Year : 2017 | Volume
: 5 | Issue : 2 | Page : 35--41
Vetaala Grahonmada: Parkinson's disease with obsessive-compulsive disorder?/autoimmune neuropsychiatric disorder?
Prasad Mamidi, Kshama Gupta
Department of Kaya Chikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat, India
Dr. Prasad Mamidi
Department of Kaya Chikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat
Bhoot vidya (ayurvedic psychiatry) is one of the specialties of Ayurveda and it deals with various psychiatric conditions caused by affliction of evil spirits or mythological personalities. Unmada (a broad term which consists of various psychiatric problems) is a major psychiatric condition described in Ayurvedic classical texts and it is characterized by deranged mental functions. Bhootonmada is caused by affliction of evil spirits or supernatural powers or extraterrestrial forces. Vetaala grahonmada (VG) is one among the 18 types (deva, asura, rishi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala) of bhutonmada. Till date, there were no studies available on VG, and the present study aims at better understanding along with the clinical applicability of VG. VG is characterized by Satyavaadinam (truthfulness/honesty), Parivepanam (tremors), Dhoopa gandha maalya ratim (fond of perfumes and garlands), and Ati nidraalum (excessive sleepiness). Parkinson's disease (PD) is traditionally regarded as a movement disorder. Behavioral and psychological symptoms or neuropsychiatric syndromes associated with PD are frequent. They include anxiety, depression, psychosis, sleep, sexual and impulse control disorders, apathy, and cognitive dysfunction. The various features of VG have shown similarity with PD comorbid with obsessive-compulsive disorder (OCD) and excessive daytime sleepiness. VG also has shown similarity with various other conditions such as “autoimmune neuropsychiatric movement disorders.” VG is having similarity with a comorbid condition of PD with OCD.
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Mamidi P, Gupta K. Vetaala Grahonmada: Parkinson's disease with obsessive-compulsive disorder?/autoimmune neuropsychiatric disorder?.Int J Yoga - Philosop Psychol Parapsychol 2017;5:35-41
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Mamidi P, Gupta K. Vetaala Grahonmada: Parkinson's disease with obsessive-compulsive disorder?/autoimmune neuropsychiatric disorder?. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2017 [cited 2023 Jun 10 ];5:35-41
Available from: https://www.ijoyppp.org/text.asp?2017/5/2/35/225624
Unmada (a broad term which includes various psychiatric problems under one roof) is a major psychiatric illness described in all Ayurvedic classics and is characterized by deranged mental functions. The etymological meaning of Unmada is “a state of disturbed mental functions.” Deviation of manas (mind), buddhi (decision), smriti (memory), sangya gyanam (orientation and responsiveness), bhakti (desire), sheela (habit), cheshta (activity), and achaara (conduct) (either all of them or some) is the characteristic pathological feature of Unmada.“Bhuta vidya” (Ayurvedic psychiatry) is one of the eight branches of Ayurveda. It deals with the 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 supernatural being/ghost), and rakshasa (class of demon fond of violence) for the cure of diseases originating from their malignant influence. The word “bhuta” denotes “supernatural power“/”demon“/”extraterrestrial force“/”paranormal force” or a popular “mythological personality.” Bhutonmada is characterized by abnormal behavior and psychomotor activity seen in a person all of a sudden without any visible or known etiopathology (idiopathic). There are 18 types of bhutonmada (deva, asura, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala) and Vetaala grahonmada (VG) is one among them.
There is no description available regarding VG in Charaka samhita,Sushruta samhita, and Madhava nidana. Only lakshanas (signs and symptoms) of VG are explained in Ashtanga samgraha and Ashtanga hridaya. The description of VG is similar in both texts (Ashtanga samgraha and Ashtanga hridaya). VG is characterized by the features such as Satyavaadinam (truthfulness/honesty), Parivepanam (tremors), Dhoopa gandha maalya ratim (fond of perfumes and garlands), and Ati nidraalum (excessive sleepiness)., Till date, there were no studies available on VG and it is an underexplored concept of Ayurveda. The present study is focused at better understanding VG along with its clinical applicability. The various features of VG have shown similarity with Parkinson's disease (PD) comorbid with obsessive-compulsive disorder (OCD) and excessive daytime sleepiness (EDS). VG also has shown similarity with various other conditions such as “autoimmune neuropsychiatric movement disorders.” These similarities have been explored in the following sections.
PD is traditionally regarded as a movement disorder. In the recent years, nonmotor symptoms have been considered the significant factors of disability at all stages of PD. PD is clinically characterized by motor signs such as bradykinesia, rigidity, postural instability, and rest tremor. Although the diagnosis of PD is based on the motor signs, nonmotor aspects of the disease are extremely common and disabling. Nonmotor symptoms of PD are frequent and they can precede the motor signs by several years. These nonmotor symptoms are challenging in advanced stages of PD, and they frequently limit the effective treatment of motor signs, leading to increased disability and poor quality of life. Some PD patients consider their nonmotor symptoms even more disabling than their actual motor signs. Behavioral and psychological symptoms or neuropsychiatric syndromes associated with PD are frequent. They include anxiety, depression, psychosis, sleep disorders, sexual and impulse control disorders, apathy, and cognitive dysfunction.
Obsessions are persistent ideas, thoughts, impulses, or images which are intrusive and senseless. The patient recognizes that the obsessions come from his/her own mind and are not imposed from without. Commonly, obsessions consist of repetitive thoughts of violence, contamination, or doubt. Compulsions are repetitive, purposeful, and intentional behaviors which are often performed in response to an obsession. The patient normally recognizes that this behavior is excessive or unreasonable or unrealistic. Compulsions commonly involve handwashing, counting, checking, or touching. When a person attempts to resist a compulsion, a sense of mounting inner tension arises. Patients who suffer from OCD symptoms represent a spectrum of diseases, much as the symptoms of Parkinsonism can arise from PD (idiopathic) or other brain pathology. Obsessive-compulsive symptoms arise in conjunction with numerous neurologic illnesses. There is an increased rate of OCD in patients with closed head injury and also some infections (Sydenham's chorea (SC), von Economo's encephalitis, a wasp sting) cause secondary brain damage, particularly in the basal ganglia, which later results in OCD. OCD also occurs with PD, multiple sclerosis, and most importantly, Gilles de la Tourette's syndrome (GTS).
Comorbidity of Parkinson's disease and obsessive-compulsive disorder
Increased number of cases of OCD also occurred after an outbreak of encephalitis lethargica (von Economo encephalitis), which is clinically characterized by Parkinsonism. There is a high frequency of OCD in idiopathic PD patients. Individuals with PD also share a particular personality profile. This personality profile includes various features such as low novelty-seeking behavior, high harm avoidance, less predisposition to addiction, shyness, introspectiveness, morality, inflexibility, and lower expression of anger. It is well known that patients with PD manifest several dysfunctions of fronto-basal ganglia circuitry. Dysfunction in the limbic circuitry may also be responsible for the occurrence of obsessive-compulsive traits in patients with PD. There is a relation between obsessive-compulsive symptomatology and the severity of motor impairment in PD. Relations between PD and OCD have been previously suggested in other studies. A previous work has described complex mannerisms and organized rituals in conjunction with the obsessive-compulsive phenomenon in patients with PD. Obsessive-compulsive symptoms may be an important but unrecognized feature in some patients with idiopathic PD. Obsessive-compulsive symptoms appeared late during the disease progression in patients with idiopathic PD.
Higher frequency of obsessive-compulsive personality disorder (OCPD) has been found among PD patients (40%). The characteristics of OCPD, as defined by the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) criteria, appear to overlap with the “Parkinsonian personality,” consistently reported in literature over time. PD is characterized by dysfunction in the fronto-basal ganglia circuitry and a similar circuitry has also been implicated in the pathophysiology of OCD. It is believed that the higher incidence of obsessive-compulsive symptoms in PD is due to the involvement of a shared circuitry. The presence of OCD in cases of postencephalitic Parkinsonism was observed. A systematic study in thirty patients with PD has shown that 17 of them presented a total score for obsessive-compulsive symptoms above that of the controls. Encephalitis lethargica that was described by von Economo in 1917 frequently presents Parkinsonian and obsessive-compulsive symptoms as part of its clinical manifestations. OCD may be more frequent in patients with PD, a frequent disorder characterized mainly by degeneration of neurons in the substantia nigra. Based on these facts, it seems that OCD and PD can exist together and the association between them is also frequent.
Similarity of etiology, pathogenesis, course, and prognosis of Vetaala grahonmada
, Parkinson's disease, and obsessive-compulsive disorder
In Ayurveda, bhutonmada is the condition that the causative factors cannot be traceable and prajnaparadha (intellectual blasphemy) or karma (idiopathic) plays an important role in the pathogenesis of bhutonmada. Grahas (demon/supernatural forces/evil spirits) seize the persons only at specific times. The time of grahavesha (possession) is considered as “chhidra kaala” Most of the chhidra kaalas mentioned in ayurvedic texts are, “when the person indulging in sinful activities,” or “not following sadvritta (code of conduct),” or “during illness,” or “during delivery time,” etc., and these chhidra kaalas denote stressful events or vulnerable periods or guilt. Actions of past life (daiva) are linked to diseases and acts as precipitating factors for the manifestation of various diseases (especially psychiatric diseases). Diseases arising out of such actions performed in previous life (daiva) are not amenable to any therapeutic measures. Bhutonmada is a condition in which there is no fixed time for aggravation or alleviation of the symptoms. Bhutonmada can occur at any time and cannot be understood on the basis of doshic (biological) parameters. In bhutonmada, the onset is sudden or instantaneous without significantly affecting the body physiology. As the number of grahas is infinite, their symptoms are also infinite. In bhutonmada, the symptoms occur suddenly without any visible reason or precipitated by chhidra kaala. The course of the disease in bhutonmada is also unpredictable. The occurrence or aggravation of symptoms in bhutonmada is not specific. The prognosis of bhutonmada is also unpredictable and it depends on the purpose for which the graha seized the person.
There is no description available in ayurvedic classical texts regarding the specific etiology, pathogenesis, course, and prognosis of VG. The common etiology, course, and prognosis mentioned for bhutonmada/grahonmada are applicable for VG also. Like other bhutonmadas, in VG also, the etiopathology, course, and prognosis are idiopathic and unpredictable. Only the description of lakshanas (signs and symptoms) of VG is available in ayurvedic texts.,,,,
The pathophysiology of PD with nonmotor symptoms is complex, multifactorial, and involves neurodegenerative process and psychological mechanisms. The etiopathogenic mechanisms that underlie neuronal death in idiopathic PD are as yet unknown. Various hypotheses such as free radical-oxidative damage, mitochondrial dysfunction, and excitotoxic damage, and genetic and immune or infective inflammatory mechanisms are proposed. The current theories for cell death mechanisms in PD are mainly centered on induced apoptosis. Immune abnormalities, antibodies against dopaminergic neurons and sympathetic ganglion cells, and increased IgG immunity in the cerebrospinal fluid to heat shock proteins have been noted in the patients of PD. A body of evidence is building up in favor of the underlying immune mechanisms in a wide variety of movement disorder syndromes. The link is still weak in the idiopathic neurodegenerative disorders such as PD and even in the poststreptococcal “auto-immune” syndromes such as SC, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS), and the related disorders; the final evidence is yet to be presented. Idiopathic tic disorder, GTS, and OCD are considered to be different expressions of primary dysfunction of corticostriatal circuits. The exact etiopathology is as yet unknown, but with the finding of immune mechanisms and response to immune modulation in SC/PANDAS which shares similar features, a search is on for the same in these idiopathic disorders.
Even though various hypotheses such as genetic, biological, behavioral, and psychosocial factors are put forward, the actual etiology of OCD is still unknown. The pathogenesis, course, prognosis, and clinical features of OCD are divergent, multifactorial, unpredictable, and not completely understood till date. A previous study has opined that features of OCD are seen in various grahonmadas. OCD with GTS resembles with “Sangama graha.“ Various features such as the complex and overlapping clinical presentation, variable prognosis, unknown psychopathology, and idiopathic presentation in OCD, PD, and autoimmune neuropsychiatric movement disorders show similarity with the etiopathology, course, prognosis, etc., explained for grahonmada/bhutonmada.
Similarity of clinical picture in between Vetaala grahonmada and Parkinson's disease with obsessive-compulsive disorder
Various lakshanas of VG such as Satyavaadinam, Parivepanam, Dhoopa gandha maalya ratim, and Ati nidraalum resemble various features of PD associated with OCD. The similarity in between the signs and symptoms of these two conditions (VG and PD with OCD) is as follows.
Elevated moral standards as “moral perfectionism,” that is, “as a general background, People who think, or learn, that all of their value-laden thoughts are of significance will be more prone to suffer with obsessions as in particular types of religious beliefs and instructions.” Scrupulosity is a term that is often used to indicate religious symptoms in OCD and is often expressed as unwanted obsessive thoughts about unsacred happenings or deities (e.g., Satan), a fear of sin or a preoccupation with thoughts about whether one has sinned, and extreme religious behavior (excessive confession or prayer). Scrupulosity is a condition characterized by obsessions and compulsions, which involves various religious themes, pathological guilt, doubt and/or worry about sin, and excessive religious behaviors. Obsessions with religious themes were the fifth common type of obsessions in OCD. An obsession may be a thought, image, or impulse of doing something which the person considers sinful or it may include doubts whether he/she confessed a sin, completely purified himself/herself, said the right prayer, entirely trusted in God, etc., and compulsions are behavioral acts or mental rituals that often manifest as the need to get reassurance from religious leaders about whether the person has adequately prayed, confessed a sin, repetitive confessions, repeating a prayer over and over, checking whether the person has done all necessary things in an appropriate way, or washing to get sure that one is clean enough before praying. Patients with scrupulosity engage in longer periods of highly distressing moral rumination or deep and intense episodes of thinking and reflection. Periods of rumination may involve philosophical analysis of currently bothersome moral issues or a meticulous review of past indiscretions. Individuals with scrupulosity, who by nature impose strict moral standards upon themselves and are hypervigilant of moral/religious sin, might be exquisitely sensitive to intrusive sexual or sacrilegious thoughts which conflict with their belief/value system.
Patients with PD display a specific cluster of personality traits consisting of increased rigidity, conscientiousness, industriousness, orderliness, and cautiousness. Patients with PD were less novelty seeking than controls. Low novelty-seeking patients were described as being rigid, stoic, slow tempered, frugal, orderly, and persistent. Some of these are obsessive traits. Several reports have evaluated the association between personality traits and PD, generally suggesting a personality profile characterized by industriousness, inflexibility, punctuality, cautiousness, and lack of novelty seeking. On the bases of these evidences, a premorbid “Parkinsonian personality” has been suggested and it has been hypothesized that it could be a possible early manifestation of the neurological changes in the brain. Various miscellaneous obsessions such as “fear of not saying just the right thing” and religious obsessions such as “excessive concern with right/wrong,” “excessive morals,” and “concerns with sacrilege and blasphemy” are the features of OCD which resemble “Satyavaadinam” of VG. Even “Parkinsonian personality” also has shown similarity with “Satyavaadinam” of VG.
PD is clinically characterized by motor signs such as bradykinesia, rigidity, postural instability, and rest tremors. PD is a movement disorder in which tremors are one of the characteristic features. PD is caused by the degeneration of striatonigral dopaminergic neurons. Resting tremors are one of the major clinical features of PD. Essential tremor is probably the most common movement disorder and is characterized by a postural or kinetic 4–12 Hz tremor mainly involving the hands and forearms, although it can also affect the head, chin, and voice, as well as other locations. The typical tremor of PD occurs at rest but may be present with sustained posture, whereas the typical essential tremor is postural and/or kinetic but can also be present at rest in severe cases. A cardinal Parkinsonian sign such as cog wheeling rigidity may also be seen in essential tremor. Rest tremor has been described in approximately 19% of essential tremor cases and occurs more frequently in patients with tremors that are more severe or of longer duration. “Parivepanam” of VG denotes tremors of PD or other neuropsychiatric movement disorder.
Dhoopa gandha maalya ratim (fond of perfumes and garlands)
“Dhoopa gandha maalya ratim” of VG denotes that the patient of VG has been developed interest in wearing garlands, using perfumes, and preferring hygienic environment. This sudden change of behavior (excessive hygiene/rituals/religious/fear of contamination) without any visible or known cause denotes OCD. Excessive showering, bathing, grooming, cleaning or washing compulsions, excessive ritualized handwashing, fear of contamination, etc., are features of OCD  which resemble “dhoopa gandha maalya ratim” of VG.
Ati nidraalum (excessive daytime sleepiness/hypersomnia)
Sleep disorders are the most prevalent nonmotor symptom in PD. Some sleep disorders in PD may precede the onset of motor symptoms. EDS and “sleep attacks” affect half of the patients with PD and can also precede disease onset. A sudden onset of sleep during the day is a phenomenon in PD which resembles narcolepsy. Sleep disturbances in PD are common and multifactorial problems, with an incidence ranging from 40% to 90%. EDS occurs in approximately 15%–50% of PD patients. A high Epworth Sleepiness Scale score, male gender status, longer disease duration, and high disease severity have been associated with EDS. PD-related pathological changes play a role in sleepiness: an impaired arousal system has been suggested in PD. Some patients with PD exhibit EDS and a sudden onset of sleep episodes with short sleep latency and a short sleep-onset REM period, independent of the nighttime sleep conditions. This finding suggests a narcolepsy phenotype in PD patients. Narcolepsy is a sleep disorder characterized by severe daytime sleepiness, cataplexy, hypnagogic hallucination, and sleep paralysis caused by loss of orexin neurons. Sleep disorders occur in the early stages of PD and worsen as the disease progresses. EDS, sleep attacks, and episodes of micro sleep during waking hours are seen in PD.
Sleep disturbance has been recognized as an intrinsic part of PD. Especially, EDS has received a great deal of attention due to the sudden and irresistible sleep attacks, with resulting automobile accidents in patients with PD. EDS is not a secondary phenomenon, but, instead, is an intrinsic character of PD. There is evidence that cortical hypoperfusion, especially in the left parietal association cortex, and hyperperfusion in the right thalamus have been found in PD patients with EDS. Additional studies have confirmed the frequent occurrence of EDS in PD. A current hypothesis is that sleepiness or a susceptibility to EDS may be an integral part of PD, reflecting the extent of the neurodegenerative process. Although still controversial, the most frequently associated factors with the complaint of EDS in PD are dopaminergic drugs, disease severity and duration, reduced activity of daily living, and nighttime sleep problems including the apnea/hypopnea index. A high frequency of self-reported EDS in PD patients has been detected. Based on these facts, “Ati nidraalum” of VG denotes EDS in PD patients.
Similarity of Vetaala grahonmada and autoimmune neuropsychiatric disorders
Movement disorders are a common expression of neurological diseases of varied etiology. Neuroimmunology is a rapidly expanding field and new research shows that immune-mediated mechanisms may have significant roles to play in a wide spectrum of movement disorders. Thomas Sydenham in 1686 has described a disorder in children characterized by the sudden onset of rapid, involuntary, and purposeless limb movements. This movement disorder “chorea” was the first extrapyramidal movement disorder to be described clinically. In SC, the symptoms may be bilateral or may manifest as hemichorea, dysarthria, and hypotonia. Neuropsychiatric symptoms including disruptive behavior, obsessive-compulsive symptoms, emotional lability, distractibility, anxiety, and depression are frequently seen in these patients. In the 1980s, there occurred a spate of outbreaks in the United States, of a sudden-onset movement and emotional disorder in children following streptococcal throat infections. This movement disorder consisted of motor tics with prominent neuropsychiatric symptoms, usually of an obsessive-compulsive nature. These and further recognized cases were then grouped together under the new acronym PANDAS. The proposed criteria for PANDAS include: (1) onset between 3 years of age and puberty; (2) presence of OCD and/or tic disorder; (3) abrupt onset of symptoms and/or course with recurrent exacerbations and remissions; (4) abnormal neurological examination without frank chorea; and (5) temporal association of symptom exacerbation with streptococcal infection. Another new entity, termed pediatric acute-onset neuropsychiatric syndrome (PANS), has recently been proposed to acknowledge that there is a subgroup of children presenting with an abrupt onset of OCD and acute neuropsychiatric symptoms.
The pathophysiology of poststreptococcal movement disorders still remains incompletely understood. There is no evidence to suggest that streptococcal organisms or bacterial toxins enter the brain, so the immunological mechanism remains the only attractive hypothesis. These auto antigens are involved in all poststreptococcal movement disorder syndromes including SC, PANDAS, dystonia, and others. Idiopathic tic disorder, GTS, and OCD are considered to be different expressions of primary dysfunction of corticostriatal circuits. The exact etiopathology is as yet unknown, but with the finding of immune mechanisms and response to immunomodulation in SC and PANDAS which shares similar features, a search is on for the same in these idiopathic disorders. It is not clear whether some individuals are genetically predisposed to develop these disorders (SC, GTS, PANS, PANDAS, OCD, PD, etc.). Whether autoimmunity or infections that play a role even in movement disorders are currently labeled as “idiopathic.”
OCD has recently been described in association with basal-ganglia-related neurological diseases such as SC, PD, and Huntington's disease (HD). GTS also appears to be related to the basal ganglia, and is often found in association with OCD. TS is a chronic neuropsychiatric disorder characterized primarily by the presence of motor and vocal tics, defined as sudden, rapid, repetitive, stereotyped, involuntary movements or vocalizations that can be voluntarily suppressed, even if only for a short period of time. SC is a disorder affecting the basal ganglia, characterized by choreiform movements, some degree of hypotonia, and occasionally by emotional instability. Certain cases of acute OCD in childhood might represent an autoimmune cerebral disorder (with similar mechanisms to SC) even in the absence of rheumatic fever. HD is a dominant autosomal neurodegenerative disease that primarily manifests itself through choreiform movements and progressive dementia. There are few reports in the literature regarding the association of OCD in patients with HD. Psychiatrists should be aware of the presence of other disorders involving the basal ganglia, such as TS, SC, HD, and PD in patients with OCD. HD can present with neuropsychiatric symptoms, including depression, psychosis, OCD, and a frontal lobe syndrome. OCD and TS may share a common biological substrate. Various movement disorders such as SC, PANDAS, PANS, TS, and PD are associated with OCD and all of these conditions show similarity (idiopathic etiopathology, varied clinical picture, and unpredictable prognosis) with the lakshanas of VG.
“ VG“ is one among the 18 types of bhutonmada. The signs and symptoms of VG have shown similarity with PD comorbid with OCD. Signs and symptoms of VG such as Satyavaadinam, Parivepanam, Dhoopa gandha maalya ratim, and Ati nidraalum resemble the features such as tremors, scrupulosity, excessive morality, hyper religiosity, excessive hygiene, Rituality, and EDS (various features of PD and OCD). VG also has shown similarity with various autoimmune neuropsychiatric movement disorders.
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