A Comprehensive Review on Psychiatric Disorders (Amraz-e-Nafsaniya) in Relation to Harakat-o-Sukun Nafsan

Ḥarakat-o-Sukūn Nafsānī (psychic movements and repose) is one of the six essential factors (Asbāb Sitta Ḍarūriyya) described in Unani medicine and plays a vital role in maintaining both physical and mental health. Unani scholars recognized that emotional states such as happiness, grief, fear, anger, and anxiety exert profound effects on the body and mind. According to Ibn Sina (Avicenna), the heart is the source of Rūḥ Ḥaywānī, which governs emotional responses. These psychological reactions can influence the Mizāj (temperament) of the body more rapidly than many physical factors and may contribute to the development of disease when excessive or prolonged.^1–3 The significance of mental and emotional well-being has been acknowledged since ancient times. Psychiatric disorders, known in Unani medicine as Amrāḍ-e-Nafsāniyya, are characterized by disturbances in thought, mood, perception, and behavior. Modern medicine recognizes mental illnesses as a major public health concern, while classical Unani scholars described similar conditions centuries ago and emphasized the role of emotional disturbances, environmental factors, and humoral imbalance in their causation.^4,5 According to Unani literature, health depends on the equilibrium of the four humours (Akhlāṭ Arba‘a): Dam (blood), Balgham (phlegm), Ṣafrā (yellow bile), and Saudā (black bile). Disturbance of this balance, particularly as a result of abnormal psychic movements and repose, may predispose individuals to various psychiatric disorders. Classical texts describe conditions such as Malikhūliyā (melancholia), Māniyā (mania), Quṭrub, and other mental disturbances, reflecting the advanced understanding of mental health among Unani physicians.^6,7 This review aims to analyse various psychiatric disorders in relation to Ḥarakat-o-Sukūn Nafsānī and to explore their etiopathogenesis, clinical manifestations, and management from the Unani perspective. By examining classical literature alongside modern concepts, the review seeks to highlight the relevance of Unani principles in understanding and managing mental health disorders. In the foundational texts under Kulliyat (basic principles), there is a thorough exposition of Quwwat-e-Nafsaniya (mental faculties). These discussions, along with the systematic classification of mental functions, reflect the depth of early Unani scholars’ understanding of brain functions and psychological phenomena.

Quwwat responsible for psychiatric disorders

The term Quwwat means faculty refers to the ability to function. It is one of the Umoor-e-tabiya essential to human survival. Quwwat (faculty, ability to function) and Afal (function) are understood in relation to one another, because each faculty is the source of some function, and each function flows from a faculty.^1,2,8

Types of faculties

1. Quwwat-e-Nafsaniya (Psychic faculty)
2. Quwwat-e-Tabiya (Physical faculty)
3. Quwwat-e-Haiwaniya (Vital faculty) ^3,9–11

Out of these three, the psychic faculty will be discussed in detail.

Quwwat-e-Nafsaniya (Psychic faculty)

Psychic faculty is broadly classified into two subtypes -

1. Quwwat-e-muharrika (motive faculty/motor faculty)
2. Quwwat-e-mudrika (perceptive faculty/sensory faculty)^9,10

Psychic motive faculty - is responsible for producing movement by causing the contraction and relaxation of muscles and tendons, thereby enabling the extension and flexion of organs and joints. The pathways of this faculty run through the nerves which are connected to the muscles and transmit the impulses necessary for voluntary movement.

• Psychic Perceptive faculty is further divided into two.

1. Quwwat-e-khamsa zahira (external perceptive faculty)
2. Quwwat-e-khamsa batina (internal perceptive faculty)^12–14

Quwwat-e-khamsa batina (internal perceptive faculty)

There are two groups of physicians which classify internal perceptive faculty further into three and five categories.  First was the ancient group of physicians, among them were notably Majusi (930–994 A.D.) and Masihi (died 1010 A.D.), who classified internal perceptive faculty into three types:

1. Takhaiyyul (imagination)
2. Tafakkur (thinking)
3. Tazakkur (recall)¹⁰

A second group of physicians, among Qarshi (1210–1288 A.D.), classified it into five faculties:

1. Hiss-e-mushtarak (panesthesia or imagination)
2. Quwwat-e-mutakhaiyyla (thinking faculty)
3. Quwwat-e-hafeza (faculty of memory and recall)
4. Quwwat-e-wahema (instinct)
5. Quwwat-e-mutasarrifa (rationalizing faculty)¹

Ibn Rushd (1126–1198 A.D.) in his book Kitab-ul Kulliyat offers a different classification. He divides it as follows:

1. Quwwat-e-hawaas (faculty of senses)
2. Quwwat-e-zikr (faculty of recalling)
3. Quwwat-e-fikr (faculty of thinking)
4. Quwwat-e-wahema (faculty of instinct)³

Ibn-e-Rushd has also mentioned Quwwat-e-siyasia (faculty of politics) under which he has listed following Quwa:

1. Quwwat-e-takheyyul (Faculty of thoughts), located in the frontal part of brain
2. Quwwat-e-fikr (Faculty of thinking), located in the middle part of brain
3. Quwwat-e-zikr (Faculty of recalling), located in the posterior part of brain³

Following a thorough analysis, it can be said that Quwwat-e-khamsa batina (Internal perceptive faculty) can be affected in psychiatric disorders without any organic lesion, while the rest, i.e. organic lesions, along with Quwwat-e-khamsa batina can be affected in other neurological disorders.¹⁰

Ḥarakat-o-Sukūn Nafsānī

Ibn-e-Sina was the first physician who developed the relation between psychology and medicine. Body and mind have impact on each other as psychological factors are dependent on dominant khilt and Mizāj of that person. Excess of all these change the temperament, weakens the hararat-e-ghariziyah and body becomes dry and feeble. In response to Infi‘ālāt Nafsāniyya, the Rūḥ Ḥaywānῑ either moves from the interior of the body to the exterior or vice versa and the shift of Rūḥ Ḥaywānῑ can be sudden or gradual. These movements produce different effects on the body. Such as, when the Rūḥ Ḥaywānῑ moves from the interior to the exterior parts of the body, it generates heat, and helps in expelling the waste elements from the blood and heart in the form of vapours. This heat subsequently warms up the entire body, including the A‘ḍā’, Akhlāṭ, and Arwāḥ. These movements of the pneuma are a response to psychic reactions such as anger, happiness, hope, and other emotional states. However, when the pneuma moves toward the interior of the body, it is accompanied by blood. Consequently, the body's innate heat is held within the interior, making the exterior appear cold and pale. These inward movements of the Rūḥ Ḥaywānῑ occur in response to psychic reactions like fear, sorrow, and other similar emotional states.^7,8,13

Different psychic reactions and their impacts on Mizāj Badan

Unani scholars have described the impacts of psychological reactions, noting that they have similar effects on the Mizāj of the body as physical causes, which can lead to both health and disease. In comparison to food and drinks, these reactions usually have a quicker effect on the body since they do not require the extensive digestion and metabolism processes necessary for food to exert its intended effects. Furthermore, they stated that individuals who frequently experience agitation, persistent depression, excessive fear, or excessive worry over minor issues are more susceptible to developing certain diseases quickly. Understanding the harmful effects of these psychological reactions and refraining from such behaviour could reduce the risk of contracting certain illnesses.¹⁴

1. Anger

In this emotional state, the Rūḥ Ḥaywānῑ swiftly moves towards the outer regions of the body, carrying with it the Ḥarārat Gharīziyya and blood to support the body's physical functions. As a result, when a person becomes angry, his face and other exposed areas of the body may appear red and become heated. Therefore, if anger is not excessively intense, it can have potential benefits. However, extreme anger can have several negative effects on the body.^7,13,14

2. Happiness and pleasure

Happiness induces a gradual outward movement of pneuma, moderately increasing heat and moisture. However, sudden intense joy causes a rapid outward shift of pneuma, leading to a sharp depletion of internal Ḥarārat Gharīziyya, potentially disrupting heart function. In extreme cases, this can result in Shaadi-i-Marg (death due to excessive happiness).^7,13,14

3. Fear

During a state of fear, the pneuma rapidly moves from the outer regions of the body toward the inner parts. Simultaneously, the blood also moves inward, accompanied by pneuma and innate heat, leading to increased coldness and dryness in the external parts of the body. This manifests as a cold and pale surface of the skin.^7,13–15

4. Grief and Sorrow

In response to these emotions, the Rūḥ gradually moves inward, resulting in a gradual decrease in the vital faculty. This leads to a progressive weakening of all body faculty. Especially sudden grief, triggers the movement of Rūḥ and Ḥarārat Gharīziyya in abundance toward the heart.^7,13,14

5. Abashment

In such situations, individuals experience a mix of emotions and various reactions. Initially, there is a brief sense of guilt, which leads the Rūḥ Ḥaywānῑ to move inward. Afterward, the Rūḥ Ḥaywānῑ rapidly moves toward the body's surface out of anger towards the person responsible for the embarrassment.  As a result, when the pneuma moves inward, the face may appear yellow due to the gathering of blood and intrinsic heat in the inner parts of the body. Conversely, when the pneuma moves toward the body's periphery, both blood and heat follow in the same direction, causing the face to blush.^7,14 All these reactions, if they persist for a long time or occur at an extreme level, then production of the four humours or Akhlat is affected, for example, during anger, Safra increases, during sadness or grief, Sauda or black bile increases. And this humoural imbalance can cause different physical as well as psychological disorders, like Melancholia, anxiety, depression, Maniya, etc.

Psychiatric Disorders (Amraz-E-Nafsaniya)

• Malankhuliya (Melancholia)
• Anxiety (Iztirab-e-Nafs) & Depression
• Junun (Maniya, Da' al-Kalb, Şubārā and Qutrub)^6,14

Malankhuliya (Melancholia)

Malankhuliya (Melancholia) has been defined as a disorder in which the mental functions are deranged and the afflicted person is more prone towards constant grief, fear and dubious aggression and the ability to analyze and interpret things is grossly affected as enunciated by Jalinus (Galen) quoted by Zakaria Razi (850-923 A.D) in his world-renowned treatise “Kitab Al-Hawi.” The term melancholia literally means “black humour” which is the predominant causative factor.¹⁵

Causes

Malankhuliya is caused mainly due to Saudavi madda or mirra e sauda. In either case there is preponderance of Saudavi khilt particularly associated with ehteraq when it is termed as Malankhuliya Saudavi. When it is caused due to ehteraq of Dam or Safra or Balgham then it is expressed as Malankhuliya damvi, safravi and balghami respectively. Extreme grief, stress, constant thinking, and excessive alertness are sometimes the most likely contributing factors.^6,15

Pathophysiology of Malankhuliya

As we know, Ruh Nafsānī synthesized in ventricles of brain. It is produced from Quwwat Haywānīyya, which is generated in the heart. Ruh Haywānīyva ascends from heart to the brain through Rag-i- Subati. At the base of the brain these vessels are further divided into many branches, which form arterial network, called Sabak Jhilli. In this convoluted arterial networking Ruh Haywānī stays longer and gets absolute Nudj (concoction), becomes pellucid, this is called Ruh Nafsānī. This Ruh Nafsānī reaches forebrain and becomes more purified. From the forebrain it goes to midbrain, attains it temperament becomes more pellucid and purified. From midbrain it goes to hindbrain, here it becomes most pellucid and complete. by that time Quwwat Nafsaniya takes work from it and shows its functions through Ruh Nafsānī, So, whenever temperament of brain alters, simultaneously alteration in temperament of Ruh also occurs. This is because Quwwat Hadima of Jawhar -i- Dimagh becomes weak as a result Ruh didn't get absolute concoction. When Jawhar -i- Dimagh couldn't purify Ruh, so Khilt which is accumulated in the brain mingle with Jawhar -i- Ruh, as a result Ahwal Nafs gets deranged. Now, it is clear that in melancholia there is alteration in the temperament of brain because of Sawda. Whenever alteration in temperament of brain occurs, simultaneously alteration in Mizāj of Ruh Nafsāni also takes place.¹⁶

Clinical Features

In the early stage of the disease, patient remains sad without any external stimulus, thinking is perverted, deserted and finds himself occupied by loneliness and experiences delusion and hallucinations, patient mutters with himself, and most of the time remain silent, feels giddy and tinnitus, sexual and food satiety is unusually increased. The nature of fear varies from patient to patient; Some individuals develop an intense fear of death or animals, while others may become preoccupied with irrational fears, such as the sky falling. According to ancient Unani literature, the manifestations of fear are influenced by the predominance of specific humours (Akhlāṭ). When Dam (sanguinous humour), predominates, the patient tends to be cheerful, playful, and inclined toward laughter and exhilaration. Predominance of Ṣafrā (yellow bile) is associated with excessive mental activity, restlessness, and hyperactivity. In the case of excess Balgham, (phlegm), the patient often appears gloomy, sluggish, and lethargic. The features associated with the excess of Saudā (black bile) are usually more severe, serious, and intense in nature.¹⁵

Anxiety: Anxiety, defined as a subjective feeling of uneasiness, dread, or foreboding. It may present as a primary psychiatric disorder or occur as a symptom, component of or a reaction to a underlying medical condition.1 In the Unani system of medicine, anxiety disorder is referred to as Izterāb-I-Nafsāni Umūmī. The term Iẓtirāb-i-Nafsānī ʿUmūmī broadly denotes excessive worry, persistent fearful thoughts, and mental restlessness. The description of Anxiety as such not found in Unani literature but its symptoms show a considerable overlap with Melancholia.¹⁷

Depression: Dictionary of Psychological Medicine in 1892, listed mental depression as a synonym for melancholia.¹⁸ Major depression is defined as a depressed mood daily for a minimum duration of 2 weeks.  The mood may vary from mild sadness to intense despondency and may be accompanied by feelings of guilt, worthlessness, and hopelessness.^19,20 Cognitive disturbances are common and include difficulty in thinking and concentrating, persistent ruminations, indecisiveness, and, in severe cases, suicidal ideation. About 10% to 15% of all depressed patients commit suicide, and about two-thirds have suicidal ideation.²⁰ The tables below provide a structured comparison between Melancholia, Anxiety and depression.

Table no.1- Comparison between Melancholia, Anxiety and Depression