Nidana Sthana Chapter 7. Diagnosis and etiopathogenesis of psychosis disorders
|Section/Chapter||Nidana Sthana Chapter 7|
|Preceding Chapter||Shosha Nidana|
|Succeeding Chapter||Apasmara Nidana|
|Other Sections||Sutra Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana|
|Translator and commentator||Tripathi J.S., Deole Y. S.|
|Reviewer||Godatwar P., Mamidi P.|
|Editors||Khandel S.K, Godatwar P., Deole Y.S., Basisht G.|
|Year of publication||2020|
|Publisher||Charak Samhita Research, Training and Skill Development Centre|
Keywords: Unmada, Sanjna Jnana, Amarsha, himsa, Prajnaparadha, Psychosis, insanity, mental factors examination, perversion, impairment of decision making, intellectual functions.
- 1 Introduction
- 2 Sanskrit Text, Transliteration and English Translation
- 2.1 Five types of unmada
- 2.2 Individuals prone to unmada
- 2.3 Types of cognitive distortions
- 2.4 Premonitory symptoms
- 2.5 Specific features of vatika type unmada
- 2.6 Features of paittika type unmada
- 2.7 Features of kaphaja type unmada
- 2.8 Management of unmada
- 2.9 Exogenous unmada
- 2.10 Premonitory symptoms of exogenous unmada
- 2.11 Symptoms of exogenous unmada
- 2.12 Treatment of exogenous unmada
- 2.13 Role of dosha in causing various types of unmada
- 2.14 Responsible factors for unmada
- 2.15 Summary
- 3 Tattva Vimarsha(Fundamental Principles)
- 4 Vidhi Vimarsha (Applied Inferences)
- 4.1 Table 1: Behavioral and psychological manifestation of triguna
- 4.2 Table 2: Predominance of raja and vata
- 4.3 Table 3:Predominance of raja and vata
- 4.4 Table 4:Predominance of tamas and kapha dosha
- 4.5 Table 5:Predominance of Raja and Pitta dosha
- 4.6 Table 6: Predominance of Raja and Vata
- 4.7 Case Paper Format Points
- 4.8 Related Chapters
- 5 References
unmada, a major mental disorder, has been known to Ayurvedic practitioners since ancient times in India. In the Vedic period, the disease was thought to be caused due to grahas or demons, but in Ayurveda, it is considered a major mental illness. unmada as such does not describe a lone clinical entity comparable to a modern diagnostic category, rather it is a group of psychotic disorders. As the psychotic disorders cover almost all the major mental illnesses, the different types and subtypes of unmada can be separately correlated with different psychotic disorders. The clinical features of the different types of unmada resemble various types of schizophrenia, manic psychosis, psychotic depression, and depressive disorders.
Thus, unmada covers a wide range of major mental disorders and is considered synonymous with madness and mental derangement, in which a person loses contact with reality and loses the ability to regulate his actions & conduct according to the norms of the society. When doshas move upwards in the body into the head, they could cause aberrations in the functioning of manas(mind) while producing mada (delusional/ intoxicated state) in an individual. The mental status of psychotic patients is vividly described while explaining the clinical aspect of the disease. The description suggests that a patient of unmada develops derangement of all the activities of manas(mind), buddhi(intellect), ahamkara(ego) and indriyas (sense organs). The patient develops thought disturbances in the form of abnormalities of chintana(thinking), vichara(discriminating) and uha(analyzing), derangement of memory in the form of smriti nasa (memory loss.) and smriti bhramsha (memory impairment), behavioral, social and emotional disturbances in the form of abnormalities of achara, dharma and bhavas along with functional derangement of indriyas which is manifested clinically as disturbed speech and other variants such as incoherence (abaddha vakyam), thought blocking (hridaya shunyata), loosening of associations, neologism, echolalia etc. and various psychomotor disturbances.
Unmada is classified into two broad categories: nija(endogenous), or those caused by internal imbalance of dosha i.e. vata, pitta, kapha and sannipataja, and agantu nimitta, i.e., those caused by exogenous factors. Sushruta  and Vagbhatta - both are of the opinion that unmada is of six types, of which four are due to doshas, the fifth is madyaja (like intoxications) and sixth is vishaja (poison-based or poison-like). Both have described the agantuja unmada separately as the condition of amanushopasarga (due to affliction of supra-human power) and bhuta badha (due to affliction of demons), under the heading amanusopasarga pratishedha (treatment of affliction of supra-human power) and bhuta badha pratisedha (treatment of affliction of demons) respectively. The body of knowledge within Ayurveda dedicated to psychiatry underscores the advancement in scientific knowledge on this subject that existed thousands of years ago.
Sanskrit Text, Transliteration and English Translation
अथात उन्मादनिदानं व्याख्यास्यामः||१||
इति ह स्माह भगवानात्रेयः||२||
athāta unmādanidānaṁ vyākhyāsyāmaḥ||1||
iti ha smāha bhagavānātrēyaḥ||2||
athAt UnmadaanidAnaM vyAkhyAsyAmaH||1||
Iti ha smAha bhagavAnAtreyaH||2||
Now we shall expound the chapter "Unmada Nidana" (Diagnosis and etiopathogenesis of psychosis disorders). Thus said Lord Atreya.[1- 2]
Five types of unmada
इह खलु पञ्चोन्मादा भवन्ति|
iha khalu pañcōnmādā bhavanti|
Iha Khalu pa~jconmAdA bhavanti|
There are five types of unmada such as those caused due to the three doshas, sannipata (simultaneous vitiation of the three doshas), and exogenous causes. 
Individuals prone to unmada
तत्र दोषनिमित्ताश्चत्वारः पुरुषाणामेवंविधानां क्षिप्रमभिनिर्वर्तन्ते; तद्यथा- भीरूणामुपक्लिष्टसत्त्वानामुत्सन्नदोषाणां समलविकृतोपहितान्यनुचितान्याहारजातानि वैषम्ययुक्तेनोपयोगविधिनोपयुञ्जानानां तन्त्रप्रयोगमपि विषममाचरतामन्याश्च शरीरचेष्टा विषमाः समाचरतामत्युपक्षीणदेहानां व्याधिवेगसमुद्भ्रमितानामुपहतमनसां वा कामक्रोधलोभहर्षभयमोहायासशोकचिन्तोद्वेगादिभिर्भूयोऽभिघाताभ्याहतानां वा मनस्युपहते बुद्धौ च प्रचलितायामभ्युदीर्णा दोषाः प्रकुपिता हृदयमुपसृत्य मनोवहानि स्रोतांस्यावृत्य जनयन्त्युन्मादम्||४||
tatra dōṣanimittāścatvāraḥ puruṣāṇāmēvaṁvidhānāṁ kṣipramabhinirvartantē; tadyathā- bhīrūṇāmupakliṣṭasattvānāmutsannadōṣāṇāṁsamalavikr̥tōpahitānyanucitānyāhārajātāni vaiṣamyayuktēnōpayōgavidhinōpayuñjānānāṁ tantraprayōgamapi viṣamamācaratāmanyāśca śarīracēṣṭā viṣamāḥsamācaratāmatyupakṣīṇadēhānāṁ vyādhivēgasamudbhramitānāmupahatamanasāṁ  vākāmakrōdhalōbhaharṣabhayamōhāyāsaśōkacintōdvēgādibhirbhūyō'bhighātābhyāhatānāṁ vā manasyupahatē buddhau ca pracalitāyāmabhyudīrṇā  dōṣāḥprakupitā hr̥dayamupasr̥tya manōvahāni srōtāṁsyāvr̥tya janayantyunmādam||4||
Tatra doṣanimitta scatvarah puruShANAm evaMvidhAnAM KShipramabhinirvartante; tadyathA ---bhIrUNAmupakliShTasattvAnAmutsannadoShANAMsamalavikRutopahitAnyanucitAnyAhArajAtAnivaiShamyayuktenopayogavidhinopayu~jjAnAnAM tantraprayogamapi viShamamAcaratAmanyAshcaharIraceShTA viShamAHsamAcaratA matyupakShINadehAnAM vyAdhivegasamudbhramitAn AmupahatamanasAMvA kAmakrodhalobhaharShabhayamohAy AsashokacintodvegAdibhirbhUyo~abhighAt AbhyAhatAnAM vA manasyupahate buddhau ca pracalitAyAmabhyudIrNA doShAH prakupitAhRudayamupasRutya manovahAni srotAMsyAvRutya janayantyUnmadaam||4|| tatra doShanimittAshcatvAraH
This verse describes the qualities of a person prone to getting afflicted with unmada, as well as the conditions that are conducive to the affliction of the disease:
- Four types of doshika unmada quickly manifest in individuals who are fearful, confused and complicated, who do not know societal rules and norms, and who lead erratic lifestyles and dietary habits (unclean, unwholesome, untimely eating habits, as well as neglecting any prescribed dietetic rules). Doshas in such individuals are in a volatile state and are prone to getting vitiated.
- Resorting to specific lifestyle activities that are not conducive to good health, especially when
- the body is exceedingly weak & cachexic;
- the person is ailing from various diseases;
- the mind is afflicted repeatedly by desires, anger, greed, excitement, fear, attachment, exertion, anxiety and grief; and
- the person is subjected to excessive mental trauma / physical assault.
Such individuals often get afflicted with subclinical mental disorders, leading to unstable intellect because of volatile doshas. When the seat of consciousness, wisdom, and the system that regulates mental activities are badly affected, then all these factors lead to the manifestation of unmada. 
Types of cognitive distortions
unmādaṁ punarmanōbuddhisañjñājñānasmr̥tibhaktiśīlacēṣṭācāravibhramaṁ  vidyāt||5||
unmada is again defined as cognitive distortion pertaining to mind, intellect, consciousness, knowledge, memory, desire, attitude, activities and behavior. 
तस्येमानि पूर्वरूपाणि; तद्यथा- शिरसः शून्यता, चक्षुषोराकुलता, स्वनः कर्णयोः, उच्छ्वासस्याधिक्यम्, आस्यसंस्रवणम्, अनन्नाभिलाषारोचकाविपाकाः, हृद्ग्रहः, ध्यानायाससम्मोहोद्वेगाश्चास्थाने, सततं लोमहर्षः, ज्वरश्चाभीक्ष्णम् उन्मत्तचित्तत्वम्, उदर्दित्वम् अर्दिताकृतिकरणं च व्याधेः, स्वप्ने चाभीक्ष्णं दर्शनं भ्रान्तचलितानवस्थितानां रूपाणामप्रशस्तानां च तिलपीडकचक्राधिरोहणं वातकुण्डलिकाभिश्चोन्मथनं निमज्जनं च कलुषाणामम्भसामावर्ते चक्षुषोश्चापसर्पणमिति(दोषनिमित्तानामुन्मादानां पूर्वरूपाणि भवन्ति)||६||
tasyēmāni pūrvarūpāṇi; tadyathā- śirasaḥ śūnyatā, cakṣuṣōrākulatā, svanaḥ karṇayōḥ, ucchvāsasyādhikyam, āsyasaṁsravaṇam, anannābhilāṣārōcakāvipākāḥ,hr̥dgrahaḥ, dhyānāyāsasammōhōdvēgāścāsthānē, satataṁ lōmaharṣaḥ, jvaraścābhīkṣṇam, unmattacittatvam, udarditvam  , arditākr̥tikaraṇaṁ ca vyādhēḥ, svapnēcābhīkṣṇaṁ darśanaṁ bhrāntacalitānavasthitānāṁ rūpāṇāmapraśastānāṁ ca tilapīḍakacakrādhirōhaṇaṁ vātakuṇḍalikābhiścōnmathanaṁ nimajjanaṁ cakaluṣāṇāmambhasāmāvartē cakṣuṣōścāpasarpaṇamiti  (dōṣanimittānāmunmādānāṁ pūrvarūpāṇi bhavanti)||6||
Tasyemani pUrvarUpANi; tadyathA- shirasaH shUnyatA, cakShuShorAkulatA, svanaH karNayoH, ucchvAsasyAdhikyam, AsyasaMsravaNam, anannAbhilAShArocakAvipAkAH, hRudgrahaH, dhyAnAyAsasammohodvegAshcAsthAne, satataM lomaharShaH, jvarashcAbhIkShNam,unmattacittatvam,udarditvamarditAkRutikaraNaM ca vyAdheH, svapne cAbhIkShNaM darshanaM bhrAntacalitAnavasthitAnAM rUpANAmaprashastAnAM ca tilapIDakacakrAdhirohaNaM vAtakuNDalikAbhishconmathana nimajjanaM ca kaluShANAmambhasAm AvartecakShuShoshc ApasarpaNamiti (doShanimittAnAm UnmadaAnAM pUrvarUpANi bhavanti)||6||
Following are the premonitory symptoms of unmada:
- Blankness of thought,
- Restless eyes,
- Prolonged exhalation,
- Disinclination towards food associated with anorexia and indigestion,
- Feeling of tightness in cardiac region,
- Uncalled for attention, fatigue, confusion and panic,
- Continuous horripilation,
- Frequent fever,
- Erythematous rashes over the body,
- Distorted faces (as in Bell’s palsy or facial paralysis)
- Dreams with the following recurrent themes--
- Terrifying & inauspicious objects that are wandering, moving and unstable;
- Riding over the wheel of an oil press;
- Being churned by whirl-winds;
- Sinking in dirty whirl-pools; and
- Distortion of eyes.
These are the pre-monitory symptoms of unmada caused by the vitiation of doshas. 
Specific features of vatika type unmada
ततोऽनन्तरमेवमुन्मादाभिनिर्वृत्तिरेव| तत्रेदमुन्मादविशेषविज्ञानं भवति; तद्यथा- परिसरणमजस्रम्, अक्षिभ्रुवौष्ठांसहन्वग्रहस्तपादाङ्गविक्षेपणमकस्मात्,सततमनियतानां च गिरामुत्सर्गः, फेनागमनमास्यात्, अभीक्ष्णं स्मितहसितनृत्यगीतवादित्रसम्प्रयोगाश्चास्थाने, वीणावंशशङ्खशम्यातालशब्दानुकरणमसाम्ना, यानमयानैः, अलङ्करणमनलङ्कारिकैर्द्रव्यैः, लोभश्चाभ्यवहार्येष्वलब्धेषु, लब्धेषु चावमानस्तीव्रमात्सर्यं च, कार्श्यं, पारुष्यम्, उत्पिण्डितारुणाक्षता वातोपशयविपर्यासादनुपशयता च; इति वातोन्मादलिङ्गानि भवन्ति(१);
tatō'nantaramēvamunmādābhinirvr̥ttirēva| tatrēdamunmādaviśēṣavijñānaṁ bhavati; tadyathā- parisaraṇamajasram, akṣibhruvauṣṭhāṁsahanvagrahastapādāṅgavikṣēpaṇamakasmāt  , satatamaniyatānāṁca girāmutsargaḥ, phēnāgamanamāsyāt, abhīkṣṇaṁ smitahasitanr̥tyagītavāditrasamprayōgāścāsthānē, vīṇāvaṁśaśaṅkhaśamyātālaśabdānukaraṇamasāmnā,yānamayānaiḥ, alaṅkaraṇamanalaṅkārikairdravyaiḥ, lōbhaścābhyavahāryēṣvalabdhēṣu, labdhēṣu  cāvamānastīvramātsaryaṁ ca, kārśyaṁ, pāruṣyam,utpiṇḍitāruṇākṣatā, vātōpaśayaviparyāsādanupaśayatā ca; iti vātōnmādaliṅgāni bhavanti(1);
tatredamUnmadaavisheShavij~jAnaM bhavati; tadyathA- parisaraNamajasram, akShibhruvauShThAMsahanvagrahastapAdA~ggavikShepaNamakasmAt satatamaniyatAnAM ca girAmutsargaH, phenAgamanamAsyAt, abhIkShNaM smitahasitanRutyagItavAditrasamprayogAshcAsthAne,vINAvaMshasha~gkhashamyAtAlashabdAnukaraNamasAmnA, yAnamayAnaiH, ala~gkaraNamanala~gkArikairdravyaiH, lobhashcAbhyavahAryeShvalabdheShu, labdheShu cAvamAnastIvramAtsaryaM ca, kArshyaM, pAruShyam, utpiNDitAruNAkShatA, vAtopashayaviparyAsAdanupashayatA ca; iti vAtonmAdali~ggAni bhavanti(1);
After the above stage, unmada manifests. The distinctive features of vatika type of unmada are as follows:
- Constant wandering
- Sudden spasm of eyes, eyebrows, lips, jaws, and irregular movements of shoulder, fore-arms and legs;
- Continuous, irrelevant and incoherent speech;
- Frothing from the mouth;
- Frequent smiling, laughing, dancing, singing and playing musical instruments in inappropriate situations;
- Loudly imitating the sounds of lute, flute, conch, samya (cymbal played by right hand), and tala (cymbal played by left hand);
- Riding phantom vehicles;
- Adoration of self by false ornaments;
- Craving for food articles that are not available;
- Disgust and hatred for food articles that are readily available.
- Emaciation and roughness;
- Protruding dusky red eyes;
- Aggravation by vata-provoking factors; and
- Pacification by factors which are opposite to vata
These are the features of vatika type of unmada. [7-1]
Features of paittika type unmada
अमर्षः, क्रोधः, संरम्भश्चास्थाने, शस्त्रलोष्ट्रकशाकाष्ठमुष्टिभिरभिहननं स्वेषां परेषां वा, अभिद्रवणं, प्रच्छायशीतोदकान्नाभिलाषः, सन्तापश्चातिवेलं, ताम्रहरितहारिद्रसंरब्धाक्षता, पित्तोपशयविपर्यासादनुपशयता च; इति पित्तोन्मादलिङ्गानि भवन्ति(२) ;
amarṣaḥ, krōdhaḥ, saṁrambhaścāsthānē, śastralōṣṭrakaśākāṣṭhamuṣṭibhirabhihananaṁ svēṣāṁ parēṣāṁ vā, abhidravaṇaṁ, pracchāyaśītōdakānnābhilāṣaḥ,santāpaścātivēlaṁ, tāmraharitahāridrasaṁrabdhākṣatā, pittōpaśayaviparyāsādanupaśayatā ca; iti pittōnmādaliṅgāni bhavanti(2);
Amarshah krodhaH, saMrambhashcAsthAne, shastraloShTrakashAkAShThamuShTibhirabhihananaM sveShAM pareShAM vA, abhidravaNaM, pracchAyashItodakAnnAbhilAShaH, santApashcAtivelaM, tAmraharitahAridrasaMrabdhAkShatA,pittopashayaviparyAsAdanupashayatA ca; iti pittonmAdali~ggAni bhavanti(2);
- Intolerance, anger and excitement at inappropriate occasions;
- Inflicting injury on self or on others by weapons, brickbats, whips, sticks and fist.
- Running around
- Desire for shade, cold water and food having cooling effect;
- Prolonged anguish;
- Ferocious eyes with coppery, green or yellow color;
- Aggravation of the signs and symptoms by pitta provoking factors
- Pacification by factors which are opposite to pitta
are the features of paittika type of unmada.[7-2]
Features of kaphaja type unmada
स्थानमेकदेशे, तूष्णीम्भावः, अल्पशश्चङ्क्रमणं, लालाशिङ्घाणकस्रवणम्, अनन्नाभिलाषः,रहस्कामता, स्वप्ननित्यता, शौचद्वेषः, बीभत्सत्वं, श्वयथुरानने, शुक्लस्तिमितमलोपदिग्धाक्षत्वं, श्लेष्मोपशयविपर्यासादनुपशयता च; इति श्लेष्मोन्मादलिङ्गानि भवन्ति(३);त्रिदोषलिङ्गसन्निपाते तु सान्निपातिकं विद्यात्; तमसाध्यमाचक्षते कुशलाः||७||
sthānamēkadēśē, tūṣṇīmbhāvaḥ, alpaśaścaṅkramaṇaṁ, lālāśiṅghāṇakasravaṇam, anannābhilāṣaḥ, rahaskāmatā, bībhatsatvaṁ, śaucadvēṣaḥ, svapnanityatā,śvayathurānanē, śuklastimitamalōpadigdhākṣatvaṁ, ślēṣmōpaśayaviparyāsādanupaśayatā ca; iti ślēṣmōnmādaliṅgāni bhavanti(3); tridōṣaliṅgasannipātē tu sānnipātikaṁ vidyāt; tamasādhyamācakṣatē kuśalāḥ||7||
sthAnamekadeshe, tUShNImbhAvaH, alpashashca~gkramaNaM, lAlAshi~gghANakasravaNam, anannAbhilAShaH, rahaskAmatA, bIbhatsatvaM, shaucadveShaH, svapnanityatA, shvayathurAnane,shuklastimitamalopadigdhAkShatvaM,shleShmopashayaviparyA sAdanupashayatA ca; iti shleShmonmAdali~ggAni bhavanti(3); tridoShali~ggasannipAte tu sAnnipAtikaM vidyAt; tamasAdhyamAcakShate kushalAH||7||
- Prefers to live at one place (doesn’t move/ immobility)
- Meek and mum, prefers not to speak;
- Excessive salivation and nasal secretions;
- Disinclination for food
- Prefers loneliness
- Frightening appearance;
- Aversion for cleanliness;
- Always drowsy;
- Edematous face;
- White and timid eyes full of dirt;
- Aggravation of the signs & symptoms by kapha provoking factors
- Pacification by factors which are opposite to kapha
These are the features of kaphaja type of unmada.
Features of sannipatika type unmada: In the unmada caused by the combined vitiation of all the three doshas, all the symptoms mentioned above are simultaneously manifested. This type of unmada is considered to be incurable. [7-3]
Management of unmada
साध्यानां तु त्रयाणां साधनानि- स्नेहस्वेदवमन विरेचनास्थापनानुवासनोपशमन नस्तःकर्मधूमधूपनाञ्जनावपीड प्रधमनाभ्यङ्गप्रदेह परिषेकानुलेपनवधबन्धनावरोधन वित्रासनविस्मापनविस्मारणापतर्पण सिराव्यधनानि, - भोजनविधानं च यथास्वं युक्त्या, यच्चान्यदपि किञ्चिन्निदानविपरीतमौषधं तदपि कार्यं स्यादिति||८||
sādhyānāṁ tu trayāṇāṁ sādhanāni- snēhasvēdavamanavirēcanāsthāpanānuvāsanōpaśamananastaḥkarmadhūmadhūpanāñjanāvapīḍapradhamanābhyaṅgapradēhapariṣēkānulēpanavadhabandhanāvarōdhana-vitrāsanavismāpanavismāraṇāpatarpaṇasirāvyadhanāni, bhōjanavidhānaṁ ca yathāsvaṁ yuktyā, yaccānyadapi kiñcinnidānaviparītamauṣadhaṁ kāryaṁ tadapisyāditi||8||
SadhyanaM tu trayANAM sAdhanAni -snehasvedavamanavirecan AsthApanAnuvAsanopashamananastaHkarmadhUmadhUpanA~jjanAvapIDa pradhamanAbhya~ggapradehapariShekAnulepanavadhabandhanAvarodhana- vitrAsanavismApanavismAraNApatarpaNasirAvyadhanAni,ca yathAsvaM yuktyA, yaccAnyadapi ki~jcinnidAnaviparItamauShadhaM tadapi kAryaM syAditi||8||
Modalities of treatment of the three types of curable unmada are:
- Oleation, fomentation, emesis, purgation, asthapana enema, anuvasana enema
- Alleviation therapies
- Nasal medication, smoking, fumigation, collyrium, avapida and pradhamana types of nasal medication
- Massage, ointment, affusion, and unction
- Assaulting at times, tying, solitary confinement, frightening, and inducing shock
- Depleting therapies and venesection.
Suitable diets should be given according to the requirement of the patient. Such other therapies as would work against the causative factors of the disease should also be given. 
उन्मादान् दोषजान् साध्यान् साधयेद्भिषगुत्तमः|
अनेन विधियुक्तेन कर्मणा यत् प्रकीर्तितम्||९||
unmādān dōṣajān sādhyān sādhayēdbhiṣaguttamaḥ|
anēna vidhiyuktēna karmaṇā yat prakīrtitam||9||
UnmadaAn doShajA sAdhyAn sAdhayedbhiShaguttamaH|
Anena vidhiyuktena karmaNA yat prakIrtitam||9||
Thus it is said :
A competent physician should selectively employ the above-mentioned therapies to treat the curable types of unmada caused by the vitiation of doshas as per the fundamental principles of the prescribed therapy. 
यस्तु दोषनिमित्तेभ्य उन्मादेभ्यः समुत्थानपूर्वरूपलिङ्गवेदनोपशयविशेषसमन्वितो भवत्युन्मादस्तमागन्तुकमाचक्षते|
केचित् पुनः पूर्वकृतं कर्माप्रशस्तमिच्छन्ति तस्य निमित्तम् |
तस्य च हेतुः प्रज्ञापराध एवेति भगवान् पुनर्वसुरात्रेयः|
प्रज्ञापराधाद्ध्ययं देवर्षिपितृगन्धर्वयक्षराक्षसपिशाच गुरुवृद्धसिद्धाचार्यपूज्यानवमत्याहितान्याचरति, अन्यद्वा किञ्चिदेवंविधं कर्माप्रशस्तमारभते; तमात्मना हतमुपघ्नन्तो देवादयःकुर्वन्त्युन्मत्तम्||१०||
yastu dōṣanimittēbhya unmādēbhyaḥ samutthānapūrvarūpaliṅgavēdanōpaśayaviśēṣasamanvitō bhavatyunmādastamāgantukamācakṣatē|
kēcit punaḥ pūrvakr̥taṁ karmāpraśastamicchanti tasya nimittam|
tasya  ca hētuḥ prajñāparādha ēvēti bhagavān punarvasurātrēyaḥ|
prajñāparādhāddhyayaṁ dēvarṣipitr̥gandharvayakṣarākṣasapiśācaguruvr̥ddhasiddhācāryapūjyānavamatyāhitānyācarati, anyadvā kiñcidēvaṁvidhaṁkarmāpraśastamārabhatē; tamātmanā hatamupaghnantō dēvādayaḥ kurvantyunmattam||10||
Yastu dosanimittebhyah Unmadaebhyah samutthAn purvarUpa linga vedanopaSaya visesa samanvito bhavatyUnmadaastamAgantukamAcakShate Kecit punaH pUrvakRutaM karmAprashastamicchanti tasya nimittam|
hetuH ca praj~jAparAdha eveti bhagavAn punarvasurAtreyaH|
praj~jAparAdhAddhyayaM devarShipitRugandharvayakSharAkShasapishA caguruvRuddhasiddhAcAryapUjyAnavamatyAhitAnyAcarati, anyadvA ki~jcidevaMvidhaM karmAprashastamArabhate; tamAtmanAhatamupaghnanto devAdayaH kurvantyunmattam||10||
The type of unmada having etiology, premonitory symptoms, signs and symptoms, pain and favorable therapeutics (upashaya) different from those of the types of unmada caused by the vitiation of doshas are known to be of exogenous type. Some scholars hold the view that this type of unmada is caused by the effect of the activities of the past life. Lord Atreya considers intellectual errors as the causative factor of this condition. Due to intellectual errors, the patient disregards the Gods, ascetics, ancestors, gandharvas, yakshas, rakshasas, pishachas, preceptors, elders, teachers and the other respectable ones. He also resorts to undesirable and inauspicious (or blasphemous) activities. The gods etc. cause unmada in him because of his own inauspicious activities. 
Premonitory symptoms of exogenous unmada
तत्र देवादिप्रकोपनिमित्तेनागन्तुकोन्मादेन पुरस्कृतस्येमानि पूर्वरूपाणि भवन्ति; तद्यथा- देवगोब्राह्मणतपस्विनां हिंसारुचित्वं, कोपनत्वं, नृशंसाभिप्रायता,अरतिः ओजोवर्णच्छायाबल वपुषामुपतप्तिः, स्वप्ने च देवादिभिरभिभर्त्सनंप्रवर्तनं चेति; ततोऽनन्तरमुन्मादाभिनिर्वृत्तिः||११||
tatra dēvādiprakōpanimittēnāgantukōnmādēna puraskr̥tasyēmāni pūrvarūpāṇi bhavanti; tadyathā- dēvagōbrāhmaṇatapasvināṁ hiṁsārucitvaṁ, kōpanatvaṁ,nr̥śaṁsābhiprāyatā, aratiḥ, ōjōvarṇacchāyābalavapuṣāmupataptiḥ, svapnē ca dēvādibhirabhibhartsanaṁ pravartanaṁ cēti; tatō'nantaramunmādābhinirvr̥ttiḥ||11||
tatra devAdiprakopanimittenAgantukonmAdena puraskRutasyemAni pUrvarUpANi bhavanti;tadyathA-devagobrAhmaNatapasvinAM hiMsArucitvaM,kopanatvaM, nRushaMsAbhiprAyatA, aratiH,ojovarNacchAyAbalavapuShAmupataptiH,svapne ca devAdibhirabhibhartsanaM pravartanaM ceti;tato~anantaramUnmadaAbhinirvRuttiH||11||
The premonitory symptoms of exogenous unmada are as follows:
- Desire for inflicting injury upon the gods, cows, brahmins and ascetics;
- Desire for inflicting cruel acts, torture, etc. on living beings
- Impairment of ojas, colour, complexion and physical strength
- Abuse and incitement of the gods etc. in dreams.
unmada manifests soon after the occurrence of these premonitory symptoms. 
तत्रायमुन्मादकराणां भूतानामुन्मादयिष्यतामारम्भविशेषो भवति; तद्यथा- अवलोकयन्तो देवा जनयन्त्युन्मादं,गुरुवृद्धसिद्धमहर्षयोऽभिशपन्तः , पितरो दर्शयन्त: स्पृशन्तो गन्धर्वाः, समाविशन्तो यक्षाः राक्षस्त्वात्मगन्धमाघ्रापयन्तः, पिशाचाः पुनरारुह्य वाहयन्तः||१२||
tatrāyamunmādakarāṇāṁ bhūtānāmunmādayiṣyatāmārambhaviśēṣō bhavati; tadyathā- avalōkayantō dēvā janayantyunmādaṁ,guruvr̥ddhasiddhamaharṣayō'bhiśapantaḥ, pitarō darśayantaḥ  , spr̥śantō gandharvāḥ, samāviśantō yakṣāḥ, rākṣasāstvātmagandhamāghrāpayantaḥ, piśācāḥpunarāruhya vāhayantaḥ||12||
tatrAyam Unmadakaranam bhUtAnAmUnmadaayiShyatAmArambhavisheSho bhavati; tadyathA-avalokayanto devA janayantyUnmadaaM, guruvRuddhasiddhamaharShayo~abhishapantaH, pitaro darshayantaH spRushanto gandharvAH, samAvishanto yakShAH, rAkShasAstvAtmagandhamAghrApayantaH,pishAcAH punarAruhya vAhayantaH||12||
The various divine entities unleash their wrath on the individual as follows:
- Godly spirits cause devonmada (divine unmada)
- Preceptors, elders, adepts and ascetics cause unmada by their curse
- Ancestors by manifesting themselves;
- Gandharvas by their touch;
- Yakshas by entering the host;
- Rakshasas by making the person inhale the odor of their bodies,
- Pishachas by seizing and riding the host.
Symptoms of exogenous unmada
तस्येमानि रूपाणि भवन्ति ; तद्यथा- अत्यात्मबलवीर्य पौरुषपराक्रम ग्रहणधारणस्मरणज्ञानवचनविज्ञानानि; अनियतश्चोन्मादकालः||१३||
tasyēmāni rūpāṇi bhavanti; tadyathā- atyātmabalavīryapauruṣaparākramagrahaṇadhāraṇasmaraṇajñānavacanavijñānāni  , aniyataścōnmādakālaḥ||13||
rUpANi bhavanti;tadyathAatyAtmabalavIryapauruShaparAkramagrahaNadhAra NasmaraNaj~jAnavacanavij~jAnAni aniyatashconmAdakAlaH||13||
Characteristics of a patient afflicted with exogenous unmada are:
Untimely, uncertain and uncalled for manifestations superhuman strength, valor, manliness, enthusiasm, power of understanding and retention, memory, spirituality, logical and scientific knowledge and power of speech. 
उन्मादयिष्यतामपि खलु देवर्षिपितृगन्धर्वयक्षराक्षसपिशाचानां गुरुवृद्धसिद्धानां वा एष्वन्तरेष्वभिगमनीयाः पुरुषा भवन्ति; तद्यथा- पापस्य कर्मणः समारम्भे, पूर्वकृतस्य वा कर्मणः परिणामकाले, एकस्य वा शून्यगृहवासे,चतुष्पथाधिष्ठाने वा, सन्ध्यावेलायामप्रयतभावे वा पर्वसन्धिषु वा मिथुनीभावे, रजस्वलाभिगमने वा विगुणे ,नियमव्रतब्रह्मचर्यभङ्गे वा, महाहवे वा, देशकुलपुरविनाशे वा, महाग्रहोपगमने वा, स्त्रिया वा प्रजननकाले, विविधभूताशुभाशुचिस्पर्शने वा, वमनविरेचनरुधिरस्रावे, अशुचेरप्रयतस्य वा चैत्यदेवायतनाभिगमने वा,मांसमधुतिलगुडमद्योच्छिष्टे वा, दिग्वाससि वा, निशि नगरनिगमचतुष्पथोपवनश्मशानाघातनाभिगमने वा, द्विजगुरुसुरयतिपूज्याभिधर्षणे वा, धर्माख्यानव्यतिक्रमे वा, अन्यस्य वा कर्मणोऽप्रशस्तस्यारम्भे, इत्यभिघातकाला व्याख्याता भवन्ति||१४||
unmādayiṣyatāmapi khalu dēvarṣipitr̥gandharvayakṣarākṣasapiśācānāṁ guruvr̥ddhasiddhānāṁ vā ēṣvantarēṣvabhigamanīyāḥ puruṣā bhavanti; tadyathā-pāpasyakarmaṇaḥ samārambhē, pūrvakr̥tasya vā karmaṇaḥ pariṇāmakālē, ēkasya vā śūnyagr̥havāsē catuṣpathādhiṣṭhānē vā, sandhyāvēlāyāmaprayatabhāvē vāparvasandhiṣu vā mithunībhāvē, rajasvalābhigamanē vā, viguṇē vā'dhyayanabalimaṅgalahōmaprayōgē, niyamavratabrahmacaryabhaṅgē vā, mahāhavē vā,dēśakulapuravināśē vā, mahāgrahōpagamanē vā, striyā vā prajananakālē, vividhabhūtāśubhāśucisparśanē vā, vamanavirēcanarudhirasrāvē, aśucēraprayatasya vācaityadēvāyatanābhigamanē vā, māṁsamadhutilaguḍamadyōcchiṣṭē vā, digvāsasi vā, niśi nagaranigamacatuṣpathōpavanaśmaśānāghātanābhigamanē vā,dvijagurusurayatipūjyābhidharṣaṇē vā, dharmākhyānavyatikramē vā, anyasya vā karmaṇō'praśastasyārambhē, ityabhighātakālā vyākhyātā bhavanti||14||
Unmadayisyatamapi khalu devarShipitRugandharvayakSharAkShasapishAcAnAM guruvRuddhasiddhAnAM vA eShvantareShvabhigamanIyAH puruShA bhavanti;tadyathA- pApasyam,karmaNaH samArambhe, pUrvakRutasya vA NaH pariNAmakAle,ekasya vA shUnyagRuhavAse catuShpathAdhiShThAne vA,sandhyAvelAyAmaprayatabhAvevA parvasandhiShu vA mithunIbhAve, rajasvalAbhigamane vA, viguNe vA~adhyayanabalima~ggalahomaprayoge, niyamavratabrahmacaryabha~ggevA,mahAhave vA,deshakulapuravinAshe vA, mahAgrahopagamane vA, striyA vA prajananakAle, vividhabhUtAshubhAshucisparshanevA,vamanavirecanarudhirasrAve,ashuceraprayatasyavAcaityadevAyatanAbhigamanevA, mAMsamadhutilaguDamadyocchiShTevA,digvAsasi vA,nishi nagaranigama catuShpathopavana shmashAnAghAtanAbhigamane vA,dvijagurusurayatipUjyAbhidharShaNe vA, dharmAkhyAnavyatikrame vA, anyasya vA karma No~aprashastasyArambhe, tyabhighAtakAlA vyAkhyAtA bhavanti||14||
Persons get afflicted by unmada caused by godly spirits, ascetics, ancestors, gandharvas, yakshas, rakshasas, pishachas, preceptors, elders and adepts in the following circumstances, places and time:
- In the beginning of sinful acts;
- When the consequences of prior (sinful) acts of the person (committed in the present life or the past) manifest their effect (karmic effects);
- (Living) in a deserted house or crossing roads alone;
- Sexual intercourse during the junctures of day and night or during the new moon and full moon nights (considered inappropriate and inauspicious for sex).
- Sexual intercourse with a lady during her menstrual period;
- Recitation of scriptures, religious offerings, auspicious rites and sacrifices in improper manner.
- Dishonoring a vow and discontinuing a religious duty or observance of celibacy
- Fierce battles;
- Destruction of countries, communities and towns;
- Onset of inauspicious planets in the sky;
- Post-partum depression;
- Coming in contact with different types of inauspicious and unclean creatures;
- Emesis, purgation and bleeding;
- Visiting a chaitya (sacred tree) or temple when unclean and not following the prescribed rules;
- Not using mouthwash after eating meat, honey, sesame seeds, sugar candy and alcohol;
- While being naked;
- Visiting cities, towns, crossroads, gardens, cremation grounds, slaughter houses at night;
Insulting dvija (twice born), preceptors, Gods and divinities, ascetics and the learned;
Thus, described were some circumstances in which a person attracts the wrath of gods, divinities, and the sages and gets afflicted with unmada. 
त्रिविधं तु खलु उन्मादकराणां भूतानामुन्मादने प्रयोजनं भवति; तद्यथा- हिंसा, रतिः, अभ्यर्चनं चेति तेषां तं प्रयोजनविशेषमुन्मत्ताचार विशेषलक्षणैर्विद्यात्| हिंसा, अप्सु वा स्थलाच्छ्वभ्रे निमज्जति, पतति, शस्त्रकशाकाष्ठलोष्टमुष्टिभिर्हन्त्यात्मानम्, अन्यच्च प्राणवधार्थमारभते किञ्चित्, विद्यात्; तमसाध्यं साध्यौ पुनर्द्वावितरौ||१५||
trividhaṁ tu khalūnmādakarāṇāṁ bhūtānāmunmādanē prayōjanaṁ bhavati; tadyathā- hiṁsā, ratiḥ, abhyarcanaṁ cēti| tēṣāṁ taṁ prayōjanaviśēṣamunmattācāraviśēṣalakṣaṇairvidyāt| tatra hiṁsārthinōnmādyamānō'gniṁ praviśati, apsu nimajjati, sthalācchvabhrē vā patati, śastrakaśākāṣṭhalōṣṭamuṣṭibhirhantyātmānam, anyaccaprāṇavadhārthamārabhatē kiñcit, tamasādhyaṁ vidyāt; sādhyau punardvāvitarau||15||
Trividham Tu khalUnmadaakarANAM bhUtAnAmUnmadaane prayojanaM bhavati; yathA hiMsA,ratiH, abhyarcanaM ceti| teShAM taM prayojanavisheShamunmattAcAravisheShalakShaNairvidyAt| tatra hiMsArthinonmAdyamAno~agniM pravishati,apsu nimajjati, sthalAcchvabhre vA patati, shastrakashAkAShThaloShTamuShTibhirhantyAtmAnam, anyacca prANavadhArthamArabhate ki~jcit, vidyat tamasAdhyaM vidyAt; sAdhyau punardvAvitarau||15||
unmada is caused by the above mentioned agents with the following objectives:
- as a consequence of one’s sinful acts
- affection/love/pleasure and
- to make the individual pay obeisance to Gods
The prognosis of unmada can be judged from the characteristic features of the patient. When the intention of the afflicted agents is to inflict injury, then the patient enters into fire, sinks into water, falls into a pit, provokes others to hurt him, strikes himself with weapons, whips, sticks, brick bats, his own fist etc. He may also adopt to such other means of killing himself. This type of unmada is incurable.
The other two types of intentions i.e. for affection/love/pleasure or to offer prayer give rise to variants of unmada that are curable. 
Treatment of exogenous unmada
mantrauShadhimaNi ma~ggala balyupahArahomaniyama vrataprAyashcitopavAsa svastyayana praNipAtagamanAdIni||16||
For the curable variants of exogenous unmada, the prescribed therapies are:
- Incantation of mantras,
- Wearing of gems and jewels according to astrological indications,
- Performance of auspicious and religious rites and sacrifices, oblations
- Taking a vow, performing religious duties, penance, fasting, blessings, obeisance and pilgrimage. 
Role of dosha in causing various types of unmada
एवमेते पञ्चोन्मादा व्याख्याता भवन्ति||१७||
ēvamētē pañcōnmādā vyākhyātā bhavanti||17||
Evamete pa~jconmAdA vyAkhyAtA bhavanti||17||
In the following verses, the five types of unmada have been explained. 
ते तु खलु निजागन्तुविशेषेण साध्यासाध्यविशेषेण च प्रविभज्यमानाः
पञ्च सन्तो द्वावेव भवतः| तौ च परस्परमनुबध्नीतः कदाचिद्यथोक्तहेतुसंसर्गात् |
तयोः संसृष्टमेव पूर्वरूपं भवति, संसृष्टमेव च लिङ्गम्| तत्रासाध्यसंयोगं साध्यासाध्यसंयोगं चासाध्यं विद्यात्, साध्यं तु साध्यसंयोगम् |
तस्य साधनं साधनसंयोगमेव विद्यादिति||१८||
tē tu khalu nijāgantuviśēṣēṇa sādhyāsādhyaviśēṣēṇa ca pravibhajyamānāḥ pañca santō dvāvēva bhavataḥ|
tau ca parasparamanubadhnītaḥ kadācidyathōktahētusaṁsargāt|
tayōḥ saṁsr̥ṣṭamēva pūrvarūpaṁ bhavati, saṁsr̥ṣṭamēva ca liṅgam|
tatrāsādhyasaṁyōgaṁ sādhyāsādhyasaṁyōgaṁ cāsādhyaṁ vidyāt, sādhyaṁ tu sādhyasaṁyōgam|
tasya sādhanaṁ sādhanasaṁyōgamēva vidyāditi||18||
Te khalunijAgantuvisheSheNa sAdhyAsAdhyavisheSheNa capravibhajyamAnAH pa~jca santo dvAveva bhavataH |
tau ca parasparamanubadhnItaH kadAcidyathoktahetusaMsargAt |
tayoH saMsRuShTameva pUrvarUpaM bhavati,saMsRuShTameva ca li~ggam|
tatrAsAdhyasaMyogaM sAdhyAsAdhyasaMyogaM cAsAdhyaM vidyAt, sAdhyaM tu sAdhyasaMyogam| tasya sAdhanaM sAdhanasaMyogameva vidyAditi||18||
The unmada of five types can be further classified as endogenous or exogenous or as curable or incurable. At times, due to the combination of etiological factors (of endogenous and exogenous types), these could also manifest in hybrid forms. Such forms would exhibit a combination of both the types of unmada in their premonitory as well as actual symptoms. However, it is important to note that:
- Combination of the incurable types or of the curable and incurable types result in an incurable condition.
- Combination of curable types results in curable conditions that should be treated using a combination of therapies. 
Responsible factors for unmada
नैव देवा न गन्धर्वा न पिशाचा न राक्षसाः|
न चान्ये स्वयमक्लिष्टमुपक्लिश्नन्ति मानवम्||१९||
naiva dēvā na gandharvā na piśācā na rākṣasāḥ|
na cānyē svayamakliṣṭamupakliśnanti mānavam||19||
naiva devA na gandharvA na pishAcA na rAkShasAH|
na cAnyesvayamakliShTamupaklishnanti mAnavam||19||
Neither gods, nor gandharvas, nor pishachas nor rakshasas afflict a person who himself is free from misdeeds. The primary cause of unmada in an individual is the consequences of his own misdeeds and not other agents like the gods etc. 
ये त्वेनमनुवर्तन्ते क्लिश्यमानं स्वकर्मणा |
न स तद्धेतुकः क्लेशो न ह्यस्ति कृतकृत्यता||२०||
yē tvēnamanuvartantē kliśyamānaṁ svakarmaṇā|
na sa taddhētukaḥ klēśō  na hyasti kr̥takr̥tyatā||20||
ye tvenamanuvartante klishyamAnaM svakarmaNA|
na sa taddhetukaH klesho na hyasti kRutakRutyatA||20||
If the primary cause of unmada is misdeeds of the individual, then how could the causation of these exogenous unmada be attributed to divinities? Misdeeds committed already cannot be undone, but good deeds can pacify or neutralize the effects of these exogenous factors. 
प्रज्ञापराधात् सम्भूते व्याधौ कर्मज आत्मनः|
नाभिशंसेद्बुधो देवान्न पितॄन्नापि राक्षसान्||२१|
prajñāparādhāt sambhūtē vyādhau karmaja ātmanaḥ|
nābhiśaṁsēdbudhō dēvānna pitr̥̄nnāpi rākṣasān||21||
pragnAparAdhAt sambhUte vyAdhau karmaja AtmanaH|
nAbhishaMsedbudho devAnna pitRUnnApi rAkShasAn||21||
All the diseases whether karmaja (due to misdeeds) or atman (due to one’s self) are caused due to intellectual errors. The Gods, ancestors or rakshasas shall not be blamed for any disease. 
आत्मानमेव मन्येत कर्तारं सुखदुःखयोः|
तस्माच्छ्रेयस्करं मार्गं प्रतिपद्येत नो त्रसेत्||२२||
ātmānamēva manyēta kartāraṁ sukhaduḥkhayōḥ|
tasmācchrēyaskaraṁ mārgaṁ pratipadyēta nō trasēt||22||
AtmAnameva manyeta kartAraM sukhaduHkhayoH|
tasmAcchreyaskaraM mArgaM pratipadyeta no traset||22||
One should hold himself responsible for his happiness and miseries. Therefore, one should follow the path of welfare without apprehensions. 
ते च तेभ्यो विरोधश्च सर्वमायत्तमात्मनि||२३||
tē ca  tēbhyō virōdhaśca sarvamāyattamātmani||23||
te ca tebhyo virodhashca sarvamAyattamAtmani||23||
Prayers to the Gods etc. and resorting to wholesome dietary and lifestyle habits act as antidotes to the misdeeds of the individual. Thus, the choice either to avert or get afflicted with unmada rests with the individual himself. 
सङ्ख्या निमित्तं प्राग्रूपं लक्षणं साध्यता न च|
उन्मादानां निदानेऽस्मिन् क्रियासूत्रं च भाषितम्||२४||
saṅkhyā nimittaṁ prāgrūpaṁ lakṣaṇaṁ sādhyatā na ca|
unmādānāṁ nidānē'smin kriyāsūtraṁ ca bhāṣitam||24||
sa~gkhyA nimittaM prAgrUpaM lakShaNaM sAdhyatA na ca|
UnmadaAnAM nidAne~asmin kriyAsUtraM ca bhAShitam||24||
In summary, types of unmada and their etiology, premonitory symptoms, symptoms, curability or otherwise, and their modes of treatment have been described in this chapter. [ 24] Thus ends the seventh chapter on diagnosis of unmada in Nidana Sthana in the treatise composed by Agnivesha and redacted by Charak. 
Tattva Vimarsha(Fundamental Principles)
- The unmada pathology involves psychic dosha (rajas and tamas) and body doshas ( vata, pitta and kapha).
- The individuals with low mental strength and emotionally unstable with the mind afflicted repeatedly by desires, anger, greed, excitement, fear, attachment, exertion, anxiety and grief are more prone for unmada.
- Improper diet and lifestyle play important role in causing unmada. Therefore these shall be checked in management.
- unmada involves cognitive distortion pertaining to mind, intellect, consciousness, knowledge, memory, desire, attitude, activities and behavior. These factors shall be assessed to determine severity of disease, management protocol and prognosis.
- The dosha dominance shall be assessed for deciding the protocol for management of nija(endogenous) unmada.
- Intellectual error is the basic cause of exogenous unmada.
- Exogenous unmada is characterized by untimely, uncertain and uncalled for manifestations, superhuman strength, valor, manliness, enthusiasm, power of understanding and retention, memory, spirituality, logical and scientific knowledge and power of speech.
- The diagnosis of exogenous type is based upon clinical presentation resembling with specific extra-human factors mentioned in the text.
- The treatment of exogenous unmada includes psycho-spiritual therapies.
- No other factor can afflict a person who is free from misdeeds. The primary cause of unmada in an individual is the consequences of his own misdeeds and not other agents like the gods, etc.
- Misdeeds that are committed already cannot be undone, but good deeds can pacify or neutralize the effects of exogenous factors.
- All the diseases are caused due to intellectual errors. The Gods, ancestors or demons shall not be blamed for any disease. One should hold himself responsible for his happiness and miseries. Therefore, one should follow the path of welfare without apprehensions.
Vidhi Vimarsha (Applied Inferences)
As the present chapter deals with the psychopathogenesis and diagnosis of unmada, the fundamental approach of Ayurveda in the etiopathogenesis of psychiatric diseases needs to be discussed. Charak considers violation of dietetic rules as an important causative factor for unmada. Both body and mind are affected by diet. unmada occurs in individuals taking diet in manners forbidden by the dietetic rules, consuming improper dietary articles, food articles that are unclean and ill prepared, incompatible and vitiated. According to Chandogya Upanishad, quality of mind depends upon the food taken by the individual. Once digested, the food is divided into three components – gross (sthula), medium (madhyam) and (sukshma). The subtle portion of the food nourishes the mind. Bhagavad Gita also opines that the sattvika, rajasika and tamasika types of buddhi (intellect) is derived from the characteristics associated with the type of diet. Thus, Ayurveda considers that incompatible, vitiated food articles affect the physical as well as mental state of an individual, predisposing him to psychiatric illnesses in general, if he is already harboring other causative factors.
Secondly, psychiatric illnesses with special reference to unmada are not only associated with the vitiation of manas doshas but there is vitiation and provocation of sharira doshas as well. It points to the fact that though psychiatric illnesses are associated with subtle pathological changes at the bio-energetic level, they are also simultaneously accompanied by qualitative as well as quantitative changes/imbalances in the neurotransmitters and other bio-chemicals at the physical level. Thus, the normal psychological processes as well as the psychopathologies, operate simultaneously at multiple levels (biological, bio-energetic) and also at subtler levels where the intangible thought processes start appearing in the relatively tangible field of bio-energy. All this needs extensive exploration using the available scientific tools.
Thirdly, entire thought processes, attitudes, emotional experiences, desires and behaviors of an individual, which are relatively intangible, have the capacity to bring about qualitative as well as quantitative changes in the manas and sharira doshas, agni, and ojas. These psychological factors are also capable of bringing about structural as well as functional changes in the dhatus (body tissues), malas (biological byproducts and wastes) and srotasas (macro and micro-channels). These are some of the most fundamental considerations. which needs special attention.
The eight psychological and behavioral factors are described here that get imbalanced when the individual is afflicted with mental diseases. These factors are- manas, buddhi, sanjna jnana, smriti, bhakti, sheela, chesta and aachara. This provides a basis for objectively and empirically assessing the mental functions of a patient afflicted with unmada. Using this understanding, Ayurvedic institutions have been able to create a rubric to analyze patients and conduct various mental health studies. A three-stepped approach to creating such a scale is as follows:-
- In depth study of various definitions, synonyms, commentaries available on the eight factors.
- Screening the available descriptions in a scientific way.
- Developing an elaborate and objective assessment scale based on Ayurvedic principles for making it more understandable and useful in a clinical set up. The scale has been named as ashta manas bhava pariksha (assessment of eight mental faculties).
Now described in some detail would be each of the eight psychological and behavioral factors used in Ayurvedic studies on mental health:
- The term manas in this context refers to the thought, affect and emotional aspect of mind. Therefore, the various kinds of thought abnormalities like delusions and delusional ideations, and states of mood e.g. depressed, elated, anxious etc are assessed under this factor.
- The term buddhi (ya buddhi niscayatmika) [Cha.Sa.Sharira Sthana 1/23] refers to intellect, decision making, and problem solving aspects of mental functioning. Standardized tools for assessing intelligence e.g. Weschler Intelligence scale, Bhatia Battery for Performance Test of Intelligence etc. and clinical methods of test judgement are useful in this regard.
- The term sanjna jnana refers to the awareness of surroundings and response to external stimuli and measures, phenomena such as orientation and responsiveness, and attention and consciousness. Clinical methods available for measuring these aspects should be used.
- The term smriti refers to all components of memory, such as immediate retention and recall, recent memory and remote memory including learning acquisition. The available tools of memory measurement viz. digit span, object recall, Weschler Memory scale, PGI Memory scale etc. are useful for assessing this factor.
- The term bhakti refers to the normal, intact, altered and unusual desires related to food, dress, entertainment, study, work, hobby, sex etc. which are measured under this aspect.
- The term sheela refers to habits, temperament and general behavior, which are measured under this aspect.
- The term cheshta measures the psychomotor activity by clinically observing the retardation, agitation, restlessness, co-operativeness/ non-co-operativeness etc. in a psychiatric patient.
- Finally, the term achara refers to personal and social conduct measured by misbehavior, quarrel, disrespect to elders and other respectable and other similar activities by a psychiatric patient.
Some exogenous causative factors of unmada along with their mode of psychiatric infliction in a person have been enumerated below. However, these details are taken with contemporary assumptions, experiences and clinical practices applicable to a particular disease. Many of these beliefs and practices are still extant in many parts of the world. One of the bodies of practices in this field of study, Bhutavidya, was one of the eight branches of Ayurveda. The diagnosis of these exogenous factors is based upon the clinical features, behavior patterns and time of affliction. These factors are being studied well under the purview of demonology, parapsychology. The beliefs regarding ghosts, demons are noted and studied to know exact mechanism behind them. However psychiatrist caution to rule out any other mental disorder first before labeling it as a demon. The negative energies in the cosmos may be regarded in view of exogenous factors causing unmada. Rajas and tamas are responsible for negativities, while sattva for positivity. Therefore these must be considered as psycho-dynamic factors to be treated.
Last but not the least, there is a clear message in the chapter that every individual is himself responsible for his wellbeing, happiness and miseries. The behavioral tendencies and lifestyles adopted by the individual are based on his own choices and all types of unmada are the result of intellectual blasphemy by the individual himself – be it endogenous or exogenous.
Table 1: Behavioral and psychological manifestation of triguna
|Enlightening||Propulsive & dynamic||Inhibitive|
|Efforts for more knowledge||Over expression of pain & pleasure||Ignorant|
|Cleanliness||Active||Excessive Fatigue of sense organs|
|Theism (Appreciates existence of Almighty)||Industrious||Atheism|
|Straight forward dealing||Egoistic||Inactive|
|Of good memory, intellect||Pretender||worrying|
|Prompt to learn||Jealous||Commits Mistakes|
Table 2: Predominance of raja and vata
|Disease||Clinical features||Predominant dosha|
|1. Panic attack|
|Palpitation, sweating||raja, pitta|
|Trembling or shaking||vata|
|Sensation of shortness of breath Feeling of choking||vata|
|Chest pain or discomfort||vata|
|Nausea or abdomen distress||vata|
|Feeling dizzy, unsteady lightheaded or Faint||pitta|
|De-realization or depersonalization||raja, vata and pitta|
|Feeling of losing control or going crazy||raja|
|Fear of dying||raja, vata|
|Chills or hot flushes||vata |
Table 3:Predominance of raja and vata
|Disorder||Clinical features||Predominant dosha|
|Excessive anxiety & worry (apprehensive expectation)||raja, vata|
|The person finds it difficult to control the worry||raja, vata|
|Being easily fatigued||raja, vata|
|Difficulty concentrating or mind going blank||raja, vata|
|Irritability||raja, pitta vata|
Table 4:Predominance of tamas and kapha dosha
|Disease||Clinical Features||Predominant dosha|
|Major Depressive Illness|
|Depressed mood most of day||tama, kapha|
|nearly every day as indicated by either subjective report (eg. feels sad or empty)||tama, kapha|
|or observation made by others (eg. appears fearful)||Vata|
|Markedly diminished interest or||vata, kapha tama, kapha|
|pleasure in all or almost all activities most of the day|
|Significant weight loss when not dieting or||tama|
|weight gain or decrease or increase in appetite nearly every day.||kapha tama|
|insomnia or hypersomnia nearly everyday||vata kapha tama|
|Psychomotor retardation or agitation||tama|
|fatigue or loss of energy nearly everyday||tama|
|Feeling of worthlessness or excessive or inappropriate guilt||tama kapha|
|Diminished ability to think or concentrate or indecisiveness||tama kapha|
|Recurrent thoughts of death,recurrent suicidal ideas||tama, kapha|
Table 5:Predominance of Raja and Pitta dosha
|A distinct period of abnormality and||raja, pitta|
|persistently elevated, expansive or irritable mood.||raja, pitta|
|Inflated self esteem or grandiosity||raja pitta|
|Decreased need for sleep||vata, raja|
|More talkative than usual||vata|
|Flight of ideas||raja vata|
|increase in goal directed activity||raja pitta|
|or psychomotor agitation||raja pitta|
|Excessive involvement in pleasurable activities that have a high potential for painful consequences||raja, pitta, vata|
|During the period of mood disturbance any three or more of above Symptoms have persisted|
Table 6: Predominance of Raja and Vata
|Social withdrawal, often with deterioration in personal care,||tama, kapha|
|Loss of ego boundaries with inability to perceive onself as Separate||Alpasatva with excessive raja and tama|
|Loose thought association, often with slowed thinking or over inclusive||raja vata|
|and rapid shifting from topic to topic||raja, vata|
|Autistic absorption of inner thoughts||raja|
|frequent sexual or religious preoccupation||raja tama, kapha|
|Auditory hallucinations||raja, vata|
|Hypersensitive to environmental stimuli||raja, vata|
|Impaired concentration Depersonalization wherein one behaves like a detached observer of one's own actions.||raja and vata|
Case Paper Format Points
The format for the clinical assessment of manovahasrotas or The psychiatric assessment:
Every psychiatric history should cover the following points:
- History of present illness
- Previous disorders and the nature and extent of treatment.
- Family history, important for genetic aspects and family influences, helping in understanding the familial traits.
- Personal history: childhood development, adolescent adjustment, level of education and adult coping patterns.
- Sexual history
- Current life functioning
- Current medications, alcohol or drug abuse
- Personality: is defined as the sum of those characteristics that make a person into individual he is. These characteristics include behaviour, both actions and reactions; attitude to self; ways of relating to others, both socially and sexually, attitude to authority, level of independence, mood, fantasy life, religious beliefs and moral altitudes and interests and hobbies.
The mental status examination
- Appearance: note unusual modes of dress, use of makeup etc. very helpful for evaluation of bhootonmada and vataja unmada
- Activity and behavior: Gait, gestures, co-ordination of bodily movements. akshibhruvaushthamsahanvagrahastapadangavikshepanamakasmat
- Affect: outward manifestation of emotion such as depression, anger, fear or lack of emotional response eg. krodha, sudeen
- Mood: the patients report of feelings and observable emotional manifestations eg. rahasyakamata, narivivikta priyata, amarsha
- Speech: coherence, spontaneity, articulation, hesitancy in answering and duration and response. Eg. vaka mandam pratihatavacchyam
- Content of thought: Association, obsession, depersonalization, delusions, hallucinations, Paranoid, ideation, anger, fear or unusual experiences. Eg. amartya vaka vikrama virya cheshta dnyanadi vidnyan baladibhi
- Orientation to person, place, time and circumstances.
- Remote and recent memory and recall
- General knowledge
- Ability to identify by naming, reading and writing
- Right to Left differentiation
- Judgment regarding common sense problems
- Sushruta. Uttara Tantra, Cha.62 Unmadapratishedam Adhyaya verse 4-5. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005.