lead to food refusal (anna dveshinam). Alcohol abuse may lead to decreased appetite and keep the body away from absorbing vital nutrients which results in a number of vitamins and mineral deficiency.[16]Madya priyata” or “vividha suraa vikaara lipsu” (alcohol dependence/alcohol abuse) is one of the features of RG which also may cause loss of appetite (anna dveshinam). Even “deenata” (depression) as explained as one of the signs of RG may also produce loss of appetite or anorexia (anna dveshinam).

Ati balinam/Vipula balo (excessive energy levels/increased motor activity)

Increased activity is found in 90% of the cases of mania.[15] Increased energy levels or increased motor activity is one of the features of “Irritable mania.”[9] Patients with acute manic episode often show “grandiosity.”[7] Inflated self-esteem is typically present in mania, ranging from uncritical self-confidence to marked grandiosity, and may reach delusional proportions. Increase in goal-directed activity often involves excessive planning of and excessive participation in multiple activities, for example, sexual, occupational, political, and religious activities. The person may simultaneously take on multiple new ventures, increased sociability (calling friends or strangers at all hours of the day or night), psychomotor agitation, restlessness, expansiveness, grandiosity, and doing multiple tasks simultaneously.[14] All of which supports the view of “ati balam”/”vipula balam” of RG. “Anaahaaramapi ati balinam” (excessive energy levels even poor intake of food) or “vipula balo” (excessive energy levels) of RG denotes the condition of Mania.

Nirlajja (disinhibition)

Disinhibition and impulsive behavior can be seen in antisocial personality, mania, and drug as well as alcohol dependence.[19] Both sexes have showed increased sexual intercourse in mania and patient of mania with comorbid bipolar and substance abuse have showed high-risk hypersexual behavior.[20]Madya priyata” (alcohol abuse) also produces disinhibition which brings out the behaviors that are normally repressed.[21] Substance abuse can lower inhibitions and increase impulsive behaviors which lead to very informal sexual liaisons and also drug dependency. The high number of sexual partners in people with ASPD associated with addiction. Among individuals with severe mental illness, addiction is associated with an increase in a variety of risk behaviors, with multiple sexual partners being the most common.[22] The patients with schizophrenia may also display inappropriate sexual behavior like public masturbation.[17] All of these behaviors denote “Nirlajja” of RG.

Apriya vaadinam/Parusha bhaashinam (harsh speech/hostile comments)

In mania, if the person's mood is irritable, speech may be marked by complaints, hostile comments, or angry tirades. The person may be hostile and physically threatening to others. Some individuals, especially those with psychotic features, may become physically assaultive.[14]

Ashuchi/Shaucha dvesha (lack of hygiene)

Poor appearance (impaired self-care or lack of hygiene) suggests functional deterioration associated with psychotic mania.[9] In schizophrenia decreased functioning in work, social relations and self-care (poor self-care and personal hygiene) are common.[17] Lack of hygiene may be due to the presence of madya priyata (alcoholic abuse), deenata (depression), or underlying psychosis in RG.

Stree priyata (hypersexuality)

There is a clear association found between risky sexual behavior and common psychiatric disorders. Young people diagnosed with substance dependence, schizophrenia spectrum, and antisocial disorders were more likely to engage in risky sexual intercourse, contract sexually transmitted diseases and have sexual intercourse at an early age, i.e., before 16 years. Young people with mania were more likely to report risky sexual intercourse and have sexually transmitted diseases. The likelihood of sexually risky behavior found increased by psychiatric comorbidity. The strongest association of risky sexual behavior was with disorders characterized by disinhibition or a pattern of impulsive behavior such as antisocial personality, mania and drug and alcohol dependence.[19] Sexual or erotic excitement has been noted as a feature of mania since 1892. In 57% of manic patients, hypersexuality is found. Hypersexuality is listed in the diagnostic criteria of BPD in DSM V (Diagnostic and Statistical Manual of Mental Disorders 5). Manic episode has three stages, starting as heightened sexual thoughts and sexual activity in the first stage and then progressing to sexual preoccupation and ending in sexual delusions. Patients with co-occurring BPD and substance abuse have exhibited high-risk hypersexual behaviors.[20]Stree priyata” explained as one of the features of RG denotes hypersexuality which is commonly seen in ASPD, BPD/mania, and substance abuse.

Rakta, amisha priyam (fond of/craving for nonvegetarian food)

The person suffering with RG craves for meat and blood which may indicate cruelty/violence/aggressiveness toward animals (as present in ASPD, mania) or deficiency of various nutrients in the body (so cravings develop toward such type of foods which may correct the nutritional deficiency). There are no direct references related to cravings for particular food items in psychiatric disorders but latest research shows that various nutritional deficiencies might produce antisocial and offending behavior. A number of studies have suggested links between poor diet and depression, anxiety, impulsivity, and aggression. Improving the nutritional status through micronutrient supplementation improves the antisocial and offending behavior. Offenders with low blood vitamin concentrations were significantly more likely to commit rule violations than offenders with normal concentrations. Individuals whose low micronutrient levels were corrected showed greatest decrease in violence. Specific micronutrients have been studied in relation to mood and behavior and these include omega-3 fatty acids, folic acid, zinc, magnesium, and Vitamin D. Impulsive behavior, which includes ADHD, self-harm, homicide, and suicide, has been studied in relation to omega-3. Lower levels of omega-3 in the body have been found to be associated with self-harm and impulsivity.[23]

Low levels of the neurotransmitters serotonin and dopamine may be related to low levels of omega-3. This has been noted in alcoholics (madya priyata of RG) including those with a history of violent, impulsive behaviors. Low fatty acid levels were associated with aggression. Folic acid is important for the metabolism of the neurotransmitters serotonin, dopamine, and norepinephrine. Dietary supplementation of folic acid may affect mood. Zinc is involved in brain and neurotransmitter function and its deficiency may play a role in the etiology of ADHD. Children with ADHD (when zinc given alone) has showed significant improvement in hyperactivity and impulsivity. Magnesium has many roles in the functioning of the central nervous system including neurotransmission. Psychiatric symptoms of magnesium deficiency can range from apathy to psychosis.[23]

The most common nutritional deficiencies seen in patients with mental disorders are of omega-3 fatty acids, B vitamins, minerals, and amino acids. Some biochemical abnormalities in people with BPD include oversensitivity to acetylcholine, excess vanadium, Vitamin B deficiencies, a taurine deficiency, anemia, omega-3 fatty acid deficiencies, and Vitamin C deficiency. A deficiency of taurine may increase a bipolar patient's manic episodes. In addition, eighty percent of bipolar sufferers have some Vitamin B deficiencies (often accompanied by anemia).[24]Madya priyata (alcohol abuse) in RG may further deteriorates food intake (”alpahaaramapi” and “anna dveshinam”) and cause various nutritional deficiencies. Poor intake of food is common in alcohol abuse. Alcohol impairs digestion and absorption of many nutrients from the small intestine. These include B1, B6, B12, choline, folic acid and other Minerals. Liver impairment due to alcohol abuse hampers the absorption of the fat-soluble vitamins A, D, E, and K. Folic acid which helps make red blood cells is diminished by alcohol. Thus, anemia may develop more easily with alcohol abuse, especially with low levels of Vitamin B12 and reduced absorption and storage of iron.[16]

The lack of appetite caused by alcohol abuse also makes it harder to get needed nutrients. Alcohol also causes a chemical imbalance in the brain involving the neurotransmitters dopamine and serotonin. Dopamine cannot be obtained directly from food, but tyrosine (an essential amino acid and a dopamine precursor) is abundant in several protein-rich foods such as chicken, turkey, avocado, nuts, and seeds. By eating foods rich in tyrosine, the brain will be able to synthesize dopamine. Proteins are high in amino acids, which are necessary for dopamine production. Chicken, red meat, dairy products, and eggs all contain the amino acid tryptophan, which the body can convert into niacin. Foods such as fish, eggs, chicken, turkey, and red meat supply the body with adequate amino acids.[16] Tryptophan poor diet produced high rates of aggressive behavior. In children, zinc and/or iron deficiencies are also related to increased aggressive behavior as iron deficiency may reduce dopaminergic transmission.[8] By considering all these facts, it can be assumed that the cravings toward nonvegetarian food items as mentioned in RG (rakta, amisha priyam) denotes the underlying deficiency of folic acid, iron, essential amino acids, proteins, vitamins, minerals, and various other micronutrients. The underlying anemia and nutritional deficiency in people with ASPD with substance abuse (alcohol abuse) may show cravings for nonvegetarian food items.

Madya priyata (alcohol abuse)

CD and ASPD are established risk factors for SUD in both general population and among persons with schizophrenia and other severe mental illnesses. Having a psychiatric illness increases vulnerability to a comorbid SUD, with the highest risk associated with ASPD and its developmental precursor, CD. Among individuals with alcohol or drug use disorder, ASPD is associated with a more severe course of addiction, including an earlier onset, more rapid progression to dependence, and greater social, legal, and physical consequences of use. Substance abuse can lower inhibitions and increase impulsive behavior, leading to very informal sexual liaisons, and drug dependency. The strong association between ASPD and criminal behavior is consistent with linking ASPD to criminal behavior and violence in persons with schizophrenia and other severe psychiatric disorders. Violence and criminality in schizophrenia can be partly attributed to a subgroup of persons with ASPD who are “early starters,” whose antisocial behavior predates the onset of their schizophrenia. For these individuals, substance abuse may complicate their criminal tendencies.[22]

There is a strong association between alcohol consumption and aggressive behavior ('madya priyata and krodhata/kroorata in RG). People with ASPD may be particularly susceptible to alcohol-related aggression. The current criteria for ASPD, as described in DSM–IV, include a behavioral pattern that begins before age 15 and comprises at least three of the following behaviors: repeated criminal acts, deceitfulness, impulsiveness, repeated fights or assaults, disregard for the safety of others, irresponsibility, lack of remorse. A positive correlation exists between the quantity of alcohol consumed and the frequency of violent acts, including sexual assault, child abuse, and homicide. Alcohol impairs higher reasoning or “executive” brain functions which allows more basic or impulsive brain functions to take over. Alcohol causes disinhibition or brings out behaviours. Alcohol alters the activities of neurotransmitters like gamma–amino butyric acid and serotonin. Both of these neurotransmitters have been associated with aggressive behavior.[21]Madya priyata” mentioned in RG denotes alcohol abuse and its associated complications. By considering these facts, it seems that the lakshanas such as “krodha drishtim,” “bhairavaasya,” “bhrukuti udvahantam,” “praharantam,” “roshanam,” “shooram” and “krooram” along with “madya priyata” denote the comorbidity of ASPD, SUD, BPD, and schizophrenia.

Maalya priyata (fond of garlands)

Manic patients may frequently change their dress, makeup, or personal appearance to a more sexually suggestive or dramatically flamboyant style that is out of character for them. Manic patients may engage in activities that have a disorganized or bizarre quality.[14] Although in severe mania there may be poor self-care (”ashuchi” or “shaucha dvesha” as explained in RG), the manic patient usually dresses up in gaudy and flamboyant clothes.[25] Wearing garlands made by flowers and other such makeup related flamboyant dressing or appearance denotes underlying manic episode of RG.

Deenam (depression)

Presence of “deenata” in RG along with other features such as “stree priyata.” “nashta nidra,” “nisha vihaari,” “vipula bala/ati bala,” “krodhata,” “abhidhaavantam,” “praharantam,” “sambhramam” denotes a depression along with mania in a same patient which indicates underlying “BPD.” Bipolar II disorder is characterized by one or more major depressive episodes accompanied by at least one hypomanic episode. Cyclothymic disorder is characterized by at least 2 years of numerous periods of hypomanic symptoms and numerous periods of depressive symptoms. When criteria for manic episode and major depressive episode both met, it should be considered as “Mixed episode.” The individual with mixed episode experiences rapidly alternating moods (sadness, irritability, euphoria) accompanied by symptoms of both manic episode and a major depressive episode. It seems that “deenata” and “vipula balam” together denotes mixed episode.[26]

Shankitam (suspiciousness)

Persecutory delusions are the most common feature of “paranoid schizophrenia;” when these persecutory types of delusions are associated with “grandiose delusions” and anger, the individual is predisposed to violence. The person with persecutory delusions believes that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Individuals with persecutory delusions are often resentful and angry and may resort to violence against those they believe are hurting them.[27]Shankitam” of RG denotes delusions/schizophrenia.

Annakaale hasantam/akasmaat hasantam, gaayantam, rudantam (inappropriate behavior/disorganized behavior)

Annakaale hasantam (laughing at the time of food intake) and akasmaat hasantam, gaayantam, rudantam (suddenly laughing, singing, and crying; inappropriate behavior) denotes gross disorganized behavior or inappropriate behavior, which commonly found in schizophrenia or delusional disorder. Grossly disorganized behavior may manifest itself in a variety of ways, ranging from childlike silliness to unpredictable agitation. The individual with schizophrenia may display inappropriate effect like smiling, laughing, or a silly facial expression in the absence of an appropriate stimulus.[17]

Nirarthakam paribhaashamaanam (pressure of speech or inappropriate speech or disorganized speech)

Speech in mania patient is typically pressured, loud, rapid, and difficult to interrupt. Individuals may talk nonstop, sometimes for hours without regard for other's wishes to communicate. Speech is sometimes punning, joking, and amusing irrelevancies. The person with mania becomes more talkative than usual or displays pressure to keep talking.[14] Even speech of individuals with schizophrenia may be disorganized in a variety of ways. The person with schizophrenia may “slip off the track” (derailment or loose associations), answers to questions may be completely unrelated (tangentiality) and severe disorganized speech which is incomprehensible and resembles with receptive aphasia (incoherence or word salad).[17]Nirarthaka paribhaashamaanam” of RG denotes mania or schizophrenia.


  Comorbidity of Various Psychiatric Conditions Top


Comorbidity in psychiatry is highly prevalent and has received a great deal of attention because of its importance for clinical management and research. Knowledge that disorders often co-occur, either concurrently or sequentially and will shape diagnostic and therapeutic practice. Psychiatric disorders are polythetic. They not only share diagnostic features but almost never possess uniquely pathognomonic symptoms. The heterogeneity inherent in psychiatric disorders may lead to findings of comorbidity that do not apply across the entire clinical population and may result in “pseudo-comorbidity.” Unfortunately, there are no means of identifying phenocopies (syndromes that look similar but have distinct etiologies, be they genetic, environmental, or otherwise influenced).[13] Various psychiatric conditions such as ADHD, SUD, ASPD, BPD, CD, and schizophrenia are usually comorbid with one another. ADHD can persist into adulthood and be associated with other mental health problems such as depression, BPD, and schizophrenia. ADHD is one of the most significant predictors of substance misuse in adolescents. CD and ADHD are two childhood disorders that are commonly associated with juvenile delinquent behavior. ADHD continues into adulthood with an increased risk of developing CD, substance abuse and antisocial personality disorder. Both ADHD and CD are correlated with an adult diagnosis of antisocial personality disorder, especially if onset occurs before age six.[28]

BPD and cluster B personality disorders could be part of a continuum. They both share impulsivity as a core feature. Substance abuse, suicidality and criminal behavior, potentially related to impulsivity, cut across ASPD and BPD. ASPD and BPD mechanistically or genetically related for early age of onset, overlapping early clinical manifestations, evidence for familial associations including coexistence of antisocial and mood disorder characteristics in family and twin studies, similar clinical problems including substance-use disorders and suicidality; approximately 10% of individuals with BPD have ASPD.[29] The relationship between ASPD symptoms and course of illness could result from greater occurrence of antisocial behavior during episodes, especially manic. ASPD symptoms could also be related to SUDs.[30] By considering all the above facts, it seems that the lakshanas of RG resemble with various psychiatric conditions such as ADHD, CD, BPD, ASPD, SUD and schizophrenia or comorbid condition among them.


  Conclusion Top


RG lakshanas such as “krodha drishtim,” “bhrukuti udvahantam,” “bhairavaananam,” “ati shoornam,” “ati nishtooram,” “praharantam,” “shastra abhilashinam,” “roshanam” and “apriya vaadinam” indicates aggressiveness, violence, impulsivity, and cruelty, which are the characteristic features of “Antisocial personality disorder.” Lakshanas such as “tvaritam abhidhaavantam,” “sasambhramam,” “nashta nidra,” “nisha vihaari,” “anaahaaramapi ati balinam” “vipula balam,” “stree, madya, maamsa, maalya priya” and “nirarthaka paribhaashamaanam” indicate “Mania.” “Deenata” denotes “depression;” depression and mania in same individual denotes “BPD.” Lakshanas such as “shankitam,” “annakaale hasantam,” “akasmaat hasantam, gaayantam, rudantam,” “ashuchi or shaucha dvesham,” and “nirarthaka paribhaashamaanam” indicate “schizophrenia” or “delusional disorder.” RG resembles with the comorbid condition of antisocial personality disorder with psychotic mania and alcohol abuse.

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