|Year : 2018 | Volume
| Issue : 1 | Page : 41-50
Deva grahonmada: Interictal behavior syndrome of temporal lobe epilepsy?/obsessive-compulsive disorder with mania?
Kshama Gupta, Prasad Mamidi
Department of Kaya Chikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat, India
|Date of Web Publication||31-May-2018|
Dr. Kshama Gupta
Department of Kaya Chikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
Deva grahonmada (DG) is a type of grahonmada (psychiatric disorders with unknown etiopathology). DG is one among the 18 types (deva, asura, rishi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala) of grahonmada. Grahonmada is caused by affliction of evil spirits or super natural powers or extraterrestrial forces. The present study aims at better understanding of DG and its clinical significance. DG is characterized by features such as Phulla padmopamukham (charming/bright/gracious face), Varchasvinam (active/energetic/vigorous), Saumya drishtim (pleasant or auspicious look), Akopanam (peaceful), Gambheera (calm/composure/dignifi ed/grandiosity), Apradhrushya (invincible/not to be vanquished/grandiosity), Alpa vaak, sweda, vit, mootra (diminished speech, sweat, feces, and urine), Bhojana anabhilaashinam (not interested in food), Deva, dvija, guru bhaktam (following rituals/hyper-religiosity), Shuchim (excessive hygiene), Anidra (decreased need for sleep/sleeplessness), Samskruta vaadinam (refi ned/sacred speech), Chiraat aksheeni nimiliyantam (staring), Dadhi, ksheera, sura abhipraayam (fond of milk, yoghurt, and alcohol), Shukla maalya, ambara, sarita, pulina priyam (fond of white garments, garlands, and engaged in pleasurable activities/euphoria), Nistandri (energetic), Vara daayinam (offering boons/grandiosity),Surabhi (pleasant smelling), Santushta (happy/ecstasy/euphoric), and Avitatha prabhaashi (speaking truth). These features of DG have shown similarity with various psychiatric or neuropsychiatric conditions such as “interictal behavior syndrome (IBS)” of “temporal lobe epilepsy (TLE)” and/or “obsessive-compulsive disorder (OCD)” and/or “Mania” and/or “Psychosis.” DG has shown similarity with IBS of TLE and/or OCD with mania.
Keywords: Deva grahonmada, interictal behavior syndrome, mania, obsessive-compulsive disorder, psychosis, temporal lobe epilepsy
|How to cite this article:|
Gupta K, Mamidi P. Deva grahonmada: Interictal behavior syndrome of temporal lobe epilepsy?/obsessive-compulsive disorder with mania?. Int J Yoga - Philosop Psychol Parapsychol 2018;6:41-50
|How to cite this URL:|
Gupta K, Mamidi P. Deva grahonmada: Interictal behavior syndrome of temporal lobe epilepsy?/obsessive-compulsive disorder with mania?. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2018 [cited 2020 Aug 9];6:41-50. Available from: http://www.ijoyppp.org/text.asp?2018/6/1/41/233608
| Introduction|| |
“Bhoota vidya” (Ayurvedic psychiatry) is one of the eight specialties of Ayurveda. Bhoota vidya is a specialty which deals with the diseases produced by the influence of evil spirits/supernatural powers and making offerings to deva, pishacha, gandharva, yaksha, rakshasa, etc. for cure of diseases originating from their malignant influence. Grahonmada is a condition characterized by the presence of abnormal behavior and psychomotor activity in a person with abnormal speech, potency, activities, intelligence, knowledge, strength, etc. Grahonmada can occur at any time and cannot be understood on the basis of doshic parameters (idiopathic). Grahonmada is characterized by various behavioral abnormalities such as abnormal strength, energy, enthusiasm, cognitive deficits, deficits of memory, speech abnormalities, and abnormality in perceiving self and environment. In Ayurvedic classical texts, 18 types of grahonmadas are described. They are deva, asura, rishi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala. Deva grahonmada (DG) is one among these 18 types of grahonmada.
According to Acharya Charaka, DG is characterized by features such as Saumya drishtim (pleasant or auspicious look), Apradhrushya/adhrushya (invincible/not to be vanquished/grandiosity), Akopanam (peaceful), Aswapna/anidra (decreased need for sleep/sleeplessness), Bhojana anabhilaashinam (not interested in food), Alpa sweda, vit, mootra, vaata (diminished sweat, feces, urine, and flatus), Shubha gandham (pleasant smelling), and Phulla padma vadanam/tejasvi (charming/bright/gracious face). According to Acharya Sushruta, Santushta (happy/ecstasy/euphoric), Shuchim (excessive hygiene), Gandha maalya (fond of perfumes and garlands), Nistandri (energetic), Avitatha prabhaashi (speaking truth), Samskruta prabhaashi (refined/sacred speech), Sthira nayana (loss of blinking/staring), and Vara pradaata (offering boons/grandiosity) are the features of DG.
In Ashtanga samgraha (written by vriddha Vagbhata) along with the above features, Alpa vaak (diminished speech), Deva, dvija, guru bhaktam (following rituals/hyper-religiosity), Shukla maalya, ambara, sarita, pulina priyam (fond of white garments, garlands, and engaged in pleasurable activities/euphoria), and Dadhi, ksheera, sura abhipraayam (fond of milk, yoghurt, and alcohol) have been added. Similar description (as in Ashtanga samgraha) has been found in Ashtanga hridaya (written by Vagbhata). The description of DG in “Madhava nidaana” is almost similar to the description given by Acharya Sushruta.
Till date, no studies have been conducted on DG and it is an unexplored concept. The present study is focused at better understanding of DG by correlating with the relevant modern psychiatric or neuropsychiatric conditions. The clinical picture of DG shows similarity with various psychiatric/neuropsychiatric conditions such as “interictal behavior syndrome” (IBS) of “temporal lobe epilepsy” (TLE) and/or “obsessive-compulsive disorder” (OCD) and/or “mania” and/or “psychosis.” This similarity has been explored in the following sections.
Etiology, pathogenesis, course, and prognosis of Deva grahonmada
As no specific etiology, pathogenesis, course, and prognosis are mentioned in Ayurvedic classical texts for DG, the common etiopathology, course, and prognosis mentioned for grahonmada are applicable for DG also. Grahonmada is the condition where the causative factors are not traceable and Prajnaparadha (intellectual blasphemy) or Karma (actions of present and past life) plays an important role in the pathogenesis of grahonmada. Grahas (supernatural powers/evil spirits/extraterrestrial forces) seize the persons only at specific times. Time of grahavesha (when graha seizes the person) is considered as “chidra kaala.” Commonly mentioned Chidra kaalas are when the person indulging in sinful activities, not following sadvritta (code of conduct), during illness, at the time of delivery, etc. These Chidra kaalas will lead to guilt or stress.
According to the Hindu philosophy, the “Law of Karma” has been the pivot around which the major traditions of culture and philosophy revolve. It implies that there is a cause–effect relationship to every event in one's life and upholds the doctrine of previous and future lives. The deeds of the past life determine the quality of the present life which in turn fashion that of the next. Excessive religious beliefs, cultural practices, personality styles, and beliefs in the Hindu philosophy of “Karma” may be acting as pathoplastic forces.
In Ayurveda, “karma” is considered as an etiological or causative factor for various diseases which are idiopathic in origin. The action performed in the previous life (known as “daiva”) also acts as a causative factor for the manifestation of various diseases. Diseases arising out of such actions (performed in previous life) are not treatable. Unlike doshonmada (psychiatric diseases caused by doshic imbalance), in grahonmada, the onset is sudden or instantaneous without significantly affecting the body's physiology. In Grahonmada, the symptoms occur suddenly without any reason or triggered by chidra kaala (stressful factors) and the course of the disease is unpredictable. The occurrence or aggravation of symptoms in grahonmada is not specific. As grahonmada is not related to shareeraka doshas (bodily humors), the prognosis is unpredictable. Hence, in DG also (just like other grahonmadas), the etiopathology, course, prognosis, etc. are idiopathic/unpredictable. Only signs and symptoms of DG are explained in Ayurvedic texts; no specific etiology, pathogenesis, course, and prognosis are explained for DG.,,,,
| Similarity of Deva Grahonmada With Various Psychiatric/neuropsychiatric Conditions|| |
There is a striking similarity found between the clinical picture of DG and various psychiatric or neuropsychiatric conditions, which has been elaborated in the following sections.
Interictal behavior syndrome of temporal lobe epilepsy
There is an evidence that TLE is associated with personality traits and psychiatric symptoms collectively known as the “Interictal (i.e., between seizure events) behavioral syndrome” or “Geschwind's syndrome.” TLE patients present with psychiatric symptoms and personality features including affective dysregulation, irritability, impulsiveness, anxiety, obsessive-compulsive symptoms (OCS), paranoia, abnormal patterns of social interaction, grandiosity, schizophrenic-like symptoms, dissociative states, hypergraphia, and hyper-religiosity. Geschwind and others have focused on specific interictal behavioral phenomena including hypergraphia, hyper-religiosity, intense emotion, and unusual patterns of social interaction. A number of studies have confirmed the association of TLE with a broad spectrum of neuropsychiatric syndromes such as mood disorders, panic attacks, OCS, and schizophreniform disorders. The existence of a continuum of temporal lobe liability that extends into the normal population and people who are on the liable side of this continuum has displayed the major themes of ictal and interictal experiences but without convulsions. Individuals may present with a clinical profile which resembles interictal behavioral syndrome without the pathologic evidence for temporo-limbic seizure disorder.
Various features of IBS of TLE include hyper-religiosity which is characterized by the excessive interest in the cosmic and supernatural powers, the conviction that the person has some special significance in the world or some messianic mission; hypergraphia which is manifested as detailed accounts of daily events being recorded, or with the elaboration of texts often with a moral or religious theme; viscosity which is another feature that refers to stickiness of thought processes, a bradyphrenia, but also to an “interpersonal adhesiveness,” or increased social adhesion; and circumstantiality which is characterized by thought with slow rambling speech and having difficulty in terminating conversations. Unfortunately, diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) are of no help in understanding these syndromes, as they are simply not included in them (Trimble M). There are 18 elements included in “epileptic personality change” and they are: (1) Humorlessness or sobriety, (2) Sadness or depression, (3) Emotionality, (4) Circumstantiality, (5) Philosophical interest, (6) Sense of personal destiny, (7) Viscosity or interpersonal stickiness, (8) Dependence, (9) Aggression, (10) Obsessionality, (11) Paranoia or suspiciousness, (12) Sense of guilt, (13) Hypergraphia or excessive writing, (14) Changes to or diminution of sexual drive, (15) Hypermorality, (16) Religiosity, (17) Elation or mood change, and (18) Anger or irritability.,
More recently, a pattern of alterations in behavior, emotionality, and intellectual preferences has been described during the interictal period in patients with TLE. Characteristics ascribed to temporal epileptics include religiosity (holding deep religious beliefs, often idiosyncratic, multiple conversions, and cosmic consciousness), philosophical interests (nascent metaphysical or cosmological preoccupations), hypermoralism (attention to rules with inability to distinguish significant from minor infractions, preoccupation with moral dilemmas, and punitive zeal), hypergraphia (keeping of extensive diary, detailed notes, and writing autobiography or novel), and obsessiveness (orderliness, compulsive attention to detail, ritualism, and perseveration). IBS of TLE includes features of affect (deepening emotion), thought (philosophic, religious, and moralistic interests), and behavior (viscosity, circumstantiality). Hypergraphia is one of the relatively more obvious traits of IBS. It is difficult to differentiate “temporal lobe personality” with deepened emotionality, circumstantial thought, philosophical and religious concerns, hypergraphia, and alterations in sexuality from interictal dysphoric mood disorder (IDMD). The IDMD is characterized by an intermittent and pleomorphic symptomatology (e.g., irritability, depressive moods and anxiety, headaches, insomnia, and euphoric states) accompanied also by more positive behavioral features (quiet, modest, devoted, amicable, helpful, industrious, thrifty, honest, and deeply religious).
Temporal lobe epilepsy and hyper-religiosity
TLE is a form of epilepsy in which the seizures are localized in the medial and/or lateral temporal lobe. TLE is the most common form of localized epilepsy. TLE has been linked to religions most often. In addition, TLE is the only form of epilepsy in which hyper-religiosity has been reported as a relatively common symptom associated with a personality disorder that occurs in TLE. Religious symptoms in TLE occur during a seizure (ictal), after a seizure (postictal), and in between two seizures (interictal). The religious experiences of patients with TLE can be divided in two categories. The first category is ictal and postictal seizures and the second category is the long-lasting religious symptoms which are interictal. Ictal religious experiences may occur during ecstatic seizures and mostly last for few seconds to minutes. An ecstatic seizure is characterized by feelings of pleasure, happiness, and contentment. Postictal religious experiences are frequently related to postictal psychosis which starts hours to days after the seizure and is characterized by auditory and visual hallucinations, delusions (which may be religious), paranoia, affective changes (mania), and aggression. In TLE patients, 27.3% of postictal psychoses are religious. Interictal seizure is the last period of epilepsy in which religiosity can be a symptom. Interictal religiosity is a more stable trait than the religious experiences in ictal and postictal seizures. It has been observed that some people with TLE can develop a personality disorder (Gastaut–Geschwind syndrome) and is characterized by hyper-religiosity with religious issues (which is more often than not in contrast to the premorbid religious interest of the patient), a higher rate of religious conversions, hypergraphia, hyposexuality, and irritability. A link between religious symptoms in interictal personality disorder and postictal psychosis has been found. Medial and lateral temporal lobe areas are the most important brain areas involved in religiosity in TLE.
William James has denoted two main types of religiosity: religious habits and moral rules of everyman and the intense ecstatic experiences of mystics and saints. Interictal religiosity may be perceived more as a personality trait than a behavioral phenomenon. The main symptoms observed in “Geschwind–Gastaut syndrome” are hyper-religiosity and moralism (increased interest in religious, cosmic, supernatural topics, and attention to rules displayed by patients), hypergraphia (tendency to keep highly detailed writings, diaries, and notes, often centered on religious topics), hyposexuality (diminished attention to sexual matters and decreased sexual activity), and emotional lability and irritability (visible mood changes due to the irrelevant reasons or for no reason and anger outbursts). Content analysis of the religious experiences of TLE patients has also revealed that their religious experiences differed both in content and in intensity from the religious experiences of normal people. Higher incidence of comorbid neuropsychiatric symptoms has been found in patients with epilepsy who display increased religiosity.
Epilepsy, mood disorders (especially mania), and psychosis stand out among human disorders that trigger an excess of spiritual experiences. A subgroup of persons with epilepsy shows intense religious experiences in relation to seizures or postictal states and also persons with epilepsy are more likely to be religious than those in the general population. Several case reports have documented religious or mystical experiences during partial seizures. The nature of ictal religious seizures varies, including intense emotions of God's presence, the sense of being connected to the infinite, hallucinations of God's voice, the visual hallucination of a religious figure, as well as clairvoyance and telepathy or repetition of a religious phrase. Intense religious experiences and delusions often occur during postictal psychoses. These symptoms tend to be prolonged, often lasting hours to days, in contrast with ictal phenomena. While ictal and postictal religiosity are “religious fevers,” interictal religiosity usually takes the form of a heightened state of religious conviction. Interictal religiosity is a more continuous behavioral trait or a personality feature among individuals with TLE. These individuals have unusually strong religious beliefs, often associated with an increased sense of personal destiny, strong moral beliefs, and philosophic interests. Changes in either temporal or frontal lobe functions would contribute to increased religious interests as a personality trait. Determining the precise boundaries between premonitory, ictal, postictal, and interictal experiences can be difficult. Intense religious experiences occur with alterations of brain function and support neurologic mechanisms; these include sleep deprivation, sensory isolation, hallucinogenic drugs, schizophrenia, mania, neurosyphilis, and dementia.
Temporal lobe epilepsy and staring
One of the hallmarks of TLE in adults is the occurrence of automatisms. Simpler automatisms include oro-alimentary (lip smacking), gestural (hand fumbling), and blinking movements. Given the lack of well-developed verbal communication skills in children aged 0–3 years, it is usually impossible for clinicians to properly assess for auras at seizure onset. Rather, the earliest signs of such seizures in infants and toddlers may be behavioral arrest, staring, and lip cyanosis. The most common aura reported by older children is alterations in self-perception and psychic (or a dreamy state) phenomena. Complex partial seizures of mesial temporal origin typically begin with oro-alimentary or hand automatisms in contrast to those of neocortical onset, which often begin with staring, without automatisms or epigastric phenomena.
Temporal lobe epilepsy, depersonalization, and derealization
Specific paroxysmal symptoms, such as a rising abdominal sensation, déjà vu, and depersonalization or derealization strongly suggest the possibility of TLE. Patients with TLE and other forms of epilepsy often show impairments in attention, memory, mental processing speed, executive functions, mood, personality, and drive-related behaviors. Depersonalization and derealization can be caused by seizure activities. These phenomena could be interpreted as weak forms of complex partial seizure or consciousness impairment. Some patients complain of “absurdity” about the surroundings during the seizure which can be interpreted as some peculiar kind of alteration of perception of the surroundings, presumably similar to derealization. There is a special kind of psychic seizure called “prescience,” which indicates a sense of knowing what is going to happen from now on. While it is theoretically difficult to take prescience as a disorder of memory, which is bound only to the past and never to the future, practically, prescience is frequently seen in combination with déjà vu.
Temporal lobe epilepsy and aphasia
Sensory and motor aphasias can appear as simple partial seizures, although these disturbances would appear more frequently as postictal symptoms which are observed after complex partial seizures involving the speech-dominant hemisphere. Occasionally, abundant but empty speech is observed after complex partial seizures involving the nondominant hemisphere. This is regarded as a release phenomenon rather than a stimulated symptom, whereas aphasias are defective symptoms.
Heightened well-being (very pleasant filling of the whole body with a wave of warmth or well-being), enhanced self-awareness (during the seizure, the patient feels very conscious, more aware, and the sensations, everything, seem bigger, overwhelming, every sensation is stronger, see more colors than before, and having more detailed perceptions), feeling of dilated time (patient feels entirely wrapped up in the bliss, in a radiant sphere without any notion of time or space, and moments seem without beginning and without end), intense serenity and bliss (feeling of complete serenity, total peace, no worries, and feeling everything as beautiful and great), feeling of overload (the pleasure goes crescendo until it reaches a peak), and mystic/religious experience (feelings of an orgasm but not at all sexual, religious feelings, well-being of almost spiritual consonance, not fearing death anymore, and seeing the world differently) are the characteristic features of “Ecstatic seizures. ” Ecstatic auras of focal epilepsy usually originates from temporal lobe. Geschwind's syndrome, an interictal syndrome reported in some patients with TLE consisting of the association of hyper-religiosity, hypergraphia, and hyposexuality, could have some overlapping features with ecstatic seizures.
Similarity of Deva grahonmada and interictal behavior syndrome of temporal lobe epilepsy
A person suffering with DG behaves like “God” (hyper-religiosity, hypermorality, excessive hygiene, hyposexuality, grandiosity, etc.) all of a sudden without any visible cause. The features of DG such as Phulla padmopamukham, Varchasvinam, Saumya drishtim, Akopanam, Gambheera, Apradhrushya, Alpa vaak, Bhojana anabhilaashinam, Deva, dvija, guru bhaktam, Shuchim, Samskruta vaadinam, Dadhi, ksheera, sura abhipraayam, Shukla maalya, ambara, sarita, pulina priyam, Nistandri, Vara daayinam, Surabhi, Santushta, and Avitatha prabhaashi denote hyper-religiosity, hypermorality, grandiosity, hypergraphia, obsessionality, mood changes, depersonalization and derealization, and elation and ecstasy of “IBS” or “Geschwind syndrome” or “Epileptic personality” or “Temporo-limbic personality” or “Interictal personality traits” of TLE. “Sthira nayana” or “Chiraat aksheeni nimiliyantam” denotes “Staring seizures.” “Alpa vaak” denotes “aphasia” seen in TLE. By considering all the above facts, it seems that signs and symptoms of DG resemble with IBS of TLE.
| Obsessive-Compulsive Disorder and Hyper-Religiosity|| |
OCD includes a range of clinical characteristics with two major components. First, the intrusion of thoughts, ideas, or compulsions and second, the resulting triggering of abnormal behaviors or rituals. OCS may be seen in OCD itself, or may appear in other psychiatric conditions. However, despite a number of case reports, no unifying theory of causation have been clearly established. There are four main sources of vulnerability to the development of obsessions; they are elevated moral standards (such as sensitivity, introversion, and strict and rigid morality), specific cognitive biases, depression, and anxiety proneness. Elevated moral standards as “moral perfectionism” that is “as a general background, people who are thought, or learn, that all of their value-laden thoughts are of significance will be more prone to obsessions as in particular types of religious beliefs and instructions.”
Scrupulosity is a psychological condition characterized by obsessions and compulsions involving religious themes, pathological guilt, doubt and/or worry about sin, and excessive religious behaviors. Epidemiologic studies found that obsessions with religious themes were the fifth common type of obsessions in OCD. An obsession may be a thought, image, or impulse of doing something the person considers sinful or it may include doubts whether he/she confessed a sin, completely purified himself/herself, said the right prayer, and entirely trusted in God. It may also be the sudden intrusion of blasphemous thoughts or swear words against God. Compulsions are behavioral acts or mental rituals that often manifest as the need to get reassurance from religious leaders about whether the person has adequately prayed, confessed a sin, repetitive confessions, repeating a prayer over and over, checking whether the person has done all necessary things in an appropriate way, or washing to guarantee one is clean enough before praying. Patients with scrupulosity often engage in longer periods of highly distressing moral rumination, or deep and intense episodes of thinking and reflection. Periods of rumination may involve philosophical analysis of currently bothersome moral issues or a meticulous review of past indiscretions. Some scrupulous patients may also frequently experience derealization and depersonalization or the loss of attachment with reality and personal identity because of various aspects of religious principle and practice. Scrupulosity is a term that is often used to indicate religious symptoms in OCD and is often expressed as unwanted obsessive thoughts about unsacred happenings or deities (e.g., Satan), a fear of sin or a preoccupation with thoughts about whether one has sinned, and extreme religious behavior (excessive confession or prayer).
Religious OCD symptoms, often referred to as scrupulosity, typically involve “seeing sin where there is none” and are frequently focused on minor details of the person's religion, to the exclusion of more important domains. Examples include unwanted sacrilegious obsessional thoughts (e.g., about the Devil), excessive doubt regarding whether one has committed a sin (e.g., daydreaming while praying), and extreme religious behavior (e.g., excessive confession). Individuals with scrupulosity, who by nature impose strict moral standards upon themselves and are hypervigilant of moral/religious sin, might be exquisitely sensitive to intrusive sexual or sacrilegious thoughts which conflict with their belief/value system. Clinical observations indicate that patients with religious obsessions typically use neutralizing strategies (e.g., thought suppression, mental phrases, or prayers) to neutralize these kinds of obsessions. Individuals with intense religious scruples, relative to those with less religiosity, also evidence higher scores on measures of obsessionality, and on dysfunctional beliefs about the over importance of thoughts, the need to control unwanted intrusive thoughts, perfectionism, and responsibility.
Similarity in between Deva grahonmada and obsessive-compulsive disorder
Aggressive obsessions such as “fear of doing something else embarrassing” or “fear might harm others;” contamination obsessions such as “excessive cleanliness;” religious obsessions such as “concerned with sacrilege and blasphemy,” “excessive concern with right/wrong,” and “excessive morals;” miscellaneous obsessions such as “fear of not saying just the right thing” and “colors with special significance;” cleaning and washing compulsions such as “excessive ritualized handwashing,” “excessive showering, bathing, grooming, and cleaning;” miscellaneous compulsions such as “need to tell,” “rituals involving blinking or staring,” and “ritualized eating behaviors” are similar with the features such as “Akopanam,” “Bhojana anabhilashinam,” “Shuchi,” “Sthira nayanam,” “Avitatha samskruta prabhaashi,” “Deva, dvija, guru bhaktam,” “Shukla maalya ambara sarita pulina priyam,” and “Alpa vaak” of DG.
| Mania/bipolar Disorder and Hyper-Religiosity|| |
Mania is a mood disorder. Manic episode is a constant abnormal, irritable, or elevated mood along with features such as grandiosity and/or high self-esteem, less need for sleep, more talkative, racing thoughts, easily distractible, more goal-directed activity or psychomotor agitation, and/or involvement in pleasurable activities. Even though there has not been done much research on the connection between mania and religiosity, two reports clearly show that this link does exist. In a study to investigate the phenomenology of bipolar I disorder, it was found that 18.5% of the 184 adult patients showed hyper-religiosity as a symptom. A strong correlation was found between manic symptoms and religious experiences. In a much larger study of 1136 psychiatric inpatients in the mid-western and eastern United States, 15% of those with bipolar disorder had religious delusions. In the United States, approximately 15%–22% of those with mania/bipolar disorder have religious delusions. In Great Britain and Europe, 21%–24% of patients with schizophrenia have religious delusions, and in Japan, the rate is 7%–11%. Less information is available for Brazil, but rates of religious delusions exceeding 15% are likely.
Fischer examined the relationship among creative, manic, psychotic, and mystical states. He hypothesized that these states vary along the dimension of arousal as measured by specific electroencephalogram amplitude characteristics, with mystical rapture being the highest state of arousal (ecstatic), psychotic, and manic, the next highest (hyperaroused) followed by creativity (aroused). A special relationship between artistic creativity and manic-depressive illness was observed by Kraepelin. The mood changes in mania can contribute significantly to the development of mystical states, and the sensory enhancement can foster creativity. Various changes can be induced by psychosis which facilitates the development of creative, mystical, and visionary states. Patients with mania are described as good salesmen, who utilize hypermorality and conventionality as tools for bargaining. The acutely manic patient is often able to alienate himself/herself from family, friends, and therapists alike. The manic individual, with extroverted drive, can establish rapid, superficial liaisons with those around him/her. Initially, he/she seems friendly, bright, cheerful, resourceful, and entertaining. Patients with mania are often judgmental, critical, moralistic, and speak about issues which involve self-discipline and responsibility. The manic may enter into grandiose schemes.
Similarity in between Deva grahonmada and mania
DG lakshanas (signs and symptoms) such as Santushta, Nistandri, Gambheera, Apradrhrushya, Aswapna/Anidra, Bhojana anabhilashinam, Shukla maalya, ambara, sarita, pulina priyam, and Vara pradaata denote a manic episode characterized by grandiosity, elevated and expansive mood/euphoria, inflated self-esteem, decreased need for sleep, and hyperactivity. Deva, dvija, guru bhaktam, Shuchim, Samskruta vaadinam, Chiraat aksheeni nimiliyantam, Dadhi, ksheera, sura abhipraayam, and “Alpa vaak” of DG resemble with the features of hyper-religiosity seen in mania/bipolar disorder.
| Schizophrenia/psychosis and Hyper -Religiosity|| |
Schizophrenia is a neuropsychiatric disorder characterized both by positive (delusions and hallucinations) and negative (deficient emotional, cognitive, and motivational functioning) symptoms. Religious symptoms are frequently observed in patients with schizophrenia. It is believed that the religious delusions may be secondary to the auditory hallucinations attributed to the God or Devil. Religious symptoms are believed to be a secondary and highly culturally dependent syndrome in patients with schizophrenia. Religious delusions exist on a continuum between the normal beliefs of healthy individuals and the fantastic beliefs of the psychotic patients. In psychotic patients, religious delusions are usually accompanied by other symptoms and/or behaviors of mental illness and do not appear to serve any positive function. Compared to other delusions, religious delusions appear to be held with greater conviction than other delusions. Persons with severe and persistent mental illness often present for treatment with religious delusions.
Various studies have reported religious or spiritual delusions and hallucinations in 43% of schizophrenic patients. Delusions seem to be more common than hallucinations as a religious symptom in schizophrenia. Three types of delusions are known to have religious content in some patients. These types are persecutory delusions, grandiose delusions, and belittlement delusions. In a religious context, patients may feel as if the Devil is persecuting them. In grandiose delusions, patients believe that they are very important people, so they might believe that they are God, a prophet, or somebody who has been sent by the God. Patients with religious delusions have reported a significantly higher religiosity, more conviction about their delusions, and reported that they were more confident about the external origin of their hallucinations (e.g., God, Satan). These observations are very similar to hyper-religiosity, since these patients show higher religiosity in general, more conviction about the religious content of their delusion, and often thought that their hallucinations originated from the God or another religious figure.
The predominant paranoid delusion with a religious theme was the delusion of possession, which occurred in the majority of patients with complex partial seizure disorder (CPSD), bipolar mania, and schizophrenia. Grandiose delusions with religious references were also common, particularly in bipolar, CPSD, and schizophrenic patients. Almost invariably, these patients at some time during the psychotic episode believed themselves to be a religious hero or savior of some kind, for example, Jesus, Buddha, God, and Prophet. In summary, this preliminary study indicates that psychotic phenomena with religious themes commonly occur in psychosis, although their frequency and type of expression appear to vary by diagnosis.
Similarity in between Deva grahonmada and schizophrenia/psychosis
Various lakshanas of DG such as Santushta, Nistandri, Gambheera, Apradrhrushya, Aswapna/Anidra, Bhojana anabhilashinam, Shukla maalya, ambara, sarita, pulina priyam, and Vara pradaata, Deva, dvija, guru bhaktam, Shuchim, Samskruta vaadinam, Chiraat aksheeni nimiliyantam, Dadhi, ksheera, sura abhipraayam, and “Alpa vaak” resemble schizophrenia or psychosis characterized by “grandiose delusions”/”religious delusions”/”delusions of possession.”
| Comorbidity of Temporal Lobe Epilepsy, Obsessive-Compulsive Disorder, Mania, and Schizophrenia|| |
An increased prevalence of OCS has been noted in refractory epilepsy, particularly with TLE. In epilepsy, mood disorders including depression and anxiety are frequent. It is unclear whether the behavioral changes that occur following seizures or with epilepsy may arise from the epilepsy itself; may appear as a form of forced change induced by the seizure; might arise from reactive or released behaviors after the seizure; or may be a comorbid psychiatric condition (which often occur in epilepsy). More specifically, TLE patients occasionally showed clinical features of compulsive behavior. The symptoms in the TLE group included doubting, ordering, hoarding, checking, neutralizing and washing, and emphasizing the more compulsive components rather than the obsessive moiety of this duality. Obsessionality is a TLE trait in patients with a biological predisposition, with a prior psychiatric history. According to a study, 22% of TLE patients had features of OCD but which had examined a refractory TLE population. About 10% of TLE patients had OCD and 24% had subsyndromal OCD. Patients with TLE have greater obsessions with contamination and a compulsion to wash, with symmetry/exactness obsessions and ordering compulsion. Some patients with TLE have greater preoccupation with existential aspects of religion.,
Evidence of association between neurological (e.g., epilepsy) and psychiatric (e.g., schizophrenia) disorders and increased religiosity/excessive religious behaviors is well known. TLE is often perceived as a neurological condition in which altered religiosity may be observed. Small case studies have associated OCS with epilepsy. Obsessive traits were described within the range of an interictal personality change associated with TLE. Two further studies focused on the prevalence of OCD in persons with TLE and found a higher prevalence than in the general population.
Patients with epilepsy may experience a number of psychiatric and cognitive symptoms or behavioral manifestations during the period around the ictus (Peri-ictal). Peri-ictal psychiatric symptoms contribute substantially to disability and distress among people with epilepsy. Historically, it was accepted that patients could develop psychoses in the context of the postictal state, the features of which were often manic or hypomanic or a mixed mood episode with psychotic features. This postictal psychosis is characterized by grandiose delusions as well as religious delusions in the setting of a markedly elevated mood and the feeling of mystic fusion of the body with the universe. Manic/hypomanic symptoms are reported in 22% of patients, often with associated psychotic phenomenology. Postictal manic episodes last for a longer period and have a higher frequency of recurrence than postictal psychoses. Recent studies pointed out that symptoms of bipolar disorder are common in epilepsy. Moreover, the symptomatology of mood disorder in epilepsy is often atypical, intermittent, and pleomorphic and fails to meet DSM-IV-TR categories. According to the recent studies, manic or hypomanic symptoms are not rare in epilepsy. TLE is considered to present a relatively specific risk factor, notably for affective disorders because of the major involvement of the limbic system both in seizure generation in TLE and in the regulation of affect and mood.
Psychiatric manifestations of epileptic seizures have been known for years, both for idiopathic cases and those describing patients with seizures with mental health abnormalities following traumatic brain injuries. Various neuropsychiatric conditions such as anxiety, depression, bipolar disorder, attention-deficit hyperactivity disorder, sleep, and movement disorders were more likely to be self-reported by patients with epilepsy than those without it. Half of the patients with epilepsy and psychosis could have been easily diagnosed with schizophrenia alone. Irrespective of the clinical caveats, psychosis in TLE may have either relapsing-remitting course (concurrent with seizures), chronic (involving interictal phase), or combinatory with various complexity and expressiveness of thought disorder or perceptual abnormalities. Postictal psychosis varies from grandiose and religious delusions with elevated moods to mixed manic-depressive-like psychosis or bizarre behavior. Interictal behavioral traits were described decades ago and included circumstantiality, dramatization, excessive mental “chewing” (viscosity and hyper-religiosity), and altered sexual behavior.
TLE is associated with increased activity and blood flow in the frontal lobes, just like OCD and schizophrenia. Even though not all the four disorders (TLE, OCD, mania, and schizophrenia) have the same deviances in the frontal lobes, they all seem to have impaired functioning of this brain area. Hyper-religiosity in schizophrenia, TLE, and mania all seem to be triggered by a psychosis (in TLE and schizophrenia) or lack of contact with reality (in mania, during which a person believes he or she can do anything or believes he or she is very important). Decreases in white matter and gray matter (in some areas of the brain) are found in all four disorders throughout the limbic system. The frontal lobes (especially the prefrontal area), the temporal lobes, and the limbic system are the main areas of the brain that seem to be involved in hyper-religiosity. White matter deficiencies are also found in all four disorders throughout the brain, which suggests a general atrophy of connections of networks within the brain. The brain areas which were activated during this regular expression of religion and were also found to be involved in hyper-religiosity were the right medial orbito-frontal cortex, the right middle temporal cortex, the left medial prefrontal cortex, the left anterior cingulate cortex, and the left insula. These are all areas of the frontal and temporal lobes and the paralimbic system.
By considering the above facts, it seems that conditions such as TLE, OCD, mania, and schizophrenia are comorbid with each other and hyper-religiosity is a common feature among all these four disorders. It seems that DG explained in Ayurvedic literature may be any one of the above four disorders or a comorbid condition among them. Further studies are required to substantiate this hypothesis.
| Conclusion|| |
“ DG“ is one among the 18 types of grahonmada. The signs and symptoms of DG have shown similarity with various psychiatric or neuropsychiatric conditions. Deva grahonmada seems to be a condition of interictal personality trait or behavioral syndrome of TLE comorbid with various psychiatric conditions such as OCD and/or bipolar disorder and/or psychosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mamidi P, Gupta K. Obsessive compulsive disorder – 'Sangama graha': An ayurvedic view. J Pharm Sci Innov 2015;4:156-64.
Jadavji V, Acharya T, editors. Agnivesha, Elaborated by Charaka and Dridhabala Commentary by Chakrapani. Charaka Samhita, Chikitsa Sthana, Unmada Chikitsitam Adhyaya, 9/20. Varanasi: Chaukhamba Surbharati Prakashan; 2008. p. 469.
Trikamji Acharya VJ, Acharya NR, editors. Sushruta. Sushruta Samhita, Commentary by Dalhana. Uttara Tantra, Amanusha Upasarga Pratishedha Adhyaya, 60/8. Varanasi: Chaukhamba Orientalia; 2009. p. 794-5.
Sharma S, editor. Vriddha Vagbhata. Ashtanga Sangraha, Commentary by Indu, Uttara Tantra, Bhoota Vigyaneeyam Adhyaya, 7/10. 3rd
ed. Varanasi: Chowkhamba Sanskrit Series Office; 2012. p. 668-9.
Paradkara Vaidya BH, editor. Vagbhata. Ashtanga Hridaya, Commentary by Arunadatta and Hemadri, Uttara Tantra, Bhoota Vigyaneeyam Adhyaya, 4/13-15. 9th
ed. Varanasi: Chowkhamba Sanskrit Series Office; 2005. p. 791.
Tripathi B, editor. Madhavakara. Rogavinischaya/Madhava Nidana, Unmada Nidana, 20/18, Commentary 'Madhukosha' by Vijayarakshita & Shrikanthadatta. 1st
ed. Varanasi: Chaukhamba Surbharati Prakashan; 2012. p. 487-8.
Sethi BB, Dube S. Guilt in India (social, cultural and psychological perspectives). Indian J Psychiatry 1982;24:101-6.
] [Full text]
Aycicegi-Dinn A, Dinn WM, Caldwell-Harris CL. The temporolimbic personality: A cross-national study. Eur J Psychiat 2008;22:211-24.
Fukao K. Psychic seizures and their relevance to psychosis. In: Stevanovic D, editor. Temporal Lobe Epilepsy, Epilepsy– Histological, Electroencephalographic and Psychological Aspects. Croatia: InTech; 2012. Available from: https://www.cdn.intechopen.com/pdfs-wm/30016.pdf
. [Last accessed on 2017 Aug 22].
Herzog AG. Psychoneuroendocrine aspects of temporolimbic epilepsy. Part III: Case reports. Psychosomatics 1999;40:109-16.
Bear D, Levin K, Blumer D, Chetham D, Ryder J. Interictal behaviour in hospitalised temporal lobe epileptics: Relationship to idiopathic psychiatric syndromes. J Neurol Neurosurg Psychiatry 1982;45:481-8.
Sachdev HS, Waxman SG. Frequency of hypergraphia in temporal lobe epilepsy: An index of interictal behaviour syndrome. J Neurol Neurosurg Psychiatry 1981;44:358-60.
Helmstaedter C, Witt JA. Multifactorial etiology of interictal behavior in frontal and temporal lobe epilepsy. Epilepsia 2012;53:1765-73.
Okruszek L, Kalinowski K, Talarowska M. Religiosity as a symptom of selected neuropsychiatric disorders. Med Sci Tech 2013;54:136-40.
Devinsky O, Lai G. Spirituality and religion in epilepsy. Epilepsy Behav 2008;12:636-43.
Nickels KC, Wong-Kisiel LC, Moseley BD, Wirrell EC. Temporal lobe epilepsy in children. Epilepsy Res Treat 2012;2012:849540.
Blair RD. Temporal lobe epilepsy semiology. Epilepsy Res Treat 2012;2012:751510.
Devinsky O. Diagnosis and treatment of temporal lobe epilepsy. Rev Neurol Dis 2004;1:2-9.
Gschwind M, Picard F. Ecstatic epileptic seizures–the role of the insula in altered self-awareness, PDF. Epileptologie 2014;31:87-98.
Kaplan PW. Epilepsy and obsessive-compulsive disorder. Dialogues Clin Neurosci 2010;12:241-8.
Nelson EA, Abramowitz JS, Whiteside SP, Deacon BJ. Scrupulosity in patients with obsessive-compulsive disorder: Relationship to clinical and cognitive phenomena. J Anxiety Disord 2006;20:1071-86.
Olatunji BO, Abramowitz JS, Williams NL, Connolly KM, Lohr JM. Scrupulosity and obsessive-compulsive symptoms: Confirmatory factor analysis and validity of the Penn inventory of scrupulosity. J Anxiety Disord 2007;21:771-87.
Koenig HG. Religion, spirituality and psychotic disorders. Rev Psiq Clin 2007;34 Suppl 1:40-8.
Lukoff D. Transpersonal perspectives on manic psychosis: Creative, visionary, and mystical states. J Transpers Psychol 1988;20:111-39.
Janowsky DS, Leff M, Epstein RS. Playing the manic game. Interpersonal maneuvers of the acutely manic patient. Arch Gen Psychiatry 1970;22:252-61.
Brewerton TD. Hyperreligiosity in psychotic disorders. J Nerv Ment Dis 1994;182:302-4.
Arnold LM, Baumann CR, Siegel AM. Gustav Flaubert's “nervous disease”: An autobiographic and epileptological approach. Epilepsy Behav 2007;11:212-7.
Mula M, Monaco F. Ictal and peri-ictal psychopathology. Behav Neurol 2011;24:21-5.
Wiglusz MS, Cubała WJ, Gałuszko-Węgielnik M, Jakuszkowiak-Wojten K, Landowski J. Mood disorders in epilepsy-diagnostic and methodological considerations. Psychiatr Danub 2012;24 Suppl 1:S44-50.
Swinkels WA, van Emde Boas W, Kuyk J, van Dyck R, Spinhoven P. Interictal depression, anxiety, personality traits, and psychological dissociation in patients with temporal lobe epilepsy (TLE) and extra-TLE. Epilepsia 2006;47:2092-103.
Beletsky V, Mirsattari SM. Epilepsy, mental health disorder, or both? Epilepsy Res Treat 2012;2012:163731.