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Apasmara Nidana (view source)

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

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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'' ====

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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.

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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'' ====

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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'' ====

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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'' ====

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''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.

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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 ===

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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/>

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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 ===

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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.

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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.

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|-

! Bhrūvyudāsa

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

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

|-

! Satatam akshi vaikrutam

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

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

|-

! Ashabda shravanam

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

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

|-

! Lala prastrava

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

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

|-

! Singhanaka prastrava

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

+

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

|-

! Anannabhilashanam

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

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

|-

! Arochaka

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

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

|-

! Avipaka

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

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

|-

! Hridaya graham

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

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

|-

! Kukshe aatopa

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

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

|-

! Daurbalyam

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

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

|-

! Asthibheda

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

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

|-

! Angamarda

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

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

|-

! Moha

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

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

|-

! Tamas darshanam

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

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

|-

! Murchcha

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| 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

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| 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

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| 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

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| 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

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| 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

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| dancing || majja

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| dancing || [[majja]]

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! Vyadhana

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| needling like sensation || majja

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| needling like sensation || [[majja]]

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! Vyathana

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| pain || majja

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| pain || [[majja]]

|-

! Vepana

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| tremors || majja

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| tremors || [[majja]]

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! Patanadini

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| falling etc. || rasa-rakta,

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

majja

|-

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−

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.

−

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.

+

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.

−

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''.

−

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.

+

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.

−

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 ===

−

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.

+

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.

+

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.

−

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.

+

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.

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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]]. ''[[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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