Manovikaras -  Psychological; Disorders   With Special   Reference -To   Satwavajaya Chikitsa  -Enlightening    Psycho - Behavioral Therapy.
B.S. Venkataram Ex-Director, CRI (Ay.), Ccras.

A careful reading of charaka samhita reveals that the study of manasm vyadhi - menial disorder was an area specialization and that the experts in the speciality -manasavyadhi bheshajavedi (psychiatrists) existed in the past. According to ayurveda, sharera (body) and manah (mind) are the two adhisthanas (seats) of disease manifestation. The discordance of doshas (bio-functional entities) is 'disease' while their harmonious state is 'health'
Diseases are classified from different viewpoints for facilitating accurate diagnosis and effective management. Under one such classification vyadhi is categorized as shariradhisthta, manodhistitha and ubhayadhisthita meaning physical, psychological and dual type diseases. In physical diseases (he involvement of shareera doshas viz., Vata, pitta, kapha will be predominant. Psychological disorders will have dominant involvement of manodoshas viz., Rajas and tamas - the impelling and impeding forces of mind. In dual type diseases, the active involvement of both shareera doshas and manodoshas will be very clearly observable.

Kama (passion), krodha (anger), chittodwega (anxiety), bhaya (fear) and a number of other emotional states have been quoted as manodhisthtitha vikaras or manovikaras. Unmada (functional psychosis), apasmara (epilepsy) arc the examples given for ubhayadhistita vikaras -/dual type diseases. Shareerika vikaras (physical diseases) like jwara (fever), kustha (dermatitis), atisara (diarrhoea) and many others have been dealt with elaborately in terms of their aetiology, types, pathogenesis, treatment, prognosis, diet and other details. No such descriptions are available for any of the conditions under manovikaras. Therefore considerable difficulty is faced in understanding them. On the other hand, the dual type diseases like unmada, and apasmara which are generally recognized under manovikaras by ayurvedic practitioners have also been well documented in the classics like other physical diseases. Kashayapa observes that 'psychological disorders are to be managed like physical diseases. It may be difficult sometimes to follow this recommendation. Physical diseases are well managed through yukti vyapashraya chikitsa (rational therapy) - i.e. a successful management of manovikaras and ubhayadhisthita vikaras which have the active involvement of manas depends more on satwavajaya chikitsa (enlightening psycho behavioral therapy) -s.c. and daivaivyapashraya chikitsa (divine therapy) - d.c. these therapies can directly influence manah, but in actual practice y.c. is given more importance instead of s.c. and d.c. this outlook prevents total remission of the illness as seen often
On the basis of the classical descriptions, mamovikaras can be defined as a group of clinical conditions affecting the individuals with alpasatwa (weak psyche) and characterized by behavioral changes in them due to:
A.   Discordance of manodoshas or both manodoshas and shareera dosha
B.   Vitiation of manovaha srotamasi (channels carrying psychological impulses);
C.   Impairment of function of manah viz., Indrayabhigraha (perception and motor control), manonigraha (mental control), ooha (guess) and vichara (thought)
D. Changes in one or more of the eight factors in charaka's definition of unmada viz., Manah (mind), buddhi (decision), smrthi (memory), sanjnajnana (orientation and responsiveness), bhakthi (desire), sheela (habit and temperament), chesta (psycho motor activity) and achara (conduct), warranting active s.c. and d.c. along with y.c.

  1. Classification of manovikaras (psychological conditions). Manodhisthita vikara (m.v.): under this group conditions reflecting exaggerated emotions in individuals with alpasatwa are listed. They can be understood as emotional disorders or neurotic conditions best managed with s.c. and d.c. with secondary y .c.

Kama - passion; b. Krodha - anger; c. Lobha - greed; d. Moha -infatuation; e. Irsha - envy, manah - pride; g. Shoka - grief; it. Chiltodvega - anxiety; i. Chinta - worry; j. Bhaya - fear; k. Harsha -jubilation; i. Vishada - anguish; m. Abhyasuya-jealousy; n. Matsarya- hostility, and others. (c.v.6; s.su. 1).
2.    Ubhayadhisthita vikara (u.v.). On studying the various disease conditions described in the classics, it is possible to consider two groups of u.v. with significant involvement of manah (mind) as u.v.a. and u.v.b.
Ubhayadhisthita vikara-a (u.v.A.): These conditions which are caused/triggered by active involvement of manodoshas, often present themselves as physical disorders in the individuals-with --alpasatwa. They do not respond adequately to y.c, until the imbalance of manodoshas is resolved and tranquility of mind restored/achieved. S.c. plays an important role in their successful management in addition to y.c. these can be considered under somatised neurotic conditions a. jwara (fever) due to kama, krodha, shoka, abhishapa (curse), abhichara (sorcery); b. Atisara (diarrhoea) due to bhaya , shoka; c. Shosha (emaciation) due to shoka; d. Stanyanasha (loss of breast milk) due to shoka, krodha; e. Manasa arochaka (stress triggered anorexia); f. Dwistarthayogaja chardi (vomiting due to contact with nasty objects g. garbhasrava (abortion) /garbhachyuti (miscarriage) (due to shoka, krodha, bhaya, udvega, and other such conditions (c.su.25; c.c.3; c.c.19; s.u. 41; V.u. 23; v.n. 5; V.sh. 1).
Common stress related disorders like hypertension, bronchitis, pruritis, diabetes, gastritis, irritable bowel syndrome and others may also be considered along with these conditions.
Ubhayadhisthita vikara-b (u.v.B). These conditions are caused due to the prolonged indulgence by the individual with alpasatwa, in unwholesome diet and erratic behavior / activities of daily living. Shareera doshas gradually get vitiated and adversely affect the manodoshas. These are treated with active y.c. and s.c. as well as D.c. with equal importance. Functional psychotic conditions can be studied under this group. Some of the conditions listed are mentioned under nanatmaja vikaras. Although managed with y.c., the role of s.c. and d.c. for their total successful management cannot be underscored since these conditions also are intimately related to mental activities .a. Unmada (psychosis); b. Apasmara (epilepsy); c. Apatantraka (puerperal psychosis); d. Mada (intoxication); e, moorcha (fainting); f. Sanyasa (syncope); g. madatyaya (alcoholic psychosis); h. Jalasantrasa (hydrophobia); i. Atatwabhi nivesha (alzemiers?) (obsessive compulsive disorders);], aswapna i,(insomnia); k. Tandra (stupor); L. Nidradhikya (hypersomnia); m. Anavasthita chitiatwa (fickle mindedness); n. Atipralapa (prating); o. Ashabda shravvana (auditory hallucination); p. Bhrama (giddiness); q. Tama pravesha (blackout) and other such conditions (c.su.120; c.su.24; c.n.7; c.,n.8; c.c.9; c.c.10; c.si.9; s.k.7; S.u.62).
Probable sequence in the clinical manifestation of manovikaras
1.      Manodhistita vikara (tn.v.): alpasatwa (as) + mithyavihara (miv)—mano dosha prakopa (mdp) - Shareera Dosha prakopa (sdp) -mano vaha srothovaigunya (msv) - manah karma vikriti (mkv) — vikara pradhurbhava (vp).
2.      Ubhayadhisthita vikara-a (u.v a), as + miv + ma - sudden violent mdp - sdp -msv— mkv - vp.
3.      Ubhayadhisthita vikara B-  (u.v. B). as- ma + miv - sdp -i- mdp - msv - mkv - vp.
Comparative descriptions of clinical conditions under Manodhistita vikara,(m.v.), Ubhayadistita vikara A (u.v.A) and Ubhayadistita vikara B (u.v.B) Groups.
\ manodhistita vikara (m.v.):          ,
1.   Cause

  1. Mithyavihara (miv) (prajnaparadha - erratic behaviour / ADL.

B alpasatvva ( weak psyche)
2.    Process of onset
A.     Primary imbalance of manodosha ; b. Secondary minimal involvement of secondary dosha ; c. Mild manovahasroto vaigunya (vitiation/obstruction in the pathways of mind); d. Swanigraha (self control) e. Vichara (thinking) functions of manah affected; e.; .sheela and chesta disturbance, mild to moderate of Prakruti not affected; f manifested as mild to moderate emotional disturbance with mild to moderate physical discomforts; g. Prakruti not affected.
3.     Treatment.
A.        Patient aware of his condition approaches the doctor for treatment, b. Condition well managed with primary collaborative satwavajaya chikitsa of a type and secondary concurrent palliative y.c. suitable d.c. chosen with patient's consent also beneficial during the period of treatment and even later to prevent recurrence.
Ubhayadhisthita vikara A
Cause: similar to Manodhisthita vikara.
2.    Process of onset
A and b. Sudden intense imbalance of manodosha due to menial stress resulting in mild to moderate involvement of shareeradosha. C. Sudden momentary intense vitiation in the pathways of mind; d. Swanigraha severely affected; e. As in in.v; f. Manifested as physical illness consequent to severe mental shock or intense emotional state; g. As in m.v.
Treatment  :-
Responds to y,c. Only if the underlying emotional disturbances are resolved. well managed with y.c with \  current s.c. of a type. Suitable d.c. chosen with patient's consent can be beneficial during the treatment and even later to prevent recurrence.
Ubhayadistita vikara B
1 Cause: a. Mithyahara (unwholesome food) and mithya vihara (prajnaparadha) -erratic behavior /ADL h. As in mv.
2.   Process of onset
A.   Gradual accumulation and vitiation of shareeradosha ; b. Gradual or sudden imbalance of manodosha; c.  Severe
vitiation/obstruction in pathways of mind; d. In general, all functions of  mana grossly disturbed in varied degrees; e. Sheela, chesta, achara, manah, budhi etc; are distinctly affected in varied degrees; f. Manifested as a severe mental disturbance with abnormal behavioural changes and distinctive physical signs and symptoms depending on the doshas involved; g, prakrti severely affected.
Treatment  :-
Patient not aware of his condition often, socially disturbing , usually brought by relatives/friends for treatment. Generally managed with y.c. with active purificatory measures and palliative drugs with suitable diet. Sc of b type required on short/long term duration. L)c can be of significant benefit both during illness and even later for prevention of relapses.
Three treatment strategies in Ayurveda
1.   Daivavypashraya (divine therapy) -dc. - making use of mantra (incantations), oushadha (herbs), mani (gems), mangala (propitiatory rites), bali (oblations), upahara (offerings), homa (sacrifice), niyama (vows), prayaschilta (expiation), swastyayana (benedictions), pranipata (prostrations), gamana (pilgrimage), etc.
2.   Yuktivyapashraya (rational therapy) - yc - judicious administration of diet and drugs.
3.   Satwavajaya (enlightening psycho behavioural therapy) - sc - restoration of satwa (state of mental clarity) and weakening the negative influence of rajas and lamas in order to withdraw mind from indulging in unwholesome objects.
C.su. 11.
Satwawajaya Chikitsa - Enlightening Psycho Behavioural Therapy
Satwa is the natural positive state of consciousness or state of mental clarity. Rajas and tamas are the other two not so positive but strong impelling and impeding characters of mind. In a state of illness, satwa is strained and the mind indulges in unwholesome objects. In Manodhistita vikaras, and both Ubhayadistita vikaras (a and b) type of disorders where in mana is involved this will be more obvious due to the strong influence of rajs and tamas. The aim of this therapy is to withdraw mind from indulging in unwholesome objects. This is achieved by diluting the negative effects of rajas and tamas go restore satwa the positive stale of mind.
The descriptions available in the chapters on unmade and others in Charaka Samhita and Sushsrutha Samhita are indicative of the measures used under s.c., let us examine.
1.   The patient's well wishers may calm him with words of religious or moral import. They may announce the loss of something he dearly loves or show him some marvels to bring his agitated mind to normalcy,
2.    Intimidation, thrashing, terrorizing, coaxing by offering the object craved for, exhilaration or causing delight, pacification, frightening and astonishing. These being causative of forgetfulness serve to reclaim the mind to normality from its insane fixation.
3.   The imbalance of manodosha is resolved through spiritual knowledge, professional expertise, fortitude or self-confidence, memory and concentration.
4.   Mental disorders resulting from an excess of desire, grief, delight, envy or greed should be allayed by bringing the influence of mutually opposite emotions to neutralise the prevailing ones. C. su. l, C.c.9; su. 62.
A careful review   of these descriptions enables grouping this therapy under two categories -- a and b considering their practical utility.
Category a: (collaborative).
Ashwasana - verbal assurances
Santwana - consoling
Dhee prabhodana - inducing intelligence
Dhairya pravardhana - confidence/courage building
Jnana bodhana- kducating on higher values of life
Vijnana bodhana - facilitating professional excellence.
Smriti vardhana - enhancing memory
Samadhi vardhana — helping to enhance sustained concentration.
These measures are suitable in patients who are aware of their emotion-linked problems, well motivated to regain health, approach the therapist voluntarily and Extend active co-operation to the therapist during treatment.
Category B ( prescriptive)
Vismaya - perplexing
Harshana - causing delight
Trasana - scaring
Tarjana - intimidation
Tadana - beating
Dehadukha bhayotpadana causing Fear of physical pain
Pranabhayotpadana - causing fear of death
These measures can be very beneficial in patients who are not aware or adequately aware of their conditions, exhibit abnormal behavioural changes, not motivated, usually brought to the therapist by their relatives or friends, do not extend adequate co-operation in the management, remain passive recipients of therapy, sometimes requiring measures that inllict physical pain or even fear of death temporarily in order to withdraw mind which is violently agitated / astrayed,
In view of the above, it is possible to conclude that the a type is more suitable in the management of m.v. , u.v.A and very few of the u.v.B disorders. B type is more suitable in the management of unmada the most important condition and certain stages of madatyaya under u.v.B disorders.
Treating manovikaras dominated by certain specific emotions through their opposite ones will have to be planned and administered very cautiously for two reasons; first, the emotions are usually interlinked and second, it is not easy to fix one emotion X as the opposite of another emotion Y
In addition to the above, instructions under achararasayana, sadvitta, lokapurusha sambandha, manovegadharana and dinacharya of which enhance the quality of life and state of satva by aiding personality development, verbal skills, worldly wisdom, commitment to social obligations, Eco-friendly life style, are to be followed to the possible extent during and even after treatment. They bestow total relaxation and make mind strong and disciplined to remain in a state of equipoise without yielding to the negative influences of rajas and lamas and release positive energies and strengthening immune systems.
Means of SC: counseling using real life instances, biographies of great personalities, sheela, stories of panchatantra, ramayana, mahabharatha and AV aids, music, yoga, vocational training programmes and the like to keep the mind engaged in a positive and productive activity.
Dc measures have been recommended as an active component of treatment in a number of diseases including those where manah is mainly involved like unmada, apasmara, certain types of jwara, madatyaya and others.
Unfortunately dc does not find the place it merits in today's practice. It is necessary to realize the importance of dc which is aimed at augmenting satwa, the positive mental slate and include it as a necessary constituent to be administered properly in the treatment of manovikaras in particular. The religious background/belief of the patient and the kind of manovikara suffered should be considered before adopting dc measures.
Manovikara   chikitsa   -   management   of   psychological disorders.
Recommended order to be followed in adopting the three management strategies in different types of manovikara.
1.   MV:
A)   long term of s.c. of a type; b. selective d. c and c) y.c. with emphasis on satvvika ahara (balanced diet) and shamanaoushadha (palliative drugs).
2.   UVA:
A)   y.c. with due stress on palliative drugs and light food; b) s.c. of a type and c) selective d.c.
3.   UVB:
A)   y c,   with   emphasis   on   both   shodhana   (purificatory)   and   shamana (palliative) measures/drugs and wholesome diet; b) short or long term s. c. of B type depending on the condition of the patient and c) concurrent well planned medium/long term d.c.