Ayurvedic Management of Schizoaffective Disorder, Maniac Type – A Case Report

Introduction

Schizoaffective disorders are chronic debilitating psychotic disorders identified as a variant of either schizophrenia or mood disorder [1, 2]. A schizoaffective disorder is diagnosed in cases of the subjects having both affective as well as psychotic symptoms [3]. Though schizoaffective disorders are positioned discretely in ICD-

10 and DSM-V, it remains a controversial topic in psychiatric nosology [4]. This disorder is fundamentally heterogeneous which may either reflect the co-occurrence of two relatively common psychiatric illnesses - schizophrenia and mood disorder, or alternatively, it may be a variant of schizophrenia in which mood symptoms are more prominent and severe than usual. Conversely, this condition may also reflect severe forms of major mood disorders in which episode-related psychotic symptoms are prominent2. Studies point that 30% of the cases occur in the age group between 25 and 35 years. Life time prevalence of Schizoaffective disorder is 0.3% and the occurrence is more frequent in women than in men [5]. Three subtypes of Schizoaffective disorders have been described which includes Maniac type, Depressive type and mixed type. Maniac type of Schizoaffective disorder manifests with Schizophrenic and maniac symptoms in the same episode of illness [6].

The exact etiopathology of schizoaffective disorder is still not known. Studies report that in addition to the genetic link, abnormalities in dopamine, norepinephrine, and serotonin, white matter abnormalities in multiple areas of the brain, reduced hippocampal volumes and distinct deformations in the medial and lateral thalamic regions in subjects with schizoaffective disorders [5]. Patients with schizoaffective disorder suffer from cognitive impairments especially in domains of memory, executive functions, cognitive flexibility, reasoning, and problem solving [7]. These impairments causes reduced occupational and social functionality in the subjects. They are commonly managed with antipsychotics, mood stabilizers, anti-anxiety agents and sedatives [8].

Ayurveda appreciates the importance of mental health along with the physical wellbeing for a healthy life. While explaining the Ashtangas or the 8 specialities of Ayurveda, Acharyas positioned the field of psychiatry as a separate branch and termed it as Bhutavidhya [9]. Unmada is a major disorder described in which encompasses a wide variety of psychiatric illness. In unmada the impairments in the domains of Ashta Vibhramas leads to the manifestation of various clinical conditions available [10].

The present case of schizoaffective disorder exhibited the co-occurrence of maniac symptoms such as hyperverbal speech, increased selfesteem and elated mood and also psychotic symptoms including hallucinations and delusions. The case was diagnosed as unmada because of the impairment in Ashtavibhramas and a final diagnosis of Vatha Paittika Unmada was done based on the atypical symptoms prominent in the subject. A sodhana based treatment strategy was planned which included snehapana, virechana, shirodhara, matravasti and nasya.

Clinical Presentation with History

A 30-year-old Muslim woman who has completed the Teachers Training course, hailing from a family of middle socio-economic status from Malappuram was brought to the out-patient department of the hospital by her parents. She presented herself with primary concerns of decreased attention and concentration, increased anger, increased fear that someone will harm her, severe headache and occasional hearing of strange sounds. On detailed interrogation with the parents she was found to have complaints such as elevated mood, continuous, irrelevant hyperverbal speech, increased self-esteem, increased anger, irritability and impulsivity.

Detailed history revealed that she was an introvert right from her childhood who had very few friends while at school and she always used to complain about the sincerity of the few friends she already had. She used to get disturbed on watching even mild violence in films. Her academic performance was average and she got married while she was studying in plus- two. While at her husband’s home, she had high energy in doing household activities and also completed her studies in between but she had difficulty in her family relations, especially with her in- laws.

The symptomatic picture began seven years back when her mother in law tried to attack her with a knife and she was forced to stay back there itself for 2 more days. After the incident she developed incoherent talks and crying spells complaining that someone was always coming to attack her. She was reported to be taken to a psychiatrist and the symptoms subsided after the medication.

The second episode appeared 1 year later when her 1½ year old daughter drowned in a bucket of water for which she was badly blamed by her in-laws. After this incident she was too much disturbed and incoherent talks developed again and she was found roaming about in the house. She had visual hallucinations of her died daughter standing beside her. She also had suicidal thoughts at that time. Later when the symptoms subsided, she was forcefully sent for the teaching job by her husband but she could not continue the job.

Meanwhile the issues with her in- laws became worse and she was sent to her own home by the husband. She developed great anxiety about her children’s future and whether her husband would divorce her. In the last 8 months she was experiencing elevated mood, pressure of speech and increased self-esteem. She listens to devotional songs of all religion in specific time intervals and sings them loudly in a humorous way. She also posts voice clips with strange contents concerning her life and also religious matters in the family groups.

She describes varying strange plans about the future and shows excessive self confidence that she is extraordinarily talented to bring these plans into action. She gets irritated and aggressive when someone stands against her and shouts at them rudely. She destroys things in rage and also harms herself, her children, parents and husband. She also feels as if she is hearing sounds as like that of a school or someone cooing. She also complains about decreased attention and difficulty in concentrating in the activities.

Mental Status Examination

The patient appeared moderately built with adequate grooming and her age appeared a little younger than as stated. She was comfortable about the interview and was co-operative to all the queries. Normal eye contact was maintained and a working and empathetic relationship was established easily. The psychomotor behaviour appeared to be normal. Her speech was rapid, pressurised and elaborative. Tangentiality and flight of ideas were evident in the speech and she unpredictably shifted to unnecessary details. The mood was elated and the affect was found to be congruent with the mood. She described grandiose delusions regarding her extraordinary talents to excel in all the strange plans she had about her future. She reported elementary auditory hallucinations like hearing the sound as that of schools or someone cooing. She also reported visual hallucinations of her died daughter in the past life.

She was conscious and well oriented about time, place and person. The attention and concentration were mildly impaired. Memory was found to be intact and there was no impairment in abstract thinking, intelligence, judgement and reading and writing. The insight was graded as 2.

Blood and urine routine investigations were within the normal limits. She was on psychiatric medication after the first attack of symptoms which was 7 years before, and the symptoms relieved within one week and she discontinued the medicines without any medical advice. She is not on any psychiatric medication since then.

Ayurvedic Clinical Examination

In the Ayurvedic perspective Dasavidha pareeksha was performed and lead to these observations. Sareerika prakriti was assessed as Vata pitta and Manasika prakriti as RajasaTamasa. There were Vata predominant atypical features such as constant irrelevant speech and inappropriate singing. Association of Pitta predominant features such as irritation, anger, excitement in inappropriate occasions, attacking others, and continuous state of anguish were also evident. There was involvement of Rajo dosha also in the pathology. She belonged to Sadharana desha and the Kala was Visarga. She was having Madhyama satva and Abhyavaharana sakthi and Jarana Sakti was also Madhyama. Srothas involved was Manovahasrothas and the precipitating factors of the disease were found to be Katu amla lavana aharas, vidahi ahara, Mano vyakulatha and stressful situations.

Diagnostic Focus and Assessment

As the maniac symptoms and psychotic symptoms were both prominent in the clinical picture, the diagnosis of Schizoaffective disorder – maniac type (F 25.0) was eventually done as per the diagnostic criteria mentioned in WHO’S International Classification of Disease 10. The assessments were done using Brief psychiatry Rating Scale (BPRS) and Young Mania Rating Scale on the 1st day, 12th day, 19th day and the 30th day [11, 12].

The subject seemed to have alterations in most of the domains of Ashtavibhramas and by analysing the clinical features and aetiopathogenesis, the condition was broadly diagnosed as Unmada [10]. As the subject had Pitta predominant atypical features such as Amarsha (Irritation), Krodha (Anger), Samramba cha Asthaane (Excitement in inappropriate occasions), Mushtibhirabhi samhananam (Attacking people with fist), Santapaschaativelam (Continuous state of anguish) etc, and Vata predominant atypical features like Satatamaniyathanam cha giram Utsarga (Constant irrelevant speech) and Abheekshna Geetha prayoge Cha asthaane (Inappropriate singing), a final diagnosis was kept as Vatha paittika Unmada [13, 14].

Management

As per the initial assessments, the treatment plan was formulated and executed as follows:

The internal medications were fixed as: 1. Drakshadi kwatha – 15 ml + 45 ml warm water BD [15].

2. Ashwagandha + Yashtimadhu + Shankupushpi Choorna (Equal) – ½ tsp BD with lukewarm water [16, 17, 18].

After the IP treatment, the following medicines were advised to continue upto 1 month

• Tikthaka gritham – 2 tsp Morning
• Chandanadi Thailam – Padabhyanga and Shiro abhyanga
• Ashwagandha + Shankupushpi Choorna (1:1) – ½ tsp BD with lukewarm water
• Advised to practise Pranayama daily. Table 1: Treatment Procedures with Rationale.

Discussion

Unmaada is a condition which encompasses a wide range of psychiatric illness under a single heading. In Unmada the etiological factors cause Tridosha dushti which afflicts the Hrdaya (the abode of intellect) and Manovahasrothas which results in the perversion of Mana and Budhi. Unmada involves the impairment of the eight psychological factors known as Ashtavibhrama which includes Mano vibhrama, Buddhi vibhrama, Samjnajnana vibhrama, Smriti vibhrama, Bhakti vibhrama, Seela vibhrama, Cheshta vibhrama and achara vibhrama.

In the clinical picture of the present case of Schizoaffective disorder the subject was found to be of Upaklishta satva (Confused mind) and she was continuously subjected to psychological stressors such as Krodha (Anger), Bhaya (fear), Soka (grief), Chinta (excessive thoughts) and Udvega (Anxiety). Rajodosha was found to be aggravated in the pathology. Impairments were found in all the domains of Ashta Vibhrama except Samjna and Smrithi.

Among the Tridoshas, Vatha dosha has a major role in the normal functioning of mind and in this case normal functions of Vatha were affected and she had features of continuous irrelevant speech and inappropriate singing. There were also features of Pitta dushti including increased anger, irritability, excitement in inappropriate instances, destructive mentality and she used to harm herself and others. Considering all these factors, a diagnosis of VataPaittika Unmada was done and the treatment was planned accordingly. In order to address the Vatha pitta predominance of the symptoms, the samana drugs selected were Drakshadi Keatha and a combination of Ashwagandha, Sweta Shankupushpi and Yashtimadhu Churna. Ashwagandha and Sweta Shankupushpi are proven antistress, anxiolytic drugs and Yashtimadhu is effective in impairment of buddhi or intellect.

Considering the deranged agni of the patient, Takrapanawas administered initially for 3 days, to bring about Pachana, Rukshana and Srothosodhana [24]. After Takrapana, Snehapana was administered till the observance of Samyak Snigdha lakshanas [25]. Vatha is the controller of the mind and Medha is the property of Pitta. So, the normalcy of Pitta and proper channelling of Vatha are major concerns in psychiatric disorders [26]. In the individual, both these Doshas were found to be vitiated. Ghritha was selected as the Sneha considering the Vatha pittahara nature and also the lipophilic nature of the Blood brain barrier [26]. Snehapana also brings about the Utkleshana of vitiated Doshas which makes it to be easily eliminated by Sodhana therapy. After Snehapana improvements were observed in anger, irritability and auditory hallucinations. After that, Abhyanga and Ushmasweda was done for 3 days which was intended to bring about liquefaction of the vitiated Doshas.

Virechana was planned as the Sodhana procedure, which when properly administered brings about Indriyaprasada, Buddhi prasada, Srothovisuddhi, Laghuta, Agnivriddhi, Anamayatva and Vathanulomana [27]. After Virechana, improvements were noted in the rate, amount and the pressure of speech. She also reported the complete absence of auditory hallucinations after sodhana. As severe stress was involved in the etiopathology of the condition, Shirodhara was administered for 7 days, considering its relaxant responses in Stress induced disorders. This procedure is reported to produce a released state of awareness, a total feeling of wellness and mental clarity. The centre of the forehead has close connections with Pineal gland and in the yoga tradition this spot is known as Ajna Chakra. The dripping of oil on the Ajna Chakra is proposed to have a meditation like effect leading to an adaptive response to the basal stress [28]. The informants reported significant reduction in anger, irritability and aggressive behaviour after Shirodhara.

On psychometric examination it was observed that, the symptoms such as tangentiality, flight of ideas and impairment in rate and amount of speech persisted. Attributing to the Vatha predominance of these symptoms and Vasthi being the important procedure in the pacification of Vatha, Matravasthi was administered for 7 days. In order to bring Vatha further to normalcy and to provide normalcy to Shiras, Indriya and other sense organs, Sneha nasya was performed for 7 days [29, 30, 31]. Counselling sessions were given to deal with her intellectual and behavioural issues. Counselling was provided to the parents also to make them aware about the importance of social support to be given while tackling the situation. There was considerable reduction in the scores of Brief psychiatry Rating Scale (BPRS) and Young Mania Rating Scale after the management. At the time of discharge following medicines were prescribed.

Conclusion

Ayurveda have always given due importance to the wellbeing of mind or mental faculties along with the physical components of health. Psychiatric ailments are discussed under the branch of Bhutavidya which put forth various idealistic modalities of treatment strategies in this respect. The disease entity, Unmada assembles a wide range of psychiatric ailments under one terminology. This case report summarizes a case of Schizoaffective disorder, maniac type, diagnosed as Vatha Paittika Unmada , and the subject was managed effectively with the selected treatment protocol. The protocol was aimed at bringing the vitiated Tridoshas to normalcy, and, supportive therapy in the form of counselling was also contributed. There were marked improvements in the hallucinations, delusions and maniac symptoms of the subject. Further research works and documentations are needed for the generalization of the results and to fill the gaps in the literature regarding Ayurvedic Psychiatry. Such studies will pave the way for the establishment of empathetic helping hands to a lot who suffers from various mental issues.