Ayurveda management of Generalized Anxiety Disorder

Introduction

Anxiety is defined as a subjective feeling of apprehension or dread about the present or the past accompanied by a number of autonomic and somatic signs and symptoms. It is the feeling of fear with no adequate cause.² According to ICD 10 & DSM IV, symptoms of Generalized Anxiety Disorder are worry, apprehension, psychological arousal, muscle tension, sleep disturbances and restlessness.³ Generalized Anxiety Disorder is what many people experience in day today life, interferes with the ability to participate in relationship, careers and other aspects of life. Such type of symptoms and disorders are increasing day by day because of present day’s lifestyle as well as the challenges of materialistic competitive world.⁴ Anavastitha Chittata –“A State of consciousness gripped with fear and uncertainty in response to stressful event paving to ,restlessness agitation of the mind,” a maelstrom of increased circular current of stressful thoughts is one of the symptom of Vataja Nanatmaja Vikaras mentioned in Ayurveda are the main features of “ Chittodwega”⁵ which is clinically related to the symptoms and features of Generalized Anxiety Disorder. The Management is Yuktivyapashraya and Satwavajaya⁶ (pharmacological and nonpharmacological approach), to address the somatic and the mind which is pre -occupied with fear, perturbed, confusion, indecisiveness and perplexity. Dhi Dhairya Atmadi vijnana⁷ are the ideal therapies indicated for patients afflicted with predominant features of bhaya (fear), dukha (sadness) and kopa (anger).

PATIENT INFORMATION

CASE STUDY

A 27 year old male patient a businessman by profession was admitted in Sri Dharmasthala Manjunatheswara College of Ayurveda and Hospital, Hassan, Karnataka (IP-040074), for having chief complaints of excessive irrational fear, pre-occupied thoughts about physical health and business issues in the early morning, difficulty in concentrating, confusion, increased somatic pain at early morning, fatigue, insomnia, and at times experiencing palpitation with sweating. Mid in the year 2015 , he was complaining of pain and burning sensation in the throat, difficulty in swallowing especially solid food, heart burn, leading to a negative impact on his weight loss. On and off symptoms of burning sensation in the chest was reported throughout 2015. The recurrent health issue was disturbing the patient. Endoscopy in 2016-2017 revealed no pathological involvement in the upper GIT and he was diagnosed for Generalized Anxiety disorder and was put on Nuxvenla OD 50 and Rivotril. Pre morbid personality: The patient basically had no difficulty in interpersonal relationship with family friends and work colleagues, was ease of making friendship and maintaining good social relationship, was a sportsperson involved in sports activities. In his earlier teen years he was predominantly optimistic stable cheerful, selfconfident and quite thoughtful of others, Decision making, acceptance, responsibility, perseverance and foresight were intact, During his pre university period one of his close neighbor friend passed away which led to him feeling depressed and worried ,two incidences of unknown people throwing an unknown powder substance on him while driving , was terrified, shaken trembled with fear and was gradually affecting his sleep pattern.

CLINICAL FINDINGS

On examination, patient was weighing 70kg, height 5 feet 6 inches tall; his vitals were within normal limits. On Mental Status Examination patient was well cooperative ,well groomed, well socially behaved maintained eye contact during conversation was seeking help to resolve his issues, had good comprehension, well socially behaved and was responding well to the questions put forth, On general assessment patient was complaining of loss of sleep, constipation, early morning fatigue, increased somatic pain preoccupied negative thoughts about health, racing thoughts in relating to his future business, sensitivity to uncertain threat. Hamilton Anxiety rating⁸ scale was used before therapy which was scoring 27 which indicated moderate to high levels of anxiety. Subject is not a known case of type 2 DM and Hypertension.

Diagnostic assessment

Based on the symptoms presented the diagnosis was made to Chittodwega (Generalized Anxiety Disorder) with mild features of depression. And on routine blood investigation, all parameters assessed were all within normal limits. Based on signs, symptoms and examination, he was diagnosed as a case of Generalized Anxiety Disorder as per ICD 10 F41.1 criteria and treatments were started. Assessment of the patient before and after the intervention was done using Hamilton’s Anxiety Rating scale.

Therapeutic intervention

The treatment protocol included detoxification therapy followed by psychotherapy. Total duration of treatment was 14 days. The Treatment planned were deepana^9,10, and pachana^9,10 with panchakola phanta for the first two days, followed by Sarvaanaga udwartana11, sarvaanga parisheka¹² with dasamoola kwatha. Shiropichu with Amalaki jatamamsi choorna mixed with brahmi taila, counseling and relaxation followed by yoga and pranayama was advised for two days. During Snehapana Counseling was carried out. After two days of Deepana and Pachana, snehapana¹³ with Kalyanaka gritha¹⁴ for 7 days in increasing dose followed by vishrama kala¹⁵ for two days with Sarvaanga Abhyanga¹⁶ with moorchita taila and Bashpa sweda¹⁷ was administered. Virechana¹⁸ with trivrit lehya¹⁹ 60grams and draksha kashayam 50 ml was administered after Vishrama kala. The patient had 10 Vegas and he was advised to follow Samsarjana karma²⁰ for 3 days

FOLLOW-UP AND OUTCOMES

On first follow up after 30 days, Sleep pattern has improved, somatic pain relieved and bowel movement was regulated, The patient has stopped taking Rivotril .25mg.On 2nd follow up after a period of one month. He was advised to continue Kalyanaka gritha 10ml twice before food and manasamithra vati²¹ 2 tablets with milk before going to bed.

DISCUSSION

Ayurveda management of Chittodwega was based on pacifying tridosha. In the present case increased somatic pain at early morning, fatigue, insomnia and constipation were the chief complaints. Hence the case was evaluated as vata pradhana pittaja conditon. Vata -pittahara, brumhana, tridoshahara dravya play a major role along with vata pittahara pathya. Since the condition was chronic, there was an accumulation of morbid dosha (vata and pitta dosha), hence Virechana which is one of the major shodhana procedure in panchakarma was opted as it was the suited procedure for expelling the morbid dosha. Virechana karma (Therapeutic purgation) is one among the Panchakarma therapies, which eliminates excessive vitiated Dosha in general and Pitta Dosha in particular from the body through the anal route. Before performing the pradhana virechana karma, poorva karma procedures (udwartana and sarvaanga parisheka) external treatments and internal medication for correcting the improper metabolism was performed on the first two days. Ayurveda metabolizing formulations (ama pacana and deepana dravyas) was administered to improve and correcting Agni which aids in digestion. Mode of action of udwartana and parisheka can be described locally as well as systemically. In udwartana the (dry powder massage) and saarvanga parisheka (a type of sudation therapy) helps in clearing bahirmarga morbid dosha vitiated kapha and restores normalcy functions of vata which was hindered. Generalized muscle stiffness, pain and heaviness were relieved. The patient felt light, nourished and fresh. Snehapana with kalyanaka gritha was started on 3rd day starting with 30ml dosage and gradually increasing every day for next 6 days. The procedure improves the normal function of samana vayu and udana vayu at sharrerika and manasika state. Snehapana helps in clearing the channels of rasa vaha srotas due to pitta vaigunyam and brings the doshic pacaka pitta at the koshta level which is ready for expulsion, simultaneously in improving the satwa bala and clearing manovaha srotas which is occluded with tamoguna and improving the the function of udana vata and sadhaka pitta . After snehapana, vishrama kala for two days was followed with abhyangam with moorchita taila and Bashpa swedana, then followed by virechana with Trivrit lehyam of 60 gms and Drakshadi kashayam of 100ml, patient had 10 vegas, was advised peyadi krama for 3 days. During the time of discharge his sleep pattern improved, early morning somatic pain was relieved and bowel movement were regulated. Usage of rivotril. 25mg was stopped during discharge.

CONCLUSION

The influential factors of drug distribution in blood depends mainly difference in blood flow, lipid solubility and ionization. An aqueous soluble drug is usually absorbed in extra cellular spaces. They do not diffuse to the CSF and other body cavities, whereas lipid soluble drugs are readily available to extra and intra cellular spaces. Blood brain barrier (BBB) has a lipophilic molecular structure. This makes the lipids and lipid soluble drugs pass easily through BBB. So the drugs which are given in the form of ghee which are lipids rapidly absorbs in the target areas of central nervous system. Traditionally prepared ghee contains DHA, an omega 3 long chain poly unsaturated fatty acid. This is seen in high concentration in brain cells too. Moreover studies have shown that DHA have positive outcome in cognitive decline. Ghee is known to have antioxidant property which acts upon the degenerative brain cells and repair them. It also acts in normalizing the chemical changes in brain by balancing the neurotransmitters. By applying the theory of similarity, it can be said Mastishka (brain) which resembles molten ghee can be supplemented with clarified butter in various therapies.²² Thereby a combined detoxification and psychotherapy was found to be effective in managing Generalized Anxiety Disorder. There was a significant improvement in the physical and in psychological domain. The improvement achieved after the treatment has paved motivation for the patient where he is still under medication and following relaxation techniques and pranayama techniques which was taught during the treatment regime.