Light on Ayurveda Journal, Spring 2008: Vol. VI, No. 3

AYURVEDIC MANAGEMENT OF INSOMNIA (ANIDRA)

William Courson, MSNHS, D.Ayur.
Director, New Jersey Institute of Ayurveda

“Dependent on sleep are happiness and misery, corpulence and leanness, strength and weakness, potency and impotency, intellect and non-intellect, life and death. Sleep undertaken untimely, excessively and negatively takes away happiness and life like the other death-night. Sleep, if undertaken properly, provides happiness and life like the flashed true knowledge provided to a yogin.” -
Charka Samhita, Sutrasthana 21:36-38

Scope & Epidemiology

Over one-quarter of the population of the USA report occasional sleep-related problems, while nearly 10% experience chronic insomnia of moderate to severe intensity. According to the U.S. Department of Health and Human Services, approximately 60 million Americans suffer from insomnia each year. Insomnia tends to increase with age and affects about 40 percent of women and 30 percent of men. (1)

Disordered sleep can contribute to or play a primary part in the etiologies of cardiovascular, digestive, hormonal and immune disorders, and can cause emotional disturbances, memory impairment, impaired motor skills, decreased work efficiency, and increased risk of trauma (through traffic accidents, occupational hazards, etc.). Truly, there are few if any realms of bodily or psychological functioning that are left unaffected by sleep. Charaka lists among the results of deficient sleep (Sutrasthana 21:50) chlorosis, headache, sensations of coldness and heaviness in body parts, muscular aches, anorexia, heart irregularities, edema, nausea, rhinitis, urticaria, skin eruptions, fatigue, cough, throat disorders, srotorhoda, fever, sensory deficiencies, and an augmentation of the effects of toxin accumulation. (2)

The most commonly reported sleep disorder is insomnia (anidra). Insomnia is defined as difficulty falling or staying asleep or a sensation of unrefreshing sleep. Insomnia may be treated as a disorder in itself but is often suggestive of the presence of other disorders

Sleep Requirements & Prakruti

According to ayurveda, the amount of sleep required to maintain a state of health depends largely upon an individual’s prakruti and their age (given the predominance of kapha in infancy and childhood, pitta in youth and early adulthood and vata in the aged).

Kapha constitutions require the most sleep: between eight to nine hours nightly in order to feel rested. Kaphaja sleep requirements need to be balanced against the unhealthy propensity of kaphaja individuals to oversleep or engage in day-time sleeping. Consequently, to ensure that a both a sufficient amount of sleep as well as a healthy waking time are attained, kaphas should arrange their schedule so as to provide for 8 to 9 hours of sleep with rising at some point near sunrise, when sattva guna predominates. For example, retiring at 10:00pm will provide a kapha individual with an adequate 8 hours sleep if rising is timed for 6:00pm.

Pittas ordinarily require seven to eight hours sleep, and. Vata types manage with six to seven hours of sleep nightly. Again, so as to ensure both a sufficient amount of sleep as well as a healthy waking time, such individuals should base their time of retiring on the hours of sleep required with a bias toward ensuring awakening at some point close to or before sunrise. By way of illustration, A pitta type retiring at 10:00pm and arising at 5:00am will have enjoyed 7 hours sleep, while a vata type retiring at 10:00pm and rising at 4:00am will have experienced a sleep of 6 hours, all of which are generally speaking doshically appropriate in an otherwise healthy and normal individual.

Sleep requirements also vary according to age or stage of life. Infants can sleep as much as 15 or 16 hours out of every 24 while young children frequently sleep 10 hours or more daily. At the other extreme, the elderly rarely enjoy a sound, unbroken sleep of more than four to six hours.

Classification & Etiology

Insomnia (Sanskrit: anidra) may be of two types: initial insomnia (difficulty falling asleep) and sleep maintenance insomnia (difficulty maintaining sleep). Insomnia can also be classified in terms of its duration: transient, short-term, or chronic. Transient and short-term insomnia are caused by similar factors, but short-term insomnia usually requires a greater disturbance.

Transient insomnia can be described as lasting from one night to a few weeks and is usually caused by events that alter normal sleep pattern, such as traveling or sleeping in an unaccustomed environment.

Short-term insomnia ordinarily lasts about two to three weeks and is usually attributed to emotional factors such as anxiety or stress.

Chronic insomnia is seen to occur most nights and may last for a period of months.

Insomnia is also classified on the basis of the dosha(s) involved in its manifestation.

Insomnia is an almost pathognomonic sign of nervous distress, and chronic insomnia is most frequently a sign of vata derangement involving nervous tension, ungroundedness, anxiety, hyperactivity and hypersensitivity. Dreams may be frightening, and accompanied by the sensations of rapid movement, running, flying, falling or being pursued or assailed by hostile entities.

Vataja insomnia most often correlates with initial insomnia (difficulty in falling asleep). Vataja insomnia can also arise out of suppressed urges (especially those of the need for sexual contact and of yawning) leading to an excess of prana and the drying up of ojas.(3) Insomnia is one of the signs of the sancaya (accumulation) phase of vata vitiation. (4) Insomnia can also present if apan vayu is provoked in the artavavaha srota during the female’s periods of ovulation as is often the case. (5) Vata dosha crests in its activity between the hours of 2:00am and 6:00am, and sleep interruptions during this period may indicate the presence of vata factors in cases of insomnia.

Pittaja insomnia most often correlates with sleep maintenance insomnia (difficulty in maintaining uninterrupted sleep). Pitta-type insomnia involves dysphoric emotional states, irritability, jealousy, anger, resentment and hatred and may follow in the wake of an argument or relational upset, or accompany a febrile or infectious condition. Dreams may be dramatic, violent, confrontational or otherwise be the venue of charged, highly emotional states. Sleep is often agitated and accompanied by jerking movements or may be broken, although the subject is usually able to return to sleep. Causes may include unresolved emotions, excessive willfulness, the desire for spitefulness or revenge or may accompany the over-consumption of hot or stimulating foods or overexposure to heat. It has been suggested by some nutritionists that a deficiency of dietary calcium and magnesium may play a role in this variety of insomnia. (6) Increased medda dhatvagni, often seen existing with heightened pitta, can also give rise to insomniac symptoms. (7) Insofar as pitta dosha tends to crest in its activity between the hours of 10:00pm and 2:00am, sleep interruptions during this period may betoken a pittaja type of insomnia.

Kapha tends toward excessive sleep, thus insomnia infrequently results from a derangement of kapha unless other doshas are involved, which oftimes manifests as a congestive disorder such as is the case with sleep apnea. Kapha individuals exposed to cold or damp environments are susceptible to mucous blockages in the nose, ear, and throat, giving rise to aggravation of kapha accompanied by headaches and respiratory difficulty which can seriously compromise the quality and quantity of sleep, since the nasal area is a center of the nervous system. Additionally, kapha’s tendency toward obesity places an undue mechanical tax on respiration resulting in sleep apnea, with periodic, unconscious interruptions in the sleep cycle. Sometimes kaphaja insomnia is characterized by early-morning awakening, and a feeling of sluggishness and exhaustion even following an ostensibly full night's sleep. (8)

Kapha dosha crests in its activity between the hours of 6pm and 10:00pm, as well as 6am and 10:00am. Sleep interruptions during this period may indicate the presence of kapha factors in cases of insomnia.

According to ayurveda, the following are the general types of imbalances at the source of most chronic conditions, including insomnia:

· Toxic accumulations (ama) in tissues and srotas
Inferior or inadequate nutrition, or improper food combining
Impaired digestive capacity (agni)
Imbalance of the nervous system and accumulation of physical and mental stress
· Impaired immune response
· Disruption of natural biological rhythms via environmental factors
· Trauma

Insomnia may in addition to the foregoing be caused by one or more of the following factors:

· Chronic medical illnesses - Certain medical illness can interfere with sleep, especially disorders of the heart (congestive heart failure) and lungs (chronic obstructive pulmonary disease), heartburn, prostatic disorders evinced by polyuria, menopause, diabetes, arthritis, hyperthyroidism and hypoglycemia.
· Sleep disordered breathing - Disorders of sleep that cause one to stop breathing while asleep may fragment sleep and cause frequent awakenings, as is the case with sleep apnea.
· Psychophysiologic ("learned") insomnia - Many people go to bed worrying about insomnia because of previous episodes. This creates an anxiety about going to sleep, which usually leads to greater difficulty sleeping.
· Biological factors – with increasing age (and the attendant onset of vata-predominance after menopause/andropause), sleep becomes lighter and more fragmented
· Lifestyle factors - Excessive caffeine consumption, alcohol and drug abuse, smoking, over-work or over-exercise and poor sleeping habits as well as the presence of other identifiable vata-related disorders (Charaka, Sutrasthana 21:55-57).
· Other causes may include the aftereffects of ayurvedic purgation and emesis, bloodletting, fasting, predominance of sattva and the suppression of tamas, late evening eating and the consumption of curd at night, late night reading, sexual overindulgence, and the result of an innately insomniac nature. (9)

Hygiene & Preventive Measures

Several steps can be taken to preclude the onset of insomnia or minimize its intensity. These include:

Develop a regular sleeping schedule. Avoid daytime sleeping and stimulating activities just before bedtime.
· Avoid stimulating drugs such as caffeine and nicotine before retiring.
· Exercise during the day (but not in the late evening).
· Avoid alcohol, which can severely disrupt sleep patterns.
· Minimize light and noise when trying to sleep.
· Maintain a comfortable bedroom temperature.
· Avoid heavy meals shortly before bedtime. Ideally, eat the last meal of the day shortly before sunset, followed two hours later by a bath in lukewarm water after which one should retire, preferably listening to either drone instruments, the sound of rustling leaves or other tranquil sounds.
· Rinse the eyes with rosewater, then add a drop of ghee (clarified butter) into each eye. Keep the eyes closed and sleep.
· Comb the hair before retiring.
· Massage feet, calves, nape of the neck and shoulders with ghee.
· Take medications that may be stimulating, or those that may cause you to wake up to urinate long before bedtime.
· Increase exposure to sunlight in the morning, and avoid it later in the afternoon (5-6 PM).
· Sexual activity with one’s partner may promote sleep. Orgasm triggers a surge in the body’s production of oxytocin and endorphins that may act as sedation One study found that 32 percent of 1,866 U.S. females engaged in sexual activity for the purpose of, inter alia, promoting sleep. (16) Per ayurveda, sexual contact should ideally be initiated not less than 2 hours after eating one’s evening meal.

Additionally, there are some behavioral techniques that can be very helpful in treating insomnia, including relaxation therapy, sleep restriction, stimulus control, and cognitive therapy. Meditation and certain yoga asanas are also of great usefulness.(10) Chanting of the bij mantra “ram” is said to be especially beneficial. (11)

Sage Charaka employed a range of therapies in managing insomnia:

Massage, anointing, baths, meat-soups of domestic, aquatic and marshy animals, rice with curd, milk, fat, wine, mental ease, pleasant smells and sounds, gentle rubbing, saturating drops and paste on eyes, head and face, a well-covered bed, comfortable room and proper time, including establishing the same time each night – these bring shortly the sleep which has been disturbed by some factor.” Charaka Samhita, Sutrasthana 21:52-54

If insomnia is of the vataja type, the patient should follow a vata-pacifying diet emphasizing sweet, sour and salty-tasting foods that are well-cooked and served warm. If pitta or kapha involvement is seen, the diet should be appropriately adjusted to pacify those doshas. A regular schedule should be adhered to, with set times for retiring and arising, work, recreation and taking meals.

Massaging the scalp, hands and (especially) feet (with warmed sesame oil or ghee for vata, coconut oil for pitta and mustard oil for kapha) will prove useful, as will shirodhara. Select yoga asanas should be done, but aerobic exercise avoided.

Treatment of the Shankha marma (temple marma point on either side of the skull) with gentle finger pressure and the application of Brahmi Taila or rose, sandalwood or lotus oils using alternating clockwise and counterclockwise circular movements may be useful. (12)

The use of the following essential oils on the pulse points or in conjunction with marma therapy and/or shirodhara is recommended: lavender , blue chamomile, mandarin, neroli, nutmeg, tangerine, valerian root, vetiver and/or hops (13).

Especially useful herbs include tagarah (Valeriana wallachi, VPK-), jatamansi (Nardostachys grandiflora, VPK=), gokshura (Tribulus terrestris, VPK=, primarily V-), jaiphal (Myristica fragrans, VK-P+), ashwagandha (Withania somnifera, VK-), bala (Sida cordifolia, VPK=), brahmi (Bacopa monniera, VPK=, V+ in high doses) and Mandukaparni (Centella asiatica, VPK=, primarily KP-). (14)

A good formula can be composed of the foregoing utilizing 2 parts ashwagandha, 2 parts tagarah, 1 part jaiphal, and 1 part yashti madhu (licorice, glycorrhiza glabra). In the case of hypertensive patients, de-glychorrhized licorice should be used. For chronic insomnia, 3 to 6 grams are taken with warm milk and ghee or with warm water before bedtime.

When used in pittaja insomnia, tagarah should be omitted as it may aggravate the condition.

Useful Western herbs include skullcap, betony, chamomile, hops and passion flower.(15)

With respect to yogic techniques in the treatment of insomnia, several are particularly beneficial. Including dirga pranayama (the breathing technique known as the ‘three-part breath’) known to calm the mind and ground the attention in the present moment. Ananda balasana (happy baby pose) and Suptabadakonasana (Goddess pose) have the effect of easing tension on the lower back and hips and opening the groin muscles through gentle stretching. These promote deep relaxation, and can be performed in bed. Finally, the posture known as Shavasana (corpse pose) which traditionally ends every yoga class, is an equally appropriate way to end one’s day waking day. This asana helps to create a break from ongoing mental agitation and allows one to process sensory stimuli received through one’s daily conscious activities and interactions, providing an ideal asana to promote deep relaxation and healthful sleep.

NOTES

(1) National Institute of Neurological Disorders and Stroke; Brain Basics: Understanding Sleep (http://www.ninds.nih.gov, retrieved on.12/31/2007)
(2) Van Loon, G.; Charaka Samhita: A Handbook on Ayurveda, Vol. II (Lulu Inc., Morrisville, NC) 2002. pp.651-652
(3) Dash, Vd. Bhagwan; Fundamentals of Ayurvedic Medicine (Konark, Delhi) 1979, pp.70-71
(4) Tirtha, Swami Sadashiva; Ayurvedic Encyclopedia (Ayurvedic Holistic Center Press, Bayville NY) 1998. p. 47
(5) Lad, V.: Textbook of Ayurveda: Fundamental Principles (The Ayurvedic Press, Albuquerque, NM) 2002. p. 176
(6) Frawley, D.; Ayurvedic Healing: A Comprehensive Guide (Motilal Banarsidas Publishers, Delhi) 1989. p. 243
(7) Lad, Op. cit., p. 141
(8) Tirtha, Op.cit., p. 27; p. 36
(9) Frawley, Op.cit., p. 242-243
(10) Frawley, Op.cit., p. 242
(11) Tirtha, Op.cit., p. 112
(12) Frawley, D., Ranade, S. & Lele, A.: Ayurveda & Marma Therapy (Lotus Press, Twin Lakes, WI) 2003. pp. 193-194
(13) Miller, L. & Miller, B: Ayurveda & Aromatherapy (Lotus Press, Twin Lakes, WI) 1995. pp. 263-312
(14) Pole, S.: Ayurvedic Medicine: The Principles of Traditional Practice (Churchill-Livingstone, Philadelphia PA) 2006. p. 338
(15) Frawley, Op.cit., p. 242
(16) Ellison, C.R.: Women’s Sexualities. (New Harbinger Publications, Oakland, CA) 2000, from www.plannedparenthood.org/files/PPFA/fact-sexual-expression.pdf

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