Bhutonmada or Grahonmada (psychiatric and/or neuropsychiatric conditions described in Ayurveda having an idiopathic manifestation) is a specific type of Unmada (broad diagnostic entity that encompasses a wide range of psychiatric conditions) explained in Ayurvedic (a holistic system of medicine) texts characterized by various abnormal or superhuman behaviour, perception, speech and memory. Craving towards specific foods and alcohol are the common clinical findings across Bhutonmadas. Several Ayurvedic terms are used in the context of Bhutonmada to describe various dimensions and intensities of cravings, from a mild preference to an intense, addictive desire. The idea of quantifying cravings (in the context of Bhutonmada) using Ayurvedic terminology has been proposed in the present work. The present work also explores how contemporary psychological concepts of attentional biases, cognitive errors, information processing errors, maladaptive and impulsive behaviours can be interpreted in Ayurveda primarily through the concepts of Dhee, Dhriti, Smriti Vibhrama (attentional memory biases) and Pragnaparadha (cognitive errors/biases). Madyaamisha Sakta Drishti (a clinical feature of Bhutonmada characterized by sustained gaze on alcohol and meat-related visual cues), and its similarities to the modern concept of attentional bias to alcohol and specific food-related visual cues, measured using eye-tracking technology in contemporary practice, has been explored in the present work.

Keywords: Ayurveda, craving, grahonmada, pragnaparadha, psychiatry, unmada

Unmada (psychosis) is a broad Ayurvedic diagnostic entity that incorporates various psychiatric and neuropsychiatric illnesses.¹ It is characterized by the derangement of various mental functions, including perception, cognition, memory, psychomotor activity, personality, and behaviour.² According to Ayurvedic texts, Unmada is classified in different ways by various authors, though certain core types remain consistent across most texts.³ Bhutonmada, or Grahonmada, or Agantuja Unmada is a specific type of Unmada, characterized by a range of abnormal and/or superhuman behaviours, including heightened energy, reckless actions, speech abnormalities, and enhanced or impaired cognitive functions.⁴ It is believed to be caused by the possession of ‘Graha’ or ‘Bhuta’ (demon/evil spirit/an idiopathic entity) rather than Doshic imbalance (vitiation of body humors). Contemporary Ayurvedic researchers and scholars explore the concept of Bhutonmada as a framework for understanding various complex and multi-faceted psychiatric and/or neuropsychiatric conditions, rather than literal demonic possessions.⁵

The classification and clinical presentation of Bhutonmada vary significantly across different Ayurvedic texts. Sushruta Samhita lists eight types (Deva, Asura, Gandharva, Yaksha, Pitru, Naga, Rakshasa, and Pishacha), while the Charaka Samhita describes eleven types and the Ashtanga Sangraha & Hridaya enumerates eighteen types of Bhutonmada. These classifications are based on the presumed Bhuta/Graha causing the condition, and are considered innumerable in total.¹ An analysis of Bhutonmada, suggests that it’s associated alcohol misuse and abnormal eating behaviours have complex origins and significant clinical implications. While the specific role of these behaviours in Bhutonmada is still being researched, modern perspectives from addiction science and nutritional psychiatry provide potential insights. Specific food cravings, and alcohol abuse are not just peripheral symptoms of Bhutonmada but are intertwined with the psychological distress of the condition.¹ 

Ayurvedic texts describe cravings with several terms that indicate different intensities, from a mild preference to an intense, addictive desire. The quantification and pathophysiology of cravings, especially in the context of Bhutonmada, requires further in-depth exploration. Various attentional biases, cognitive distortions, and errors in information processing that drive cravings for food and alcohol in Bhutonmada context require further clarity, and the present work is aimed at it. The present work also explores the utility of the clinical feature, ‘Madyaamisha Sakta Drishti’ (a sustained, compulsive focus on alcohol and meat/specific food items) of Bhutonmada as an objective clinical and diagnostic parameter for assessing attentional bias to food- and alcohol-related visual cues.

Classical Ayurvedic texts along with commentaries, published articles on Bhutonmada/Grahonmada, and contemporary literature pertaining to attentional biases, cognitive errors, cravings, alcohol addiction or abuse, specific food cravings, etc., have been searched by using appropriate keywords from the databases including Google Scholar, PubMed, and Scopus. Open-access and full-length research articles published in the English language were included. Conclusions have been drawn after analysing and interpreting the obtained literature

Ayurvedic terminology for cravings in Bhutonmada context

In Ayurveda, the concept of cravings (food and alcohol related) is represented by several terms including Madyaamisha Sakta Drishti, Abhipraayam (opinion/preoccupied towards food and alcohol), Ratim (pleasure seeking/strong desire), Ruchim (hedonic hunger/delicious food cravings), Priyam (liked/intense desire to specific food items), Yaachinam (begging/food or alcohol seeking behaviour), Abhilaashinam (affection/longing for/desiring), Bahvaashinam (hyperphagia), Lolam (greedy/lustful/gluttony), Kshudaatura (homeostatic hunger/pathological hunger), Bahu Bhuk (excessive food intake/hyperphagia), Bhramaad Bhojinam (gluttony/hedonic hunger/dysregulated food consumption) and Kshudadhikam (excessive hunger) in Bhutonmada context (Table 1). Craving towards specific foods and alcohol are the common clinical findings across Bhutonmadas. Cravings toward meat (Amisha/Maamsa) may denote an underlying deficiency of various micronutrients such as proteins, amino acids, minerals, vitamins, folic acid etc. Alcohol addiction or dependence is a common finding seen in the symptomatology of various Grahonmadas.¹ It is evident that cravings and dysregulated consumption of alcohol and specific foods is a common comorbid finding across Bhutonmadas.¹

The word Abhipraayam denotes intention or desire or preoccupied or anticipatory domain of a craving or addiction. Dadhi (curd), Ksheera (milk) and Sura (alcoholic beverage) Abhibpraayam is one of the clinical features of Deva Grahonmada. It may represent the social positive reinforcement behaviour or a cognitive component of cravings. Several terms such as Abhilaashinam/Abhilaasha, Ruchim, Ratim and Priyam represent emotional dimension of craving with moderate intensity. These terms denote active craving phase with an intense desire or urge towards alcohol or specific food items. These terms may represent anticipation of the pleasure or expectation of reward and positive reinforcement.¹ The word ‘Madya’ or ‘Sura’ denotes an alcoholic beverage, ‘Amisha’ or ‘Maamsa’ denotes meat and ‘Sakta Drishti’ represents fixed gaze on a specific object/a fondness for alcohol and meat. Madyaamisha Sakta Drishti is one of the clinical features of Nishada Grahonmada and it represents fixed gaze on a craved object such as alcohol and specific food items (meat).⁶ Madyaamisha Sakta Drishti may denote attentional bias to alcohol and food related visual cues and a seeking phase. The terms Yaachinam and Kshudaatura may represent underlying physiological states or homeostatic hunger or food seeking behaviours whereas terms such as Kshudadhikam, Bahu Bhuk, Bhramaad Bhojinam, Bahvaashinam and Lolam represents dysregulated food consumption behaviours, gluttony, hyperphagia, and hedonic hunger. These terms denote severe addictive behaviours, executive dimension of cravings and consumption phase of drugs/specific food items. These Ayurvedic terms could also be used to quantify the intensity of cravings/addictive behaviours in the context of Bhutonmada (Figure 1).

Figure 1 Ayurvedic terminology for craving quantification.

Attentional biases, cognitive errors and cravings in Bhutonmada context

Craving is defined as a subjective experience of intense desire and an urgency to use a substance (seeking alcohol or a specific food item) or perform a behaviour (consuming alcohol or specific foods). Craving is a multi-dimensional and complex phenomenon, involving emotional (Ruchim, Ratim, Priyam, Abhilaashinam etc.), cognitive (Abhipraayam), physiological (Kshudaatura) and sensory (Sakta Drishtim) components.⁷ Feeding involves cognition (learning, decision making, memory), emotion (craving, motivation), sensory (taste, visual, olfactory) and motor behaviours. Food-related behaviours could be examined by three phases, food craving, seeking, and consumption. Food craving phase is characterized with high desire and preoccupation toward food (Priyam, Abhipraayam, Ratim, Ruchim etc.). Food seeking phase is characterized by searching and approaching for food (Sakta Drishti & Yaachinam). Food consumption phase denotes actual consumption of the food (Bahu Bhuk, Bahvaashinam, Bhramaad Bhojinam etc).⁸ Meat supplies various nutrients, high-quality proteins, vitamin B12, retinol, omega-3 fatty acids, iron, zinc and other bioactive compounds.⁹ Specific food cravings to high-calorie/energy dense food items (dairy products, meat etc.) found across Bhutonmadas may also represent underlying deficiency states or homeostatic hunger.¹ Problematic food and alcohol consumption are often comorbid¹⁰ and this comorbidity is seen across the clinical presentation of various Bhutonmadas.¹

Alcohol users show an attentional bias towards alcohol-related cues (Madya Sakta Drishti) in the environment. Based on cognitive models of substance use, Madya Sakta Drishti may denote a cognitive phenomenon where a person's attention is automatically drawn towards alcohol-related cues (Madya Sakta Drishti). This bias is considered a causal factor in dysregulated and excessive drinking (Paana Ratim). Spending more time fixated on alcohol-related images (Madya Sakta Drishti) is a sign of attentional bias toward alcohol cues, and individuals with higher-risk substance use patterns typically exhibit this bias more strongly than others. This heightened attention can impair processing of other information and is a common feature in addictive behaviours.¹¹ An attentional bias is the tendency to selectively focus on substance-related cues in the environment. Selective visual attention drives the persistence of addiction through a self-reinforcing "bias-craving-bias" cycle. The visual probe task is a common method for measuring alcohol-related attentional bias. Attentional engagement and/or disengagement both attentional biases are strongly linked to alcohol consumption frequency and quantity.¹² Cue-elicited craving is a key component of theories like the incentive-sensitization theory, which suggests that repeated drug use sensitizes the brain to drugs and cues, increasing a person's desire for them. Cues also lead to attentional biases towards alcohol, creating a cycle where increased attention to cues heightens craving, which in turn strengthens attentional bias leading to and maintaining drug-seeking behaviour.¹³

Decision-making is determined by the interaction between the two systems, reflective system (associated with conscious, deliberate and controlled responses and responsible for higher-level cognitive functions such as executive control and working memory), and the impulsive system (associated with automatic, habitual, reward-seeking and appetitive behaviours and operates on a more unconscious level and driven by immediate urges and desires). Substance abuse would emerge from an imbalance, caused by the under-activation of the reflective system, and the over-activation of the impulsive system.¹⁴ Attentional biases related to alcohol, further encourages drinking-related behaviours (approach behaviours) as a result of explicit (conscious craving) or implicit (unconscious wanting) processes.¹⁵ Impaired attentional processing (the inability to effectively control and direct one's attention), craving induced sensitization (with repeated use, the brain's response to the cue or trigger for a reward becomes more and more intense, independent of the actual pleasure received from the reward), increased saliency of cues (stimuli associated with the desired substance or behaviour become more attention-grabbing and stand out more in the environment), information processing bias (the general tendency for people to pay more attention to things that are relevant to their current concerns or goals), automatic detection (The initial capture of attention by concern-related stimuli happens involuntarily and without conscious effort), desire related thoughts and behaviours (the detection of a cue triggers a cascade of thoughts about the desired item and leads to subsequent actions to obtain it), initial orientation (the first stage of attention bias, where a person rapidly directs their attention toward a salient cue), and gaze maintenance/delayed disengagement (the second stage, where a person finds it difficult to shift their attention away from a salient cue) are the various types of attentional biases and/or information processing errors in cravings/addictive behaviours.¹⁶

Higher intake of palatable foods may be caused by high impulsivity (high preference for immediate reward or poor motor response inhibition) and high susceptibility to food-related impulses (approach bias toward food). Attentional impulsivity (inability to focus), motor impulsivity (acting without thinking), and non-planning impulsivity (lack of future forethought) are the three facets of impulsivity. Trait impulsivity is a predisposition to act quickly and without planning, disregarding negative outcomes.¹⁷ Attentional biases can be measured by indirect inference (reaction time), or directly (e.g., by monitoring eye movements), or by other measures including eye-tracking (ET) technology. The ET technology is useful to detect the oculomotor activity such as eye gaze, position, or movement. Key eye-movement parameters include pupillary dilation, saccades, first fixation (earliest attention), and dwell time or number of fixations (sustained attention). These parameters can be used to analyse how attention is deployed, from initial processing to deliberate cognitive processing.¹⁸

The process of Gnanotpatti (perception), is a complex interaction involving the external world (Indriyaartha), the sensory organs (Indriya), the mind (Manas), the intellect (Buddhi), and the soul (Atma). It moves from initial sensory contact to final conscious knowledge, incorporating the specific cognitive functions of Dhee (discriminative ability or selective attention), Dhriti (sustained or focused attention), and Smriti (working memory). Buddhi (cognition/decision taking capacity/intellect) is the faculty of higher reasoning and understanding. The components of Pragya/Pragna/Buddhi are Dhee, Dhriti, and Smriti. The information is passed to the intellect (Buddhi/Pragna), which uses its three components to process the data, Dhee, Dhriti and Smriti. Proper functioning of the three mental faculties, Dhee, Dhriti, and Smriti is considered essential for healthy perception and cognition. Any derangement, or Vibhrama, of these faculties leads to Pragyaparadha/Prajnaparadha, denotes cognitive errors or biases.¹⁹ The various types of Bhutonmada described in Ayurvedic texts often mention specific cravings or addictive behaviours, such as craving meat, sweets, or alcohol. These descriptions reflect how the impairment of (Vibhrama/Vibhramsha) cognitive faculties (Dhee), willpower (Dhriti), and memory (Smriti) manifest in concrete, dysfunctional behaviours and cognitive errors (Pragyaparadha) (Table 1). 

Alcohol and specific food-related cravings and addictive behaviours are commonly seen across the symptomatology of various Bhutonmadas (psychiatric and/or neuropsychiatric disorders having an idiopathic origin/manifestation). Several Ayurvedic terms are used in the context of Bhutonmada to describe various dimensions and intensities of cravings. The Ayurvedic concepts of Dhee, Dhriti, Smriti Vibhrama (impairment of selective, sustained attention and memory) and Pragnaparadha (cognitive biases/errors) provide a robust framework for understanding modern psychological issues such as attentional biases, cognitive errors, information processing errors, and maladaptive/addictive behaviours related to alcohol and specific food cravings. Ayurvedic terminology can be used to describe the intensity of cravings by using various terms, primarily sourced from descriptions of Bhutonmada. These terms range in intensity from mild preference to a strong, demanding urge. Ayurvedic terminology could be used to inform the development of a scale or a questionnaire to quantify craving intensity. Madyaamisha Sakta Drishti, a clinical feature mentioned in the context of Bhutonmada, which refers to attentional bias to alcohol and specific food-related visual cues or a specific type of abnormal or stuck gaze/vision, has conceptual similarities to the contemporary eye-tracking technology in modern medical practice. Sakta Drishti seems to be an objective, quantifiable, and cost-effective way to measure gaze patterns as a diagnostic parameter to identify attentional biases, alcohol and specific food-related cravings in the context of Bhutonmada.

None.

The authors declare that there are no conflicts of interest.

1. Mamidi P, Gupta K. Food cravings, disordered eating behaviour and alcohol abuse in Bhutonmadas - An exploratory review. J Psychol Clin Psychiatry. 2023;14(1):11‒17.
2. Agnivesha, elaborated by Charaka and Dridhabala, and commentary by Chakrapani. Charaka Samhita, Nidana Sthana, Unmada Nidanam Adhyaya, 7 / 5. Acharya J T, editor. Varanasi: Chaukhamba Surbharati Prakashan; 2008. p. 223.
3. Gupta K, Mamidi P. Madonmada of Bhela samhita: Trauma- and stressor-related disorders? J Appl Conscious Stud. 2022;10:42–49.
4. Vriddha Vagbhata. Ashtanga Sangraha, commentary by Indu, Uttara Tantra. Bhoota Vignaneeyam Adhyaya, 7 / 26. 3rd ed. Sharma S, editor. Varanasi: Chowkhamba Sanskrit Series Office; Third edition 2012. p. 671.
5. Gupta K, Mamidi P. Grahonmada or Bhutonmada: Ayurvedic Psychiatric and Neuropsychiatric Conditions. J Integr Health Sci. 2024;12(1):3–10. 
6. Gupta K, Mamidi P. Nishaada grahonmada: Behavioral and Pscyhological symptoms of dementia? / Frontotemporal dementia? / Hebephrenia? J Neuro Behav Sci. 2018;5(2):97–101.
7. Miele C, Cabé J, Cabé N, et al. Measuring craving: A systematic review and mapping of assessment instruments. What about sexual craving? Addiction. 2023;118(12):2277–2314.
8. Lee YH, Kim M, Lee M, et al. Food Craving, Seeking, and Consumption Behaviours: Conceptual Phases and Assessment Methods Used in Animal and Human Studies. J Obes Metab Syndr. 2019;28(3):148–157. 
9. Leroy F, Smith NW, Adesogan AT, et al. The role of meat in the human diet: evolutionary aspects and nutritional value. Anim Front. 2023;13(2):11–18.
10. Karyadi KA, Cyders MA. Preliminary support for the role of alcohol cues in food cravings and attentional biases. J Health Psychol. 2019;24 (6):812–822.
11. Roberts W, Fillmore MT. Attentional bias to alcohol-related stimuli as an indicator of changes in motivation to drink. Psychol Addict Behav. 2015;29(1):63–70.
12. Heitmann J, Jonker NC, Ostafin BD, et al. Attentional bias for alcohol cues in visual search-Increased engagement, difficulty to disengage or both? PLoS One. 2020;15(1):e0228272. 
13. Ramirez JJ, Monti PM, Colwill RM. Alcohol-cue exposure effects on craving and attentional bias in underage college-student drinkers. Psychol Addict Behav. 2015;29(2):317–322. 
14. Bollen Z, Field M, Billaux P, et al. Attentional bias in alcohol drinkers: a systematic review of its link with consumption variables. Neurosci Biobehav Rev. 2022;139:104703.
15. Stacy AW, Wiers RW. Implicit cognition and addiction: a tool for explaining paradoxical behaviour.Annu Rev Clin Psychol. 2010;6:551–575. 
16. Albery IP, Michalska M, Moss AC, et al. Selective attentional bias to food-related stimuli in healthy individuals with characteristics towards orthorexia nervosa. Eat Weight Disord. 2020;25(5):1225–1233.
17. Meule A, Platte P. Attentional bias toward high-calorie food-cues and trait motor impulsivity interactively predict weight gain. Health Psychol Open. 2016;3(1):2055102916649585.
18. Alexandra Ghiţă, Olga Hernández-Serrano, Manuel Moreno, et al. Exploring Attentional Bias toward Alcohol Content: Insights from Eye-Movement Activity. Eur Addict Res.2024;30(2):65–79.
19. Mamidi P, Gupta K. Attention deficit disorder – Anavasthita chittata. Indian J Anc Med Yoga. 2016;9(4):149–160.