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 Table of Contents  
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 6-13

Gandharva grahonmada: Bipolar disorder with obsessive-compulsive disorder/mania?

Department of Kayachikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat, India

Date of Web Publication14-Dec-2017

Correspondence Address:
Dr. Kshama Gupta
Department of Kayachikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijny.ijoyppp_17_17

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Gandharva grahonmada (GG) is one among 18 types of bhootonmada or grahonmada. Bhootonmada comprises a vast category of psychiatric problems which are assumed to be caused by affliction of evil spirits or super natural powers or extra terrestrial forces or idiopathic factors. The present study aims at better understanding of GG and its clinical applicability to the present day psychiatry practice. GG is characterized by Chandam/Teekshnam (anger/aggressiveness/irritability/hostility/violence), Saahasikam (risk taking behaviour/agitation/increased psychomotor activity), Gambheera and Adhrushya (grandiosity /agitation), Nrutyantam, gaayantam, mukha vaadyaani kurvantam (dancing, singing and playing music), Pulina vanaantaropasevi, hrishtaatma, prahasati, haasya kathaanuyogam (engaged in pleasurable activities/euphoria), Snaana, maalya, anulepana, dhoopa, gandha ratim (flamboyant appearance / obsessive compulsive symptoms), Shringaara leelaabhiratim (hyper sexuality), Rakta vastram (wearing red colour garments), Paana ratim (alcohol abuse), Svaachaaram (virtuous conduct), Chaaru chaalpa shabdam and alpa vyavahaaram (hypomania/mixed episode/mania with depressive symptoms) etc features. These features of GG show similarity with mania or hypomania or bipolar disorder (BD) comorbid with obsessive compulsive disorder (OCD). Samrambha grahonmada and hasana grahonmada are two subtypes of GG which also resembles with mania. 'Samrambha grahonmada' resembles with 'irritable/aggressive mania' whereas 'hasana grahonmada' denotes 'grandiose / elated mania'.

Keywords: Ayurveda, bipolar disorder, Gandharva grahonmada, hypomania, mania, obsessive-compulsive disorder

How to cite this article:
Gupta K, Mamidi P. Gandharva grahonmada: Bipolar disorder with obsessive-compulsive disorder/mania?. Int J Yoga - Philosop Psychol Parapsychol 2017;5:6-13

How to cite this URL:
Gupta K, Mamidi P. Gandharva grahonmada: Bipolar disorder with obsessive-compulsive disorder/mania?. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2017 [cited 2024 Feb 23];5:6-13. Available from: https://www.ijoyppp.org/text.asp?2017/5/1/6/220774

  Introduction Top

Unmada (a broad term which denotes various psychiatric problems under one umbrella) is a major psychiatric illness described in all Ayurvedic classics which is characterized by deranged mental functions.[1]“Bhuta vidya” (Ayurvedic psychiatry) is one of the eight branches of Ayurveda. It is explained as the branch which lays down incantation and mode of exorcising, evil spirits and making offerings to deva (divine beings), pishacha (class of demon fond of flesh), gandharva (class of demon fond of entertainment), yaksha (living super natural being/ghost), and rakshasa (class of demon fond of violence) for the cure of diseases originating from their malignant influence.[2]Bhutonmada/Grahonmada is a psychiatric condition which is caused by bhoota/graha (evil spirits/extraterrestrial forces/supernatural powers) and is characterized by various abnormal behaviors. 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. Gandharva grahonmada (GG) is one among these 18 types of grahonmada.[3]

According to Acharya Charaka, GG is characterized by the features such as chandam (excessive anger), saahasikam (risk-taking behavior), teekshnam (violent/hostile), gambheeram (grandiose), adhrushyam (uncontrollable), mukha vaadya nritya geeta anna ratim (engaged in pleasurable activities), paana ratim (alcohol abuse), snaana maalya dhoopa gandha ratim (fond of bathing and makeup), rakta vastra (preference to red color dresses), bali karma (interested in sacrificing animals/violence), haasya kathaanuyogam (fond of comics), and shubha gandham (good body odor).[4] According to Acharya Sushruta, hrishtaatma (positive mood/euphoria), pulina vanaantaropasevi (enjoying at gardens, pools and islands), svaachaara (virtuous conduct), priya parigeeta gandha maalya nrutya (engaged in singing, dancing, playing music, and wearing garlands), prahasati (laughing/giggling), and chaaru chaalpa shabdam (reduced speech) are the features of GG.[5] In Ashtanga samgraha (written by vriddha Vagbhata) along with the above features, shringaar leela abhirati (hyper sexuality (hyper sexuality) is also mentioned. Two subtypes of GG, “Sarmrambha grahonmada” and “Hasana grahonmada” are also mentioned in Ashtanga samgraha.[6] The description of GG in “Ashtanga hridaya[7] and in “Madhava nidaana[8] is almost similar to the above texts.

Till date, no studies have been conducted on GG, and it is an underexplored topic in Ayurvedic psychiatry field. The present study is focused on better understanding of GG by correlating it with modern psychiatry. The clinical picture of GG shows marked similarity with mania/hypomania/bipolar disorder (BD) comorbid with obsessive-compulsive disorder (OCD). The similarity between GG and mania or BD with OCD has been elaborated in the following sections.

  Bipolar Disorder/mania Top

BD earlier known as manic-depressive psychosis is characterized by recurrent episodes of mania episode and depression in the same patient at different times. These episodes can occur in any sequence. The current episode in BD is specified as hypomanic, manic without psychotic symptoms, manic with psychotic symptoms, mild or moderate depression, severe depression with psychotic or without psychotic symptoms, and mixed episode or in remission. BD is further classified into bipolar I and bipolar II disorders.[9] The manic episode is defined as a distinct period of abnormal and persistently elevated, expansive, or irritable mood. The mood disturbance must be accompanied by inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, and increased involvement in pleasurable activities with a high potential for painful consequences. The elevated mood is described as euphoric, unusually good, cheerful, or high. Persons with mania may change their dress, makeup, personal appearance to a more sexually suggestive or dramatically flamboyant style which is out of character for them. They may also engage in disorganized or bizarre activities, gambling, antisocial behaviors, and becomes hostile.[10]

[TAG:2]Etiology, Pathogenesis, and Prognosis of Gandharva Grahonmadaand and Bipolar Disorder[/TAG:2]

There is no specific etiology, pathogenesis, and prognosis explained for GG in Ayurvedic texts. The samaanya nidaana, sampraapti, and saadhyaasaadhyata (common etiology, pathogenesis, and prognosis) explained for grahonmada is also applicable for GG. Grahavesha (affliction by evil spirit/extraterrestrial force/supernatural power), prgnaaparaadha/karma (deeds of present life or previous life) are explained as causative factors for grahonmada. In bhootonmada, the symptoms occur suddenly without any reason or triggered by chidra kaala (stressful factors) and the course of the disease is also unpredictable. The prognosis of bhootonmada is also unpredictable.[3] As in GG in BD also etiology, pathogenesis, course, and prognosis of the disease are not fully understood yet even though they are so many theories have been prevailing.

Current academic theories of BD can be broadly categorized as “biological,” “genetic,” and “psychosocial.” Genetic studies show that BD is one of the most inheritable of all mental disorders; with up to 80% concordance rates in monozygotic twins. Biological theories include abnormalities in the hypothalamic–pituitary–adrenal axis and neurotransmitter systems. Mania can be induced by sleep deprivation and a disruption of circadian rhythms, which adds a further dimension to biological theories. Psychosocial theories of etiology include stressful life events and dysfunctional attempts to avoid depression. A dysregulation of self-esteem, childhood trauma, and abuse has also been linked with BD. It is believed that BD is caused by a complex interaction of genetic, biological, and psychosocial factors, which is known as the “diathesis-stress” model.[11] BD is common, disabling, recurrent mental health condition of variable severity. Onset is often in late childhood or early adolescence. The clinical course of BD varies. Environmental factors are strongly associated with the inheritance pattern. These factors include stressful life events, suicide of a family member, disruptions in the sleep cycle, family members with high expressed emotion, a communication pattern defined as emotionally over involved, hostile, and critical. Psychosocial stress is known to trigger manic and depressive symptoms.[12] A rapid cycling pattern of moods is associated with a poorer prognosis. Approximately, 15% of bipolar II disorder patients continue to display mood lability and interpersonal or occupational difficulties.[10]

[TAG:2]Similarity between Gandharva Grahonmadaand and Bipolar Disorder With Obsessive-Compulsive Disorder[/TAG:2]

There is striking similarity found between the clinical picture of GG and BD with OCD as follows.

Chandam/Teekshnam (anger/aggressiveness/irritability/hostility/violence)

Chandam (excessive anger) and teekshnam (violent/hostile) of GG denotes anger, aggression, irritability, hostility, violence or agitation of mania, hypomania, or BD. Irritability must be present for the diagnosis of mania or hypomania.[13] Aggression is an overt action intended to harm others. This term denotes human and animal behavior, whereas violence denotes aggression among humans. Verbal aggression includes screams, abuse, or threats. Hostility denotes unfriendly attitudes. Overt irritability, anger, resentment, or verbal aggression is the manifestation of hostility. The prevalence of violent behavior in BD is as high as in schizophrenia. Clinicians have been aware of violent behavior in BD for a long time. BD patients have shown significantly higher aggression scores than control groups. A factor analysis showed that aggression in BD was associated with paranoia and irritability and this irritable aggression remained stable in time across consecutive manic episodes. Another study has revealed that aggression is associated with irritability, uncooperativeness, impatience, and lack of insight. A study has revealed four subtypes of mania, one of them labeled as “aggressive.” Neuropsychological dysfunction, perhaps as a trait, is a predisposing factor for aggression in bipolar patients. These neuropsychological findings with the elevated trait hostility and impulsivity could be seen as a part of a diathesis that predisposes some bipolar patients to become aggressive when experiencing the stress of a manic episode. Impaired insight is linked to aggressive behavior in psychiatric disorders including BD.[14] Irritability and disruptive-aggressive behavior are the two features of “Young Mania Rating Scale” (YMRS).[15],[16]

Manic euphoria may turn into dysphoria and irritability, especially when others question the manic person's omnipotent attitude or confront his expansion. Dysphoria denotes a condition of disagreeableness, nervous tension, hostile emotional reactivity, and propensity for aggressive acting out. BD and schizophrenia are the two major psychiatric illnesses that are likely to predispose to homicide. Notably, these are two disorders which have special characteristics in men that may mediate the association with violence. Affective impulsivity was significantly more important during the manic phase of BD (50%) versus the depressed phase (11.5%). Deficits in the emotion regulation domain sub construct may play a major role in both BD and schizophrenia. Poor emotion regulation is a major risk factor for impulsive violence, which is often the major factor in homicides perpetrated by males with these disorders.[17] Studies have shown that traits related to emotional instability and hostility are elevated in bipolar spectrum disorders, even in euthymia.[18] The irritability associated with mania has a much more hostile, vicious, and attacking in quality. Along with irritability, extremely impairing dysphoric and explosive episodes occur daily with little or no precipitant in adolescents with mania. These explosions can last up to an hour or longer and may involve destruction of property. During these rages, adolescents are hard to calm and often lash out physically at those around them. Swearing and hostile comments are also common. Other clinical presentations of adolescents with BD are variable, including disruptive behavior, moodiness, irritability, impulsivity, low frustration tolerance, and explosive anger followed by periods of guilt.[19]

Saahasikam (risk-taking behavior/agitation/increased psychomotor activity)

Increased motor activity not only was more important than changes in mood in characterizing mania but also represents the core feature of the syndrome. Among all, six symptoms of mania, the item “increased energy” was the one that presented the highest factorial loading.[13] During manic episode, legal involvement is more likely among those with symptoms with a high risk of painful consequences. Remitted euthymic bipolar patients have distinct impairments of psychomotor speed and executive function. Acute agitation is a common presentation of a manic episode.[14] Increased risk-taking behavior, increased motor activity, and increased impulsivity are the important features comprising the clinical state of mania.[20] Impulsiveness is a clinical feature of BD. Impulsivity refers to a predisposition toward unplanned reactions without consideration of consequences and can include risky decision-making, self-reported high-risk attitudes, poor response inhibition, and rapid decision-making. BD is often characterized by impulsive behavior and increased tendency to work toward a reward, often without sufficient planning. Bipolar patients consistently show abnormalities on measures of impulsivity and show deficits on behavioral tasks which require planning and forethought.[21]

Mania is characterized by reckless behavior such as impulsive spending and sexual indiscretions.[11] Novelty seeking (a personality trait) found elevated in bipolar spectrum disorders even in euthymia.[18] Oppositional or impulsive behavior with increased energy are the cardinal symptoms of BD with mania in adolescents. Premorbid features of adolescence BD most frequently mentioned in psychiatric literature are hyperactive behavior, easily excited, hyper alert, and frequent changes of mood.[19] Excessive confidence, increased energy, psychomotor agitation, willingness to engage in reward oriented behaviors without considering the potential negative consequences are the key features of mania.[22] Increased motor activity – energy is one of the items of YMRS.[15],[16]Saahasikam of GG denotes risk taking behavior/agitation/increased psychomotor activity seen in mania.

Gambheera and Adhrushya (grandiosity/agitation)

Delusions (or ideas) of grandeur (grandiosity) with markedly inflated self -esteem is found in mania. The person with mania is unusually alert, trying to do many things at one time. There is marked increase in activity with excessive planning and at times execution of multiple activities. The mood becomes expansive which is unceasing and unselective enthusiasm for interacting with people and surrounding environment. The mood may become irritable, especially when the person is stopped from doing what he wants. There is an increased psychomotor activity ranging from over activeness and restlessness to manic excitement where the person is involved in ceaseless activity.[9] These features of grandiosity, agitation/restlessness of mania resembles with “gambheera” and “adhrushya” of GG.

Nrutyantam, gaayantam, mukha vaadyaani kurvantam (dancing, singing, and playing music)

Studies have provided consistent evidence for elevated rates of BD in samples of famous individuals. Several of these studies suggest that creativity is particularly likely among those with either mild forms of BD. Musicians have been shown to have higher scores on measures of manic and cyclothymic temperament. According to a study, 43% of creative writers were found to meet criteria for bipolar spectrum disorders. Overall, studies of those engaged in creative occupations have suggested that BD and risk of BD are over-represented. It appears as though creativity might be more apparent in those with milder forms of the BD. It is evident that many famous artists, musicians and authors have gone through periods of manic symptoms, particularly when very mild manic symptoms are considered. Bipolar spectrum disorders and family history of BD are related to high levels of lifetime creative accomplishment. Heightened impulsivity in BD promotes expressiveness without constraints and also openness to experience which may be the reason for creativity. Positive emotional states broaden attention and thinking, widening the array of precepts', thoughts, and images that come into awareness. Positive emotions relax inhibitory control and open awareness to unattended information. One of the common symptoms of manic episodes is intense euphoria.[22]

People with BD believe that their positive moods and manic symptoms can enhance creativity. Manic symptoms may bolster creative productivity. Creativity was specifically related to more adaptive symptoms of mania, such as increased activity, less need for sleep, excitement, engagement in new activity, enhanced thinking, and faster thought processes. BD is related to many of these precursors to creativity, including elevated tendencies toward impulsivity, openness to experience, ambition, confidence, and positive mood states.[22] Research suggests relationships between creativity and affective illness, specifically BD. Children with familial BD have higher creativity than healthy control children.[23] Creativity is typically defined as behaviors or thoughts that are both novel/original and adaptive/useful. BD is significantly over-represented among samples of authors, poets, and visual artists. About 8.2% of those in creative professions (including architecture/design, musical composition, musical performance, theater, expository writing, fiction writing, and poetry) appeared to have had experiences of mania. BD was over-represented in the most creative occupations, such as painting, writing, and lighting design. Hypomanic traits in healthy samples have been found to predict self-rated creativity, divergent thinking fluency, and a biographical measure of spontaneous everyday creative achievement. Positive affectivity might promote more divergent, creative thinking, and impulsivity may foster production of novel products without self-censorship.[24] In the case of BD, however, it is likely that reducing severe manic episodes may actually enhance creativity in many individuals.[25]Nrutyantam, gaayantam, mukha vaadyaani kurvantam, etc. features of GG resembles with elation/euphoria of manic episode.

Pulina vanaantaropasevi, hrishtaatma, prahasati, haasya kathaanuyogam (engaged in pleasurable activities/euphoria)

Euphoria must be present for the diagnosis of mania or hypomania.[13] In manic episode, excessive engagement in pleasurable activities is commonly seen.[14] Mania is characterized by a centrifugal expansion, connected with a general sense of omnipotence and appropriation. Manic mood is not so much a state of happiness and cheerfulness, but rather a state of superficial elation and often experienced with feelings of flying or floating. Due to excess of drive and the expansivity of the body, the space of the manic person changes into an unlimited, homogeneous medium of projects and activities. The patient's self is exteriorized and extended in his environment, trespassing on others territories regardless of barriers of decency or respect. “The world is too small for this being in expansion and distances become smaller.” Space is lived as if it were vast, open, and lacking resistance. Attractive qualities or opportunities abound, all objects seem equally close, available, and ready to use, leading to the notorious excessive consumption. The manic mode of existence is volatile, playful, and provisional; both the past and the future lose their influence on the present.[26] Elevated mood is one of the features of YMRS.[15],[16] Mania is characterized by euphoric mood.[11] Euphoric mood is generally described as giddy, goofy, hyper excited, silly states with laughing fits. Adolescents unpredictably switching in and out of depression, irritable mania with explosions, and euphoric mania throughout the day, almost every day, with very little time spent in a regular age-appropriate mood state.[19]Pulina vanaantaropasevi, hrishtaatma, prahasati, haasya kathaanuyogam etc. features of GG denote euphoria/elated mood seen in mania/hypomania.

Snaana, maalya, anulepana, dhoopa, gandha ratim (flamboyant appearance/obsessive compulsive symptoms)

OCD has a complex relationship with BD. Clinicians see patients who start out looking like they have classic OCD and end up looking like they have definite BD without OCD. OCD is the most commonly seen comorbid anxiety disorder in bipolar patients. A study has found that for those with either Bipolar I or II, 21% had comorbid OCD. Those with pure OCD have more checking compulsions while those with comorbidity exhibit more obsessions that are classified as “others” which they described as “existential, philosophical, and/or superstitious.” High rates of comorbid obsessive compulsive symptoms among patients with BD (38.7%) are found. BD with OCD patients had higher likelihood to be also diagnosed with nicotine, substance use disorders and alcohol use disorders. Contamination, religious and aggressive obsessions are positively associated with BD-OCD comorbidity. The types of compulsions differ between those with comorbid bipolar and OCD and those with just OCD. While the most common compulsions were cleaning/washing and counting, lower rates of compulsions than obsessions in the BD-OCD group is found. Patients of BD-OCD comorbidity were reported to have higher rates of cleaning, and counting compulsions. High comorbidity rates for obsessive compulsive symptoms in BD patients (38.7%) are found. It also revealed a higher educational level in the BD-OCD group compared to only BD group. The most common obsessions were contamination, religious, and aggressive obsessions and the most common compulsions were cleaning/washing and counting compulsions in BD-OCD group.[27] Excessive showering, bathing, grooming, cleaning or washing compulsions and contamination obsessions of OCD resemble with “snaana, maalya, anulepana, dhoopa, gandha ratim” of GG.

Shringaara leelaabhiratim (hyper sexuality)

Increased libido is found in manic episode.[14] Manic state of mood is due to an excess of drive, energy and disinhibition. The body seems to have lost all inner resistance that normally hinders a person from acting out every impulse immediately. Lack of distance and disinhibition, often a sexualized behavior to the point of promiscuity, may have a destructive effect on personal relationships and leads to divorce.[26] Along with alteration in mood the clinical state of mania comprises a cluster of symptoms which also involves hypersexual behavior.[20] Sexuality is often increased in adults with BD during hypomanic or manic episodes. The previous studies have found increased sexuality in manic compared to depressed patients. In addition, 40 percent of the Bipolar I and II patients have reported elevated sexuality as an enduring interepisodic trait in a study. Some studies have reported that increased interest in sex and frequent change of sexual partners were more common among patients with BD compared with patients with unipolar depression and normal controls. Bipolar I patients placed more value on sex, had more interest in sex, and desired and engaged in intercourse more frequently than Bipolar II or comparison groups. According to a study, 40 percent of cyclothymic patients had “episodic or unexplained promiscuity or extramarital affairs” and that Bipolar II patients manifested diverse types of sexual excess including sexual infidelity, overt bisexuality, and sexual activity many times per day.[28]Shringaara leelaabhiratim of GG denotes hyper sexuality of mania or hypomania.

Rakta vastram (wearing red-color garments)

Red color has highest affective value and revealed uninhibited expression. Warm colors such as red, yellow, and orange seem to hold most attention in the beginning years of life. The warm color dominant subjects are characterized by an intimate relation to the visually perceptible world. They are receptive and open to external influences. They seem to submerge themselves rather readily in their social environment. Their emotional life is characterized by warm feelings, suggestibility, and strong affects. In the subject-object relationship, the emphasis is on the object. In a broad way, the spectrum may be divided into colors of long-wave length (red and orange) and colors of short wave length (green and blue) with yellow occupying a middle position. Emotionally, the red end of the spectrum is exciting. Red colors tend to increase bodily tension and to stimulate the autonomic nervous system.[29] The person suffering with mania usually dressed up in gaudy and flamboyant clothes.[9] Miscellaneous obsession like “colors with special significance” (preferring particular colors) is also one of the features of OCD which may be found comorbid with BD.[3] Preference to wear red-color dress or preferring objects of red color indicates the exteriorization, centrifugal dispersion, disinhibition, and euphoria of manic episode.

Paana ratim (alcohol abuse)

Substance abuse is a major comorbidity in bipolar patients. Bipolar patients with comorbid substance abuse have more severe course. Some studies have also noted less favorable treatment outcomes among bipolar patients with a comorbid substance abuse. High lifetime rates of alcohol abuse (48.5%) and drug abuse (43.9%) have been found in bipolar subjects. In addition to high rates of alcohol and drug abuse, lifetime abuse rates were high for cocaine (24.5%) and marijuana (36%). Substance abuse is a major comorbidity in bipolar patients, with nearly 60% of the cohort having a lifetime history of some substance abuse. Rates were particularly high for alcohol (48.5%), cocaine (24.2%), and marijuana (36.0%). Few studies have reported on the active drug abuse during acute manic or mixed episodes.[30]Paana ratim ” of GG denotes alcohol abuse comorbid with BD.

Svaachaaram (virtuous conduct)

Due to grandiose ideation, increased sociability, overactivity, and poor judgement, the manic person is involved in high-risk activities such as buying sprees, reckless driving, foolish business investments, distributing money to unknown persons, etc., and also may become irritable or violent at times.[9]Svaachaaram (virtuous conduct or excessive morality) of GG does not show any similarity with manic episode, but it may indicate the obsessive compulsive features of OCD comorbid with BD. Religious obsessions such as excessive concern with right or wrong, concerned with sacrilege and blasphemy, excessive morals; miscellaneous obsession like fear of not saying just the right thing, colors with special significance, etc. cleaning and washing compulsions such as excessive showering, bathing, grooming, cleaning, etc. obsessive compulsive features [3] resemble “svaachaaram .” Svaachaaram of GG denotes OCD comorbid with BD.

Chaaru chaalpa shabdam, alpa vyavahaaram (hypomania/mixed episode/mania with depressive symptoms)

In BD, mixed states are essentially considered the co-presence of symptoms of opposite polarity (both manic and depressive features at same time). According to DSM-IV-TR (Diagnostic and statistical manual for mental disorders – IV – Text revision) criteria, it is possible to diagnose a mixed episode in the co-presence of criteria to diagnose either a manic or major depressive episode. In the ICD-10 (International classification of diseases), the term “mixed episode” indicates the co-presence or rapid cycling of prominent depressive and manic or hypomanic symptoms. At present, in the absence of widely-accepted opinion, the literature is filled with a variety of terms that are often interchangeable and used inappropriately to indicate similar concepts such as, mixed state, mixed mania, dysphoric mania and mania with depressive symptoms. Mixed states are not a mere overlap of depressive and manic features, but rather the combination of an episode of affective alteration with a dominant temperament of opposing polarity.[31]

Three types of mixed states depending on the type of interaction of temperament or affective interaction has been observed. They are, Type B-I: Depressive temperament + psychotic mania; Type B-II: Cyclothymic temperament + major depression, and Type B-III: Hyperthymic temperament + major depression. Type B-I mixed states comprise psychotic episodes which are characterized by productive, solid psychotic symptoms, and strong emotional perplexity with sudden mood swings that are almost indistinguishable from the acute phases of schizophrenia spectrum disorders. Type II mixed states are generally nonpsychotic in nature and classically require the manifestation of a cyclothymic temperament in the context of inhibited depression. Thus, together with mood deflection, hyperphagia, hypersomnia and asthenia, other symptoms appear intermittently such as racing thoughts, excessive joking, fits of rage, emotional tension, restlessness, impulsivity, disinhibition and dramatic suicide attempts. The third type of mixed states manifests as major depressive episodes in the context of stabile hyperthymic temperament. This type of mixed states are characterized by persistent dysphoria together with irritability, agitation, asthenia and marked racing of thoughts, panic attacks and insomnia, obsessive ideas of suicide associated with suicidal impulses and discomforting sexual hyper arousal. Substance abuse with alcohol or drugs is frequently found.[31] Even though the person suffering with mania shows pressure of speech (more talkative than usual due to racing thoughts), he may become less talkative during mixed episode, or hypomania or when associated with OCD (religious or miscellaneous obsessions like excessive concern with right/wrong, fear of not saying just the right thing, concerned with sacrilege and blasphemy etc).

According to Ashtanga samgraha (an Ayurvedic text written by vriddha Vagbhata) there are two subtypes of GG. They are “Samrambha grahonmada” and “Hasana grahonmada.” Samrambha grahonmada is characterized by “shiro dhunaanaam” (shaking head/agitation) and “kalaham kurvantam” (excessive fighting/quarrelling with others), whereas hasana grahonmada is characterized by “jaagarookam” (sleeplessness/decreased need for sleep), pathantam (excessive reading/studying) and hasantam (excessive laughing).[6]Samrambha grahonmada resembles with “Dysphoric mania”[32] or “Irritable/aggressive mania,” whereas hasana grahonmada have similar features with “Euphoric mania”[32] or “Grandiose/elated mania.”

  Conclusion Top

GG is one among 18 types of grahonmada. The signs and symptoms of GG such as chandam, teekshnam, saahasikam, gambheera, adhrushya, nrutyantam, gaayantam, mukha vadyaani kurvantam, pulina vanaantaropasevi, hrishtaatma, prahasati, haasya kathanuyoga, snaana maalya anulepana dhoopa gandha ratim, shringaaraleelabhiratim, rakta vastram, paana ratim, svaachaaram, chaaru chaalpa shabdam, and alpa vyavahaaram show similarity with irritability, risk-taking behavior, grandiosity, agitation, euphoria/elation, flamboyant dressing, hyper sexuality, alcohol abuse, and various obsessive compulsive features commonly found BD with OCD. GG shows similarity with mania or hypomania or BD with OCD. Samrambha grahonmada resembles with “irritable/aggressive mania,” whereas hasana grahonmada denotes “grandiose/elated mania.”

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