AYURVEDIC TREATMENTS
Excerpted from: Prathikanti, S. Ayurvedic Treatments. In Lake, J and Spiegel, D (ed.),
Clinical Manual of Complementary and Alternative Treatments in Mental Health.
Washington, DC: American Psychiatric Press, Inc. 2006.
Introduction
Ayurveda (ah' yoor vay da) is the indigenous health and healing system of India. Most scholars regard Ayurveda as the oldest extant medical tradition in the world, with Ayurvedic remedies appearing in the Rig Veda more than 6000 years ago. The word Ayurveda is derived from two Sanskrit roots: ayu meaning “life” or “living,” and veda, meaning “knowledge.” Thus, Ayurveda is the “knowledge of living,” and concerns itself with maximizing health, vitality and longevity through wise lifestyle choices. Ayurveda offers treatment for thousands of ailments, but its primary emphasis is on preventing illness and optimizing health through careful attention to one's nutrition, activity, circadian rhythms, seasonal and environmental influences, psychological attitudes, and spiritual practices.
Five Elements and Three Doshas
In the Ayurvedic worldview, all aspects of the universe, including human beings, are a manifestation of panchamahabhuta, or Five Great Elements: Space, Air, Fire, Water and Earth. Bhuta is often translated from Sanskrit as “element,” but in this context, an element is not a concrete substance. Rather, each great element may be viewed as a creative energy with its own special attributes. For example, the creative Element of Space has the attribute of expansiveness, Air the attributes of lightness and mobility, Fire the attributes of heat and luminosity, Water the attribute of moistness and Earth the attribute of solidity. The manifestation of these five great elements in countless permutations and combinations gives rise to the cosmos.
The grossest expression of the five great elements is in physical matter, including all structures of the human body. However, the five great elements also manifest in more subtle, dynamic form called doshas or bio-energetic principles. Each dosha is a combination of two great elements and possesses the attributes of its component elements. There are three doshas in all: Vata, Pitta, and Kapha. All the physiological functions and bio-energetic processes collectively called life-from respiration and metabolism to feeling and thinking-are governed by Vata, Pitta and Kapha.
All three doshas-Vata, Pitta and Kapha-are necessary for life. However, at birth, each human being is endowed with a unique proportion of each dosha. This unique balance of Vata, Pitta and Kapha is called the individual's constitution. From an Ayurvedic perspective, one is healthy and has optimal somato-psychic functioning when all three doshas are “in balance”--that is, when the three doshas remain in the unique proportions characteristic of one's constitution. The three doshas in constitutional balance are said to confer enormous immunity, resilience and recuperative energy. An individual who maintains tri-dosha balance has the intrinsic capacity to metabolize and heal from a great deal of physical and emotional stress. Throughout life, however, any number of factors-both internal and external-can disturb one's tri-dosha balance. With sustained imbalance of the three doshas, there is impaired capacity to meet biological and psychological challenges, and illness eventually ensues. Thus, health is a dynamic process that relies on each person sustaining the doshas in the optimal proportions comprising his or her constitution. Health is sustained tri-dosha balance while illness is sustained tri-dosha imbalance.
Ayurveda views the mind (manas) as being created and sustained by the same Five Great Elements as the body (shareera). However, in the mind, the generative potential of the Great Elements does not manifest as tangible body tissues, but as subtle “structures” of consciousness, such as ego (ahankara), will (ittcha), and intellect (buddhi). Vata, Pitta and Kapha-the bio-energetic principles derived from the Great Elements--govern not only different somatic functions, but also different mental functions. Vata, the bio-energetic principle of movement, enables the mind to be mobile, perceptive, and expressive. Pitta, the bio-energetic principle of heating and transformation, allows the mind to properly “digest” sensory input and formulate correct responses. Kapha, the bio-energetic principle of binding and stabilizing, allows the mind to have equipoise and long term memory. In concert, the three doshas create unique patterns of perceiving, thinking, feeling, remembering and reacting that comprise an individual's special personality and temperament.
When Vata, Pitta and Kapha are in balance, harmony prevails at both the psychological and the physical level. Sustained imbalance of any dosha tends to precipitate illness, which may be classified broadly as follows: 1) illness with predominance of somatic disturbance, 2) illness with predominance of psychological disturbance, or 3) illness with significant somatic and psychological disturbance. The tendency toward a specific dosha imbalance and the tendency to develop illness with significant psychological features are both influenced by one's unique constitution as well as one's lifestyle and environment.
Interestingly, in ancient Ayurvedic nosology, insanity (unmada) is classified as an illness with significant somatic and psychological disturbance. According to Charaka, unmada is characterized by abnormalities in behavior, speech, cognition, affect, and body habitus:
[A person with unmada] shows confusion of the intellect, extreme fickleness of mind, agitation of the eyes, unsteadiness, incoherence of speech, mental vacuity… and is unable to know pleasure from pain, and right behavior or duty. Deprived of memory, understanding or his wits, he keeps his mind wavering restlessly…and [may be] wasted in his body. (Charika Samhita, as quoted by Haldipur, 1984)
Moreover, the nature of psychological and somatic symptoms associated with unmada varies according to whether the afflicted individual is of Vata, Pitta or Kapha predominance.
[A Vata-type unmada is marked by] laughing, smiling, dancing, singing, speaking, bodily movements and weeping-- all of which are out of place--and leanness of the body and reddish complexion. [A Pitta-type unmada is marked by] impatience, fury, nudity, wrathful abuse of others, running away, heat of body, rage, desire for cool food and drink, and a yellow complexion. [A Kapha-type unmada is marked by] excessive sleep, silence, little disposition for movement, dribbling of saliva or nasal discharge, disinclination for food, love of solitude, and pallor. (Charika Samhita, as quoted by Haldipur, 1984)
In general, Vata imbalance with extreme psychological disturbance may result in paranoia, hallucinations, or manic features. Pitta imbalance with extreme psychological disturbance tends to be associated with aggression, violence or antisocial behavior. Finally, Kapha imbalance with extreme psychological disturbance involves apathy, abulia, social withdrawal, or mutism.
From the various ancient descriptions of unmada, it seems this Ayurvedic diagnosis may have encompassed a wide range of modern-day psychotic presentations, including bipolar mania, schizophrenia, depression with psychosis, or delirium with psychosis. A one-to-one correspondence between Ayurvedic and DSM diagnoses is unlikely. Still, in perusing the ancient texts, there is a clear concordance between many Ayurvedic syndromes and modern day categories of psychiatric illness. For example, Ayurvedic signs and symptoms for cittavasada (depression), cittodvega (anxiety disorder), atattvabhinivesa (obsession), apatantraka (hysteria/conversion disorder), gagodvega (hypochondriasis), and madatyaya (alcoholism) quickly strike chords of recognition in the modern physician. According to Charaka, all of these disorders involve varying dysfunction of eight essential aspects of mind: emotion, reasoning, orientation, learning/memory, attachment, habit, psychomotor function, and behavior.
Interestingly, neurological disorders such as delirium, epilepsy, neurasthenia, Parkinson's Disease, vertigo, coma and mental retardation are also considered part of Graha Chikitsa. Ayurvedic physicians seemed to appreciate--thousands of years ago-the fundamental connection between neurology and psychiatry and the fallacy of separating “organic” from “functional” disorders. Ayurveda recognizes that for some neuropsychiatric conditions, dosha disturbance may begin at the mental level but manifest more at the somatic level (conversion disorder); other times, dosha disturbance may begin at the somatic level but manifest more at the mental level, altering consciousness (neurological disorders). However, for the Ayurvedic physician, the diagnostic focus is not on deciding whether the patient's condition is somatically-based or whether it is “all in the head.” Rather, the focus is on identifying which dosha, or set of doshas, is disturbed in the patient as evidenced by the overall pattern of somatic and psychological symptoms. Treatment then involves correcting the specific dosha imbalance through appropriate physical, psychological and spiritual remedies. According to Charaka, “The number of diseases is uncountable, but the number of doshas is definitely three” (Charaka Samhita, III 6.5). Thus, Charaka contends that an astute Ayurvedic physician should feel no reluctance in treating a novel disorder previously undescribed in medical texts; each symptom of the disorder can ultimately be identified and treated in terms of dosha imbalance. For a more in-depth discussion of psycho-pathology and its treament within Ayurveda, readers are referred to Satya Pal Gupta (1976).
Ayurvedic treatment of any illness, including neuropsychiatric illness, is encapsualted in Charaka's famous adage: “purify, pacify, and remove the cause of disease” (Charaka Samhita I 1.3). The first therapeutic step is to purify the body-mind complex through cleansing procedures (panchakarma) intended to remove gross and subtle toxins that accumulate with dosha imbalance; the longer the dosha imbalance has been in place, the more rigorous should be the purification process. Next, pacification of dosha imbalance is undertaken: this may involve nutritional therapy, yoga postures, herbal medicine, and a number of lifestyle changes designed to soothe an aggravated dosha and strengthen a depleted dosha. Finally, the cause of illness is removed. In Ayurveda, illness may be caused by external factors such as pathogens, trauma, and poor lifestyle choices, as well as by internal factors such as maladaptive cognitions and affects; these etiologic factors must be removed whenever possible so as to prevent recurrence of illness. However, an even deeper etiologic factor must also be addressed: in Ayurveda, the ultimate source of all illness and suffering is one's fundamental alienation from the cosmic consciousness (Atman) that is said to underlie the entirety of the manifest universe. Thus, psychospiritual intervention through a variety of meditative and metaphysical practices is considered to be an integral aspect of the Ayurvedic physician's healing art (Frawley, 1997).
In classical Ayurveda texts, two groups of herbs--the medhya and vajikarana herbs--comprise the most common botanical remedies for neuropsychiatric ailments. According to tradition, medhya herbs provide special nourishment to neuronal tissue and are thus used to enhance memory, cognition, and coping with psychological disturbance. Medhya herbs include brahmi (Bacopa monnieri), mandukaparni (Centella asiatica), shankapushpi (Convolvulus pluricaulis), ashwagandha (Withania somnifera), sarpagandha (Rauwolfia serpentina), jatamansi (Nardostachys jatamansi) and vacha (Acorus calamus). The vajikarana herbs are said to enhance libido, vigor and zest for life; traditionally, these herbs are used as both aphrodisiacs and antidepressants. The vajikarana herb most commonly used in psychiatric conditions is kapikacchu (Mucuna pruriens). Although medhya and vajikarana herbs may be used singly, they are more often administered in polyherb formulas called rasayanas. Rasayanas may consist of only a few herbs, or may include complex combinations of several hundred herbs and minerals.
Numerous clinical trials support the traditional use of medhya herbs to improve cognitive function in people with diverse sources of cognitive disability. Individuals with mental retardation, children with Attention Deficit/Hyperactivity Disorder (ADHD), and adults with Age-Associated Memory Impairment (AAMI) or Age-Related Cognitive Decline are among the most studied populations. Just among these three populations, at least 11 randomized, double-blind, placebo-controlled trials have examined cognitive effects of Ayurvedic herbs (see Table below).
Ancient Ayurvedic texts asserted that the toxicity or medicinal value of a given substance depends entirely upon its correct preparation and application: "A potent poison may be converted into an excellent medicine by the correct method of preparation, while even the best medicine becomes a potent poison if used badly" (Charaka Samhita, I 1.126). Toxicology (Agada Tantra) and the conversion of poisons into medicinal agents comprise a core branch of traditional Ayurvedic knowledge. The importance of following traditional Ayurvedic de-toxification procedures is exemplified by Aconitum ferox. Historically, the rhizome of this Ayurvedic plant was considered to be quite toxic, and modern investigation confirmed its toxicity by isolating a lethal aconitine alkaloid. Ancient Ayurvedic physicians converted this toxic rhizome into a valuable anti-inflammatory and analgesic agent through an elaborate detoxification process (Gogtay, Bhatt, Dalvi et al, 2002). This process involves boiling the rhizome in two parts cow urine for seven hours a day on two consecutive days, followed by boiling the rhizome in two parts cow milk for seven hours a day on two consecutive days; afterwards, the rhizome is thoroughly washed in warm water, and then cut, dried and ground according to special instructions. A modern animal study has demonstrated that when these detoxification steps are followed in their entirety and in the correct sequence, the lethal aconitine alkaloid is converted to a substance with an extremely wide margin of safety (Thorat and Dahanukar, 1991). However, when proper detoxification does not occur, the aconitine alkaloid may cause life-threatening cardiac toxicity and fatalities (Chan, Tomlinson, and Critchley, 1993).
Traditional Ayurvedic medicines called bhasmas contain not only herbs, but minerals and gems such as copper, iron, zinc, mercury, arsenic, lead, gold, silver, diamond, and pearl. As with aconitine, these substances must be converted from toxic agents into therapeutic agents via elaborate Ayurvedic detoxification procedures. For example, in the Ayurvedic de-toxification of lead (Thatte, Rege, Phatak et al, 1993), unprocessed lead is first heated until it glows, then dipped thrice in a mixture of sesame oil, buttermilk, cow urine and three herbs. Next, the lead is heated again and dipped in a powder of tamarind and hot pepper. Finally, the lead is mixed with arsenic sulphide and heated at a fixed temperature in a wrapping of betel leaf. This entire detoxification procedure is repeated 30 times before the lead is rendered safe for use in a bhasma. Ancient Ayurvedic texts describe tests to ensure that various bhasmas have been properly prepared and de-toxified; for example, if a bhasma containing copper is added to yogurt and causes discoloration a few hours later, then this is an indication of impurity (Joshi, 1998).
Traditional Ayurvedic physicians carefully hand-prepared their herbal remedies. Herbs were cultivated in specific soils and harvested at particular times of day and season to enhance their purity and efficacy. Elaborate methods for de-toxifying certain ingredients were meticulously observed. Ingredients and dosage were adjusted to suit the tri-dosha constitution of the patient. Specific dietary recommendations and panchakarma practices were used to modulate pharmacological effects. This fastidious and individualized approach to the manufacture and use of Ayurvedic remedies minimized the risk of adverse effects while maximizing their healing powers (Thatte, Rege, Phatak et al, 1993; Gogtay, Bhatt, Dalvi et al, 2002).
As Ayurveda becomes more popular in the modern era and the global demand for Ayurvedic medicine increases, mass production of over-the-counter Ayurvedic herbal remedies is common. In this context, responsibility for ensuring proper preparation and use of Ayurvedic remedies has shifted from individual Ayurvedic physicians to manufacturing companies or regulatory agencies that may be less adherent to correct Ayurvedic practice. For example, in the modern setting, generic Ayurvedic remedies may be sold directly to patients without regard for their unique tri-dosha constitutions and without consultation from an Ayurvedic physician. Plant materials contaminated by pesticides or pollutants may be used in herbal preparations. Herbs may be misidentified and substituted in traditional Ayurvedic formulas. Traditional, time-consuming detoxification procedures may be circumvented. Herbs may be combined into new formulations not described in traditional texts. In addition, patients may combine Ayurvedic remedies with allopathic pharmaceuticals unknown to the ancients; adverse interactions have been reported between some allopathic drugs and Ayurvedic medicinal ingredients (Table 3).
Thus, safeguards inherent in the traditional preparation and prescription of Ayurvedic medicines have been weakened in modern times. Significant toxicities and adverse reactions may occur. There have been several recent reports of heavy metal toxicities related to the use of some Ayurvedic medicines (Ernst, 2002; Centers for Disease Control and Prevention, 2004; Saper, 2004). These toxicities appear largely to be the result of contamination or improper processing and preparation of Ayurvedic medicinal ingredients; in some cases, patients are using the remedies in higher doses or for longer duration than recommended. As of December 2002, stringent Good Manufacturing Practices (GMPs) for Ayurvedic medicines went into effect in India (Gogtay, Bhatt, Dalvi et al, 2002). Most large-scale Indian manufacturers of Ayurvedic medicine have demonstrated compliance with these GMPs, but small manufacturers may escape regulatory attention and still produce improperly prepared Ayurvedic products for consumption in India and abroad. New GMP requirements for imported and domestic herbal products are awaiting final approval in the United States; once implemented, the new GMPs will protect consumers from exposure to toxic herbal products.