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Abstract
Context: Indian models of personality are seldom explored in relation to alcohol dependence. Triguna is an Indian model of personality originating from the Sankhya philosophy, whereby three gunas, Sattva, Rajas and Tamas describe personality features. Additionally, the trait of Non attachment which is a concept discussed extensively in Bhagavad Gita is also studied along with Triguna. Aims: The current study discusses these concepts and attempts to explore their relationship with personality and subjective well-being, among men with and without alcohol dependence. Subjects and Methods: A cross-sectional survey method was adopted, with a sample of 84 men from the community without alcohol dependence, screened through alcohol use disorders identification test and 30 men diagnosed with alcohol dependence. Informed consent was obtained from all the participants. Statistical Analysis Used: The data were analyzed using descriptive statistics, independent sample t-test, and Mann–Whitney U-test. Results: Men without alcohol dependence scored significantly higher on variables such as Sattva, extraversion and conscientiousness, positive affect, and life satisfaction, than men in the clinical group. Men who were diagnosed with alcohol dependence, scored significantly higher on Tamas, neuroticism, and negative affect. Conclusions: This novel understanding of the personality structure of patients with alcohol dependence from the Triguna perspective may be helpful in the development of indigenous psychological interventions for alcohol dependence.
Keywords: Alcohol dependence, India, nonattachment, personality, subjective well-being, Triguna
How to cite this article: Introduction 
Personality
Personality has been defined as individual differences in characteristic patterns of thinking, feeling, and behaving.[1] The recent definitions of personality, both internal and interpersonal aspects, are emphasized.[2] Thus, it is described as the specific mental organization and processes that produce an individual's characteristic pattern of behavior and experiences, which are the between-person or inter-personal and within-person or intra-personal senses of “personality.”[2]
The “big five” theory of personality
The existing personality models used widely in psychological research, such as the Big Five model, is based on the assumption that all individual personality differences are encoded in the language people use to describe others. Thus, such a lexical approach collates a list of adjectives and all the different words people use to build the theory of personality. The five domains of personality, as described in the five-factor model, are neuroticism, extraversion, agreeableness, openness to experience, and conscientiousness. Extraversion has been described as one's tendency to experience positive emotions such as joy and excitement.[3] While neuroticism is the individual differences in the tendency to experience negative emotions, such as anxiety, depression, irritability, anger, and shame.[3] Conscientiousness reflects orderliness, responsibility, and dependability.[4] Agreeableness describes individual differences in being likeable, pleasant, and harmonious in relation to others.[5] Finally, openness/intellect represents individual differences in cognitive exploration, the tendency to seek, detect, appreciate, understand, and utilize both sensory and abstract information and to engage with it.[3]
In spite of existing research, it has been suggested that the cross-cultural universality of trait structures needs to be approached with caution, given that the anthropological perspective emphasizes that culture influences personality.[6] Given this background, it is unfortunate that the cultural differences and the unique issues of Indian society have largely been ignored.[7] However, in recent years, there have been some welcome developments in this area. Though empirical research based on Indian concepts is still in its infancy, the potential for applying this knowledge is abundant. In this article, one such concept Triguna, has been explored further.
The model of Triguna (i.e., Sattva, Rajas, and Tamas), which is the Indian concept of personality, has been mentioned in the Chandogya Upanishad and was described in Charaka Samhita, Bhagavad Gita, and Patanjali Yogasutras.
Valamheeyathe, vyadhayaaapyayyanthe, yasmaddheena: prannajjahaadi, yadindriyanaamabhigraahakam cha “mana” ithyabhidheeyathe;
thannividhamakhyayathe-shudham, rajasam, thamasamithi
(Charaka Samhita, SariraSthana, Chapter 3, Verse 13)[8]
Triguna model primarily pertains to the Samkhya philosophy, which describes two realities such as spiritual and material, known as Purusha and Prakriti, respectively. Purusha is the Supreme Consciousness, and Prakriti is the matter. Surprisingly, in this model, along with the physical body, even the mind is considered material, though subtle. The characteristics of the gunas are as follows: Sattva guna is characterized by balance, peace, equanimity, and qualities such as cleanliness, truthfulness, dutifulness, detachment, discipline, contentment, and staunch determination. Attributes of Rajas include intense activity, desire for sense-gratification, little interest in spiritual elevation, the envy of others, and materialistic tendencies. Tamas guna is manifested in dullness, lethargy, fatigue, and even depression. Other qualities associated with it include mental imbalance, anger, ignorance, arrogance, and helplessness.[9]
Triguna conceptualizes a holistic understanding of personality in terms of physical, mental, and spiritual dimensions. It is not one guna that characterizes the personality but the interactions of the three gunas. As per Charaka Samhita, Triguna composes the psyche and an individual's predominant guna is determined at the time of fertilization itself, which is the first step in the development of a human being. The texts further suggest that the predominance of guna varies from person to person as well as from time to time.[10]
Swardhendriyarthasankalpavyabhi
charanaanjanekamekasminpurushesattvam, rajastamasattvagunayogyacha; nachaanekathvam, nahyekam, hyekakalamanekeshupravarthathe,; thasmannaikakalasarvendriyapavarthi
Yahunamchabheekshnampurushamanuvar thathesattvamthatsathvamevopde shanthimunayobahulyanusayath
(Charaka Samhita, Sutra Sthana, Chapter 8, Verse 5 and 6).
Triguna in clinical populations
Although there have been many studies on Triguna, few studies have been carried out in clinical populations.[11],[12] The levels of Sattva, Rajas, and Tamas were compared between 20 patients diagnosed with mild–moderate depression, with a community sample. It was found that the clinical group was higher on Rajas, followed by Tamas, and Sattva was lowest in this group. In the general population, Sattva was higher than Rajas, followed by Tamas.[13] Similarly, another study comparing patients having anxiety disorders with community controls found that the two groups differed significantly on Triguna. The clinical group scored higher on Tamas and Rajas factors, and the community group was high on Sattva. The study findings also revealed that Sattva was positively correlated, and Rajas and Tamas were negatively correlated with quality of life.[14] While personality is one of the most studied variables in addiction, no study was found on Triguna in substance use.
Nonattachment
Along with Triguna, the other indigenous concept studied here is nonattachment, which has also been conceptualized as a personality variable. Nonattachment has been variously described as the subjective quality of ease and balance, along with a lack of fixation on mental representations, objects, ideas, images, and mental independence. It does not imply a lack of connectedness but involves a responsive and caring involvement in the present situation and a genuine interest in other people.[15],[16],[17] Earlier studies have reported nonattachment is associated with positive mental health; however, no published research on this aspect was found in the clinical populations.[18]
Subjective well-being
Subjective well-being (SWB) has been defined as people's conscious experiences of happiness, in terms of hedonic feelings and cognitive satisfaction.[19] Thus, SWB measures both cognitive judgments and affective reactions.[20] Affect pertains to the experience of a feeling or an emotion. It is a broad term that is used to cover mood, feeling, attitude, preference, and evaluations.[21] The affective component of SWB refers to pleasure or happiness in terms of frequent positive affect (PA) and infrequent negative affect (NA). PA reflects the extent to which a person feels enthusiastic, active, and alert. In contrast, NA is a general dimension of subjective distress and un pleasurable engagement, that subsumes a variety of aversive mood states, including anger, contempt, disgust, guilt, fear, and nervousness.[22] Further, the Circumplex model of affect is a dimensional approach that proposes two fundamental neurophysiological systems as the basis of any affect. One system is related to valence, which is a pleasure-displeasure continuum, and the other is arousal or alertness.[23] Thus, both activated and deactivated PA (e.g., feeling excited vs. relaxed), and activated and deactivated NA (e.g., feeling angry vs. exhausted) are part of the affective repertoire. In addition, the cognitive component of SWB refers to life satisfaction, which has been defined as a global assessment of a person's own quality of life, according to his/her chosen criteria.[24] These chosen criteria form a subjectively set standard by the individual with which they compare their level, to make a judgment of their satisfaction.
Alcohol dependence
As per the aims of the study, the clinical population chosen for the study was men with alcohol dependence syndrome. According to the International Classification of Diseases-10, a dependence syndrome is defined as a cluster of physiological, behavioral, and cognitive phenomena, in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviors that once had greater value.[25] The desire to take psychoactive drugs, alcohol, or tobacco is a central descriptive characteristic of dependence. The diagnostic guidelines of the dependence syndrome include: (i) A strong desire to take the substance, (ii) difficulties in controlling the substance-taking behavior, (iii) a physiological withdrawal state, (iv) evidence of tolerance, (v) progressive neglect of alternative pleasures or interests, (vi) persisting with the substance use despite clear evidence of overly harmful consequences.
Aim and rationale of the study
Although the role of personality and emotions in addictive behaviors is comparatively well researched, little research interest has been given to understanding addiction using the Indian models of personality. Assessment of the relationship of Triguna with the diagnosis of alcohol dependence will throw more light on the differential relationship of the 3 gunas with mental health and well-being. It will also provide insights for planning innovative indigenous treatment strategies. Currently, different treatment modalities are available for alcohol dependence, such as pharmacological and nonpharmacological. However, the outcome of this study may provide guidance for the development of treatment modalities in this area based on Indian psychology in future. For example, including Triguna based strategies in psychological interventions, in terms of Sattva enhancinglife-style, activities etc.
Therefore, we aimed to compare men with and without alcohol dependence on Indian concepts of Triguna and nonattachment, along with their personality and SWB.
Subjects and Methods Participants
A cross-sectional survey method was adopted for the current study, and it was conducted after approval by the institute's ethics committee. The study included a clinical group of men with alcohol dependence, and a community group of men without alcohol dependence. The age group of the sample was between 18 and 50 years, with a minimum of 10 years of formal education and the ability to read, write and comprehend English. Alcohol use disorders identification test (AUDIT) scale was used as a screening tool for alcohol dependence, with AUDIT scores below 8 being the inclusion criteria for the community group of 84 men without alcohol dependence, who were selected from colleges and various organizations. For the clinical group of men with alcohol dependence, a sample of 30 male patients diagnosed with alcohol dependence and admitted at the Centre for Addiction Medicine, NIMHANS, a tertiary mental health care center, were selected. The AUDIT scale was also administered in this group for documentation purposes.
Measures
A sociodemographic datasheet was developed by the researcher to gather basic socio-demographic data such as age, education, occupation, marital status, religion, living arrangement, income and presence of alcohol use, and in the clinical group, the details about alcohol use, such as duration, type and use of other substances, apart from alcohol. For all the standardized measures which are not in the public domain, requisite permission was taken from the authors for using in the study. Informed consent was taken from all the participants.
The alcohol use disorders identification test-alcohol use disorders identification test
AUDIT contains 10 questions with regard to the drinking pattern of the participants.[26] It can be administered as a self-report scale as well as in the form of the interview. For the current study, a self-report version was administered. This scale has been validated in Indian sample with a high internal reliability of 0.92.[27]
Vedic personality inventory
This inventory has 56 items to assess Vedic concept of Gunas, as related to personality.[9] It gives a standardized score for each Guna. The participants were asked to give their agreement to the given statements on a 7-point scale. It has an internal consistency ranging from 0.70 to 0.92 for the Gunas. Its reliability coefficient is in the range of 0.74–0.79, and it has been widely used in the Indian context.[9]
Nonattachment scale-7
This is the short version of a 30-statement nonattachment scale developed by Sahdra et al.,[16],[28] It contains seven statements rated on a 6-point scale which tries to understand the view of the participant relating to the world, relationships, and feelings. It has been used in the Indian context and has an internal consistency of 0.81.[18]
Big five aspect scale
Big Five Aspect Scale (BFAS), an open-source alternative measure of five major personality traits, was used in this study.[3] It contains 100 statements, which the participant has to rate on a 5-point Likert scale from Strongly Agree to Strongly Disagree. It has five broad domains, namely, neuroticism, extraversion, agreeableness, openness/intellect, and conscientiousness. The test–retest reliability of the scale ranged from 0.82 to 0.89 for the domains.
Satisfaction with life scale
It is a five item Likert type scale, which has to be rated on a 7-point scale and the scores fall in the range of 5 (low satisfaction) to 35 (high satisfaction).[29] It has been widely used in the Indian context. The test-retest correlation coefficient was found to be 0.82, and coefficient alpha was 0.87.[30]
Positive and negative affect schedule revised
The Positive and negative affect schedule revised version was used to assess the SWB of the participants.[31] It contains 26 words describing various emotions and feelings, and the participants were asked to rate each word according to its frequency in their life. It exists in both trait and state versions. For the current study, the trait version of the scale was used. The reliability of the PA scale ranged from 0.86 to 0.90, the NA scale from 0.84 to 0.87. This scale has been used in the Indian setting.[30]
Procedure
During the pilot phase of the study, the data was collected from 2 clinical and 4 community samples, by administering the selected tools to understand the difficulties in collecting data, the time required to complete the test and obtain feedback on the same. Since no published literature was found using BFAS in the Indian context, we established the test-retest reliability of the BFAS in the Indian population. For this purpose, 30 students were recruited from a nursing college. The sample consisted of 24 females and 6 males belonging to the age group of 19–21 years. Informed consent was obtained from the sample before the data collection. It was mentioned in the informed consent that the respondents would be approached after a month for retest of the scale. The test-retest coefficient was found to be satisfactory for neuroticism (0.704), extraversion (0.801), agreeableness (0.822), openness/intellect (0.734), and conscientiousness (0.715). For the ten factors under these five domains, the coefficient ranged between 0.499 and 0.789, suggesting an acceptable level of test–retest reliability. The internal consistency represented by Cronbach's alpha for neuroticism, agreeableness, conscientiousness, extraversion, and openness/intellect is 0.798, 0.661, 0.717, 0.705, and 0.717, respectively. Subsequently, the data was collected for the main phase from the clinical and community sample. Details of the sample are described in the results section.
Statistical analysis
A quantitative analysis was performed using SPSS (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Sociodemographic details of the samples were obtained through descriptive statistics such as mean, standard deviation (SD), frequency, and percentage. Correlations were obtained using both parametric and nonparametric measures, and comparison of means was made using t-test, for both clinical and community samples. Chi-square, t-test and Mann–Whitney U-test were used to compare the clinical and the community groups with respect to sociodemographic details and other study variables.
Results Socio-demographic details of the participants
The study sample in both community and clinical group had a mean age of 33 years (±9.6 years and ± 7.7 years, respectively). Among the clinical sample, most of the participants were educated up to graduation (40%), were employed (66.6%), belonged to the Hindu religion (76.7%), and were unmarried (56.7%). Among the community sample, 71.4% were graduates, and 62% were employed. Further, most of them belonged to the Hindu religion (69%) and were unmarried (47.6%). As mentioned earlier, in the community group AUDIT scores were used as a screening tool, and those above the cut-off (8 and above) were removed from the analysis, leading to a mean score of 1.27. The clinical group had AUDIT scores above 8 (mean score 23.2) and was diagnosed with alcohol dependence by the Centre for Addiction Medicine. Sixty percent of this clinical group also reported using other substances besides alcohol. The clinical and community groups were also compared on sociodemographic variables and using Chi-square test, which only indicated differences with respect to education. Greater number of study participants in the clinical group were educated up to PUC (12th std), while a higher percentage of the community sample had completed graduation. The groups did not show any statistically significant differences on age, employment status, and marital status when compared using t-test/Chi-square.
Comparison between clinical and community samples on the study variables
The normalcy of distribution was analyzed, and normal distribution was not attained for AUDIT score, Satisfaction with life scale score, Rajas, PA-activated and PA-deactivated, and NA-deactivated. The community and clinical groups were further compared on Triguna, nonattachment, personality, satisfaction with life and PA and NA, using independent sample t-test or Mann–Whitney U-test, depending on normalcy results. The mean and SD values, along with the comparison results between the two groups, are given in [Table 1].
Comparison on triguna
On Triguna, the clinical group scored higher on Tamas and lower on Sattva, and the two groups were significantly different (P < 0.001). Rajas was not significantly different between the two groups.
Comparison on nonattachment
The two groups were not significantly different on nonattachment, although a trend was visible with the clinical sample having slightly lower nonattachment (P = 0.80).
Comparison on big five personality traits
Among the big five personality traits, the clinical group was significantly higher on neuroticism (P < 0.001) and lower on conscientiousness (P < 0.005) and also significantly lower on extraversion (P < 0.05). The groups were not significantly different in agreeableness and openness/intellect.
Comparison on subjective well-being
The clinical group was lower on SWB, in terms of significantly lower life satisfaction (P < 0.001), total PA (P < 0.005), and deactivated PA (P < 0.001). The clinical group was also significantly higher on total NA and activated NA (both with P < 0.001), as well as deactivated NA (P < 0.05). There was a trend on activated PA with the clinical sample being lower on that too (P = 0.059).
Correlation of Sattva with other study variables
The correlation of Triguna with other variables are given in [Table 2]. In both the groups, Sattva was positively correlated with conscientiousness (clinical group = 0.72; community group = 0.61), satisfaction with life, PA-total, activated and deactivated, and negatively correlated with neuroticism, NA-total, activated and deactivated. In the clinical group, it was also negatively correlated with the AUDIT scores and in the community group, it positively correlated with other personality traits such as agreeableness, extraversion, and openness.
Correlation of rajas with other study variables
In both the groups, Rajas was negatively correlated with conscientiousness, PA (total and deactivated). In the clinical group, it was also negatively associated with agreeableness. Further, in the community group, it was also positively associated with neuroticism, NA (total, activated, and deactivated), and negatively associated with life satisfaction and PA total and deactivated.
Correlation of tamas with other study variables
In both the groups, Tamas was positively correlated with neuroticism and NA (total and activated), and it was negatively correlated with conscientiousness, life satisfaction, and PA (total, activated, and deactivated). In the community sample, it was also positively associated with deactivated NA, and negatively associated with extraversion and openness.
Correlation of nonattachment with other study variables
In both the groups, nonattachment was negatively correlated with neuroticism. In the community group, it was also positively correlated with agreeableness, extraversion, and openness, PA (total, activated, and deactivated), as well as negatively associated with NA (total, activated, and deactivated). Other correlations were not statistically significant at 0.05/0.01 level, in both clinical as well as community samples.
Discussion The current study aimed to compare men with and without alcohol dependence on Indian concepts of Triguna and nonattachment, along with their personality and SWB. It was found that among people with alcohol dependence, there is a predominance of Tamas guna. Tamas supposedly leads to a need to be inactive and a feeling of exhaustion along with anger, depression, helplessness, fear, sorrow, and uncertainty.[9] In our study, Tamas was also related to neuroticism, a tendency to be sensitive to negative emotions, and negatively associated with conscientiousness, all of which may explain dependence on substances. In the past, similar findings were reported where a group of patients with anxiety disorder were higher on Tamas, compared with a community sample.[14] Past literature has also suggested that depression and anxiety could be causal factors for dependence on substances, including alcohol.[32] Alcohol-dependent individuals show significantly high neuroticism, extraversion, anxiety, and depression.[33] Therefore, it is possible that Tamas leads to negative emotions, thus making one vulnerable to alcohol dependence. However, such an analysis could not be done due to the small sample size.
On the other hand, Sattva was relatively lower in the clinical participants. The community group was higher in Sattva, a trait associated with higher conscientiousness, satisfaction with life, PA, agreeableness, extraversion, openness, and lower NA. This goes with the theory that Sattva is associated with mental equilibrium and contentment and may incorporate a range of desirable qualities.[9] Some of the Vedic Personality Inventory items also captured qualities such as contentment, cleanliness, and dutifulness.
Rajas was not significantly different between the two groups. Probably modern lifestyle pushes people in general toward higher Rajas, in terms of materialistic attitudes, action orientation, passion, high energy, and drive. Thus, Rajas did not emerge as a differentiating factor between the community sample and those diagnosed with alcohol dependence. More empirical research is required to understand the consequences of dominant Rajas on mental health in modern times. While it may be suggested that such increased activity, enthusiasm, passion, and movement are essential for goal achievement, the negative consequences of it will be attachment towards materialistic needs, poor regulation of emotions, dissatisfaction, and desire for need gratification. All of these negative consequences may affect the well-being of a person and make them vulnerable to episodes of depression.[13] Current study results also support this, where Rajas was associated with lower life-satisfaction, lower positive affect and higher NA. Rajas was also associated with lower conscientiousness and agreeableness and higher neuroticism. In another interesting cross-cultural study, higher levels of Rajas was reported in the Indian sample, as compared to Americans and Czechs.[11] However, the generalizability of this particular study results may be limited. Thus, overall, Sattva seems to be associated with well-being, while Rajas and Tamas are associated with mental illnesses such as anxiety, depression and alcohol dependence.[14],[13]
Counter intuitively, nonattachment was not significantly different between the two groups, and only a trend level difference was found. It has been reported that people consider attachments and possessions as the normal state of functioning.[15] Probably, the kinds of attachments differed in both groups, but they still had similar levels of Asakti/attachments. Since a trend of lower nonattachment was present in the clinical group, future studies may explore this association with a larger sample size. Additionally, nonattachment was positively associated with agreeableness, extraversion and openness, along with PA and negatively with neuroticism and NA.
Examining the SWB of the participants, PA and NA were significantly different between the two groups. In the clinical participants, the affect was predominantly negative in nature. While PA and life satisfaction were significantly higher in the community group. As mentioned earlier, Triguna also influences affect, and vice versa. The need to experience PA more frequently and intensely can be one reason for substance use.
Approach and avoidance of alcohol are related to negative and PA, respectively. Elevated NAs showed a significantly higher approach rate for alcohol, and elevated PA showed a higher avoidance rate for alcohol.[34] The clinical group also had lower life satisfaction. Alcohol dependence can lead to a decreased repertoire of activities, leading to lost opportunities since some of these activities might have enhanced the individual's well-being. On the other hand, low life satisfaction may also lead to more alcohol consumption, thus accounting for the comparatively lower life satisfaction in the clinical group.[35]
Specifically, while conceptualizing alcohol dependence, it can be understood that increased Tamas, decreased Sattva, lower PA and life satisfaction, and high NA, together may lead to vulnerability for dependence. However, our study findings are not conclusive of the influence of Rajasic characteristics and nonattachment, on alcohol dependence.
Limitations
The Indian psychological concepts explored in the study (Triguna and nonattachment) are abstract, and available tools may not fully capture the exact construct. This might also explain the results associated with Rajas, and nonattachment, some of which did not emerge significant as expected from the theoretical underpinnings. Cross-sectional design and purposive sampling were used, and quantitative analysis was done, which has limitations when it comes to gaining in-depth insight. The sample was selected only from urban Bengaluru, and due to language constraints, there was a requirement to include only an educated population with fluency in English; hence, the study may not represent a population who differ in education or life in a rural area. Due to the nature of the study, and the alcohol-dependent sample being in treatment for addiction, the details of alcohol consumption were not assessed. Due to the need for screening as per inclusion and exclusion criteria and the availability of samples, the clinical and community sample size differs. Similar limitation of clinical sample size is present in other studies with the Triguna. Although this may not have any major implication on the analysis using t-test, it may lower the power of the t-test.
Furthermore, considering the relationship of Sattva guna with life satisfaction and affect, it can also be presented as an indigenous concept whose characteristics can be explained by referring to both, personality and affect. Also, the scope of conceptualizing Triguna as a trans-diagnostic model, using it for early detection, and planning for the prevention of alcohol and other substance use, or preventing other mental health problems, can be studied further. Since this was a correlational study, future studies can use appropriate methodology to establish causation. Theoretically, all three gunas are considered essential for the existence of the individual. However, the predominance of Sattvikaguna at, a trait level, is considered essential to one's well-being and psycho-spiritual growth. This does not mean that the other gunas must be destroyed; they have their utility at the state level, but it is the harmony among the three, and overall higher Sattva, that leads to well-being. The findings are in line with Charaka Samhita, an Ayurvedic text which suggests life-styles that lead to the development of Sattva guna are important for well-being.[36] Since mental health is holistic, influenced by biological and social correlates, and cannot be confined just to the psychological aspects of a person, integrative treatment approaches suitable to this model maybe popularized.
Conclusions The study aimed to compare men with and without alcohol dependence on Indian concepts of Triguna and nonattachment, along with their personality and SWB. It was found that compared to the community sample of men without alcohol dependence, the clinical sample of men with alcohol dependence had higher scores of Tamasic guna, neuroticism and NA. They also have lower levels of Sattva, conscientiousness, extraversion, PA, and life satisfaction. The two groups were not significantly different on nonattachment, although a trend was visible with the clinical sample having slightly lower nonattachment. The findings need further research on other kinds of addictions, including behavioral addictions.
Acknowledgment
The authors would like to thank Dr. Mariamma Philip, Additional Professor, Department of Biostatistics, NIMHANS, Bengaluru, for her valuable inputs in the manuscript.
Ethical clearance
The study was recommended and approved by the Institutional Ethics Committee of National Institute of Mental health and Neurosciences, Bengaluru and it was communicated through the letter NO.NIMH/DO/IEC (BEH. Sc. DIV)/2016 dated 16.05.2017.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
Correspondence Address:
Jyotsna Agrawal
Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijoy.ijoy_128_22
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