E-ISSN:2456-3110

Case Report

Drug Induced

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 7 JULY
Publisherwww.maharshicharaka.in

Ayurvedic approach in Drug Induced Insomnia - A Case Study

Rahul H1*, Anna RJ2
DOI:10.21760/jaims.9.7.56

1* Rahul H, Assistant Professor, Department of Panchakarma, Vaidyaratnam Ayurveda College, Ollur, Kerala, India.

2 Rose Joju Anna, House Surgeon, Department of Panchakarma, Vaidyaratnam Ayurveda College, Ollur, Kerala, India.

Ayurveda is a life science which proclaims the importance of daily necessities like food, sleep, exercise for a healthy life. Sleep or Nidra is considered as one among the sub pillars of life (Thrayopasthamba). Nidranasa or Anidra is a state of sleeplessness which is an effect of increased Vatadosha. The potential cause of this sleeplessness can be anything like an adverse effect of certain drugs as in this case. In this case study, the patient was having a migraine headache and was under medication continuously for 120 days. After this he gradually developed sleeplessness and he was contracted to a person who was having a sleeping hours of two, even after taking sleeping pills. This shattered his physical as well as mental condition. Ayurvedic treatments planned for this was an integrated approach including internal medicine, external therapies and maintaining suitable environment for his condition. External therapies like Padabyanga, Shirodhara, Hapushadi Yapana Vasti gave a considerable relief. The Insomnia severity index score was 24 while admission and was reduced to 13 after treatments. Safe, effective, systematic approach without any adverse effects gave improvement in quality of life of the patient.

Keywords: Anidra, Padabyanga, Hapushadi Yapana Vasti, Insomnia, sleeplessness

Corresponding Author How to Cite this Article To Browse
Rahul H, Assistant Professor, Department of Panchakarma, Vaidyaratnam Ayurveda College, Ollur, Kerala, India.
Email: 		Rahul H, Anna RJ, Ayurvedic approach in Drug Induced Insomnia - A Case Study. J Ayu Int Med Sci. 2024;9(7):354-359.
Available From
https://jaims.in/jaims/article/view/3358

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-05-16 2024-05-25 2024-06-05 2024-06-15 2024-06-25
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 12.99

© 2024by Rahul H, Anna RJand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Ayurveda is a medical science which promotes health in all aspects like physical, mental and even spiritual. Ayurvedic principles are grounded upon the theories of Panchamahabhuta, Tridosha, Sapthadathu etc. Apart from this the concept of Thrayopasthamba[1] the three sub pillars of life are also significant. Nidra (Sleep) is one among the three sub pillars of life.

Proper and undisturbed sleep is irrefutably one of the most needed requirements for a healthy life. Aacharya Charaka describes that happiness, misery, nourishment, emaciation, strength, weakness, virility, sterility, knowledge, ignorance, life and death, everything is depending upon proper sleep.[2]

As per this Ayurveda, the sleep which occurs as a result of Rathri Swabhava (nature of night) is the best and is considered as Bhuthadathri. It nurses all the living beings and supports life as a nursing mother (Dathri) does.[3] But there are multiple factors which contribute to Anidra (sleeplessness). In Ayurveda all those factors yield to the aggravation of Vata Dosha which in turn obstruct sleep and induce sleeplessness.[4]

In a broad aspect we can contemplate that Anidra is a result of increased Vatadosha along with Pittadosha and a depreciation of Kaphadosha. Insomnia is also known as the Disorder of Initiation and/or Maintenance of Sleep (DIMS) which can be difficulty in initiating sleep, difficulty remaining asleep and non-restorative sleep.

Nowadays insomnia is very common, with nearly 15-30% of general population complaining of a period of insomnia per year and are necessarily requiring treatment.[5] Insomnia can be manifestation of diverse causes like physical or mental ailments, substance withdrawal, drug induced or cumulative effect of group of medicines etc.

Substance/medication-induced sleep disorder is a condition characterized by disturbances in sleep patterns or quality, resulting from the use or abuse of medications, illicit drugs, or alcohol. Legitimate use of tranquillisers is an indisputable option in treating insomnia but may experience deceleration in positive symptoms on withdrawal or may end up in adverse effects.

This case was unique by itself since the insomnia was due to an additive effect of certain drugs which were given for migraine headaches. Migraine is a recurrent neurovascular disorder involving several pathophysiological mechanisms.[6] The patho-physiology involved in these types of headaches are still under scrutiny. A wide range of medicines falling under assuaging the symptoms will be used on account of this. This situation may fall into various sleep problems as migraine prophylaxis and sleep is a complex which is interconnected with one another.

Felicitous Ayurvedic treatments of Anidra can be effective for insomnia and can give considerable relief. Even the eradication of the root cause of insomnia can be benefited from Ayurveda. The possible internal and external therapies to establish the equilibrium of increase in Vata-Pitta Dosha and decrease in Kapha Dosha can be adopted in cases of Anidra. Here the patient was addressed with various external and internal therapies like Padabyanga, Siroabyanga etc.

Patient Information

A 33-year-old male patient came to OPD with complaints of reduced sleep for 6 months. He was having a migraine headache and was usually present once a month. He took allopathic medications for this since his headache was affecting his day to day life. He took medications for 120 days continuously and the frequency of headache reduced. But he noticed a reduction in sleep after the intake of these medicines and began to take sleeping pills (sedative hypnotics and benzodiazepines). Even though he was hardly having 2 hours of sleep at night. He was neither having sleep during day time nor felt drowsy. His mental condition started to deteriorate thinking of his sleeplessness and he came to our OPD for its management. We got him admitted and started IPD management.

Clinical findings

Systemic examination

Respiratory, cardiovascular and central nervous system functions were under normal limits. Reflexes were normal.

Diagnostic Assessment

The diagnosis was done using proper history taking and using the assessment tool - Insomnia Severity Index.


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Insomnia is a prevalent health complaint that is often difficult to evaluate reliably. Insomnia Severity Index (ISI) is a brief screening measure of insomnia and is an outcome measure in treatment research[7]

Therapeutic Intervention

The major treatment principle which was adopted in this case was to mitigate Vata Dosha and the Rukshatha thus formed. Aacharyas have mentioned various treatment modalities and modification of diet which will help Anidra. It includes Abhyanga, Samvahana, Siro Lepa, intake of milk etc.

The treatment plan adopted was as follows:

Internal medicines

Table 1: Internal medicines

From 02.05.2024
Name of medicineDosageTime of administration
Chandanasavam30mLThrice daily, before food
Manasamitram Vatakam0-0-2, with milkAfter food
Shankupushpi Churna10g with hot milkAt night, after food

External therapies

Table 2: External therapies

Starting date of therapyProcedureMedicine usedNumber of days of the procedure
02.05.2024ThalamKachooradi Churna with Ksheerabala Taila32 days
02.05.2024PadabyangaDanwantharam Kuzhamb31 days
02.05.2024Udwarthanam followed by steam bathKolakulathadi Churna3 days
06.05.2024Abyanga followed by Dasamoola Ksheeradhara Ksheerabalataila7 days
13.05.2024SirodharaChandanadi Taila14 days
27.05.2024Matra VastiKsheerabala Taila1 day
27.05.2024Shashtika Pinda SwedaKsheerabala Taila7 days
27.05.2024SirobyangaChandanadi Taila7 days
28.05.2024Hapushadi Yapana VastiKsheerabala Taila and Kalyanaka Ghrita3 days

Follow-up and Outcomes

Patient was assessed based on insomnia severity index along with his sleeping hours. The initial stage of this condition started as gradual sleeplessness to a sleep of maximum 2 hours at night.

The patient was having no practice of day time sleep as well as he was having an active day time. The Insomnia Severity Index (ISI) is a 7-item self-report questionnaire assessing the nature, severity, and impact of insomnia. The usual recall period is the last month and the dimensions evaluated are: severity of sleep onset, sleep maintenance, and early morning awakening problems, sleep dissatisfaction, interference of sleep difficulties with daytime functioning, noticeability of sleep problems by others, and distress caused by the sleep difficulties. A 5-point Likert scale is used to rate each item (from 0 to 4).[8]

After the treatment, the ISI score was reduced to 13 from a score of 24.

Table 3: Insomnia severity index scoring

Criteria04.05.’2427.05.’2402.06.’24
The current (i.e., last 2 weeks) severity of insomnia problem(s)
1.  Difficulty falling asleep:
2.  Difficulty staying asleep:
3.  Problem waking up too early.		4
1
4		3
0
3		3
0
2
How satisfied/dissatisfied with the current sleep pattern?422
To what extent the sleep problem interferes with daily functioning (e.g. daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.)422
How noticeable to others the sleeping problem is in terms of impairing the quality of life?322
How much worried/distressed about the current sleep problem?432
Total241513
InterpretationClinical insomnia
(Severe)		Clinical insomnia
(Moderate Severity)		Sub threshold insomnia

While analysing the Insomnia severity index score, more than 40 percentage response is observed which can be considered as moderate response in clinical terms. The sleeping hours was assessed on a daily basis. The treatment was starting with a sleeping hour of 2 and it became 4 hours gradually while Dasamoolaksheeradhara along with internal medicines. After Shirodhara along with internal medicines 1 hour augmentation in sleep was observed and the patient felt relieved from the anxiousness due to sleeplessness.


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Discussion

Ayurveda deemed sleeplessness as Anidra which is primarily a Vatadoshakopavikara hand in hand with the vitiation of other two Doshas. The Rukshata attributed by Vatadosha can be the potential cause resulting in Anidra. Along with that a change in the Shariraprakriti due to the involvement of certain drugs may add to cause an adverse impact.

Here, the patient was having migraine and was under medication continuously for about 120 days. The accumulation of undesirable compounds in the body created a reno - hepatic toxicity and resulted in insomnia and was not making headway even after the intake of sedative hypnotics as well as benzodiazepines. Insomnia was acting predatorily on the mental health of the patient and hence was in a necessity to have some reassurance.

The main objective of the therapy was to improve the duration of sleep and re-establish the psychological state of the patient from the dilemmas he had because of this insomnia. Later, preserving this situation even after tapering the medicines and therapies was the extended intention. Apart from this preserving an environment suitable for his condition, both in mental and physical terms, was a need of the hour. For fulfilling this, he was allotted with a comparatively silent and sufficiently darker area during the IPD treatment. A yoga therapy mainly focusing on relaxation was a choice along with.

The internal medicines preferred was Chandanasavam,[9] Manasamitram Vatakam[10] and Shankupushpi Churna[11] three of them which has beneficial implications on higher centres. Chandanasavam through the potency of drugs in it can relieve the excess body heat generating and is Hridya, which can be interpreted as pleasing, soothening other than being a cardio tonic. Manasamithram Vatakam was administered in a view that it can reduce Manodosha in other terms factors affecting the mind to generate adverse impacts. It is also Medhya which clearly stating it has action on higher centres. Shankupushpi Churna was the third medicine which is a Medhya Rasayana as per Aacharya Charaka. Apart from this various studies have been done to establish the wide spectrum of actions of Shankupushpi Churna. It is said that it can activate the sleep inducing areas of the brain, namely, preoptic nucleus.[12]

Such sedative activity is directly linked to the presence of phytoconstituents like convolamine and scopoletin which act similarly to GABA-A agonists, thereby bringing about the effects of sedation.[13] Both Manasamithram Vatakam and Shankupushpi Churna was taken in milk since the treatment principles of Anidra includes intake of milk as a sleep promotor.

The external therapies were ushered with a Rukshana therapy and extended in such a way that the patient will be receiving Brimhana therapy as well as Shodhana therapy to remove the existing adverse reactions happening in the body. Owing to this, the therapy is started with Udwarthana and then Dasamoolaksheeradhara as a preparatory phase of therapy.

Udwarthana which is helpful in Pachana of possible Amadosha was administered with Kolakulathadi churna. Kolakulathadi Churna[14] is specifically indicated for pacifing Vatadosha. After which Dasamoolaksheeradhara[15] which is primarily a Vata – Pittahara modality is made use to bring down the Rukshata and body temperature. Ksheerabala Taila[16] used for Abyanga prior to Dasamoolaksheeradhara serves the same Pittahara function and the effect was evident since there was increase in sleeping hours gradually and stress was seemed to be reduced. The therapeutic effect may be due to the diffusion of Ksheera through the fine pores.[17]

The major treatment that was planned to give was Sirodhara.[18] A drastic alteration and sustenance in sleep pattern was observed after doing Shirodhara which was one among the Murdha Taila.[18]

Murdha Taila is the process of applying oil on to the Moordha (head) in different modes and is of 4 types namely, Siroabyanga, Sirasekam, Siropichu and Sirovasti. Siraseka or Sirodhara is a continuous oil dripping therapy which is basically a Pittahara Chikitsa. It mainly addresses Sirasthoda, Daha etc and has special indications to reduce stress, anxiety, and insomnia and to relax

the nervous system.[19] By choosing Chandanadi Taila[20] which is prepared from predominantly Sita Dravyas act in adherence with that of Shirodhara through its Pittahara property. Sirodhara was switched to Siroabyanga[21] after yielding a persistent sleep duration of 5 hours.


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Dhara in any way tends to normalize the entire body and achieve a decreased activity of Sympathetic nervous system with lowering of brain cortisone and adrenaline level, synchronising the mind and spirit and this continues even after the relaxation. Lying in supine position also helps in relaxation.[17]

The next phase of treatment was in such a way to reinforce the accomplished state and to efface the abiding adversities from the body. The attempts of doing Shastika Pinda Sweda were to sustain the normalised Doshavastha and psychological state. Shashtika Pinda Sweda is considered as a nourishing therapy and was done with an Abyanga using Ksheerabala Taila.

Hapushadi Yapana Vasti[22] was done succedent to Shastika Pinda Sweda after a Matra Vasti with Ksheerabala Taila. This was in an intention to achieve removal of residues, and to have simultaneous action on higher centres. Hapushadi Yapana Vasti is having a cognent effect on Budhi and Medha. It also ameliorates Jatharagni and Bala. Opting Tiktaka Ghrita[23] in addition to Ksheerabala Taila as Sneha Dravya in Hapushadi Yapana Vasti, was in an objective to have explicit action in higher centres in addition to Pittaharatwa properties.

Concurrently with all these treatments, Padabyanga[24] was a quotidian procedure done at night with Dhanwantaram Kuzhamp[25] since it has the capability to stabilize Vatadosha. Padabyanga is done in a systematic manner by incorporating 12 steps which ensures a soothing massage over all the planes of the foot. Probable action of Padabyanga is estimated as it can normalise the two important neurotransmitters Serotonin and Norepinephrine, which regulates a wide variety of Neuropsychological process along with sleep. Thus, it induces relaxation and natural sleep.[26]

Conclusion

Sleep is one of the most important daily needs of a man to keep his life rhythm. For conservation of energy sleep is a must in one's life. While a person experiences sleeplessness, many changes from normal rhythm can be observed in mental and physical aspects. As per Ayurveda, this changes in equilibrium will result in the disharmony of Tridosha status. To reestablish this multiple efforts will be required. Internal medicines along with external therapies will be required.

Creating an environment suitable for patient's condition is also a necessity. Ayurveda has wide range of therapies which includes Brimhana, Shodana etc which will help in Anidra or Insomnia. The modalities taken in this case was safe, effective and readily available. Through a sustained and systematic approach, the quality of life of patient was improved.

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