understanding anxiety disorder from ayurveda …...title understanding anxiety disorder from...

Title

Understanding Anxiety disorder

from Ayurveda 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 kama (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 falling or staying a sleep, or restless unsatisfying sleep

Anidra (Insomnia), Nidra nasha (disturbed 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): mantra,

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 (milk), ghrta (ghee), draksa (grapes), panasa (jack fruit) brahmi (Centella asiatica- plant)

• Animal products - Animal meats

• Shroto shuddhi 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). Smriti (memory), samadhi (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, compassion, – A yogic lifestyle. – Dharana (Japa) and Dhyana (Tapas)

• 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 group

Outcome measures Results

1. U Jana et al

2010

N=35 Patients

with GAD

Both Genders

Age grp 18-60

years

Encapsulation of 500mg plant extract of Centella Asiatica (CA) . 1 Cap BD A/F Followed up at day 30 and day 60 after starting of medication,

Nil Subjective scores of five self reported questionnaires including stress scale, anxiety scale, depression scale, adjustment scale and attention scale

The baseline score of anxiety index was declined to 13.1%in 30 days and 26.0% in 60 days after the treatment of CA. Self-perceived stress levels improved was also noted. 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 group

Control group

Outcome measures Results

2.Bhattacharya

et al 2011

33 Subjects with

GAD

20-M

13-F

Avg.Age: 36.2yrs

Acorus calamus plant extract (ACE) in a fixed dose regimen (500mg/ capsule, twice daily AF)

Nil Five self reported questionnaire s including stress scale, anxiety scale, depression scale, adjustment scale, and attention scale, Assessments were done at baseline, on 30th day and on 60th day.

ACE not only significantly (p<0.001) attenuated anxiety related disorders, but it also significantly (p<0.001) reduced stress phenomenon and its correlated depression,. ACE further significantly (p<0.001) improved the willingness to adjust.

3.Yogita A et all

2011

Clinical trial

60 subjects with

GAD

Group A: n=20 Treatment grp Khusmandadi Ghrita , 10ml orally twice daily AF with for 4 weeks

Group B:

n=20

Placebo grp

Capsule of

Sugar

powder

250mg/tid

for 4 weeks.

BPRS, HAMA abefore and after the treatment

Khusmandadi ghrita has provided significant relief on HARS (p<0.001) and Manasa bhava pariksha compared to Placebo group HAMA(P<0.05)


Control group Outcome measures

Results

4. Pandey R

et al 2014

60 subjects

25-65 years of

age. Both

genders

Medhya vati (equal proportions of ghana sattva of Brahmi, Shankhapushpi, Guduchi and Yashtimadhu) (Group B) 1 gm given T.D.S. for 15 days.

Placebo:

Galactose filled

gelatin capsule

(Group A)

250 mg were given B.D. for 15 days

Hamilton

anxiety rating

scale. (HAM-A)

Ayurvedic

symptoms

checklist of

GAD

Pre and Post

assessments

after 15 days.

HAM A scores were significant (p<0.0001) in all its domains in Group B compared to group A (Not significant (p>0.001). Medhya vati showed statistically extremely significant improvement (p<0.0001) in Symptoms , while the effect of Control drug (placebo) was statistically insignificant.



Results

5. Vishal et al

2014

Patients with

GAD (N=34),

Group A (18

Patients)

Group B (13

Patients)

Follow up for 2

months every

15 days after

the treatment.

Were administered Ashwangandha choorna (12gms in three divided doses with milk after food for 1 month)

Ashwagandha

compound

(Ashwangandha,

shankhapushpi

and Yastimadhu)

(12gms in three

divided doses

with milk after

food for 1 month)

HAM A Ashwagandha churna provided significant improvement on HAM A after 30 days of treatment. Ash.chu provided 65.64% and Ash.compound provided 70.50% improvement on HAM A. Ash.chu provided better improvement in signs and symp over Ash.comp, which was maintained even during follow up of the treatment.



Results

6. Saxena A et

al 2014

Clinical trial

N=19 patients

with GAD

Shirodhara with Ksheera bala taila

Nil HAM A There was statistically significant (p<0.001) improvement seen in all the domains of HAMA.



Results

7.Vishal et al

2015

Comparative

study

Patients with

GAD (N=33),

Randomly

selected and

alloted from

OPD/IPD basis

Group A (17

Patients)

Group B (16

Patients)

Group A: Guduchi Vati 500mg TID a/f with water for 1 month.

Group B:

Mandookaparni

Vati

500mg TID a/f

with water for 1

month.

HAM A There was reduction (% change) in clinical symptoms in both the groups after treatment. There was statistically significant improvement in different domains of HAMA in both the groups (p<0.05). There was no significant difference seen in between the groups.



Results

8.Rastogi S et

al 2016

13 Pateints

with GAD (11-

M, 2 –F)

10 sittings of shirodhara (for 45 mins)in a span of 3 weeks and followed up in a treatment free period for another three weeks Using Ksheera bala taila

Nil HAM A (At

baseline , after

3 weeks and

after 6 weeks)

Between baseline and first follow up a reduction in HAM-A-score was observed (8.85 ± 1.72) which was also Sig statistically (p < 0.001). Between first and second 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

2015

30 patients with GAD

Randomly divided in

to two groups

Group A

Group B

Group B, patients were treated with Parasika Yavani (Hyoscymus niger Linn) capsule (250 mg) at night after meal with water for 28 days.

Group A, patients were

treated with relaxation

therapy/yogic

techniques,

i.e., Shithilikarana

Vyayama (3–5

min), Surya

Namaskara (3

rounds), Nadi Shuddhi

Pranayama (9

rounds), Brahmari

Pranayama (3

rounds), Aum chanting

(9 times), Pancha

Kosha meditation

and Yoga Nidra (10 min)

in morning time for

duration of 30 min.

HAMA In both Groups, highly significant (<0.001) results were observed in almost all symptoms such as excessive worry, difficulty in controlling worry, restlessness, irritability, insomnia, fatigue, muscle tension, concentration problem, anticipation of worst, fears, crying spells, breathlessness, loneliness, unsatisfactory sleep, 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

2015

Clinical trial

N=60

Patients with GAD

Group 1:n=30

Group 2:n=30

Group 1: Shankhapushpi Panaka 15ml BD with water a/f for 1 month Shirodhara with Mansyadi kwatha for 48 mins for 21 days

Group 2:

Tab.Sertaline 50mg OD

at bedtime for 30 days

HAMA Highly siginificant results were found between both the groups (p<0.001). Shankhapushpi Panak and Shirodhara with 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

2017

Case report

19 year old Female

with GAD

Shirodhara with dashmoola kshira kwatha. Pratimarsha nasya with Ksheerabala taila Oral MEDICATIONS: Sarawatarishta , 2TSF/BD Ashwagandharishta, 2TSF/BD Brahma Rasayana 5gm BD. Avipattikara churna 2gms BD for 14 days.

Nil Subjective signs and symptoms Difficulty in initiation and broken/ disturbed sleep.

Improvement in the sleep (main chief complaint), Anxiety, krodha (anger), bhaya (fearfulness) was observed.



Results

12. Tubaki B R

et al 2016

Open label

Randomized

Controlled

Parallel group

study

N=72

Patients with GAD

with comorbid

generalized social

phobia.

Right handed

20-55 years

Block

randomization

Group 1: n=24 Manasamitra vataka (100mg, BD for 30 days) Group 2: n=24

Oral medications

similar to grp 1 +

shirodhara with

brahmi taila for

first 7 days

Group 3:n=24

Received Tab.

Clonazepam 0.25mg

(morning) and

0.50mg (night) for 30

days

HAM A Sleep Diary (Sleep quality assessment) Whole night polysomnography and sleep architecture assessment for 2 whole consecutive nights before and after the treatment. (EEG,EOG,EMG)

Ayurvedic treatments were found to be more effective in promoting and preserving SWS (Slow wave sleep) thus maintaining the normal sleep architecture. Clonazepam grossly altered the sleep architecture in patients with GAD.



Results

13.Divya Z et al

2017

32 Patients with

GAD

Randomly divided

into two groups

(Group A: 16, 1

drop out)

Group B: 16, 1

drop out

Group A classical Nasya karma followed by oral administration of Sarasvata Choorna Nasya Karma was given by Panchagavya Ghrita. eight Bindu (4 ml) in each nostril for 7 days followed by a gap of 7 days, likewise 4 regimens were given. Sarsvata Choorna was given 2 g thrice a day with honey and ghee after food for 60 days

Group B ? HARS There was statistically highly significant improvement observed in total score of HARS in both groups (P < 0.001). In Group A, improvement was observed by 69.69% whereas in Group B 41.01% of improvement observed.



Results

14. Pillai C C

et al 2018

A case report ( 57 years old male patient )

Nasya (nasal administration) with Brahmi Ghruta for 20 mins And Abhyanga (massage) with Ksheera bala taila : 40mins followed by Shamanaushadhis (internal medicines) One week of IP treatment and further 21 days of OP level administration of medicine (Saraswatha choornam )

Nil Hamilton’s Anxiety Rating Scale

A significant reduction in score from 18 to 13 on Hamilton’s Anxiety Rating Scale and improvement in symptoms was observed after treatment.



Results

15. Ramana GV

et al 2018

Clinical trial

N=100

Patients with GAD

Group 1: n=50

Group 2: n= 50

Group 1: Ashwagandha churna 1.5gms BD Mandookaparni churna 1.5gms BD with water a/f for 12 weeks orally.

Group 2: Similar oral

medications as

group 1 along with it

Shirodhara with

ksheerabala taila for

30 mins for initial 7

days only

HAM A (at baseline, on 28th, 56th and 84th day) Ayurvedic factors assessed dashavidha and sroto pariksha.

In group 1 mean score of HAMA was decreased from 19.38 (baseline)to 15.02(84th day). In group 2 mean 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 Dravya 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

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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 Sanskrit 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, Sutra 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.

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