Title

Understanding Anxiety disorder from perspective

Presenter Dr. Pooja More

Chair person Dr. Kishore Kumar R Assistant professor of Ayurveda Dept. of Integrative Medicine NIMHANS Contents

• Introduction • Classification of diseases in Ayurveda • Chittodvega w.r.t GAD • Neurobiology of Anxiety Ds • Signs and Symptoms • Line of treatment in Ayurveda • Ayurveda and anxiety (scientific studies)

Introduction

• Mental disorder is mentioned as 3rd health burden in India according WHO survey. • Anxiety disorders - Most prevalent psychiatric condition in the world. • Estimates indicate one year prevalence range from 3 to 8% and lifetime prevalence between 5 to 8%. • Kaplon and shadock 2015

• Usual onset in late adolescence or early adulthood. • GAD - Persistent excessive anxiety and worries about day to day events or activities at least for a period of 6 months.

• Genetic, biochemical, environmental and psychological profiles form major risk factors for GAD

• People having personality traits like anxiety, anger, hostility, impulsiveness, pessimism, and depression are more prone to GAD.

Classification of diseases in Ayurveda

• Diseases have been broadly classified into 3 broad categories.

• These arbitrary demarcations are made only for the clinical advantages . – Sarira vikara (physical diseases) like jvara (fever), atisara (diarrhoea), etc. – Manasavikara (mental disorders) like (desire), soka (grief), abhyasuya (jealousy) etc – Ubhayatmaka vikara (diseases wherein both body and mind are affected) like, unmada (psychosis), apasmara (epilepsy) and similar conditions.

• It is not possible to strictly categorise the diseases as physical, mental etc., since the diseases effect the living body which is a combination of sarira (body ), indriya (senses), satwa (mind) and atma (soul).

• In manasika vikara namely, udvega (anxiety) kama, soka, etc., manas is affected initially and sarira later

Ayurveda

• Ayu : Shareera, Indriya, satva and atma

• Satva = Manas (chitta or chetana)

• Manas – derived from the root ‘mana’ means – Which perceives – Leads to knowledge – Which analyses by special knowledge

• Manas is defined as a substance which establishes the contact between soul and body and which regulates the functions of indriyas.

• Satva, rajas and tamas are the normal characteristics of mana, called as triguna or mahaguna.

Ayurveda

• Anxiety - chittodvega in Ayurveda (mano vikara) • Vitiation of – Rajas and tamas (Mano gunas) – Vata and pitta (sharirika gunas) • Kama, krodha, lobha, moha, irshya, shoka, bhaya • Anidra, daurbalyata. • Medhya drugs have the property of reducing anxiety and promote mental health. • Shirodhara- soothens the mind

Ayurveda

• Chittodvega has been used by Charaka more classically and listed under Manas Dosha Vikara.

• Chittodwega is one among many types of Manasika Vikara explained in Ayurveda.

• ‘Anavasthita Chitta’ is explained under 80 types of Nanatmaja Vata Vikara.

• Rajah and Tamah Manas Doshas are vitiated in chittodvega and person having Alpa Satva are more prone to the disease as Alpa satva indulges in Prajnaparadha. Chittodvega

• Chitta : Derived from root ‘chit’ means ‘to percieve, fix the mind upon, to observe, to aim at, to intend, to understand, to know’.

• Udvega: derived from the root ‘Ud’ means ‘Anxiety, upward movement, separation, upon, on, over’

• So chitta (mind) + udvega (anxiety) = Chittodvega (Anxious state of mind).

According to chakrapani • ‘chitta udvignata chittodvegaha’ Chittodvega

• There is lack of description of about symptomology of Chittodvega in Ayurvedic texts.

• Unmada is a major psychological disorder (impairment of orientation i.e. psychosis).

• Chittodvega is one of the minor psychological disorders (no disorientation as the patient can perform his/her day to day activities without much difficulty i.e. neurosis)

Neurobiology of Anxiety Ds

All anxiety Ds have two components • Fear • Worry

So we need to understand the neurophysiology of both.

• Fear: Un pleasurable emotional state consisting of psychophysiological changes in response to a realistic threat or danger.

• Worry: to think about problems or unpleasant things that might happen in a way that makes you feel unhappy and frightened.

Anxiety can be deconstructed, or broken down, into the two core symptoms of fear and worry. These symptoms are present in all anxiety disorders, although what triggers them may differ from one disorder to the next.

Looking Afraid/ Affect of fear

• Feelings of fear are regulated by reciprocal connections between the amygdala and the anterior cingulate cortex (ACC) and the amygdala and the orbitofrontal cortex (OFC). • Specifically , it may be that over activation of these circuits produces feeling of fear What will you do ?

• Fight ! • Flight !! • Freeze !!! Avoidance/ Fight/Flight/Freeze motor response

• Feelings of fear may be expressed through behaviours such as avoidance which is partly regulated by reciprocal connections between the amygdala and the periaqueductal gray (PAG) . • Avoidance in this sense is a motor response and may be analogous to freezing under threat.

• Other motor responses are to fight or to run away (flight) in order to survive threats from the environment.

GAD vs Chittodvega GAD Chittodvega restlessness, feeling keyed up or on the edge Sammoha (Illusion) Being easily fatigued Ayasa (Easy fatiguability) Intellect/ difficulty concentrating or Unmattchittatvam (Inability to concentrate) mind going blind Shirash Shoonyata (mind going blank) irritability, Krodha (Anger or agression) Somatic (Muscular) /muscle tension Angamarda (aches and pains) Insomnia /Sleep disturbances (difficulty in Anidra (Insomnia), Nidra nasha (disturbed sleep) falling or staying a sleep, or restless unsatisfying sleep Respiratory Symptoms Ucchawasasyadhikyam (Dyspnoea) Gastro Intestinal Symptoms Anannabhilasa (Anorexia) Avipaka (Impaired digestion) Cardio vascular Symptoms Udvega (palpitations) Hridgraha (tightness in chest region) Sensory (Sensory) Swanokarnayo (Tinnitus) Line of treatment

• Acharya Charaka recommends three types of chikitsa.

– Daivavyapasraya chikitsa (Divine/Spiritual therapy): , aushadha (wearing sacred herbs), mani (wearing precious gems), mangala (propitiatory rites), Upahara (offerings), gamana (pilgrimage) etc. – Yukti vyapashraya (Logical therapy): administration of proper diet and medications for shamana and shodhana purpose and then rasayana. – Satwavajaya (Psychotherapy) : Counselling to avoid krodha etc.

– Cha.su.1/54

Yuktivyapasraya chikitsa

Components: • Ahara (Diet) • Shodhana chikitsa • Shamana chikitsa • Ausadhi (Drug therapy)

Yuktivyapasraya chikitsa

Ahara • Ksira (), ghrta (), draksa (grapes), panasa (jack fruit) brahmi (Centella asiatica- plant) • Animal products - Animal meats

• Shroto and then shamana aushadhi

Ausadha (medicines)

Rasayana (tonics) Shodhana

Therapies • Brahmi (Bacopa monnieri), • Mandukaparni (Centella asiatica), • Sankhapushpi (Convolvulus pluricaulis), • Guduchi (Tinospora cardifolia), • Ashwagandha (Withania somnifera)

Satvavajaya chikitsa

• Satwavajaya chikitsa: Satva: mind Avajaya : bringing the mind under control.

• The main aim of this therapy is to restrain mind from unwanted thought process, replacing negative ideas, proper channeling of presumptions and proper advices through Jnanam (Knowledge), vijnyanam (analytical thinking), dhairya (courage). (memory), (concentration).

• Mental disorders causes by kama, Soka, bhaya etc should be countered by inducing the opposites passion in order to neutralize the causative ones. (Charaka)

Satvavajaya chikitsa

• Components – Dinacharya (daily regimen), – Ritucharya (Seasonal regimen), – Sadvrtta (code of virtues)/Achara rasayana – Roganutpadana (Prevention of diseases), – Annapanavidhi (Rules pertaining to food and drinks) Sadvrtha/Achara rasayana (behavioral approaches) • Achara rasayana: – Moral, ethical, and benevolent conduct: – Truth, nonviolence, personal and public cleanliness, – Mental and personal hygiene, – Devotion, , – A yogic lifestyle. – Dharana () and Dhyana () • Achara Rasayana - Role in both etiology as well as treatment • Practice of Achara rasayana will reduce the stress and anxiety improves the psychoneuro-immunity Ayurveda and Anxiety (Scientific Base) Study Subjects Intervention group Control Outcome measures Results group 1. U Jana et al N=35 Patients Encapsulation of Nil Subjective scores of The baseline score of 2010 with GAD 500mg plant five self anxiety index was Both Genders extract of Centella reported declined to 13.1%in 30 Age grp 18-60 Asiatica (CA) . questionnaires days and 26.0% in 60 years including stress scale, days after the 1 Cap BD A/F anxiety treatment of CA. scale, depression Followed up at day scale, adjustment Self-perceived stress 30 and day 60 after scale and attention levels improved was starting of scale also noted. medication, Adjustment score also improved by 35.2%, Attention level improved by 27.8%

Each of these results were statistically significant (p<0.01) Study Subjects Intervention Control Outcome measures Results group group 2.Bhattacharya 33 Subjects with Acorus calamus Nil Five self reported ACE not only et al 2011 GAD plant extract (ACE) questionnaire s significantly (p<0.001) 20-M in a fixed dose including stress scale, attenuated anxiety 13-F regimen (500mg/ anxiety scale, related disorders, but Avg.Age: 36.2yrs capsule, twice daily depression scale, it also significantly AF) adjustment scale, and (p<0.001) reduced attention scale, stress phenomenon and its correlated Assessments were depression,. done at baseline, on 30th day and on 60th ACE further day. significantly (p<0.001) improved the willingness to adjust. 3.Yogita A et all 60 subjects with Group A: n=20 Group B: BPRS, HAMA abefore Khusmandadi ghrita 2011 GAD Treatment grp n=20 and after the has provided Khusmandadi Placebo grp treatment significant relief on Clinical trial Ghrita , 10ml orally Capsule of HARS (p<0.001) and twice daily AF with Sugar Manasa bhava for 4 weeks powder pariksha compared to Placebo group 250mg/tid HAMA(P<0.05) for 4 weeks. Study Subjects Intervention Control group Outcome Results group measures 4. Pandey R 60 subjects Medhya vati Placebo: Hamilton HAM A scores et al 2014 25-65 years of (equal Galactose filled anxiety rating were significant age. Both proportions of gelatin capsule scale. (HAM-A) (p<0.0001) in all genders ghana sattva of (Group A) its domains in Brahmi, Ayurvedic Group B Shankhapushpi, 250 mg were symptoms compared to Guduchi and group A (Not given B.D. for 15 checklist of Yashtimadhu) significant days GAD (Group B) (p>0.001).

1 gm given T.D.S. Pre and Post Medhya vati for 15 days. assessments showed after 15 days. statistically extremely significant improvement (p<0.0001) in Symptoms , while the effect of Control drug (placebo) was statistically insignificant.

Study Subjects Intervention Control group Outcome Results group measures 5. Vishal et al Patients with Were Ashwagandha HAM A Ashwagandha 2014 GAD (N=34), administered compound churna provided Ashwangandha (Ashwangandha, significant Group A (18 choorna shankhapushpi improvement on Patients) and Yastimadhu) HAM A after 30 Group B (13 (12gms in three days of treatment. divided doses Patients) (12gms in three with milk after Ash.chu provided divided doses food for 1 65.64% and Follow up for 2 with milk after month) Ash.compound months every food for 1 month) provided 70.50% 15 days after improvement on the treatment. HAM A.

Ash.chu provided better improvement in signs and symp over Ash.comp, which was maintained even during follow up of the treatment. Study Subjects Intervention Control group Outcome Results group measures 6. Saxena A et N=19 patients Shirodhara with Nil HAM A There was al 2014 with GAD Ksheera bala statistically taila significant Clinical trial (p<0.001) improvement seen in all the domains of HAMA. Study Subjects Intervention Control group Outcome Results group measures 7.Vishal et al Patients with Group A: Group B: HAM A There was 2015 GAD (N=33), Guduchi Vati Mandookaparni reduction (% 500mg TID a/f Vati change) in clinical Comparative Randomly with water for 1 500mg TID a/f symptoms in both study selected and month. with water for 1 the groups after alloted from month. treatment.

OPD/IPD basis There was

statistically Group A (17 significant Patients) improvement in Group B (16 different domains Patients) of HAMA in both the groups (p<0.05).

There was no significant difference seen in between the groups.

Study Subjects Intervention Control group Outcome Results group measures 8.Rastogi S et 13 Pateints 10 Nil HAM A (At Between al 2016 with GAD (11- sittings of baseline , after baseline and M, 2 –F) shirodhara (for 3 weeks and first follow up a 45 mins)in a after 6 weeks) reduction in span of 3 weeks HAM-A-score and followed up was observed in a (8.85 ± 1.72) treatment free which was also period for Sig statistically another three (p < 0.001). weeks Between first Using Ksheera and second bala taila follow up intervals an increase in HAM-A score was observed but it was not significant statistically (p = 0.104) Study Subjects Intervention group Control group Outcome measures Results

9. Aparna J et al 30 patients with GAD Group B, patients were Group A, patients were HAMA In both Groups, highly 2015 treated with Parasika treated with relaxation significant (<0.001) Randomly divided in Yavani (Hyoscymus therapy/yogic results were observed to two groups niger Linn) capsule techniques, in almost all (250 mg) at night after i.e., Shithilikarana symptoms such as Group A meal with water for 28 Vyayama (3–5 excessive worry, days. difficulty in Group B min), Surya controlling worry, Namaskara (3 restlessness, rounds), Nadi Shuddhi irritability, insomnia, Pranayama (9 fatigue, muscle rounds), Brahmari tension, Pranayama (3 concentration rounds), Aum chanting problem, anticipation (9 times), Pancha of worst, fears, crying Kosha meditation spells, breathlessness, and Nidra (10 min) loneliness, in morning time for unsatisfactory sleep, duration of 30 min. night mares, and loss of interest, palpitations and in headache.

Moderate improvement observed in 18 patients of Group A and 14 patients of Group B Study Subjects Intervention group Control group Outcome measures Results

10. Purnima R et al N=60 Group 1: Group 2: HAMA Highly siginificant 2015 Patients with GAD Shankhapushpi Tab.Sertaline 50mg OD results were found Panaka 15ml BD with at bedtime for 30 days between both the Clinical trial Group 1:n=30 water a/f for 1 month groups (p<0.001). Group 2:n=30 Shirodhara with Shankhapushpi Panak Mansyadi kwatha for and Shirodhara with 48 mins for 21 days Mansyadi Kwatha give same results in sign and symptoms of Chittodvega, GAD in DSM-IV and on Hamilton Anxiety Rating Scale when compared with Tab. Sertraline. 11. Bhushal N et al 19 year old Female Shirodhara with Nil Subjective signs and Improvement in the 2017 with GAD dashmoola kshira symptoms sleep (main chief kwatha. complaint), Anxiety, Case report Difficulty in initiation krodha (anger), bhaya Pratimarsha nasya and broken/ (fearfulness) was with Ksheerabala taila disturbed sleep. observed.

Oral MEDICATIONS: Sarawatarishta , 2TSF/BD Ashwagandharishta, 2TSF/BD Rasayana 5gm BD. Avipattikara churna 2gms BD for 14 days. Study Subjects Intervention Control group Outcome Results group measures 12. Tubaki B R N=72 Group 1: n=24 Group 3:n=24 HAM A Ayurvedic et al 2016 Patients with GAD Manasamitra Received Tab. treatments were with comorbid vataka (100mg, BD Clonazepam 0.25mg Sleep Diary (Sleep found to be more Open label generalized social for 30 days) (morning) and quality effective in Randomized phobia. 0.50mg (night) for 30 assessment) promoting and Controlled Right handed days preserving SWS Group 2: n=24 Whole night (Slow wave sleep) Parallel group 20-55 years Oral medications polysomnography thus maintaining study similar to grp 1 + and sleep the normal sleep Block shirodhara with architecture architecture. randomization assessment for 2 brahmi taila for first 7 days whole consecutive Clonazepam nights before and grossly altered the

after the sleep architecture treatment. in patients with (EEG,EOG,EMG) GAD. Study Subjects Intervention Control group Outcome Results group measures 13.Divya Z et al 32 Patients with Group A Group B ? HARS There was 2017 GAD classical Nasya statistically highly Randomly divided followed by significant into two groups oral administration improvement of Sarasvata observed (Group A: 16, 1 Choorna in total score of HARS in both drop out) Nasya Karma was groups (P < 0.001). Group B: 16, 1 given by drop out Panchagavya In Ghrita. eight Bindu Group A, (4 ml) in each improvement was nostril for observed by 7 days followed by 69.69% whereas a gap of 7 days, in Group B 41.01% likewise 4 regimens of improvement were given. observed. Sarsvata Choorna was given 2 g thrice a day with honey and ghee after food for 60 days Study Subjects Intervention Control group Outcome Results group measures 14. Pillai C C A case report Nasya (nasal Nil Hamilton’s A significant et al 2018 ( 57 years old administration) Anxiety Rating reduction in male patient ) with Brahmi Scale score from 18 to Ghruta for 20 13 on mins Hamilton’s Anxiety Rating And Abhyanga Scale and (massage) with improvement in Ksheera bala symptoms was taila : 40mins observed after followed by treatment. Shamanaushadhi s (internal medicines)

One week of IP treatment and further 21 days of OP level administration of medicine (Saraswatha choornam )

Study Subjects Intervention Control group Outcome Results group measures 15. Ramana GV N=100 Group 1: Group 2: Similar oral HAM A (at In group 1 mean et al 2018 Patients with GAD Ashwagandha medications as baseline, on 28th, score of HAMA Group 1: n=50 churna 1.5gms BD group 1 along with it 56th and 84th day) was decreased Clinical trial Group 2: n= 50 from 19.38 Mandookaparni Shirodhara with Ayurvedic factors (baseline)to th churna 1.5gms BD ksheerabala taila for assessed 15.02(84 day). with water a/f for dashavidha and 30 mins for initial 7 12 weeks orally. sroto pariksha. In group 2 mean days only score of HAMA was decreased from 18.62 (baseline) to 14.38(84th day).

There was statistically significant (p<0.001) improvement in both the groups.

Oral administration of the medications with/without combination of shirodhara is found effective in patients with GAD. Conclusion

• No detailed explanation about the disorder. • No RCT’s • No Specific scales

References

• Bhattacharyya.D., Sur TK., Lyle N., Jana U., Debnath PK. A clinical study on the management of generalized anxiety disorder with vaca(acorus calamus). Indian journal of traditional knowledge. October 2011. Vol 10(4):668-671. • Yogita Ahir., Ila Tanna., B.Ravishankar.,HM Chandola. Evaluation of clinical effect of Kushmandadi ghrita in generalized anxiety disorder. Indian journal of traditional knowledge. April 2011. Vol 10(2):239-246. • Jana U., Sur TK ., Debnath PK ., Bhattacharyya D . A clinical study on the management of GAD with Centella Asiatica. Nepal Med Coll J 2010; 12(1): 8-11. • Bhusal N., Prakash S., Mangal G. Shirodhara in the management of chittodvegajanya anidra (insomnia due to GAD). International Journal of applied research.2017;3(8):160-162. • Basavaraj R. Tubaki., Anupriya Verma., Arun Sasidharan., S. Sulekha., T. N. Sathyaprabha. , D. Sudhakar. , C. R. Chandrashekar., G. S. Lavekar., Bindu M. Kutty. Manasamitra Vataka and Shirodhara treatments preserve slow wave sleep and promote sleep continuity in patients with generalized anxiety disorder and co- morbid generalized social phobia. Current science, vol. 111, no. 2, pages: 283-292. 25 july 2016. Special section: integrative medicine. References

• Sanjeev Rastogi1,2,*, Antriksha Baiswar1, Anil Nischal3, Prem Swarup Srivastava4, Anuradha Nischal. Effects of shirodhara in generalized anxiety disorder. TANG (Humanitas Medicine). 2016 / Volume 6 / Issue 4 / e27. • Ranjana Pandey, Pawankumar Godatwar, B. K. Sevatkar, Ashish Reja. A Randomized Controlled Upshayatmaka Trial of Medhya Vati On Manasa Roga W.S.R. To Anxiety Disorder. Journal of Ayurveda. Oct-Dec 2014. Vol.VIII No.4: 35-45. • Pillai CC, Chacko J, Soman D, Kundagol MC. Ayurvedic management of generalized anxiety disorder – A case report. J Ayu Herb Med 2018;4(3):111-113. • Aparna J, Mahesh V. Critical Study on 'Adhyatma Guna Samgraha' in Relation to 'Shubhaashubha Pravrtinivrti Hetu' w.s.r to Management of Anxiety. Department of Basic Principle, PG Dissertation Submitted to Gujrat Ayurved University, Jamnagar; 2015. • Divya Z, Kalpana P. A Comparative Clinical Study of Panchagavya Ghrita Nasya and Sarsvata Choorna in the Management of Chittodvega w.s.r. to Generalized Anxiety Disorder. Department of Panchakarma, PG Dissertation Submitted to Gujrat Ayurved University, Jamnagar; 2017. • Zala DS, Thakar AB, Bhatt NN. Review of research works done on generalized anxiety disorder at institute for postgraduate teaching and research in Ayurveda, Jamnagar. Indian J Health Sci Biomed Res 2017;10:231-6. References

• Dr. Purnima rao, dr. Jitendra kumar, dr. Udai raj saroj, prof. R.K. Jhoshi. Clinical evaluation of the efficacy of shankhapushpi panak and shirodhara with mansyadi kwatha in the management of chittodvega w.S.R. To generalized anxiety disorder. World journal of pharmaceutical research. 2016. Vol 05, issue 01, 1312-1328 • Ramana GV, Gupta H, Sudhakar D, Singh R, Rana R, Singhal R. Clinical Evaluation of Ashwagandha and Mandookaparni in the Management of Manodwega (Generalized Anxiety Disorder). J Res Ayurvedic Sci 2018;2(2):70-79. • Ajay Saxena. P.K. Rai., Ajay Meena., Anupam Srivastava., Kiran Srivastava., Priyanka Pandey. Clinical Trial of Shirodhara in Chittodvega Vis-À-Vis Generalized Anxiety Disorders. Research Journal of Pharmacology and Pharmacodynamics. 6(3): July- September, 2014, 141-145. • Vishal G..Narayan prakash b., Suhas K shetty., Savitha HP., Arun raj GR. Comparitive study on the efficacy of ashvagandha churna and ashvagandha compound in the management of generalized anxiety disorder (chittodvega). International journal of pharmacy & therapeutics, 5(3), 2014, 220-226. • Vishal G., Suhas K shetty., Narayan prakash B., Savitha HP. A comparative study on guduchi vati and mandookaparni vati in the management of chittodvega (generalized anxiety disorder). IAMJ: volume 3; issue 7; july- 2015. 2030-2040. References

• Fasnath Arabi and M Jithesh.Test anxiety and its Ayurvedic approach. International Journal of Herbal Medicine 2017; 5(6): 87-91. • Agnivesh, “Charak ” revised by Charaka & Dridhbala with “Ayurved Deepika commentary”, by Chkarapanidatta, edited by Vd. Jadavaji Trikamji Acharya, published by Chaukhamba Surbharati Prakashan, Varanasi, Reprint-2008, Ch.Vi 6/5 pp.254. • Acharya YT. Charaka: with Āyurveda Deepika Commentary of Chakrapani: Chaukhambha Orientalia; Varanasi 2002, 383,384 • 31. Ranade S. Natural healing through Ayurveda. First edition. Delhi: Motilal banarasidass publishers private limited; year: 1994, reprint: 1996, 6. • 32. Acharya YT. Charaka: Charaka Samhita: Chaukhambha Orientalia; Varanasi 2002. chikitsa sthana. 1/4/ 30-35. • M.G. Ramu . B.S. Venkataram . Manovikara (mental disorders) in ayurveda .Ancient science of life, vol. IV, no.3 january 1985, page 165-173. • G. Babu ., G.C. Bhuyan., G.P. Prasad., S. Anitha. Role of Achara rasayana In Chittodvega. Ancient science of life. Vol : No.XXVI (4) April, May, June 2007.

References

• Sadock BJ, Sadock VA, Pedro Ruiz MD. Kaplan and Sadock’s Synopsis of Psychiatry, 11th ed. Wolters Kluwer; 2015. 407-410. • Acharya Jadavaji Trikamji, editor. Charaka Samhita of Agnivesha, Vimana Sthana, Ch.6/Ver.5; 5th ed. Varanasi: Chaukhambha Sansthan; 2001. • Hari Shastri Paradkar, editor. Ashtanga Hridaya of Vagbhata, Uttara Tantra, Ch.39/Ver.142, reprint ed. Varanasi: Chaukhambha Orientalia; 2011. • Acharya Jadavaji Trikamji, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana, Ch. 1-3/Ver. 33-34; 5th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 2001. • Acharya Jadavaji Trikamji, editor. Charaka Samhita of Agnivesha, Sthana, Ch. 5/Ver. 81- 83; 5th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 2001. • Acharya Jadavaji Trikamji, editor. Charaka Samhita of Agnivesha, Sutra Sthana, Ch. 1/Ver. 54; 5th ed. Varanasi: Chaukhambha Sanskrit Sanst han; 2001. • Acharya Jadavaji Trikamji, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana, Ch. 1-1/Ver. 7; 5th ed. Varanasi: Chaukhambha Sanskrit Sanst han; 2001.

Thank You