Changes

'''b) Rapid eye-movement (REM) sleep.'''

'''b) Rapid eye-movement (REM) sleep.'''

NREM sleep is divided further into four stages based on variations in brain wave patterns, eye movements, and muscle tone. In the course of a period of sleep, NREM and REM sleep alternate cyclically. A normal sleep episode begins with a short period of NREM stage 1, progressing through stage 2, followed by stages 3 and 4, and finally to REM. The individuals do not remain in REM sleep throughout the night. The cycle between the stages of NREM and REM continues.  NREM sleep constitutes about 75 -80% of the total duration of sleep, and REM sleep constitutes the remaining 20 – 25%. The function of cyclic change between these two types of sleep is not yet understood.

NREM sleep is divided further into four stages based on variations in brain wave patterns, eye movements, and muscle tone. In the course of a period of sleep, NREM and REM sleep alternate cyclically. A normal sleep episode begins with a short period of NREM stage 1, progressing through stage 2, followed by stages 3 and 4, and finally to REM. The individuals do not remain in REM sleep throughout the night. The cycle between the stages of NREM and REM continues.  NREM sleep constitutes about 75 -80% of the total duration of sleep, and REM sleep constitutes the remaining 20 – 25%.<ref>Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 2, Sleep Physiology. Available from: https://www.ncbi.nlm.nih.gov/books/NBK19956/</ref> The function of cyclic change between these two types of sleep is not yet understood.

However, irregular cycling or absent sleep stages are associated with sleep disorders.  E.g. Individuals with narcolepsy enter sleep directly into REM sleep instead of entering sleep through NREM.  

However, irregular cycling or absent sleep stages are associated with sleep disorders.<ref>Zepelin H, Siegel JM, Tobler I. Mammalian sleep. In: Kryger MH, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia: Elsevier/Saunders; 2005. pp. 91–100</ref> E.g. Individuals with narcolepsy enter sleep directly into REM sleep instead of entering sleep through NREM.<ref>Carskadon M, Dement W. Normal human sleep: An overview. In: Kryger MH, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia: Elsevier Saunders; 2005. pp. 13–23.</ref>

There are seven types of sleep based on the causes of sleep.  

There are seven types of sleep based on the causes of sleep.  

*Parasomnias  

*Parasomnias  

*Sleep-related movement disorders and other sleep disorders.  

*Sleep-related movement disorders and other sleep disorders.<ref>Michael J. Sateia , MD, International Classifi cation of Sleep Disorders-Th ird Edition Highlights and Modifications, Contemporary Reviews in Sleep Medicine, 146#5 CHEST NOVEMBER 2014 :1387-1394</ref>

As per Ayurveda, the clinical presentations of sleep disorders may be broadly classified into two types.

As per Ayurveda, the clinical presentations of sleep disorders may be broadly classified into two types.

Excess consumption of fats in the diet causes excess accumulation of fat (medas) and [[kapha dosha]]. This leads to obstruction in body channels, heaviness in the body and lethargy. This causes excessive sleep or hypersomnolence. [A. S. Sutra Sthana 9/30-33]

Excess consumption of fats in the diet causes excess accumulation of fat (medas) and [[kapha dosha]]. This leads to obstruction in body channels, heaviness in the body and lethargy. This causes excessive sleep or hypersomnolence. [A. S. Sutra Sthana 9/30-33]

Narcolepsy is a chronic neurological disorder that affects the brain’s ability to control sleep-wake cycles. People with narcolepsy have excessive, uncontrollable daytime sleepiness. They may also suddenly fall asleep at any time, during any kind of activity. The exact cause of narcolepsy is unknown in contemporary sciences. People with type 1 narcolepsy have low levels of the chemical hypocretin, which is an important neurochemical that regulates wakefulness and REM sleep.The relation between high-fat diet and narcolepsy needs further research.  

Narcolepsy is a chronic neurological disorder that affects the brain’s ability to control sleep-wake cycles. People with narcolepsy have excessive, uncontrollable daytime sleepiness. They may also suddenly fall asleep at any time, during any kind of activity. The exact cause of narcolepsy is unknown in contemporary sciences. People with type 1 narcolepsy have low levels of the chemical hypocretin, which is an important neurochemical that regulates wakefulness and REM sleep.<ref>Available from : https://www.mayoclinic.org/diseases-conditions/narcolepsy/symptoms-causes/syc-20375497</ref>The relation between high-fat diet and narcolepsy needs further research.  

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*[[Vata dosha]] predominant diseases, [[vata dosha]] dominance in basic body constitution ([[prakriti]]), aggravation of [[vata]] / [[vata]] along with [[pitta]] in the body due to any cause[Cha.Sa.[[Sutra Sthana]]21/55-57], [A. S. Sutra Sthana 9/34-36]

*[[Vata dosha]] predominant diseases, [[vata dosha]] dominance in basic body constitution ([[prakriti]]), aggravation of [[vata]] / [[vata]] along with [[pitta]] in the body due to any cause[Cha.Sa.[[Sutra Sthana]]21/55-57], [A. S. Sutra Sthana 9/34-36]

Research shows an increased prevalence of insomnia in women and older adults. In women, insomnia is more prevalent during menarche and menopause.Comorbid medical disorders, psychiatric disorders, and night duties or rotating shifts are significant risks for insomnia.

Research shows an increased prevalence of insomnia in women and older adults.<ref>National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005.</ref> In women, insomnia is more prevalent during menarche and menopause.<ref>Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSMIV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics. 2006;117:e247–56</ref>Comorbid medical disorders<ref>Clinical correlates of insomnia in patients with chronic illness.Katz DA, McHorney CA,Arch Intern Med. 1998 May 25; 158(10):1099-107.</ref>,psychiatric disorders<ref>Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?Ford DE, Kamerow DBJAMA. 1989 Sep 15; 262(11):1479-84.</ref>, and night duties or rotating shifts<ref>Insomnia: epidemiology, characteristics, and consequences.Roth T, Roehrs T, Clin Cornerstone. 2003; 5(3):5-15.</ref> are significant risks for insomnia.

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Loss of sleep causes body ache, heaviness in the head, frequent yawning, stiffness, tiredness, giddiness, impaired digestion, stupor, and other [[vata]] predominant diseases. [A.S. Sutra Sthana 9/37] Suppression of natural sleep urge causes frequent yawning, body ache, stupor, diseases of head, and heaviness of eyes. [Cha. Sa. [[Sutra Sthana]] 7/23]

Loss of sleep causes body ache, heaviness in the head, frequent yawning, stiffness, tiredness, giddiness, impaired digestion, stupor, and other [[vata]] predominant diseases. [A.S. Sutra Sthana 9/37] Suppression of natural sleep urge causes frequent yawning, body ache, stupor, diseases of head, and heaviness of eyes. [Cha. Sa. [[Sutra Sthana]] 7/23]

The persons with insomnia can develop the conditions causing hypoxemia and dyspnoea, gastroesophageal reflux disease, pain conditions, and neurodegenerative diseases.  Among the primary sleep disorders, restless legs syndrome (RLS), periodic limb movement disorders (PLMD), and sleep-related breathing disorders (snoring, dyspnoea, sleep apnoea) often present with an insomnia symptom.  

The persons with insomnia can develop the conditions causing hypoxemia and dyspnoea, gastroesophageal reflux disease, pain conditions, and neurodegenerative diseases.<ref>Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007;3(5 Suppl):S7-S10.</ref> Among the primary sleep disorders, restless legs syndrome (RLS), periodic limb movement disorders (PLMD), and sleep-related breathing disorders (snoring, dyspnoea, sleep apnoea) often present with an insomnia symptom.<ref>The impact and prevalence of chronic insomnia and other sleep disturbances associated with chronic illness.Ancoli-Israel S, Am J Manag Care. 2006 May; 12(8 Suppl):S221-9.</ref>

Research shows a relationship between inadequate sleep and medical conditions like hypertension,  obesity and type-2 diabetes, cardiovascular disease and arrhythmias,mood disorders,neurodegeneration and dementia,and impaired immune functioning.

Research shows a relationship between inadequate sleep and medical conditions like hypertension<ref>Grandner M, Mullington JM, Hashmi SD, et al. Sleep duration and hypertension: Analysis of > 700,000 adults by age and sex. J Clin Sleep Med. 2018;14(6):1031–1039. doi: 10.5664/jcsm.7176.</ref>,  obesity and type-2 diabetes<ref>Reutrakul S, Van Cauter E. Sleep influences on obesity, insulin resistance, and risk of type 2 diabetes Metabolism. 2018;84:56–86. doi: 10.1016/j.metabol.2018.02.010.</ref>, cardiovascular disease and arrhythmias <ref>Gottlieb DJ, Somers VK, Punjabi NM, Winkelman JW. Restless legs syndrome and cardiovascular disease: a research roadmap. Sleep Med. 2017;31:10-17. doi:10.1016/j.sleep.2016.08.008</ref> <ref>May AM, Van Wagoner DR, Mehra R. OSA and cardiac arrhythmogenesis: mechanistic insights [published online September 29, 2016] Chest. 2017;151(1):225–241. doi: 10.1016/j.chest.2016.09.014.</ref>,mood disorders<ref>Lyall LM, Wyse CA, Graham N, et al. Association of disrupted circadian rhythmicity with mood disorders, subjective wellbeing, and cognitive function: a cross-sectional study of 91 105 participants from the UK Biobank Lancet Psychiatry. 2018;5(6):507–514. doi: 10.1016/S2215-0366(18)30139-1.</ref>,neurodegeneration and dementia<ref>Pillai JA, Leverenz JB. Sleep and neurodegeneration: a critical appraisal Chest. 2017;151(6):1375–1386. doi: 10.1016/j.chest.2017.01.002</ref> <ref>Sprecher KE, Koscik RL, Carlsson CM, et al. Poor sleep is associated with CSF biomarkers of amyloid pathology in cognitively normal adults. Neurology. 2017;89(5):445-453. doi:10.1212/WNL.0000000000004171</ref>,and impaired immune functioning.<ref>Watson NF, Buchwald D, Delrow JJ, et al. Transcriptional Signatures of Sleep Duration Discordance in Monozygotic Twins. Sleep. 2017;40(1):zsw019. doi:10.1093/sleep/zsw019</ref>

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Diseases of head, giddiness, disorientation, obstruction in body channels, hampered digestion, edema, nausea, nasal discharge, pain in one side of head, itching, pain and eruptions over skin, stupor, throat diseases, augmented activity of poisons are the untoward effects of improper and untimely sleep. [A.S. Sutra Sthana 9/30-33]  

Diseases of head, giddiness, disorientation, obstruction in body channels, hampered digestion, edema, nausea, nasal discharge, pain in one side of head, itching, pain and eruptions over skin, stupor, throat diseases, augmented activity of poisons are the untoward effects of improper and untimely sleep. [A.S. Sutra Sthana 9/30-33]  

The International Classification of Sleep Disorders (ICSD-2) includes “excessive daytime sleepiness” (EDS) as an essential feature for three diagnostic categories: narcolepsy, hypersomnia and behaviourally induced insufficient sleep syndrome. It is also associated with various diseases, including psychiatric and neurological disorders, pulmonary and cardiac conditions.  

The International Classification of Sleep Disorders (ICSD-2) includes “excessive daytime sleepiness” (EDS) as an essential feature for three diagnostic categories: narcolepsy, hypersomnia and behaviourally induced insufficient sleep syndrome. It is also associated with various diseases, including psychiatric and neurological disorders, pulmonary and cardiac conditions.<ref>Slater G, Steier J. Excessive daytime sleepiness in sleep disorders. J Thorac Dis. 2012;4(6):608-616. doi:10.3978/j.issn.2072-1439.2012.10.07</ref>

===Indications of day time sleep===

===Indications of day time sleep===

== Current researches==

== Current researches==

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In the conventional management of insomnia, non-benzodiazepine hypnotics are the first line pharmacotherapeutic agents, followed by benzodiazepines, amitriptyline and antihistamines.

In the conventional management of insomnia, non-benzodiazepine hypnotics are the first line pharmacotherapeutic agents, followed by benzodiazepines, amitriptyline and antihistamines.<ref>Saddichha S. Diagnosis and treatment of chronic insomnia. Ann Indian Acad Neurol.2010;13(2):94-102. doi:10.4103/0972-2327.64628</ref>

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!Compound/ single drug !! Ingredients !! Dose/duration/ vehicle

!Compound/ single drug !! Ingredients !! Dose/duration/ vehicle

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|Mamsyadi ghrita  ||Ghee processed with Nardostachys jatamansi(jatamamsi), Convulvulus pluricaulis (shankhapushpi), Withania somnifera(ashwagandha),Valeriana wallichii (tagara) || 20 g twice a day orally with luke warm water for 6 weeks.

|Mamsyadi ghrita<ref>Anil Kumar Singh; A clinical study of manasika bhavas in anidra w.s.r to stress

</ref> ||Ghee processed with Nardostachys jatamansi(jatamamsi), Convulvulus pluricaulis (shankhapushpi), Withania somnifera(ashwagandha),Valeriana wallichii (tagara) || 20 g twice a day orally with luke warm water for 6 weeks.

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|Tagaradi Kwatha ||Nardostachys jatamansi (jatamamsi), Convulvulus pluricaulis (shankhapushpi), Withania somnifera (ashwagandha), Valeriana wallichii (tagara), Bacopa monnieri (brahmi),Vitis vinifera (draksha), Picrorhiza kurrooa (katuki), Hedyotis corymbosa (parpataka), Aegle marmelos(bilwa),Premna Serratifolia/integrifolia(agnimantha), Oroxylum indicum(shyonaka), Stereospermum suaveolens(patala), Gmelina arborea (gambhari), Solanum indicum(bruhati), Solanum xanthocarpum(kantakari),Desmodium gangeticum(shalaparni), Uraria picta(prushniparni), Tribulus terrestris(gokshura), Cyperus rotundus (musta), Pterocarpus santalinus (raktachandana), Cassia fistula(aragwadha) || 40gm/day (In two divided doses each of 20 gms) in decoction form for 6 weeks

|Tagaradi Kwatha<ref>Vansh bina ,A clinical study on Manasika Bhavas in AnidraW.S.R to stress induced insomnia

</ref> ||Nardostachys jatamansi (jatamamsi), Convulvulus pluricaulis (shankhapushpi), Withania somnifera (ashwagandha), Valeriana wallichii (tagara), Bacopa monnieri (brahmi),Vitis vinifera (draksha), Picrorhiza kurrooa (katuki), Hedyotis corymbosa (parpataka), Aegle marmelos(bilwa),Premna Serratifolia/integrifolia(agnimantha), Oroxylum indicum(shyonaka), Stereospermum suaveolens(patala), Gmelina arborea (gambhari), Solanum indicum(bruhati), Solanum xanthocarpum(kantakari),Desmodium gangeticum(shalaparni), Uraria picta(prushniparni), Tribulus terrestris(gokshura), Cyperus rotundus (musta), Pterocarpus santalinus (raktachandana), Cassia fistula(aragwadha) || 40gm/day (In two divided doses each of 20 gms) in decoction form for 6 weeks

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|Parasikayavani capsule || Hyoscyamus niger (parasikayavani)-1/4 part and Nardostachys jatamansi (Jatamansi)-1 part, triturated 7 times in juice of Convulvulus pluricaulis (shankhapushpi) and 7 times in juice of Benincasa hispida (kushmanda)||5 Capsules, with luke warm water, at bed time, for 1 month.

|Parasikayavani capsule<ref>M.P.S.K.R. Muthugala ,Evaluation of Parasikayavanyadi capsule in the management of Anidra W.S.R. to insomnia, MD thesis, IPGT & RA, Jamnagar, 2013.</ref> || Hyoscyamus niger (parasikayavani)-1/4 part and Nardostachys jatamansi (Jatamansi)-1 part, triturated 7 times in juice of Convulvulus pluricaulis (shankhapushpi) and 7 times in juice of Benincasa hispida (kushmanda)||5 Capsules, with luke warm water, at bed time, for 1 month.

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|Apamargadi vati || Achyranthes aspera (apamarga), Asteracantha longifolia (kokilaksha), Perstrophe bicalyculata Linn (kakajangha), Psoralia corylifolia (bakuchi) ||1 gm trice a day, with buffalo milk, for 8 weeks.

|Apamargadi vati<ref>Nirmal Dhamini, Role of Manasa Bhavas in Anidra and its management withcertain indigenous drugs and Shirodhara,(MD thesis), IPGT & RA, Jamnagar, 2004;143-7.</ref> || Achyranthes aspera (apamarga), Asteracantha longifolia (kokilaksha), Perstrophe bicalyculata Linn (kakajangha), Psoralia corylifolia (bakuchi) ||1 gm trice a day, with buffalo milk, for 8 weeks.

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|Powder of root of Piper longum(pippali moola) || -- ||2 gm twice a day with jaggery (guda), after food , for 4 weeks

|Powder of root of Piper longum(pippali moola)<ref>Krutika joshi , A pharmaco clinical evaluation of Pippalimoola (root of piper longum) W.S.R to insomnia, , (PhD thesis), IPGT & RA, Jamnagar,2014</ref> || -- ||2 gm twice a day with jaggery (guda), after food , for 4 weeks

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|Leaf powder of Nardostachys jatamansi (Jatamansi) || -- || 3 gm powder with honey (5g), ½ hour before bed time for 4 weeks.

|Leaf powder of Nardostachys jatamansi (Jatamansi)<ref name=kal>Kalpesh panara , A pharmaco clinical evaluation of Beejapoorapatra (leave of citrus medica linn.) W.S.R to insomnia, (PhD thesis), IPGT & RA, Jamnagar,2014</ref> || -- || 3 gm powder with honey (5g), ½ hour before bed time for 4 weeks.

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|Powder of Citrus medica Linn(beejapura) leaves || -- || 3 gm powder with honey (5g), ½ hour before bed time for 4 weeks

|Powder of Citrus medica Linn(beejapura) leaves<ref name=kal/> || -- || 3 gm powder with honey (5g), ½ hour before bed time for 4 weeks

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|Insomrid tablet || Withania somnifera (ashwagandha), Rauvolfia serpentina (sarpagandha), Nardostachys jatamansi (jatamamsi), Valeriana wallichii (tagara), Hyoscyamus niger (parasika yavani)|| 2 tab (each of 500 mg) in the morning after breakfast and night after the dinner with luke warm milk for 30 days.

|Insomrid tablet<ref>Pokharel S, Sharma AK. Evaluation of Insomrid Tablet and Shirodhara in the management of Anidra (Insomnia). Ayu. 2010;31(1):40-47. doi:10.4103/0974-8520.68209</ref> || Withania somnifera (ashwagandha), Rauvolfia serpentina (sarpagandha), Nardostachys jatamansi (jatamamsi), Valeriana wallichii (tagara), Hyoscyamus niger (parasika yavani)|| 2 tab (each of 500 mg) in the morning after breakfast and night after the dinner with luke warm milk for 30 days.

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The liquids used for Shirodhara in clinical trials are as follow:

The liquids used for Shirodhara in clinical trials are as follow:

*Oil processed with Nardostachys jatamansi (jatamamsi taila)  

*Oil processed with Nardostachys jatamansi (jatamamsi taila)<ref>joshi chinmay-,Comparative study on the effect of Sneha Dhara and Jala Dhara in Anidra,( MD Thesis), IPGT & RA, Jamnagar 2013</ref>

*Decoction of 10 medicinal plant roots known as “Dashamoola” [Aegle marmelos(bilwa),Premna Serratifolia/integrifolia(agnimantha), Oroxylum Indicum(shyonaka), Stereospermum Suaveolens(patala), Gmelina Arborea(gambhari), Solanum Indicum(bruhati), Solanum Xanthocarpum(kantakari),Desmodium gangeticum(shalaparni), Uraria Picta(prushniparni), Tribulus Terrestris(gokshura)]

*Decoction of 10 medicinal plant roots known as “Dashamoola”<ref>Anil Kumar Singh; A clinical study of manasika bhavas in anidra w.s.r to stress

induced chronic insomnia and its management with mamsyadi ghrita and dashamula kwatha shirodhara, (MD thesis),IPGT & RA, Jamnagar, 2007; 204-9</ref> [Aegle marmelos(bilwa),Premna Serratifolia/integrifolia(agnimantha), Oroxylum Indicum(shyonaka), Stereospermum Suaveolens(patala), Gmelina Arborea(gambhari), Solanum Indicum(bruhati), Solanum Xanthocarpum(kantakari),Desmodium gangeticum(shalaparni), Uraria Picta(prushniparni), Tribulus Terrestris(gokshura)]

*Buffalo’s milk (mahisha dugdha)  

*Buffalo’s milk (mahisha dugdha)<ref>Vansh bina ,A clinical study on Manasika Bhavas in AnidraW.S.R to stress induced insomnia

*Ksheerabala taila   

*Ksheerabala taila<ref>Nirmal Dhamini, Role of Manasa Bhavas in Anidra and its management withcertain indigenous drugs and Shirodhara,(MD thesis), IPGT & RA, Jamnagar, 2004;143-7.</ref>  

The duration of the procedure done in the clinical trials ranges from 30-45 minutes daily for 2-3 weeks, preferably in morning. The temperature range of liquid was 38-40 degree Celsius. A clinical trial showed efficacy of lukewarm water as equal to medicated oil in shirodhara procedure. The combined therapy with oral medication and local procedures shows appreciable results in the management of insomnia.

The duration of the procedure done in the clinical trials ranges from 30-45 minutes daily for 2-3 weeks, preferably in morning. The temperature range of liquid was 38-40 degree Celsius.<ref>Pokharel S, Sharma AK. Evaluation of Insomrid Tablet and Shirodhara in the management of Anidra (Insomnia). Ayu. 2010;31(1):40-47. doi:10.4103/0974-8520.68209</ref> A clinical trial showed efficacy of lukewarm water as equal to medicated oil in shirodhara procedure.<ref>joshi chinmay-,Comparative study on the effect of Sneha Dhara and Jala Dhara in Anidra,( MD Thesis), IPGT & RA, Jamnagar 2013</ref> The combined therapy with oral medication and local procedures shows appreciable results in the management of insomnia.

==Theses works ==

==Theses works ==