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Apasmara Nidana (view source)

Revision as of 12:42, 23 September 2021

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For example, elevated temperature in ''jwara'' can cause ''raktapitta'' and ''raktapitta'' can cause ''jwara''. Both the diseases (i.e ''jwara'' and ''raktapitta'') may lead to ''shosha'' (depletion of ''~~dhatus~~''). [17]

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For example, elevated temperature in ''[[jwara]]'' can cause ''raktapitta'' and ''raktapitta'' can cause ''[[jwara]]''. Both the diseases (i.e ''[[jwara]]'' and ''raktapitta'') may lead to ''shosha'' (depletion of ''[[dhatu]]s''). [17]

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''Pratishyaya'' (rhinitis) leads to ''kasa'' (cough) which further leads to ''kshaya'' (depletion of ''dhatu''), consequently resulting in ''sosha'' (emaciation). [19]

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''Pratishyaya'' (rhinitis) leads to ''kasa'' (cough) which further leads to ''kshaya'' (depletion of ''[[dhatu]]''), consequently resulting in ''sosha'' (emaciation). [19]

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It is seen that a single causative factor, ruksha (dry) can cause many diseases such as ''jwara'' (fever), ''bhrama'' (vertigo) and ''pralapa'' (delirium) etc., while the same single factor (''ruksha'') may cause just one disease (''jwara'') [25]

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It is seen that a single causative factor, ruksha (dry) can cause many diseases such as ''[[jwara]]'' (fever), ''bhrama'' (vertigo) and ''pralapa'' (delirium) etc., while the same single factor (''ruksha'') may cause just one disease (''[[jwara]]'') [25]

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''Jwara'' alone may be caused by a combination of several causative factors including but not limited to ''ruksha''(dry) etc. and many causes like, ''ruksha'' (dry, rough) etc. may lead to several diseases. [26]

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''[[Jwara]]'' alone may be caused by a combination of several causative factors including but not limited to ''ruksha''(dry) etc. and many causes like, ''ruksha'' (dry, rough) etc. may lead to several diseases. [26]

==== Diagnostic aspect of symptoms ====

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One symptom i.e. ''jwara'' can be considered common to many diseases that have irregular onset, while ''santapa'' (elevated temperature) is considered a symptom of only one disease i.e. ''jwara''.[28]

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One symptom i.e. ''[[jwara]]'' can be considered common to many diseases that have irregular onset, while ''santapa'' (elevated temperature) is considered a symptom of only one disease i.e. ''[[jwara]]''.[28]

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Irregular onset (and similar other symptoms) appear in the case of ''jwara'', while similar symptoms also occur in ''shwasa'' (dyspnea), ''hikka'' (hiccups), and other similar diseases. [29]

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Irregular onset (and similar other symptoms) appear in the case of ''[[jwara]]'', while similar symptoms also occur in ''shwasa'' (dyspnea), ''hikka'' (hiccups), and other similar diseases. [29]

==== Therapeutic considerations ====

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The diseases originating from ''amashaya'' are cured by ''langhana'' (fasting), only whereas only a single disease entity ''jwara'' also can be treated by the single therapy of ''langhana'' (fasting). [31]

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The diseases originating from ''amashaya'' are cured by ''[[langhana]]'' (fasting), only whereas only a single disease entity ''[[jwara]]'' also can be treated by the single therapy of ''[[langhana]]'' (fasting). [31]

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For treating a single disease like ''jwara'', multiple therapies like light diet, etc. are needed and the same multiple therapies like light diet etc. are needed to subside many diseases like ''jwara''(fever), ''shwasa''(dyspnea), ''hikka''(hiccups) etc. [32]

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For treating a single disease like ''[[jwara]]'', multiple therapies like light diet, etc. are needed and the same multiple therapies like light diet etc. are needed to subside many diseases like ''[[jwara]]''(fever), ''shwasa''(dyspnea), ''hikka''(hiccups) etc. [32]

==== Prognostic aspect in therapy ====

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Generally, ''~~doshas~~'' that are spread over obliquely (in the transverse direction) afflict the patient for a longer time. In that condition, treatment should not be initiated in a hurry without proper assessment of body strength and digestive power.

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Generally, ''[[dosha]]s'' that are spread over obliquely (in the transverse direction) afflict the patient for a longer time. In that condition, treatment should not be initiated in a hurry without proper assessment of body strength and digestive power.

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These ''~~doshas~~'' should be alleviated first by treatment, or they should be carefully be drawn to the ''koshtha'' (bowel). After knowing their status in ''koshtha'', the wise physician should eliminate them through the nearest route. [38-39]

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These ''[[dosha]]s'' should be alleviated first by treatment, or they should be carefully be drawn to the ''koshtha'' (bowel). After knowing their status in ''koshtha'', the wise physician should eliminate them through the nearest route. [38-39]

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To sum up this chapter, etiological factors, premonitory symptoms, signs and symptoms, therapeutic relief, pathogenesis, historical origins and brief line of treatment of apasmara have been described in this section. Since this is the concluding chapter of the [[Nidana Sthana]], a summary to the entire section has also been provided here, stating that starting from ''jwara'' all eight diseases have been dealt with separately in eight chapters, each with etiological factors, symptomatology, prognosis and brief line of management.

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To sum up this chapter, etiological factors, premonitory symptoms, signs and symptoms, therapeutic relief, pathogenesis, historical origins and brief line of treatment of apasmara have been described in this section. Since this is the concluding chapter of the [[Nidana Sthana]], a summary to the entire section has also been provided here, stating that starting from ''[[jwara]]'' all eight diseases have been dealt with separately in eight chapters, each with etiological factors, symptomatology, prognosis and brief line of management.

A compendium of diseases with etiological factors, their synonyms, symptoms of the diseases have been provided as an epilogue to the chapter. [42-44]

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== Tattva Vimarsha (Fundamental Principles) ==

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*Apasmara is a disease due to vitiation of three ''sharira ~~doshas~~'' and two ''manas ~~doshas~~''.

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*Apasmara is a disease due to vitiation of three ''sharira [[dosha]]s'' and two ''[[manas]] [[dosha]]s''.

*The causative factors of apasmara mainly include consuming unhygienic, impure, decomposed food and encountering inauspicious things that are not compatible with one’s sensibilities.

*Diet is important for sustaining physical and psychological health. Improper dietary habits can lead to various psychosomatic disorders associated with apasmara.

*Apasmara originates from the heart, which is the center of consciousness and emotions per Vedic texts. The clinical presentation includes impaired heart-brain coordination leading to transient loss of memory, erratic movements, and blackouts. Analysis of the heart-brain connection is very important in the pathology of apasmara.

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*''Psychological'' stressors like excessive passion, anger, fear, greed, attachment, excitement, grief, anxiety, worry, perturbation etc. precipitate episodes of apasmara in a person afflicted with excessively aggravated ''dosha''.

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*''Psychological'' stressors like excessive passion, anger, fear, greed, attachment, excitement, grief, anxiety, worry, perturbation etc. precipitate episodes of apasmara in a person afflicted with excessively aggravated ''[[dosha]]''.

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*apasmara, depending upon the predominant ''dosha'', can be diagnosed on the basis of frequency of episodes, duration of loss of consciousness, pattern of abnormal movements, and types of objects perceived (in aura phase) prior to the occurrence of an actual episode.

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*apasmara, depending upon the predominant ''[[dosha]]'', can be diagnosed on the basis of frequency of episodes, duration of loss of consciousness, pattern of abnormal movements, and types of objects perceived (in aura phase) prior to the occurrence of an actual episode.

*Purification therapies using strong medicines, observing a healthy diet and lifestyle are considered the primary forms of treatment of apasmara. Non-pharmacological measures like ''mantra'' (holy chants) and ''sattvavajaya chikitsa'' (mind training for restraint, such as cognitive behavior therapy) aid in the treatment of apasmara.

*There can be one causative factor for many diseases or multiple causative factors for single disease.

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*There could be a single treatment for many diseases or many treatments for a single disease.

*The duration of treatment depends upon prognosis of the disease. A disease at the onset may be curable but if not treated, could worsen into a palliable or incurable variant.

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*The subtle changes in ''dosha'', and the three states of a disease (aggravated, normal, or diminished) should be carefully observed along with proper assessment of body strength, digestive power and mental ability .

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*The subtle changes in ''[[dosha]]'', and the three states of a disease (aggravated, normal, or diminished) should be carefully observed along with proper assessment of body strength, digestive power and mental ability .

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*The ''~~doshas~~'' that spread obliquely (in the transverse direction) afflict patient for a longer time. These ''~~doshas~~'' should be managed first, or they should be carefully drawn to ''koshtha'' (bowel) by proper measures. After analyzing them in ''koshtha'', the physician should eliminate them through the nearest route.

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*The ''[[dosha]]s'' that spread obliquely (in the transverse direction) afflict patient for a longer time. These ''[[dosha]]s'' should be managed first, or they should be carefully drawn to ''koshtha'' (bowel) by proper measures. After analyzing them in ''koshtha'', the physician should eliminate them through the nearest route.

== Vidhi Vimarsha (Applied Inferences) ==

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=== Definition of apasmara ===

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apasmara is defined as the occasional loss of consciousness due to deterioration of ''smriti'' (memory), ''buddhi'' (intellect) and ''sattva'' (mind), characterized by ''tamahpravesha'' (entering darkness/ blackouts) and ''bibhatsa cheshta'' (abnormal movements).

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apasmara is defined as the occasional loss of consciousness due to deterioration of ''[[smriti]]'' (memory), ''[[buddhi]]'' (intellect) and ''sattva'' (mind), characterized by ''tamahpravesha'' (entering darkness/ blackouts) and ''bibhatsa cheshta'' (abnormal movements).

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As explained by Sushruta, ''smriti'' in context of apasmara is ''bhutarha vijnana'' i.e. orientation of external world and consciousness. ''Dhi-buddhi'' (intellect) is ''karya-akarya vibhaga karini'' i.e. discriminating power between right and wrong. ''Sattva'' is referred as ''~~mana~~'' (mind) and ''dhairya'' (temperance, patience). A patient of apasmara suffers from deterioration of all these three important mental faculties (''dhi, buddhi'' and ''smriti'').

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As explained by Sushruta, ''[[smriti]]'' in context of apasmara is ''bhutarha vijnana'' i.e. orientation of external world and consciousness. ''Dhi-buddhi'' (intellect) is ''karya-akarya vibhaga karini'' i.e. discriminating power between right and wrong. ''Sattva'' is referred as ''[[manas]]'' (mind) and ''dhairya'' (temperance, patience). A patient of apasmara suffers from deterioration of all these three important mental faculties (''dhi, [[buddhi]]'' and ''[[smriti]]'').

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The first cardinal sign of this deterioration is ''tamapravesha'' , i.e., ''jnana abhava'' or loss of knowledge and the ability to acquire new knowledge. The second cardinal sign, ''bibhatsa cheshta'', indicates involuntary movements of body due to lack of brain’s control or improper coordination. Sushruta narrated that due to these features of apasmara, the disease often leads to death (''antakrita''). Dallhana comments that the dreadfulness of this disease is due to the fact that an afflicted person may fall into water or fire due to lack of orientation.

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The first cardinal sign of this deterioration is ''tamapravesha'' , i.e., ''jnana abhava'' or loss of knowledge and the ability to acquire new knowledge. The second cardinal sign, ''bibhatsa cheshta'', indicates involuntary movements of body due to lack of brain’s control or improper coordination. Sushruta narrated that due to these features of apasmara, the disease often leads to death (''antakrita''). Dallhana comments that the dreadfulness of this disease is due to the fact that an afflicted person may fall into water or fire due to lack of orientation.

=== Impairment of knowledge and coordination ===

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According to [[Ayurveda]], knowledge of external objects is processed through sense organs , to the mind-intellect, culminating in the spirit. This chain or sequence for attainment of knowledge is important for proper functioning of memory (encoding, storage and retrieval) and intellect (cognition) [Fig.1]. Occasional impairment of coordination in the sequence consisting of sense organs-intellect-mind-spirit is seen in apasmara. This may lead to decrease in cognitive performance of an individual.[Fig. 1: Faculty involved in attainment of knowledge]

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In conventional medicine, three major factors that cause disturbance in cerebral neurotransmission leading to blackouts and epilepsy viz. hypo-perfusion, hypo-metabolism, and hypoxia have been described in relevant medical texts. These disturbances lead to abnormal discharges, improper signal transduction in the neurotransmitter channels, and seizures. As a consequence, cellular dysfunctions in the brain, disruptions of the memory mechanism, and disturbed coordination of movements may occur causing the clinical manifestation of apasmara. The role of these three factors and its impact on memory and cellular dysfunction in the pathogenesis of epilepsy need to be elucidated. The three pathological effects are comparable to the changes created by vitiation of ''kapha, pitta'' and ''vata''. Differentiation between these three types of manifestations is described further.

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In conventional medicine, three major factors that cause disturbance in cerebral neurotransmission leading to blackouts and epilepsy viz. hypo-perfusion, hypo-metabolism, and hypoxia have been described in relevant medical texts. These disturbances lead to abnormal discharges, improper signal transduction in the neurotransmitter channels, and seizures. As a consequence, cellular dysfunctions in the brain, disruptions of the memory mechanism, and disturbed coordination of movements may occur causing the clinical manifestation of apasmara. The role of these three factors and its impact on memory and cellular dysfunction in the pathogenesis of epilepsy need to be elucidated. The three pathological effects are comparable to the changes created by vitiation of ''[[kapha]], [[pitta]]'' and ''[[vata]]''. Differentiation between these three types of manifestations is described further.

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Per [[Ayurveda]], ''smriti'' is ''atmaja'' (originated from the soul) and ''sattvaja'' (originated from the mind). This means that ''smriti'' (memory) of a person is essentially related with soul and mind. The Bhagavad Gita describes the consequences of excessive indulgence in sensory activities leading to excessive affliction resulting in an increase in passion, then anger, and then lack of knowledge. This further leads to deterioration of ''smriti'' and then affecting the intellect. This sequence lays the ground for apasmara.

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Per [[Ayurveda]], ''[[smriti]]'' is ''atmaja'' (originated from the soul) and ''sattvaja'' (originated from the mind). This means that ''[[smriti]]'' (memory) of a person is essentially related with soul and mind. The Bhagavad Gita describes the consequences of excessive indulgence in sensory activities leading to excessive affliction resulting in an increase in passion, then anger, and then lack of knowledge. This further leads to deterioration of ''[[smriti]]'' and then affecting the intellect. This sequence lays the ground for apasmara.

=== ''Tattva Sara'' ===

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Three factors of mind, memory, intellect and consciousness are impaired in apasmara. Due care should be taken to protect and manage these three. Herbs like ''medhya rasayana'' and treatment modalities like ''sattvajaya chikitsa'' are known to promote activities of mind, intellect and consciousness.

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Three factors of mind, memory, intellect and consciousness are impaired in apasmara. Due care should be taken to protect and manage these three. Herbs like ''medhya [[rasayana]]'' and treatment modalities like ''sattvajaya chikitsa'' are known to promote activities of mind, intellect and consciousness.

=== Predisposing factors for apasmara ===

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==== ''Rajas–tamas'' affliction ====

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The first factor, ''rajas - tamas'' affliction, signifies the role of mind in etio-pathology of apasmara. ''Rajas'' is a ''guna'' (tendency or attribute) responsible for the initiation of every kind of activity and symbolizes energy, while ''Tamas'' is the ''guna'' symbolizing inertia, dulling or stopping of activities. These two play an important role in the coordination of activities within the sequence of sense organs-mind-intellect-spirit, in the attainment of knowledge as well as to maintain the orientation of external world (consciousness). A ''rajas-tamas'' affliction, therefore, adversely impacts coordination of activities and perverts the mind and intellect, landing the patient into loss of orientation and consciousness. A “distressed” state of mind, caused by ''rajas-tamas'' affliction, is an important etiological factor responsible for various psychosomatic disorders such as epilepsy. Therefore, rehabilitating the ''rajas - tamas'' balance (and thus, achieving harmony between all the three ''~~gunas~~'') is of utmost importance in preventing the pathology and maintenance of health. Neurologically, initiation of action through neurotransmitters such as acetylcholine, while inhibition of action through dopamine can be categorized under ''rajas'' and ''tamas'' respectively. Synchronization of discharges in the cerebral region is a result of ''rajas-tamas'' balance. Disturbance in this ''rajas-tamas'' balance and depletion of ''sattva'' leads to hypersynchronization, resulting in seizures. Threshold of neuronal activity is due to balance between ''sattva, rajas'' and ''tamas''. It is ''sattva'' that maintains the normal threshold of neuronal activities. Decreased ''sattva'' and/or increased ''rajas'' and ''tamas'' can alter the threshold of neurons.

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The first factor, ''rajas - tamas'' affliction, signifies the role of mind in etio-pathology of apasmara. ''Rajas'' is a ''[[guna]]'' (tendency or attribute) responsible for the initiation of every kind of activity and symbolizes energy, while ''Tamas'' is the ''[[guna]]'' symbolizing inertia, dulling or stopping of activities. These two play an important role in the coordination of activities within the sequence of sense organs-mind-intellect-spirit, in the attainment of knowledge as well as to maintain the orientation of external world (consciousness). A ''rajas-tamas'' affliction, therefore, adversely impacts coordination of activities and perverts the mind and intellect, landing the patient into loss of orientation and consciousness. A “distressed” state of mind, caused by ''rajas-tamas'' affliction, is an important etiological factor responsible for various psychosomatic disorders such as epilepsy. Therefore, rehabilitating the ''rajas - tamas'' balance (and thus, achieving harmony between all the three ''[[guna]]s'') is of utmost importance in preventing the pathology and maintenance of health. Neurologically, initiation of action through neurotransmitters such as acetylcholine, while inhibition of action through dopamine can be categorized under ''rajas'' and ''tamas'' respectively. Synchronization of discharges in the cerebral region is a result of ''rajas-tamas'' balance. Disturbance in this ''rajas-tamas'' balance and depletion of ''sattva'' leads to hypersynchronization, resulting in seizures. Threshold of neuronal activity is due to balance between ''sattva, rajas'' and ''tamas''. It is ''sattva'' that maintains the normal threshold of neuronal activities. Decreased ''sattva'' and/or increased ''rajas'' and ''tamas'' can alter the threshold of neurons.

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The state of mind afflicted due to ''rajas'' and ''tamas'' can be considered as ‘distressed mind’ observed as important causative factor for various psycho somatic disorders like epilepsy.

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~~The state of mind afflicted due to ''rajas'' and ''tamas'' can be considered as ‘distressed mind’ observed as important causative factor for various psycho somatic disorders like epilepsy.~~

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==== ''Sharira dosha'' vitiation ====

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The second important factor is imbalance of ''doshas'' at the somatic level. There are three terms used to indicate the state of ''~~doshas~~'' which predisposes apasmara:

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The second important factor is imbalance of ''doshas'' at the somatic level. There are three terms used to indicate the state of ''[[dosha]]s'' which predisposes apasmara:

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*First is ''udbhranta'' (moving upwards in vitiated state). The upward direction of flow of ''~~doshas~~'' may indicate the pathway of apasmara from the heart to the brain. The pathology starts from the abode of consciousness i.e. heart, spreading upwards afflicting sense organs. In [[Chikitsa Sthana]], the term ''vibhranta'' is used to denote this condition.

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*First is ''udbhranta'' (moving upwards in vitiated state). The upward direction of flow of ''[[dosha]]s'' may indicate the pathway of apasmara from the heart to the brain. The pathology starts from the abode of consciousness i.e. heart, spreading upwards afflicting sense organs. In [[Chikitsa Sthana]], the term ''vibhranta'' is used to denote this condition.

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*The second state is ''vishama'', meaning a state of disequilibrium. Imbalanced ''~~doshas~~'' create a favorable environment for apasmara. *The third state is ''bahu'' (excessive), meaning that the imbalance is excessive enough to affect the brain-mind system. This suggests that the ''~~doshas~~'' are in an aggravated state of imbalance and predispose to the disease. The condition also points towards manifestation of apasmara as a result of other somatic disease pathologies.

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*The second state is ''vishama'', meaning a state of disequilibrium. Imbalanced ''[[dosha]]s'' create a favorable environment for apasmara. *The third state is ''bahu'' (excessive), meaning that the imbalance is excessive enough to affect the brain-mind system. This suggests that the ''[[dosha]]s'' are in an aggravated state of imbalance and predispose to the disease. The condition also points towards manifestation of apasmara as a result of other somatic disease pathologies.

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The disease condition is a result of combination of the above states of ''~~doshas~~'' with the ''rajas-tamas'' affliction. These are ''sanchaya'' (accumulation), ''prakopa'' (aggravation) and ''prasara'' (spread) stages of the disease - important somatic factors for causation of apasmara.

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The disease condition is a result of combination of the above states of ''[[dosha]]s'' with the ''rajas-tamas'' affliction. These are ''sanchaya'' (accumulation), ''prakopa'' (aggravation) and ''prasara'' (spread) stages of the disease - important somatic factors for causation of apasmara.

The cumulative presentation suggests the psychosomatic nature of the disease where the psyche and soma are equally involved in the pathogenesis. This is important while treating apasmara, because this indicates that only administering anti-epileptic drugs is not enough in treating apasmara. The treatment of underlying psychological factors shall also be given due emphasis.

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==== Role of diet ====

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The third key factor is the role of quality of diet in the causation of the disease. Charak uses terms like ''samala'' (impure), ''vikrita'' (deformed/altered), ''upahita'' (mixed), and ''ashuchi'' (unclean/unhygienic) as adjectives to describe food articles that cause apasmara. Sushruta uses terms like ''viruddha'' (incompatible or of contradictory/antagonistic nature) and ''malina'' (bad) for the same factors. Besides providing nutrition to the body, diet plays a great impact on the mind as well. It is mentioned in the texts that the nutrition of soma and psyche occurs through food and food habits. Yogic texts narrate the role of food in nourishing five sheaths of the body, called ''annamaya kosha, pranamaya kosha, vijnanamaya kosha, manomaya kosha'' and ''anandmaya kosha''. Therefore, diet is not only important for proper functioning of the three ''~~doshas~~'', but also for nourishment of the mind and the soul. Charak as well as Sushruta have acknowledged the role of unclean, unhygienic, unwholesome, incompatible diet in the causation of apasmara. Dallhana commented that this includes the diet that is ''dwishta'' (disliked by mind or taken with hatred feeling), ''amedhya'' (not satisfying mind) and ''paryushita'' (stale). All these types of diet can cause disturbance in the body and mind. As per conventional medicine, a diet that is deficient in certain vitamins and minerals and that which increases neurotoxins may lead to neurological disorders. Therefore, biochemical changes in the above mentioned causative foods may lead to deficiencies of important nutrients and cause increase in neurotoxins resulting in apasmara like disorders. Moreover, some gastrointestinal symptoms have been described further as premonitory symptoms of apasmara. The role of diet and food habits as a cause of apasmara needs to be further researched. These factors are to be avoided during the treatment of apasmara. Not following /proper dietary rules is one of the key causes for the formation of ''ama''. ''Ama'' produces free radicals leading to excessive oxidative stress and tissue injuries. Therefore, following proper dietary habits is important in preventing the pathogenesis of the disease. Furthermore, this suggests the possibility of food contamination as a causative factor for epilepsy. A case of endrin-laced taquitos causing seizures in the US is an example of food contamination causing epileptic seizures .<ref> K Waller, T J Prendergast, A Slagle, R J Jackson.Seizures after eating a snack food contaminated with the pesticide endrin. The tale of the toxic taquitos. West J Med. 1992 Dec; 157(6): 648–651 </ref>

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The third key factor is the role of quality of diet in the causation of the disease. Charak uses terms like ''samala'' (impure), ''vikrita'' (deformed/altered), ''upahita'' (mixed), and ''ashuchi'' (unclean/unhygienic) as adjectives to describe food articles that cause apasmara. Sushruta uses terms like ''viruddha'' (incompatible or of contradictory/antagonistic nature) and ''malina'' (bad) for the same factors. Besides providing nutrition to the body, diet plays a great impact on the mind as well. It is mentioned in the texts that the nutrition of soma and psyche occurs through food and food habits. Yogic texts narrate the role of food in nourishing five sheaths of the body, called ''annamaya kosha, pranamaya kosha, vijnanamaya kosha, manomaya kosha'' and ''anandmaya kosha''. Therefore, diet is not only important for proper functioning of the three ''[[dosha]]s'', but also for nourishment of the mind and the soul. Charak as well as Sushruta have acknowledged the role of unclean, unhygienic, unwholesome, incompatible diet in the causation of apasmara. Dallhana commented that this includes the diet that is ''dwishta'' (disliked by mind or taken with hatred feeling), ''amedhya'' (not satisfying mind) and ''paryushita'' (stale). All these types of diet can cause disturbance in the body and mind. As per conventional medicine, a diet that is deficient in certain vitamins and minerals and that which increases neurotoxins may lead to neurological disorders. Therefore, biochemical changes in the above mentioned causative foods may lead to deficiencies of important nutrients and cause increase in neurotoxins resulting in apasmara like disorders. Moreover, some gastrointestinal symptoms have been described further as premonitory symptoms of apasmara. The role of diet and food habits as a cause of apasmara needs to be further researched. These factors are to be avoided during the treatment of apasmara. Not following /proper dietary rules is one of the key causes for the formation of ''ama''. ''Ama'' produces free radicals leading to excessive oxidative stress and tissue injuries. Therefore, following proper dietary habits is important in preventing the pathogenesis of the disease. Furthermore, this suggests the possibility of food contamination as a causative factor for epilepsy. A case of endrin-laced taquitos causing seizures in the US is an example of food contamination causing epileptic seizures .<ref> K Waller, T J Prendergast, A Slagle, R J Jackson.Seizures after eating a snack food contaminated with the pesticide endrin. The tale of the toxic taquitos. West J Med. 1992 Dec; 157(6): 648–651 </ref>

==== Improper methods – lifestyle factors ====

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The fourth etiological factor of epilepsy is not following the prescribed rules of diet and lifestyle. The ''upayoga vidhi'' lists improper dietary habits, lifestyle and code of conduct that lead to disturbances in soma and psyche. Sushruta has elaborated the role of incorrect or excessive indulgence in activities of sense organs and locomotor organs as the foremost causative factor for apasmara. This is suggestive of disturbances in the knowledge coordination chain leading to lack of attainment of knowledge. This factor also indicates role of unhealthy regimens and behavior in patho-physiology of epilepsy. The factor underlies ignorance towards proper ''dinacharya'' (diurnal regimen), ''ratricharya'' (night regimen) and ''ritucharya'' (seasonal regimen). The lifestyle and behavior of a person is important for achieving normalcy in the psychic plane and for avoiding psychological disorders. This also suggests the inclusion of ''prajnaparadha'' (intellectual blasphemy) described in [[Sharira Sthana]]. ''Achara rasayana'' (code of conduct) should be followed as a therapeutic regimen in the management of apasmara. The psycho-neuro-biological basis of etiopathological factors causing neurological disorders is being extensively researched with positive outcomes. Psycho-social distress is an important underlying factor for such disorders through impairment of hypothalamo-pituitary-adrenal axis. The preventive measures to be included are correct and productive indulgence in the sensory and locomotor activities as per capacity of an individual. Psychotherapy is believed to be effective in the management of apasmara.

+

The fourth etiological factor of epilepsy is not following the prescribed rules of diet and lifestyle. The ''upayoga vidhi'' lists improper dietary habits, lifestyle and code of conduct that lead to disturbances in soma and psyche. Sushruta has elaborated the role of incorrect or excessive indulgence in activities of sense organs and locomotor organs as the foremost causative factor for apasmara. This is suggestive of disturbances in the knowledge coordination chain leading to lack of attainment of knowledge. This factor also indicates role of unhealthy regimens and behavior in patho-physiology of epilepsy. The factor underlies ignorance towards proper ''[[dinacharya]]'' (diurnal regimen), ''ratricharya'' (night regimen) and ''ritucharya'' (seasonal regimen). The lifestyle and behavior of a person is important for achieving normalcy in the psychic plane and for avoiding psychological disorders. This also suggests the inclusion of ''prajnaparadha'' (intellectual blasphemy) described in [[Sharira Sthana]]. ''Achara rasayana'' (code of conduct) should be followed as a therapeutic regimen in the management of apasmara. The psycho-neuro-biological basis of etiopathological factors causing neurological disorders is being extensively researched with positive outcomes. Psycho-social distress is an important underlying factor for such disorders through impairment of hypothalamo-pituitary-adrenal axis. The preventive measures to be included are correct and productive indulgence in the sensory and locomotor activities as per capacity of an individual. Psychotherapy is believed to be effective in the management of apasmara.

==== Improper techniques ====

−

Observance of improper ''tantra'' (techniques/methods) makes the person prone to apasmara and is the fifth causative factor. This includes iatrogenic factors such as improper follow ups of [[Panchakarma]] procedures leading to vitiation of ''~~doshas~~'' in the body. The other meaning of ''tantra'' might be related to spiritual practices that are related to the supernatural powers mentioned earlier as reasons for causing epilepsy. Improper use of these tantric therapies can result in epilepsy.

+

Observance of improper ''tantra'' (techniques/methods) makes the person prone to apasmara and is the fifth causative factor. This includes iatrogenic factors such as improper follow ups of [[Panchakarma]] procedures leading to vitiation of ''[[dosha]]s'' in the body. The other meaning of ''tantra'' might be related to spiritual practices that are related to the supernatural powers mentioned earlier as reasons for causing epilepsy. Improper use of these tantric therapies can result in epilepsy.

−

Iatrogenic causes can increase susceptibility to apasmara. Therefore all procedures should be followed properly in order to prevent complications.

+

Iatrogenic causes can increase susceptibility to apasmara. Therefore all procedures should be followed properly in order to prevent complications.

==== Incorrect postures and movements ====

−

The sixth etiological factor constitutes of wrong postures and movements. Since the coordination of movements is regulated by ''dhi-buddhi-smriti'', any imbalance in the sense organs-mind-intellect-spirits sequence not only impairs movement of limbs but also increases the propensity of getting afflicted with apasmara. Conversely, wrong postures and movements are a result of disturbances in the sense organs-spirits sequence that lead to incorrect attainment of knowledge with the manifestation of apasmara.

+

The sixth etiological factor constitutes of wrong postures and movements. Since the coordination of movements is regulated by ''dhi-[[buddhi]]-[[smriti]]'', any imbalance in the sense organs-mind-intellect-spirits sequence not only impairs movement of limbs but also increases the propensity of getting afflicted with apasmara. Conversely, wrong postures and movements are a result of disturbances in the sense organs-spirits sequence that lead to incorrect attainment of knowledge with the manifestation of apasmara.

Uncomfortable sitting, sleeping, positioning, irregular, uncoordinated movements of body (e.g. improper dance, sports etc.) can predispose apasmara.

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==== Excessive degeneration and debility ====

−

The seventh and last etiological factor i.e. excessive degeneration or debility may lead to pathogenesis of apasmara , pointing at ''dhatukshayajanya vataprakopa'' (vitiation of ''vata'' due to depletion of tissues) as a root cause. The degeneration might be a secondary condition resulting from other diseases. Hypo-perfusion and low levels of oxygen and metabolism could result in brain cell dysfunctions causing seizures. This is analogous to the concept of ''ati upakshaya'' in [[Ayurveda]]. Therefore, a clinical examination of depletion of tissues (''dhatukshaya'') could be considered as a treatment component in the management of apasmara.

+

The seventh and last etiological factor i.e. excessive degeneration or debility may lead to pathogenesis of apasmara , pointing at ''dhatukshayajanya vataprakopa'' (vitiation of ''[[vata]]'' due to depletion of tissues) as a root cause. The degeneration might be a secondary condition resulting from other diseases. Hypo-perfusion and low levels of oxygen and metabolism could result in brain cell dysfunctions causing seizures. This is analogous to the concept of ''ati upakshaya'' in [[Ayurveda]]. Therefore, a clinical examination of depletion of tissues (''dhatukshaya'') could be considered as a treatment component in the management of apasmara.

Acute and severe electrolyte imbalances (hyponatremia, hypocacemia and hypomagnesemia) frequently cause seizures.

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In addition to the above factors, Sushruta has quoted two more factors for predisposition of apasmara. ''Veganigraha sheelanam'' i.e. habitual suppression of natural urges and ''gachchatam cha rajaswalam'' i.e., having sexual intercourse with menstruating women can make the individual more susceptible to epilepsy. Recent research suggests that menotoxins secreted by the female body during menstruation significantly impact the psyche of a person accompanying that female.

−

On the first of these two factors, per [[Ayurveda]], suppression of any of the thirteen types of natural urges may lead to various disorders. Suppressing natural urges leads to ''vata''-dominant disorders and as ''vata'' is the regulator of mind-related activities, this consequently can result in neuropsychiatric disorders like apasmara. All the urges are stimulated, regulated and completed by the nervous system. Inhibition of these factors might lead to impairment of neurotransmission which can be a cause for neuropsychiatric disorders. Furthermore, suppression of urges can lead to accumulation of waste materials inside the body creating various diseases.

+

On the first of these two factors, per [[Ayurveda]], suppression of any of the thirteen types of natural urges may lead to various disorders. Suppressing natural urges leads to ''[[vata]]''-dominant disorders and as ''[[vata]]'' is the regulator of mind-related activities, this consequently can result in neuropsychiatric disorders like apasmara. All the urges are stimulated, regulated and completed by the nervous system. Inhibition of these factors might lead to impairment of neurotransmission which can be a cause for neuropsychiatric disorders. Furthermore, suppression of urges can lead to accumulation of waste materials inside the body creating various diseases.

−

On the second factor mentioned here, the correlation between having an intercourse with menstruating ~~woman~~ and getting afflicted with epilepsy needs to be researched further. [[Ayurveda]] strictly forbids sharing things with a menstruating woman, leave aside touching or having sexual relations with one. While there are reasons of following sacredness associated with this, sex with a menstruating woman is also indicative of exposure to unclean objects described earlier as the origin of apasmara. The psycho-neuro-endocrinological axis behind this view of Sushruta needs to be explored.

+

On the second factor mentioned here, the correlation between having an intercourse with menstruating women and getting afflicted with epilepsy needs to be researched further. [[Ayurveda]] strictly forbids sharing things with a menstruating woman, leave aside touching or having sexual relations with one. While there are reasons of following sacredness associated with this, sex with a menstruating woman is also indicative of exposure to unclean objects described earlier as the origin of apasmara. The psycho-neuro-endocrinological axis behind this view of Sushruta needs to be explored.

Thus, from the above descriptions, etiopathological factors of apasmara can be categorized into dietary factors, lifestyle factors, psychological factors, behavioral factors and iatrogenic factors. All the above predisposing factors can be scanned for epigenetic modifications with respect to personality types, behavior patterns and occurrence of apasmara in such cases. This will be useful in identifying the disease at a primitive stage, breaking the pathogenesis at an intermedial stage and prevention of further deterioration and complications at later stage. There might be certain epigenetic patterns/changes due to the above mentioned etiological factors, which make the person more susceptible to get affected.

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[[File:psycho-dynamics.png|500px|'''Fig.2: Psycho-dynamics in Apasmara'''|thumb ]]<br>

−

'''Fig.2: Psycho-dynamics in apasmara'''

+

'''Fig.2: Psycho-dynamics in apasmara'''

=== Six stages of pathogenesis of epilepsy (''shatkriyakala'' for apasmara) ===

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==== ''Sanchaya'' ====

−

The first stage of accumulation of pathogenic factors (vitiated ''~~doshas~~'') starts at their own sites. It is initiated right from the first exposure to unclean objects and other etiological factors mentioned earlier. This stage is characterized by mild disturbances in the psyche (''rajas'' and ''tamas'') and soma (''~~tridosha~~'').

+

The first stage of accumulation of pathogenic factors (vitiated ''[[dosha]]s'') starts at their own sites. It is initiated right from the first exposure to unclean objects and other etiological factors mentioned earlier. This stage is characterized by mild disturbances in the psyche (''rajas'' and ''tamas'') and soma (''tri[[dosha]]'').

==== ''Prakopa'' ====

−

If the individual excessively indulges in observing causative factors for a significant period, then the ''~~doshas~~'' proceed to the next stage of pathology i.e. ''prakopa''. The ''~~doshas~~'' are vitiated at their own site. In case of apasmara, the doshas reside at the vessels, above the heart (the site of consciousness) in a leena (dormant) state [Cha.Sa.[[Chikitsa Sthana]] 10/6].

+

If the individual excessively indulges in observing causative factors for a significant period, then the ''[[dosha]]s'' proceed to the next stage of pathology i.e. ''prakopa''. The ''[[dosha]]s'' are vitiated at their own site. In case of apasmara, the doshas reside at the vessels, above the heart (the site of consciousness) in a leena (dormant) state [Cha.Sa.[[Chikitsa Sthana]] 10/6].

==== ''Prasara'' ====

−

Whenever the provocative emotional factors like worries, passion, anger etc. trigger these ''~~doshas~~'', the vitiated ''dosha'' moves upwards affecting the sense and locomotor organs. This will present the ''prasara avastha'' (stage of spread) of the disease.

+

Whenever the provocative emotional factors like worries, passion, anger etc. trigger these ''[[dosha]]s'', the vitiated ''[[dosha]]'' moves upwards affecting the sense and locomotor organs. This will present the ''prasara avastha'' (stage of spread) of the disease.

==== ''Sthanasamshraya'' ====

−

Thereafter in ''sthanasamshraya avastha'' of apasmara (change in stage, triggering premonitory signs and symptoms), the stridden ''~~doshas~~'' take pathways of sense organs and locomotor organs alerting manifestation of the disease. This is called the aura stage of epilepsy.

+

Thereafter in ''sthanasamshraya avastha'' of apasmara (change in stage, triggering premonitory signs and symptoms), the stridden ''[[dosha]]s'' take pathways of sense organs and locomotor organs alerting manifestation of the disease. This is called the aura stage of epilepsy.

==== ''Vyakta'' ====

−

Then, the ''vyakta'' i.e. manifestation stage of apasmara is apparent due to excessive aggravation of ''~~doshas~~''. The severity of paroxysms depends upon ''sharira bala'' (physical strength that helps do physical work as well as prevent manifestations of diseases, includes genetic predisposition as well), ''hetu'' (strength of causative agents depending upon their exposure) and ''sattva bala'' (strength of mind). The clinical manifestation will be a product of interactions between these factors. Common clinical features of the disease will start showing at this stage.

+

Then, the ''vyakta'' i.e. manifestation stage of apasmara is apparent due to excessive aggravation of ''[[dosha]]s''. The severity of paroxysms depends upon ''sharira bala'' (physical strength that helps do physical work as well as prevent manifestations of diseases, includes genetic predisposition as well), ''hetu'' (strength of causative agents depending upon their exposure) and ''sattva bala'' (strength of mind). The clinical manifestation will be a product of interactions between these factors. Common clinical features of the disease will start showing at this stage.

==== ''Bheda avastha'' ====

−

''Bheda avastha'' is the stage of differentiation depending upon the dominance of ''~~doshas~~''. This will predominantly depend upon the genetic constitution of the person as well as the intake of alleviators and pacifiers of that particular ''dosha''. If there are some pacification factors in between, then the progression of disease stops at that stage only blocking presentation of clinical features.

+

''Bheda avastha'' is the stage of differentiation depending upon the dominance of ''[[dosha]]s''. This will predominantly depend upon the genetic constitution of the person as well as the intake of alleviators and pacifiers of that particular ''[[dosha]]''. If there are some pacification factors in between, then the progression of disease stops at that stage only blocking presentation of clinical features.

−

If we critically analyze and compare the pathophysiology, it can be observed that unlike modern research, the brain did not figure in Charak’s analysis of disease or their pathologic basis, nor did he emphasize the role of an exogenous or supernatural power (''agantuka'') factor in the causation of epilepsy. Charak has clearly mentioned heart, the abode of self and consciousness, as the origin for apasmara. In the seizure state, ''~~doshas~~'' stride upwards through ''dhamanis'' (vessels), affecting the ''~~indriyas~~'' (sense and locomotor organs) leading to erratic movements and loss of consciousness. Sushruta and Vagbhata have specifically mentioned the ''samajnavahishu srotasu'' (channels of consciousness) as the pathway of spread of ''~~doshas~~'' and as a site for the disease.

+

If we critically analyze and compare the pathophysiology, it can be observed that unlike modern research, the brain did not figure in Charak’s analysis of disease or their pathologic basis, nor did he emphasize the role of an exogenous or supernatural power (''agantuka'') factor in the causation of epilepsy. Charak has clearly mentioned heart, the abode of self and consciousness, as the origin for apasmara. In the seizure state, ''[[dosha]]s'' stride upwards through ''dhamanis'' (vessels), affecting the ''[[indriya]]s'' (sense and locomotor organs) leading to erratic movements and loss of consciousness. Sushruta and Vagbhata have specifically mentioned the ''samajnavahishu srotasu'' (channels of consciousness) as the pathway of spread of ''[[dosha]]s'' and as a site for the disease.

As per [[Ayurveda]], the heart (and not the brain), is the locus or abode of the mind, consciousness and soul , and emotional factors are considered as some of the root causes for triggering epilepsy. The clinical presentation of epilepsy represents the derangement of functions of neurons of central nervous system, but the origin of this derangement shall have been predisposed much earlier due to psycho-pathological factors enlisted above. The acute onset of seizure can be precipitated due to emotional factors. The mechanism of this phenomenon and exact psycho-neuronal pathways behind this are worthy of study.

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=== Types of apasmara ===

−

There are four types of apasmara depending upon the predominance of ''dosha''. The first thing of significance is that all these are ''sharira ~~doshas~~'' and not ''manasa ~~doshas~~''. This implies that apasmara is predominantly a somatic disease in which psychological factors play a role in pathogenesis. The important aspect of management should be focused at the somatic level supported by psychotherapy. The role of genetic constitution is important in the study of clinical manifestations of apasmara as well as their response either to treatments involving allopathic anti-epileptic medications or to Ayurvedic treatment modalities. The diagnosis of dominance of ''dosha'' is also important in deciding the treatment modalities prescribed in cases of apasmara. The epigenetic variation of the four types of apasmara and the categorization of etio-pathological factors to lead the epigenetic modification resulting into specific type of apasmara is worthy of study.

+

There are four types of apasmara depending upon the predominance of ''dosha''. The first thing of significance is that all these are ''sharira [[dosha]]s'' and not ''manasa [[dosha]]s''. This implies that apasmara is predominantly a somatic disease in which psychological factors play a role in pathogenesis. The important aspect of management should be focused at the somatic level supported by psychotherapy. The role of genetic constitution is important in the study of clinical manifestations of apasmara as well as their response either to treatments involving allopathic anti-epileptic medications or to Ayurvedic treatment modalities. The diagnosis of dominance of ''[[dosha]]'' is also important in deciding the treatment modalities prescribed in cases of apasmara. The epigenetic variation of the four types of apasmara and the categorization of etio-pathological factors to lead the epigenetic modification resulting into specific type of apasmara is worthy of study.

==== ''Agantu Apasmara'' ====

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Similar to this, Vagbhata in Ashtanga Hridayam, has described the variants of the disease caused due to demons/evil spirits possessing the children. The cardinal signs of ''graha'' possession (or affliction) include continuous fever and crying. The general features are fear, too much yawning, movement of eyebrows, timidity, discharge of froth from mouth, upward gaze, biting of lips and teeth (grinding), wakefulness (absence of sleep), crying, moaning, aversion for the breast, change of voice, and scratching its own body or that of the mother by nails without any reason. [A.H Uttara Sthana 3/3-5]<ref name=Hridaya/>

−

In conventional medicine, epilepsy in children is described in detail. However, the etiology of some variants of epilepsy is mentioned to be idiopathic. As described in context of ''skanda'' and ''skandapasmara'', the involvement of supernatural powers in causing apasmara is a matter of debate and falls in the purview of theology. Considering its importance and prevalence, apasmara of unknown etiology can be categorized as of the fifth type i.e. ''agantu apasmara''. Sushruta and his commentator Dallhana support this view that any variant of the disease which occurs without any reason, acutely and without any rational pathology shall be considered as ''agantu''. Per Charak [Cha.Sa.[[Chikitsa Sthana]] 10/53], the etiopathology, clinical features and management of this fifth type are on the lines of ''agantu unmada''. As commented by Chakrapani, in case of ''agantu'' or ''bhutapasmara'', the etiology of being seized by some external factors is considered primary and the involvement (''anubabdha'') of ''dosha'' as secondary. It is important to note here that since clinical patho-physiology cannot take place without the involvement of ''~~doshas~~'', therefore ''agantu'' should technically be considered as one of the four doshic variants of apasmara mentioned earlier, in order to follow the ''sankhya niyam''a i.e. rules of numeral classification.

+

In conventional medicine, epilepsy in children is described in detail. However, the etiology of some variants of epilepsy is mentioned to be idiopathic. As described in context of ''skanda'' and ''skandapasmara'', the involvement of supernatural powers in causing apasmara is a matter of debate and falls in the purview of theology. Considering its importance and prevalence, apasmara of unknown etiology can be categorized as of the fifth type i.e. ''agantu apasmara''. Sushruta and his commentator Dallhana support this view that any variant of the disease which occurs without any reason, acutely and without any rational pathology shall be considered as ''agantu''. Per Charak [Cha.Sa.[[Chikitsa Sthana]] 10/53], the etiopathology, clinical features and management of this fifth type are on the lines of ''agantu unmada''. As commented by Chakrapani, in case of ''agantu'' or ''bhutapasmara'', the etiology of being seized by some external factors is considered primary and the involvement (''anubabdha'') of ''[[dosha]]'' as secondary. It is important to note here that since clinical patho-physiology cannot take place without the involvement of ''[[dosha]]s'', therefore ''agantu'' should technically be considered as one of the four doshic variants of apasmara mentioned earlier, in order to follow the ''sankhya niyam''a i.e. rules of numeral classification.

=== Premonitory signs of apasmara ===

−

The table 1 depicts the premonitory signs of apasmara described in the Ayurvedic texts. Each sign has a specific patho-physiology in terms of ''dosha'' and ''dushya'' behind its manifestation. The enlisted signs are the alerting signals or premonitory symptoms of apasmara before the onset of seizures. The probable system involved as per conventional medicine is also enlisted for every sign, so that it would be easier to consider the pathophysiological similarities and differences between the two medical streams.

+

The table 1 depicts the premonitory signs of apasmara described in the Ayurvedic texts. Each sign has a specific patho-physiology in terms of ''[[dosha]]'' and ''[[dushya]]'' behind its manifestation. The enlisted signs are the alerting signals or premonitory symptoms of apasmara before the onset of seizures. The probable system involved as per conventional medicine is also enlisted for every sign, so that it would be easier to consider the pathophysiological similarities and differences between the two medical streams.

</div>

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|-

! Bhrūvyudāsa

−

| abnormal / twitching of eyebrows || vata – rajas || majja || nervous system [NS]

+

| abnormal / twitching of eyebrows || [[vata]] – rajas || majja || nervous system [NS]

|-

! Satatam akshi vaikrutam

−

| constant abnormal/ irregular movements of eyes || vata – rajas || majja || NS

+

| constant abnormal/ irregular movements of eyes || [[vata]] – rajas || majja || NS

|-

! Ashabda shravanam

−

| auditory hallucinations || vata –rajas || manas || NS, psychiatric disorder

+

| auditory hallucinations || [[vata]] –rajas || [[manas]] || NS, psychiatric disorder

|-

! Lala prastrava

−

| excess secretion of saliva || kapha || rasa || NS, digestive system[DS]

+

| excess secretion of saliva || [[kapha]] || [[rasa]] || NS, digestive system[DS]

|-

! Singhanaka prastrava

−

| excess nasal mucus discharge || kapha || rasa ||NS, respiratory system

+

| excess nasal mucus discharge || [[kapha]] || [[rasa]] ||NS, respiratory system

|-

! Anannabhilashanam

−

| lack of appetite || kapha- Pitta || rasa || DS, NS

+

| lack of appetite || [[kapha]]- [[Pitta]] || [[rasa]] || DS, NS

|-

! Arochaka

−

| aversion to food and drinks [anorexia] || Kapha ~~–pitta –vata~~ || rasa || DS, Psychiatric disorder

+

| aversion to food and drinks [anorexia] || [[Kapha]] –[[pitta]] –[[vata]] || [[rasa]] || DS, Psychiatric disorder

|-

! Avipaka

−

| indigestion || pitta || rasa || DS, NS

+

| indigestion || [[pitta]] || [[rasa]] || DS, NS

|-

! Hridaya graham

−

| heavyness of precordium/ congestion/ constriction in cardiac region || kapha, vata || mamsa,majja || NS, musculo skeletal system,

+

| heavyness of precordium/ congestion/ constriction in cardiac region || [[kapha]], [[vata]] || [[mamsa]],[[majja]] || NS, musculo skeletal system,

|-

! Kukshe aatopa

−

| puffiness/ swelling in the hypogastric region || vata, kapha || rasa, purisha, mutra || DS, urinary system

+

| puffiness/ swelling in the hypogastric region || [[vata]], [[kapha]] || [[rasa]], [[purisha]], [[mutra]] || DS, urinary system

|-

! Daurbalyam

−

| debility, loss of strength || kapha, vata || rasa, mamsa, majja || NS, musculoskeletal system

+

| debility, loss of strength || [[kapha]], [[vata]] || [[rasa]], [[mamsa]], [[majja]] || NS, musculoskeletal system

|-

! Asthibheda

−

| splitting / breaking [pain] sensation in bones || vata || asthi, majja || skeletal system

+

| splitting / breaking [pain] sensation in bones || [[vata]] || [[asthi]], [[majja]] || skeletal system

|-

! Angamarda

−

| generalized bodyache/ twisting/churning pain in body || vata || mamsa, majja || musculo-skeletal system, NS

+

| generalized bodyache/ twisting/churning pain in body || [[vata]] || [[mamsa]], [[majja]] || musculo-skeletal system, NS

|-

! Moha

−

| confused state of mind [leading to lack of knowledge] || vata, kapha, Tama || rasa, majja || NS, psychiatric disorder

+

| confused state of mind [leading to lack of knowledge] || [[vata]], [[kapha]], Tama || [[rasa]], [[majja]] || NS, psychiatric disorder

|-

! Tamas darshanam

−

| black outs / temporary loss of vision without alteration in consciousness || pitta, vata || rasa- rakta-majja || cardio-vascular/ cerebro vascular system, NS

+

| black outs / temporary loss of vision without alteration in consciousness || [[pitta]], [[vata]] || [[rasa]]- [[rakta]]-[[majja]] || cardio-vascular/ cerebro vascular system, NS

|-

! Murchcha

−

| syncope / a fatal condition characterized by loss of consciousness and postural tone due to vitiation of blood || pitta, kapha || rasa, rakta, majja || cardio-vascular/ cerebro vascular system, NS

+

| syncope / a fatal condition characterized by loss of consciousness and postural tone due to vitiation of blood || [[pitta]], [[kapha]] || [[rasa]], [[rakta]], [[majja]] || cardio-vascular/ cerebro vascular system, NS

|-

! Abhikshnam Bhrama

−

| frequent vertigo/ dizziness || pitta, vata, rajas || rasa, rakta, rajas || cardio-vascular/ cerebro vascular system, NS, psychiatric disorder

+

| frequent vertigo/ dizziness || [[pitta]], [[vata]], rajas || [[rasa]], [[rakta]], rajas || cardio-vascular/ cerebro vascular system, NS, psychiatric disorder

|-

! Swapne cha || ! colspan="4" | In dreams

|-

! Mada

−

| slight intoxication, becoming out of senses showing uncanny or abnormal behaviour || rowspan="6" | vata, rajas, kapha || rasa, rakta, manas || rowspan="6" | Cardio-vascular/ Cerebro vascular system, NS, psychiatric disorder

+

| slight intoxication, becoming out of senses showing uncanny or abnormal behaviour || rowspan="6" | [[vata]], rajas, [[kapha]] || [[rasa]], [[rakta]], [[manas]] || rowspan="6" | Cardio-vascular/ Cerebro vascular system, NS, psychiatric disorder

|-

! Nartana

−

| dancing || majja

+

| dancing || [[majja]]

|-

! Vyadhana

−

| needling like sensation || majja

+

| needling like sensation || [[majja]]

|-

! Vyathana

−

| pain || majja

+

| pain || [[majja]]

|-

! Vepana

−

| tremors || majja

+

| tremors || [[majja]]

|-

! Patanadini

−

| falling etc. || rasa-rakta,

+

| falling etc. || [[rasa]]-[[rakta]],

majja

|-

Line 1,145: Line 1,145:

−

The abovementioned pre-clinical features are observed in the fourth stage of ''shatkriyakala'' (pathogenesis). These may be considered as aura in apasmara patients. These are important in view of prevention of apasmara progression to epileptic seizure. In conventional medicine text books, some of the above signs like auditory and visual hallucinations are referred. These signs need to be searched upon for their prevalence, categorization as per ''dosha'' dominance, involvement of ''dosha'' attributes in order to establish precise guidelines for early prevention and management of disease.

+

The abovementioned pre-clinical features are observed in the fourth stage of ''shatkriyakala'' (pathogenesis). These may be considered as aura in apasmara patients. These are important in view of prevention of apasmara progression to epileptic seizure. In conventional medicine text books, some of the above signs like auditory and visual hallucinations are referred. These signs need to be searched upon for their prevalence, categorization as per ''[[dosha]]'' dominance, involvement of ''[[dosha]]'' attributes in order to establish precise guidelines for early prevention and management of disease.

</div>

Table 2: Differentiation between types of apasmara

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Su: As described by Sushruta in Sushruta Samhita AH: As described in Ashtang Hridaya

−

The specific features of all the four types of apasmara are described in Table 2. ''Vata'' type of apasmara manifests itself with repeated seizures of short duration and increased frequency of attacks. The speed, severity and abnormality of movements are more in this case. This is due to ''chala'' (movable), ''laghu'' (light), and ''sukshma'' (minute) attributes of ''vata dosha''. ''Vata'' is the initiator of all activities including those of the body and the mind. The regulation and coordination of the sequence of sense and locomotor organs – mind-intellect-soul for attainment of knowledge is performed by ''vata''. ''Prana vata, udana vata'' and ''vyana vata'' are involved in the pathophysiology of apasmara. The clinical manifestation of ''vataja'' apasmara may be due to repeated, excess, hyposynchronous discharges in neurons of the central nervous system. Transient hypoxia leading to dysregulation of brain functioning, and neurological diseases similar to epilepsy syndromes can be categorized under this type of apasmara.

+

The specific features of all the four types of apasmara are described in Table 2. ''[[Vata]]'' type of apasmara manifests itself with repeated seizures of short duration and increased frequency of attacks. The speed, severity and abnormality of movements are more in this case. This is due to ''chala'' (movable), ''laghu'' (light), and ''sukshma'' (minute) attributes of ''[[vata dosha]]''. ''[[Vata]]'' is the initiator of all activities including those of the body and the mind. The regulation and coordination of the sequence of sense and locomotor organs – mind-intellect-soul for attainment of knowledge is performed by ''[[vata]]''. ''Prana vata, udana vata'' and ''vyana vata'' are involved in the pathophysiology of apasmara. The clinical manifestation of ''vataja'' apasmara may be due to repeated, excess, hyposynchronous discharges in neurons of the central nervous system. Transient hypoxia leading to dysregulation of brain functioning, and neurological diseases similar to epilepsy syndromes can be categorized under this type of apasmara.

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In ''pitta apasmara'', the frequency, duration of paroxysms will be comparatively less than those observed in ''vata'' type. The ''ushna'' (hot) and ''tikshna'' (acrid) attributes of ''pitta'' are responsible for the pathology of paroxysms. ''Sadhaka pitta'' located at the heart and the functions responsible for accomplishment of activities are responsible for this apasmara. ''Tamahpravesha'' is a sign primarily of ''pitta''-dominance in which metabolism or transformation at the cellular level might be an underlying pathology. Derangement of ''sadhaka pitta'' implies the decrement or depletion in psychological performance in apasmara patients. Since ''pitta'' is responsible for all metabolic activities, the derangement of metabolism at the cellular level is an important pathological factor and the enzymatic pathways might be held responsible. The types of epileptic syndromes originating due to metabolic disorders like hepatic encephalopathy can be categorized under this type. Changes in body temperature, excess thirst, and perspiration are specific differentiating features of ''pitta apasmara''. The cerebral conditions due to derangement of metabolisms can be enlisted here.

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In ''[[pitta]] apasmara'', the frequency, duration of paroxysms will be comparatively less than those observed in ''[[vata]]'' type. The ''ushna'' (hot) and ''tikshna'' (acrid) attributes of ''[[pitta]]'' are responsible for the pathology of paroxysms. ''Sadhaka pitta'' located at the heart and the functions responsible for accomplishment of activities are responsible for this apasmara. ''Tamahpravesha'' is a sign primarily of ''[[pitta]]''-dominance in which metabolism or transformation at the cellular level might be an underlying pathology. Derangement of ''sadhaka pitta'' implies the decrement or depletion in psychological performance in apasmara patients. Since ''[[pitta]]'' is responsible for all metabolic activities, the derangement of metabolism at the cellular level is an important pathological factor and the enzymatic pathways might be held responsible. The types of epileptic syndromes originating due to metabolic disorders like hepatic encephalopathy can be categorized under this type. Changes in body temperature, excess thirst, and perspiration are specific differentiating features of ''[[pitta]] apasmara''. The cerebral conditions due to derangement of metabolisms can be enlisted here.

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In cases of ''kaphaja apasmara'', the ''sthira'' (stable), ''manda'' (slow), and ''snigdha'' (unctuous) attributes of ''kapha'' are responsible for delayed onset, prolonged duration as well as minimal frequency of paroxysms in apasmara. Excessive sleep and hypothermia specifically suggest ''kaphaja apasmara''. Hypoperfusion and hypovolemic conditions leading to cerebral dysfunction can be considered as attributes of ''kaphaja apasmara''.

+

In cases of ''kaphaja apasmara'', the ''sthira'' (stable), ''manda'' (slow), and ''snigdha'' (unctuous) attributes of ''[[kapha]]'' are responsible for delayed onset, prolonged duration as well as minimal frequency of paroxysms in apasmara. Excessive sleep and hypothermia specifically suggest ''kaphaja apasmara''. Hypoperfusion and hypovolemic conditions leading to cerebral dysfunction can be considered as attributes of ''kaphaja apasmara''.

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Finally, the ''sannipatika'' type of apasmara presents itself with complex mixed features due to overlapping of all ''~~doshas~~''. The prognosis is poor leading to incurability of disease. This might be a mixed presentation of neuronal, endocrinal, circulatory and metabolic pathways.

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Finally, the ''sannipatika'' type of apasmara presents itself with complex mixed features due to overlapping of all ''[[dosha]]s''. The prognosis is poor leading to incurability of disease. This might be a mixed presentation of neuronal, endocrinal, circulatory and metabolic pathways.

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While considering the clinical pictures of a disease, the attributes of ''~~doshas~~'' responsible for variation in pathologies at somatic and psychological level should be emphasized. Important mechanisms of loss of consciousness and abnormal movements at the somatic level, and impairment of intelligence and memory at psycho-pathological levels needs to be focused. The epigenetic patterns related to particular signs and symptoms originated from ''doshic'' pathologies can be researched to reveal new treatment methods and management aspects. The genetic constitution of a person plays a significant role in making him prone to developing certain type of disorders. Therefore, as discussed above for ''vata apasmara'' can become more apparent after taking ''vata''-aggravating diet and lifestyle in ''vata prakriti'' individuals that can get alleviated by using ''vata shamana'' (i.e., ''vata''-pacifying) diet and lifestyle. Furthermore, if anti-epileptic drugs are used more judiciously depending upon the ''dosha'' and ''prakriti''-specific diagnosis, then the treatment regimen can be made much more precise leading to beneficial results in patients. As discussed in the section of predisposing factors, the preventive lifestyle and dietary regimens can be designed to prevent incidence of epilepsy, reduce the dose of drugs with supportive diet and lifestyle therapy and prevent further progression of disease. Therefore, training of epileptics regarding causative and avoidable factors is of utmost importance. The epigenetic variations in epileptics due to enlisted causative agents should be studied as a part of genomic and proteomic research.

+

While considering the clinical pictures of a disease, the attributes of ''[[dosha]]s'' responsible for variation in pathologies at somatic and psychological level should be emphasized. Important mechanisms of loss of consciousness and abnormal movements at the somatic level, and impairment of intelligence and memory at psycho-pathological levels needs to be focused. The epigenetic patterns related to particular signs and symptoms originated from ''doshic'' pathologies can be researched to reveal new treatment methods and management aspects. The genetic constitution of a person plays a significant role in making him prone to developing certain type of disorders. Therefore, as discussed above for ''[[vata]] apasmara'' can become more apparent after taking ''[[vata]]''-aggravating diet and lifestyle in ''[[vata]] [[prakriti]]'' individuals that can get alleviated by using ''[[vata]] shamana'' (i.e., ''[[vata]]''-pacifying) diet and lifestyle. Furthermore, if anti-epileptic drugs are used more judiciously depending upon the ''[[dosha]]'' and ''[[prakriti]]''-specific diagnosis, then the treatment regimen can be made much more precise leading to beneficial results in patients. As discussed in the section of predisposing factors, the preventive lifestyle and dietary regimens can be designed to prevent incidence of epilepsy, reduce the dose of drugs with supportive diet and lifestyle therapy and prevent further progression of disease. Therefore, training of epileptics regarding causative and avoidable factors is of utmost importance. The epigenetic variations in epileptics due to enlisted causative agents should be studied as a part of genomic and proteomic research.

=== Differential diagnosis of apasmara ===

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Other disorders such as ''mada'' (intoxication) and ''murchcha'' (syncope) also show the signs of loss of consciousness, but ones without convulsions. In ''unmada'', there is impairment of ''buddhi'', and it does not manifest itself with loss of consciousness. ''Akshepa'' (abnormal movements) is a ''vata''-predominant disease characterized with convulsions, but the consciousness is intact and there is no froth discharge. This makes apasmara a distinct disease apart from other disorders.

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Other disorders such as ''mada'' (intoxication) and ''murchcha'' (syncope) also show the signs of loss of consciousness, but ones without convulsions. In ''unmada'', there is impairment of ''[[buddhi]]'', and it does not manifest itself with loss of consciousness. ''Akshepa'' (abnormal movements) is a ''[[vata]]''-predominant disease characterized with convulsions, but the consciousness is intact and there is no froth discharge. This makes apasmara a distinct disease apart from other disorders.

=== Prognosis of apasmara ===

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Epilepsy due to vitiation of all the three ~~doshas~~ and showing all clinical features of the ''sannipatika'' variant (i.e., of all the other three ''doshic'' variants) is chronic in nature and that, which has occurred in a person with excess degenerative condition and depleted ''~~dhatus~~'', is considered incurable. In case of degenerative conditions and chronic diseases, any case of apasmara due to vitiation of even a single ''dosha'' can be considered incurable.

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Epilepsy due to vitiation of all the three [[dosha]]s and showing all clinical features of the ''sannipatika'' variant (i.e., of all the other three ''doshic'' variants) is chronic in nature and that, which has occurred in a person with excess degenerative condition and depleted ''[[dhatu]]s'', is considered incurable. In case of degenerative conditions and chronic diseases, any case of apasmara due to vitiation of even a single ''[[dosha]]'' can be considered incurable.

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Bad prognostic signs of apasmara patients can often turn fatal. If one, in his wakeful state sees darkness where there is no darkness and hears all types of sound even when there is no sound, he succumbs to apasmara. If a patient, while dancing in an intoxicated state is caught by a ''preta'' (soul of a dead person) with his head facing downwards, he is sure to succumb to an attack of apasmara.

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Bad prognostic signs of apasmara patients can often turn fatal. If one, in his wakeful state sees darkness where there is no darkness and hears all types of sound even when there is no sound, he succumbs to apasmara. If a patient, while dancing in an intoxicated state is caught by a ''preta'' (soul of a dead person) with his head facing downwards, he is sure to succumb to an attack of apasmara.

=== Reasons behind aggressive and dormant stages of apasmara ===

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From the above sections, it is clear that apasmara occurs in episodes. The patient after seizure regains consciousness like waking up from sleep (''suptavat pratibuddhyate''). Therefore, there are two stages of disease : one is aggressive stage of ''~~doshas~~'' and the second is dormant stage of ''~~doshas~~''. Sushruta describes that there are two forms of pathogenesis: One form follows the six stages viz. ''sanchaya'' etc.(''kramopayogad'') of the disease in sequence and takes considerable time to manifest disease with gradual onset. The other form manifests acutely in a short time (''kshanikatwat''). The first form is seen in ''nija'' (endogenous) pathologies of disease. The other form is seen in ''agantu'' (exogenous) apasmara. Sushruta gives examples of a seed in the ground that sprouts only during ''sharad ritu'' (autumn) though it rains at other times. Analogous to this example, the virulent form of the disease develops due to a ''dosha'' getting aggravated in very short time and manifesting its different symptoms due to some factors catalyzing the accelerated aggravation. It is quite clear from the detailed descriptions in this chapter, though, that all forms of apasmara are caused by ''dosha'' only. [Su.Sa.Uttara Tantra 61/1821]

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From the above sections, it is clear that apasmara occurs in episodes. The patient after seizure regains consciousness like waking up from sleep (''suptavat pratibuddhyate''). Therefore, there are two stages of disease : one is aggressive stage of ''[[dosha]]s'' and the second is dormant stage of ''[[dosha]]s''. Sushruta describes that there are two forms of pathogenesis: One form follows the six stages viz. ''sanchaya'' etc.(''kramopayogad'') of the disease in sequence and takes considerable time to manifest disease with gradual onset. The other form manifests acutely in a short time (''kshanikatwat''). The first form is seen in ''nija'' (endogenous) pathologies of disease. The other form is seen in ''agantu'' (exogenous) apasmara. Sushruta gives examples of a seed in the ground that sprouts only during ''sharad ritu'' (autumn) though it rains at other times. Analogous to this example, the virulent form of the disease develops due to a ''[[dosha]]'' getting aggravated in very short time and manifesting its different symptoms due to some factors catalyzing the accelerated aggravation. It is quite clear from the detailed descriptions in this chapter, though, that all forms of apasmara are caused by ''[[dosha]]'' only. [Su.Sa.Uttara Tantra 61/1821]

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The example states the fact that favorable environment for precipitating factors plays major role in disease episodes. Depending upon the defense system of the body – its natural and acquired immunity - as the background for disease and factors aggravating the ''dosha'' as offending agents, the interaction between the two defines severity, intensity and frequency of occurrence of episodes of disease as shown in chart. [ Fig.4: Manifestation of episodes ]

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The example states the fact that favorable environment for precipitating factors plays major role in disease episodes. Depending upon the defense system of the body – its natural and acquired immunity - as the background for disease and factors aggravating the ''[[dosha]]'' as offending agents, the interaction between the two defines severity, intensity and frequency of occurrence of episodes of disease as shown in chart. [ Fig.4: Manifestation of episodes ]

[[File:mainfastation.png|500px|'''Fig.4: Manifestation of episodes'''|thumb]]<br>

Therefore, for prevention and management of a disease, it is important either to build up the strength of defense system i.e. improving the ''sharira bala'' (physical strength) and ''sattva bala'' (mental strength), or pacify/weaken the aggravating causative factors or both.

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=== Management of apasmara ===

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Although the management of apasmara is described further in [[Chikitsa Sthana]], principles of management are given in this chapter. The curable types of epilepsy should be carefully treated with strong elimination and alleviation therapies according to the vitiated dosha. ''~~Doshas~~'' present in the vessels above the heart need to be removed which require strong measures requiring medicines having higher penetrability, higher potency and highest bio-availability. With this objective, ''tikshna samshodhana'' (strong elimination) and ''samshamana'' (alleviation therapies) are employed. When extrinsic causative factors are involved (''agantu apasmara''), then ''mantras'' etc., will be useful.

+

Although the management of apasmara is described further in [[Chikitsa Sthana]], principles of management are given in this chapter. The curable types of epilepsy should be carefully treated with strong elimination and alleviation therapies according to the vitiated [[dosha]]. ''[[Dosha]]s'' present in the vessels above the heart need to be removed which require strong measures requiring medicines having higher penetrability, higher potency and highest bio-availability. With this objective, ''tikshna samshodhana'' (strong elimination) and ''samshamana'' (alleviation therapies) are employed. When extrinsic causative factors are involved (''agantu apasmara''), then ''mantras'' etc., will be useful.

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The rationale behind advocating strong elimination therapies is the deeper location and excess vitiated state of ''[[dosha]]s''. As described in patho-physiology earlier the ''[[dosha]]'' are in dormant state in the vessels above heart. Therefore to remove these ''[[dosha]]'', strong eliminatory therapies are needed. The strength of the prescribed medicine is decided by their higher penetrability, potency and bio-availability.

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The rationale behind advocating strong elimination therapies is the deeper location and excess vitiated state of ''doshas''. As described in patho-physiology earlier the ''dosha'' are in dormant state in the vessels above heart. Therefore to remove these ''dosha'', strong eliminatory therapies are needed. The strength of the prescribed medicine is decided by their higher penetrability, potency and bio-availability.

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=== Practical application of principles ===

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#Clinical correlation with modern radiological investigations like CT etc. and EEG for better clinical diagnosis of apasmara

#Enlisting newly introduced disease commonly observed in society into the umbrella of apasmara e.g. Alzheimer’s dementia, depression etc.

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#Retrospective analyses of all signs and symptoms enlisted in the modern text books and formulating probable ''samprapti'' / pathophysiology (''dosha-dushya sammurchchna'') based on ''dosha'' dominance behind manifestation of each sign and symptom can be formulated for better understanding in Ayurvedic perspective.

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#Retrospective analyses of all signs and symptoms enlisted in the modern text books and formulating probable ''samprapti'' / pathophysiology (''dosha-dushya sammurchchna'') based on ''[[dosha]]'' dominance behind manifestation of each sign and symptom can be formulated for better understanding in Ayurvedic perspective.

#Assessment criteria in [[Ayurveda]] and modern science, modern investigation methods and technologies, biomarkers which are well established may be enlisted.

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* [[Apasmara Chikitsa]]

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==References==

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