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Management of Anidra with Nidra caps - a placebo comparative study, Kamalaxi. M. Angadi, 2005-2008, Post Graduate Studies & Research Center, D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG

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Anidra kc001 gdg

  1. 1. “Management of Anidra with Nidra caps - a placebo comparative study” By Kamalaxi. M. Angadi Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the degree of Ayurveda Vachaspati M.D. In Kayachikitsa Under the Guidance of Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P. (German) M.A., [Ph.D] (Jyotish) Department of KayachikitsaPost Graduate Studies & Research CenterD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG 2005-2008
  2. 2. D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 This is to certify that the dissertation “Management of Anidra with Nidra caps - a placebo comparative study” is a bonafide research work done by Kamalaxi. M. Angadi in partial fulfillment of the requirement for the post graduation degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University of Health Sciences, Bangalore, Karnataka.Date: GuidePlace: Gadag Prof. Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish) Professor in Kayachikitsa DGMAMC, PGS&RC, Gadag
  3. 3. J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 Endorsement by the H.O.D, principal/ head of the institution This is to certify that the dissertation entitled “Management of Anidra with Nidra caps- a placebo comparative study” is a bonafide research work done by Kamalaxi. M. Angadiunder the guidance of Prof. Dr. Shiva Rama Prasad Kethamakka, M.D. (Ayu) (Osm),C.O.P (German), M.A., [Ph.D] (Jyotish), Professor in Kayachikitsa in partial fulfillment of therequirement for the post graduation degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)”Under Rajeev Gandhi University of Health Sciences, Bangalore, Karnataka.. (Dr. V. Varadacharyulu) (Dr. G. B. Patil) Professor & HOD Principal, Dept. of Kayachikitsa DGM Ayurvedic Medical College, PGS&RC Gadag Date: Date: Place: Gadag Place: Gadag
  4. 4. Declaration by the candidate I here by declare that this dissertation / thesis entitled “Management of Anidra withNidra caps - a placebo comparative study” is a bonafide and genuine research work carriedout by me under the guidance of Prof. Dr. Shiva Rama Prasad Kethamakka, M.D. (Ayu)(Osm) M.A. (Jyotish), [Ph.D (Jyotish)], Professor in Kayachikitsa, DGMAMC, PGS&RC, Gadag.DatePlace Gadag Kamalaxi. M. Angadi
  5. 5. Copy right Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences, Karnatakashall have the rights to preserve, use and disseminate this dissertation/ thesis in print orelectronic format for the academic / research purpose.DatePlace Gadag Kamalaxi. M. Angadi© Rajiv Gandhi University of Health Sciences, Karnataka
  6. 6. Abstract of “Management of Anidra with Nidra caps - A placebo comparative study”Key words: Anidra, Nidranasha, Insomnia, Nidra cap, Placebo, sleep efficiency, Tamas interms of RATR, Somnus Rasayana Anidra vis-à-vis Primary insomnia is one of the important diseases pertaining tothe Vata disorder affects the people of all age groups. The study objective is – to evaluatea Nidrajanaka prabhava (sedation) with Nidra caps in comparison to placebo compared.Simple random sampling technique with comparative clinical trial is adopted here undertwo groups to test the significance. Induction of sleep it is said that when the mind getsexhausted or becomes inactive, the sensory and motor organs become inactive then theindividual gets sleep. Onset of sleep is related to the increases of Tamas always. Here,tamo-abhava is reticular activity transmission and tamobhava is RATR. When Vata alongwith rajas gets increased the above told phenomena will not takes place leading toAnidra. Here the rational combination Nidra cap is with bhutaghna manasa doshaharaJatamamsi, vatahara and mastishka shamaka prabhava Tagara, adaptogen and immunomodulator Ashwagandha and Vata hara and deepaniya Pippali moola are able to actagainst the symptoms of Anidra and induces the good sleep. . The parameters show Highsignificance with Nidra caps as good sedative. Among the subjective and objectiveparameters the Nidra cap group shows more High significance than the placebo groupand said to effective. Thus it is fair to conclude the Nidra cap has putative Nidra janakaprabhava.
  7. 7. Acknowledgement Any research is not an individual effort. It is a contributory effort of many hearts,hands and heads. I am very much thankful to the subjects of this study. I am extremely happy to express my deepest sense of gratitude to my beloved andrespected guide Prof. Dr. K.Shiva Rama Prasad, M.D., C.O.P. (German), M.A., [Ph.D.],for his guidance and timely help. I express my gratitude to Dr. V. V. Varadacharyulu Professor and H.O.D for hisadvice and encouragement in every step of this work. I am sincerely grateful to Dr. G. B. Patil, Principal, for his encouragement andproviding all necessary facilities for this research work. I extend my gratitude to Dr. R. V. Shettar, Dr. G. Purushottamacharyulu, Dr. P.Shivaramudu, Dr. M. C. Patil, and Late. Dr. Dilip Dr. G. S. Hiremath. Dr. G.Danappagoudar. Dr. S. H. Doddamani. Dr. Rajashekhar. Dr. S. N. Belawadi. Dr.Nedugundi, Dr. Samudri, Dr. Kubersankh. Dr. Mulgund. Dr. J. Mitti. Dr. Mulki Patil. Dr.Yasmin A.P. Dr. B. G .Swami all my U.G. Lecturers for time-to-time help offered. I express my immense gratitude to my statistician Nandakumar, Tippanagoudar(Lab), V.B. Mundinamani (librarian) and Shyavi and Kerur for facilitating me incollection and production of my thesis. My deep senses of gratification to my inspirations of this study are my husbandShivanand. B. Manvi and my parents Mallappa. S. Angadi and Neelamma. M. Angadiwho are architects of my career. I am extremely happy to express my deepest sense ofgratitude to my mother-in-law Sharanamma.B.Manvi and my beloved son Bhuvan. Last but not least I express my deepest thankfulness whose names are not takenhere but helped me a lot along with my kith and kilns to my family members and Dr.Sanjeevkumar and all my senior and junior friends. (Dr. Kamalaxi M. Angadi)
  8. 8. Contents of “Management of Anidra with Nidra caps - a placebo comparative study” by Kamalaxi. M. AngadiChapter Content Pages 1 Introduction 1 to 7 2 Objectives 8 to 10 3 Literary Review 11 to 59 4 Methods 60 to 71 5 Results 72 to 95 6 Discussion 96 to 108 7 Conclusion 109 to 111 8 Summary 112 to 114 9 Bibliographic References i to vi 10 Annex 1 – Master Charts Data of trial 1 to 8 11 Annex 2 – Case sheet 1 to 6 -1-
  9. 9. Tables of “Management of Anidra with Nidra caps - a placebo comparative study”SN TITLE OF TABLE PAGE1 Stages of sleep in the NREM 302 Synonyms of Anidra 383 Anidra Ahara Nidana 414 Anidra Vihara Nidana 415 Chikitsa atiyogajanya Nidana of Anidra 416 Anidra Manasika Nidana 417 Symptoms of Anidra 428 Anidra – Samprapti ghataka 459 Bahya Upacharas for Nidranasha 4710 Aahara Upacharas for Nidranasha 4811 Manasika Upacharas for Nidranasha 4812 Anya upachara for Nidranasha 4913 Single drugs useful for Nidranasha 5014 Distribution of Patients by Age- Gender in Group A & B 7315 Gender wise Results in Group – A (Placebo cap) 7516 Gender wise Results in Group –B (Nidra cap) 7517 Religion wise Results in Group – A (Placebo cap) 7618 Religion wise Results in Group – B (Nidra cap) 7619 Occupation wise Results in Group – A (Placebo cap) 7720 Occupation wise Results in Group – B (Nidra cap) 7821 Economical status wise Results in Group – A (Placebo cap) 7922 Economical status wise Results in Group – B (Nidra cap) 7923 Diet wise Results in Group – A (Placebo cap) 8024 Diet wise Results in Group –B (Nidra cap) 8125 Showing chief complaints of Anidra 8226 Showing Associated complaints of Anidra 83 -2-
  10. 10. 27 Showing Mode of onset in Anidra 8428 Showing Anidra course in study 8429 Showing Anidra frequency in study 8530 Showing Anidra duration in study 8531 Showing Anidra preceding factors in study 8632 Showing Anidra change of regularities in study 8733 Showing Anidra Nidana in study 8734 Showing Anidra Nidra (sleep) Examination in study 8835 Showing Anidra Results of the Group A (Placebo caps) in study 8936 Showing Anidra Results of the Group B (Nidra caps) in study 9137 Subjective Statistical assessment Group-A 9238 Objective Statistical assessment Group-A 9239 Subjective Statistical assessment Group- B 9240 Objective Statistical assessment Group-B 9241 Comparative Statistical assessment of Both Groups 9342 Comparative Statistical assessment of Both Groups in % of 94 comparison Figures and Photos of “Management of Anidra with Nidra caps - a placebo comparative study”SN TITLE OF FIGURES AND PHOTOS PAGE1 Schematic diagram of Anidra Samprapti 432 Ingredients of Trial drug Nidra cap 573 Distribution of Patients by Age- Gender in Group A & B 734 Gender wise Results in Group – A (Placebo cap) 755 Gender wise Results in Group –B (Nidra cap) 766 Combined Religion wise Results 777 Occupation wise Data of Both Groups 788 Economical status wise Data of Both Groups 809 Combined Diet data of Group A & B 8110 Associated compliant in the study 8311 Results of the Group A (Placebo caps) 9012 Results of the Group B (Nidra caps) 91 -3-
  11. 11. Chapter – 1 Introduction Barenked Ladies sung “Who needs sleep?” as - “Now I lay me down not to sleep I just get tangled in the sheets, I swim in sweat three inches deep, I just lay back and claim defeat… Lids down, I count sheep, I count heartbeats, The only thing that counts is that I won’t sleep…. My mind is racing, Filled with lists of things to do And things I’ve done. Another sleepless night’s began….” How the food, water and air are essential for life, like the same sleep i.e. Nidra is alsovery much essential. ‘The best bridge between despair and hope is good night’s sleep. Soundrestorative sleep is the foundation of a healthy life. Hence, the Ayurveda explains Nidra asone among the “Trayo-Upasthambha” i.e. primary tripod of life. In Shakespeare’s words the sleep is - indeed a positive thing, a reactive process, awinding up of the vital clock, a recharging of life’s battery or “Chief nourisher at life’s feast”.Three sub-pillars are diet, sleep and celibacy. If these three are fulfilled properly, the body issupported well by these pillars, it continues well endowed with strength, complexion anddevelopments till the complexion of life span provided one abstains from harmful practiceswhich will be explained here itself 1. Management of Anidra with Nidra caps – Introduction 1
  12. 12. Ahara Ahara, partaking food confers satisfaction and immediate strength supports the body, increases span of life, radiance, enthusiasm, memory, valiance and digestive capacity 2. It is a fact that the empty stomach doesn’t give sleep. Brahmacharya The end product of ahara rasa is said as the shukra dhatu. Loss of shukra causes death on the other hand conservation of sukra promotes life. Thus it is said as the shukra is the bala (strength) for purusha (human) ultimately 3. Nidra Sleep enjoyed at the proper time bestows nourishment, good color (Complexion), and strength, enthusiasm, keenness of digestive power, wakefulness and maintains normalcy of tissues 4. Hence, these three trayopasthmbha exhibits their importance in the life and necessityof the induction or regulation of the Nidra effect to add flavor to the life. As we know thatsatisfaction alone is sufficient to have better life thus the satisfaction of the Nidra gives raiseevery positive effect to live happy and healthy. The importance of sleep is well accepted by modern science also, because of itsrestorative, recuperative and resting actions to the living organisms. We spend at least 1/3rd ofour lives asleep. Yet little understand why our body requires it or for what reasons natureoften chooses to transform the soothing slumbers of youth into the restless tossing ofmaturity. Only for the last half century has this universal subject of human concern or distressstimulated seriousness and physiologists and neurological physicians to examine its mysteriesand mechanisms. Management of Anidra with Nidra caps – Introduction 2
  13. 13. Now a day due to altered lifestyles busy schedule and stressful living conditions,struggle for existence etc, the (sleeplessness) Anidra (Insomnia) became a major problem.Incidences / Prevalence of Anidra According to American Association 5 of sleep medicine, Insomnia is “the inability tofall asleep or to stay asleep; A broader definition of insomnia is difficulty initiating sleep,difficulty maintaining sleep, early-morning awakening with difficulty resuming sleep or unrefreshing sleep. The subject must also suffer some degree of impairment in socialoccupational, or other important areas of daytime functioning. Now a days about 40% women and 30% men and about 25% of elderly people and15% of the general population suffer from this altered sleep i.e. insomnia 6. Nidranasha/Anidra is not discussed as a disease anywhere in the classical texts, 7mentioned as vataja nanatmaja vikara bears much weight in this regard. The merits anddemerits, classification and the management of insomnia are also dealt along with the conceptof sleep in every Ayurvedic treatise.Recent researches on Anidra So far the problem of Nidra, Anidra and the management of Anidra are concerned, it issurprising, and that research work carried out on this topic is very less 8: • Dr. Kala Kasliwal (1984), in N.I.A. Jaipur, has carried out the study on Nidra and tried some Nidra janana drugs to assess their efficacy in inducting the sleep. • In P.G.T and R.A Jamanagar- Dr.U.D.Joshi (1987) has carried out a study on Anidra, an etiopathological and manage mental approach. • Dr. Kavitha Trivedi (1995) has carried out the comparative study of shirodhara and shirobasti in the management of Anidra. Management of Anidra with Nidra caps – Introduction 3
  14. 14. • Dr. Prakash. B.(2000) has carried out the management of asvapna (sleep disorders) with certain indigenous drugs and ashwagandha taila dhara, • Dr. Muralidhar Pujar carried out a comparative study on Nidranasha/AnidraMention of lacunae in current knowledge The management of Nidranasha/Anidra in contemporary sciences mainly depends onmost commonly available antidepressant drugs, sedatives, tranquillizers and hypnotic drugs.The drawback with this approach is drug dependence, tolerance towards the drugs andreoccurrence of the symptoms on withdrawal of the drug. Apart from these internalmedications, counseling, cognitive therapy, physiotherapy and meditation have also beenadvised. Still we find no satisfactory and safe measures for Nidranasha/Anidra.Purpose of the Study In comparison to the therapeutic procedure of different systems of medicine,Ayurveda has a very good approach towards the treatment of Nidranasha/Anidra by bothinternal and external medications. The main purpose of the study is to evaluate a medication which doesn’t give any drugdependence along with tolerance. Chiefly the purpose relays on two areas viz. 1) control ofVata and 2) correction of Manasa vyakula Bhavas which cause the Anidra. Such medicamentunder the principles of Ayurveda based upon the theories and concepts are erected as “Nidracaps”. Charaka has mentioned that the controller and stimulant of the mind is Vata. TheVatahara herbs are said to be the best medicines to induce sleep as they are the Kaphapromoters. The Kapha is of “Tamo” guna, thus the dravyas which are of Kapha in nature offerbetter relaxation and induction of sleep. Management of Anidra with Nidra caps – Introduction 4
  15. 15. Chinta, Shoka, Bhaya, Krodha and other disturbed Manasa bhava, are stressors playsan important role in causing Anidra. The Nidra cap is designed as cost effective and correctsthe disturbed mental faculties and provoked Vata. Thus pacify all kinds of stressors to achievethe state of tranquility leading to deep relaxation which helps in the normalization andstabilization of manasa bhava to make patient healthy and happy. As the internal medication is concerned a number of herbal preparations and plantextracts have been used with varying degree of success in the management ofNidranasha/Anidra. Among them – 1. Tagara 9 (Valerian walichi), 2. Jatamamsi 10 (Nordostachys jatamamsi), 3. Ashwagandha 11 (Withania somnifera), 4. Pippalimoola 12 (piper longum) – When made as a rational combination induces sleep in a better way making the Doshasamyata in the body. The rationality of the combination is justified by the rasa, guna, veerya,vipaka and karma prabhava attributed to the individual drugs with Nidrajanakatwa prabhavaembedded in them.Hypothesis and Research questions According Ayurveda sleep is induced by the increase of the inert universal attributecalled Tamas. The term Tamas literally means darkness. Satva, Rajas and Tamas are the threemajor or universal attributes that pervade the universe. These three attributes play animportant role in the functioning of the mind, of them rajas and Tamas are the vitiators ofmind (manodosha) because there predominance affects mental diseases. Management of Anidra with Nidra caps – Introduction 5
  16. 16. Sleep is a periodic functional state of man and higher animals, characterized byspecific changes in vegetative and motor systems by the absence of purposeful activity andsensory interaction with the environment. Sleep is characterized by the inhibition of consciousmental activity. Onset of sleep is related to the increase of Tamas and Kapha. Both these principleseffect inertia, sleep usually occurs at night as the surroundings are dark and are predominatedby Tamas. This dark environment naturally increases the Tamas in human beings according tothe theory of generality. During night the biological channels are blocked by Kapha. The sensory and motorfaculties are fatigued by day’s work. The fatigued faculties become sluggish in their work andwill loose their activity. Considering the physical plane, the humor Kapha i.e. responsible forconservation of energy has a role in inducing sleep, Kapha is stable and sluggish. Increase ofsatva is conducive to mental health, rajas represents action. They gradually withdraw from their objects. The functions of the mind also areblocked by the increase of Tamas. Mind gets detached from the faculties and its action ofenjoying the faculties ceases. This stage is called sleep, even in sleep mind maintains itsconnection with the soul. The hypothesis is made on the basis of Vata shamaka in terms of controlling the mindthrough its functions. The present medicine acts as Vata shamaka in terms of regulating themind thus sleep is induced by initiating the Tamas. The important factor responsible forreduction of sleep has been shown to be the fatigue of neuromuscular function which in turnunable to pass on proprioceptive impulses may be the Tamas. The action of the trial drug is Management of Anidra with Nidra caps – Introduction 6
  17. 17. compared to the placebo, to rule out the psyche involvement in induction of sleep. At thisjuncture many questions are raised such as - 1. What is the Tamas which induces the Nidra in living beings? 2. How Rajas and Tamas disturb the mind to induce Anidra? 3. How Vata is responsible for disturbing the inhibition of conscious mental activity i.e. sleep 4. What is the role of Kapha in sleep? The search for the answers are made at this study named as – “MANAGEMENT OFANIDRA WITH NIDRA CAPS - A PLACEBO COMPARATIVE STUDY”, under theheadings of Introduction, Objectives, Literary study, Methodology, Results, Discussion andConclusion along with necessary documents and appendices attached. Management of Anidra with Nidra caps – Introduction 7
  18. 18. Chapter – 2 Objectives Today’s man has become a tired and chronically sleep-deprived generation.Technology and the industrial revolution is one of the biggest factors. People live in a fast-paced, high-tech world that operates 24 hours a day. Working fields like a myriad ofbusinesses and services are accessible around the clock. Television, radio and movie channelsbroadcast day and night. To cope up such conditions occurring around the clock, people worklong hours and something must be sacrificed. Unfortunately sleep is a very common thing tosacrifice. Consequently, insomnia has spread up very widely like other harassing diseases. Insomnia has a great impact on social, occupational and other functioning areas of theindividual. The modern medical science is still not having a definite treatment for this disease.Although, hypnotics and sedatives are there in all the prescriptions of psychiatrists and inmaximum prescriptions of general practitioners their role in curing the disease is very limitedrather the patients will be addicted for the particular drug. There comes the relevancy of our Ayurvedic principles for the treatment, whichreveals that the medicine or treatment that cures one disease and creates some other is not agood therapy, but the therapy which cures one disease and does not create any other, is the 13right treatment . Hence, here a humble attempt had been done to give an effectivemanagement process for the disease Anidra. Management of Anidra with Nidra caps – Objectives 8
  19. 19. Aims & Objectives 1) To evaluate the Nidrajanaka prabhava (sedation) of Nidra cap in Anidra Dosha involvement in Anidra is Tridosha with predominance of Kapha. But the deviations from the normalcy of Dosha are to be considered with due importance. Vata and Pitta are in increased state, while in case of Kapha, the diminished is observed usually. As in Anidra, mainly Vata Prakopa occurs due to its Chala and Laghu Guna vitiate, thus keeps the mind active, causing Anidra. The ingredients of the Nidra capsules are with Vata Dosha hara action having snigdha guna, ushna veerya, with the sedative and hypnotic action, otherwise understood as the Tamas initiation. By observing all these characteristics of medicine, Nidra caps, it seems to be very much beneficial in the management of Anidra for obtaining the requisite results, viz. induction of Tamas, initiation of sedation, relaxing the body mind, etc. 2) To evaluate the Nidrajanaka prabhava (sedation) of placebo in Anidra Anidra is one of the pshyco-somatic disease condition, many a times, the anxious or phobic or even depressive patients, respond to the placebo. Thus the placebo is responsible for many temporary successes in therapy acting on the mind. As we know that many times placebo is used to understand the differentiate phenomenon of the psyche physical disturbances, with good success of specifying the relief of the problem, for a comparison to understand the Nidra cap efficacy, the placebo sedation effect is undertaken as one of the objective. Hence, taken comparative study to evaluate the effect of Nidra cap is justifiable. Management of Anidra with Nidra caps – Objectives 9
  20. 20. 3) To compare the Nidrajanaka prabhava (sedation) of placebo and Nidra cap inAnidra The study is incomplete if a comparative clinical Trial of sleep inductive effectof the Nidra caps internally to pacify the Dosha in Anidra and placebo to overcome thepsychosomatic origin of the disease Anidra is not compared. Thus the trial iscompared at the clinical efficacy with respect to the subjective and objectiveparameters chosen. At this attempt the group-A and group-B designated withrespective medicaments of Placebo and Nidra caps, are observed for the efficacy ofnidrajanaka prabhava (sedation) effect drawn in the comparative statement. Management of Anidra with Nidra caps – Objectives 10
  21. 21. Chapter – 3 Literary Review In fact, Nidra looks like a glimpse of Pralaya, which carries peace but in darkness.After this glimpse of Pralaya – man awakens fresh like Srujana. For the living beings in theworld, it is an essential phenomenon for maintenance and restoration of both – body andmind. Since the dawn of the civilization the thinkers of the world tried to study the sleep, itsnature and causes. In India, from the Vedic and Upanishad period, the Yogis have studied theYogic phenomena pertaining to various stages associated with Atma. They have termed thesestages as Jagritavastha (waking state), Svapnavastha (dream state), Sushuptavastha (sleepstate) and Samadhi Avastha (the conscious sleep phase having Detachment from the externalworld in different degrees).IMPORTANCE OF SLEEP Ahara, Nidra and Brahmacharya are the three factors, which play an important role inthe maintenance of a living organism. In the Ayurvedic literature, these factors i.e. Ahara,Nidra and Brahmacharya have been compared with the three legs of sub-support and havebeen termed as the three Upastambhas 14. The inclusion of Nidra in the three Upastambha proves its importance. Whilediscussing about Nidra, the ancient Acharyas have stated that happiness and sorrow, growthand wasting, strength and weakness, virility and impotence and the knowledge and ignoranceas well as the existence of life and its cessation depend on the sleep 15. According to Kashyapa, getting good sleep at a proper time is one of the 16characteristics of a healthy man . The importance of sleep for health and recovery fromdiseases has been recognized intuitively if not scientifically in the modern texts; nearly all Management of Anidra with Nidra caps – Literary Review 11
  22. 22. doctors recommended that their patients should get plenty of rest and their advice is followedbecause that is just what patients want to do whether such sleep does have any adoptive valueis, however, unknown. Many disorders are associated with abnormal patterns of sleep. Someimportant findings of sleep are listed below: Sleep is one of the factor upon which the patternof GH secretion is dependant. (Factors are stage of development, nutritional state, sleep stage,stress and exercise.) Secretion is enhanced by sleep with levels highest during slow-wavesleep and lowest during REM sleep. Oxygen consumption is lower during sleep, facilitatingan anabolic process. Physiological activities (e.g. exercise) and pathological disorders (e.g.hyperthyroidism), which lead to increased catabolism are associated with increased slow-wave sleep. Reduced activity and metabolic turnover (e.g. paraplegia and hypothyroidism) areassociated with decreased slow-wave sleep. Hormones that inhibit anabolic processes (e.g.corticosteroids, adrenaline and noradrenaline) are inhibited during sleep.Etymological derivation of Nidra The word Nidra is feminine formed by the prefix ni+dra+rak+ta. This is a state ofnature which causes encapsulation to the consciousness of a person 17.Definition Ever since modern people are unable to define it accurately from the time it is aquestion in every mind that what is sleep, how it occurs and what is its role in health. But thegreat sages of India had the perfect knowledge regarding the sleep. The definitions are asfollows - 1. Sleep is the mental operation having the absence of cognition for its grasp. Vyas while commenting Patanjali Yoga darshana made a statement as – “sleep is a state of unconsciousness, but the consciousness remains about his own unconsciousness 18. Management of Anidra with Nidra caps – Literary Review 12
  23. 23. 2. According to Mandukya Upanishad Nidra is a condition in which ‘Atma’ does not have any dream or desire for anything and that state is called ‘susupti” 19. 3. Chhandogya upanaishad states that “the state in which the mind is unaware about surroundings or will not have any dream is termed as sputa or Nidra 20. 4. Nidra is defined as the temporary loss of contact with Jnanendriya and Karmendriya to the manas 21. 5. Charaka affirmed that when the mind (as well as soul) gets exhausted or becomes inactive and the sensory and motor organs become inactive then the individual gets sleep 22. 6. Susruta described the sleep occurs when the Hridaya the seat of chetana is covered by Tamas 23. 7. Dalhana the commentator of Susruta states that Nidra is the state of combination of mind and intellectual in which the person feels happy 24. 8. Astanga sangraha Vagbhata stated that - the manovaha srotas become accumulated with sleshma and mind is devoid of sense organs because of fatigue, when individual fell asleep 25. 9. Sharangadhara mentions that Nidra is a state where predominance of Kapha and Tamas is witnessed 26. 10. Adhamalla defines that the Nidra is a state in which the tamoguna combines with Kapha where mohavastha of indriya and mana is observed 27.Phenomena of Nidra There is a natural relation of sleeping and waking during 24 hrs. The sleep comesnaturally during the night but it is not necessary consequence of darkness, as is proved by Management of Anidra with Nidra caps – Literary Review 13
  24. 24. those persons who have to work in night sleeps in the day and readily adopt themselves to thiscondition. Authors of ancient Hindu literature made crystal clear explanations regarding thephysiology of sleep. They explained it in different ways according to their working field andconceptualized. These explanations regarding the phenomena of Nidra may be summed andclassified under four groups - 1. Theories of Upanishad 2. Theories of Yoga 3. Theories of Ayurveda 4. Contemporary concepts developed1) Theories of Upanishad 28 a) Ancient seers of Chandyogyopanishad stated that the Atma moves from Hridaya through the nadis and gets lodged inside the membranous sac around the Hridaya, then the sleep is induced. b) Brihadaranyakopanishad 29 explains that the Nidra occurs when Atma goes into rest in space in side the Hridaya2) Theories of Yoga The yogic philosophers have made a clear explanation regarding sleep resembles asSamadhi state which is entirely different from it. They studied ‘Yoga Nidra’ pertaining tovarious states associated with Atma. They have termed these states as Jagratavastha – waking consciousness Svapnavastha – dreaming Management of Anidra with Nidra caps – Literary Review 14
  25. 25. Susuptavastha – dreamless sleep Turiyavastha – conscious dreamless sleep 30 Maharshi Patanjali states that the Sleep is a state in which all activities of thoughtand feeling come to an end. In sleep the senses of perception rest in the mind, the mind in theconsciousness and unconsciousness in the being. In deep sleep, the senses of perception ceaseto function, because their king, the mind, is at rest.3) Theories of Ayurveda a) Tamo prabhava theory According Susruta 31, the sleep is induced by the increase of the inert universal attribute called Tamas. The term Tamas literally means darkness. Satva, Rajas and Tamas are the three major or universal attributes that pervade the universe. These three attributes or dimensions play an important role in the functioning of the mind and even body, of them rajas and Tamas are capable to vitiate mind (Manas). Because of their predominance’s affects and afflicts the mind the mental diseases are resultant. On the other hand the satva increase can cause the conductive to mental health and Rajas which represents in action. Onset of sleep is related to the increases of Tamas always. These said principles affect inertia on general. Sleep usually occurs at night as the surroundings are dark and are predominated by Tamas. This dark environment naturally increases 32 the Tamas in human beings according to the theory of generality . Apart from this the bioelectrical cells, which are in the body, sustain the energy for activity in the day light by getting charged through Sun light. At the night the Human is the only capable to generate Bioelectricity through the activity of digestion (Jatharagni). At the Management of Anidra with Nidra caps – Literary Review 15
  26. 26. darkness the person reserves the energy and wish to retire as the activities arerestricted and energy levels are inhibited.b) Theory of Klama (Fatigue) The sensory and motor faculties are fatigued by day’s work. The fatiguedfaculties become sluggish in their work and will loose their activity. They graduallywithdraw from their objects. The mind functions are also blocked by the increase andinfluence of Tamas. Mind gets detached from the faculties and its action of enjoyingthe faculties ceases. This stage is entitled as sleep. But even in the sleep also mindmaintains its connection with the soul, as it is “Ubhayendriya” – dualistic organ 33.c) Theory of Swabhava Nidra Sleep is a natural function of Tamas where in both satva and rajas acts againstthe sleep induction. Apart from sleep Tamas causes of fear, ignorance, depression andlaziness also. Satva represents cognition and enlightenment. It is the cause ofawakening: Nevertheless sleep is included among any natural diseases. Hence, theSatva is against the ignorant and inert sleep. Rajas on par with satva represent actionand hence, it is also a factor against to sleep induction, where the physical and mentalactivities are subdued or restrained 34.d) Kapha Dosha theory Kapha is said as the strength of the living being. Such Kapha when obliteratesthe channels because of the over activity of the body the mind withdraws from thesensory activities and induces the sleep as physical rest to the body. Such Nidra alsoassociates with the Tamas to fulfill the sound sleep 35. Management of Anidra with Nidra caps – Literary Review 16
  27. 27. 4) Contemporary Concepts of Sleep Sleep remains one of the great mysteries of modern neuroscience. We spend nearlyone-third of our lives asleep, but the function of sleep still is not known. Fortunately, over thelast few years’ researchers have made great headway in understanding some of the braincircuitry that controls wake-sleep states, but no single explanation can accepted as the finalword for the understanding of physiology of sleep 36. The views regarding the phenomenon ofthe sleep throw light upon the phenomenon occurring during the rest and refreshing effect. 1) Vascular Theory: Probably the oldest theory is that sleep is induced by a reduction in the blood supply to the brain or at least to the conscious centers. This is the so-called ischemic theory. 2) Pavlov’s Theory: As a result of his study of conditioned reflexes in dogs, Pavlov proposed a theory for sleep, base upon the cortical inhibition caused by the repeated elicitation of a conditioned response without reinforcement. The condition inhibition slowly spreads the entire cortex that causes sleep. 3) Chemical Theory: Some have favored the chemical theory. According to this concept some chemicals, like lactic acid, acetylcholine, bromide or specific fatigue toxins were supposed to accumulate during the waking hours which irritates the nerve cells of brain and causes sleep as a result. Management of Anidra with Nidra caps – Literary Review 17
  28. 28. 4) Kleitman’s Theory: Sleep is caused due to reduction of the muscle tone anddischarge of less afferent impulses, thereby, keeping the cerebral cortexinactive.5) Oxygen Theory: Explains sleep depends upon the utilization of oxygen.Whenever brain utilizes less oxygen, at that time sleep is taking place.6) Hypothalamus Theory: This theory states that there is a sleep center in thehypothalamus. The stimulation of which is responsible for sleep. Toexplain this some experiments were carried out.7) Parasympathetic Theory (Acetylcholine Theory – Dixit): The depression of the sympathetic center is stated to beresponsible to inducing the sleep and as such sleep is regarded as aparasympathetic function.8) Lactic Acid Theory: Sleep is supposed to be caused due to accumulation of lacticacid in the nervous tissues.9) Serotonin Theory: The most conspicuous stimulation area for causing almostnatural sleep is the raphe nuclei in the lower half of pons and in themedulla. Nerve fibers from these nuclei spread widely in the reticularformation and upward into the thalamus, neocortex, hypothalamus and Management of Anidra with Nidra caps – Literary Review 18
  29. 29. most areas of the limbic system. Ending of these nerve fibers secrete serotonin. It has been assumed by the experiment that serotonin is a major transmitter substance associated with production of sleep 37. 10) Neuronal Centers theory 38 Stimulation of some areas in the nucleus of tractus solitarius (the sensory region of the medulla and pons) – also promotes sleep. These regions perhaps act by exciting the raphe nuclei and serotonin system. Stimulation of several regions in the diencephalon can also help promote sleep, including – a) The rostrum part of the hypothalamus, mainly in suprachiasmal area and b) An occasional area in the diffuse nuclei of the thalamus.Types of Nidra Ayurveda has different opinions regarding the types of sleep. Basically Nidra can beclassified into type’s viz. Svabhavika (natural) and Asvabhavika (abnormal). Out of theformer Svabhavika Nidra is regularly every night, which offers beneficial effects for theliving beings, whereas the later Asvabhavika is one can be due to different causes ofpathological in origin.1) Charaka classification of Nidra 39 Charaka classifies the sleep condition into seven folds. He agrees with the ancientauthors who considered the sleep is Bhutadhatri. Sleep comes at night, spontaneously andregularly as a natural instinct and that the other categories were either due to sin or thedisease. The seven types described by Charaka run as under - Management of Anidra with Nidra caps – Literary Review 19
  30. 30. 1. Tamobhava Nidra 2. Sleshma Samudbhava Nidra 3. Manah Shrama Sambhava Nidra 4. Sharira Shrama Sambhava Nidra 5. Agantuki Nidra 6. Vyadhyanuvartini Nidra 7. Ratri Svabhava Prabhava NidraBrief descriptions of said Charaka types of Nidra are elaborated is as follows -a) Tamobhava Nidra: Generally the sleep is due to the effect of Tamas, but the Tamobhava Nidra asparticularly due to the excessive Tamas causing sleep. When Satva and Rajasa arediminished in excess and the seat of Atma and Mana i.e. Hridaya is covered by thevitiated Tamas, then the organization become inert or inactive. According to some scholars, the Tamodbhava Nidra resembles with Sanyasacondition described by Charaka, which is the comatose state. The sleep caused byTamas is also the root cause for all sinful acts. Tamas always causes excessive sleep. Thus, the individual is unable to performthe virtuous files and so he subjects himself to sinful behavior.b) Sleshma Samudbhava Nidra: Sleshma is the material state of Tamas and as such the Sleshma and the Tamasare having identical properties. When the Sleshma increases in the body the sleepensues. Therefore, it is called Sleshma Samudbhava Nidra. Management of Anidra with Nidra caps – Literary Review 20
  31. 31. c) Manah Shrama Sambhava Nidra: The person also gets the sleep as the result of exertion. Due to excessivemental stress and strain, the mind gets tired and unable to perform its activities; as aresult the animal gets sleep.d) Sharira Shrama Sambhava Nidra: The person also gets the sleep due to physical exertion. When a personindulges in excess physical activities he feels too much tired. The body and minddesire to take rest and agitate to work further and the person gets sleep.e) Agantuki Nidra: Sometimes the cause of sleep remains obscure and the cause is not explainable.However, the sleep is followed by the death and as such Chakrapani has termed thissleep as a death signal (Arishta) 40.f) Vyadhyanuvartini Nidra: There are some diseases like Sannipata Jwara where severe weakness of thepatient and follows the condition just similar to coma. This type of sleep is termed asVyadhyanuvartini Nidra.g) Ratri Svabhava Prabhava Nidra: As has been stated earlier the sleep is a natural phenomenon and it comes at aparticular time cyclically in the night. There is no specific or particular reason for this 41kind sleep and it is termed as Bhutadhatri . It has been observed that even theindividual who has slept during the daytime would also feel sleepiness in the night,which is quite a natural phenomenon. Management of Anidra with Nidra caps – Literary Review 21
  32. 32. 2) Susruta classification of Nidra 42 Susruta described only three types of Nidra viz. Vaishnavi or Svabhaviki, Tamasiand Vaikariki Nidra. The detailed description is as follows. a) Vaishnavi or Svabhaviki Nidra: Svabhaviki Nidra is caused due to the Maaya or illusionary effect attached to the power of Vishnu Maaya. Here, Maaya is a desire of the Manasa to get detached from the worldly sensory objects on account of the tiredness of Manasa; and the seat of Manasa and the Sleshma and Tamas cover Atman. This mostly happens in the night and individual gets sleep. The Tamoguna dominant persons may go to sleep at any time i.e. day or night. But a person having Rajoguna in excess may get sleep sometimes in the day or in the night, because of Chalatva of Rajasa. The person having qualities dominated by Satva Guna sleeps at the midnight, because, at this time Tamas is excess and Satva will be decreased (Dalhana). The term Papma has been used to describe the Tamobhava of Nidra and also to mention the sinful activities. b) Tamasi Nidra: It is the lack of consciousness preceding the death. Tama dominant Kapha induces this due to the blockage of Sanjnavaha Srotasa, and this Nidra cannot awaken individual. c) Vaikariki Nidra: This is a condition of insufficient sleep due to the decrease of Kapha and increase of Vata and also due to mental and physical pain, distress etc. the Management of Anidra with Nidra caps – Literary Review 22
  33. 33. 2,3 person doesn’t enjoy the sufficient and sound sleep in quantity and quality . Disturbed sleep is also a type or Vaikarika Nidra.3) Vagbhata classification of Nidra 43 Astanga Sangraha Vagbhata followed the Charaka’s view with a slight change inthe names. He also mentioned seven types. The commentator Indu opined that the Tamobhvais Antya i.e. comes at the time of death and Agantuka means Shastra Praharadina (due toinjury) and considered these are due to Vyadhis. 44 Astanga Hridaya Vagbhata considered only four types of Nidra and included theall seven types in this viz. Akala sevitha, Ati prasangath sevitha, Nacha sevitha andNishevitha. The commentator Hemadri considered them as – The properly taken sleep bringshappiness, nourishment, strength, virility, knowledge and life to the individual. Theimproperly taken other three types may kill the individual like the Kalaratri, who killed alldemons. Instead of above seven fold classification we can make three types of classifications interms of Tamas. As we seen that sleep is due to manodosha Tamas, but here Tamas means not 45alone, the other manasika doshas are there i.e. according to Charaka vimansthana Doshaanubhandhya anubhandha concept the Nidra can be made into mainly three types. Tamasika nidra Rajayukta tamasika nidra Satvayukta tamasika Nidra 46 According to Susruta another sets of Nidra viz. Tamasika Nidra is sleeps both day & night, Rajayukta tamasika Nidra get sleeps either in the day or night and Satvayukta tamasika nidra sleep at midnight. Management of Anidra with Nidra caps – Literary Review 23
  34. 34. Sleep and immunity There is much evidence to support the theory that sleep is a period of growth andanabolic activity but little about the role of sleep in recovery from illness. Excessive sleep,sleepiness fatigue and fever are symptoms of nearly all infections diseases and chronicinflammatory disorders. Fever probably protects during illness, but the effects of sleep are more difficult to measure. Many processes could contribute to the link be in sleep and immune response. Forexample the circadian release of melanotonin during the night is thought to counteract theimmuno-suppression association with glucocentricoids, melatonin is known to regulate boththe release of uptokines and cell mediated immunity. Several molecules play a part in the regulation of sleep and immune processesmuranyl peptides that are produced by macrophages from phagocytosed bacterial cell wallsand certain viral products also increase the length of sleep and the production of modifiers ofthe immune response, one class of that is called cytokines. Cytokines are concerned with theamplification, coordination and regulation of the immune response. Specific ccytokinesknown to effect sleep include interleukin L-alpha, interleukin l-beta, tunor necrasis factor andinterferon – alpha. Though the studies regarding the close association between sleep and immuneregulation are carried out, further elucidation is required to prove this any how rest is part ofthe host’s defense against infection 47.Nidra as Rasayana In Shakespeare’s words the sleep is - indeed a positive thing, a reactive process, awinding up of the vital clock, a recharging of life’s battery and “Chief nourisher at life’s Management of Anidra with Nidra caps – Literary Review 24
  35. 35. feast”. Rasayana 48 (Achara) gives rise regularized sound sleep and vice versa the regularizedsleep patterns induce Rasayana effect. Health is a first muse and sleep is the condition toproduce it. The goal of the Ayurvedic approach is to create more potent individuals throughincreased Ojas (immunity), which is the finest end product of digestion & metabolism thatprovides energy, enthusiasm, happiness, clarity of thinking, better coordination between the 49body and mind . Only the sound most restful (stage IV) sleep generates Ojas. A soundquality sleep provides ultimate rest to the mind and senses, with enhanced capacities ofmental and physical work ability for the next day. On the other hand, lack of sleep vitiates &initiates Vata, Ama (endo toxins), etc in the body.Total Body Restoration: The hypothesis is that sleep is a process by which the whole body may be restored.This theory is based on an accumulation of evidences. The consumption of oxygen is lowestduring slow wave sleep. Though the process of catabolism and anabolism are continuous, therelative rates vary according to whether the subject is awake or asleep, and it has been shownthat the rate of anabolism is at its peak during sleep. Growth hormone is released mainly at night, also in association with slow wave sleepand also treatment of short stature by growth hormone is more effective if given at night.Further more, cell mitosis is at a peak during sleep 50. It has been postulated that slow wave sleep being more important for macromolecularsynthesis and REM sleep for removing the synthetic products of slow wave sleep to maintainsynaptic connections which is necessary to maintain cognitive function (ABC of SleepDisorders) 51. Management of Anidra with Nidra caps – Literary Review 25
  36. 36. Brain Restoration: 52 Some research workers have postulated that it is the brain not the body thatrecuperates during sleep and that sleep counteracts the effects of the metabolism of the brainduring the day. They also claim that the exercise included increases in slow wave sleep can beexplained by an increase in brain temperature and metabolism and alter sleep deprivation it ispsychological rather than physiological deficits that are most apparent. This emphasizes thatrestorative function is central rather than general. No one hypothesis completely explains the complexities and vagaries of sleep, buttaken together may form the foundation of the explanation for the indisputable need for sleep.Nidra and prakriti Individuals vary sleep with the prakriti i.e. personality and vayah (age factor). Thesleep requirement differs with relation to either psychological or somatic personalities. Thesleep according to prakriti is classified into two groups’ - a) According to Deha prakriti and b) According to manasa prakriti.a) Nidra - Deha prakriti The sleep is produced by tamoguna and sleshma so according to the prakriti of aperson the quality and quantity of sleep varies. An individual of Kapha prakriti gets moresleep which is sound also, while a person of Vata prakriti gets less sleep is related to the ageor vayah. In balyavastha, Kapha is predominant, so child sleeps more time than the youth. Invriddhavastha, Vata is predominant, so the old aged gets very less sleep. Apart from the dehaprakriti some naturally get less sleep 53. Management of Anidra with Nidra caps – Literary Review 26
  37. 37. b) Nidra - Manasa prakriti: 54 Susruta described only three types of Nidra viz. Vaishnavi or Svabhaviki, Tamasiand Vaikariki Nidra.1) Svabhaviki Nidra: Svabhaviki Nidra is caused due to the Maaya or illusionary effect attached to thepower of Vishnu Maaya. Here, Maaya is a desire of the Manasa to get detached from theworldly sensory objects on account of the tiredness of Manasa; and the seat of Manasa and theSleshma and Tamas cover Atman. This mostly happens in the night and individual gets sleep.The Tamoguna dominant persons may go to sleep at any time i.e. day or night. But a personhaving Rajoguna in excess may get sleep sometimes in the day or in the night, because ofChalatva of Rajasa. The person having qualities dominated by Satva Guna sleeps at themidnight. Because, at this time Tamas is excess and Satva will be decreased (Dalhana) The term Papma has been used to describe the Tamobhava of Nidra and also tomention the sinful activities.2) Tamasi Nidra: It is the lack of consciousness preceding the death. Tama dominant Kapha induces thisdue to the blockage of Sanjnavaha Srotasa, and this Nidra cannot awaken individual.3) Vaikariki Nidra: This is a condition of insufficient sleep due to the decrease of Kapha and increase ofVayu and also due to mental and physical pain, distress etc. the person doesn’t enjoy the 2,3sufficient and sound sleep in quantity and quality . Disturbed sleep is also a type orVaikarika Nidra. Management of Anidra with Nidra caps – Literary Review 27
  38. 38. Nidra and kala 55 Manu the great law maker has described the divisions of time, and then hasremarked that the thirty muhurta period (24hours) is divided by the sun into day and night, theday being intended for the activities and the night designed for the rest and repose. Naturally the night is described as a proper time for sleep. The person should notawake at night and should not sleep in day time because both are Dosha prakopaka. It isadvised to take sleep avoiding at the first and last parts of night. As the sleep is one among 56five varjyas of sandhya kala, if taken the person becomes needy or sparse . As it is wellknown concept that early morning awakjening is good for health and also to get Bramhajnana.Relationship between the Nidra and Dosha – Dhatu – Malas By the previous descriptions regarding sleep it is very clear that sleep is havingimportant role in the maintenance of equilibrium of body. As Nidra is said to be Kaphadominant process, it also maintains the equilibrium between three humors. In Ayurvedicclassics, it is mentioned that in the kaphaja vikaras, Nidra and tandra are commonly seen andin vataja vikaras sleeplessness occurs and in pittaja vikaras lack of sleep is one of thesymptoms 57. 58 The equilibrium of the dhatus also depends upon the sleep. Charaka and Susruta59have stated that by means of proper sleep the dhatusamya, the nourishment of the body, theincrease of strength and the stability of life are achieved. When the decrease of Rasa Dhatuoccurs, the sleep is diminished and the dhatus get proper nourishment again only when theproper sleep is enjoyed. By the proper sleep the digestion power is properly mentioned andthe Agni functions remain normal. The evacuation of the bowel and the emptying of theurinary bladder take place properly, if a person has slept well. Management of Anidra with Nidra caps – Literary Review 28
  39. 39. The bad habits of waking at night and sleeping at day time have been stated toprovoke all the three doshas.Karma of Nidra at different dhatu level • Rasa – pushti and varnaprada • Rakta –varna, agnidipti • Mamsa –pushti and bala • Meda –attractiveness (shriman) • Asthi –bala • Majja –varna, utsaha • Ojas –jivana • Manasa – gyana, and sukhaSTAGES OF SLEEP During each night, a person goes through stages of two types of sleep that alternatewith each other. The EEG (Electro encephalogram), EOG (Electro occulogram), EMG(Electro myogram) can be conveniently record during the sleep by fixing small silverelectrodes to the scalp and to the face before the subject goes to sleep. EOG reveals theeyeball movements while EMG indicates the tension of the muscles. Based on these recordstwo kinds of sleep classified are - 1) Non Rapid Eye Movement Sleep (NREM) 2) Rapid Eye Movement Sleep (REM)NREM Sleep: In NREM type of sleep the brain waves are very slow, so it is also called slow-wavesleep. This sleep is exceedingly restful and is associated with decrease in peripheral vasculartone and many other vegetative functions of the body. Management of Anidra with Nidra caps – Literary Review 29
  40. 40. Characteristics of NREM Sleep: Most sleep during each night is of slow-wave variety and it is deep, restful type ofsleep. NREM sleep is composed of four stages. (75 percent in young) Table – 1 Stages of sleep in the NREM Stage I Stage II Stage III Stage IV 5% 45% 12% 13% NREM sleep is a peaceful state relative to waking. Because the decrease of pulse rate, respiratory rate, blood pressure, basal metabolic rate is seen in this state. The deepest portion of NREM sleep (stage III & IV) is sometimes associated with unusual arousal characteristics. The organization during arousal during stage III or IV may result in specific problems including enuresis, somnambulism and stage IV nightmares or night terrors. NREM sleep is frequently called ‘dreamless sleep’, but dreams do occur during it. These dreams are not usually remembered whereas those of REM sleep are likely to be remembered 60.REM sleep (Paradoxical Sleep, Desynchronized Sleep): 61 REM sleep is a qualitatively different kind of sleep characterized by a high level ofbrain activity and physiological activity levels similar to those in wakefulness. In a normalnight of sleep, bouts of REM sleep lasting 5 to 30 minutes usually appear on the averageevery 90 minutes, the first such period occurring 80 to 100 minutes after the person fallsasleep. When the person is extremely sleepy, the duration of each bout of REM sleep is shortand even may be absent. Management of Anidra with Nidra caps – Literary Review 30
  41. 41. Characteristics of REM Sleep It is usually associated with active dreaming. The person is even more difficult to arouse by sensory stimuli than during deep slow- wave sleep and yet people usually awaken in the morning during an episode of REM sleep, not from slow-wave sleep. The muscle tone throughout the body is exceedingly depressed, indicating strong inhibition of the spinal projections from the excitatory areas of the brain stem. Probably the most distinctive feature of REM sleep is dreaming. The heart rate and the respiratory rate usually become irregular, which is characteristic of the dream state. Despite the extreme inhibition of peripheral muscles, a few irregular muscle movements occur. These include, in particular, rapid movements of the eyes. The brain is highly active in REM sleep and the overall brain metabolism may be increased as much as 20%. This type of sleep is also called paradoxical sleep because it is a paradox that a person can still be asleep despite marked activity in the brain. However, the brain activity is not channeled in the proper direction for people to be fully aware of their surroundings and therefore to be awake.EEG Changes in Different Stages of Wakefulness & Sleep: Alert wakefulness is characterized by high frequency β waves, whereas quietwakefulness is usually associated with α waves. Slow-wave sleep is divided into four stages.In the first stage of slow-wave sleep, the voltage of the EEG waves becomes very low; this isbroken by “sleep spindles”, that is, short spindle-shaped bursts of α waves that occurperiodically. In stages II, III and IV of slow-wave sleep, the frequency of the EEG becomes Management of Anidra with Nidra caps – Literary Review 31
  42. 42. progressive slower until it reaches a frequency of only 1 to 3 waves per second in stage IV,these are typical δ waves 62. It is often difficult to a difference between REM sleep brain wave pattern and that ofalert awake person. The waves are irregular high frequency β waves which are suggestive ofexcess but desynchronized nervous activity as found in the awaken state. Therefore, REMsleep is frequently called desynchronized sleep.PHYSIOLOGY OF SLEEP When Manas is exhausted then sleep occurs this phenomenon can be understood inthis manner. According to Howell, sleep is due to cerebral ischaemia. Cerebral cortex is theseat of higher centers like pre and post central gyrus, association area etc., which have thecorrelation with mental activities described in Ayurveda. So due to the reduction in cerebralblood supply Manas becomes Klanta that causes sleep 63-64. Further, during sleep, Indriyas (both Jnanendriya and Karmendriya) become inactiveby the detachment from their sense organs or from their work. Kleitman explains that due toreduction of muscle tone and discharge of less afferent impulses, the cerebral cortex remainsinactive. This can be interpreted in the terms of ‘Guru’ and ‘Varanaka’ properties (accordingto Sankhya theory) of Tamas. Fatigue of the muscles with consequent reduction oftransmission of afferent impulses to the cerebral cortex and thereby keeping it inactive seemsto be a possible factor in the production of sleep 65-66.HOW SLEEP IS REGULATED During wakefulness, the brain is kept in an alert state by the interactions of two majorsystems of nerve cells, in the upper part of the pons and in the midbrain, which makesacetylcholine as their neurotransmitter, sends inputs to the thalamus, to activate it. It in turn Management of Anidra with Nidra caps – Literary Review 32
  43. 43. activates the cerebral cortex, and produces a waking EEG pattern. However, during REMsleep the cholinergic nerve cells and the thalamus and the cortex are in a condition similar towakefulness but the brain is in REM sleep. The difference is supplied by three sets of nervecells in the upper part of the brain stem: nerve cells that contain the neurotransmitter a)norepinephrine b) serotonin and c) histamine. These monoamine neurons fire most rapidlyduring wakefulness, but they slow down during slow wave sleep, and they stop during REMsleep. The brain stem cell groups that control arousal are in turn regulated by two groups ofnerve cells in the hypothalamus. One group of nerve cells, in the ventrolateral preopticnucleus, contains inhibitory NT (neurotransmitter), galanin and GABA. When theventerolateral pre-optic neurons fire, they are thought to turn off the arousal system, causingsleep, damage to the ventrolateral preoptic nucleus produces irreversible insomnia (Anidra). Asecond group in the lateral hypothalamus acts as an activating switch. They contain the NTorexin and dynorphin, which provide an excitatory signal to the arousal system, particularly tothe monoamine neurons. Recent studies show that in humans with narcolepsy, the orexinlevels in the brain and spinal fluids are abnormally low. Two main signals control thiscircuitry. First, there is homeostasis. There is an intrinsic need for a certain amount of sleepeach day. Some people think that a chemical called adenosine may accumulate in the brainduring prolonged wakefulness, and that it may drive sleep homeostasis. The other majorinfluence on sleep cycle is the body’s circadian clock, the suprachiasmatic nucleus. Thesenerve cells in the hypothalamus contain clock genes, which go through a biochemical cycle ofalmost exactly 24 hours, sleep, hormones and other bodily functions. The suprachiasmatic Management of Anidra with Nidra caps – Literary Review 33
  44. 44. nucleus provides a signal to the ventrolateral preoptic nucleus and probably the orexinneurons 67.The Depth of Sleep: The depth of sleep is not constant throughout the sleeping period, but varies from hourto hour. Experiments upon man in which auditory stimuli were employed to arouse the subjectat different time or in the movements of the sleeper were recorded indicate that the depth ofsleep follows a characteristic curve. In most adults sleep deepens rapidly to the end of the firsthour, after which it lessens sharply for a time, and then more slowly till the time of waking.Generally, sleep taken during the daytime is lighter than that during the night. Deep sleep isdreamless, dreams occur only during light sleep and chiefly in the period, which just precedewaking. In sleep, unconsciousness is not uniform for all senses; the depth of sleep is greatestfor the sensations of smell and least for those of pain, hearing and touch. The sleeprequirement of different persons varies widely; it also alters with age. The following areaverage figures for the hours of sleep required at different periods of life: • Newborn (infant) 18 – 20 hours • Growing children 12 – 24 hours • Adults 7 – 9 hours • Aged (old) persons 5 – 7 hoursPhysiological Changes Accompanying Sleep: 68 During sleep most bodily functions are reduced their basal levels. The blood pressure is lower, the systolic pressure showing a decline of from 10 to 30 mmHg. If the sleep is disturbed by exciting dreams the blood pressure might be elevated well about the normal waking level. Management of Anidra with Nidra caps – Literary Review 34
  45. 45. The pulse rate is slowed by from10 to 30 beats. The metabolic rate is reduced by from 10 to 15% below the basal level and the rectal temperature by a fraction of a degree Fahrenheit. The heat regulating mechanisms are depressed. The respirations are slowed as a rule they also tend to become irregular or periodic. Muscle tone is minimal, the knee jerk is abolished and a positive Bebinski may be present. The thresholds for most somatic reflexes are definitely raised. Vasomotor reflexes, however, are more active. The pupils are usually constricted, the light reflect is retained. The eyeballs are turned upwards and outwards. Urine volume is reduced and the specific gravity is raised. The secretion of sweat gland is considerably increased. Gastric secretion is increased or little altered during sleep. Lacrimal and salivary secretions are reduced.PHYSIOLOGICAL EFFECTS OF SLEEP Charaka explains that in the night, the Hridaya (heart) gets contracted and the Srotasa(the channels of circulation) as well as the Koshtha (the gastro-intestinal tract) are contracted,the body elements get softened 69. According to modern view, sleep causes two major types of physiological effects. 1) Effects on the Nervous System itself. 2) Effects on the other structures of the body Management of Anidra with Nidra caps – Literary Review 35
  46. 46. The first one seems more important because lack of sleep wakefulness cycle in thenervous system at any point below the brain cause neither harms to the body organs nor anyderanged function. On the other hand, lack of sleep certainly does affect the functions of the centralnervous system. Prolonged wakefulness is often associated with progressive malfunction ofthe mind and sometimes even causes abnormal behavioral activities of the nervous system.So, in the absence of any definitely demonstrated functional value of sleep, we mightpostulate that the principle value of sleep is to restore the natural balance among the neuronalcenters 70. Sleep does have moderate physiological effects on the peripheral body. For instance,during wakefulness, there is enhanced sympathetic activity and hence increases the muscletone. Conversely, during slow-wave sleep, sympathetic activity decreases whileparasympathetic activity increases. Therefore, a ‘restful’ sleep ensues – fall in blood pressure,respiratory rate and pulse rate, and skin vessels dilate, activity of GIT sometimes increases,muscles fall into a mainly relaxed state, and the overall basal metabolic rate of the body fallsby 10 to 30 percent.FUNCTIONS OF SLEEP – 71-72 Sleep at the nighttime makes for the balance of the body constituents (Dhatusamya),alertness, good vision, and good complexion and fired digestive power. Susruta described that, those who takes proper sleep in proper time will not sufferfrom disease, the mind of them will be peaceful, they gain strength and good complexion,good virility, their body will be attractive, they won’t be lean or fatty and they live goodhundred years 73. Management of Anidra with Nidra caps – Literary Review 36
  47. 47. Despite the wealth of information that is accumulating about the biochemistry andphysiology of sleep, its precise nature and functions are not exactly known to the modernphysiology. A number of theories have been proposed, which include the hypothesis thatsleep is needed; for consolidation of memory, for binocular vision, or as part ofthermoregulatory evolution, for conservation of energy. The most widely held theory aboutthe function of sleep is that its senses as a period of recuperation or restoration. There are twoways in which this hypothesis is interpreted; total body restoration and neurologicalrestoration.Disease review By going through the previous description, it is quite evident that Nidra is not only animportant but an essential phenomenon of life, which affects the body and mind equally in afavorable way when it is enjoyed in a rightful manner. Otherwise the inadequate Nidra(Anidra) leads to various problems like dukha, karshya, abala, klibata, ajnana at last leads todeath also 74. Charaka 75 explains Nidra and Nidranasha in context of ninditi purusha at sutra sthana 76.which is included in 80 nanatmaja Vata vikaras But has no explanation of management ateither in Chikitsa sthana or else where. 77 Susruta describes it under the chapter of garbha vyakarana shariram might be – ofNidra plays a role in nutrition and development of the body. He also describes vaikarika Nidra(sleep disorders) in the same chapter along with Chikitsa. Vruddha Vagbhata 78 of Astanga sangraha mentions Nidra and Nidra vikara along withChikitsa in viruddha annavijnaniya adhyaya and in Vagbhata 79 of Astanga hridaya dicuss thesame in annaraksha adhyaya, while affirming trayopastambha. Management of Anidra with Nidra caps – Literary Review 37
  48. 48. 80 Sarangadhara resolute the Anidra in vataja nanatmaj vikara, alpa Nidra in pittajananatmaja vikara and atinidra under kaphaja nanatmaja vikara.Deprivation of Anidra It is composed of two words ‘A’+’Nidra’. The suffix ‘A’ provides negative meaningto the act of Nidra 81. Anidra means less or no sleep. Ayurveda Vishwakosha part I 82 explainsAnidra as Nidranasha. In Ayurvedic texts the term ‘Anidra’ is used indicating a pathologicalcondition in which A+ is devoid of sleep.Synonyms of Anidra Table – 2 Synonyms of AnidraSno Synonyms CS SS AH AS YR MN HS BS DN RN1 Anidra + + + + + + + +2 Alpa Nidra + + +3 Aswapna + + + +4 Jagarana + + +5 Nidranasha + + + + + +6 Nidra vighata + +7 Nasta Nidra + + + + + +8 Nidra dourbalya +9 Nidra bhramsha +10 Nidra kshaya + +11 Nidra bhanga +12 Nidra vinasha +13 Nidra cheda +14 Nishi jagarana + +15 Nidra viparyaya +16 Prajagarana + + + +17 Veatanidra + + Management of Anidra with Nidra caps – Literary Review 38
  49. 49. Alpa Nidra: Alpa means small minute 83 which refers to reduction in sleep time.Jagarana: 84 85 Jagarana means awake or waking Nidra rahita, Nidra abhava which refers to theloss of sleep or no sleep.Nidra kshaya: Kshaya means harsa, adarshana, bhanga 86 so, this term refers to disturbances in sleepreduction in sleep time.Nidra bhanga; 87 The word bhanga means breaking splitting, dividing, this shows disturbances ofsleep.Nidra chheda: Chheda 88 means cutting off, a section, apiece which shows disturbances during sleep,Nidra bhramsha: 89 The term ‘bhramsha’ means to drop, fall down, cessation, loss which refers toreduction in sleep time.Vigata Nidra: 90 The term ‘vigata’ means gone, disappear, ceased which can be correlated with lossof sleep or reduction in sleep time.Nasta Nidra: 91 Nasta means lost, disappeared deprived which convey the meaning of loss of sleep.By seeing all these synonyms Nidranasha can be considered as difficulty in initiation of sleepreduction in sleep time and disturbances during sleep either one or more (icd-10) 92. Management of Anidra with Nidra caps – Literary Review 39
  50. 50. Nidana PanchakaNidana Charaka mentions the causes for Anidra as – eva eva cha vigneyo nidranashasyahetavaha 93 the factors are Atiyoga of vamana, Atiyoga of virechana, Atiyoga of nasyakarma,Atiyoga of rakta mokshana and Atiyoga of dhoomapana. Due to the excess use of thesefactors makes the Vata vitiation and Anidra is inducted. Ati vyayama, Ati upavasa andAsukha shayaa are the causatives of Vata vitiation, thus the Anidra is induced. Ati chinta, Ati krodha and Ati bhaya are the manasika karana leading to tama kshayaand rajo vruddi induces the Anidra. Along with these, some others Chikitsa procedures of Atinidra advised by Charaka canalso are considered as causative factors for Anidra, which are as follows. Satva audarya (increased satwa), Tamojayee (conqueror of tama), Karya (engaged inwork), Kala (old age), Vikara (disease), Prakriti (personalities such as Vata) and Vayu (VataDosha) are the causes of Anidra 94-95. Further Susruta has mentioned some extra Nidana factors which may cause Anidra;these factors are Vata vridhi, Pita vridhi, Manastapa, Kshaya and Abhighata 96. Bhavamishra considers atiyoga of nasya, upavasa, vyayama, chinta, dukha, bhaya,Kapha kshaya as the causative factors of Anidra /Nidranasha 97. Astanga sangraha Vagbhata mentions Nidana which may cause the Anidra are asfollows. Lobha, Harsha, Vyatha, Atimaithuna, Ati kshudha, Rukshanna sevana, Yavannasevana and Anjana are said to cause Anidra with their individualized qualities embedded 98. At consideration of all these Nidana factors, the sharirika doshas such as Vata, Pitta,and manasika Dosha raja are the principal causative factors for Anidra /Nidranasha. Management of Anidra with Nidra caps – Literary Review 40
  51. 51. Table – 3 Anidra Ahara NidanaAhara CS SS AS AH BS HS BPRookshanna - - + - - - -Yavaanna - - - - + - - Table – 4 Anidra Vihara NidanaVihara CS SS AS AH BS HS BPVyayama + - - + + - +Upavasa + - - + - + -Asukhasaiyya + - + - - - -Kshudha - - + - - - -Atimaithuna - - + - - - - Table -5 Chikitsa Atiyogajanya Nidana of AnidraChikitsa CS SS AS AH BS HS BPAtiyogajanyaVamana + - + + - - -Virechana + - + - + - -Nasya + - + - + - -Rakta mokshana + - + - - - -Dhoomapana + - + + + - -Sveda - - - + - - -Anjana - - - + - - -Langhana - - - + + - - Table -6 Anidra Manasika NidanaManasika CS SS AS AH BS HS BPBhaya + - - - - + +Chinta + - + + - + +Krodha + - - + - - +Manastapa - + - - - - -Shoka - - + + - - +Vyatha - - + - - - -Harsha - - + - - - -Lobha - - - - - + - Management of Anidra with Nidra caps – Literary Review 41
  52. 52. In addition to above discussed causative factors, Susruta has mentioned abhighata andkshaya as Nidana of Anidra 99.Purvarupa Purvarupa is not mentioned for Anidra in any Ayurvedic classics.Rupa In Ayurvedic classics some symptoms are mentioned due to holding up of sleepschedule. They are in the following table. Table – 7 Symptoms of AnidraRupa CS 100 SS 101 AH 102 AS 103Jrumbha + + + +Angamarda + + + +Tandra + + + +Shiroroga + - - -Shirogourava - + + +Akshigaurava + + - -Jadya - - + +Glani - - + +Bhrama - - + +Apakti - - + +Vataroga - - + + Charaka has described the symptoms are suppression of sleep; yawning, body ache,drowsiness, head disorders and heaviness in eyes are caused. Susruta has described followingsymptoms due to restraint of sleep. Yawning, body aches, stiffness in the body, head and eyesdrowsiness are the symptoms caused by restraint of sleep. Vagbhata has mentioned that due toAnidra – malaise, heaviness in head, yawning, laziness, languor, giddiness, indigestion, stuporand vatajanya rogas will be manifested. Management of Anidra with Nidra caps – Literary Review 42
  53. 53. Anidra Samprapti Anidra is not explained as a separate disease in Ayurveda, thus no where theSamprapti is available. Depending upon the Dosha, dushya involvement Anidra isemphasized. Anidra is mentioned as Vata vikara with pita vriddhi associated with some otherdisease states or symptoms which is common in aged people. Figure – 1 Schematic diagram of Anidra Samprapti Nidana Ahara , Vihara & Anya Manasika Vata Vruddhi (Chala, Rooksha & Laghu) Rajo Vruddhi (Chala, Rooksha & Laghu) Pitta Vruddhi (Ushna & Teekshna) Tama Kshaya (Snigdha, Guru & Manda) Kapha Kshaya (Snigdha, Guru & Manda) Leads to Leads to Tama Kapha kshaya kshaya kshaya Kapha & Tama avarana to the chetana Hrudaya / Sanjnavaha srotas Anidra At the description of Nidra it is mentioned that Kapha, Tamas, Hridaya and sanjavaha 104srotas are responsible for it . But yogic concept defines Nidra as - when Atma having Management of Anidra with Nidra caps – Literary Review 43
  54. 54. contact with manomaya kosha then susupti avastha (sleep) occurs. Consequently, when thereis any changes appear in this physiological process or path it causes the Anidra 105. Hence it isevidential that the Vata Pitta, raja, Hridaya and sanjnavaha srotas play an important role in theSamprapti of Anidra. Thus it is concluded that the vitiation of involved factors leads to thecondition of Anidra/ Nidranasha.Types of SampraptiSankhya: According to Ayurveda, Asvapna/ Anidra is of two types viz., either due toVataprakopa or Pittaprakopa 106.Vikalpa: In Anidra, mainly Vata Prakopa occurs and it’s Chala and Laghu Guna vitiates,which keeps the mind active, causing Anidra. Thus the Dosha amshamsha kalpana isessential.Pradhanya: In Pradhanya Samprapti of Anidra, the predominance of morbid humors aredescribed in terms of the comparative and superlative degrees. As Anidra is of VatajaNanatmaja Vyadhi, vitiation of Vata takes place, and Pitta dominance is not ruled out. Thusthe validation of the Dosha pradhanyata is essential.Bala: Bala of Anidra i.e. Vyadhi can be distinguished by the strength of manifestation ofsymptoms, severity, duration etc, which will help as a prognostic tool.Kala: Kala is an important factor, while considering Nidra as well Anidra. Charaka107mentioned the Nishi Kala cause Nidra naturally. Sleeping at day time is contra indicated. Notsleeping at night indicates that Kala interferences to cause the Anidra – thus the time factorhave an influential effect on Anidra / Nidra. Management of Anidra with Nidra caps – Literary Review 44
  55. 55. SAMPRAPTI GHATAKA Table - 8 Anidra – Samprapti ghatakaDosha Vata & Pitta (Vriddhi), Kapha (Kshaya)Dushya RasaSrotas Manovaha, RasavahaSrotodushti Prakara Atipravritti (Over indulgence)Adhisthana HridayaAgni JatharagnDosha: Dosha involvement in Anidra is said as Vata, Pitta and Kapha. But the deviation fromthe normalcy is to be considered with due importance. Vata and Pitta are in Vruddhi state,while in case of Kapha, the Kshaya is usually observed.Dushya: As the Anidra is a psycho-somatic condition, initially no dushya is involved. Laterin due course the Dhatu involvement occurs to give rise associated symptoms and conditionsof Anidra viz. Glani, Aruchi, Apakti etc, which are the symptoms of Annavaha srotas andRasa Dhatu, do has their role in Samprapti of Anidra, as they provide Tushti, Preenana for theentire body.Srotas: The role of Manovaha Srotasa is understood without any controversy in Anidra as themind psychologically and body physically takes rest voiding the external stimuli. In thiscontext, Rasavaha Srotas too have a pivotal role in the pathogenesis of Anidra. Seat ofManovaha and Rasavaha is Hridaya where the functions of different levels originate from thesame. Moreover, the etiological factors responsible for Rasa Dushti are said to be psychodisturbing, such as Chintyanam Chatichintanat, where the chetana and stawa are disturbed. Management of Anidra with Nidra caps – Literary Review 45
  56. 56. Srotodushti Prakara: Over indulgence of Manas is a common feature of Anidra, attributedto the Manovaha sroto Atipravritti. But the sanga of Rasavaha srotas can not be ruled out, asthe symptoms of Rasavaha sroto dusti is witnessed.Adhisthana: Hridaya is the abode for Rasa and Mana. It is the platform where the wholeSamprapti process is supposed to be observed. As earlier stated, Hridaya is the bed rock forMana and its role in Anidra is well defined.Agni: Here, vitiation of Jatharagni takes place, because proper Nidra is said to enhance theAgni 108. Apakti and Aruchi are the symptoms of Anidra, indicates the vitiation of Agni.UPADRAVA In Ashtanga Sangraha, it is mentioned that increased Vata is due to Anidra producesKapha kshaya. The decreased and dried Kapha sticks in Dhamanis walls and causeSrotorodha. This, results in so much exhaustion that eyes of the patient remain wide open andwatery secretion from eyes. This dangerous exhaustion is Sadhya up to three days thenbecomes Asadhya 109.Upashaya and Anupashaya As upashaya and anupashaya are not available in texts, they can be evolved. Mamsasevana, madya, ksheera and ksheera vikaras, abhyanga, utsadana, tarpana and sneha sevanaetc., can be considered as upashaya of Anidra, whereas rukshanna, yavanna, dhoomapana,krodha, shoka etc., can be considered as its anupashaya. Management of Anidra with Nidra caps – Literary Review 46
  57. 57. Chikitsa in general There is no specific line of treatment mentioned for Anidra in our texts. Dependingupon the Chikitsa mentioned is in different contexts, for Anidra can be broadly divided into 2types 1. Bahya Chikitsa 2. Abhyantara Chikitsa. Abhyantara Chikitsa can be again subdivided into (a) ahara pradhana Chikitsa (b) aushadha pradhana Chikitsa. Our acharyas have given more importance to bahya upacharas such as moordhni taila,abhyanga etc. and manasika upacharas such as manonukula vatavarana manonukula vishayagrahana etc., along with these therapeutic measures are also described along with somespecific aharas for patients of Anidra. All these therapeutic measures in the different contextsmay be classified into the following groups’ viz. Bahya upachara, Manasika upachara,Ausadha upachara and Ahara upachara. Table – 9 Bahya Upacharas for Nidranasha Bahya CS SS AH AS YR BP KS HS BS BR Upachara Abhyanga + + + + + + - - + - Utsadana + - - - - - - - - - Samvahana + + - + + + - - - + shitarpana + - + + - + - - - - Moordhni Taila + + - - - - - - - - Udvartana - + + + - + + - - - Shirobasti - - + + - - - - - - Shirastarpana - - + - - - - - - - Karnapoorana - - - + - - - - - - Padabhyanga - - - + + - - - - - Angamardhana - - - - - - - - - - Mardana - - - - - - - + - - Shirolepa + - - - - - - - - - Vadana lepa + - - - - - - - - - Management of Anidra with Nidra caps – Literary Review 47

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