|Year : 2018 | Volume
| Issue : 6 | Page : 461-465
Preta grahonmada - Catatonia?
Kshama Gupta, Prasad Mamidi
Department of Kaya Chikitsa, Abhilashi Ayurvedic College and Research Institute, Abhilashi University, Mandi, Himachal Pradesh, India
|Date of Submission||23-Feb-2018|
|Date of Acceptance||05-Jul-2018|
|Date of Web Publication||15-Nov-2018|
Department of Kaya Chikitsa, Parul Institute of Ayurveda, Parul University, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
Unmada (a broad clinical entity which includes various psychiatric problems) is a major psychiatric condition described in Ayurvedic classics, and it is characterized by deranged mental functions. Unmaada is classified into two groups, doshajaunmaada (occurs due to vitiation of humors inside the body) and bhutonmaada or grahonmaada (not related to vitiation of humors and not caused by the factors inside the body). Bhootonmada is caused by the affliction of evil spirits or supernatural powers or extraterrestrial forces. Preta grahonmada (PG) is one among 18 types (deva, asura, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala) of grahonmada. Till date, no studies have been conducted on PG, and the present study aims at better understanding of PG along with its clinical utility. PG is characterized by Pretakriti, cheshta, and gandha (appearance, behavior/activities and emitting odor-like dead body), Trinacchedinam (purposeless activities), Bheetam (fear or anxiety), and Aahaaradveshinam (aversion to food). Catatonia is a complex neuropsychiatric syndrome characterized by a broad range of motor, speech, and behavioral abnormalities. “Waxy flexibility,” “posturing,” and “catalepsy” are among the well-recognized motor abnormalities associated with catatonia. Catatonia is characterized by the features such as stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypy, agitation, grimacing, echolalia, and echopraxia. Other common symptoms are motor resistance to simple commands, posturing, rigidity, automatic obedience, and repetitive movements. The features of PG have shown similarity with “Catatonia.” There is profound similarity found between PG and Catatonia.
Keywords: Catalepsy, catatonia, neuropsychiatric, Preta grahonmada, Unmada, waxy flexibility
|How to cite this article:|
Gupta K, Mamidi P. Preta grahonmada - Catatonia?. Med J DY Patil Vidyapeeth 2018;11:461-5
| Introduction|| |
Unmada (a broad clinical entity which include various psychiatric problems) is a major psychiatric condition described in Ayurvedic classics and it is characterized by deranged mental functions. “Bhutavidya” (Ayurvedic psychiatry) is one of the eight branches of Ayurveda. It is explained as the branch which lays down incantation and mode of exorcising, evil spirits and making offerings to deva (divine beings), pishacha (class of demon fond of flesh), gandharva (class of demon fond of entertainment), yaksha (living super natural being/ghost) and rakshasa (class of demon fond of violence) for the cure of diseases originating from their malignant influence. Unmaada is classified into two groups, doshajaunmaada (occurs due to vitiation of humors inside the body) and bhutonmaada or grahonmaada (not related to vitiation of humors and not caused by the factors inside the body). Sushruta has described eight types of bhutonmada, Charaka Samhita 11 types and in Ashtanga Hridaya 18 types are explained. The 18 types of bhutonmada are deva, asura, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana and vetala. Preta grahonmada (PG) is one among these 18 types of grahonmada.
There is no description available regarding PG in Charakasamhita,Sushrutasamhita and Madhavanidana. The lakshana's (signs and symptoms) of PG are explained in Ashtangasamgraha and Ashtangahridaya. The description of PG is similar in both texts (Ashtangasamgraha and Ashtangahridaya). PG is characterized by the features such as Pretakriti, Pretacheshta and Pretagandha (appearance, behavior, and emitting odor-like dead body), Trinacchedinam (purposeless activities), Bheetam (fear or anxiety) and Aahaaradveshinam (aversion to food)., Till date, no studies have been conducted on PG and it is an under explored the concept of Ayurveda. The present study is focused at better understanding of PG by correlating with the relevant modern psychiatric or neuropsychiatric conditions. The clinical picture of PG shows similarity with “Catatonia.” This similarity has been explored in the following sections.
| Review Methodology|| |
Ayurvedic material related to “Preta grahonmada”/“Grahonmada”/“Bhutonmada” was collected from major Ayurvedic texts with their commentaries such as, Charaka samhita, Sushruta samhita, Ashtanga sangraha, Ashtanga hridaya, and Madhava nidana. Materials pertaining to “Catatonia” (relevant) were collected from electronic databases “Google scholar search,” and “Google search” published/appeared from 2000 to December 2016. The key words used for search were, “Catatanoia,” “Catatonic schizophrenia,” “Mutism,” “Catatonia stupor,” “Psychomotor activity in Catatonia,” “Fear in catatonia,” “Anxiety in catatonia,” “Catalepsy,” “Waxy flexibility,” “Negativism in catatonia,” “Posturing in catatonia,” “Bhutonmada,” “Grahonmada,” and “Catatonia in Ayurveda.” Abstracts and full-text articles in English only were considered.
| Catatonia|| |
Catatonia is a syndrome of motor dysregulation associated with a variety of illnesses. The hallmark of the syndrome catatonia is stupor accompanied by psychomotor disturbances. Historically, catatonia was regarded as a complication of schizophrenia; however, recent evidence indicates catatonia's association with schizophrenia is merely historical and that most cases diagnosed in a psychiatric setting are associated with mood disorders. Although catatonia was described as linked with various neurological and medical conditions since its description, only in the last decade has catatonia been associated with autoimmune, infective, metabolic, and genetic disorders. Despite its common occurrence, catatonia remains a poorly understood, poorly studied, and poorly recognized syndrome, presenting with a variety of psychiatric and medical illnesses. Difficulties in the clinical conceptualization and management of catatonia have been called “the catatonic dilemma.” Many areas of overlap make the presentation of catatonia unclear. Clinicians do not recognize the often complex presentations of catatonia.
Catatonia is defined by the presence of three or more of the following symptoms;
- Catalepsy (passive induction of postures held against the gravity)
- Waxy flexibility (slight and even resistance to repositioning by the examiner)
- Stupor (no psychomotor activity and no reactivity to the environment)
- Agitation, not influenced by external stimuli
- Mutism (no or minimal verbal response)
- Negativism (opposing or not responding to external stimuli or instructions)
- Posturing (spontaneous and active maintenance of posture against gravity)
- Mannerism (odd caricatures of ordinary actions)
- Stereotypes (repetitive, frequent, and nongoal oriented movements)
- Echolalia (repeating the words spoken by the examiner)
- Echopraxia (mimicking of movements made by the examiner).
The catatonic syndrome is seen in two principal forms; hypokinetic (withdrawn type), or hyperkinetic (excited type). Some patients may display the features of both types during the course of the illness. Patients with hypokinetic or withdrawn type of catatonia, typically appear awake, watchful, but with minimal spontaneous speech and movement. It is commonly associated with mutism, stupor, negativism, obsessional slowness and posturing. Hyperkinetic or excited type catatonia is characterized by agitation, combativeness, verbigeration (disorganized over productive speech), stereotypies, grimacing and echophenomena.
| Similarity between Preta Grahonmada and Catatonia|| |
There is striking similarity found between the two conditions, i.e., PG and Catatonia.
| Similarity of Etiology, Pathogenesis, Course, and Prognosis of Preta Grahonmada and Catatonia|| |
As there is no specific etiology, pathogenesis, course, and prognosis mentioned in Ayurvedic classical texts for PG, the common etiology, course, and prognosis mentioned for Bhutonmada/Grahonmada is applicable for PG also. In Bhootonmada, the symptoms occur suddenly without any visible reason. Bhutonmada/Grahonmada is precipitated by chidrakaala (various stressful factors) and the course of the disease is also unpredictable. The occurrence or aggravation of symptoms in bhutonmada is not specific. The prognosis of bhutonmada is also unpredictable. Pragyaparadha (intellectual blasphemy) and Karma (idiopathic factors) are the basic factors behind the pathogenesis of bhutonmada. For PG also (just like other bhutonmada's) the etiopathology, course, and prognosis are idiopathic/unpredictable. No specific etiology, pathogenesis, course, and prognosis are explained for PG in Ayurvedic texts; only the description of PG lakshana's is available.,,,,
Catatonia used to have an extremely variable prognosis, ranging from good recovery to acute onset with rapid progression to death. The greatest factor in determining prognosis in a catatonic syndrome is the nature and severity of comorbid or underlying conditions. Catatonia usually presents acutely but may present insidiously. Catatonia can be transient or chronic, and last for weeks, months, and even years. Catatonic patients are at risk for severe complications such as pneumonia, decubitus ulcers, malnutrition, dehydration, contractures and thrombosis, and delay in diagnosis and management are associated with increased morbidity. Although it may become life-threatening, catatonia has an excellent prognosis if recognized and treated early. Various features of catatonia or catatonic syndrome like the complex, overlapping clinical presentation, variable prognosis, unknown psychopathology and idiopathic presentation resembles with the etiopathology, course, and prognosis as explained for Grahonmada/Bhutonmada.
| Similarity of Clinical Picture in between Preta Grahonmada and Catatnoia|| |
Various lakshana's of PG such as Pretakriti, Pretacheshta, Pretagandha, Trinacchedinam, Bheetam, and Aahaaradveshinam features resembles with various features of hypokinetic or withdrawn type of catatonia. The similarity in between the signs and symptoms of these two conditions (PG and Catatonia) is as follows;
| Pretakriti (Appearance Like Dead Body)|| |
Catatonia is one of the most perplexing of all psychiatric syndromes. For no apparent reason, a person may become mute, freeze for minutes or hours on end without any discernable awareness of the outside world, appear seemingly impervious to pain, and allow their limbs to be bent in all sorts of awkward positions. Kahlbaum has described the primary characteristics of catatonia as follows: the patient remains entirely motionless, without speaking, and with a rigid, mask-like facies, the eyes focused at a distance; patient seems devoid of any will to move or react to any stimuli; there may be fully developed “waxen” flexibility as in cataleptic states. The general impression conveyed by such patients is an immobility induced by severe mental shock. In hypokinetic or withdrawn type of catatonia, the patient appears to be awake and watchful, but with minimal spontaneous speech and movement. It is commonly associated with mutism, stupor, negativism, obsessional slowness and posturing. “Mutism”– ranges from complete to partial. Some patients may mumble or utter brief and often incomprehensible phrases. “Immobility”– Some patients may lie in the bed for long periods, neither moving, blinking nor even swallowing, others may make brief movements probably to change their posture. “Waxy flexibility”– “Lead pipe” rigidity combined with tendency to place limbs in awkward positions for prolonged period of times. “Automatic obedience”– doing exactly what they are told even if it puts them in danger. Motor immobility is described along with negativism, automatic obedience, mutism, echopraxia, and verbigeration in catatonia. Various features seen in catatonia such as mutism, catatonic stupor (absence of psychomotor activity and not reacting to external stimulus), catalepsy, negativism, posturing, waxy flexibility, grimacing, rigidity and immobility denotes “Pretaakriti” or appearance-like a dead body as explained in PG.
| Pretacheshta (Behavior-Like Dead Body)|| |
Pretacheshta of PG denotes lack of movements or immobility such as a dead body. In catatonia also, similar features can be seen. Catatonia is a complex neuropsychiatric syndrome characterized by a broad range of motor, speech, and behavioral abnormalities. “Waxy flexibility,” “posturing” and “catalepsy” are among the well-recognized motor abnormalities seen in catatonia. “Mutism,” manifested by minimal, or no verbal communication, and probably, the most frequently observed sign of catatonia; however, the diagnosis is not applicable in the presence of aphasia. Although typically associated with hypokinetic catatonia. “Catatonic stupor” is manifested by patient's absence of movement or other reaction to any stimulus while awake. Patient is extremely hypoactive, immobile, and minimally responsive to stimuli including pain. Stupor can occur independently or in combination with mutism. “Waxy flexibility” is a motor sign of catatonia elicited by the examiner who manipulates the body or extremities to assume certain postures which the patient can maintain for a prolong periods of time. There may be an initial resistance which is soon followed by slow release, as if bending a warm candle hence the term waxy flexibility. “Catalepsy” refers to the maintenance of fixed postures in the sitting or standing position for prolong periods of time with minimal movement regardless of external stimuli, including pain. The positions assumed by the patient are unusual and appear uncomfortable to the observer. The patients can adopt statuesque postures with minimal movement lasting for several hours without any apparent fatigue or discomfort. Other examples include twisting of the body, standing on one leg like a stork, holding one arm outstretched for a long time and also squatting with extension of arms. “Rigidity” consists of a stiff position which the patient attempts to maintain despite efforts to be moved. The state of withdrawal, also interpreted as “social negativism,” is a condition manifested by the patient's refusal to eat, drink, or make eye contact. Various features such as mutism, catatonic stupor, waxy flexibility, catalepsy, and rigidity of catatonia are similar to “Pretacheshta” described in PG.
| Pretagandha (Emitting Odor Like Dead Body)|| |
Decline of activities of daily living (ADL), bowel and bladder incontinence, disruptions in cognition along with psychotic or quasi-psychotic features may be the causative factors for lack of personal care, loss of hygiene, and emitting foul smell in catatonia patient. The presence of the symptoms such as, stupor, catalepsy, negativism, posturing, motor resistance to commands, rigidity and chronic, deteriorating illness of catatonia may be the factors for lack of personal care, and ultimately leading to bad odor. The immobile, rigid catatonics are often at risk of the malignant syndrome. While standing, sitting, or lying down for extended periods of time, they develop pooling of lymphatic and vascular fluids, with possible separation of proteins from aqueous serum. Immobile catatonics are also at risk for pulmonary emboli, edema, and dehydration of moist membranes. Dry sclera puts the eyes at risk for ulceration and infection. Protracted rigidity leads to rhabdomyolysis and kidney failure. Many cases of immobile catatonia develop fever, it is always serious and potentially life-threatening. Catatonia is more frequently associated with mania, melancholia, and psychotic depression. Karl Kahlbaum described catatonia as an independent psychiatric syndrome characterized by cyclic course and alternating manic, depressive, and psychotic phases, with an eventual deteriorative course. Catatonia can accompany many different psychiatric illnesses and somatic diseases. Catatonic patients suffer from schizophrenia (30%), while a majority has a bipolar disorder (43%). Catatonia is such a chronic, deteriorating, progressive condition comorbid with mood disorders such as depression and psychotic conditions such as schizophrenia which leads to severe impairment in ADL, total lack of self-care, and poor hygiene and the patient may emit bad odor due to these factors.“Pretagandha” of PG denotes lack of personal care, lack of hygiene and emitting bad odor in a chronic, deteriorating, and immobile catatonic patient.
| Trinacchedinam (Purposeless Activities)|| |
The word “Trinacchedinam” refers to “plucking grass with toes.” It is one of the lakshana's of PG. Trinacchedinam refers to purposeless activities or mannerisms or stereotypies or increased motor activity or agitation of catatonia. One of the main symptoms of catatonia are “a change in motor activity” (reduced or less often increased motor activity) and unusual movements (stereotyies, grimacing, infrequent blinking, motor or vocal tics, posturing etc). Patients of catatonia with schizophrenia have shown disorganized activity. Stereotypic movements (which are repetitive, frequent, and nongoal directed movements) and mannerisms (odd caricatures of ordinary actions) are also features of catatonia., In excited type of catatonia, purposeless behavior, excessive movements, and also movements which are often awkward, wooden, and bizarre are seen. Periods of agitation in catatonia are characterized by extreme hyperactivity with constant motor unrest and purposeless motor activity, and the patient may collapse eventually from exhaustion. Stereotypy is a common movement disorder seen in catatonia which is defined as involuntary, coordinated, patterned, rhythmic, seemingly purposeless movement, or utterance performed repeatedly over time. Some of the motor stereotypies that are seen in catatonia include body rocking, hand waving, nose wrinkling, shoulder shrugging, and repetitive mouth and jaw movements. Mannerisms are another clinical feature of catatonia characterized by repetitive, idiosyncratic movements or gestures that are unique to the individual such as suing hands when talking. Catatonic excitement refers to extreme hyperactivity with constant motor restlessness which is apparently nonpurposeful. Stereotypy, mannerisms, and agitation of catatonia denotes “Trinacchedinam” of PG.
| Bheetam (Fear or Anxiety)|| |
The thesis that catatonia may primarily be a fear reaction, closely related to the animal defence strategy “tonic immobility” (immobility characterized by muscular tension), is not a new one. Catatonia is now seen as a largely nonspecific syndrome. Vast majority of the persons experiencing catatonic stupor report feeling “frozen” or “petrified” and experience “extreme fear” during the episode. According to a study, using the “Hamilton Anxiety Scale,” it was found that there is a strong and significant correlation between anxiety and catatonic symptoms. Thus, although limited research has been conducted to date, severe anxiety has been reported in psychiatric, iatrogenic and medical catatonias. The concept of catatonia as a fear response provides more explanatory power than the dominant view of catatonia as a motor disorder. Although the latter is superficially accurate, it is unable to adequately explain many aspects of catatonia, such as the presence of anxious and fearful expressions, the potential lethality, the communicative abnormalities, and the presence of undirected aggressive behavior. Catatonia as a fear response can explain all of the above in addition to the motor disturbances. Who develop catatonic symptoms are vulnerable personalities, specifically higher levels of anxiety and impulsivity traits as well as in substantial number of patients to the extent of personality disorder level of psychopathology. It seems that fear or anxiety seen in catatonia resembles with “bheetam” explained in PG.
| Aahaaradveshinam (Aversion to Food)|| |
Changes in oral intake-like reduced appetite, slowing down of food intake along with decline of ADL are main features of catatonia or catatonic syndrome. Reduced food intake, albeit related to reduced speed, chewing, or swallowing has been observed in patients of catatonia. It was also observed that despite there is reduced speed, reduced food intake and decline in functioning in the patients of catatonia, they were remained well fed and kept relatively active by the care taken by their family members. Negativism is one of the features of catatonia in which the patients fail to do what is expected or does opposite of it (refusal of food?). “Social negativism” which is also a feature of catatonia may include “turning away when addressed, refusing to open the eyes and closing the mouth when offered food or liquids.” The state of withdrawal, also interpreted as “Social negativism” is a condition manifested by the patient's refusal to eat, drink, or make eye contact. Various features of catatonia such as catalepsy, catatonic stupor, negativism, posturing, mutism, and rigidity may be responsible for refusal to take food and liquids in catatonic patients. “Aahaaradveshinam” explained in PG seems to be equivalent to refusal to take food due to social negativism or catalepsy or rigidity of catatonia.
| Conclusion|| |
“Preta grahonmada” is one among 18 types of bhutonmada. The signs and symptoms of PG have shown similarity with catatonia. Signs and symptoms of PG such as pretakriti, pretacheshta, pretagandha, trinacchedinam, bheetam and aahaaradveshinam resembles with the features of catatonia such as mutism, catatonic stupor, posturing, waxy flexibility, catalepsy, negativism, stereotypy, mannerisms, catatonic rigidity, agitation, and grimacing. Preta grahnomada resembles catatonia.
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