This post contains excerpts from my essay "Ayurvedic Perspectives on Autoimmune Disorders: Pathology and Treatment" written in 2019 for my research project at the California College of Ayurveda. The full text covers an in-depth review of both modern and Ayurvedic perspectives on autoimmune disorders, their pathogenesis and treatment principles, focusing on common rheumatoid conditions. If you wish to read the full text, please e-mail me at valerie@intrepidayurveda.com.
This essay is for educational purposes only. The information contained herein is not a substitute for a health care evaluation by a qualified professional.
What were once considered uncommon incidences, autoimmune diseases (ADs) are now known to affect an estimated 3-5% of people around the globe. Despite many advances in understanding underlying mechanisms, the pathology of ADs remains poorly understood in modern medical research. On the other hand, although autoimmunity itself is a relatively modern concept, contemporary Ayurvedic practitioners are applying age-old principles from classical Ayurvedic texts to understand disease pathology and methods of treatment. The science of Ayurveda looks at disease as a disturbance of homeostasis caused by unwholesome habits and diet. [i] Even conditions that have advanced to affect complex organ systems are rooted in these fundamental causes. And so, Ayurveda has been used to understand and manage complicated ADs that would normally require advanced immunosuppressive drug therapy.
This review provides an overview of ADs from a classical Ayurvedic perspective, touching briefly upon some modern medical concepts. It is impossible to cover all categories of AD in one review, so this essay will utilize common rheumatoid disorders as examples to expound on the wider principles behind ADs, as the research on autoimmune rheumatoid disorders is extensive and covers both organ-specific and multi-organ system AD.
What is an Autoimmune disease?
The immune system normally functions as a mechanism to keep us safe from disease-causing pathogens. To do this, the immune system forms antibodies and activated T cells to fight off substances marked as harmful.[ii] The immune system is normally able to distinguish our own body’s cells from foreign bacteria, viruses, and other pathogens. However, the immune system can malfunction on the body to cause problems. An autoimmune disease is “a disease that occurs when the body produces antibodies to a substance that is endogenous to the body. The auto antibody attacks and causes injury to the tissues of the body.”[iii]
One of the key concepts to understanding AD is the concept of tolerance. Immunological tolerance was subsequently defined as “ability to live with – or tolerate – self,”[iv] or “an ability of the immune system to prevent itself from targeting self-molecules, cells or tissues.”[v] Although normal healthy people have T cells circulating in their bodies that are able to direct immune responses against self-antigens, they also have regulatory mechanisms that constantly work to suppress self-harming immune responses, “thus maintaining tolerance to self.”[vi] It is the failure of the immune system to maintain tolerance that is the basis for AD. As tolerance is something acquired, the functionality of this mechanism can vary from person to person, making some more susceptible to weakness and abnormalities than others. ADs can affect a specific tissue or part of the body, or it can affect the entire person as a systemic condition.
An Ayurvedic Perspective
Key concepts
Agni - There are several other concepts in Ayurveda that are essential to maintaining good health, and ultimately in preventing ADs. Within every individual is the power of agni. Agni can be thought of as the digestive fire of the body, responsible for metabolism of not only food but also sensory input. Agni is maintained by proper eating habits, including not only what is eaten but how and when. While healthy agni provides our vitality, deranged agni is the cause of most diseases.
Ama - Faulty agni often leads to build up of undigested food and toxins in the body, referred to in Ayurveda as ama[iii]. Ama is responsible for most diseases in Ayurveda, producing symptoms such as lethargy, indigestion, obstruction of flow of wastes, anorexia, amongst other symptoms.[v] Ama has the ability to accumulate in the tissues causing issues such as inflammation, and the deeper ama penetrates the more difficult the disease. Caraka explains continued unwholesome eating habits results in amavisha, a condition that is said to resemble poisoning.[vi] It is important to note that the disturbance of digestion and therefore the formation of ama can also be caused by mental stress. When we are emotionally disturbed, we are creating the physical grounds for toxic conditions and disease.
Ojas – Ojas is the basis for immunity and resilience in Ayurveda. Just as an increase in ama debilitates the body, a decrease in ojas weakens it. To maintain healthy ojas, it is important for an individual to follow a healthy diet and lifestyle while avoiding excessive mental stressors. As mental health is intricately linked with ama formation, so it is also to the preservation of ojas. Preserving and building ojas in Ayurveda goes hand-in-hand with maintaining a healthy immune system.
Ayurvedic Perspectives on the Pathology of Autoimmune Disorders
From the Ayurvedic perspective, autoimmune diseases are “considered primary disorders of ojas.”[i] Ojas is what maintains the immune system, but it is also allows the body to thrive and withstand stress. In autoimmune diseases, the suggestion is that an individual has neglected practices of supporting ojas, and has also in the process disturbed digestion and allowed for toxicity to build up in the body so that the immune system is no longer properly functioning to fight off disease. There are also several theories as to why a body with low ojas may attack its own tissues. However, it is important to first understand how Ayurveda explains the etiology and pathogenesis of disease in general.
Causes & Pathogenesis - Modern medical research focuses on trying to identify single causal agents of AD, with attention on the activities of the immune system at the cellular level. However, in Ayurveda, etiology is traced back to the root cause of disease before the appearance of prodromal symptoms, based on the idea that all disease starts from digestive disturbances due to doshic vitiation.
The pathogenesis of a disease is described in six stages – accumulation, aggravation, overflow, relocation, manifestation, and diversification.[iii]
Accumulation describes when a dosha is rising in the body, but the symptoms are barely noticeable. At this stage, the condition is easily reversible.
Aggravation occurs when accumulation reaches its peak, and symptoms are noticeable but remain at the site of the dosha in the digestive system.
Overflow occurs when the doshas were not effectively managed in the first two stages and the doshas overflow to the circulatory system (rasa and rakta dhatus). Symptoms at this stage are described is “mild and transient.”
Relocation is the next stage where the overflowed dosha(s) travels to another site in the body. The site may be a point of weakness or may choose another part of the body it has affinity to. Disease will affect that part of the body.
Manifestation is the fifth stage and is where the relocated dosha settles and manifests disease at its new site.
Diversification is the final stage and the most serious, where the disease causes serious complications and can cause permanent damage to the body.[iv]
As with all diseases, how the pathogenesis of ADs unfolds depends on the doshas involved. By looking at varying examples one can get a general understanding of how elements such as ama, agni, ojas and the doshas play a role. Let's look at an example of an imbalance originating in the stomach that progresses into inflammation and then gradually into AD:
"Gurgling in stomach after eating (accumulation) may turn into bloating (aggravation). Constipation could then ensue (dissemination) followed by intestinal permeability (localization). If left untreated, undigested food particles may leak through the permeable intestines and flood the bloodstream, creating chronic inflammation, perhaps in the form of arthritis (manifestation). The untreated inflammation could, in turn, cause the body to attack itself and create an autoimmune disease (disruption)."[v]
In this example, what starts as digestive discomfort leads to ama (undigested food) leaking into the bloodstream and causing inflammation. As discussed previously, inflammation is intricately linked with AD such as rheumatoid arthritis. In the final stage, one could posit that low ojas is also involved, hampering the immune system’s ability to effectively function, causing it to indiscriminately attack its own tissues in an attempt to attack the ama that has permeated to the joints.
The above is merely one example of AD pathogensis - each individual case will have a unique set of circumstances. What causes the ama that leads to inflammation can come from a variety of sources known to provoke autoimmune conditions, such as pollutants, allergens, toxic chemicals, poorly digested foods, etc. [vi] What part of the body becomes inflamed may also differ depending on what parts of the body present weakness in that individual. Whatever the case, the underlying mechanisms are the same, but the manifestation for each person is unique.
Ayurvedic Treatment Principles of Autoimmune Disorders
Once a patient has been evaluated and given an Ayurvedic diagnosis, there are three major goals in treatment that must be addressed in all ADs: Eliminate ama, build ojas, and reverse the Nidana. Reversing the cause (“Nidana parivarjana”), prevents and delays relapse of disease conditions. Eliminating ama (also known as purification, or “Nitya Shodhana”) clears the body of toxins and other debris. Building ojas, or rasayana therapy, helps with immunity and tissue repair.[i]
Reverse the Nidana (cause)- As previously discussed, the cause of disease boils down to improper diet and harmful habits, or lifestyle. Reversing the nidana refers to correcting these habits, but it is easier said than done. Part of an Ayurvedic practitioner’s responsibility is to guide the patient through changing diet and lifestyle to better balance the doshas. This can involve changing routines as well as eating habits. It may sound simple, but it is a crucial aspect of treatment.
Eliminate Ama - The elimination of ama is essential in treating autoimmune disorders, as ama is what causes tissue destruction and inflammation in ADs. When ama is spread out throughout the tissues of the body, they can be lodged in places that are hard to reach, so it is impossible to force ama out of the body before it is drawn back into the digestive system. Intensive purificatory processes such as panchakarma are described in the classical texts such as the Ashtanga Hridayam and the Caraka Samhita outlining the procedures in which to draw toxins out from the tissues in the body and move them back to the digestive tract for purgation[ii, iii] By first administering these therapies, ama is drawn from the deeper tissues back into digestive system where they can be readily expelled.
Sadhanashree and Shridhara emphasize that in the case of autoimmune disease specifically, there is obstruction caused by tissue debris and apoptosis (that can be equated to ama) that is responsible for harmful immune responses, and that purification is required to clear the channels of the body. [iv] Following purification, and after properly analyzing the patient’s constitution, imbalances, environment, habits, and strength, the practitioner can choose the method of treatment most appropriate to addressing the doshas and dhatus involved.[v] As previously emphasized, the practitioner’s responsibility is to individualize the treatment plan of the patient by following the basic doshic principles that guide the practitioner towards the most appropriate treatment path.
Rebuild ojas - ADs are considered a result of low ojas and high ama, so it is important to consider rasayana therapy as a cornerstone for treatment in all presentations of ADs. Rasayana means rejuvenation, is the Ayurvedic means in which to rebuild ojas. However, the classical texts warn that rasayana cannot just be simply administered to anyone. The proper preparatory procedures must be done to make sure that the body is ready to receive therapy, “It should be administered…to those who are self-controlled, who have undergone... purificatory therapies. Rasayana (rejuvenation)…therapies administered to those whose body has not been purified becomes useless.”[viii] It is therefore necessary to eliminate ama before attempting to rebuild ojas. It is also necessary to make sure the behaviors and lifestyle choices that brought about the ama are also rectified. If an individual is not able to rectify the behaviors that brought about the ama in the first place and has not taken the proper steps to purify his body of toxic wastes, rasayana therapy cannot be done effectively.
For the prepared individual, the classical texts provide a variety of herbal formulas, regimens, and methods by which to engage in rasayana therapy.[ix] Certain foods that rebuild strength and vitality are also considered rejuvenative. However, it is not only food and medicine that can be rejuvenative, but lifestyle as well. Stress plays a significant role in the strength of the immune system, so one cannot underestimate the power of stress reduction as a part of rasayana therapy.
Conclusion
The manifestations of ADs are diverse, complex and often unpredictable. However, the Ayurvedic knowledge of pathogenesis and fundamental principles behind disease unlocks the potential for medical practitioners to connect patients’ symptoms to doshic imbalances, providing information regarding not only the potential origins of the condition but also a pathway to the appropriate protocols for treatment. Through the research of contemporary Ayurvedic practitioners and the guidance of the classical texts, the literature has identified dysfunction in ojas, ama, and doshic equilibrium as key contributors leading to AD. Ayurvedic approaches to treatment show enormous potential as a complementary method of managing ADs alongside modern medicine.
Introduction & Overview - References
[i] Murthy, K.R. Srikantha, translator. Vagbhata's Aṣṭāṅga Hṛdayam: Text, English Translation Notes, Appendix and Indices. Vol. 2, Chowkhamba Krishnadas Academy, 2018, p. 7.
[ii] Pawar, U. V. “Ayurvedic Interpretation of SLE (Systemic Lupus Erythematous).” European Journal of Pharmaceutical and Medical Research, vol. 4, no. 1, 2017, pp. 557-560. https://storage.googleapis.com/journal-uploads/ejpmr/article_issue/1483439842.pdf. Accessed 22 December 2019. [iii] Halpern, Marc. Clinical Ayurvedic Medicine. 6th Edition, California College of Ayurveda, 2012, Chapter 7, p.30.
[iv] Rosenblum, Michael D., et al. “Treating human autoimmunity: current practice and future prospects.” Science Translational Medicine, vol. 4, no. 125, 2012, 125sr1. PMC, doi:10.1126/scitranslmed.3003504, p.1. [v] Wang, L., Wang, F‐S., Gershwin, M.E. “Human autoimmune diseases: a comprehensive update,” p.370. [vi] Rosenblum, Michael D., et al. “Treating human autoimmunity: current practice and future prospects,” p.1-2.
An Ayurvedic Perspective - References
[iii] Virmani M., Kaushik A.K., and Virmani G. “Rheumatoid arthritis diagnosis according to Ayurveda texts W.S.R. Amavata.” International Journal of Complementary & Alternative Medicine, vol. 12, no.3, 2019, pp. 97-103. MedCrave, DOI: 10.15406/ijcam.2019.12.00456. [v] Wnkhede, Arun U, Khirodkar, Sushma R, Zombade, Dinesh N. “Role of Rasayana Chikitsa in Auto-immune Disease with Special Reference to Amavata.” International Ayurvedic Medical Journal, vol. 5, no. 2, February 2017, pp.432-437. https://pdfs.semanticscholar.org/2282/54018d8640b56f70953292d42621ff14f0e7.pdf. Accessed 30 November 2019, p.434. [vi] Sharmā Ram Karan, and Vaidya Bhagwan Dash. Agniveśas Caraka saṃhitā: (Text with English Translation & Critical Exposition Based on Cakrapāṇi Dattas Āyurveda Dīpikā). Vol. 2, Chowkhamba Sanskrit Ser. Office, 2019, p.137.
Ayurvedic Perspectives on the Pathology of Autoimmune Disorders - References
[i] Halpern, Marc. Clinical Ayurvedic Medicine, Chapter 7, p. 31. [iii]Halpern, Marc. Principles of Ayurvedic Medicine. 11th Edition, California College of Ayurveda, 2016, p.171-175. [iv] Ibid, p.171-175. [v] Easterly, Erin. “Basic Principles of Ayurvedic Medicine,” The Chopra Center, https://chopra.com/articles/basic-principles-of-ayurvedic-medicine. Accessed 30 November 2019. [vi] Wnkhede, Arun U, Khirodkar, Sushma R, Zombade, Dinesh N. “Role of Rasayana Chikitsa in Auto-immune Disease with Special Reference to Amavata,” p.433.
Ayurvedic Treatment Principles of Autoimmune Disorders
[i] Sadhanashree, P., and Shridhara B.S. “An Ayurvedic Approach to Systemic Lupus Erythematosus: A case report,” p. 2278. [ii] Murthy, K.R. Srikantha, translator. Vagbhata's Aṣṭāṅga Hṛdayam: Text, English Translation Notes, Appendix and Indices. Vol. 1, p.188. [iii] Sharmā Ram Karan, and Vaidya Bhagwan Dash. Agniveśas Caraka saṃhitā: (Text with English Translation & Critical Exposition Based on Cakrapāṇi Dattas Āyurveda Dīpikā). Vol. 2, Chowkhamba Sanskrit Ser. Office, 2019, p.137-38. [iv] Sadhanashree, P., and Shridhara B.S. “An Ayurvedic Approach to Systemic Lupus Erythematosus: A case report,” p. 2278. [v] Sharmā Ram Karan, and Vaidya Bhagwan Dash. Agniveśas Caraka saṃhitā: (Text with English Translation & Critical Exposition Based on Cakrapāṇi Dattas Āyurveda Dīpikā). Vol. 2, p.137-38. [viii] Ibid, p.381. [ix] Ibid. [x] Wnkhede, Arun U, Khirodkar, Sushma R, Zombade, Dinesh N. “Role of Rasayana Chikitsa in Auto-immune Disease with Special Reference to Amavata,” p.436. [xi] Sadhanashree, P., and Shridhara B.S. “An Ayurvedic Approach to Systemic Lupus Erythematosus: A case report,” p. 2277.