Role of Shirodhara and Abhyanga on serum cortisol in Anxiety – A case report

Abstract

Chittodvega, classified as a Mano-Vikara (psychological disorder) in Ayurveda, can be correlated with general anxiety disorder. The disturbance of Vata Dosha plays a critical role in its manifestation. Ayurvedic treatments such as Abhyanga (oleation) and Shirodhara (dripping of medicated oil or other suitable liquid on forehead) are known to pacify Vata. Abhyanga helps to stabilize the body, while Shirodhara enhances concentration, promoting mental stability. Both procedures synergistically balance VataDosha, addressing the physiological and psychological aspects of Chittodvega.A 50-year-old male patient presented with complaints of anxiety at Ch. Brahm Prakash Ayurveda Charak Sansthan, New Delhi. He underwent a 14-day treatment regimen, including 7 days of hospitalization and 7 days of follow-up. The treatment involved Abhyanga(Oleation) with Til Taila (sesame oil) and Shirodhara with Dashmool Siddha Ksheer (herbal milk decoction), aimed at assessing their impact on serum cortisol levels. Both, morning and evening cortisol level of this patient was within the normal range before and after the treatment. This study was done only to check the effectiveness of Abhyanga and Shirodhara on serum cortisol level. Observable changes were found in serum cortisol along with a reduction in the patient's anxiety symptoms, demonstrating the efficacy of these Ayurvedic interventions in managing Chittodvega.

1. Introduction

Chittodvega is a term derived from two Sanskrit words: "Chitta," denoting the mind or perception, and "Udvega," which signifies distress, agitation, or anxiety, encapsulating an anxious state of mind. Consequently, Chittodvega can be equated with anxiety in the context of Western medical literature. The concept of Tridosha is integral to understanding the manifestation of this condition. Vata dosha is implicated in mental and cognitive disturbances, giving rise to symptoms such as fear, grief, and confusion. Among the five varieties of Pitta dosha, Sadhak Pitta, and among the types of Kapha dosha, Tarpaka Kapha, when vitiated, can contribute to the emergence of Chittodvega. Chittodvega represents a physiological state characterized by an intricate interplay of cognitive, somatic, emotional, and behavioral components. A thorough examination of both Ayurvedic and contemporary literature reveals a striking resemblance between the signs and symptoms of Chittodvega and those associated with generalized anxiety disorder. Anxiety is defined by the intensity of subjective experiences linked to incessant thought processes, apprehension, nervousness, and worry, all of which are often accompanied by heightened activity of the autonomic nervous system [1]. Elevated serum cortisol levels are frequently observed in various psychological disorders, including depression and bipolar disorder [2].Stress is a prevalent precipitant of Vataprakopa [3], and within the framework of Abhyanga karma (as elucidated in the Dincharya Adhyay of Sutra-sthan), Acharya Vagbhata stated that it embodies Jara-Shrama-Vataha. The Ushna (heating), Vataghana (Vata-reducing), Twachya (skin-nourishing), and Medhya (cognition-enhancing) properties of Til Tail (sesame oil) render it advantageous for performing Abhyanga. Furthermore, Shirodhara significantly contributes to enhancing concentration, a benefit well-documented in contemporary Ayurvedic literature.

2. Patient information

A 50-year-old male patient presented with complaints of anxiety in enclosed spaces and crowded areas, which have persisted for the past ten years. He has been taking antidepressant and anxiolytic medications daily for the last three years, but his symptoms have progressively worsened. Consequently, the patient visited the Panchakarma OPD at CBPACS Hospital, Khera Dabar, Najafgarh, Delhi, accompanied by his wife, to explore potential Ayurvedic treatment options.According to the patient, he experienced his first episode at the age of 15, during which he felt discomfort in social gatherings, accompanied by excessive sweating. These symptoms have progressively intensified over the years and are now associated with additional issues such as claustrophobia, irritability, and disturbed sleep patterns. Initially mild, these symptoms have significantly impacted the patient's daily activities over the past five years. Despite adhering to a regimen of antidepressants and anxiolytics for the last three years, he has not achieved the expected relief.The patient reported that his appetite, bowel function, and urinary frequency are normal. There is no significant history of major illnesses within the family. His medical history indicates that he has been on antidepressant and anxiolytic medications, specifically Venlafaxine 37.5 mg and Etizolam 0.5 mg, taken once daily for three years. Additionally, he has a five-year history of hypertension and is currently prescribed Telmisartan 20 mg, taken once daily in the morning.

3. Clinical findings and diagnosis

The patient was subjected to thorough psychiatric evaluation which was completed through information provided by the patient and his wife. Patient was apprehensive, worried about his daily activities, uncomfortable while having meal, afraid or anxious while alone, in a dark place and in a lift, having disturbed sleep, headache, fatigue etc. Patient was inclined to avoid crowded places and over gathering because of obvious reasons.

On the basis of complaints, the patient was diagnosed with Chittodvega.

4. Timeline of intervention

5. Treatment progress

As the patient admitted his evening and morning blood samples were collected on 15^th and 16^th of November respectively, in order to Assess the serum cortisol level (as detailed in Table 2). As the procedure started, from the very first day patient was sharing the improvement he is observing in himself. On the first day, the patient did not experience any uneasiness despite skipping lunch, which had not occurred in the past five years. On the second day, he did not experience the jerky, twitch-like movements during Shirodhara that were present on the first day of treatment. On the third day, he observed an improvement in the discomfort that typically followed meals. By the fourth and fifth days of treatment, he began using the elevator without fear. On the sixth and seventh days, he started socializing with nearby individuals without the usual fear of agoraphobia. After seven days of treatment, the patient experienced significant relief from symptoms such as discomfort during meals, anxiety when alone, in dark places, or in an elevator. Additionally, he reported improvements in sleep quality, reduced headaches, and increased interaction with family members. The level of serum cortisol decreases to 10.73ug/dl in the morning sample and 5.85ug/dl in the evening sample taken on 7^th and 8^th day of the treatment respectively.

6. Therapeutic intervention

After carefully considering all protocols and obtaining informed consent for therapeutic intervention and the discontinuation of previous internal medications, the following treatment plan was implemented with informed consent. This comprehensive approach was designed to address the patient's condition holistically and facilitate a positive therapeutic outcome.

• a.Abhyanga: The patient received a 30-minute lukewarm Abhyanga with Till Tail (sesame oil) daily for seven consecutive days, performed in the forenoon.
• b.Shirodhara Following the Abhyanga, the patient underwent Shirodhara with Dashmool Ksheer (A herbal milk infusion) for 30 minutes each day over a span of seven days.
• c.Pathya-Apthya as per classical texts including Ahar and Vihar.

7. Follow up and outcomes

The patient experienced significant relief from symptoms as the treatment progressed, with noticeable improvements observed from day one, as outlined in the timeline. Furthermore, there were substantial changes in serum cortisol levels in both morning and evening samples, as detailed in the accompanying table. Upon follow-up in the OPD after 15 days, the patient reported considerable alleviation of symptoms and appeared markedly more relaxed and satisfied with the treatment received.

8. Discussion

Acharya Charak has mentioned “Niyata Praneta Cha Mansa” as karma of Vata dosha i.e.; vata dosha is responsible for activity of mind. Vata Dosha resides in Sparshan Indriya which further resides in Twak [4] and as Abhyanaga is Twachya, that’s why Abhyanga pacifies the Vata Doshas with the help of Bhrajak Pitta. Secretion of dopamine and serum serotonin increases after oil massage [5] which leads to relaxation of mind and subsequently it decreases the level of serum cortisol. Shirodhara probably normalizes the two important neurotransmitters Serotonin and Norepinephrine [6], which regulates a wide variety of neuropsychological processes along with sleep [7]. Dashmoola possesses Shothahara, Tridoshaghna and Aama Pachan property due to which it is found to be indicated in Vatavyadhi as a Pradeha, Parisheka and Abhyanga. Ksheer possesses Snigdha, Vatahara, and Bruhana properties. So Shirodhara with Dashmoola Ksheer found to be effective in Chittodvega. Morning level of serum cortisol from 5-23 mcg/dL and evening level from 3-13 mcg/dL is considered to be normali. The morning and evening serum cortisol level of this patient was within normal range, these blood investigations were done in order to check either abhyanga and Shirodhara has effect on serum cortisol level or not. After treatment, clearly appreciable results seen in subjective parameters while changes in biochemical parameters were inconclusive.

9. Limitations

This study was conducted on a patient whose serum cortisol levels were within the normal range. However, there is an opportunity to perform these two therapies on a population group with abnormal serum cortisol levels associated with generalized anxiety disorders. Additionally, parameters to assess improvements in concentration levels were not utilized in the present study. Therefore, a separate investigation could be undertaken to evaluate the effectiveness of these therapies based on this specific criterion.

10. Conclusion

Abhyanga and Shirodhara both shows the improvement in concentration and fear to crowded place. These two therapies also shown observable change in serum cortisol level. It showed appropriate responsiveness in general anxiety disorders management and hence, the therapy was found to be effective in the management of Chittodvega.

Funding sources

None.

Conflict of Interest

None.

Declaration of generative AI in scientific writing

We hereby declare that the manuscript is entirely the original work. I affirm that no generative AI tools or artificial intelligence applications were used in any part of the manuscript preparation, including drafting, editing, or data analysis. All scientific content, conclusions, and language within the manuscript have been developed through our expertise and efforts and by our mentor’s guidance, ensuring compliance with the ethical and academic standards required by JAIM.

Author Contributions

Dr. Ashu Sharma: Conceptualization, methodology/study design, visualization, resources, Writing – original draft Dr. Megha Sugandh: methodology/Study design, visualization, Writing – original draft, writing- Review and editing Dr. Arun Gupta: Conceptualization, Supervision Dr. Atul Bhardwaj: Supervision, Writing – review and editing.