International Journal of Yoga - Philosophy, Psychology and Parapsychology

REVIEW ARTICLE
Year
: 2021  |  Volume : 9  |  Issue : 1  |  Page : 23--31

Vishesha or Upa Grahonmadas: Various Psychiatric and Neuropsychiatric Conditions


Prasad Mamidi, Kshama Gupta 
 Department of Kayachikitsa, R. B. Ayurvedic Medical College & Hospital, Agra,Uttar Pradesh, India

Correspondence Address:
Dr. Prasad Mamidi
Department of Kayachikitsa, R. B. Ayurvedic Medical College & Hospital, Agra, Uttar Pradesh
India

Abstract

Bhutavidya (Ayurvedic psychiatry) is one among the eight specialties of Ayurveda (an ancient Indian system of medicine). Bhutavidya deals with the diseases (psychiatric or neuropsychiatric) caused by “bhuta” or “graha” (idiopathic factors) and their management. Unmada (broad term which includes various psychiatric conditions) is a disease characterized by deranged mental functions. “Bhutonmada” (psychiatric conditions caused by idiopathic factors) is a type of unmada caused by affliction of “bhuta” or “graha.” Eighteen types of bhutonmada are explained in samhita's (ancient Ayurvedic texts). Previous works have explored these 18 grahonmadas and compared them with various psychiatric and neuropsychiatric conditions. Vishesha or Upa grahonmadas are the subtypes of these 18 grahonmadas, and their description is found only in “Ashtanga sangraha” (Ayurvedic textbook of medicine written by Vriddha Vagbhata). Description of 16 “Vishesha” or “Upa grahonmadas” is available in “Ashtanga sangraha.” Till date, no studies have been conducted on Vishesha grahonmadas, and the present study aims at exploring Vishesha grahonmadas with contemporary psychiatric conditions. Ayurvedic literature related to “Vishesha grahonmadas” has been collected from major classical Ayurvedic texts and from their commentaries. Electronic databases “Google” and “Google Scholar” have been searched to find out the relevant studies using appropriate keywords. Sixteen Vishesha grahonmadas explained in Ashtanga sangraha have shown resemblance with various psychiatric and neuropsychiatric conditions such as mood disorders, schizophrenia, frontotemporal dementia, Tourette's syndrome, extra pyramidal movement disorders, temporal lobe epilepsy, autism, personality disorders, Parkinson's disease, and attention-deficit/hyperactivity disorder. The contemporary perspective of ancient psychiatric concepts as demonstrated in the present article provides new insights and paves way further studies.



How to cite this article:
Mamidi P, Gupta K. Vishesha or Upa Grahonmadas: Various Psychiatric and Neuropsychiatric Conditions.Int J Yoga - Philosop Psychol Parapsychol 2021;9:23-31


How to cite this URL:
Mamidi P, Gupta K. Vishesha or Upa Grahonmadas: Various Psychiatric and Neuropsychiatric Conditions. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2021 [cited 2021 Jul 25 ];9:23-31
Available from: https://www.ijoyppp.org/text.asp?2021/9/1/23/311405


Full Text



 Introduction



Bhutavidya (Ayurvedic psychiatry) is one among the eight specialties of Ayurveda (an ancient Indian system of medicine). Bhutavidya deals with the diseases (psychiatric or neuropsychiatric) caused by “bhuta” or “graha” (idiopathic elements) and their management. Unmada (broad term which includes various psychiatric conditions) is a disease characterized by deranged mental functions. “Bhutonmada” or “Grahonmada” (psychiatric conditions caused by idiopathic factors) is a type of unmada caused by affliction of “bhuta” or “graha.” The cause of affliction is Pragnaparadha or Karma (consequences of bad deeds done in the present or past life). The course of bhutonmada is unpredictable, and the onset is sudden. Bhutonmada in general is characterized by abnormal behaviors in terms of exhibition of strength and enthusiasm, defects in perception, memory, abnormality of speech, and abnormality in perceiving self and the environment.[1],[2] Eighteen types of bhutonmada (deva, asura, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala) are explained in Ashtanga sangraha[3] and Ashtanga hridaya[4] (ancient Ayurvedic textbooks of medicine). In “Sushruta samhita” (an Ayurvedic text on surgery written by Acharya Sushruta), description of eight types of bhutonmada (deva, asura, gandharva, yaksha, pitru, naga, rakshasa, and pishacha) is available,[5] whereas in “Charaka samhita” (an Ayurvedic textbook of medicine written by Agnviesha), eleven types of bhutonmadas are found (deva, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, brahma rakshasa, and pishacha).[6] Previous works have explored different grahonmadas and compared them with various psychiatric and neuropsychiatric conditions.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]

Vishesha (special) or Upa (subtype) grahonmadas are the subtypes or minor grahnomada's and their description is found only in “Ashtanga sangraha” (Ayurvedic textbook of medicine written by Vriddha Vagbhata).[3] Description of 16 “Vishesha grahonmadas” under six major grahonmadas is available (Deva vishesha-Eshwara, Indra, Dhanada and Varuna; Gandharva vishesha-Samrambha and Hasana; Yaksha vishesha-Manivara and Vikata; Brahma rakshasa vishesha-Yagnasena; Rakshasa vishesha-Vishakha, Sangama, Vidyunmali and Virupaksha; Pishacha vishesha-Kashmala, Kusha, and Nistejasa) in Ashtanga sangraha only.[3] Till date, no studies have been conducted on Vishesha grahonmadas. The present study is aimed at exploring the similarities of 16 Vishesha grahonmadas with various psychiatric or neuropsychiatric conditions.

 Review Methodology



Ayurvedic literature pertaining to “Vishesha grahonmadas” has been collected from all major classical Ayurvedic texts such as “Charaka samhita,” “Sushruta samhita,” “Ashtanga sangraha,” and “Ashtanga hrudaya” along with their commentaries. “Indu” commentary has been referred for “Ashtanga sangraha” text. Electronic databases “Google” and “Google Scholar” have been searched to find out the relevant studies and reviews pertaining to various psychiatric and neuropsychiatric conditions published till July 2020, irrespective of their appearance or publication year. The key words used for searching were, “Unmada,” “Bhutonmada,” “Grahonmada,” “Vishesha grahonmada,” “Upa grahonmada,” “Schizophrenia,” “Hebephrenia,” “Oculogyric crisis,” “Catatonic schizophrenia,” “Catatonia,” “Demenita,” “Mood disorders with psychosis,” “Bipolar disorder with psychosis,” “Bipolar psychosis,” “Mania with psychotic features,” “Frontotemporal demenita,” “Tourette's syndrome,” “Attention-deficit/hyperactivity disorder,” “Obsessive–compulsive disorder,” “Tourette's syndrome-plus,” “Extra pyramidal movement disorders,” “Parkinson's disease,” “Phobia,” “Psychotic mania,” “Irritable mania,” “Dementia,” “Autism spectrum disorder,” “Asperger's disorder,” “Selective mutism,” “Antisocial Personality disorder,” “Borderline personality disorder,” and other relevant terms. Abstracts as well as full text, open access articles in English language were only considered.

 Deva Vishesha Grahonmadas



Deva grahonmada is one among 18 types of grahonmadas. The clinical picture of deva grahonmada has shown similarity with conditions such as “Interictal behavior syndrome” (IBS) of “Temporal lobe epilepsy” (TLE), “Obsessive–Compulsive Disorder” (OCD), “Mania” and “Psychosis.” Four subtypes or “Deva vishesha grahonmadas” are described (Eshwara, Indra, Dhanada, and Varuna).[3]

Eshwara grahonmada

Eshwara grahonmada is a subtype of deva grahonmada, and it is characterized by the features such as govrishamiva nadantam (behaving or dancing like a mad cow or bull or agitated bull-like behavior or irritability or impulsiveness), deepta mukha nayana (blazing or reddish face and eyes or agitated or furious eyes and face or anxious face), and adeeptena swarena abhashamanam (speaking with strong or energetic voice or speaking loudly or giving boons or pressure of speech).[3] TLE patients with psychiatric symptoms have shown personality features such as affective dysregulation, irritability, impulsiveness, anxiety, grandiosity, abnormal social interactions, schizophrenia-like symptoms, dissociation, and intense emotions.[21] Schizophrenia is a neuropsychiatric disorder characterized by both positive (delusions and hallucinations) and negative (deficient emotional, cognitive, and motivational functioning) symptoms. Persecutory (e.g., devil, demons, super natural forces, and evil spirits) and grandiose (e.g., people believe they are God, Jesus, a prophet, a saint, or an angel) type of delusions are seen in schizophrenia.[22] 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 (may cause reddish eyes or deepta nayana), pressure of speech (adeeptena swarena abhashamanam), flight of ideas, distractibility, and increased involvement in pleasurable activities (govrishamiva nadantam). There is an increased psychomotor activity ranging from over activeness and restlessness to manic excitement where the person is involved in ceaseless activity.[8] Euphoric or cheerful mood (govrishamiva nadantam), decreased need for sleep, restlessness, agitation (deepta mukha nayana), grandiosity, increased energy levels, and pressure of speech (adeeptena swarena abhashamanam), etc., features of Mania resembles with the features of eshwara grahonmada. Eshwara grahonmada has shown similarity with the conditions such as mania (psychotic or elated), positive symptoms (religious or grandiose delusions) of schizophrenia, and IBS in TLE.

Indra grahonmada

Indra grahonmada is a subtype of deva grahonmada and it is characterized by “vaacha visrujantam (giving boons or having control over) megha (clouds), stanita (thunder), vidyut (lightening), and vrishti (rain) (person afflicted by indra grahonmada behaves like a lord of sky and atmosphere or person afflicted by indra grahonmada shows features of grandiosity such as he can control clouds, thunders, lightening, and rain).[3] Epilepsy, mood disorders (especially mania), and psychosis may trigger an excess of spiritual or religious experiences. Several case reports have documented religious or mystical experiences during partial seizures. The nature of ictal religious seizures varies including intense emotions of presence of God, 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. 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.[23] Religious or spiritual delusions and hallucinations are common in schizophrenic patients. Three types of delusions (persecutory, grandiose, and belittlement) are known to have religious content in schizophrenic patients. In grandiose delusions, patients believe that they are very important people, so they might believe they are God, a prophet, or somebody who has been sent by God. Grandiosity and high self-esteem, religious delusions, or hyperreligiosity are seen in Mania or bipolar disorder (BD).[12] In indra grahonmada, person behaves like “lord of sky and atmosphere” and his content of speech includes having control over clouds, thunders, lightening, rain, etc. Indra grahonmada resembles with grandiosity commonly seen in mania, schizophrenia, and in patients of TLE.

Dhanada grahonmada

Dhanada grahonmada is a subtype of deva grahonmada, and it is characterized by “vaacha dhanani (speaking about money) prayacchantam (giving or offering), acchindantam (taking or collecting)” (person afflicted by dhanada grahonmada behaves like a lord of money or wealth or person afflicted by dhanada grahonmada shows features of grandiosity).[3] The person afflicted by dhanada grahonmada always speaks about giving or collecting money (money transactions) inappropriately which can be stated as grandiosity or grandiose delusions seen in mania or schizophrenia.

Varuna grahonmada

Varuna grahonmada is a subtype of deva grahonmada, and it is characterized by “surasava samagandha” (smelling like alcohol) and ”kashta trina rajjvadi sarvam pashamabhimanyamanam” (perceiving all objects as a noose or rope or chain or abnormal perception or delusions or hallucinations).[3] Substance abuse is a major comorbidity in bipolar patients. High lifetime rates of alcohol abuse and drug abuse has been found in bipolar subjects.[8] ”Surasava samagandha” mentioned in varuna grahonmada indicates a person who consumes excessive alcohol (substance or alcohol abuse) due to which he may emit alcohol like odor. “Sura abhiprayam” (excessive indulgence in alcohol or alcohol abuse) is mentioned as one of the features of deva grahonmada, and this condition is considered as abuse of alcohol found in mania or BD.[12] ”Kashta trina rajjvadi sarvam pashamabhimanyamanam” denotes abnormally perceiving every object like a noose or rope or chain due to an underlying delusional belief or hallucinations. Varuna grahonmada has shown resemblance with “psychotic mania” or “schizophrenia.”

 Gandharva Vishesha Grahonmadas



Gandharva grahonmada is one among the 18 types of “bhutonmadas.” The features of gandharva grahonmada have shown similarity with BD comorbid with OCD.[8] Description of two subtypes (Samrambha and Hasana) of gandharva grahonmada is available in “Ashtanga sangraha.”[3]

Samrambha grahonmada

Samrambha grahonmada is a subtype of gandharva grahonmada, and it is characterized by the features such as ”shiro dhunaanaam” (shaking head or psychomotor agitation) and ”kalaham kurvantam” (excessive fighting or quarrelling with others or impulsiveness or aggressiveness). Samrambha grahonmada resembles with “Dysphoric mania” or “irritable or aggressive type of mania.”[8] Tourette syndrome (TS) is a neuropsychiatric disorder characterized by a combination of multiple motor (shiro dhunaanaam) and vocal tics. TS is distinguished by erratic movements of the whole body. The most frequent comorbidity was attention deficit/hyperactivity disorder (ADHD), and a variety of other neuropsychiatric disorders, such as OCD and BD, were observed with TS. Increased incidence of anxiety, insomnia, hostility (kalaham kurvantam), coprolalia, self-injurious behavior, and personality disorders has also been observed. The patient of TS manifests impulsivity, aggressive behavior, distractibility, irritability, and abnormally increased energy (kalaham kurvantam). His motor (shiro dhunaanaam) and vocal tics increased in frequency. TS-Plus (comorbid condition of TS + ADHD + OCD + BD) is a neuropsychiatric condition, in which impulsivity, motor tics, aggressive behavior, irritability, etc., can be seen.[24] During manic episode, person's mood becomes irritable and speech may be marked by complaints, hostile comments, or angry tirades. The person may become hostile and physically threatening to others and also may become physically assaultive (kalaham kurvantam). Psychomotor agitation (shiro dhunaanaam?) is also one of the common features of mania.[17] Samrambha grahonmada has shown similarity with “Mania” or “TS-Plus.”

Hasana grahonmada

Hasana grahonmada is a subtype of gandharva grahonmada, and it is characterized by the features such as “jaagarookam” (sleeplessness or decreased need for sleep), pathantam (excessive reading or studying), and hasantam (excessive laughing). Hasana grahonmada has shown similarity with “Euphoric mania” or “Grandiose or elated mania.”[8] BD is significantly overrepresented among samples of authors, poets, and visual artists. Most of the people in creative professions (including architecture or design, musical composition, musical performance, theater, expository writing, fiction writing, and poetry) (pathantam?) appeared to have had experiences of mania.[25] Decreased need for sleep is one of the seven diagnostic criteria of BD or mania. Although the ability to maintain energy without sleep is characteristic of mania, manic patients still likely require sleep to sustain life. Disruption of the daily rhythm may often occur before episodes of mania in bipolar patients. The person during manic episode awakens several hours with felling full of energy (jagarookam). When the sleep disturbance is severe, the person may go for days without sleep and yet not feel tired.[26] The overly joyous or euphoric mood during manic episode may seem out of proportion to reality, and cheerfulness may be inappropriate for the circumstances. During manic episode, the person may laugh, joke, (hasantam), and talk in a continuous stream, with uninhibited familiarity.[27] Hasana grahonmada has shown resemblance with Mania.

 Yaksha Vishesha Grahonmadas



Yaksha grahonmada is one among the 18 types of “bhutonmadas.” The clinical picture of yaksha grahonmada has shown similarity with comorbid conditions of BD with OCD.[11] There are two subtypes (Manivara and Vikata) of yaksha grahonmada have been described in “Ashtanga sangraha.”[3]

Manivara grahonmada

Manivara grahonmada is a subtype of yaksha grahonmada, and it is characterized by the features such as hrishita romanam (goose bumps), urdhvekshanam (upward deviation of eyes or gaze), prahrushta nayana (excited or agitated or anxious eyes or dilated pupils), chandam (impulsive or aggressive or furious), parusham (violent or rough or harsh or aggressive), and maha ninada (loud speech or voice or shouting or making abnormal sounds).[3] Oculogyric crisis (OGC) is a neurologic manifestation characterized by sustained dystonic, conjugate, and typically upward deviation of the eyes (urdhvekshanam) lasting from seconds to hours. OGCs have been reported in association with numerous conditions such as neurometabolic and neurodegenerative movement disorders and also as a consequence of focal brain lesions. Clinical presentation may vary from very brief and subtle eye deviation accompanied by neck flexion, jaw opening, blepharospasm, tongue protrusion, and autonomic signs (perspiration, papillary dilation, and increases in blood pressure and heart rate). In addition, psychiatric symptoms such as agitation, anxiety, visual, tactile and auditory hallucinations, distortions of body schema, catatonic symptoms, mood disorders (depression or mania), and obsessive–compulsive behaviors may occur. OGCs were found in hypomyelination with atrophy of the basal ganglia and cerebellum (HABC) syndrome, rapid-onset dystonia Parkinsonism, Perry syndrome, Wilson's disease, Chediak–Higashi syndrome, and ataxia-telengiectasia and Parkinsonism.[28]

Hypothermia is defined as a core temperature of <35.0°C and it is commonly seen in malnourished, alcoholic, mentally ill, sepsis, shock, or whose mobility is limited by disability or injury, etc., conditions. Malnutrition, hypothyroidism, and neurological disorders which impairs judgment, dementia, schizophrenia, and disorders which impair motility, Parkinson's disease (PD), amyotrophic lateral sclerosis, Wernicke encephalopathy, multiple sclerosis, etc., conditions are associated with hypothermia.[29] In those conditions, goose bumps (hrishita romanam) may be seen due to underlying hypothermia. “Prahrushta nayana” may indicate dilated pupils seen in OGC or elated or agitated eyes seen in BD or mania. Aggression, hostility, impulsivity, irritability, etc., (chandam and parusham) features are seen in ADHD, oppositional defiant disorder (ODD), conduct disorder (CD), BD, and TS-Plus.[17] “Maha ninada” indicates vocal tics or abnormal loud sounds or speech seen in TS or TS-Plus or in mania. Manivara grahonmada indicates a neuropsychiatric or neurodegenerative conditions such as OGC, TS-Plus, and BD (organic or secondary).

Vikata grahonmada

Vikata grahonmada is a subtype of yaksha grahonmada, and it is characterized by the features such as raho hasita nrutya geeta acharantam (laughing, dancing, and singing when alone), and akeerne maunam (not speaking in groups or selective mutism (SM) or social withdrawal or social phobia or negativism of catatonia).[3] SM is interpreted as an extreme form of social phobia and it is characterized by consistent failure to speak in social situations (akeerne maunam) despite having ability to speak in other situations.[30] Catatonia is characterized by mutism (minimal or no verbal response) (akeerne maunam) and negativism (opposing or not responding to external stimuli or instructions).[14] Comorbid psychiatric conditions associated with SM include depression, panic disorders, dissociative disorders, obsessive–compulsive behavior, and Asperger's disorder (AD). AD is a mild form of autism that inhibits social interactions, peculiar speech, and nonverbal communication.[31] Mixed symptoms of depression (social withdrawal – akeerne maunam) and mania (euphoric or elated mood – hasita nrutya geeta acharantam) can be seen in BD.[32] SM can be seen in or it may get overlapped with ASD (Autism spectrum disorders).[33] By considering all these facts, it seems that vikata grahonmada has a resemblance with the conditions such as BD, ASD, AD, catatonia, schizophrenia, social phobia, and SM.

 Brahma Rakshasa Vishesha Grahonmadas



Brahma rakshasa grahonmada is one among the 18 types of “grahonmadas.” BRG has shown similarity with conditions such as BD or TS or TS-Plus (comorbid condition of TS + ADHD + OCD + BD).[17] “Yagnasena graha” is the only subtype of BRG explained in “Ashtanga sangraha.”[3]

Yagnasena grahonmada

Yagnasena grahonmada is a subtype of brhma rakshasa grahonmada, and it is characterized by the features such as vikruta swaram bhashayantam (speaking with abnormal voice or tone or harsh voice or speech or vocal tics or abnormal or inappropriate speech), utrasayantam (frightening or scaring or threatening), brahma vaadinam (having knowledge of or speaking on sacred texts or hyper religiosity), samskruta bhashinam (perfect or refined speech), and bahusha toyam yachayantam (begging for water or polydipsia or dehydration).[3] Hoarseness and dysphonia (vikruta swaram bhashayantam) are often a result of vocal cord polyps which in turn are linked to vocal trauma. Vocal cord lesions are of multifactorial origin; vocal cord abuse appears to be paramount to the development of such pathology. Chronic vocal cord abuse can occur due to vocal tics in TS. Chronic minor vocal cord abuse due to vocal tics in TS patients may produce laryngeal lesions.[34] ”Utrasayantam” denotes threatening behavior or aggression or hostility which can be seen in ADHD, ODD, CD, TS, BD, BPD (Borderline personality disorder) and ASPD (Antisocial personality disorder). Increased irritability, rage attacks, drug abuse, depression, and antisocial behaviors are common among patients with TS. Patients of TS may display impulsivity, aggressive behavior, irritability, and abnormally increased energy. Socially unacceptable coprolalic utterances such as shouting obscenities, racial slurs, and gestures are the cardinal features of TS. NOSI (Non obscene complex socially inappropriate behaviors) and disinhibition behaviors such as insulting others and other socially inappropriate comments are also seen in TS patients.[18]

“Brahma vaadinam” denotes hyperreligiosity or becoming philosophical (excessively talking on philosophical subjects or sacred texts). Religious symptoms are more severe in patients of TS comorbid with OCD and ADHD. There is a clear and strong association between TS and OCD.[17] Religious obsessions, excessive morality, excessive concern with sacrilege, and blasphemy and excessive concern with right or wrong and fear of not saying just the right thing, etc., are seen in OCD,[1] and they are similar with “brahma vaadinam” and “samskruta bhashinam” of yagnasena grahonmada. Disturbances of fluid and electrolyte balance have been found in acute exacerbations of BD, and it has been attributed to redistribution of electrolytes and water within body compartments, changes in fluid and solute intake, altered fluid, and electrolyte metabolism. Mania is associated with pathological variations in body weight, retention of water, and is accompanied by pathological thirst (bahusha toyam yachayantam).[35] By considering all these facts, it can be assumed that yagnasena grahonmada denotes TS-Plus (TS + OCD + BD).

 Rakshasa Vishesha Grahonmadas



Rakshasa grahonmada is one among the 18 types of “grahonmadas.” Rakshasa grahonmada has shown similarity to ASPD comorbid with “Psychotic mania.”[16] Four subtypes or “Rakshasa vishesha grahonmadas” are described (Vishakha, Sangama, Vidyunmali, and Virupaksha).[3]

Vishakha grahonmada

Vishakha grahonmada is a subtype of rakshasa grahonmada, and it is characterized by the features such as parusha cchavim (rough complexion), bhumim tadayantam (aggressive behavior, or self-injurious behaviors or motor tics or purposeless movements), and akasmat rudantam (crying suddenly without any reason or mood lability).[3] Melasma, local hyper pigmentation over the face, is upsetting for many individuals. Depressive disorders, major depressive episode, or recurrent depressive disorder are the most common associated psychiatric morbidities of melasma.[36] Vitamin B12 deficiency has been implicated as a cause of peripheral neuropathy, subacute combined degeneration of the spinal cord, ataxia, optic atrophy, psychosis, depression, and dementia. Cutaneous manifestations associated with Vitamin B12 deficiency are skin hyperpigmentation, vitiligo, angular stomatitis, and hair changes.[37] Pellagra (characterized by dermatitis, dementia, and diarrhoea), a disease from niacin deficiency, may be associated with psychiatric disorders, mainly behavioral deterioration and dementia.[38] “Parusha cchavim” denotes rough complexion or hyperpigmentation seen in psychiatric conditions such as nutritional deficiency induced (niacin and Vitamin B12) dementia, and Melasma with depressive disorders.

BPD is characterized by marked impulsivity (bhumim tadayantam), instability of mood (akasmat rudantam) and interpersonal relationships, and suicidal behavior. The affective symptoms in BPD involve rapid mood shifts (akasmat rudantam), in which emotional states tend to last only a few hours. Patients with BPD may show “micro psychotic” phenomena, auditory hallucinations, paranoid trends, and depersonalization states.[39] Aggressive behavior includes verbal and physical acts such as yelling, swearing, kicking, throwing, punching, hitting, and pushing (bhumim tadayantam). Temper outbursts, mood swings (akasmat rudantam), aggression, disruptive behaviors, rage attacks, anger, low frustration tolerance, and irritability are seen in TS-Plus patients (TS + ODD + ADHD + BD). Vishakha grahonmada resembles with TS-Plus or BPD or BD with psychosis.

Sangama grahonmada

Sangama grahonmada is a subtype of rakshasa grahonmada, and it is characterized by the features such as bhinna gadgada kantham (interrupted voice or stuttering or vocal tics), angani bhanjayantam (abnormal involuntary movements or motor tics), jihvam parilihanam (licking things with tongue), akshamalaya japamanam (doing meditation with string of beads in hands), and shoucham abheekshnam kurvanam (doing cleaning frequently).[3] “Shoucham abheekshnam kurvaanaam” represents washing or cleaning compulsions and “akshamaalaya japamaanam” represents religious obsessions or praying compulsions. Other symptoms such as abnormal body movements (angani bhanjayantam), speech disturbances (bhinna gadgada kantham) resemble TICS (abnormal involuntary movements) of various types. Sangama grahonmada has shown resemblance with comorbid conditions of TS and OCD.[1]

Vidyunmali grahonmada

Vidyunmali grahonmada is a subtype of rakshasa grahonmada and it is characterized by the features such as krudhyantam megha vidyut asate (becoming aggressive in the absence of clouds and lightening or abnormal or inappropriate behavior), jalavrishtim samantat (perceiving water and rain everywhere or delusions or altered perceptions), and shakata nishpiditam (feeling like squeezed by carriage or cart or altered kinesthetic perception or delusions).[3] Research in schizophrenia has emphasized deficits in higher cognitive functions including attention, executive function, as well as memory. In schizophrenia, the relationship between perceiving subject and world is radically altered. Disturbances of perception were reported for auditory, visual, and kinesthetic perception in schizophrenia. Both pervasive and subtle alterations of perception occur in schizophrenia and they are related to altered self-experience results in delusions or deficits in perceptual processing. Delusional interpretations of perception, hyperreflexivity, disrupted perceptual or automatic processing, disruption of perceptual organization, loss of common sense, perceptual fragmentation, perceptual processing deficits, disrupted self-experience, perceptual rigidity, delusions, etc., seen in schizophrenia[40] resemble with features of vidyunmali grahonmada.

Virupaksha grahonmada

Virupaksha grahonmada is a subtype of rakshasa grahonmada, and it is characterized by the features such as ama mamsa palala mulaka apupa paramaanna yachinam (begging for meat, paste of sesame seeds, and sweet dishes or craving for nonvegetarian and carbohydrate-rich foods), and ruksha cchavim (rough complexion).[3] Cravings toward nonvegetarian food items denote underlying deficiency of folic acid, essential amino acids, iron, proteins, vitamins, minerals, and various other micronutrients. The underlying anemia and nutritional deficiency in people with ASPD with substance abuse (alcohol abuse) may show cravings for nonvegetarian food items.[16] Changes in dietary and eating behavior are a common manifestation of frontotemporal dementia (FTD) such as altering their dietary preferences. FTD patients develop obsessions with particular foods. Semantic dementia patients are more likely to exhibit food fads or early changes in food preferences.[41] It seems that “ruksha cchavi” and “ama mamsa palala yachinam” of virupaksha grahonmada denotes craving toward particular food items (rich in proteins and carbohydrates) due to underlying nutritional deficiency (especially Vitamin B12) in various psychiatric conditions such as FTD, dementia, ASPD, psychosis, etc.

 Pishacha Vishesha Grahonmadas



Pishacha grahonmada is one among 18 types of grahonmadas. These features of pishacha grahonmada were found similar to FTD associated with malnutrition or Vitamin B12 deficiency.[20] Three subtypes of Pishacha grahonmada are explained (Kashmala, Kusha, and Nistejasa).[3]

Kashmala grahonmada

Kashmala grahonmada is a subtype of pishacha grahonmada, and it is characterized by the features such as bhojanam drushtva hasantam (smiling by seeing food or inappropriate behavior), visvaram kroshantam (crying or weeping with abnormal voice or mood lability), and nitya bheetam (frightened or paranoia?).[3] “Hasantam” and “Kroshantam” (inappropriate laughing or smiling and weeping) in a same patient indicate fluctuations of mood or lability of mood. “Nitya bheetam” denotes excessive fear which may be due to underlying paranoid delusions. The clinical picture of kashmala grahonmada denotes BD or schizophrenia or mood disorder with psychosis.

Kusha grahonmada

Kusha grahonmada is a subtype of pishacha grahonmada, and it is characterized by the features such as sarvagatrani spandayantam (abnormal involuntary movements of the body), muhurmuhu dhavantam (wandering or psychomotor agitation or hyperactivity), and bheeshayamana (frightening or threatening or aggressiveness).[3] Behavioral subtype of FTD, in which patient presents with behavior and personality changes including change of mood (bheeshayamana), motivation, and inhibition, with severe implications for social conduct. Restlessness, agitation, and compulsive behaviors (muhurmuhu dhavantam) were observed in FTD patients. Some patients of FTD are fatuous, purposelessly overactive, easily distracted, and lacking concern. Distractibility and purposeless over activity are associated with atrophy of the orbitomedial frontal lobes and temporal pole in FTD patients. Repetitive behaviors include simple repetitive acts and verbal or motor stereotypes such as lip smacking, hand rubbing or clapping, counting aloud, humming, counting, checking, cleaning, wandering, repetitive trips to the bathroom, collecting and hoarding objects, pathological gambling, and rituals involving touching, grabbing, and superstitious acts (sarvagatrani spandayantam). Euphoria, hypomania, emotional lability, childish excitement, and acquired extroversion can occur in FTD which mimics the BD.[20] Sarvagatrani spandayantam may also denote neuropsychiatric conditions such as PD, EPMD (extrapyramidal movement disorders), TS, TS-Plus, dementia, etc., Kusha grahonmada has shown resemblance with various conditions such as FTD, BD with psychosis, ADHD, EPMDs, TS, TS-Plus, PD, and dementia.

Nistejasa grahonmada

Nistejasa grahonmada is a subtype of pishacha grahonmada, and it is characterized by the features such as vaidyam drushtva kupyantam (becoming aggressive by seeing physician), bhramad bhojinam (eating food while moving around or restlessness or wandering), bahvashinam (hyperphagia), bhasmagunthana shayanam (sleeping on heap of sweepings), striyo margo rundhanam (obstructing women on the way or hyper sexuality), and mutra purisha vimardana (smearing urine and feces on body or unhygienic or inappropriate behaviour).[3] Bizarre alterations in dressing, personal neglect, disorganization, inappropriateness, and lack of insight (bhasmagunthana shayanam) are seen in FTD. Neglecting self-hygiene (mutra purisha vimardana) and collecting weird objects can be seen in behavioral variant of FTD. Features of “Negative symptoms of schizophrenia” such as decrease in self hygiene and lack of insight are seen in FTD also. Dietary changes are frequent and typically take the form of overeating (hyperorality) (bahvashinam) with a preference to sweet foods in FTD patients. Strange eating habits (bhramad bhojinam) are found in patients of FTD. Hypersexuality or disinhibition features such as making sexually inappropriate comments, public urinating, inappropriate touching, kissing, grabbing, public masturbation, and other hypersexual behaviors (striyo margo rundhanam) are also found in FTD patients. FTD patients display socially inappropriate behavior, poor insight, hallucinations, and paranoid delusions (vaidyam drushtva kupyantam).[20] It seems that nistejasa grahonmada denotes various conditions such as FTD and schizophrenia (hebephrenia or disorganized or catatonic types). Sixteen Vishesha grahonmadas have shown similarity with various psychiatric conditions [Table 1].{Table 1}

 Conclusion



Vishesha grahonmadas or Upa grahonmadas are subtypes explained under 18 major grahonmadas. Their description is available only in “Ashtanga sangraha.” The present article tries to illustrate some of the new evidence that can be derived from this fresh source (Vishesha grahonmadas). Description of 16 Vishesha grahonmadas is available in Ashtanga sangraha and they have shown resemblance with various psychiatric and neuropsychiatric conditions such as mood disorders, schizophrenia, frontotemporal dementia, Tourette's syndrome, extra pyramidal movement disorders, TLE, autism, personality disorders, PD, and attention-deficit/hyperactivity disorder. The contemporary perspective of ancient psychiatric concepts as demonstrated in the present article provides new insights and paves way further studies.

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Conflicts of interest

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