Prevalence of Manasikahetu (Psychological factors) in patients suffering from Ajirna (Indigestion)

Introduction

Psychological well-being can be considered as equally essential as physical well-being. With good psychological health, one can work well, feel happy during leisure time, and contribute to society. In special cases, chronic health issues could affect mental health. If untreated, it may result in depression and suicide.^[1], ^[2] It was previously shown that the patients suffering from physical illnesses such as inflammatory polyarthritis, diabetes mellitus, psoriasis, migraine, asthma, or epilepsy had a higher risk for self-harm. ^[3] In a recent report in USA concluded that sleep disorders, renal disease, migraine, HIV/AIDS, chronic obstructive pulmonary disorder, congestive heart failure, cancer, traumatic brain injury, and even back pain have been linked to increased suicide risk. ^[1] The study further identified that the risk of suicide become doubled with the increased morbidity-associated with the disease. Clinicians treating patients with physical illness less frequently detect psychological disorders. Management of mental illness by decreasing the feeling of burdensome and educating the carers and patients can effectively increase the quality of life.^[4] Hence, it is vital to treat both the physical as well as mental aspects of the disease.

The digestion of food plays a vital role in good health. In modern medicine, dyspepsia is described as indigestion in addition to acid build up and the distress with empty stomach. Symptoms attributed to dyspepsia are vomiting, difficulty in swallowing, appetite loss, anaemia, and weight loss. Modern medicine suggests proton pump inhibitors for dyspepsia management, along with tricyclic anti-depressants or prokinetic therapies.^[5]

According to Ayurveda, the origins of a disease could be physical or mental, or both. ^[6] Mithyayog, Ayog, and Atiyog Kaal, Buddhi, and Indriya are the main causative factors of any disease where involvement of both body and mind is inevitable. ^[6] In physical ailments, first the tridoshas get affected, and later the rajas and tamas doshas become strained. On the other hand, in mental disorders, the rajas and tamas doshas get affected first, leading to the disturbance of the tridosha in the body. Once the tridosha of the body gets involved, it potentially disturb the psychological component i.e., Manas (mind); especially rajas and tamas dosha. In Ayurveda, digestive power is compared to fire and called as Agni. However, the occurrences of indigestion or dyspepsia (Mandagni) due to various reasons often leads to psychological distress and the presence of undigested food inside the body is known as Ajirna. The primary symptoms of Ajirna are indigestion, anorexia, tenesmus, vomiting, fever, body ache, yawing, giddiness, fainting, headache, malaise, and abdominal distension.^[7] Ajirna is classified as per the vitiation of the different doshas: Vishtabdh Ajirna (Vata dosha), Vidagdh Ajirna (Pitta dosha), and Aam Ajirna (Kapha dosha). Other minor types of Ajirna are Prativasara Ajirna (nutrients not digested), Dinapaki Ajirna (next day digestion), and Rasashesh Ajirna (average delay incompletion of digestion).^[6] Previous clinical studies concluded that the use of herbo-mineral and polyherbal preparation can help to reduce the situation of Ajirna.^[8], ^[9] Moreover, another review article emphasized that the co-occurrences of Manasikahetu with Ajirna disorders which is due to the various causal effects such as- erratic life style, abnormal dietic regimen adherence, stress and mental disturbance. ^[10] A study conducted in 2011 showed that dyspepsia patients had a high risk of major depressive episodes (threefold risk) and generalized anxiety disorder by twofold risk. ^[11] However, the aberrations in the brain regions in patients suffering from functional dyspepsia were linked to depression and anxiety. ^[12] Hence, it is of great concern to study the longitudinal correlation of psychological distress and dyspepsia in order to treat digestive disorders and prevent a very adverse mental health condition.

In our study, we prepared a questionnaire to understand the prevalence of psychological issues in patients suffering from Ajirna. Further, we would elucidate that the co-occurrence of various dyspeptic symptoms with mental illness. Therefore, the use of trance-therapies like Sattvaavajaya Chikitsa, meditation, and yogasana can be proposed for the beneficial outcome of symptomatic relief and preventive measure from mental distress, especially in young Ajirna patients.

Materials and Methods

A cross-sectional observational study was conducted on pre-diagnosed patients of Ajirna, having age group of 20-60 years of either sex. The study was approved by the Institutional Ethics Committee (No: AY/PG/046/2019-20 IEC), and every participant signed an informed consent form before starting the study. We included individuals having the following symptoms in our study: Glani (tiredness), Gaurav (clumsiness), Vishtambha (improper defecation/ bloating), Bhrama (giddiness), Marutamoodhata (abdominal distension), Vidbandha (dry/hard stools) or Atipravrutti of mala (increased quantity of stool). However, the individuals who had the following symptoms or disease were excluded from the current study like- Crohn’s disease, Celiac disease, ulcerative colitis, pancreatitis, all types of rare syndromes of the gastrointestinal tract, intestinal obstruction, oesophageal cancer, pancreatic cancer, rectal cancer, colon cancer, tuberculosis, syphilis, and congenital disorders.

Results

In order to understand the linkage between Ajirna and psychological disorders, the prepared questionnaire was given to the pre-diagnosed patients. It helped to obtain data related to demographic distribution, education, clinical symptoms, duration, lifestyle pattern, and psychological condition of the patients. Out of the100 patients assessed, 51% were males, and 49% were females, with age ranging from 20-60 years. Regarding marital status, 79% of the patients were married, and 21% were unmarried. A person’s personality can be dependent on three doshas, known as vata, kapha, and pitta. In ayurveda, the combinations of these dosha contributes to a person’s physiological and mental health, which is known as ‘Prakruti’. ^[13] In our study, there was a noticeable difference in the frequency distribution of the different combinations of Prakruti. The predominant Prakruti in the patients were Pitta + Vaata and Vaata + Pitta, with frequencies of 44% and 28%, respectively ([Table 1]).

Among all the Ajirna patients (indigestion), the 47% of the population had Ajirna once per month and 44% once per week ([Table 2]).

Furthermore, the 67% of the patients suffered from chronic indigestion, and the rest from acute indigestion (33%). Ajirna patients were majorly affected by dry or hard stools (89%), abdominal distension (85%), and incomplete defecation or bloating (54%) ([Table 3]).

According to Ayurveda, the consumption of excess water during digestion often resulted in the indigestion of food and further dyspepsia due to lack/dilution of peptic juice. ^[14] Here, we were keen to understand the correlation of water intake with Ajirna symptoms in our study. Among all Ajirna patient, 72% of the patients consumed excess water daily, where 57% of the patient had a water intake of 2-4 litres/day and 15% had 4-6 litres/day. The rest of the patients drank an optimal quantity of water, 1-2 litres per day (28%). It was found that 70% of the patients had a habit of restraining the defecation reflex, and most of the patients were controlling the defecation reflex once a week (34%) or occasionally (30%) ([Table 4] ).

Since, Ajirna and psychological well-being were shown to be correlated, we evaluatedthe emotional quotient of the Ajirna patients. Most of the patients had multiple emotional disturbances with the parameters overlapping among the Ajirna cases. Most of the patients agreed to be sentimental (90%), short-tempered (76%), a habit of restraining crying reflex (72%), episodes of emotional breakdown (71%), regular suffering from grief (40%), and loss of emotional productivity (24%) ([Table 5]). Fright issues in Ajirna patients were found to be due to different reasons like imagining scenarios (26%), attempting something new (15%), environment (8%), and mob (4%)([Table 5]).

Discussion

Ayurveda is an age-old traditional medical practice in India which conceptualizes the presence of five physical elements (ether, earth, fire, water and air) constituting the universe including human body and three doshas which distinguishes the individuality of humans termed as Prakriti. The Prakriti is a combination of a person’s physical, physiological and mental traits which is independent of socio-demographic variabilities. ^[15] Hence, the massive similarities between western medicine’s psychologic somato types and Indian medicine’s Prakriti, together offer a proposal for definite genopsycho-somato typing of humans. The three doshas namely-Vata, Pitta and Kapha which represents movement,digestion and cumulation, respectively. Each doshas are related to the expression of various nuclear transcription factors which profoundly regulate the embryonic development, adult homeostasis, and metabolism of the human. ^[13] A systematic review has emphasized on the Prakriti with metabolic disorders, chronic disease and genetic abnormalities. Therefore, the early identification of Prakriti of newborn babies along with genetic screening would help to improve not only the personalized medicine but also personalized dietary and lifestyle changes from early age. This can be achieved personalized optimization of health management practices. ^[16] The manifestation of Ajirna includes Adhman (abdominal distension), Vishtambha (incomplete defecation), dry/hard stools, bloating, and clumsiness in patients which indicate the involvement of the gastrointestinal tract distress in disease pathogenesis. ^[7] Since Prakriti determines the constitutional blocks of the human being, therefore it is of great importance to identify the Prakriti of a patient before the commencement of treatment regime. ^[17] In our study, we found that chronic indigestion is prevalent in Ajirna patients, and it is episodic occurring every week or month. The prevention of Ajirna is difficult due to the inability to identify the Ajirna pathology and lack of appropriate treatment. Thus, the frequent chronic indigestion takes a toll on the physical and further the mental health of Ajirna patients.

Ayurveda suggests that one should drink water only when you feel thirsty. However, modern medicine advises a high intake of water for proper hydration. The power (Agni) of the body helps in the digestion of food and high intake of water during digestion is like dousing fire with water. As per Ayurveda concepts, high intake of water can be harmful for health. ^[14] The undigested food (Aama), in addition to weakened digestive fire (Mandagni), leads to Aama dosha, which can, in turn, give rise to various disorders (Roga. ^[8] The patients in our study were found to drink 2-4 litres of water per day which might be the cause of Ajirna. Additionally, the restraining of the defecation reflex affects the functioning of Aapaanavayu, causing vimargagaman and Vata dosha in the body. ^[10] It is assumed that increased water intake may clear the bowels, but the current cross-sectional study points out the harmful effects of increased water intake.

Functional dyspepsia patients suffer from somatoform, depressive, and anxiety disorders. ^[18] A clinical study by Magni et al. (1987), where 86.8% of the patients with functional dyspepsia suffered from psychiatric disorders. ^[19] Psychotropic drugs including both the anti-depressive and anti-anxiety properties were more effective in managing functional dyspepsia symptoms than psychotropic drugs with only anti-depressive properties. The ability of psychotropic medications to manage dyspepsia indicates that emotional disturbances are associated with dyspepsia. ^[20] We found a high prevalence (71%) of psychological disturbances (Manasika Hetu) in the Ajirna patients as most of them restrained crying reflex. It is known that an increased incidence of restrained crying reflex leads to Vata-vruddhi, and increased suppression of emotional stress leads to Agnimandya, further establishing the relationship between digestive and psychological problems. Moreover, we found that Ajirna patients suffered from grief; a state of mixed positive and negative emotions, which in later stages gets dominated by negative feelings, leading to psychological issues.^[21] In a special case report, a 58-year-old woman was diagnosed of suffering from severe dyspepsia for 2 years, which did not subside with pharmacological treatment. On probing further, the development of dyspepsia coincided with the death of her son due to cancer and she blamed her ailment for that, further the hypnotic treatment cured the woman from her grief and led a normal life. ^[22] We also found that majority of the Ajirna patients were short-tempered. Short temper could be associated with intermittent explosive disorder or depression and includes emotional outbursts leading to physical aggression and anger, and negative consequences with patients feeling guilty later on. ^[23] The Ajirna/dyspepsia and emotional stress are correlated because anxiety or emotional stress can increase the fight or flight response(adrenaline) in the brain. ^[24] As the brain uses high amounts of energy for its functional execution, the body diverts most of the energy from digestion to brain which further reduces the digestive efficiency. Also, the anxiety can increase serotonin levels in the body, which has an inhibitory effect on the gut, leading to indigestion or Ajirna (10). However, a randomized clinical study emphasized on the use of serotonin agonist for the treatment of functional dyspepsia anxiety.^[25] Hence, it is advisable to treat the psychological issues in along with, instead of treating Ajirna alone.

In present study 38 patients of Ajirna were observed who were suffering from Fright issues and had a habit of Restraining Defecation Reflex. After applying chi square test p value noted was 0.861, which is > 0.05. Hence it can be said that there is no correlation amongst these two observations.

The early diagnosis and treatment of Ajirna are essential as in later stages; the disease can proceed to numerous upadravas like severe vomiting. A previous study on Ajirna patients showed that Sattvavajaya Chikitsa helped improve Vataja, Pittaja, and Kaphaja symptoms. A type of Adravyabhoota Chikitsa, Sattvavajaya Chikitsa, helps improve mental problems in Ajirna patients. Physicians can suggest relaxing muscles in addition to deep concentration (Indriya-Nirapeksha Jnana prevention) and detachment of Mana and Indriyas from Vishayas (Indriya-Sapeksha Jnana prevention). Sattvavajaya Chikitsa, helps to reduce the stress and enhance the strength of the Sattva.^[26] Available evidences indicates that psychological therapies may benefit patients with functional dyspepsia, especially those with chronic symptoms. ^[27] Therefore, the psychological problems associated with the Ajirna patients could be treated with trance-therapy or Sattvavajaya Chikitsa. Finally, psychological treatment will help to lower the rate of Ajirna incidence in middle-aged patients, provide symptomatic relief, and can act as a preventive measure in young adults.

Conclusion

Ajirna is not only related to the physical illness such as- gastro-intestinal distress, abdominal pain and improper excretion habit, but also resulted in various mental disturbance, emotional outbreak and ultimately adverse life situations. In this scenario, we have shown the etiological evidences and dominance of Manasika hetu in Ajirna patients. Therefore, our study proposed that both bodily and psychological treatment of Ajirna, is crucial for an effective outcome. Mental stress is the growing problem in the society due to multiple causes like- profession, life style changes, irregular dietary pattern, which is hard to be eradicated. Therapies like Sattvaavajaya Chikitsa, meditation, and yogasana could be regularly practiced in order to prevent not only dyspepsia or Ajirna, but also various life-style associated disease and for the improvement of mental health.

Source of Funding

None.

Conflict of Interest

None.