|
 
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| CASE REPORT |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 9-13 |
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Management of Levetiracetam induced anxiety disorder (Chittodwega) using Gorakhmundi (Sphaeranthus indicus Linn) Ghana vati: A case report
Sumedh Sanjay Joshi1, Bhargav Vijay Bhide2, Tanuja Manoj Nesari2
1 Department of Dravyaguna, RJVS Bhaisaheb Sawant Ayurved Mahavidyalaya, Sawantwadi, Maharashtra, India
2 All India Institute of Ayurveda, New Delhi, India
| Date of Submission | 27-Apr-2022 |
| Date of Acceptance | 14-Dec-2022 |
| Date of Web Publication | 21-Mar-2023 |
Correspondence Address:
Dr. Sumedh Sanjay Joshi
Department of Dravyaguna, RJVS Bhaisaheb Sawant Ayurved Mahavidyalaya, Sawantwadi - 416510, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jacr.jacr_35_22
With an exponential rise in population and subsequently intensified socioeconomic stress, the incidence of mental health disorders like anxiety possess a significant great health burden on society. Levetiracetam is an antiepileptic drug indicated in the management of partial-onset, tonic myoclonic, and tonic-clonic seizures. However, it is associated with severe adverse drug reactions such as psychosis, anxiety, suicide, and allergic reactions. The presenting symptoms of anxiety disorder can be identified as Chittodwega (~anxiety), which is a Manasa vikara (~psychological disorder) in the context of Ayurveda. This case report shows the effect of the Ayurvedic drug Gorakhmundi in relieving the symptoms of anxiety in Levetiracetam-induced anxiety. A 50-year-old female patient who is a known case of seizures presented to the outpatient department with symptoms of anxiety. The patient was diagnosed with levetiracetam-induced anxiety and was suffering from heaviness in the head, palpitation, irritability, tingling sensation in extremities, irrational fear, diminished sleep, and intermittent gastrointestinal disturbances. The patient assessment was done on the basis of the Hamilton Anxiety Rating Scale (HAM-A) and Manasa bhava parikshana (~assessment of psychological parameters) according to the principles of Ayurveda. The patient was treated with Gorakhmundi ghana vati (500 mg) twice a day for two months. The patient showed complete remission of symptoms after two months of treatment. A significant change was observed in pre- and post therapy assessment through the HAM-A and Manasa bhava parikshana. The case report highlights the effective use of Ayurveda treatment for the management of drug-induced anxiety disorder in an epileptic patient.
Keywords: Chittodwega, Drug-induced anxiety, Gorakhmundi, Medhya, Single drug regimen, Sphaeranthus indicus
How to cite this article:
Joshi SS, Bhide BV, Nesari TM. Management of Levetiracetam induced anxiety disorder (Chittodwega) using Gorakhmundi (Sphaeranthus indicus Linn) Ghana vati: A case report. J Ayurveda Case Rep 2023;6:9-13 |
How to cite this URL:
Joshi SS, Bhide BV, Nesari TM. Management of Levetiracetam induced anxiety disorder (Chittodwega) using Gorakhmundi (Sphaeranthus indicus Linn) Ghana vati: A case report. J Ayurveda Case Rep [serial online] 2023 [cited 2023 May 30];6:9-13. Available from: http://www.ayucare.org/text.asp?2023/6/1/9/372248 |
| Introduction | |  |
Generalized Anxiety Disorder (GAD), a common variant of anxiety disorders, has a 19.0% prevalence in Indian adults.[1] Studies revealed that one out of every 14 people meets the diagnostic criteria for anxiety, posing a significant health burden on society.[2] The incidence of anxiety seems to be directly proportional to the increasing population and subsequently increasing socioeconomic stress. Anxiety affects many spheres of a person's life, including interpersonal and social relationships hampering functional life.
According to the Ayurveda literature, an anxiety disorder can be compared to the condition defined as Chittodwega. According to the National Health Portal, Chittodwega (~anxiety) is a psychological and physiological state characterized by cognitive, somatic, emotional, and behavioral components.[3] Anxiety is often accompanied by physical sensations such as palpitations, nausea, chest pain, shortness of breath, diarrhea, chills, dry mouth, pain, and headache. Somatic signs of anxiety may include pale skin, sweating, tremors, and pupillary dilation.[3]
The general line of management of any disease in Ayurveda includes three primary approaches, Daivavyapashraya (~spiritual healing), Yuktivyaprashaya (~rational therapeutic measures), and Satvavajaya (~psychotherapy). Dhi (~intelligence), Dhairya (~confidence), and Atmadi vigyana (~knowledge of self) are indicated predominantly for the management of psychological disorders associated with excessive Bhaya (~fear), Dukha (~sorrow), and Kopa (~anger). Yuktivyapashraya chikitsa includes various therapeutic measures, including Shodhana (~purifying) and Shamana (~palliative) therapy. Medhya rasayana (~intellect enhancer) is a class of drugs that help in enhancing cognition and functioning of the mind. Thus, the rational use of Medhya rasayana is considered helpful in managing various psychological disorders, including GAD.
Although various experimental studies are available regarding the use of Gorakhmundi as an anxiolytic agent, no clinical evidence is available regarding its efficacy in managing anxiety disorder in adults. This case study throws light upon the use of Gorukhmundi ghana vati as a single drug in managing levetiracetam-induced anxiety diagnosed as Chittodwega.
| Patient Information | | |
A 50-year-old female, housewife, having a history of hypothyroidism for one to two years complaining of uneasiness, two episodes of mild seizures (First in February 2019 and second in March 2020), heaviness in the head, palpitation, increased anger, tingling sensation in extremities, irrational fear, diminished sleep and intermittent gastrointestinal disturbances (intermittent for the last one year) approached the outpatient department (OPD) of a tertiary care Ayurveda hospital.
| Clinical Findings | | |
In February 2019, the patient had an episode of seizure along with precipitation of above said complaints, it was diagnosed provisionally as epilepsy by the neuro physician and the patient was put on anticonvulsant Levetiracetam (500 mg) once a day for five months (February-June 2019). Further, in March 2020, there was a recurrence of seizures and psychological symptoms such as irritability, sleeplessness, and heaviness in the head. Thus, Levetiracetam (500 mg) once a day was again started, but an increase in behavioral discomfort was observed, and hence, the patient was shifted over to Fluoxetine (250 mg) twice a day by the neuro physician. The use of phenytoin further produced rashes all over the body; thus, patient approached for Ayurvedic medications and visited OPD of a tertiary care Ayurveda hospital. The patient was advised to continue the allopathic medicines he was taking during the treatment. The patient had no surgical history. Family history showed no relevance to the present condition.
| Timeline | | |
The timeline, along with the observations, is depicted in [Table 1].
| Diagnostic Assessment | | |
The patient was well-oriented, cooperative, well groomed, and made eye contact but was not willing to talk much. The patient was well aware of her situation but was not able to convey her thoughts properly. All the senses and vitals were normal; no obvious abnormality was noted on systemic examination. She presented with no evidence of any psychological trauma. A computerized tomography scan brain and magnetic resonance venography of the brain were done on February 19, 2020, which showed the absence of any abnormality.
Ashtavidha pariksha (~ eight-fold examination)
On examination, it was evident that the patient had regular pulse rate of 68/min. Jivha (~tongue) was Sama (~coated). Normal Mala pravrutti (~frequency of feces) with 1-2 times/day, Mutra pravrutti (~frequency of micturition) was also normal with 5–6 times/day. No abnormality was noted in Shabda (~speech), Sparsha (~touch), and Drik (~vision). The patient was Krusha (~lean) with 51 kg weight and 150 cm height. Based on the detailed history, the diagnosis was made as Chittodwega associated with occasional Bhrama (~seizures). On routine investigation, all hematological and laboratory parameters like urine routine were found normal. The assessment of the patient was made on the basis of the Hamilton Anxiety Rating Scale (HAM-A)[4] and pro forma for the assessment of Manasa bhava[5] mentioned in Ayurveda classics. HAM-A was obtained to be 31, suggesting severe anxiety [Table 2] and [Table 3].
| Therapeutic Interventions | | |
Fluoxetine was continued, and non-therapeutic counseling was done. Triphala churna (3 gm) before going to bed and Avipattikara churna (3 gm) twice a day before meals were started to combat symptoms such as anorexia, loss of appetite, and constipation. On the next visit (after 15 days), there was no change in symptoms. All routine hematological and urine parameters were found within the normal limits, and no change was found in psychological symptoms. The patient was prescribed Gorakhmundi ghana vati (1500 mg) twice daily on an empty stomach with milk as Anupana (~vehicle) for two months. Apart from this, the patient was advised to take Smritisagara rasa (500 mg) and Saraswatarishta (20 ml) before going to bed, only if any evidence or prodromal phase of seizure occurs.
| Follow-up and Outcome | | |
Follow-up was done at every 15 days intervals until two months, and the patient was examined for symptoms of anxiety and the occurrence of seizures at each follow-up visit. Hamilton's anxiety rating score was found to be nine when assessed after two months, suggestive of mild to no anxiety. As the patient overlooked single evidence of a seizure, there was no need to consume Smritisagara rasa and Saraswatarishta during treatment as well as during the follow-up period.
| Discussion | | |
GAD is characterized by excessive, exaggerated anxiety and worries about everyday life events with no apparent reasons for worry. Ayurveda psychiatry has given two distinct disorders named Unmada (~psychosis) and Apasmara (~seizure disorders).[3] A diagnosis of Chittodwega was made based on the presenting symptoms and eliminating Unmada and Apasmara diagnoses based on the lack of cardinal symptoms for both.
Chitta refers to the psyche and Udvega refers to anxiety.[6] Chittodwega includes both psychological as well as somatic aspects. Somatic manifestations include giddiness, fatigue, fainting, tremors, weakness, lassitude, excessive thirst, and body aches while psychological manifestations incorporate fear, grief, confusion, difficulty in sleep, fearful anticipation, and disturbed sensory faculty.[3] Ayurveda classics have given a separate class of drugs named Medhya which has the potential to deal with psychological disorders. Medhya activity has many components such as nootropic, anxiolytic, anti-oxidant, anti-psychotic, anti- Parkinsonism More Details, and anti-amnestic activity.[7] Kaiyadeva nighantu and Bhavaprakasha nighantu have praised Mundi for its Medhya potential, which can be elaborated on the basis of Rasapanchaka (~pharmacodynamic attributes) of Mundi. Gorakhmundi has Madhura rasa (~sweet taste), responsible for Majja dhatu vardhana (~enhancement of nervous tissue), Kapha dosha samyakara (~maintenance of good quality Kapha dosha), Tikta rasa (~bitter taste) which is responsible for Ama pachana (~digestive stimulant), Tama nashana (~pacify delusion) and Medhya karma. Katu vipaka and Ushna veerya (~hot potency) contribute to Kapha shamana and Pitta vardhana attributes of the drug.[8] Chittodvega is mainly due to the vitiation of Vata-pitta dosha and Raja dushti. Pharmacodynamic attributes of Gorakhmundi are responsible for the alleviation of Vata (Vata kshaya) and Raja (Raja shamana) and also for balancing the qualities of Pitta dosha (Pitta samyakara).[9]
According to the assessment by the HAM-A scale, it is evident that the patient has obtained significant relief in symptoms of anxious mood, tension, fears, and insomnia. Individual scores of these parameters showed significant reduction supporting the symptomatic relief achieved. Reduction in parameters of somatic anxiety and psychological anxiety shows the potential of Gorakhmundi to deal with multiple symptoms of anxiety. Reduction in HAM-A from 31 to 9 demonstrates the potential of Gorakhmundi in drug-induced anxiety. On examination of Manasa bhava, it is evident that there is a reduction in attributes of negative emotions.
It is evident that flower heads and fruits of Gorakhmundi have been reported for analgesic, mast cell stabilizing activity, neuroleptic,[10] immunomodulatory,[11] antioxidant,[12] anxiolytic, central nervous system depressant, and anticonvulsant activities.[13] It has been extensively used for anxiolytic activity in experimental models.[12] Hydroalcoholic extract of the whole plant has been experimentally evaluated for its sedative effect.[14] Ethnomedicinally, this plant is used to treat epilepsy and similar mental disorders.[15] Gorakhmundi contains an immunostimulant sesquiterpene called sphaeranthanolide. It also contains various eudesmanoids and frullanolides. It also contains cryptomeridiol stigmasterol and β-sitosterol.[16] Gorakhmundi appears to be quite higher in saponin while being low in flavonoids, alkaloids, phenols, and tannins.[17] But, no anxiolytic activity has been reported for any of the phytoconstituents obtained from the plant. Thus, it is difficult to justify the anxiolytic potential of the plant merely based on phytoconstituents. Several preclinical studies and ethnobotanical claims prove its efficacy as an anxiolytic agent.
The Snehamsa (~fat content) of milk, which is used as Anupana may help the drug cross the blood–brain barrier and calm the anxious mind, thereby bringing stability in the patient's behavior.[18] However, tryptophans present in milk may also exhibit anxiolytic effects playing a synergistic role with Gorakhmundi.[19] Rasayana kala is described in Ayurveda as the period when the stomach is empty for at least three hour.[20] According to the Shashilekha commentary on Ashtanga sangraha, when the drug is given in Rasayana kala, it exhibits the highest potency, as hindrance due to food is avoided.[20] Thus, this Kala was used for drug administration.
The patient has shown symptomatic relief after two months of treatment with Gorakhmundi ghana vati. Although the thyroid profile was not checked, there were no signs and symptoms indicative of thyroid impairment. Both symptoms got relieved after administration of the Gorakhmundi ghana vati for two months. Thus, allopathic treatment was terminated after consulting the treating neurologist. The patient was then followed up for the next two months and found free of symptoms till the last follow-up on December 14, 2021.
| Conclusion | | |
When conventional therapies juggle with the narrow therapeutic index of antipsychotic drugs, Medhya rasayana from Ayurveda comes into play where the drug does not just decrease the psychosomatic suffering but also gives an approach toward the use of a single drug regimen in the management of GAD. In the present case study, Gorakhmundi has shown promising results in the management of anxiety based on the Hamilton Anxiety Rating Scale as well assessment of Manasa bhava.
Declaration of patient consent
Authors certify that they have obtained the patient consent form, where the patient has given her consent for reporting the case along with the images and other clinical information in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Sahoo S, Khess CR. Prevalence of depression, anxiety, and stress among young male adults in India: A dimensional and categorical diagnoses-based study. J Nerv Ment Dis 2010;198:901-4.  |
| 2. | Yang X, Fang Y, Chen H, Zhang T, Yin X, Man J, et al. Global, regional and national burden of anxiety disorders from 1990 to 2019: Results from the global burden of disease study 2019. Epidemiol Psychiatr Sci 2021;30:e36. |
| 3. | Fleischman PR. Ayurveda. Int J Soc Psychiatry 1976;22:282-7. |
| 4. | Thompson E. Hamilton rating scale for anxiety (HAM-A). Occup Med (Lond) 2015;65:601. |
| 5. | Ahir Y, Tanna I, Ravishankar B, Chandola HM. Evaluation of clinical effect of Kushmandadi Ghrita in generalized anxiety disorder. Indian J Tradit Knowl 2011;10:239-46. |
| 6. | Babu G, Bhuyan GC, Prasad GP, Anitha S. Role of Achara rasayana in Chittodvega. Anc Sci Life 2007;26:33-6. |
| 7. | Kulkarni R, Girish KJ, Kumar A. Nootropic herbs (Medhya Rasayana) in Ayurveda: An update. Pharmacogn Rev 2012;6:147-53. |
| 8. | Phadke GA, Shastram D. Shuddha Ayurveda Pathyakram Samhita. 1 st ed. Bombay: 1960. p. 279. |
| 9. | Deshapande V, Sanganal L. Clinical outlook into chittodwega wsr to generalized anxiety disorder and its management in Ayurveda. Eur J Mol Clin Med 2020;7:3819-23. |
| 10. | Mhetre NA, Ambavade SD, Bodhankar SL. Neuroleptic activity of extracts of Sphaeranthus indicus flowers in mice. Indian J Nat Prod 2006;22:24-7. |
| 11. | Shekhani MS, Shah PM, Yasmin A, Siddiqui R, Perveen S, Khan KM, et al. An immunostimulant sesquiterpene glycoside from Sphaeranthus indicus. Phytochemistry 1990;29:2573-6. |
| 12. | Shirwaikar A, Prabhu KS, Punitha IS. In vitro antioxidant studies of Sphaeranthus indicus (Linn). Indian J Exp Biol 2006;44:993-6. |
| 13. | Galani VJ, Patel BG. Effect of hydroalcoholic extract of Sphaeranthus indicus against experimentally induced anxiety, depression and convulsions in rodents. Int J Ayurveda Res 2010;1:87-92. [ PUBMED] [Full text] |
| 14. | Galani VJ, Patel BG. Psychotropic activity of Sphaeranthus indicus Linn. In experimental animals. Pharmacog Res 2009;1:307-13. |
| 15. | Singh S, Semwal BC. Protective effect of methanol leaf extract of Sphaeranthus indicus L. On an experimental model of epilepsy. Indian J Nat Prod Resour 2019;10:175-80. |
| 16. | Basu NK, Lamsal PP. A chemical investigation of Sphaeranthus indicus Linn. J Am Pharm Assoc Am Pharm Assoc 1946;35:274. |
| 17. | Doss A. Preliminary phytochemical screening of some Indian Medicinal Plants. Anc Sci Life 2009;29:12-6. |
| 18. | Christensen B, Toth AE, Nielsen SS, Scavenius C, Petersen SV, Enghild JJ, et al. Transport of a peptide from bovine α(s1)-casein across models of the intestinal and blood-brain barriers. Nutrients 2020;12:3157. |
| 19. | Wong PT, Ong YP. Acute antidepressant-like and antianxiety-like effects of tryptophan in mice. Pharmacology 2001;62:151-6. |
| 20. | Sharma S, editor. Sutra Sthana. Ashtang Sangraha of Vriddha Vagbhata. 3 rd ed., Ch. 23., Ver. 14. Varanasi: Chowkhamba Sanskrit Series Office; 2012. p. 179. |
[Table 1], [Table 2], [Table 3]
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