1 Introduction

Covid 19, the recent virus outbreak declared as pandemic by WHO is threatening the world by its fast spreading nature. It is creating an alarmed situation throughout the world now also. The lockdown which is part of Covid protocol has restricted people’s freedom of movement and has forced to confine them to stay at home without having physical contact with their relatives and restrict them from social gathering also [1]. The restricted freedom and the panic situation cause fear, anxiety, behavioural issues, domestic abuses, interpersonal relationship issues etc. Such conditions are being approached for Psychological support as per the situation where Ayurveda has a major role to perform [2].

Ayurveda is the science of life and health which is based on the eternal laws of nature. This unique ancient Indian system of medicine has been flourishing in the present time in newer dimensions attracting the attention globally.

1.1 Ayurvedic psychiatry consist of

  1. (1)

    Manasaroga vignana, which deals with clinical condition where the disease and its treatment is based up on the fundamental principles of Ayurveda, that is theory of Tridosha, Panchabhoota etc.

  2. (2)

    Bhoota Vidya, which deals with psychiatric problems where the disease and its treatment is not based on basic principles.

Anxiety is a problem that ranges from mild uneasiness to distress in physical, mental and emotional setup. The data suggest that, in psychiatric clinics approximately 12% of the individuals suffer with generalised anxiety disorder.

Ayurveda follows psychosomatic approach of health. According to Ayurveda psychic factors are involved in almost all the disease pathogenesis along with physical factors, while describing psychological disorders, Acharya has quoted about chittodvega along with Kama, Krodha, Moha etc. which are the different emotional disturbances of mind.

Chittodvega is more applicable term to illustrate the whole anxious state. This can exist as a separate or can be considered as an etiological factor for other psychological disorders. Acharya Charaka explains three types of therapies in Ayurveda.

  1. 1.

    Daivavyapasraya Chikitsa: Spiritual therapy

  2. 2.

    Yuktivyapasraya Chikitsa: Physical therapy

  3. 3.

    Sattvavajaya Chikitsa: Mental therapy.

According to Charaka, Sattvavajaya chikitsa is nothing but withdrawal of mind from unwholesome objects. Counselling treatment which is followed in modern psychiatry treatment very well fit under different methods of Sattvajaya chikitsa. During this pandemic period, people hesitate to have direct consultation with doctors. In this scenario tele- counselling methods have their significant role. Tele-Counselling is an ideal option in such situations which allows all modes of communication that provide information technology platforms, which includes voice message, text message and digital data exchange which helps for diagnosing, prescription writing and evaluation.

Tele-counselling is the technology assisted distance counselling which enables counsellors and client to communicate at a distance when circumstances make this approach necessary or convenient.

Ayurveda states that both health and ill health arises first in mind which is considered as the controller of the senses and the body. Ayurveda with its holistic approach takes mind as an integral part of life. Definition of Swastha emphasizes equal importance to the mental states along with physical state.

2 What is Chittodvega??

2.1 Etymology and definition

The term Chittodvega comprise of two words-chitta and udvega where chitta is the synonym of mind.

Udvega is derived from the root “Ud” which has got several meanings in Sanskrit like superiority in place, power, upwards.on. over etc.

Chittodvega can be defined as an anxious status of mind or anxiety of mind. A reference to chittodvega is found in Charaka Samhitha vimana sthana where Charaka explains about physical and psychic doshas. Chittodvega has been used by Charaka more classically under manodosha vikara along with emotional disturbances like kama (lust), krodha (anger), lobha (greed), moha (infatuation), irsya (envy), mana (arrogance), shoka (grief) and Chinta (Worry) [3].

Even though the word Chittodvega is not explained by Susrutha, Delhana, the commentator of Susrutha Samhita has mentioned Chittodwega as synonymous with the term Shoka (Grief) [4]. He has explained similar words like Chittaviparya, Chittavibhrama in which anxiety is found. Vagbata has referred the term Chittopaplva to denote anxiety [5].

2.2 Etiological factors of Chittodvega

Even though specific causative factors are not clearly mentioned in Ayurveda, the basic pathogenic factors of the mind (Rajas and Tams) have got significant role in the causation of Chittodvega [6]. Vitiation of Rajas and Tamas are considered as prime factor in causation of Chittodvega. Tamas can not manifest its action without Rajas.

Manoabhighata (Mental trauma) is considered as the triggering factor for mental disorders. Tridoshas also play an important role in the manifestation of this disease. Vata is responsible for mental disturbance and gives rise to symptoms like fear, grief and confusion. Among the five varieties of Pitta, sadhakapitta vitiation produces mental disturbance. Among the varieties of Kapha, tarpaka kapha vitiation results in manifestation of Chittodvega.

2.3 Clinical features & Symptomatology of Chittodwega

Doshadushti

Charaka

Susruta

Vagbhata

Vata vitiation

Numbness of feet. Muscle cramps.

Pain in Flanks.

Heart burn.

Headache.

Disturbed sleep.

Auditory hallucinations.

Hoarseness of Voice.

Tremor.

Distention of abdomen.

Fatigue.

Constipation.

Pricking pain.

Pitta vitiation

Feeling of Heat.

Burning sensation.

Hyper acidity.

Excessive sweating

Chest Pain.

 

Disturbed sleep.

Kapha vitiation

Indigestion.

  

2.4 Pathogenesis of Chittodvega

The pathogenesis (Samprapti) explains mode of development of diseases due to the effect of aetiological factors and further differentiation. This is most important part in defining a disease as per Ayurvedic methodology. Since pathophysiology of Chittodvega does not explain separate mention in the Ayurvedic Samhita, with the available literature we have to explain the pathogenesis. Emotional response to problems happening in life is common but persons having Satva predominant mind can resist the ill effect of such emotional disturbances as they are un effected by such events. But the personalities with predominance of Rajas and Tamas exhibits exaggerated response to emotional disturbance [7]. When the abnormality of Manodoshas continue for more time they reach the most vitiated condition in which psychic symptoms like worry, fear and grief develop. When Psychic response continues again for longer period, they start influencing the bodily doshas and this will cause the initiation of Chittodvega.

2.5 Management of Chittodvega

Acharya Charka explained three types of therapies for physical and mental diseases [8].

  1. (1)

    Daivavyapasraya Chikitsa: Spiritual therapy

  2. (2)

    Yuktivyapasraya Chikitsa: Physical therapy

  3. (3)

    Sattvavajaya Chikitsa: Mental therapy

Among these treatment modalities Sattvavajaya Chikitsa plays an important role in the treatment of Chittodvega. Sattvavajaya chikitsa in nothing but withdrawal of mind from unwholesome objects.

2.6 The methods of this treatment are [9]

  • Vismapana (Surprising)

  • Vismarana (dememmorising)

  • Harsa (Exciting)

  • Samadhi (Meditation)

  • Jnanapradhanam (Counselling)

Chittodwega may be corelated as anxiety disorder because of close similarity in symptoms, even though neck to neck correlation is not possible for diseases from ancient and modern point of view. The word anxiety originate from Latin word “anxietas” means experience of anger. Anxiety is characterized by intense disagreeable emotional state associated with danger, which may be internal or external. It is characterised by an intense disagreeable state associated with an undefined threat to one’s physical and psychological self.

Anxiety state may be defined in terms of intensity of the subjective feeling of tension, apprehension, nervousness and worry that are experienced by individual at a particular moment and by heightened activity of the autonomic nervous system that accompanies these feelings.

2.7 Aetiopathogenesis of anxiety

figure a

There is significant difference between fear and anxiety. Fear is generally an emotional reaction to the anticipation of injury or harm from some real objective danger in the external environment. In the early 1900s, Sigmund Freud recognized anxiety as a central component of mental diseases and the term “Anxiety neurosis” was developed to describe a variety of types of Anxiety.

2.8 Types of anxiety

  1. (1)

    Train Anxiety

    This is the lifelong pattern of anxiety as a feature of temperament, apart from personality.

  2. (2)

    State Anxiety

    It refers to acute, situational bound episode of anxiety that do not persist beyond the provoking situation. During this pandemic situation most people especially elderly people and low-income group individuals are most affected by this type of Anxiety.

  3. (3)

    Free floating Anxiety

    This is a pervasive, unfocussed fear not attached to any idea, the cause is unknown perceptual disturbance.

2.9 Treatment modalities

The anxiety disorder is treated with some form of counselling or psychotherapy, either singly or in combination. Psychotherapy or Counselling is said to be effective for treating anxiety disorder.

The range of available techniques for psychotherapy are wide and includes the following:

  • Applied relaxation

  • Cognitive therapy

  • Behavioural therapy

  • Directive Counselling

  • Non-directive Counselling

Under these techniques counselling therapy has a significant role. During this pandemic situation patients prefer for non-directive counselling which may enable social distancing also. Tele-counselling comes under non-directive counselling category.

2.10 What is tele-counselling?

Tele counselling is technology assisted distance counselling which enable counsellors and the client to communicate at a distance when circumstances make this approach necessary and convenient. It is a scientific process of assistance extended by an expert in an individual situation to a needy person. This involves relationship between two persons, Counsellor and Counselee or client.

Different types of tele counselling like cyber counselling, web-based counselling and web therapy are popular.

2.11 Purpose of tele-counselling

Tele counselling will identify the problems of a person and helps people to use their existing problem-solving skills more effectively. It will help to develop new or better skills. Tele counselling provide an opportunity for the person to describe their problems and feelings for themselves. Tele-Counselling provides rapid access to medical practitioners who may not be available in person. There is higher likelihood of maintenance of records and documentation. Written documentation increases legal protection of doctors as well as patients. If used effectively, this reduces burden on secondary health care system.

2.12 Principles of tele-counselling

Few principles must be followed during this event.

  1. (1)

    Principle of individualization

  2. (2)

    Counsellor must recognize and understand the client’s unique characteristic.

  3. (3)

    Client should get a feeling that they are treated individually.

  4. (4)

    The approach should be personalised.

Non-directive counselling, in which tele counselling is included, has different steps in the process of problem solving.

  • Define the problematic situation.

  • Free expression of feelings.

  • Development of insight.

  • Classification of positive and negative feelings.

  • Termination of Counselling situation.

Tele-Counselling is more time consuming compared to direct counselling method. Here the methodology is indirect. More emphasis is on the emotional aspects of individual compared to direct counselling. A highly professional, competent and trained person with understanding of relationship skills is required for tele counselling. This helps to develop self-insight and helps the client to solve the personal problems.

2.13 Crisis counselling through tele-counselling during pandemic

Crisis Counselling can be done through tele-counselling. According to the American counselling association, crisis counselling assists individuals with copping and support after a major crisis. This can be brief, and time limited with specific goals for achieving stability, increasing an internal sense of empowerment and safety, and locating appropriate resources. Counselling can range from 15 min to 3 h and can be provided as 3–4 sessions. But this is not a substitute for long term therapy or psychiatric care. Crisis counselling can provide a safe outlet for immediate relief. This may be utilised as psychological first aid. Tele counselling focuses of reducing acute distress, restoring physical and mental stabilisation and integrates pro social copping skills.

Tele-counselling can be conducted with a smart phone which is an immediately available solution. This can be utilised by physically disabled clients also. Clients also may feel free to write and express their feelings. This helps in faster exchange of material documents.

During tele-counselling, counsellor has some responsibility. He must communicate pros and cons of tele counselling such as limitations of technology which could breach confidentiality. During network problem, counselling may be interrupted. Counsellor should provide educational qualifications to the client and he also has the responsibility of verifying client’s identity in order to ensure the counselling process an authentic and genuine one. He should obtain alternative method of contacting the client during emergency situations. He should share the confidential information of the client with his permission only.

2.14 Ayurvedic approach for “Chittodvega” (anxiety disorder) through tele-counselling

Ayurveda is a comprehensive science which gives ultimate importance to health and longevity as well as prevention, rather than treatment and cure of any diseases. These measures are to be strictly followed to bring the things under control, in the crisis of covid pandemic. Such a pandemic as Covid 19 is having an inevitable impact in the mind of people throughout the world in various levels and various age groups also, rather than affecting the body. In any individual, if the quality of life is affected during this pandemic, needs a psychological assessment as well as right intervention. This requires the help of psycho supportive therapy which is denoted as “sattvajaya chikitsa” in Ayurveda [10].

Health care professionals also faced some challenges during this pandemic. Due to the lock down, they found difficulty in providing health care services to the needy people. In such a situation Tele-Counselling is preferred. The health care professionals who are connected with their patients through digital communication can easily provide counselling through such methods.

Central Council of Indian Medicine has recently issued a detailed guideline about Tele-Medicine/Tele-Counselling practice for Ayurveda [11]. The guideline provides answers to many legal issues and advises the health professional to follow the standard guidelines. It suggests that, if the patient calls for consultation, there is no need of separate consent to be undertaken. It is important to keep the record of consultations in the form of call logs and chat records. The guideline helps to make ASU practitioners enable to use the Tele-Counselling/Tele-Medicine tools. This will be done by providing information as well as training which will be updated from time to time as in coming years tele-counselling will continue to grow and be adopted by more health care practitioners and patients in a wide variety of forms. These guidelines will provide norms and protocols relating to doctor patient relationship issues of liability and negligence, evaluation, management and treatment. This will give practical advise to ASU registered medical practitioners regarding Tele-Medicine/Tele-Counselling to encourage them to consider the use of Tele-Medicine as a part of their normal practice as well as in disasters and pandemics. This will pose unique challenges to provide healthcare which will help to treat patients without exposing doctors and their staff to infections at the time of such outbreaks.

The Tele-Counselling practice can prevent transmission of infectious diseases reducing the risk to both doctors and patients by avoiding social contact. Hence any system of medicine can adopt the advantage of Tele-Counselling/Tele-Medicine during this pandemic including Ayurveda.

Sattvajaya chikitsa must be performed in the psychologically affected individuals in step by step manner. This includes jnana (knowledge of self), vijnana (scientific reasoning), Dhairya (determination), smrithi (memory) and samadhi (attaining stability of mind) [12]. These steps can be correlated with the steps explained in non-direct counselling, in which tele counselling is included.

In the category of Jnana, knowledge of self is provided that is creating awareness of how one must perform or react in such an unfamiliar situation of pandemic. To achieve this, tele-counselling has a significant role. During tele counselling Ayurvedic practitioner can advise the clients different modalities which will help them to improve the health status of mind. The different modalities are listed below:

  • To assess about one’s own health condition, if under any medication without flaws it must be continued as per the on-going instructions of the Physician. If any features of Covid 19 are suspected, inform the authorities at the earliest.

  • To Involve in stress relieving activities such as reading, listening to music, breathing exercise as per the interest.

  • To be in touch with friends and relatives over phone or social media to keep the mind stress free.

  • To avoid believing fake news and rumours.

  • To depend on scientific journals, Govt bulletins or WHO publications for actual data regarding Covid pandemic.

  • Interact with health professionals including family doctors for the signs and symptoms of Covid and about management protocols.

In the step of Dhairya (Determination) of Satvajaya chikitsa, the following points can be advised through tele-counselling.

  • To maintain patience and to have a belief in the Ayurveda system of medicine

  • To minimise watching, reading, listening to the news about Covid which causes anxiety and stress.

  • To have a determination to obey rules of lockdown like Social distancing and Hygienic measures.

  • To have the determination to maintain a positive healthy family atmosphere.

In the step of Smriti (Application of memory), the following advises can be given through tele counselling:

  • To recollect the own experiences which happened previously where one had overcome a critical situation.

  • To give attention to those who had similar experiences with positive outcome.

  • To find opportunities to spread positive and hopeful stories of local people who have experienced Covid 19.

In the step of Samadhi (attaining stable state of mind), the following points can be advised through tele-counselling.

  • To practice yogasana which calms the body as well as mind.

  • To do regular pranayamas and breathing exercises.

  • To chant mantras may help to improve concentration.

  • To practice deep relaxation techniques (DRT)

These steps of Satvavajaya Chikitsa are applicable in Chittodvega (anxiety) and any other psychological issues related to Covid pandemic and these steps can be advised to the client through tele counselling. The medicines needed for management of anxiety also can be prescribed. For those people with features of anxiety disorder, considering the status of Dosha and severity of the condition, medicines such as Aswagandha (Withania somnifera) [13], Jatamamse (Nardostachys Jatamansi) [14], Drakshadi Kwadham [15] etc. can be prescribed. In cases of disturbed sleep which a symptom of anxiety, Tagara (Valeriena wallichii) [16], Somalata (Sarcostemma acidum) can be administered. Kushmanda Grita or Datriyadi Grita [17] can be prescribed in Chittodvega as per the digestive capacity of the person. Drugs listed as Medhyarasayanas [18] can be administered which have neuro protective actions in anxiety conditions. Such drugs have immunity enhancing properties also.

3 Conclusion

Anxiety is a problem that ranges from mild uneasiness to severe distress among various psychological disorders described in Ayurveda, Chittodvega (Anxiety disorder) is having lot of significance in the present pandemic situation. Rajas (Dosha of mind) with vitiation of Vata (one of the Tridoshas) place an important role in Chittodvega. Aetiology of anxiety disorder can be understood at the level of neurotransmitters. The drug having effect on neurotransmitter may show significant relief for anxiety disorder. Ayurvedic system of medicine is having important role in handling anxiety disorder.

Satvavajaya chikitsa, included in the division of treatment modalities of Ayurveda is very much capable of providing psychological support in Chittodvega (Anxiety disorder), which is very common in current pandemic situation. The various steps of Satvavajaya chikitsa are very similar to the steps of Tele-Counselling. During this pandemic situation, Tele counselling has an important role which will enable the patient to have psychological and medical need by following all the Covid protocols.