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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 32-40

Brahma rakshasa grahonmada: Borderline personality disorder?/tourette syndrome – plus?


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_14_17

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  Abstract 


Brahma rakshasa grahonmada (BRG) is one among 18 types of bhootonmada (psychiatric problems caused by the affl iction of evil spirits or super natural powers or extraterrestrial forces or idiopathic). Acharya Charaka and Vagbhata have described this condition. The present study aims at better understanding of BRG and its clinical signifi cance. BRG is characterized by Haasa nritya priyam (engaged in jocularity and dancing/euphoria/mania/hypomania), aakroshinam (verbal abuse), pradhaavinam (hyperactivity/pacing/running), deva dvija bhishak dveshinam (negativistic, defi ant, disobedient, hostile behavior toward authority figures) mantra veda shastra abhidayinam (religious obsessions/praying compulsions), kaashta shastraadhibhi aatmaanam ghnantam (self-injurious behavior), Chhidra prahaarinam and vaidya randhraanveshinam (exploding nature/aggressiveness/assaulting/low frustration tolerance/rage attacks), “bho” shabda vaadinam(making sounds like “bho”/vocal tics), parusham (lack of empathy/cruelty), raudra cheshtam (hostile/antisocial behavior), sheeghra gaaminam (hyperactivity/pacing/running/impulsivity), etc., features. These features of BRG show similarity with various psychiatric/neuropsychiatric conditions such as borderline personality disorder (BPD), disruptive behavior disorders (DBDs) which include oppositional defi ant disorder and conduct disorder and Tourette syndrome (TS)-plus (comorbid condition of TS with attention-defi cit hyperactivity disorder [ADHD], obsessive-compulsive disorder [OCD], and other behavioral disorders). BRG is similar to BPD or TS-Plus (TS + ADHD + OCD+DBD).

Keywords: Attention-deficit/hyperactivity disorder, borderline personality disorder, Brahma rakshasa grahonmada, disruptive behavior disorders, obsessive-compulsive disorder, Tourette syndrome


How to cite this article:
Mamidi P, Gupta K. Brahma rakshasa grahonmada: Borderline personality disorder?/tourette syndrome – plus?. Int J Yoga - Philosop Psychol Parapsychol 2018;6:32-40

How to cite this URL:
Mamidi P, Gupta K. Brahma rakshasa grahonmada: Borderline personality disorder?/tourette syndrome – plus?. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2018 [cited 2019 Mar 25];6:32-40. Available from: http://www.ijoyppp.org/text.asp?2018/6/1/32/233606




  Introduction Top


“Bhuta vidya” is one of the eight branches of Ayurveda which deals with mode of exorcising evil spirits and making offerings to deva, pishacha, gandharva, yaksha, rakshasa, etc., for cure of diseases originating due to their malignant influence. Bhutonmada/Grahonmada is a psychiatric condition caused by bhoota/graha (evil spirits/extraterrestrial forces/supernatural powers), and it is characterized by various abnormal behaviors related to the sudden change in strength, energy, enthusiasm, perception, retention, memory, speech, and also abnormality in perceiving self as well as environment. Acharya Vagbhata has described 18 types of grahonmada's. They are deva, asura, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala. brahma rakshasa grahonmada (BRG) is one among these 18 types of bhootonmada.[1]

BRG is explained in Charaka samhita,[2]Ashtanga samgraha,[3] and Ashtanga hridaya.[4] There is no description of BRG in Sushruta samhita[5] and Madhava nidaana.[6] In Charaka samhita the lakshana's (signs and symptoms) are explained briefly but in Ashtanga samgraha and Ashtanga hridaya the description is elaborate and almost similar. BRG is characterized by haasa nritya priyam (engaged in jocularity and dancing/euphoria/mania/hypomania), aakroshinam (verbal abuse), pradhaavinam (hyperactivity/pacing/running), deva dvija bhishak dveshinam (negativistic, defiant, disobedient, hostile behavior toward authority figures) mantra veda shastra abhidayinam (religious obsessions/praying compulsions), kaashta shastraadhibhi aatmaanam ghnantam (self-injurious behaviour [SIB]), Chhidra prahaarinam and vaidya randhraanveshinam (exploding nature/aggressiveness/assaulting/low frustration tolerance/rage attacks), “bho” shabda vaadinam (making sounds like “bho”/vocal tics), parusham (lack of empathy/cruelty), raudra cheshtam (hostile/antisocial behavior), sheeghra gaaminam (hyperactivity/pacing/running/impulsivity), etc., features.[3]

Till date, no studies have been conducted on BRG, and it is an under-explored concept. The present study is focused at better understanding of BRG with the help of modern psychiatry. Various psychiatric or neuropsychiatric conditions like “Borderline personality disorder” (BPD), “Disruptive behavior disorders” (DBD) like “oppositional defiant disorder” (ODD) and “conduct disorder” (CD), Tourette syndrome – plus (TS – plus) which is a comorbid condition of TS + attention-deficit/hyperactivity disorder (ADHD) + obsessive-compulsive disorder (OCD) + other associated behavioral and/or mood disorders. The description of similarity of lakshana's of BRG with various psychiatric conditions as follows.

Brief overview of oppositional defiant disorder, conduct disorder, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, and borderline personality disorder

ODD is a disruptive behavior disorder, characterized by a pervasive pattern of disobedience, defiance with hostile behavior. ODD patients discuss excessively with adults, do not accept responsibility for their misbehavior, deliberately bother others and have difficulty accepting rules, easily losing temper if things do not go their way.[7] ODD patients blame others for their own mistakes or misbehavior, being touchy or easily annoyed by others, being angry and resentful, being spiteful or vindictive, and with significant impairment in social, academic, or occupational functioning.[8]

The essential feature of CD is a repetitive and persistent pattern of behavior in which the basic rights of others or societal norms or rules are violated. Patients with CD often initiates aggressive behavior, may display bullying, threatening, intimidating, or initiates frequent physical fights, deliberate destruction of others property, acts of deceitfulness and serious violations of rules.[9] CD is defined by more serious violations such as stealing, assaulting and cruelty toward animals and people.[7]

ADHD may present with any or all of the following symptoms: Hyperactivity, distractibility, impulsivity, short attention span, forgetfulness, procrastination, poor consequential thinking, low frustration tolerance, mood liability, temper outbursts, and preference for high levels of stimulation.[10] The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe. Associated features of ADHD include low frustration tolerance, temper outbursts, bossiness, stubbornness, mood lability, demoralization, dysphoria, rejection by peers and poor self-esteem.[11]

OCD is a common anxiety disorder, and it has a significant negative impact on quality of life. OCD interferes with interpersonal relationships, academic achievements and work. The main features of OCD are the obsessions and compulsions. Obsessions are usually unwanted, intrusive, unavoidable, ego-dystonic, occasionally frightening or violent thoughts often manifest as, aggressive or intrusive thoughts, religious scrupulosity, concerns about symmetry, perfectionism, pathological doubt, pathological collecting and hoarding, contamination worries, etc., compulsions are repetitive behaviors or mental acts such as washing, cleaning, checking, touching, counting, ordering, hoarding, and conducting physical or mental rituals. Most of the OCD patients do criticize their own thoughts, and they are unable to stop such thoughts or behaviors.[1]

BPD is a chronic psychiatric disorder characterized by marked impulsivity, instability of mood and interpersonal relationships, and suicidal behavior. BPD first presents clinically in adolescence, at a mean age of 18 years. The affective symptoms in BPD involve rapid mood shifts, in which emotional states tend to last only a few hours with a strong tendency toward angry outbursts. Impulsive symptoms include a wide range of behaviors and are central to diagnosis. The combination of affective instability with impulsivity in BPD helps account for a clinical presentation marked by chronic suicidality and by instability of interpersonal relationships. Psychotic symptoms were found to predict self-harm in patients with personality disorders. Patients with BPD experience “micro psychotic” phenomena of short duration (lasting hours or at most a few days), auditory hallucinations without loss of insight, paranoid trends, and depersonalization states in which patients experience themselves or their environment as unreal.[12]

Comorbidity of borderline personality disorder, bipolar disorder, attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder

Researchers and clinicians have long noted the overlap among features and high comorbidity of bipolar disorder (BD) and BPD. The shared features of impulsivity and labile mood in both disorders make them challenging to distinguish.[13] Children who were diagnosed with ODD at a younger age may later transition to a diagnosis of ADHD, anxiety, or depression. Coexisting conditions are common in children with ODD, particularly ADHD and mood disorders. In this study, researchers found that 40% of children with ADHD also meet diagnostic criteria for ODD. Children with ODD were twice as likely to have severe major depression or BD compared with a reference group. ODD has commonly been regarded as a subject and precursor of the more serious CD, in part because most children with CD have a history of ODD. Approximately, one-third of children with ODD subsequently develop CD, 40% of whom will develop antisocial personality disorder (ASPD) in adulthood.[14] ODD or CD may be comorbid in more than half of the ADHD cases.[15] Although ODD significantly increases the risk for CD and ASPD, CD conferred a much larger risk for these outcomes. CD was associated with significantly increased risk for psychoactive substance use disorders, smoking, and BD.[16]

ADHD, ODD, and CD are three of the most prevalent disruptive behavior disorders and numerous studies have reported comorbidities among these disorders often making them difficult to isolate and understand individually. Although ADHD can co-occur with CD, the association between ADHD and CD is largely accounted for by accompanying ODD. Family studies have shown that ADHD, ODD, and CD are co-transmitted in families and thus appear to share a common familial etiology. Adolescents diagnosed with ADHD and comorbid DBDs during childhood have reported emotional dysregulation to be an important component of ADHD along with inattention and hyperactivity.[17] Behavioral problems in ADHD children tend to aggravate and during adolescence they meet the DSM criteria for ODD or CD.[18] Children with BPD present with other psychiatric disorders, particularly ADHD, ODD, CD, and anxiety disorders. Mania in juveniles has often been misdiagnosed as ADHD, CD, or schizophrenia. Symptoms such as inattention, distractibility, impulsivity and increased psychomotor activity may be common in both ADHD and BPD. A study has reported much higher rates of comorbid ODD (up to 100%), CD (up to 71%) and anxiety disorder (up to 64%) in their ADHD + BPD subjects.[19]

There is a modest association between BPD and BD. Comorbidity of BPD and BD has been found in 10%–25% of patients.[20] Both BPD and BD can be diagnosed in the same patient, and often are. Higher than expected rates of comorbidity indicates not only a relationship between two disorders, but that the two disorders are, at some level, one and the same. Several studies have demonstrated high rates of personality disorder among patients with BD, with BPD the most common diagnosis.[21] There is current scientific debate in consideration of the possibility to consider the BPD as a mood disorder within the bipolar spectrum.[22] ADHD symptoms consequently have been increasingly recognized in BPD patients. It has become common knowledge that both disorders frequently occur as life-long comorbidities. BPD was found in 24% of the combined type ADHD patients and in 10% of the inattentive ADHD patients. Childhood ADHD is a risk factor for the development of BPD in adolescence and adulthood. ADHD and BPD share some clinical features, particularly impulsivity and emotional instability and these disorders often co-occur.[23] According to a study, 60% of adults with BPD meet criteria for ADHD. This suggests that childhood ADHD may be a risk factor for BPD in adulthood.[24]

Tourette syndrome-plus

TS is a childhood-onset neuropsychiatric movement disorder characterized by multiple motor tics and one or more vocal or phonic tics. It is associated with both simple and complex tics. Complex tics include echolalia (repeated vocalizations), palilalia (repetition of words or phrases), echopraxia (repeated actions), palipraxia (repeating the last act), SIBs, complex vocalizations (e.g., animal sounds), coprolalia (swearing), and copropraxia (inappropriate touching), etc. Other associated features include nonobscene socially inappropriate behaviors and remarks, concern for symmetry, an “impulsion” (resulting from poor impulse control and the person may experience pleasure or gratification in some instances) or compulsive behavior. The incidence of tics in the absence of other associated features and comorbidities occurs in only around 10% of cases (pure-TS) while the remainder has a number of associated comorbidities (TS-plus). TS is commonly comorbid with ADHD, OCD, and autism. A number of co-existent psychopathologies have also been described in TS including anxiety, depression, learning difficulties, personality disorder, impulse control, aggression, ODD, and CD.[25],[26] The symptomatology of TS reveals marked heterogeneity.[27]


  Similarity between Brahma Rakshasa Grahonmada And Borderline Personality Disorder With Attention-Deficit/hyperactivity Disorder, Disruptive Behavior Disorder and Bipolar Disorder/tourette Syndrome-Plus Top


There is striking similarity found between the conditions such as BRG and BPD comorbid with ADHD, DBD (ODD and CD), and BD. BRG is also shows similarity with TS-Plus in terms of etiology, pathogenesis, prognosis, and symptomatology.

Etiology, pathogenesis and prognosis of brahma rakshasa grahonmada and its similar modern psychiatric disorders

There is no specific etiology, pathogenesis and prognosis explained for BRG in Ayurvedic texts. The common etiology, pathogenesis and prognosis explained for grahonmada is applicable for BRG also. The reasons explained for grahavesha (affliction by evil spirit/extraterrestrial force/supernatural power) is prgnaaparaadha/karma in the present or previous life. In bhootonmada the symptoms occurs suddenly without any 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 unspecific. The prognosis of bhootonmada is unpredictable. The prognosis of bhootonmada depends on the purpose for which the graha (supernatural being) seizes the person. The purpose of graha, seizing a person may be due to himsa (violence/aggression) or rati (attachment/desire) or abhyarchanam (for worship). When the patient is afflicted with the intention of himsa (as in case of BRG), the patient may enters in to fire or sinks in to water or falls in to a pit or any other SIB and further he may adopt such other means for killing himself. The unmada with the intention to inflict injury to self or to others (himsatmaka) is said to be asadhya (untreatable).[1] BRG also a type of “rakshasa grahnomada” with “himsa” and it is asadhya in nature.

Even though, genetic, behavioral, psychosocial, organic, biological, stress factors, traumatic life events, and other causes are explained as etiological factors for various psychiatric disorders such as BPD, DBD, OCD, TS and BD, exact cause, pathogenesis, etc., are still incomplete. There is no single cause or even greatest single risk factor found for ODD. No single transmitter or neurologic pathway has been identified as the root cause for ODD. ODD is clearly familial, but research has yet to determine what role genetics play because studies on the genetics of the disorder have produced inconsistent results. The natural history of ODD is also not completely understood yet.[14] Understanding the causes of BPD is still at beginning stages. As with most mental disorders, no single factor explains the development, and multiple factors (biological, psychological, and social) all play a role in BPD.[12] Clinical experience suggests that some patients with BPD get better symptomatically over time, some stay about the same, and some get worse. However, little is actually known about the course of the syndromal phenomenology of BPD (i.e., rates of remission and recurrence), and almost nothing is known about the fate of the subsyndromal phenomenology or symptoms of BPD.[28] Pathogenesis of TS also still unknown although is thought to involve striato-cortical circuits.[1]


  Similarity between Signs and Symptoms of Brahma Rakshasa Grahonmada With Borderline Personality Disorder + Attention-Deficit/hyperactivity Disorder + Disruptive Behavior Disorder/tourette Syndrome-Plus Top


Detailed description of BRG lakshana's is available in Ashtanga samgraha (written by Vriddha Vagbhata)[3] and in Ashtanga hridaya (written by Vagbhata).[4] The analysis of each lakshana of BRG along with its relevant modern psychiatric condition is described in the following way.

Haasa nritya priyam- euphoria/mania/hypomania

High comorbidity and overlap among clinical features between BD and BPD is well documented.[13],[20] BPD may be an atypical presentation of a primary mood disturbance, probably related to the broad spectrum of bipolar-like disorders.[21] Frequent mood changes of BPD may appear to overlap with BD. The mood symptoms of patients with BPD are triggered by external events and moods usually shift between depression and anger with transient euphoria. BPD patients may also feel as if they are assuming the identity of other people to whom they are close. About 40%–50% of patients with BPD have brief periods of psychotic symptoms or dissociation. Typical symptoms include paranoid thoughts and auditory hallucinations. Depersonalization (i.e., the sensation that a person's body or self is unreal or altered in a strange way), derealization (i.e., the experience that the external world is bizarre and unreal), and illusions, which are misperceptions of existing stimuli are also commonly seen in BPD patients.[29] Patients with BPD experience “micropsychotic” phenomena of short duration (lasting hours or at most a few days), auditory hallucinations without loss of insight, paranoid trends, and depersonalization states in which patients experience themselves or their environment as unreal.[12] Quasi-psychotic thoughts were reported in BPD patients include transitory, circumscribed delusions and hallucinations, odd thinking, unusual perceptual experiences (overvalued ideas, recurrent illusions, depersonalization, and derealization), and nondelusional paranoia.[28]

When TS is associated with BD, stress induced by manic symptoms is thought to exacerbate tics, and conversely, tics are thought to stimulate or protract manic symptoms by giving rise to serious problems in both social and educational situations. The patient with TS may become dysphoric, increasingly talkative, abnormally increased levels of energy and uncontrollable with unstable moods. ADHD is common in patients with TS and is known to be associated with BD. BD is most common in TS patients with mild tics and is associated with a wide variety of other psychopathologies. Mood swings and aggressiveness frequently occur in patients with TS and many studies suggest that the two disorders (TS and BD) are related.[30] Depression and manic-depressive symptoms are common in TS patients and are an integral part of the disorder rather than being secondary to motor or vocal tics.[31] By considering all these facts “Haasa nritya priyam” of BRG denotes euphoria/hypomania/mania found in comorbid states of BD with BPD or TS.

Aakroshinam, raudra cheshtam, parusham- aggression/hostility/antisocial behavior

Impulsivity and labile mood are the features of BPD and BD.[13] ODD child may “explode” in response to a parental demand, emotionally overreact and generally lacks cognitive or emotional skills. Children with ODD and ADHD shows more aggression, have more behavioral problems and experience more rejection by peers.[14] Aggression, hostility, and emotionality are the features of ADHD, ODD, and CD.[17] Marked impulsivity, instability of mood, and disturbed interpersonal relationships are the main features of BPD.[12] Majority of BPD patients have displayed chronic feelings of anger.[28] Patients with BPD described continuous dysphoria, high emotional variability, and increased hostility. Inappropriate and intense anger is the next effective symptom of BPD and is related to affective instability.[29] Impulse control problems or impulse dysregulation along with tics is one of the features of TS-Plus.[26] Increased irritability, rage attacks, increased vulnerability for drug abuse, depression, and antisocial behaviors are also not uncommon among patients with TS and hyperkinetic disorder.[32] A patient of TS has displayed impulsivity, aggressive behavior, irritability, and abnormally increased energy.[30] The patients of TS-Plus shows rage attacks. These rage attacks in TS patients are unpredictable, have an explosive quality and patients often have a feeling of loss of control. Rage attacks in TS resemble intermittent explosive disorder. In clinical TS populations, 25%–70% experience episodic behavioral outbursts and anger control problems.[33]

CD in the TS proband was also significantly related to the presence of ADHD and several previous studies have demonstrated a link between ADHD and other disruptive behaviors, including CD and ODD. The SIB in TS is significantly associated with obsessive-compulsive behavior. Severe SIB was correlated with variables related to affect or impulse dysregulation, in particular, with the presence of episodic rages and risk-taking behaviors. Other behavioral disorders in the context of TS found that aggression, rage, ODD, and CD also have a profound negative impact on the patient's ability to function. The presence of comorbid ADHD in children with TS is associated with high rates of delinquent behavior and maladaptive behaviors (e.g., aggression to property, attacking other people, having had forensic encounters, alcohol/drug abuse). Aggressive delinquent externalizing behaviors epitomized by CD occur in patients with TS.[34] Aggressive behavior includes verbal and physical acts such as yelling, swearing, kicking, throwing, punching, hitting, and pushing. Temper outbursts, mood swings, aggression, disruptive behaviors, rage attacks, anger, low frustration tolerance, and irritability are seen in TS-Plus patients (TS with OCD and ADHD).[35]Aakroshinam, raudra cheshtam, parusham of BRG denotes aggressiveness, hostility, antisocial, disruptive, and impulse dysregulation behaviors seen in ADHD/ODD/CD/BPD/TS-Plus.

Pradhaavinam, sheeghra gaaminam- hyperactivity/pacing/running/impulsivity

Overt aggressive behaviors and covert emotional and cognitive processes in adolescents with ADHD and comorbid DBD have reported emotional dysregulation to be an important component of ADHD along with inattention and hyperactivity. There are meaningful distinctions among ADHD, ODD, and CD, especially in their correlates and outcomes, observation of their common vulnerabilities suggests that they share the same liability risk which could be either genetic, environmental, or some combination of both in origin. Keeping in mind these shared risk factors as well as overlapping symptoms especially in domains of aggression, hostility, and emotionality the developmental pathway from ADHD to ODD and CD might raise the possibility of a common psychopathological spectrum.[17] ODD is highly comorbid with ADHD, being present in 50% of these patients.[7] Symptoms such as inattention, distractibility, impulsivity, and increased psychomotor activity may be common in both ADHD and BPD. Higher rates of comorbid ODD (up to 100%), CD (up to 71%), and anxiety disorder (up to 64%) were found in ADHD with BPD subjects.[19]

Impulsivity has been defined as swift action without forethought or conscious judgment, behavior without adequate thought, and the tendency to act with less forethought than do most individuals of equal ability and knowledge. Behaviors related to impulsivity such as risk-taking, lack of planning, and making up one's mind quickly. Impulsivity can be divided into three components: (1) acting on the spur of the moment (motor activation), (2) not focusing on the task at hand (attention), and (3) not planning and thinking carefully (lack of planning). Some authors argue that impulsivity and compulsivity are opposite ends of a spectrum. Impulsivity should include the following elements: (1) decreased sensitivity to negative consequences of behavior; (2) rapid, unplanned reactions to stimuli before complete processing of information, and (3) lack of regard for long-term consequences. Impulsivity is defined here as a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to the impulsive individual or to others. Studies of patients with BPD have found that impulsivity is a key factor in the diagnosis, linking BPD to antisocial personality disorder and mania. Impulsive/hyperactive subtype of ADHD found to be associated with a high rate of comorbid symptoms of ODD and CD.[36]

Co-occurrence of TS and OCD is common and found in 40%–75% of the cases. One of the features that these pathologies may share is the sensory phenomenon, a bodily (tactile and/or musculoskeletal and visceral) or mental (e.g., inner tension and feeling of imperfection) sensation that precedes the repetitive behavior, usually disappearing after performing it. This feature is similar to obsessive symptoms, which only cease when the compulsive behavior is completed.[37] TS is distinguished by erratic movements of the whole body (multiple motor tics) and a case of TS has reported an abnormally increased energy levels.[30] Psychomotor instability is found in BD and ADHD.[38]Pradhaavinam and Sheeghra gaaminam of BRG denotes hyperactivity or impulsivity or compulsive behavior commonly seen in ADHD, OCD, BPD, and TS-Plus.

Deva dvija bhishak dveshinam, chhidra prahaarinam, and vaidya randhraanveshinam- negativistic, defiant, disobedient, hostile behavior toward authority figures

ODD is characterized by inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures. ODD patients display substantially impaired relationship with parents, teachers, and peers. Girls with ODD tend to exhibit aggression more covertly. They may use verbal rather than physical often excluding others or spreading rumors against others. ODD is commonly regarded as precursor of the more serious CD.[14] ODD is a disruptive disorder and characterized by pervasive pattern of disobedience, defiance, and hostile behavior. ODD patients do not accept their responsibility, misbehaves with authority figures, deliberately bothers others, violates social norms and loses temper.[7] Damage to the orbitofrontal cortex has been associated with disinhibited, socially inappropriate behavior and emotional irregularities in BPD patients.[38] Individuals in a manic state often attempt to manipulate the self-esteem of others, exploit areas of vulnerability, test interpersonal limits, and project responsibility or blame onto others, as is often the case with patients diagnosed with BPD, with the common result of alienating the patient from others. The manic patient expresses such behavior only while in a manic state, whereas a patient with BPD does so unremittingly.[21]

Socially unacceptable coprolalic utterances, for example, shouting obscenities, racial slurs, and gestures are the cardinal features of TS.[32] Coprophenomenon, impulsiveness, aggression, school refusal, and SIB are common in TS comorbid with OCD and ADHD.[33] Anger control problems, rage attacks, disruptive behaviors, coprolalia, and other comorbid psychopathology are common in TS patients.[34] Coprolalia (inappropriate involuntary uttering of obscenities) occurs in <1 third of clinic TS patients. Copropraxia (involuntary inappropriate obscene gestures), echolalia (imitation of sounds or words of others), and palilalia (repetition of the last word, phrase or last syllable of a word uttered by the patient) occurs in a substantial proportion of TS patients. Nonobscene complex socially inappropriate behaviors (NOSI) and disinhibition behaviors such as insulting others (e.g., aspersions on weight, height, intelligence, general appearance, breath or body odor, parts of the anatomy, and racial or ethnic slurs) other socially inappropriate comments and actions are also common in TS patients. Social difficulties such as verbal arguments, school problems, fist fights, job problems, removal from a public place, and legal trouble or arrest are commonly resulted. NOSI were common in young boys related with ADHD and CD, and it was suggested that they may well represent part of a more general dysfunction of impulse control in TS.[27] By considering all these facts, “deva dvija bhishak dveshinam, chhidra prahaarinam and vaidya randhraanveshinam” of BRG denotes disruptive behaviors seen in TS-Plus or BPD comorbid with DBD and/or ADHD.

Mantra veda shastra abhidayinam- religious obsessions/praying compulsions

The lakshana's like “deva, dvija, bhishak dveshinam” and “mantra, veda, shastra abhidayinam” both are contradictory to each other. A person with negativistic, defiant, disobedient or antisocial attitude, how can he/she shows interest in “mantra,” “veda,” and “shastra's?” A previous work on “sangama graha” (SG) has revealed that, SG is a type of rakshasa graha (demon) explained by Vriddha vagbhata (author of Ashtanga samgraha) and the person afflicted with SG shows the signs and symptoms such as broken or interrupted voice, various abnormal movements of the body parts, licking things with the tongue, doing japa (chanting) using a string of beads and performing cleaning activities always. Among those symptoms “shoucham abheekshnam kurvaanaam (excessive cleaning or washing)” represents washing or cleaning compulsions and “akshamaalaya japamaanam (chanting or praying)” represents chanting or praying compulsions or excessive religiosity or superstitious thinking or magical thinking. Other symptoms such as abnormal body movements, speech disturbances resemble TICS (abnormal involuntary movements) of various types. The symptomatology of SG resembles with the comorbid condition of TS with OCD.”[1]

Aggressiveness, sexual, religious, and hoarding symptom dimensions are more severe in TS with OCD and ADHD patients.[37] There is a clear and strong association between TS and OCD. The obsessions seen in TS have to do with sexual, violent, religious, aggressive, and symmetrical themes, the compulsions are to do with checking, ordering, counting, repeating, forced touching, symmetry, getting things “just right,” self-damage, or SIB. Certainly at a clinical level, the obsessive-compulsive symptoms or obsessive-compulsive behavior in TS appear to be ego-syntonic (personally comfortable) rather than ego-dystonic (subjectively uncomfortable) symptoms which characterize OCD.[27] Even though SG is “rakshasa” in nature, it is characterized by “japa” and “shoucha” in similar way in BRG (even it is “rakshasa” in nature) also lakshana's like “mantra, veda, shastra abhidayinam” can be seen and interestingly both SG and BRG are similar to TS with OCD. It can be assumed that, “mantra, veda, shastra abhidayinam” of BRG denotes various behaviors such as chanting, praying compulsions, excessive religiosity, superstitious thinking, magical thinking, or religious obsessions which are the characteristic features of OCD and also can be seen in OCD with TS or TS-Plus.

Almost, all clinicians who have significant experiences with borderline patients are impressed at times with their exceptional ability to sense psychological characteristics of significant others in their lives, including therapists. The inborn talent and need to discern the feelings and motivations of others, and to emphasize its positive value as well as its innateness of BPD patients, can be termed as “giftedness.” Much as one would refer to the mathematically gifted person or the musically gifted person, it can be believed that many borderline patients have a cognitive giftedness in the area of self and other perceptiveness called “personal intelligence.” Numerous authors have described an “uncanny capacity” of many borderline patients to recognize, and often to overreact to or act manipulatively or even helpfully on, unexpressed or private attitudes and judgments, hidden feelings, and unconscious impulses of other people. The intuitive talent in BPD patients can be termed as “borderline empathy.”[39] The “mantra, veda, shastra abhidayinam” of BRG may also denote such type of “giftedness” or “intelligence” of BPD patients. By considering all these facts, it can be assumed that, “mantra, veda, shastra abhidayinam” in BRG indicated OCD associated with TS.

Kaashta shastraadhibhi aatmaanam ghnantam- self-injurious behavior

Self-mutilation and suicidal behavior is common in BPD.[12],[20],[28],[29],[40] SIB is defined as commission of deliberate injury to one's own body done without the aid of the other person and is severe enough to cause tissue damage/scarring. It has been variously termed as deliberate self-harm, self-harm, superficial-moderate self-mutilation, para-suicide, self-wounding, auto-aggression, and purposive accidents. Various forms of self-injury have been described and nature of injury varies from mild to very severe form. Mild and moderately severe form of injuries include head banging, kicking the limbs, skin picking, carving words on the skin, sandpapering the face, dripping acid on the hands, biting, burning, cutting, pulling out finger and toenails, chewing fingers, and so on. Very severe forms include mutilation of various body parts such as removal of eyes, ears, genitalia, tongue, teeth, digits, and limbs. Moderately severe and repetitive SIB has been reported in BPD.[41]

SIB occurs in up to 60% of patients with TS and a variety of SIBs have been reported in individuals with TS, including compulsive skin picking, self-hitting, lip and other self-biting, filing of the teeth, head banging, and eye damage from self-poking. Individuals who had TS plus at least one other psychiatric comorbidity had a fourfold increase in SIB. The presence of OCD or mood disorders was highly correlated with SIB. SIB is very heterogeneous, and can encompass behaviors as trichotillomania (compulsive hair pulling) and ritual self-mutilation by burning or cutting. Moderate SIB includes behaviors that result in moderate tissue damage, such as skin picking or scratching that. Severe SIB includes extreme self-injurious or mutilatory behaviors that lead to permanent, potentially impairing sequelae, such as self-cutting, deliberate eye enucleation, or castration. SIB was primarily manifested as skin picking or scratching, hitting oneself or hitting objects such as a wall. All of these behaviors fall into the clinical symptom spectrum that lies between complex motor tics and compulsions. SIB in TS as defined by more serious acts of self-injury may be related to dysregulation of affect.[26]Kaashta shastraadhibhi aatmaanam ghnantam” denotes SIB commonly seen in BPD or TS.

“Bho” shabda vaadinam- phonic tics/vocal tics

TS is characterized by multiple motor tics and one or more phonic tics generally occurs many times a day in bouts; the number, frequency, and complexity of the tics change over time. Most tics encountered in TS are semi-voluntary or involuntary.[27] Simple motor tics are restricted to a small group of muscles in the body and simple vocal tics to small sounds including throat clearing (”bho” shabda vaadinam?) or sniffing.[25] Many patients of TS describe being besieged by bodily sensations that are generally localized to discrete anatomical regions such as an urge to stretch one's shoulder or a need to clear one's throat (”bho” shabda vaadinam?). These urges and internal struggle to control them can be as debilitating as tics. A large range of auditory or visual cues can also prompt tics, but the nature of these cues is usually highly selective for individual patients – a cough, a particular word (”bho” shabda vaadinam?), an alignment of angles or specific shapes.[32] A patient with TS has displayed motor and vocal tics and also the patient used to shout “Ahk” (similar to “bho” shabda vadinam?) multiple times per day along with other features of TS.[30] Speech of persons with TS is characterized by word repetitions (”bho” shabda vaadinam?), hesitations, interjections and prolongations.[33] The phonic or vocal tics of TS resembles with the “bho” shabda vaadinam of BRG.

Even though most of the lakshana's of BRG such as haasa nritya priyam, aakroshinam, pradhaavinam, deva dvija bhishak dveshinam, kaashta shastraadhibhi aatmaanam ghnantam, Chhidra prahaarinam and vaidya randhraanveshinam, parusham, raudra cheshtam, and sheeghra gaaminam denotes a comorbid condition of BPD + DBD + ADHD+BD, the lakshana's like “bho” shabda vaadinam and mantra veda shastra abhidayinam are not seen in BPD or DBD or ADHD or BD. These two lakshana's (“bho” shabda vaadinam and mantra veda shastra abhidayinam) are unique and peculiar for BRG and denotes vocal tics and obsessive compulsive phenomenon (excessive religiosity, superstitions, praying/chanting compulsions, magical thinking, etc.), and are commonly seen in TS-Plus (TS + ADHD + OCD+BD). BRG has shown striking similarity with the features of TS-Plus.


  Conclusion Top


BRG is one among 18 types of bhootonmada. BRG shows similarity with various psychiatric/neuropsychiatric conditions like BPD (Borderline personality disorder), DBD (Disruptive behavior disorders) like ODD (oppositional defiant disorder) and CD, and TS-Plus (TS comorbid with ADHD, OCD, and other behavioral disorders). TS-Plus (TS + ADHD + OCD + BD) is a neuropsychiatric condition which has shown striking similarity with the clinical picture of “BRG.”

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Conflicts of interest

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