|Year : 2020 | Volume
| Issue : 2 | Page : 75-86
Vataja Unmada: Schizophrenia or Dementia or Mood Disorder with Psychosis?
Kshama Gupta, Prasad Mamidi
Department of Kaya Chikitsa, SKS Ayurvedic Medical College and Hospital, Mathura, Uttar Pradesh, India
|Date of Submission||15-Dec-2019|
|Date of Acceptance||14-Jul-2020|
|Date of Web Publication||21-Aug-2020|
Dr. Kshama Gupta
Department of Kaya Chikitsa, SKS Ayurvedic Medical College and Hospital, Mathura, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Unmada (a broad term which includes different psychiatric conditions under one umbrella) is characterized by the derangement of manas (mind), buddhi (cognitive functions), samgna gnana (orientation), smriti (memory), bhakti (interests), sheela (character/personality), cheshtha (psychomotor activity/behavior), and achara (conduct). Unmada is classified into five (vataja, pittaja, kaphaja, sannipataja and agantuja) types, and “Vataja Unmada” (VU) is one among them. The description of VU is available in all major Ayurvedic classical texts, and it comes under “Doshaja” (psychiatric disorder which occurs due to the aggravation of doshas) category. Studies or scientific literature on VU has been lacking, and the present work is focused on to explore this condition. The etiopathology of VU denotes deficiency of various nutritional factors such as vitamins, minerals, omega-3-fatty acids, amino acids, and antioxidants. Lacking or deficiency of these nutritional factors leads to structural and/or functional damage and degeneration of the brain (neurodegenerative or demyelinating pathology) which ultimately leads to the manifestation of different degenerative psychiatric disorders. The clinical picture of VU resembles various psychiatric or neuropsychiatric conditions such as “disorganized schizophrenia” or “hebephrenia” or “catatonia” or “dementia” or “bipolar disorder with psychotic features” or “mania with psychotic features,” or “organic or secondary psychoses.” VU is a treatable condition, and it can be managed successfully by “Panchakarma” procedures along with internal medicines.
Keywords: Catatonia, dementia, disorganized schizophrenia, organic psychosis, unmada, Vataja Unmada
|How to cite this article:|
Gupta K, Mamidi P. Vataja Unmada: Schizophrenia or Dementia or Mood Disorder with Psychosis?. Int J Yoga - Philosop Psychol Parapsychol 2020;8:75-86
|How to cite this URL:|
Gupta K, Mamidi P. Vataja Unmada: Schizophrenia or Dementia or Mood Disorder with Psychosis?. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2020 [cited 2022 May 23];8:75-86. Available from: https://www.ijoyppp.org/text.asp?2020/8/2/75/292941
| Introduction|| |
Ayurveda is an ancient medical science of India, which has stood the test of time for thousands of years. Ayurveda has eight branches or specialties; among them, “Bhuta vidya” or “Graha chikitsa” (Ayurvedic psychiatry) is one. Bhuta vidya deals with the etiology, pathogenesis, clinical features, and management of different psychiatric conditions. Unmada (a psychiatric disease) is a major disease or syndrome described in most of the classical texts of Ayurveda. Unmada is characterized by the derangement of manas (mind), buddhi (cognitive functions), samgna (consciousness), gnaana (perception), smriti (memory), bhakti (interests), sheela (character/personality), cheshta (psychomotor activity/behavior), and achaara (conduct).,,, “Acharya Charaka” has mentioned five types of unmada (vataja, pittaja, kaphaja, sannipataja, and agantuja),, whereas in “Sushruta samhita,” “Ashtanga samgraha,” “Ashtanga hridaya,” “Madhava nidana,” and “Bhava prakasha,” the description of six types of unmada (vataja, pittaja, kaphaja, sannipataja, vishaja, and aadhija/manodukhaja) is available [Table 1].
“Vataja Unmada” (VU) is one among the five or six types of unmada. The description of VU is available in all major classical Ayurvedic texts, and it comes under “doshaja” (psychiatric disorder which occurs due to the aggravation of doshas) category. The detailed description of nidana (etiology), samprapti (pathogenesis), lakshana (clinical features), chikitsa (management), and sadhyaasadhyata (prognosis) of VU is available in samhitas.,,,,,, A previous study has explored the similarity between “Kaphaja unmade” and “Myxedema psychosis.” 'Grahonmada/bhutonmada has been correlated with various psychiatric or neuropsychiatric conditions in previous works.,,,,,,,,,,,, Scientific literature on VU has been lacking, and the present study is focused to explore this condition. The present study has explored the similarities between VU and various neuropsychiatric conditions such as “disorganized schizophrenia” or “hebephrenia” or “catatonia” or “dementia” or “bipolar disorder with psychotic features” or “mania with psychotic features.”
|Table 1: Classification of Unmada according to different Ayurvedic classical texts|
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| Review Methodology|| |
Ayurvedic literature regarding “VU” has been collected from major Ayurvedic texts (Charaka samhita, Sushruta samhita, Ashtanga sangraha, Ashtanga hridaya, Madhava nidaana, and Bhava prakasha) including their commentaries. Electronic databases “Google search” and “Google Scholar search” have been searched to find out the relevant studies and reviews published till December 2019, irrespective of their appearance/publication year. The keywords used for searching were, “VU,” “Unmada,” “Bhutonmada,” “Grahonmada,” “Schizophrenia,” “Hebephrenia,” “Disorganized schizophrenia,” “Catatonic schizophrenia,” “Catatonia,” “Demenita,” “Mood disorders with psychosis,” “Bipolar disorder with psychosis,” “Bipolar psychosis,” “Organic psychosis,” “Mania with psychotic features,” “Neurodegenrative psychiatric disorders,” “Demyelinating psychiatric disorders,” “Nutritional neuroscience,” “Grave's ophthalmopathy,” “Cyclothymia,” “Frontotemporal dementia,” and “Secondary psychosis.” Abstracts and full-text, open-access articles in English language were only considered. Relevant Ayurvedic material collected from the textbooks available at “SKS group of institutions library“ has been referred.
Ayurveda has proposed three doshas (patho-physiological entities), as the basis of all bodily functions and also for the manifestation of diseases. The three doshas are termed as Vata, Pitta, and Kapha. Vata is a physiological entity which regulates the functions of nervous and musculoskeletal system. Vata dosha controls and stimulates the mind, and it is responsible for enthusiasm or motivation. Vata, which restrains and impels different mental activities, is responsible for the functional format of the mind. Vata is capable of moving swiftly throughout the body. Vata is powerful, capable of vitiating all other factors, has independent movement, and its vitiation causes large number of diseases. VU is mentioned and described in all major Ayurvedic texts, and it is classified under “doshaja unmade” (psychiatric disorder which occurs due to the aggravation of patho-physiological entities).
Vataja Unmada Nidana and concepts of “nutritional neuroscience”
According to Charaka samhita (an ayurvedic textbook of medicine written by Agnivesha), various etiological factors such as excessive intake of foods which are ruksha (fat-free diet), alpa (low portion size or serving size of food/low calorie diet), sheeta (cold food) in nature, improper or excessive use of procedures such as therapeutic emesis and purgation, depletion of body tissues, excessive fasting, etc., cause accumulation and aggravation of “vata dosha.” The aggravated vata spreads and afflicts the heart of a person who has excessive psychological stress and produces unmada by deranging buddhi (cognitive functions or higher mental functions), and smriti (memory). Aggravated doshas spreads upwards and occupies the channels of the upper parts of the body (head or heart) and produce unmada. There is no specific etiology mentioned for VU in Sushruta samhita (an ayurvedic textbook of surgery written by Sushruta). Other texts also have expressed similar views.,,, Various etiological factors explained above in the context of VU denote “Nutritional deficiency.”
”Nutritional neuroscience” is an emerging discipline exploring the fact that nutritional factors are intertwined with human cognition, behavior, and emotions. Current research in “Psychoneuroimmunology” and brain biochemistry indicates that there is an association between nutritional intake, central nervous system (CNS), and immune function, which can influence an individual's psychological health status. It has been observed that, nutrient composition of diet and meal pattern can have beneficial or adverse, immediate, or long-term effects on mental health. The most common nutritional deficiencies (alpa diet) found in patients with mental disorders are of omega-3 fatty acids, B vitamins, minerals, and amino acids (which are precursors to neurotransmitters). Dietary intake and nutritional status of individuals are important factors affecting mental health and the development of various psychiatric disorders. Nutritional components which may be beneficial for mental health are omega-3 fatty acids or polyunsaturated fatty acids, phospholipids, cholesterol, niacin, folate, Vitamin B6, Vitamin B12, antioxidants, and Vitamin D. Nutritional supplement treatment may be appropriate for controlling major depression, bipolar disorder, schizophrenia, anxiety disorders, eating disorders, attention-deficit/hyperactivity disorder (ADHD), addiction, and autism.
Protein intake/individual amino acids can affect the functioning of brain and mental health. The neurotransmitter dopamine is made from the amino acid tyrosine, and the neurotransmitter serotonin is made from the tryptophan. If there is a lack of any of these two amino acids, there will not be enough production of respective neurotransmitters, which is associated with low mood and aggression. Taurine is an amino acid made in the liver from cysteine which plays a role in the brain by eliciting a calming effect. A deficiency of this amino acid may increase manic episodes in bipolar patients. Disturbances in amino acid metabolism have been implicated in the pathophysiology of schizophrenia. The brain is one of the organs with the highest level of lipids (fats). Brain lipids, composed of fatty acids, are structural constituents of membranes. It is evident that gray matter contains 50% fatty acids that are polyunsaturated in nature, and hence are supplied through diet (ruksha diet). Dieting behaviors (upavasa) have been associated with alterations in moods. Dietary omega-3 fatty acids play a role in the prevention of some disorders. Their deficiency (due to ruksha diet) can accelerate cerebral aging by preventing the renewal of membranes.
Around 8% of individuals having bipolar illness have Vitamin B deficiency. Thiamine modulates cognitive performance and its deficiency is linked with poor mood. Severe B1 deficiency can lead to beriberi, Wernicke's encephalopathy (confusion, ataxia, and nystagmus), and Korsakoff's psychosis (confabulation, lack of insight, amnesia, and apathy). Niacin deficiency can cause behavioral deterioration and dementia. Vitamin B12 delays the onset of signs of dementia. B12 deficiency can cause depression, irritability, agitation, psychosis, and obsessive symptoms. Folate deficiency is common in mood disorder patients. Folate deficiency can lead to psychiatric disorders including schizophrenia, depression, and organic psychosis, Alzheimer's disease and other types of dementia. Patients with schizophrenia have decreased vitamin C levels and dysfunction of antioxidant defenses. Increasing evidence reveals Vitamin D's role in brain function and development. Vitamin E protects neuronal membranes from oxidation; low levels may affect the brain via increased inflammation. Low plasma Vitamin E levels are found in depressed patients. Antioxidant vitamins (A, C, and E) are protective against cognitive decline and mental disorders including anxiety disorders, ADHD, autism, bipolar disorder, depression, schizophrenia, and substance abuse.
Micronutrient (e.g., iron, magnesium, and zinc) intake has been linked to structural as well as functional development of brain. Iodine plays an important role in mental health. The iodine provided by the thyroid hormone ensures the energy metabolism of the cerebral cells. Iron is essential for oxygenation and to produce energy in the cerebral parenchyma, and for the synthesis of neurotransmitters and myelin. Iron deficiency is found in children with ADHD. Selenium improves mood and diminishes anxiety. Zinc protects the brain cells against the potential damage caused by free radicals. Magnesium and zinc are beneficial in improving attention, executive functions, behavioral, and emotional problems. Low zinc levels are correlated with inattention in ADHD children. Dietary deficiencies of antioxidants and nutrients during aging may precipitate brain diseases. The brain is vulnerable to oxidative stress and tight balance between oxidative stress and antioxidant system is required to maintain the structural integrity and optimal functions of brain. By considering the above facts, it is evident that various etiological factors mentioned in VU nidana leads to deficiency states of essential nutrients which further can lead to the manifestation of different psychiatric conditions.
| Signs and Symptoms of Vataja Unmada|| |
The signs and symptoms of VU according to Charaka samhita are “Parisaranam ajasram” (roaming purposelessly), “Anga vikshepanam akasmat” (abnormal involuntary movements), “Satata and aniyata giraamutsarga” (abnormal or incoherent speech/pressure of speech), “Phenaagamana asya” (drooling of saliva), “Abheekshnam asthaane smita, hasita, nrutya, geeta and vaditra” (inappropriate behaviors like untimely and out of context smiling, laughing, dancing, singing and playing musical instruments), “Shabdanukarana” (echolalia), “Yanamayanai” (using inappropriate things as a vehicle for transport), “alankaranam analankarikai dravyai” (abnormal dressing or makeup), “Lobhashcha alabdheshu and labdheshu avamana” (greediness toward unavailable things and dishonoring available ones), “Karshyam” (thinness or emaciation), “Parushyam” (roughness), “Utpindita aruna akshata” (swelled and reddish eyes), “Matsaryam” (excessive envy), “Rodana” (crying or weeping), and “Jeerne balam” (aggravation after digestion)., According to Sushruta samhita, “Ruksha cchhavi” (rough body complexion), “Parusha vaak” (harsh speech), “Dhamani tata” (prominent veins), “Sheetatura” (intolerance to cold/hypothermia), “Krusha tanu” (emaciated body), “Sphurati anga sandhi” (trembling or twitching of body parts), “Asphotayati” (abnormal sounds coming from body parts), “Atati” (wandering), “Gaayati and nrutyasheela” (indulged in singing and dancing), “Vikroshati” (insulting or criticizing or abusing), and “Bhramati” (psychomotor agitation or wandering) are the signs and symptoms of VU [Table 2]. The signs and symptoms explained in other Ayurvedic texts are similar to the description of Charaka and Sushruta samhitas'.,,, “Bahu bhashita” (excessive and abnormal speech) is explained as one of the feature of VU in “Ashtanga hrudaya” [Table 2].
|Table 2: Vataja unmada lakshana's according to various Ayurvedic classical texts|
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Signs and symptoms of VU can be divided into two groups based on their nature (psychological or physiological). Parisaranam ajasram or Bhramati or Atati, Satata and aniyata giramutsarga or Bahu bhashita, Abheekshnam asthaane smita, hasita, nrutya, geeta and vaditra or Gaayati and nrutyasheela, Shabdanukarana, Yanamayanai and alankaranam analankarikai dravyai, Lobhashcha alabdheshu and labdheshu avamana, Matsaryam, Rodana or Vikroshati, Parusha vaak, and Buddhi and smriti upahati (decline of cognitive function and memory), etc., comes under the category of “Psychological signs and symptoms” whereas features such as Anga vikshepanam akasmat, Phenaagamana asya, Karshya or krisha tanu, Parushyam, Utpindita and aruna akshata, Ruksha cchhavi, Dhamani tata, Sheetatura, Sphurati anga sandhi, Asphotayati, and Jeerne balam etc., comes under “Physiological signs and symptoms” of VU. Both psychological and physiological signs and symptoms of VU and their similarity with various neuropsychiatric conditions have been explored in the following sections [Table 3].
|Table 3: Similarity between “Vataja unmade” and various “Neuropsychiatric conditions”|
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Psychological signs and symptoms of Vataja Unmada
Parisaranam ajasram/Bhramati/Atati (wandering/pacing/psychomotor agitation)
In Charaka samhita, “parisaranam ajasram” word has been mentioned as one of the VU lakshana. Parisaranam ajasram means “roaming or wandering frequently.”, The word, “Bhramati” is used by “Acharya Sushruta” and “Vriddha Vagbhata” (author of “Ashtanga samgraha”) has used “paryatanam ajasram.” “Parisarnam ajasram” or “paryatanam ajasram” or “bhramati,” etc., words denote purposeless movements or wandering or pacing or rummaging or psychomotor agitation seen in various psychiatric or neuropsychiatric conditions. Psychomotor agitation is characteristic of catatonia and catatonic schizophrenia. Catatonia is a syndrome of motor dysregulation associated with a variety of illnesses. Etymology aside, the hallmark of the syndrome catatonia is stupor accompanied by psychomotor disturbances. Agitation is one of the symptom among 12 mentioned in the diagnostic criteria for Catatonia. Catatonic patients may show excitation and purposeless activity. Excited catatonia is characterized by purposeless behavior. Excessive movement is associated with violent behavior directed toward oneself or others in catatonia. Catatonia is essentially a movement disorder similar to Parkinsonism More Details. The clinical features of catatonia overlap with those of Parkinsonism, which is understood to be caused by dysfunction of the basal ganglia. The syndrome of catatonia encompasses a wide range of psychomotor abnormalities.
Disorganized behavior is seen in hebephrenia and also frontotemporal dementia (FTD). Behavioral and psychological symptoms of dementia (BPSD) are complications of dementia. The most common features of BPSD are agitation, apathy, aggression, psychosis, hallucinations, and delusions. Wandering, hoarding, inappropriate behaviors, repetitive behavior and restlessness, etc., are also the features of dementia. Wandering, repetitive mannerisms, and activities are also seen in Alzheimer's dementia (AD). PMA (Psychomotor agitation) is a pathological condition characterized by a significant increase in ideational, emotional, motor, and behavioral activity associated with a variety of psychiatric and medical illnesses. Agitation generally entails the presence of “exceeding restlessness associated with mental distress” and “excessive motor activity associated with a feeling of inner tension”. Abnormal and excessive verbal, physically aggressive, and purposeless motor behaviors, heightened arousal, and significantly impaired patient functioning are the key features of agitation. The main psychiatric causes of agitation include psychotic disorders, mania, agitated depression, and anxiety disorders. In patients with bipolar disorder, agitation is often the main clinical manifestation during manic and mixed states.
Satata and aniyata giramutsarga/Bahubhashita (incoherent or irrelevant speech/pressure of speech)
“Satatam aniyatanam giramutsarga” is mentioned as one of the VU lakshana in Charaka samhita which means “always speaking incoherently or excessively or irrelevantly.” “Bahu bhashita” is mentioned in “Ashtanga hrudaya” which means “excessive speech” or “pressure of speech.” Speech abnormalities are found in various psychiatric conditions. Echolalia (unsolicited repetition of vocalizations made by another person), mutism (absence of speech), and abnormal speech patterns are seen in catatonia. A case report of catatonic patient has revealed that the patient had repeated unintelligible words and phrases for hours continuously and yelled “peanut butter, ice cream, peanut butter, ice cream” for several hours. Semantic and language alterations are found in disexecutive syndrome. In FTD, behavioral and language alterations are found. Incoherent, uninhibited and confabulatory language is strongly linked to the speech of hebephrenics. Primary progressive aphasia patients come with speech and language problems. Language problems may include difficulty in producing speech or losing the meaning of words and concepts (semantic dementia). Language problems seen in FTD variant like primary progressive aphasia and semantic dementia. Continuous flow of accelerated speech with abrupt changes from topic to topic is seen in mania. Speech is rapid, verbose, and circumstantial (including minute and unnecessary details). In severe conditions, speech may become disorganized and incoherent. The incessant talking often includes joking, puns, and teasing. The content of speech ranges from grossly inappropriate to vulgar. As mania escalates, flight of ideas may give way to clang associations. Flight of ideas and pressure of speech are characteristic of mania.
Abheekshnam asthaane smita, hasita, nrutya, geeta and vaditra/Gaayati and nrutyasheela/Yanamayanai/alankaranam analankarikai dravyai/Lobhashcha alabdheshu and labdheshu avamana (inappropriate or disorganized behavior)
“Abheekshnam asthaane smita, hasita, nrutya, geeta and vaditra” means “smiling, laughing, dancing, singing and playing musical instruments frequently at inappropriate places” is explained as VU lakshana in Charaka samhita. Whereas in Sushruta samhita, “gaayati and nrutyasheela” is mentioned as VU lakshana which means “a person always indulged in singing and dancing.” “Yanamayanai” (using inappropriate things as a vehicle for transport), “alankaranam analankarikai dravyai” (abnormal dressing or makeup), “Lobhashcha alabdheshu and labdheshu avamana” (greediness toward unavailable things and dishonouring available ones), etc., are also explained as lakshana's of VU in Charaka samhita. All these features denote various inappropriate or irrelevant behaviors commonly seen in psychotic conditions. Inappropriate dressing is found in the patients of mania. The overly joyous mood during manic episode may seem out of proportion to what is going on, and cheerfulness may be inappropriate for the circumstances. People experiencing a manic state may laugh, joke, and talk in a continuous stream, with uninhibited familiarity. Dress in manic patients may be described as outlandish, bizarre, colorful, and noticeably inappropriate. Makeup during manic episodes may be garish and overdone. Excited catatonia is characterized by purposeless behavior. Disorganized behavior is the common feature of Hebephrenia. Personality changes and behavioral disturbances are key features of FTD and occur early in the disease. Behavioral difficulties including reduced insight, reduced attention to personal care, disinhibition, and inappropriate behavior are prominent in behavioral variant FTD.
“Veena vamsha shankha shamya and taala shabdanukaranam” which means “imitating the sounds of various musical instruments like flute, lute, and conch etc., in an irrelevant way or abnormally” is explained as one of the feature of VU in Charaka samhita. In echolalia, patients just repeat what they hear and echopraxia they mimic the activities of examiner-movements are often awkward, wooden and bizarre. Verbigeration or senseless repetition of words or phrases is also found in catatonia. Disorganized behavior is one of the characteristic features of Hebephrenia. Patients with AD show behavioral symptoms such as physical and verbal aggression, motor hyperactivity, uncooperativeness, wandering, repetitive mannerisms and activities and combativeness. Personality changes and behavioral difficulties may develop as the dementia progresses. Thus irrelevant or inappropriate use or mimicking of musical sounds or instruments explained as one of the features of VU denotes disorganized or inappropriate behavioral patterns commonly seen in schizophrenia, mania, dementia and catatonia.
Matsaryam (excessive envy)
“Teevra matsaryam” means severe envy or jealousy or extreme displeasure and it is explained in Charaka samhita and Ashtanga samgraha. Negativism is one of the features of catatonia. Schizophrenia is a disabling disorder involving several brain areas and mental functions such as thought, mood, perception, and cognition. Patients with AD may also present behavioral symptoms such as physical and verbal aggression, uncooperativeness, and combativeness. In dementia, impairment of several higher cortical functions, which include memory, thinking, comprehension, calculation, learning, language, and judgment. These impairments are often seen alongside changes in emotional control, social behavior or motivation. Late phase of dementia is characterized by behavioral changes such as aggressiveness, anger, agitation, aggression, anxiety, apathy, impulsivity, irritability; and psychosis. It seems that “Matsaryam” mentioned in VU denotes negativism, aggression, uncooperativeness, anger, irritability, personality, mood and behavioral changes, and poor emotional control, etc., seen in catatonia, mania, schizophrenia and different types of dementia.
Rodana/Vikroshati/Parusha vaak (crying/weeping/abusing/harsh speech)
“Rodana” (crying or weeping) is mentioned as VU lakshana in Charaka samhita. “Vikroshati” (weeping or crying) is mentioned in Sushruta samhita whereas “Kroshana” and “Akroshana” (weeping or abusing) are mentioned in Ashtanga samgraha and Ashtanga hrudaya respectively. “Parusha vaak” is the word used by Acharya Sushruta (author of an Ayurvedic surgical text “Sushruta samhita”) which means harsh speech or verbal abuse. Dysregulation of mood is one of the features of catatonia. More than half of catatonic patients have manic depressive illness. Catatonia is more frequently associated with mania, melancholia and psychotic depression. Flat or inappropriate affect is one of the features of Hebephrenia. Crying, depression, and apathy are also the features of BPSD. In FTD, depressive symptoms such as early episodic lability, sadness, anhedonia, loss of interest, and social withdrawal are commonly found. “Parusha vaak” denotes verbal abuse or verbal aggression. Prominent impulsive behavior or frivolousness can be found in FTD patients. FTD patients have disturbed social and moral behaviors such as social inadequacy or awkwardness, tactlessness, disagreeableness, decreased manners, improper verbal or physical acts. “Rodana,” “Akroshati” and “Vikroshati” of VU denote depressive episodes seen in Bipolar disorder; dysregulation of mood in catatonia; inappropriate affect of Hebephrenia and also BPSD. “Parusha vaak” denote irritability, aggressiveness, agitation, personality and behavioral changes found in dementia, excited catatonia, mania and FTD.
Buddhi and Smriti upahata (decline of cognitive functions and memory)
“Buddhi upahata” (declined or deranged or disturbed cognitive functions) and “Smriti upahata” (memory loss or impairment) is explained in the pathogenesis of VU in Charaka samhita alone. The characteristic symptoms of Schizophrenia involve a range of cognitive dysfunctions that include perception, inferential thinking, language and communication, behavioral monitoring, affect, fluency and productivity of thought and speech, hedonic capacity and attention. Disorganized thinking is the single most important feature of Schizophrenia. “Buddhi upahata” especially resembles with “disorganized thinking” “cognitive dysfunctions” found in different types of Schizophrenia (paranoid, disorganized, catatonic, undifferentiated and residual). The essential feature of a dementia is the development multiple cognitive deficits that include memory impairment, cognitive disturbance like aphasia, apraxia and agnosis, and disturbance in executive functioning. Memory impairment is required to make the diagnosis of a dementia and is a prominent early symptom. “Smriti uapahata” especially denotes “memory impairment” seen in dementia. Thus buddhi and smriti upahata explained in the pathogenesis of VU denotes cognitive and memory impairments seen in Schizophrenia and dementia.
Physiological signs and symptoms of Vataja Unmada
Anga vikshepanam akasmat/Sphurati anga sandhi/Asphotayati (abnormal involuntary movements)
“Anga vikshepanam akasmat” is mentioned as one of the features of VU in Charaka samhita. It denotes sudden, abnormal involuntary movements of the body parts like eyes, eyebrows, lips, scapular region, jaw, shoulders, hands and feet. In Ashtanga samgraha and Ashtanga hrudaya, “Anga vikshpeana” and “Asphotana” words are used with similar meaning (various abnormal involuntary body movements with sounds). “Sphurati anga sandhi” is mentioned as one of the features of VU in Sushruta samhita which means trembling or twitching of body parts. The control of voluntary movement is due to the interaction of the pyramidal, cerebellar and extra pyramidal systems. The effects of disease of the extra pyramidal system on movement can be regards as negative (hypokinetic) and positive (hyperkinetic). Parkinson's disease (PD), Huntington's disease (HD), dystonias, Wilson's disease (WD) and various other psychiatric/neuropsychiatric conditions comes under the category of Extra pyramidal movement disorders (EPMD). Tremors, chorea (irregular, repetitive, jerking movements), athetosis (irregular, repetitive, writhing movements), dystonia (slow, sustained, abnormal movements), ballismus (explosive, violent movements), myoclonus (shock-like jerks) are the involuntary abnormal movements observed in various EPMD (Lindsay). EPMDs are common in psychiatric patients, and psychiatric syndromes are quite common in patients with EPMDs (Sanders). Tourette syndrome (TS) is one of the common causes of motor and phonic tics. Tremor, dystonia, chorea, and myoclonus are dyskinesias recognized to reflect various neurological diseases. Tics and stereotypies are distinct motor behaviors seen commonly in neuropsychiatric practice and are frequent in movement disorder clinics.
The main symptoms of catatonia are a change in motor activity (reduced and increased motor activity), unusual movements (stereotypies, grimacing, freezing, ambitendency, infrequent blinking, motor or vocal tics, posturing, and automatic obedience). Motor disturbances were prominent and impairing. Hyperkinetic or excited type catatonia is characterized by agitation, combativeness, disorganized over productive speech (verbigeration), stereotypies, grimacing and echophenomena. Patients with catatonia during the periods of agitation show autonomic instability, extreme hyperactivity with constant motor unrest and purposeless motor activity, and may eventually collapse from exhaustion. Stereotypy is a common movement disorder seen in catatonia characterized by involuntary, coordinated, patterned, rhythmic, seemingly purposeless movement or utterance performed repeatedly over time. Some of the motor stereotypies seen in catatonia include body rocking, shoulder shrugging, hand waving, opening eyes wide and then squeezing them shut, wrinkling of nose, and repetitive mouth and jaw movements. Mannerisms is another observed clinical feature which is characterized by repetitive, idiosyncratic movements or gestures that are unique to the individual such as using hands when talking. Repetitive behaviors, restlessness and agitation are found in dementia. Patients with AD may also show motor hyperactivity, uncooperativeness, wandering, repetitive mannerisms and activities and combativeness. In all types of dementia, BPSD almost always occur such as: abnormal motor behavior, agitation, disinhibition, impulsivity and irritability.
/Krisha tanu/Dhamani tata/Parushyam/Ruksha cchhavi (thinness/features of nutritional deficiencies)
Karshya (thinness/emaciation) is mentioned in Charaka samhita whereas Sushruta has used the word “Krisha tanu” with similar meaning. “Ruksha cchhavi” (rough complexion) and “Dhamani tata” (appearance of veins prominently over body parts) are also mentioned in Sushruta samhita which denotes emaciation or thinness or weight loss. In Charaka samhita “Parushya” (roughness) is mentioned as one of the features of VU. All these features denote roughness of skin and thinness of body or weight loss due to nutritional deficiency or underlying disease. Patients with AD have been identified as being at particularly high risk for PEM (Protein energy malnutrition). Weight loss in dementia patients is due to inadequate dietary intake, increased energy expenditure and dementia-related metabolic disturbances. Low BMI (Body mass index) was found in half of patients with cognitive dysfunction dementia patients. Patients with dementia have a tendency for macro and micronutrient deficiencies. Vitamin B12 is important in terms of mental functionality. Brains of patients with dementia revealed tissue deficiency of vitamin B12, demyelination, neuronal loss, and atrophy. Hyper homocysteinemia and folate deficiency are related to dementia and AD. Deficiency of various essential nutrients and their role in causing various neurodegenerative/demyelinating diseases has been explored in “VU Nidana” section. Karshya, Krisha tanu, Dhamani tata, Parushyam, and Ruksha cchhavi denotes weight loss, degeneration, emaciation, etc., caused by the deficiency of various nutritional factors.
Phenaagamana asya (drooling of saliva)
This feature of VU is explained in Charaka samhita,Ashtanga samgraha and Ashtanga hrudaya. Drooling of saliva occurs in many neurological and neuromuscular diseases such as myasthenia gravis, amyotrophic lateral sclerosis (ALS) and oculo-pharyngeal muscular dystrophy, neurodegenerative diseases such as PD, multiple system atrophy, progressive supra nuclear palsy (PSP), dementia with Lewy bodies (DLB) and corticobasal degeneration (CBD), and cerebrovascular diseases. WD is the most common treatable movement disorder. In WD along with dystonia other features such as dysarthria, drooling of saliva, parkinsonian features, abnormal gait, abnormal behavior, tremors, and declining school performance are also found. Excessive discharge of saliva may occur due to inflammation or infection in oral cavity (due to poor oral hygiene in psychosis), decreased metabolism in hypothyroidism or in myxoedema patients. It seems that “Phenaagamana asya” of VU denotes some underlying neurodegenerative disease or poor oral hygiene in psychotic conditions.
Utpindita and aruna akshata (swelled and reddish eyes)
“Utpindita aruna akshata” is mentioned as one of the features of VU in all classical Ayurvedic texts,,,,, except Sushruta samhita. “Utpindita” word denotes “swelled” or “protruding eyes” and “aruna akshata” denotes redness of eyes. Dry sclera with ulceration and infection can be seen in “Immobile catatonics.” Graves' ophthalmopathy is linked to Graves' hyperthyroidism. Eyelid retraction, proptosis, periorbital edema, chemosis and disturbances of ocular motility can be seen in Graves' ophthalmopathy. Decreased need for sleep and/or sleep disturbances is one of the diagnostic criteria of bipolar mania. Droopy or hanging eyelids, red eyes, dark circles under the eyes, and pale skin are indicative of both sleep deprivation and fatigue. Reddish eyes may denote sleep deprivation commonly found in Bipolar disorders. Red eyes and abnormal eye movements are found in various EPMDs. Congested, red eyes with itching in both eyes can be seen in WD patients. Characteristic copper-colored Kayser–Fleischer (K-F) rings in both eyes has been found in a case of WD. WD has been evidenced to cause the development of K-F ring and sunflower cataract. Virtually all patients with K-F rings have neurologic manifestations. It seems that swollen and reddish eyes can be seen in Bipolar disorders, WD, and Graves' ophthalmopathy.
Sheetatura (cold intolerance or low body temperature)
“Sheetatura or Shwaasatura” is mentioned in Sushruta samhita alone. “Sheetatura” denotes cold intolerance or low body temperature whereas “Shwaasatura” means dyspnoea. Thermoregulation is a vital function of the autonomic nervous system in response to cold and heat stress. Hypothermia is defined as a core temperature of <35.0°C. The risk of hypothermia is greater in those who are malnourished, alcoholic, mentally ill, sepsis, in shock, or whose mobility is limited by disability or injury, if they are less able to generate heat from muscle contraction or actively seek shelter. Any disorder that restricts mobility, such as PD, stroke, myopathy etc., may limit the ability to generate heat by muscle contraction or may delay efforts to reach shelter in cold weather. Hypothermia has been described in the context of hypothalamic demyelination in multiple sclerosis. The risk of hypothermia is greater in those with dementia or who have consumed alcohol. Malnutrition, hypothyroidism, neurological disorders which impair judgment, dementia, schizophrenia, disorders which impair motility, PD, ALS, Wernicke encephalopathy, and multiple sclerosis etc., comes under “disorders of the response to cold” or “cold-related illness.”Sheetatura of VU denotes hypothermia which can be seen in various neurological and psychiatric conditions as mentioned above.
Jeerne balam (aggravation after digestion)
“Jeerne balam” is mentioned as VU lakshana in all classical Ayurvedic texts,,,,, except Sushruta samhita. “Jeerne balam” denotes aggravation of the signs and symptoms of VU after digestion of the food. According to a study, patients with idiopathic PD (IPD) have shown abnormal postprandial cardiovascular responses (postprandial hypotension) and aggravation of the parkinsonian state after ingestion of a meal. Marked worsening of the parkinsonian state (tremor, rigidity, bradykinesia, posture, and gait) was found in patients of IPD after intake of meals. In hypothyroidism/myxoedema patients, after meals, due to extra load on metabolism the symptoms may get aggravated.
A wide range of neuropsychiatric symptoms are now recognized to be associated with neurodegenerative disorders (NDs), with many patients suffering from more than one of these during the course of their illness. The symptoms vary from agitation, irritability, and impulsivity through to apathy and indifference, from depression to euphoria, from delusions and hallucinations to anxiety and sleep disturbance, from loss of empathy and socially inappropriate behavior through to changes in eating behavior and stereotyped behaviors such as pacing, wandering and rummaging. These neuropsychiatric changes cut across diseases. They occur frequently in AD, small vessel cerebrovascular disease, PD and LBD, FTD and a host of other conditions including HD, PSP and CBD (Husain M). Disorders that are associated with atrophy of the CNS structures are termed NDs. The term NDs, encompasses a variety of underlying conditions, sporadic and/or familial and are characterized by the persistent loss of neuronal subtypes. These disorders can disrupt molecular pathways, synapses, neuronal subpopulations and local circuits in specific brain regions, as well as higher-order neural networks. By considering all the above facts, it seems that VU lakshanas (including both psychological and physiological) denotes “Neuropsychiatric symptoms in NDs.” Clinical picture of VU has shown similarity with various conditions such as “Catatonia,” “Hebephrenia or Disorganized schizophrenia,” Mood or Bipolar disorder with psychotic features,” “Neuropsychiatric symptoms in NDs,” “Organic or secondary psychosis” and “Thyroid-associated psychosis [Table 3].
| Management of Vataja Unmada|| |
Ayurveda has described three treatment modalities to manage unmada, “Daiva vyapashraya chikitsa” (spiritual/divine therapy), “Sattvavajaya chikitsa” (Ayurvedic psychotherapy) and “Yukti vyapashraya chikitsa” (rational use of drugs, diet, and activities). Yukti vyapashraya chikitsa deals with samshodhana (body cleansing procedures like panchakarma) and samshamana (pacifying doshas by internal medicines, diet and/or activities). Snehana (oleation), swedana (sudation) followed by evacuation procedures such as vamana (therapeutic emesis) and virechana (therapeutic purgation). For the management of VU, “Snehapana” (intake of medicated ghee or oils), “Mrudu shodhana” (mild cleansing procedures), “Niruha and/or sneha vasti” (decoction or oil enemas), “Shiro virechana” (nasal administration of medications), “Dhooma” (fumigations), “Abhyanga” (massage with oils), “Utsaadana” (powder massage), and “Sarpi paana” (intake of ghee) procedures are mentioned. Medicated ghee formulations like Kalyanaka ghrita, Maha kalyanaka ghrita, Maha paishachika ghrita, Lashunadi ghrita and Hingvadi ghrita etc., also can be used to manage VU.Acharya Sushruta has also described similar treatment for VU. VU is a treatable condition and Ayurvedic texts recommend “Snehapana” as an important treatment for VU. It seems that the procedures and medications mentioned to manage VU prevents or cures degeneration or demyelination in CNS structures.
| Conclusion|| |
VU is described in all Ayurvedic classical texts. The etiology of VU denotes deficiency of various nutritional factors, which are essential for the structural and functional integrity of brain. Pathogenesis of VU denotes atrophy or degeneration or demyelination processes in brain which leads to the disturbances of various cognitive and/or higher mental functions. Signs and symptoms of VU can be classified in to two groups, psychological and physiological. The whole clinical picture of VU resemble with various “Neurodegenerative neuropsychiatric disorders” such as AD, small-vessel cerebrovascular disease, Parkinson's disease, DLB, FTD, WD, Extrapyramidal movement disorders, HD, Progressive supranuclear palsy, CBD, Mutiple sclerosis, Myasthenia gravis and ALS etc., VU lakshana's have shown similarity with Catatonia, Hebephrenia or Disorganized schizophrenia, Mood or Bipolar disorder with psychotic features, Organic or secondary psychosis and Thyroid-associated psychosis etc., conditions also. VU is a treatable condition and “Snehapana” (intake of medicated oils or ghee) is one of the important procedures mentioned in the management.
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| References|| |
Mamidi P, Gupta K. Obsessive compulsive disorder – 'Sangama graha': An ayurvedic view. J Pharm Sci Innov 2015;4:156-64.
Gupta K, Mamidi P. Ayurvedic management of schizophrenia: Report of two cases. J Pharm Sci Innov 2016;7:41-4.
Gupta K, Mamidi P. Paryakula drishti of Unmada: Deficits of smooth pursuit eye movements and anti-saccades in schizophrenia. Int J Yoga Philosop Psychol Parapsychol 2016;4:30-5.
Gupta K, Mamidi P. Kaphaja unmada: Myxedema psychosis? Int J Yoga Philosop Psychol Parapsychol 2015;3:31-9.
Acharya JT, editor. Agnivesha, Elaborated by Charaka and Dridhabala, Commentary by Chakrapani. In: Charaka Samhita, Nidana Sthana, Unmada Nidanam Adhyaya, 7, 6-1. Varanasi: Chaukhamba Surbharati Prakashan; 2014. p. 223.
Acharya JT, editor. Agnivesha, elaborated by Charaka and Dridhabala, commentary by Chakrapani. Charaka Samhita, Chikitsa Sthana, Unmada Chikitsitam Adhyaya, 9/8-10. Varanasi: Chaukhamba Surbharati Prakashan; 2014. p. 468.
Acharya JT, Acharya NR, editor. Sushruta. Sushruta Samhita, Commentary by Dalhana. Uttara tantra, Unmada pratishedha adhyaya, 62/8. Varanasi: Chaukhamba Orientalia; 2018. p. 803.
Gupta A. Vriddha Vagbhata. Ashtanga Samgraha, Commentary by Indu, Uttara tantra, Unmada Pratishedha Adhyaya, 9/8. 1st
ed. Varanasi: Chowkhamba Krishnadas Academy; 2016. p. 220.
Paradkara H. Vagbhata. Ashtanga Hridaya, Commentary by Arunadatta and Hemadri, Uttara tantra, Unmada pratishedham adhyaya, 6/6-9. 1st
ed. Varanasi: Chowkhamba Surbharati Prakashan; 2010. p. 498.
Tripathi B. Madhavakara. Rogavinischaya Madhava Nidana, Unmada Nidana, 20/7-9. Commentary 'Madhukosha' by Vijayarakshita & Shrikanthadatta. 1st
ed. Varanasi: Chaukhamba Surbharati Prakashan; 2014. p. 381-2.
Bhavamishra. Bhavaprakasha-Madhyama khanda, Unmadadhikara, 22/7-8. 1st
ed. Vol 2. Edited and English translation by Bulusu Sitaram. Varanasi: Choukhamba Orientalia; 2010. p. 248-9.
Mamidi P, Gupta K. Guru, Vriddha, Rishi and siddha grahonmaada: Geschwind syndrome? Int J Yoga Philosop Psychol Parapsychol 2015;3:40-5.
Gupta K, Mamidi P. Gandharva grahonmada: Bipolar disorder with obsessive-compulsive disorder/mania? Int J Yoga Philosop Psychol Parapsychol 2017;5:6-13.
Mamidi P, Gupta K. Vetaala Grahonmada: Parkinson's disease with obsessive-compulsive disorder?/Autoimmune neuropsychiatric disorder? Int J Yoga Philosop Psychol Parapsychol 2017;5:5-41.
Gupta K, Mamidi P. Deva shatru Daitya Asura grahonmada: Antisocial/Narcissistic/Borderline personality disorder? Int J Yoga Philosop Psychol Parapsychol 2018;6:10-5.
Gupta K, Mamidi P. Yaksha grahonmada: Bipolar disorder with obsessive-compulsive disorder? Int J Yoga Philosop Psychol Parapsychol 2018;6:16-23.
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.
Mamidi P, Gupta K. Rakshasa grahonmada: Antisocial personality disorder with psychotic mania? Int J Yoga Philosop Psychol Parapsychol 2018;6:24-31.
Mamidi P, Gupta K. Brahma rakshasa grahonmada: Borderline personality disorder? tourette syndrome – Plus? Int J Yoga Philosop Psychol Parapsychol 2018;6:32-40.
Gupta K, Mamidi P. Nishaada grahonmada: Behavioral and Pscyhological symptoms of dementia? Frontotemporal dementia? Hebephrenia? J Neuro Behav Sci 2018;5:97-101.
Mamidi P, Gupta K. Uraga grahonmada: Extrapyramidal movement disorder? Tourette syndrome-Plus? Indian J Health Sci Biomed Res 2018;11:215-21. [Full text]
Gupta K, Mamidi P. Preta grahonmada Catatonia? Med J DY Patil Vidyapeeth 2018;11:461-5. [Full text]
Mamidi P, Gupta K. Maukirana grahonmada – Psychiatric manifestations of Graves' hyperthyroidism and ophthalmopathy? Med J DY Patil Vidyapeeth 2018;11:466-70. [Full text]
Gupta K, Mamidi P. Kushmanda grahonmada-Paraneoplastic neurological syndrome with testicular cancer? J Neuro Behav Sci 2018;5:172-6.
Mamidi P, Gupta K. Attention deficit disorder – Anavasthita chittata. Indian J Anc Med Yoga 2016;9:149-60.
Rao TS, Asha MR, Ramesh BN, Rao KS. Understanding nutrition, depression and mental illnesses. Indian J Psychiatry 2008;50:77-82.
Lim SY, Kim EJ, Kim A, Lee HJ, Choi HJ, Yang SJ. Nutritional Factors Affecting Mental Health. Clin Nutr Res 2016;5:143-52.
Lakhan SE, Vieira KF. Nutritional therapies for mental disorders. Nutr J 2008;7:2.
Balhara YP, Verma R. Psychoactive nutraceuticals. J Med Nutr Nutraceut 2012;1:27-36. [Full text]
Ramsey D, Muskin PR. Vitamin deficiencies and mental health: How are they linked? Curr Psychiatry 2013;12:37-43.
Kleinhaus K, Harlap S, Perrin MC, Manor O, Weiser M, Harkavy-Friedman JM, et al
. Catatonic schizophrenia: A cohort prospective study. Schizophr Bull 2012;38:331-7.
Wilcox JA, Duffy PR. The syndrome of catatonia. Behav Sci 2015;5:576-88.
Gupta LN, Verma KK, Singhal AK, Dayal P, Jain V, Gupta P. Catatonic syndrome– A review. Delhi Psychiatry J 2007;10:19-5.
Rasmussen SA, Mazurek MF, Rosebush PI. Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World J Psychiatry 2016;6:391-8.
Ezequiel U. Neuropsychological subtypes of schizophrenia and prefrontal circuits. Rev Neurobiol 2016;7:1-15.
Duong S, Patel T, Chang F. Dementia: What pharmacists need to know. Can Pharm J (Ott) 2017;150:118-29.
Sacchetti E, Amore M, Sciascio GD, Ducci G, Girardi P, Mauri M, et al
. Psychomotor agitation in psychiatry: An Italian expert consensus. Evidence Based Psychiatric Care 2017;3:1-24.
Dening T, Sandilyan MB. Dementia: Definitions and types. Nurs Stand 2015;29:37-42.
Camicioli R. Distinguishing different dementias. Canadian Rev Alzheimer's Dis Other Dementias 2006;8:4-11.
Ghaziuddin N, Nassiri A, Miles JH. Catatonia in Down syndrome; a treatable cause of regression. Neuropsychiatr Dis Treat 2015;11:941-9.
Ortiz BB, Araújo Filho GM, Araripe Neto AG, Medeiros D, Bressan RA. Is disorganized schizophrenia a predictor of treatment resistance? Evidence from an observational study. Braz J Psychiatry 2013;35:432-4.
Fymat AL. Dementia: A review. J Clin Psychiatr Neurosci 2018;1:27-34.
Mendez MF, Lauterbach EC, Sampson SM, ANPA Committee on Research. An evidence-based review of the psychopathology of frontotemporal dementia: A report of the ANPA Committee on Research. J Neuropsychiatry Clin Neurosci 2008;20:130-49.
American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders – Text Revision (DSM-IV-TR). Schizophrenia and Other Psychotic Disorders – Schizophrenia. 4th
ed. New Delhi: Jaypee Publications; 2000. p. 297-303.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – Text Revision (DSM-IV-TR). Delirium, Dementia, and Amnestic and other cognitive disorders – Dementia. 4th
ed. New Delhi: Jaypee Publications; 2000. p. 148.
American Academy of Family Physicians. Information from your family doctor. Tourette's syndrome: What it is and how it's treated. Am Fam Physician 2008;77:659-60.
Lees AJ. Odd and unusual movement disorders. J Neurol Neurosurg Psychiatry 2002;72 Suppl 1:I17-I21.
Wijemanne S, Jankovic J. Movement disorders in catatonia. J Neurol Neurosurg Psychiatry 2015;86:825-32.
Faxén-Irving G, Basun H, Cederholm T. Nutritional and cognitive relationships and long-term mortality in patients with various dementia disorders. Age Ageing 2005;34:136-41.
Kiliç MK, Sümer F, Ülger Z. Nutritional issues in dementia patients. Turk J Med Sci 2015;45:1020-5.
Srivanitchapoom P, Pandey S, Hallett M. Drooling in Parkinson's disease: A review. Parkinsonism Relat Disord 2014;20:1109-18.
Kumar N, Joshi D, Ansari AZ, Patidar SP, Mishra VN, Chaurasia RN. Clinical, biochemical and radiological profile of Wilson's disease from a tertiary care referral centre in India. Arch Med 2015;7:1-7.
Chan W, Wong GW, Fan DS, Cheng AC, Lam DS, Ng JS. Ophthalmopathy in childhood Graves' disease. Br J Ophthalmol 2002;86:740-2.
Cheshire WP Jr. Thermoregulatory disorders and illness related to heat and cold stress. Auton Neurosci 2016;196:91-104.
Chaudhuri KR, Ellis C, Love-Jones S, Thomaides T, Clift S, Mathias CJ, et al
. Postprandial hypotension and parkinsonian state in Parkinson's disease. Mov Disord 1997;12:877-84.
Choonara YE, Pillay V, du Toit LC, Modi G, Naidoo D, Ndesendo VM, et al
. Trends in the molecular pathogenesis and clinical therapeutics of common neurodegenerative disorders. Int J Mol Sci 2009;10:2510-57.
Gupta K, Mamidi P. Ayurvedic management of bipolar affective disorder with psychotic features: A case report. Int Res J Pharm 2014;5:932-4.
Acharya JD, editor. Agnivesha, Elaborated by Charaka and Dridhabala, Commentary by Chakrapani. Charaka samhita, Chikitsa sthana, Unmada chikitsitam adhyaya, 9/24-32. Varanasi: Chaukhamba Surbharati Prakashan; 2014. p. 470.
Acharya JT, Acharya NR. Sushruta. Sushruta Samhita, Commentary by Dalhana. Uttara Tantra, Unmada Pratishedha Adhyaya, 62/14-15. Varanasi: Chaukhamba Orientalia; 2018. p. 804.
[Table 1], [Table 2], [Table 3]