Psychiatry in ancient Indian texts: a review

HIStory of Psychtatry, ill 167-186. Prmted m England (1992), 167- Psychiatry in ancient Indian texts: a review DINESH BHUGRA* Descriptions of diff...
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HIStory of Psychtatry,

ill

167-186. Prmted m England (1992), 167-

Psychiatry in ancient Indian texts: a review DINESH BHUGRA*

Descriptions of different types of mental illness are found in ancient Indian medical and religious texts. This paper offers an insight into these descriptions and the principles of treatment. The role of observation was seen as more important than the subjective experiences of the patient. The concepts of mental illnesses prevalent in ancient India are compared with those practised in modern Western psychiatry. The implications of this comparison for research are discussed.

~onstructing a history of psychiatry in India based on indigenous traditions [1]. First, the concept of psychiatry as we know it did not exist in ancient India. Second, our view of the past tends to be coloured by Western concepts of mental illness. Depression, schizophrenia and mania are relatively modern terms, and imposing one system of diagnosis and classification on to another time and cultural setting may be problematical. The Ayurvedic physician will have applied the concepts of his day to his clinical practice. A third problem is whether ancient accounts refer to the same illness syndromes as are seen nowadays. Descriptive psychopathology is of crucial importance in this regard. The development of descriptive psychopathology requires a conceptual framework for mental events, as emphasized by both Clarke [2] and Berrios [3]. In Ayurvedic texts descriptions of objectively observable illnesses like alcoholism and epilepsy are excellent, but those of phenomena dependent upon direct questioning, e.g., hallucinations, delusions and thought disorder, are not always clear. Weiss [1] has argued that the boundaries of psychiatry are neither so constant and absolute as to represent a univeral conceptualization nor so culturally relative that fragmentation renders them incomparable. Equating the Indian concept of unmada with the Western concept of schizophrenia would be misleading if the cultural and historical contexts of both unmada and poses several problems

schizophrenia were neglected. Before the advent of the formal system of medicine in India (Ayurveda),

* Address for correspondence: Dr Dinesh Bhugra, MRC Social and Community Institute of Psychiatry, De Crespigny Park, London SE5 8AF.

Psychiatry Unit,

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priestly, magical and empirical concepts of medicine in general, and physical and mental illnesses were not clearly demarcated [4]. Ayurveda, the book of life, deals with medical and surgical diagnoses and management. The Rig-Veda is said to be the world’s oldest book, variably estimated to have been written as early as 1500 Bc or as late as 1200 Bc. Various surgical procedures were mentioned in the Rig-Veda [5] and in other Hindu holy books [6]. Of the eight tomes that originally existed, Caraka Samhita deals with medical diagnoses and management, and Sushruta Samhita deals with surgical diagnoses and techniques. Both tomes are widely followed in the traditional Indian system of healing. The successor to the Rig-Veda was the Atharva-Veda, which mentions that mental illness may result from divine curses [7]. Sushruta described in his Samhita how Lord Brahma (one of the Holy Trinity of the Hindu religion) originally wrote 1000 chapters and 100,000 verses but ’in consideration of the short life and poor intellect of the humans, he re-cast it into eight divisions’. One division described illnesses of body and mind [8]. From Lord Brahma, the teachings eventually reached a Brahmin, Bhardwaja, who taught the system to six pupils. One pupil, Agnivesha, was responsible for the first text, which was revised by Caraka. For centuries, the knowledge passed on among disciples by word of mouth. Valuable texts were rendered as poems for easy memorization and transmission. However, because new knowledge was simply added to the text, it becomes difficult to distinguish original from additional material [9]. Only relatively recently have the texts been written down and, even so, the original manuscripts have often disappeared. Originally in Sanskrit, the texts were subsequently translated into other languages. For these reasons, many discrepancies exist between different versions and translations of texts, and it is almost impossible to date them. Recently, appreciation of the descriptions of mental illness in such texts has grown [ 10, 11]. Several therapies developed then have recently been revived, as described below. Caraka Samhita, possibly dating from before 600 BC [12, 13], is the foremost of the ancient Indian medical system. Two Hindi translations [6, 14] and English translation [6] of the Caraka Samhita, with other material, have been studied for this paper. The author has personally translated relevant passages and cross-checked them with available translations. Obeyeskere [15] has described Ayurvedic practice in Sri Lanka. Caraka Samhita and other texts contain many descriptions of possession states. Texts dating from somewhat later, such as Atharva-Veda, placed more emphasis on mental illness as arising from possession by supernatural agents [ 16, 17], perhaps reflecting a change to a more magical view of religion. AtharvaVeda has ten parts, including not only sorcery and witchcraft, but also sex disorders, pathological fears, fury, unmada or insanity, hysteria, guilt and jealousy. These concepts also featured in religious texts like Ramayana and Mahabharata. The later development of a medical humoral system (comparable to the Greek one) did not displace the spiritual ideas for mental and for some physical disorders, although spiritual expanations did not become more precise text

one

169 either [2]. Prior to the development of Caraka Samhita mental illness a result of curse of gods [7].

was seen as

Principles of Ayurvedic thinking Balodhi [4] and Varma [18] have offered useful explanations of Ayurvedic principles. The Hindus class schools of thought as shastras or systems which each have a common body of doctrines (Sutra), explanation (Bhashya) and commentary (Teeka) [ 19] . The system then goes on to define its scope, purpose and outline and should follow a line of faith in reality. According to these principles Caraka Samhita is a shastra. The mind, according to Caraka, has two purposes: atomic and indivisible unity (CS Vol. III p.975). [The abbreviation CS refers to Caraka Samhita 4.] The functions of the mind are direction of the senses, control of itself, reasoning and deliberations. Beyond this is the field of intellect. Man is composed of twenty-four elements: mind plus ten organs (five cognitive and five conative), five sense objects and eight-fold prakriti or evolutes of nature. Caraka covered a wide range of human life, including anatomical, physiological, social, ethical and spiritual aspects of disease and health. He advanced a catholic and common sense view of Karma and rebirth differing from other Indian philosophies [20]. Hindu philosophy holds that life is a continuum and that rebirths are like changing of clothes. Karma is difficult to translate, but refers to a cosmic retributive justice where previous actions determine one’s personal future. However, Caraka did not consider the laws of Karma to be immutable and he allowed a limited freedom to human efforts. He recognized three primary desires underlying human actions: desire for self-preservation, desire for wealth and desire for a happy future - a kind of cognitive triad for normal well-being. He emphasized that the consequences of non-moral or ordinary actions can be averted by the exercise of human intelligence, wisdom and well-balanced conduct and by the administration of proper medical treatment. Thus, right conduct can help to preserve physical and mental health. However, moral or good actions cannot be modified or averted by human efforts. Caraka saw the body as an aggregate of cells which multiply by division under the influence of Karma (previous incarnation’s actions); Vayu (the air, equated with bio-energy) and Swabhava (personal nature). Thus both genetic and personal factors are taken into account. These cells lead to various dhatus, the development and function of which is discussed below. Caraka defined ayu (life) as a state consisting of shareera (body), indriya (senses), satva (psyche) and atma (soul). Soul is indestructible and undergoes reincarnation. Mind, the essence of life in Caraka’s view, is responsible for cognitions. It directs the senses, controls the self, reasons and deliberates. In contrast, self is conscious, but only by virtue of its connection with the senses, a view differing from orthodox schools of Indian philosophy [5]. The equilibrium between the self and the mind is paramount to good health. Manas (mind has 3

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operational qualities: satwa, rajas and tamas. These qualities are used in typologies, e.g., of food and of personality. Satwa includes self-control, knowledge and discriminative ability among its constituents. Rajas is indicated by violence, despotic envy, authoritarianism, whereas tamas reflects dullness and inaction. Disease arises from the discordance of body elements, their concordance being normal health. Freedom from disease is characterized by a sense of ’ease’, while disease is experienced as pain (CS Vol. V p.54). Curable diseases are of two kinds: those easily cured and those cured with difficulty. Incurable diseases also fall into two categories: those that are palliable and those that are absolutely irremediable. Curable diseases are divided into three further categories by reason of their requiring mild, moderate or strong treatment (CS Vol. V p.59). Prevention of disease is emphasized in the pursuit of life (CS Vol. V p.61). Fundamentals of Ayurveda Doshas

Caraka used the term doshas to apply to body fluids or humours [12] which are affected by the climatic seasons. In the tridoshic theory the three doshas are vata (dry, cold, light, subtle, unstable, clear and rough), pitta (unctuous, hot, acute, fluid, acid, mobile and pungent) and kapha (heavy, cold, soft, unctuous, sweat, stable and viscid) (CS Vol. V p.6). When the three doshas are in harmony the person is said to have an even temperament. Different diseases result from different imbalances in the doshas. The Ayurvedic theory of doshas may have developed independently of the Greek humoral theory or possibly the Hindu system may have travelled westwards [12]. In the Hindu system, mental disorders are seen as largely metaphysical. Obeyesekere [22] has suggested that the Ayurvedic principles are derived from superimposition of metaphysical ideas upon concepts of physiological function and dysfunction. Food Food and its juice (vasa) lead to production of blood (rakta) which produces flesh (mensa). From flesh arises fat (medas) which leads to bone (asthi) which in turn

produces marrow (majja). The ultimate product is semen (shukra). The production of any of these can be influenced by the individual’s personality characteristics as well as external influences like seasonal variation. Conversely, types of food influence the mind. Food could be satvik (sweet, agreeable food producing long life, strength, health and equanimity); rajasik (sour or saltish food that stimulates thirst and makes the individual restless) and tamasik (stale, insipid food, making the individual dull and indolent). Thus food maketh the man. This contribution of food to the personality characteristics of man also affects the interaction between the three doshas.

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Constitution Five types of constitution were described: three according to each dosha, one when doshas are in equilibrium and the fifth when they are not. The vata, pitta, and kapha constitutions anticipate the Kretschmerian personality types of asthenic, pyknic and athletic constitutions [23]. Vata (akin to Vayu or wind) constitution has a dry, wasted and small body with dry skin, long drawn face and low voice. He is always alert, tense, restless and talks more than normal. A man of strong likes and dislikes, he is liable to frequent mood changes, is fearful and forgets easily. He is intolerant of cold and his hair, nails and hands and feet are rough. He has a short lifespan and few children. Vata dosha has six characteristics: dryness, lightness, coldness, hardness, roughness and clearness (CS Vol. V p.72). It may become abnormal in the body and impair strength, complexion, well-being and life; thus depressing the mind and causing fear, grief and stupefaction. Pitta constitution is delicate and intolerant of heat, though very brave. He takes large quantities of food and drink and consequently is fat and flabby. He has many cutaneous moles and malodorous armpits, body and mouth. Sexual appetite is limited and he too is liable to moderate lifespan. Pitta dosha contains fire, which may produce good or bad conditions, so its consequences include digestion and indigestion; vision and loss of vision; normality and abnormality of temperature; health and diseased appearance; intrepidity and fear; anger and delight; confusion and lucidity; and other pairs of opposite qualities (CS Vol. V p.45). Kapha constitution has a pleasant, delicate and clear skin and is sexually passionate. His body is firm, stable and rounded. He is slow in his actions and speech and demonstrates no changes in mood. He has several children and also possesses strength, vitality and long life. Soma, the water element, is located in the kapha of the body and gives rise to good or evil consequences. These are compactness and flabbiness, plumpness and emaciation, zest and lassitude, virility and impotence, knowledge and ignorance, understanding and stupefaction and other such pairs of opposite qualities (CS Vol. V p.75). All three normally combine to make a man whole in his senses, possessed of strength, good complexion and ease, and assured of great longevity just as the triad of Dharma, Artha and Kama, when properly cherished, secure for him the highest good both here and in the other world (CS Vol. V p.75). Mishrit or mixed constitution has characteristics of all the above. Samprakrit or harmonious constitution results from well-balanced harmony of all humours. Thus the skin is full of lustre, oily, smooth, soft and clear, as are lips, hands and feet, nails, tongue, etc. The tone of muscles indicates endurance, stability, wealth, knowledge, happiness and health along with long life.

Personality types Linked with the three kinds of food there are three basic personality types. The personality types could lead to mental illness, through either unwholesome diet or moral transgressions [24].

172 The three basic

personality types have a further seven, six and three subtypes respectively. The satvik (pure) personality operates at an intellectual level, rajasik (passionate) at an emotional level, and tamasik (ignorant) at a very basic vegetative level. It is the predominance of one quality over others that classifies someone into a particular personality type. Together with physical constitution and cause of disease, numerous combinations of symptoms were thus possible. The seven subtypes of satvik are renowned for their good qualities and are beneficial to society: (i) Brahm (the pure) type is characterized by purity, truthfulness, insight, knowledge, ability to respond with equanimity and to refrain from sins like greed, desire, egotism, anger, jealousy and intolerance. Much self-control, can discriminate right from wrong. (ii) Rsi (or Arsh). Devoted to study, sacrifice, abstinence, such a person is caring, devoid of jealousy, covetousness, anger or pride and has keen perception and an understanding of scientific truth. He possesses a good memory and is a good speaker. (iii) Indra. Trustworthy, brave, energetic and powerful. Authoritative in action and deeds, such an individual has foresight and pursues virtue, wealth and sensual pleasure. (iv) Yama. Yama is the Hindu god of death, and has to be punctual and courteous. Thus, such a person shows exemplary character and is guided by considerations of propriety. Constantly active, has good memory and lacks feelings of attachment, envy, hate and infatuation. (v) Varuna. Varuna, the god of water who rules seas and rivers, is renowned for his poise and honest dealings. Such an individual is clean, courageous and intolerant of uncleanliness in any form. He is devoted to religious rites and enjoys swimming, boating and aquatic pursuits. (vii) Kuber. Kuber is the god of wealth, so a person with such characteristics has a luxurious prestigious life style with pursuit of virtue, wealth and happiness. He boasts appropriately, plays with children and demonstrates appropriate affect.

(viii) Gandharvas. Gandharvas are celestial musicians and dancers, hence such a person likes to sing and dance and can play musical instruments, likes poetry readings and history. He enjoys perfumes and flowers and dresses well, yet does not mock others. are therefore healthy and at peace with themselves and others. They are knowledgeable, virtuous, beautiful and tend to live longer. However, as is discussed later, these may also be types of possession states. There are six subtypes or rajasik personality (though Varma [18] suggests five), based on asurs or the rivals of gods. The literal meaning of asur is ‘not-god’, so the word can be taken as referring to demons.

These seven types

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(i) Asur is brave but despotic and terrifying. He has

no

pity and is selfish,

gluttonous

and intolerant. He

devious and irritable.

(ii) Rakshas has a devious nature, is jealous, harbours grudges and sleeps and eats a lot. (iii) Pisacha lives in luxury but is lustful and easily influenced.

unclean, a coward and a bully. He is lazy,

(iv) Sarpa is brave only when angry, hard-working but frightened while carrying out the usual tasks. He is an expert in counselling others and enjoys sensual pleasures. (v) Preta is greedy, disinclined to work, jealous and has no power of discrimination. He is lazy and likes to eat large amounts. (vi) Shakun is lustful, intolerant, naughty, fickle-minded and forms strong attachments.

In other texts, a seventh type, who is cheerful, eats and sleeps excessively, dressing up and is generous towards good causes, has been added. The three subtypes of tamasik pesonality are:

enjoys

(i) Pashu (animal) has difficulty dealing with problems, is preoccupied with sexual thoughts and eats and drinks excessively. (ii) Matsya (fish) is mentally deficient, cowardly, gluttonous, fickle and preoccupied with anger and sensuality. (iii) Vanaspatya (vegetable) is lazy, devoid of any knowledge and spends most of his time eating (25). Thus personality types are described in terms of social, intellectual, emotional and moral characteristics. Varma [ 18] suggested that the tamasik subtypes would be considered mentally or intellectually deficient. Mental state Mental state functioning is also of three types: the stable calm individual, the worrier who needs constant reasurance but is then able to cope, and a type with low self-esteem and difficulties in coping and learning from examples.

Mental disorders In

general, insanity (CS Vol. V p.607-608) results from inappropriate diet; disrespect towards the gods, teachers and the twice-born; mental shock due to excessive fear or joy; and faulty bodily activity. ’The humours in the body of the weak-minded, getting morbid by the above factors, and, in their turn, vitiating the brain, the seat of intelligence, become localized in the channels of the nervous system and derange the function of the mind’. Thus physique,

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temperament, heredity, diet, endogenous or exogenous influences, psychological and metapsychological factors are all important in aetiology. The three doshas work in unison but independently so that vulnerability of the constitution determines the type of illness [26]. Unmada (psychosis, insanity) is the excited state of mind arising from somatic and psychic doshas [27] . Caraka considered unmada to be a misplaced state of mind, understanding, consciousness, perception, memory, inclination, character and conduct. He defined unmada as the unsettled condition of eight components: manas (mind); budhi (decision); smrti (memory); bhakti (desire); sheela (habits and temperament); cheshta (psychomotor activity); achara (conduct) and sanjnanana (orientation and responsiveness). This serves as the prototype for other mental disorders, not only psychosis. Unmada could have one or more of the components in disarray. The eight types suggested by Caraka later became eighteen according to Vagbhata [1, 28] and twenty according to Saarangdhara Samhita. This increase may have reflected interactions between folk, religious and medical tradition. Perhaps also newer forms of mental illness emerged due to changing social conditions. Factors predisposing to mental disorders include a timid, weak-willed, cowardly persona; loss of mental stamina; and violation of general principles of diet and healthy living. Those who get ill without any predisposing factors are likely to suffer less severe mental disorders. Mechanisms explaining mental illness varied, since there were several theories as to the seat of mind [29]. This debate had implications for managing mental illness. Caraka thought that the mind resided in the heart, as did Sushruta [8, 30]. Bhela, however, considered the brain to be the centre of the mind. He distinguished between manas (cognitions), chitta (emotions) and budhi (intellect or insight), and described the onset of mental illness as the spread of doshas from the brain to the mind, subsequently involving the heart and affecting the understanding [30]. Thus a model of organic change producing mental disorder and leading to loss of insight existed even in ancient times. Diseases were classified in several ways, for example according to aetiology, organ of genesis, prognosis or symptomatology. The distinction between physical and mental illnesses is not always clear. Mental illnesses were classified into four types:

(i) Caused by the exclusive involvement of emotions, e.g. passion, anger, infatuation, grief, anxiety, anguish, jealousy. Treated chiefly with drugs and psycho-behavioural therapy. (ii) Caused by exclusive involvement of one of the three doshas, i.e. vata, pitta and kapha. Symptoms include auditory hallucinations, insomnia, sadness, excessive speech, fickleness of mind, etc. Treated mainly with drugs. (iii) Disorders with body-mind involvements: unmada, alcoholism, epilepsy, hysteria, obsession, toxic psychosis, etc. Treated with medication as well as psycho-behavioural treatment. envy,

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(iv) Disorders with mind-body involvement: fever due to grief, passion or anger; purging due to fear or grief, etc. Treated with psycho-behavioural techniques, the role of drug therapy being secondary in such cases. Unmada is

broadly classified as endogenous (nij) or exogenous (agantuk). The agantuk variety is linked with the concept of karma. Mental disorders are due to imbalances of vata, pitta or kapha (or combinations of humours) and to exogenous factors.

Symptoms of endogenous type Premonitory symptoms suggestive of endogenous mental illness include feelings of emptiness in the head, twitching of eye muscles, oddness of mind, lack of interest in food, excessive dreaming and weakness of body and limbs, hurried respiration, incoherence of speech, lack of mental ease and wandering of mind. The prodromal symptoms of exogenous disorder are a desire to hurt ascetics, irritability, apathy, loss of vitality and vigour, and if possessed superhuman strength, energy, capacity, grasp, memory and understanding. The vata becomes provoked by poor diet, or excessive fasting and selfpurification, thus impairing the understanding and memory as well. The symptoms of insanity produced by vata are inappropriate laughing, smiling, dancing, singing, speaking, bodily movements and weeping, together with hardness, leanness and dusky-red coloration of the skin. The pitta accumulates as the result of taking pre-digested meals or irritant and hot food. It then rapidly gives rise to acute maniacal symptoms: intolerance, turbulence, nudity, intimidation, running about, heated condition, anger, craving for shady places and cooling foods and drinks. In the person of sedentary habits, the kapha is increased in the vital organs as the result of over-feeding. It combines with heat, impairing the intellect and memory, and thus confounding the mind causes insanity (melancholia). Slowness of speech and action, anorexia, fondness for women and solitude, somnolence, vomiting, dribbling of saliva, anabasis following meals, pallor of the nails are the symptoms of insanity due to kapha. The insanity arising from combined humoral disturbance was thought incurable because of the conflicting requirements for its treatment, and physicians were advised not to waste effort on such cases (CS Vol. V p.607-610). A patient moved by intense emotion and constantly raising his hand to strike himself or those about him was regarded as incurable. One whose eyes are marked with profuse lachrymation, has his tongue bruised, nostrils dilated, skin cracking and speech unrestrained, mumbles constantly, has discoloration of body, is constantly afflicted by thirst and is foul-smelling should be left to his fate.

Symptoms of exogenous type Causes of the exogenous type of unmada include

possession by bhutas (the gods,

176 sages, gandharvas, pisachas, yaksas, rakshasas and the manes); and quarrels or failure of proper observances, in this life or the previous one. Persons not liable to possession are prophets, charitable persons and those who speak truth and perform appropriate duties [31]. The stress of maintaining lies is therefore a predisposing factor to mental illness (perhaps anticipating

preventive psychiatry). The bhutas enter invisibly and suddenly into the human body by their innate power, without causing any morbid change, ’as the rays of the sun go through a lens and burn the cotton fibres underneath it; nobody can see the rays but the result is visible. Similarly a man can be possessed - the body does not change but the results are there to be seen.’ Thus the spirits cause disease but do not physically possess human beings, which implies that the affected individuals were vulnerable and prone to mental illness. Factors predisposing to the exogenous type of insanity include (CS Vol. V p.269-270) insulting or hurting the gods, cows, Brahmanas and ascetics, irrascibility, mischief-mongering, apathy, and in dreams being despised by the gods and others. The bhutas induce madness in different ways: gods send down madness by a look; the teachers, elders, adepts and great sages by a curse; the manes by revealing themselves; the gandharvas by a touch; the yaksas by taking possession; the rakshasas by letting their body-odours be sniffed and lastly the goblins by mounting their victims and riding them. People become vulnerable to the malign influence of the bhutas at certain critical times, for example the commencement of any evil act, when failing to practise self-control during twilight, during sexual congress on full and new moon days, while cohabiting with a menstruating woman, during any impropriety in religious observance, on lapsing from discipline, vows and Brahmacharya, in battle, during an eclipse, during delivery (for a woman), during contact with inauspicious and unclean objects. There are thus three general motives for inducing insanity - cruelty, lust and the extortion of worship. The curability of the illness is linked to aetiology, the insanity due to cruelty being considered incurable. The symptoms of possession states depend on the agency responsible for the possession. Symptoms caused by bhutas are as follows: (i) (possession by) Gods. Gentle-looking, dignified, indomitable, placid, disinclined to sleep and eat, with scanty excretions, pleasant body-odour, and face radiant like a fully blossomed lotus flower. (ii) Manes. Agitated looks, somnolence, with anorexia and indigestion.

impaired speech, apathetic

to

food

(iii) Gandharvas. Fierce, impetuous, fiery, grave, indomitable, pleasant odour. Passionately fond of musical instruments, dance, singing, food, drinks, baths, garlands, incense and unguents, with love of wearing red garments. (iv) Yaksas. Frequent sleeping, weeping and laughing; fondness for dancing,

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singing, music, food, gossip, drinks, baths, garlands, incense; blood-shot eyes; speaking ill of the twice-born (the Brahamanas) and of physicians; and revealing of secrets. (v) Rakshasas. Insomnia, aversion to food and drink, surprising physical strength, and interest in weapons, blood, flesh and red-coloured ’badlands’. (vi) Brahma-rakshasas. Loud guffaws and dancing; expressing hatred and contempt for the gods, Brahmans and physicians; quoting hymns; and selfflagellation and self-mortification. (vii) Pisacas. Restlessness, dancing, singing and laughter; lack of memory; constant proclamation of sorrows; a penchant for nudity and for sitting in inappropriate places, for example on dung heaps and hay-stacks. (viii) Rsis. Tend to affect someone devoted to solitude and frequent bathing, and well-versed in law-books and scriptures. Some passages imply that unmada is not caused by the bhutas but by the individual himself whose mentally disordered condition can be specified on the basis of behaviours that are similar to the character of certain classes of demons and deities [32]. Dube et al. [33, 34] applied the ICD-9 classification to illnesses described in the ancient texts. Many ancient diagnostic categories fitted in reasonably well, though minor psychiatric disorders match less exactly. Ancient Indian approaches to selected syndromes are discussed in the followin section.

Psychiatric descriptions Depressive disorder The ancient Hindu scriptures, Ramayana and Mahabharata contain descriptions of depression [35]. Although Lord Rama and Arjuna are mythological characters, the accounts resemble the diagnostic categories of depression and anxiety state. In Ramayana [36], there is a strong family history of (unipolar) depressive disorder in the ruling dynasty. The king (grandfather) developed a depressive illness after his wife’s death, and eventually starved himself to death. His son, Lord Rama’s father, had three episodes of melancholia, each following significant life events. The first episode occurred after accidentally killing a blind man, the second and third ones after separation from his children. The last episode proved fatal. The hero of Ramayana, Lord Rama, also suffers depressive episodes. His ’once radiant body became all at one emaciated like the river floods subsiding in the summer; his red face became wan; he became despondent, absorbed in pensive thought and forgot to perform his daily allotted duties of life’. The poet’s description indicates psychomotor retardation, withdrawal, emaciation, depressed affect and the infectious quality of low mood [37]. His guru commented, ’The great delusion that has arisen in him is unlike any that springs from disappointment as of any desired object or out of a great accident’.

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Lord Rama expresses suicidal ideation and eventually kills himself. His death followed by an epidemic of suicide [ 11 ] . In Mahabharata [38], the family dispute between cousins leads one of the protagonists into depression when he realizes in battle that he will have to kill his relatives. The depressed hero, Arjun, experienced ’dry mouth, agitation, agitated thoughts, unsteadiness, wet palms and burning skin sensation.’ Venkoba Rao explained Arjun’s melancholia in psychodynamic terms [39]. At this point Lord Krishna offers counselling. Following the psychotherapy (which has been hailed as the masterpiece of psychotherapy [40]) the depression resolves. The inheritance of depression has also been described in other dynasties. Following Hindu teaching and the law of Karma, suicide was sanctioned as a religious ritual in the early Vedic period. Several Vedic hymns indicate that suicide was a prized sacrifice of the time [11]. Suicide was permitted in certain situations: Sati, at sacred sites (by drowning), incurable disease, and by ascetics [ 11 ] . Thus, despite their fictional nature, these accounts must accurately reflect their social context. If the authors described symptoms of melancholia and emphasized the significance of inheritance and life events, they must have been aware of these links. To discount such observations because they are only stories is to deny their contextual importance. The depressive’s premorbid personality is said to be obedient and obliging towards his elders. Sufferers are mute, rooted to one spot and dribbling saliva, with loss of appetite, somnolence, self-neglect, pale white face, fixed eyes, glazed look and preference for solitude. Onset occurs on the tenth day of the first (dark) fortnight (the period following full moon). was

Impotence Impotence is characterized by continual preoccupation with sexual thoughts and desires with a strong fear of approaching the partner. On approaching the partner, he becomes sweaty, breathes heavily and has palpitations. Diarrhoea and vomiting may occur. The causes may be organic or psychological [41 ] . Alcoholism (madatya) Eighty-four varieties of alcohol, their sources and individual qualities have been described [26]. There are three stages of influence, according to the level of alcohol intake (CS Vol V p.809-811). In the first stage, alcohol brings lightness of the body, supplies energy and sharpens mental faculties. It promotes sound sleep. It produces exhilaration, delight, a finer discrimination of the qualities of food and drink, and desire for music, songs, jokes and stores. In the second stage, the person becomes unbalanced. Both memory and intellect are impaired, the voice becomes thick, slurred and incoherent. Gait is unsteady and behaviour is improper. The third stage includes stupor, drowsiness, indifference to surroundings, transitory hallucinations and illusions. The person cannot differentiate between pain and pleasure and between good and evil. The person may become paralysed and loses his sense of pleasure. This also produces

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condemnation and censure by others. Alcohol reaching the brain disturbs all the ten qualities of the vital essence by its tenfold nature of action and thus leads to the derangement of the mind. As a result alcohol agitates the mind and its foundation (the heart), and quickly produces intoxication (CS Vol. V p.808). Alcoholism is of four types, the first three according to the three doshas and the fourth a combination (CS Vol. V p.813-816).

(i) Vata type. Usually affects individuals who are emaciated, but taking a limited quantity of dry food. Insomnia, chest pains, garrulity and tremors may result. (ii) Pitta type. Affects irritable individuals fond of hot and sour food. Symptoms include thirst, burning, fever, perspiration, diarrhoea, and icteric tinge of the body. The latter subsides quickly or leads to death. (iii) Kapha type. Such an individual likes sweet, fatty and nutritious food but leads a sedentary life. The symptoms are loss of appetite, vomiting, nausea, torpor, rigidity and heaviness of limbs. (iv) Tridosha type. Symptoms include generalized aches and pains, loss of appetite, dyspnoea, insomnia, vomiting, diarrhoea, visual hallucinations, delirium, confusion of mind, bad dreams and complaints of animals and birds crawling over the body. These varieties depend upon the premorbid personality of the individual as well as the type of alcohol consumed. Alcoholic dementia and alcoholic paranoia have also been described [10]. Treatment of alcoholism includes behavioural change, altered diet and mild diet.

Epilepsy (apasmar) Surviving descriptions suggest grand mal and petit mal as well as psychomotor epilepsy. Epilepsy is characterized by a paroxysmal loss of consciousness due to a disturbance of memory and understanding linked with fits. Fits involve spasmodic movements of eyes and eyebrows with dribbling of saliva. Other symptoms include impotence, anorexia, indigestion, abdominal distension, fractured bones, fainting and giddiness. The premorbid personality is often unclean, indulging in inappropriate bodily activities and dietary habits. Epilepsy is of four types:

(i) Vata type. There is usually a visual aura of jerky, fickle, harsh and dry objects. Frequent attacks of transient unconsciousness, associated with bulging eyes, incoherent speech, frothing of saliva, head drawn to one side, with irregular clenching of the fingers and vigorous movements of hands and feet.

(ii) Pitta type. Characterized by attacks of transient unconsciousness with stertorous breathing and tossing on the ground. Visual auras may precede the attack.

(iii) Kapha type. Slowly occurring attacks of

unconsciousness associated

180 with slow regaining of consciousness. There may be a visual aura, and strong convulsive movements do not occur.

(iv) Tridosha type. All regarded as incurable.

the above symptoms

are

combined and this form is

Issues in management and treatment The four basic elements of ’therapeusis’ are the physician, the drugs, the attendant and the patient (CS Vol. V p.54). Therapeusis is the name given to the combined operation of these four factors. Of the four components of therapeusis, the physician occupies the chief place, being at once the knower of disease and drugs, the instructor of the attendant and patient and prescriber of medicine and regimen (CS Vol. V p,55). The physician requires a clear grasp of theoretical knowledge, wide practical experience, skill and purity of body and mind - qualities surely relevant for his modern counterpart. One who has fourfold knowledge of aetiology, symptomatology, therapeutics and prophylaxis of diseases, is the best of physicians and is capable of curing all diseases. A wise physician should first examine the signs and symptoms and the patient’s environment. Information should be gathered using all five senses and should include authoritative testimony from wise men as well as other observers. The Ayurvedic physician should construct hypotheses and use imagination and logic to make diagnoses. The medication offered should be appropriate, abundantly available and wholesome (i.e., it should not cause any harm). It should also be available in various forms. A patient should co-operate by describing the symptoms without exaggeration, being courageous and following instructions. Marriott [42] and Nichter [43, 44] have described the role of traditional healers (vaids) and their modus operandi respectively. The attendant should have knowledge of nursing, skill, affection for the master (patient) and cleanliness (CS Vol. V p.55). Physicians are advised to treat the curable diseases, recognized as follows: (i) the causes, prodroma and symptoms are mild; (ii) the morbific factor is homologatory neither to the affected body element nor to the habitus of the patient, nor to the traits of the prevailing season; (iii) the site of disease is accessible to treatment; (iv) the disease is localized in one system, of recent onset and uncomplicated, and involves disorder of only a single humour; (v) the body is in a condition to withstand treatment; and (vi) the fourfold requisites of treatment are at hand. Formidable diseases are located in inaccessible parts, involve two humours and have spread to two systems. Incurable but palliable diseases are deep-seated, affect body elements, constantly relapse and still effect only two humours. Incurable and unmitigable diseases involve all three humours, spread to all systems of the body and cause sudden and extreme excitement, restlessness and stupefaction (CS Vol. v p.59-60). Available modalities of treatment included medication, psychotherapy and physical therapies. Before commencing medication, a thorough examination of

181 the

patient

and the diseases

was

recommended, including his residence, the type of morbidity

Medication could be used for individual symptoms or for whole. The principle was to select local herbs and medicines prepared by specially trained personnel under controlled conditions. Among traditional Indian medicines, Rauwolfia is probably the best known. The treatment of unmada consisted of cleaning and anointment with mustard oil, eating ghee for some days, and later giving strong purgatives and emetics with errhines and mustard oil. Curious or wonderful exhibitions were to be made before the patient and he would be informed of the deaths of relatives and friends. Light food such as barley and conjee water, made agreeable by the addition of carminatives, was recommended. During the cure the person should be treated, as much as possible, with kindness and consideration [8]. Treatment of bhutonmada (i.e., exogenous insanity) involved worship of the gods, to be performed in the house courtyard or at a crossroads. Other remedies like burning asafoetida, the waste products of certain animals, could also be used. Gupta [30] described the treatment of epilepsy which includes using decoction of Jotela, anointing the body with atuk and administering strong errhines, emetics and purgatives. In nervous diseases (bata byadhi), oily enemas, anointment, emetics, errhines and dietary restrictions were prescribed. seasons.

as a

As mentioned above, psychotherapy was used fairly extensively, especially in exogenous mental disorders. Talismans and charms were often employed, together with religious discourses and prayers. The patient’s relatives and friends were taught to calm him by religious and moral discourses. ’A person who has lost his mental balance due to loss of some object should be offered a substitute or, if it be not possible, words of sympathy and comfort. Another who has been affected by excess of grief, delight, envy or greed should be allayed by bringing the influence of opposite emotions to bear on the prevailing mood in order to neutralize it’ [10]. Guilt emanating from Karmic deeds was treated by culturally-determined observances, for example religious rituals, dietary restrictions [45]. Modern versions of such therapy have been used by psychiatrists in India. The role models of teacher-disciple in the Gita have been used as a paradigm for the practice of psychotherapy [46-49]. Venkoba Rao and others [50] have used traditional figures and characters from epics in explanations to their patients. They may employ parables and stories to facilitate rapport between therapist and patient and also to help the patient understand his life situation. Neki [51] has gone further to develop a conceptual framework of mental health, with elements of illumination, stability, spontaneity, harmony and freedom. He also emphasized [52] the cultural irrelevance of Western psychotherapy in India. Group therapy using the reading of shastras is sometimes used [53]. In addition, Agnihotra (a Vedic ritual of lighting a fire and adding various substances to it) has been used for treating drug addicts [54]. Physical treatments often included massage with oil. It was intended that patients should lie in the sun and be kept in comfortable rooms without

182

draughts. Yoga and meditation were frequently used in managing anxiety. Using principles of yoga [55], Vahia et al. [56-59] and Balakrishna et al. [60] has developed psychophysiological therapies. The patient first learns control of posture and breathing, followed by techniques of autonomic control and finally meditational techniques. The ultimate aim is constant and deep peace with optimum bodily functioning and social and environmental integration [56]. Shock therapy was used in some cases. Shocks were given using men trained as bandits, non-poisonous snakes, elephants, lions, etc. Threat to life was considered a more potent source of fear than mere bodily injury. Shock therapy was employed only in difficult and intractable cases. Even in modern clinical practice, it has been observed that psychotic patients get better after physical shocks, for example burns [61 ] . The signs of a man who has fully recovered from insanity include clarity of senses, perceptions, understanding, spirit and mind, together with a normal balance of the body elements (CS Vol. V p.617). A person is said to be healthy when the doshas and bodily elements in harmony, the digestion and excretion are normal, and the individual is endowed with tranquility and clarity of soul, the

mind and senses. Conclusions The

descriptions of various mental illnesses in ancient Indian texts are probably the oldest such accounts. Haldipur [62] suggested that any history of the origins of psychiatry should consider both the interventions used and their underlying concepts. The models of illness used by Ayurvedic medicine are fairly well described. According to Berrios [3], descriptive psychopathology is a languagebound activity which, despite its growing scientific formalization, depends upon written and oral traditions. As stated earlier, it is difficult to apply a single diagnostic system across different cultures and epochs. However, descriptive psychopathology can suggest which categories of distress were being recognized and trace whether those categories have changed over time. The author suggests that symptoms have changed little, despite radical changes in their interpretation and management. Ancient Indian texts represent an untapped resource of understanding and management of psychopathology. Collaboration between historians, Ayurvedic physicians and clinical psychiatrists is required to utilize their insights: clinicians need to see psychopathology in its socio-historical context and historians should try to understand the clinical context of

psychopathology. The role of religion is here emphasized, since religion is important in the diagnosis and management of many Indian patients, including those living abroad. Faith and the power of suggestion are important therapeutic factors, frequently employed by the religious temples [63]. Satyanad [64] emphasized: ’Religion is a definite pattern of ego-feeling and ego-boundaries are given specific functions. A particular self-concept, namely &dquo;who am I?&dquo; is its main

183

assumption.’ The therapeutic value of religious sentiment needs to be re-established. Fortunately, clinicians are beginning to use inventories developed from the epics to study areas of adjustment and life events [65]. A combined approach using psychiatric and spiritual insights has been shown to be effective in management of certain patients [66]. Clinicians need to assess traditional therapies more scientifically, as is apparent from studies of yogic exercises and other techniques [54]. The next step is to compare treatments in double blind trails, and to consider the implications for prevention of mental disorders. The tridoshic philosophy is still widely accepted among modern Indian patients. Folk beliefs of illness, due, for example to dietary imbalance, are still held among Asians living in the UK [67,68]. Traditional medicine thus continues to have a considerable influence among Asian and other cultures, and the ’naturalistic’ and ’personalistic’ paradigms are not incompatible [69, 70]. The roles of yoga, tantric practice and concepts of the nervous system in the genesis of mental illness have not been discussed [71-74] and will be reviewed elsewhere. The influence of Karmic thinking upon such concepts as the attribution of mental illness and locus of control needs to be examined. Symptoms of social and emotional withdrawal in some patients may be interpreted in terms of the Hindu and Buddhist philosophies of coping by withdrawal into oneself, rather than necessarily being regarded as passive-

aggressive posturing. Although, as explained above, it may be difficult to apply Western diagnostic categories, the philosophy and practice of Ayurveda have much to offer and modern clinicians should take up the challenge.

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