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Sep12
Vedic Concept with role of complementary & alternative therapy in pain management
Nayak Sukdev. Prof, Deptt of Anaesthesiology, IMS & SUM Hospital Bhubaneswar 751019, Odisha, India

Introduction:
Chronic and cancer pain is a human malady. Yoga and pranayama have been used to alleviate several disease processes by acting at cellular oxidative process for thousands of years in the ancient Indian tradition. Recently there has been considerable global interest in these simple and inexpensive techniques. These act as adjuvants with immense benefit to the suffering humanity around the globe.
Yogic approach to pain enables the patient to differentiate the pain itself versus mental picture it creates. The consequent emotional reactions to pain perception activate the sympathetic nervous system, making matters worse.
Pranayama:
Practice of pranayama quickly relaxes the nervous system, shifting the balance from the fight-or-flight sympathetic side to the more restorative parasympathetic division. Slowing the breath, lengthening the exhalation relative to the inhalation, and pausing briefly after the exhalation, all tend to shift the balance to the parasympathetic side. It also breaks the vicious cycle of stress, reduced pain threshold and reduces reactive oxygen species.

Meditation reduces the transmission of pain signals from the thalamus to the higher centers, reducing pain perception. Increased production of endogenous endorphins has also been proven.

Asanas:
Regularly doing different asanas helps by rectifying the poor anatomical alignments, dysfunctional movement patterns, engage the unused muscles, relax the overused ones, the bones also realign relieving the joint stress and soft tissues. Practice of regular asana improves sleep and breaks the vicious cycle of poor sleep and chronic fatigue; a major contributor to chronic pain.

Chanting OM:
Several studies for generations on sounds & their effects on the body & mind have shown that chanting different sounds at different pitches & intensities has beneficial effects: buttressing the role of good pronunciation. Different sounds resonate maximally in different areas of the body, and this was explicitly considered in chanting Sanskrit mantras; which connects to the different areas of the body & brain. The sound OM is primordial and has been proven by NASA to be the sound recorded near Sun. Chanting of OM is proven to be of beneficial immense health effect.

Summary:
These CAM techniques can be practiced almost anywhere as an adjuvant to the various analgesic therapies, for a synergistic effect with tremendous internal endogenous endorphin releasing benefit sans any additional extra financial burden to the patient.

Conclusion:
Chronic and cancer pain is a human malady. Yoga and pranayama are ancient Indian methods to alleviate several disease processes by acting at cellular oxidative process. Recently there has been considerable global interest in these simple and inexpensive techniques. These adjuvants shall be of immense benefit to the suffering humanity.


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Sep12
History of Palliative care in India
History of Palliative Care in India
MR Rajagopal, Firuza Patel, SC Sharma, Sukdev Nayak
Home to one-sixth of the World’s population, India has a huge burden of suffering from life-limiting diseases. Less than 1% of its population has access to pain relief and palliative care. It has a federal system of Government, health and drug control being the responsibilities of its 29 states and six Union Territories. Provision for health care and for opioid access varies from state to state, and as can be expected, this created difficulties especially when one state had to depend on a manufacturer of opioids in another state or when palliative care provisions had to be made a part of the Government’s health system.
The earliest reliable information about medicine and medical practitioners in India is available beginning from 1500 BCE. They advocated harmony of body and mind and harmonious interaction between man and universe for a healthy life. Vaidyas resorted to spiritual therapy for diseases whose causes were unknown. These were explained in terms of a patient's actions in his previous births. The cure involved appeasement of gods through prayers and offerings, recitation of mantras, and wearing of amulets and gems. Similarly, psychic therapy was applied to diseases of the mind. The Vaidya prescribed various methods at his discretion, to keep the mind away from harmful thoughts.
The absence of female vaidyas is noteworthy. As medical education began after the age of maturity, women students could not pursue them since they were married off by this age.

During Marhatta rule in the latter half of the eighteenth century, many dispensaries were constructed at the side of the route on the way to and from Puri, during the Car Festival of Lord Jagannath. Thousands of devotees from all over the sub-continent converged every year to the Puri Dham, one of the four Sacred Dhams of Hindus, during the months of June or July to attend the week-long famous festival. On account of the poor sanitary conditions existing then and the non-availability of safe potable water, many of them were naturally stricken with communicable diseases like malaria, cholera and gastroenteritis on their protracted journeys. The dispensaries served solely to render medical assistance to sick pilgrims. Many of them could neither make it to the pilgrimage nor to their home as they were very weak and sick. There was a lack of proper medical care and many died, but were provided with good tender loving care by the local people.
This dispensary continued to function admirably till the British occupation of Orissa in 1803 A.D. The British rulers, in due course of time, realised the strategic importance of this dispensary at Cuttack and converted it into a small hospital. Regular financial assistance was made available and the hospital ran smoothly for years thereafter and is now the premier medical institution of the state of Odisha.
Palliative care was born in India as the Shanti Avedna Ashram in Mumbai, a hospice, in 1986. Over the next five years, it established two more branches, one in Delhi and one in Goa; but patients outside these institutions had no access to palliative care. Three major developments occurred in the early 1990s. WHO supplied oral morphine tablets of about Rs. one crore rupees free of cost to ten Regional cancer centres (RCCs) at New Delhi (AIIMS), Mumbai (TMH), Gwalior, Ahmedabad, Guwahati, Cuttack, Bangalore, Trivandrum, Kolkata and Hyderabad in 1991, followed by another lot of Morphine tabs costing Rs. one crore. Second was the formation of the Pain and Palliative Care Society (PPCS) in Calicut in the South Indian state of Kerala in 1993, which spearheaded the rapid growth of Palliative care in the community. The third was the formation of the Indian Association of Palliative Care(IAPC) in 1994. IAPC held its first international conference at Varanasi in January 1994 (with the assistance of WHO and the Government of India) and adopted a constitution. Later it was registered as a Public Trust and Society in March 1994 in Ahmedabad. The following year, the IAPC set up a Palliative Care Drugs Committee and Educational Task Force during the Second International Conferences of IAPC were held at Ahmedabad. The third International Conferences of IAPC was jointly held with the Indian Society of Study of Pain at Konark, Odisha where both national and international delegates participated.
PPCS was formed as a registered charitable trust. It followed the work of the author over the previous six years to provide a pain management service in the Government Medical College Hospital. It was obvious that for any person with pain, the suffering goes way beyond pain as a symptom. They often have other symptoms along with psychological, social and spiritual issues often complicated by impoverishment. Typically, all treatment costs were out of pocket for the patient. It was not easy to watch families getting destroyed, including the generation that follows the patient. This experience and teachings of visiting pioneers, particularly Ms. Gilly Burn, a British nurse, brought to light the need for total care of the patient. Two doctors and one layman got together to form PPCS (3). From the point of involvement of this layperson, Mr Asok Kumar, the community was seen as an integral part of palliative care in Kerala.
The organization was started practically with no resources and was done purely based on volunteerism. As more volunteers got involved, PPCS grew as an out-patient service later adding on a home visit programme as the need became apparent. Dr. Jan Stjernsward, then Chief of Cancer and Palliative Care at the World Health Organization (WHO) and Dr. Robert Twycross, the director of the WHO Collaborating Center, Oxford, were major catalysts in this process.
This duo also catalyzed the formation of the Indian Association of Palliative Care (IAPC). Doctors from various parts of India, with a predominance of anaesthetists involved in pain management, formed the majority of founding members. From the beginning, the association envisaged a multi-disciplinary approach and welcomed volunteers as members.
Over the next few years, in the latter part of the 1990s, several new palliative care initiatives were started such as the Guwahati Pain and Palliative Care Society in Assam, the Jivodaya Hospice in Chennai, Cansupport in Delhi, the Lakshmi Palliative Care Trust in Chennai and the Karunasraya Hospice in Bangalore. Some regional cancer centres like Trivandrum, Bangalore and Delhi which already had pain management programmes, also included palliative care in their service. Though every year a few centres were added, the growth was limited considering the enormity of the Indian population.
At this time, access to opioids was not easy. Possibly as a response to the global war on drugs, India formed, in 1985, the Narcotic Drugs and Psychotropic Substances (NDPS) Act. This draconian legislation brought in stiff penalties which could even be applicable for minor clerical errors and gradually pharmacies stopped stocking morphine. This Act also mandated several different licenses, typically four to five, all of which needed to be valid at the same time. Typically again, these licenses had to be issued with the concurrence of several Government departments making the system next to non-functional. In the 13 years which followed the enactment of the NDPS Act, morphine consumption in the country fell by an alarming 92% – from around 600kg to a mere 48kg. In 1997, India’s per capita consumption of morphine ranked among the lowest in the world (113th of 131 countries). During the same period, global consumption of morphine had increased by 437%.
In 1995, Mr David Joranson, the Founder Director of Pain and Policy Studies Group in Madison Wisconsin, another WHO Collaborating Centre, entered into a partnership with palliative care pioneers in India. They analyzed the NDPS Act, identified barriers and submitted a proposal to the Government of India for simplification. Health as well as control of opioid medicines are both “state subjects” in India’s federal system of governance; it was necessary for each state to act independently.
In 1998, the pharmacologist Ravindra Ghooi approached the Delhi High Court seeking access to morphine for his mother in pain from cancer. The High Court passed an order expressing sympathy for the cause and asking Delhi Government to take prompt action. Following this and representations from Pain and Policy Study Group, the Government of India prepared a model rule for the modification of existing state regulations and asked all states to change their regulations accordingly. By India’s constitution, the state government is not obliged to follow the central government in this matter. Most states did nothing. The collaborators namely, the Pain and Policy Studies Group and Indian palliative care activists worked together through state governments. Eighteen workshops were organized in various states resulting in many of them changing the state regulations following the central government instruction.
Of these, Kerala showed a remarkable improvement in access to opioids during the subsequent years. Some states like Tamil Nadu, Karnataka and Delhi showed a modest improvement while in most other states the change was minimal. It appears that wherever there was existing palliative care activity resulting in a demand for pain relief and for morphine, the amendment of the state rules did improve the situation. It also became very clear that without such activity, the regulatory reforms would have no impact.
Since the beginning of Pain and Palliative Care Society in 1993, the community’s involvement in palliative care was steadily growing in Kerala. By the turn of the century, this was given structure and growth with the name “Neighborhood Networks in Palliative Care” (NNPC). An international conference on community participation in palliative care gave great visibility to NNPC, the media were supportive, public interest grew and truly the people of Kerala embraced palliative care. Trained volunteers are involved in palliative care, organizing palliative care services, doing nursing chores, educating families in care and in spreading awareness. Questions have been raised about the quality of services that such community-based services can give (8), but the system has indeed succeeded in providing a link between the patient and medical institutions, adding the “meso” element of the social capital that is being eroded in much of the world.
In 2003, the charitable organization called Pallium India was created to improve access to palliative care outside Kerala. Since then, palliative care centres have been established in 11 states where until then practically no such service existed. Whether they followed the complicated old “narcotic” rules or the simpler new ones in some states, access to morphine became a reality in all these centres soon after the initiative.
In 2005, Pallium India submitted a representation to the Government of Kerala and to the Government of India for the creation of palliative care policy. The Kerala state government acted on it and created a task force to formulate a draft policy. Many meetings and discussions later, in 2008, the Government of Kerala declared a palliative care policy integrating it into health care. This has since then been a huge success so that today each of about 900 local self-government institutions called panchayats employ one nurse trained in palliative care. The funds for this came through the National Rural Health Mission which, by the very function of its being, had to serve rural areas and therefore had to restrict their activities to community health centres and primary health centres. No budget allocation, unfortunately, was made for much of the activities envisaged in the palliative care policy, namely, the creation of palliative care centres in district hospitals and in tertiary referral centres. This has resulted in the anomalous situation in which the patient has to go through intolerable pain and other distress for weeks, months or years of treatment in major hospitals, to get palliative care only in the last few weeks at home through the primary health centre. The monitoring committees planned in the state policy were also not established and hence there was no forum for review and modification of strategy.
The Government of India formed a committee in 2006 involving experts from various parts of the country to create a national policy for palliative care. The committee worked together to create a draft policy document. However, following a change in one official, this did not see the light of the day. Representations to the Medical Council of India and Indian Nursing Council for the incorporation of palliative care into the undergraduate curriculum also were unsuccessful during that decade.
Following the initial growth in the 1990s, there appeared to be a plateauing of improvements in palliative care access at the national level in India. In 2007, palliative care activists took the matter to the Supreme Court of India. The petitioners were the Indian Association of Palliative Care (represented by the Chairman of its Opioid Availability Committee), Dr Ravindra Ghooi who had earlier taken the matter to Delhi High Court and Ms Poonam Bagai, a cancer survivor and founder of Cankids, a child cancer organization and Vice chair of Pallium India. Two Supreme Court lawyers, Mr Ashok Chitale (one of the trustees of Pallium India) and Niraj Sharma, gave their services gratis for this purpose. The Supreme Court accepted the case in file which in itself was a success because only about 7% of all submitted petitions are usually accepted by the Supreme Court. The petitioners argued that lack of access to palliative care violated an individual’s fundamental right to life with dignity that was guaranteed by the constitution of India and asked essentially for three things:
The central and state governments should develop palliative care policies;
The NDPS Act Of India Must Be Simplified Ensuring Access To Opioids For Those Who Need Them; And Palliative care must be made a part of undergraduate medical and nursing curricula. During periodic hearings of the case which is yet to be settled, the court’s questions to the central and state governments have been a significant factor in catalyzing action.
A further development occurred in Kerala between 2005 and 2008. Acting on a request from Pallium India, the Government of Kerala appointed a committee to draft the Palliative Care Policy for the state. The policy came into being in April 2008. It accepted palliative care as an essential part of health care in the state. However, the Government made no budget allocation for palliative care and the implementation of palliative care was left to the National Rural Health Mission (NRHM). This has been largely successful.
Kerala, though it covers only 1% of India’s land mass and contains 3% of India’s population, has now more palliative care services than the rest of the country put together. In a study published in 2008, McDermott E et al found Kerala to have 83 palliative care services as against 139 in the whole of the country. As of 2014 in Kerala, more than 170 institutions stock and dispense oral morphine.
International Advocacy has always had a major role in supporting palliative care efforts in India. In 2009, the Human Rights Watch published the results of their research, namely “Unbearable pain: India’s obligation to ensure palliative care” (13). One of its recommendations was to International Narcotics Control Board (INCB) to plan a fact-finding mission to India, with the availability of controlled substances for medical and scientific purposes as one area of focus. INCB did take up the suggestion and a delegation came to India and interacted with Government officials and representatives of palliative care associations. Its recommendations had a major role in persuading further government action. India, till around this time, did not have a proper system in place for assessing opioid consumption and reporting it to INCB and for many years, it either failed to send reports or sent clearly inaccurate reports. Following the INCB visit, the Government put into place a new functional system and from that year, we have had reasonably reliable statistics on consumption of opioids.
Recognizing that the education of professionals was the key to improvement of palliative care in the country, palliative care activists had, from the beginning, conducted educational programmes. After several trials with courses of two, four and six weeks, the six-week courses in Palliative Medicine and Nursing started by PPCS became widely popular and has been replicated in several institutions in the country. A one-year fellowship programme also was started by several institutions, though none had the approval of the Medical and Nursing Councils of India.
Continued advocacy by the palliative care community bore fruit in 2010, when the Medical Council of India accepted palliative medicine as a medical specialty and announced a post graduate course in the subject. Subsequently, in 2012, the first Doctor of Medicine (MD) course was started at the Tata Memorial Hospital in Mumbai with two places per year. Unfortunately, most of palliative care service available at this time was in the charitable sector, and there are not many academic institutions with the capacity to start palliative care courses.
Designation of the Institute of Palliative Medicine at Calicut, Kerala, as a WHO Collaborating Centre for Community Participation in Palliative Care and Long Term Care in 2010 and of Pallium India’s Trivandrum Institute of Palliative Sciences (TIPS) as a WHO Collaborating Centre for Training and Policy on Access to Pain Relief in 2012 were two significant events contributing to further progress.
In 2013, following his attendance at a side event held at the World Health Assembly in Geneva organized by Human Rights Watch and others, the Principal Secretary of Health of the Government of India, Mr Keshav Desiraju, called a meeting to create a palliative care strategy for the country’s five-year plan. Health ministry officials and palliative care activists worked together to create this strategy, the National Program in Palliative Care (NPPC), which was declared in 2012. Unfortunately, the proposed budget allocation did not materialize and hence, the implemented part of NPPC turned out to be a skeleton of the envisaged programme, with about 2% of the originally proposed budget, some money being allocated to a minority of states by the Government of India for implementing some of the parts of the NPPC.
Pallium India found the resources and organized a working group to create an implementation framework for NPPC, spelling out strategies, action items, and timelines. This was submitted both to the WHO India Office with a request for undertaking operational analysis and to the Ministry of Health. Though the operational analysis did not materialize, the document continues to be available for guidance in the implementation of NPPC.
In addition to implementing the establishment of palliative care services, the NPPC recommended undergraduate medical and nursing education as one of its targets. Pallium India subsequently organized a working group involving experts from various parts of the country, Ministry of Health officials and representatives of the Medical Council. The committee, over a six-month period of time, developed curricula for undergraduate medical and nursing education and prepared a scheme for its inclusion in the existing medical and nursing curricula. Action on this by the respective councils is yet to happen.
The Pain and Policy Studies Group at Madison, Wisconsin, in 2012, included three fellows from India in its fellowship programme and also invited two officials from the Government of India, Mr Rajesh Nandan Srivastava, Director of Narcotics in the Department of Revenue, and Dr Sudhir Gupta, Deputy Director General of Health Services. Their interactions had a positive impact, and in the subsequent year, the Department of Revenue, working with palliative care activists, developed a draft document for amendment and simplification of the existing NDPS Act. The voluntary services of a lawyer, Ms Tripti Tandon of the non-governmental organization “The Lawyers’ Collective” had given precious input into the drafting of this document. The Amendment would have the effect of uniform NDPS rules for the whole country, as it would shift the powers of legislation from the state government to the central government. The resultant document was placed before the Parliament of India in 2013. It was on the agenda for all three sessions of the Indian Parliament during 2013, but never got the required priority to be dealt with, despite advocacy campaigns by the palliative care community. Finally, during an extended winter session of the Parliament in February 2014, the Parliament passed the NDPS Amendment Act. The new Act transferred the powers for legislation on “essential narcotic drugs” (ENDs) from the state governments to the central Government. It is necessary now for the Government of India to announce uniform simplified state rules. These rules and the standard operating procedures were already prepared by the government, in consultation with the department officials with the support of Ms Tripti Tandon of Lawyers’ Collective and palliative care activists. In May 2015, the Government of India concluded the process with notifications regarding the rules to be followed by the state governments. It is up to palliative care activists and state governments to ensure that the amended rules are implemented.
If we take morphine consumption in the country as the index of access to palliative care, there has been little progress in the last several years as can be seen in Figure 1.
Considering that the official reporting of data to INCB has been erratic until recently, this graph has made use of officially communicated record of the quantity of morphine sold by the Government opium and alkaloid factory to manufacturers of formulations of morphine. Considering that morphine is the only oral opioid belonging to step III of the WHO analgesic ladder, these figures are likely to be representative, with some exceptions. In 2000, the peak was caused by a large scale purchase of morphine by the Government of India using funds from World Health Organization for free distribution to Regional Cancer Centres. We know for a fact that the bulk of it was never used and was eventually destroyed after the expiry date. The drop in consumption from 2002 to 2006 was caused by a breakdown in the Government Opium and Alkaloid Factory, following which production of morphine was reduced.
Further reading:
1. Rajagopal MR and Joranson DE. India: opioid availability – an update. J Pain Symptom Manage 2007; 33:5: 615-622.
2. Khosla D, Patel FD, Sharma SC. Palliative care in India: Current progress and future needs. Indian J Palliat Care 2012;18:149-54Subbarayappa BV. A perspective. Medicine and Life Sciences in India. In: Subbarayappa BV, editor. New Delhi: Centre for Studies in Civilizations; 2001. pp. 1–38. Chattopadhyay DP, general editor. History of Science, Philosophy and Culture in Indian Civilization; Part 2. Vol. IV) [Google Scholar]
3. Rajagopal MR and Palat G. Kerala, India: status of cancer pain relief and palliative care. J Pain Symptom Manage. 2002 ;24(2):191-3Mazars G. Indian medicine across the centuries. A Concise Introduction to Indian Medicine (La médecine indienne). Gopalan TK, translator. Ch. 1. In: Wujastyk D, Zysk KG, editors. Delhi: Motilal Banarsidass Publishers Private Limited; 2006. pp. 1–24. Indian Medical Tradition; Vol. VIII. [Google Scholar]
4. Gopinath BG. Foundational ideas of Ayurveda. Medicine and Life Sciences in India. In: Subbarayappa BV, Chattopadhyay DP, editors. New Delhi: Centre for Studies in Civilizations; 2001. pp. 59–107. History of Science, Philosophy and Culture in Indian Civilization; Part 2. Vol. IV. [Google Scholar]
5. Lochan K. Varanasi: Chaukhambha Sanskrit Bhawan; 2003. Medical education. Medicines of Early India: With Appendix on a Rare Ancient Text. Ch. 4; pp. 90–103. [Google Scholar]
6. http://www.cancercontrol.info/
7. https://www.piramalswasthya.org/
8. Palliative Care Units for Cancer Patients, Ministry of Health and Family Welfare, PIB Delhi (2017). https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1498830.
9. Salins, N., Ramanjulu, R., Patra, L., Deodhar, J., & Muckaden, M. A. (2016). Integration of Early Specialist Palliative Care in Cancer Care and Patient Related Outcomes: A Critical Review of Evidence. Indian journal of palliative care, 22(3), 252–257.


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Sep11
Anorexia Nervosa
An eating disorder causing people to obsess about weight and what they eat.





Anorexia Nervosa is a serious, potentially life-threatening eating disorder characterized by self-starvation and excessive weight loss.


The condition commonly involves emotional challenges, an unrealistic body image, and an exaggerated fear of becoming overweight or obese. If often begins during the teenage years or early adulthood, but it can begin in the preteen years. It is the third most common chronic illness among teens.


Eating disorders affect some 30 million men and women in the United States. Both men and women can develop anorexia, but it is 10 times more common in females. Nearly 1 in every 100 American women will experience anorexia some time. Anorexia nervosa is different from anorexia, which means a loss of appetite or inability to eat.


Fast facts on Anorexia Nervosa:


Here are some key points about anorexia nervosa

. Anorexia nervosa is a psychological condition that involves an eating disorder.

. Symptoms include a very low body mass index, a refusal to eat, and attempts to lose weight, even when body mass index is very low.

. It is thought to be triggered by a combination of biological, environmental, and genetic factors.

. Treatment can take some time, but with a combination of counseling and other types of therapy, recovery is possible.


Anorexia nervosa is a psychological condition and an eating disorder in which the individual loses more weight than is healthy for their height and age. The individual will maintain a body weight of 85% or less of their expected weight.


. A person with anorexia will internationally restrict their food intake, generally due to a fear of being or becoming fat, even when their body mass index is already low. They may also practice excessive, use laxatives, and vomit to reduce weight, but to a lesser extent then those diagnosed with bulimia.


.Complication can be severe. An eating disorder is reported t have the highest mortality rate of any mental illness. Treatment includes hospitalization and counseling.


Symptoms:


Anorexia nervosa is a complex condition, but the main sign is usually severe weight loss. The person may also talk about being overweight, although objective measures, such as BMI, show that this is not true.

Behavioral changes may include a refusal to eat, exercising excessively, and use of laxatives or vomiting after consuming food.



- Severe loss of muscle mass

- Hypotension, or blood pressure
- Listlessness, fatigue, exhaustion

- Lightheadedness or dizziness

- Hypothermia, or low body temperature, and cold hands and feet

- Bloated or upset stomach and constipation

- Dry skin

- Alopecia, or hair loss

- Swollen hands and feet

- Infertility

- Insomnia

- Loss of menstruation or less frequent periods

- Brittle nails

- Osteoporosis, or loss of bone density

- Irregular or abnormal heart rhythms

- Lanugo, fine downy hair growing all over the body, and increased facial hair signs of vomiting include bad breath and tooth decay, due to the acid in the vomit.


Psychological signs and symptoms include:


- Obsession with food, for examples, reading cookery books

- Excessive concern about being fat or overweight

- Frequently measuring and weighing themselves and inspecting their bodies in the mirror

- Lying about food intake

- Not eating or refusing to eat

- Reduce sex drive

- Self- denial

- Lack of emotion or a depressed mood

- Over-exercising

- Irritability

- Memory loss

- Obsessive-compulsive behavior

Food and eating become associated with guilt. It may be difficult to talk to the person about a possible problem, as they will likely refuse to acknowledge that anything is wrong.


Causes:


No single cause has been identified for anorexia nervosa. It probably happens as a result of biological, environmental, and psychological factors.


- Being susceptible to depression and anxiety

- Having difficulty handling stress.

- Being excessively worried, afraid, or doubtful about the future

- Being perfectionist and overly concerned about rules.

- Having a negative self-image

- Having eating problems during early childhood or infancy

- Having had an anxiety disorder during childhood.

- Holding specific regarding beauty and health, which may be influenced by culture or society

- Having a high level of emotional restraint or control over their own behavior and expression, the person may be overly worried about their weight and shape, but this is not necessarily the key factor.


33 and 50 % of people with anorexia also have a mood disorder, such as depression, and around half have an anxiety disorder, such as Obsessive-compulsive disorder and social phobia. This suggests that negative emotions and a low self-image may contribute, in some cases. A person may develop anorexia Nervosa as a way of gaining control of some of their life. As they exert control of their food intake, this feels like success, and so the behavior continues.


Environmental factors:



Environmental factors may include the hormonal changes that occur during puberty, plus feelings of anxiety, stress, and low self-esteem. The fashion industry and media messages suggesting that being thin is beautiful may have an impact.

- Physical, sexual, emotional or other types of abuse

- Family or other relationship problems

- Being bullied

- Fear and pressure to succeed

- A stressful life event, such as bereavement or becoming unemployed.


Genetic Factors:


Studies have found that some people with eating disorders may have an imbalance in certain brain chemicals that control digestion, appetite, and hunger. Further research is needed to confirm this. Genetic factors may affect a person's susceptibility to eating disorders, as they can run in families. between 50 to 80% of the risk for anorexia is thought to be genetic.


Vicious cycle:


Once a person starts losing weight, low weight and lack of nutrients may contribute to brain changes in a way that reinforces the behaviors and obsessive thoughts related to anorexia nervosa. The changes could involve the part of the brain that controls appetite,



Once a person starts losing weight, low weight and lack of nutrients may contribute to brain changes in a way that reinforces the behaviors and obsessive thoughts related to anorexia nervosa.



The changes could involve the part of the brain that controls appetite or they could increase the feelings of anxiety and guilt that become associated with eating.


Anorexia nervosa may have different gut microbial communities than those without the condition. The authors suggested that this could contribute to anxiety, depression, and further weight loss. People with anorexia nervosa are less able to differentiate between different types of positive emotion. This can lead to further weight-loss behavior, as self- deprivation becomes associated with a sense of pride.







Diagnosis:


Diagnosis and prompt treatment increase the chance of a good outcome.


The physician will ask the patient about weight loss, how they feel about their weight, and, for females, about menstruation. It can be hard fo the patient to open up and speak frankly about themselves. It can take years to confirm a diagnosis, especially if the person was previously obese. If the physician detects signs of anorexia nervosa, they may order tests to rule out other underlying medical conditions with similar signs and symptoms.

- Diabetes, Addison's disease

- Chronic infections, Malabsorption

- Immunodeficiency, Cancer

- Inflammatory bowel disease, Hyperthyroidism


Complications:


Complications can affect every body system, and they can be severe.


Physical complications include:


- Cardiovascular problems: These include low heart rate, low blood pressure, and damage to the heart muscle.


- Blood problems: There is a higher risk of developing leukopenia, or low white blood cell count. and anemia, a low red blood cell count.


Gastrointestinal problems: Movement in the intestines slow significantly when a person is severely underweight and eating too little, but this resolves when the diet improves.


Kidney problems: Dehydration can lead to highly concentrated urine and more urine production. The kidneys usually recover as weight levels improve.


Hormonal problems: Lower levels of growth hormones may lead to delayed growth during adolescence.


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Nov04
How to control your anxiety???
What to do to control your Anxiety:

- Notice how it is affecting you and pay attention to how you would rather be feeling.
- Remember to breathe.
- Focus on something interesting and engaging, a hobby, a project, a conversation with a friend.
- Play with a pet or children, Play a sport.
- Stay active in your life. Continue going to work and/or school.
- Take care of the children.
- Keep your house clean.
- Take care of your personal hygiene.
- Surround yourself with people who care about you.
- Engage in conversation that is interesting and meaningful.
- At other times, engage in trivial talk.
- Try to limit discussion about the anxiety to less than 5% of your conversation.
- Pay attention to whether what you are doing or thinking is what you want to be doing or thinking.


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Sep18
लेखांक १३. श्री विष्णुसहस्रनाम स्तोत्रातì
श्री विष्णुसहस्रनाम स्तोत्रातील वैश्विक चैतन्य: डॉ. श्रीनिवास कशाळीकर
लेखांक १३.

अनादिनिधनं विष्णुं सर्वलोकमहेश्वरम्
लोकाध्यक्षं स्तुवन्नित्यं सर्वदु:खातिगो भवेत् -८.
भीष्माचार्य पुढे म्हणाले, उत्पन्न होणे, वाढणे, टिकून राहणे, बुद्धिभ्रंश होणे, क्षीणता येणे आणि नाश पावणे असे सहाही विकार नसलेला म्हणून अनादिनिधनं असा, चराचराचा आणि जाणीवेच्या सर्व पातळ्यांचा स्वामी असल्यामुळे लोकाध्यक्षं असा, सर्वान्तर्बाह्य विश्व आणि जाणीवा व्यापणारा म्हणून विष्णू ह्या नावाने ओळखला जाणारा आणि सर्व सत्ताधीश असल्याने सर्वलोकमहेश्वम् असा ईश्वर; निरंतर स्तुती करण्यास म्हणजे उपासना करण्यास सर्वतोपरी योग्य आहे. ह्या सच्चिदानंदाच्या अशा सहवासामुळे, देहबुद्धीजन्य (उत्पन्न होणे, वाढणे, टिकून राहणे, बुद्धिभ्रंश होणे, क्षीणता येणे आणि नाश पावणे) अशा सर्व दु:खांपासून जीवाला मुक्ती मिळते.


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Sep18
लेखांक १२. श्री विष्णुसहस्रनाम स्तोत्रातì
श्री विष्णुसहस्रनाम स्तोत्रातील वैश्विक चैतन्य: डॉ. श्रीनिवास कशाळीकर
लेखांक १२.
भीष्म उवाच
जगत्प्रभुं देवदेवन्तम पुरुषोत्तमम्
स्तुवन्नामसहस्रेण पुरुषसततोत्थित: -६.
भीष्माचार्य म्हणाले, सर्व जगाचा (चराचर विश्वाचा) स्वामी, देवांचा देव (आपण देव म्हणून किंवा सर्वश्रेष्ठ म्हणून जी कल्पना करू शकतो त्या भ्रामक कल्पनेपलिकडे असलेला) आणि अनंत म्हणजे आपल्या जाणीवेतील सर्व मर्यादित आणि नश्वर विश्वाच्या अतीत असा पुरुषोत्तम आहे. अर्थपूर्ण अशा त्याच्या एक हजार नामांच्या आधारे त्याचे स्मरण (जप) आणि स्तुती करून आपण उद्धरले जातो. (आपल्या जडत्वातून आणि अज्ञानातून मुक्त आणि जागृत होत जातो).
तमेव चार्च्ययन्नित्यं भक्त्या पुरुषमव्ययम्
ध्यायन्स्तुवन्नमस्यंश्च यजमानस्तमेवच ७.
भीष्माचार्य मग म्हणाले, आपल्या सर्वांच्या अंतर्यामी असलेल्या ह्या अविनाशी सत्याला सगुण रूप देऊन त्या पुरुषाची भक्तिपूर्वक पूजा अर्चा करावी. त्याचे ध्यान करावे आणि त्याची स्तुती करावी. त्याला नमन करावे.
ह्याचा मथितार्थ असा की, ह्या अविनाशी तत्वाबद्दल आपल्याला असलेली सुप्त ओढ, तिच्या विरुद्ध असणाऱ्या आपल्या वासनांमुळे दुबळी होते हे जाणून त्या सर्व वासना आणि आशा आकांक्षा; जाणीवपूर्वक आणि सतत त्या पुरुषाच्याकडे वळवायच्या. अशा तऱ्हेने; सर्वान्तर्यामी नियंत्रक प्रभुत्वाने वसणाऱ्या ह्या सत्ताधीशाचा ध्यास घ्यायचा, सर्व लक्ष त्याच्यावरच केंद्रित करायचे, त्याच्याबद्दलची आपली नितांत पण सुप्त आवड मनात घोळवून ती आवड व्यक्त आणि दृढ करणारी स्तुती करायची; आणि त्याच्यापासून दूर नेणारे आपले सर्व संकुचित अस्तित्व त्याच्या चरणावर संपूर्णपणे झोकून द्यायचे, त्याच्या पायावर लोळण घ्यायची!


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Sep18
लेखांक ११. श्री विष्णुसहस्रनाम स्तोत्रात
श्री विष्णुसहस्रनाम स्तोत्रातील वैश्विक चैतन्य: डॉ. श्रीनिवास कशाळीकर
लेखांक ११.
प्रश्न ५.
को धर्म: सर्व धर्माणां भवत: परमो मत:
धर्म ह्याचा अर्थ सर्व दृश्य आणि अदृश्य अशा विश्वाला आधारभूत अशी व्यवस्था. तिचे अचूक ज्ञान आत्मसात होणे हे मनुष्य जीवनाला आधारभूत असून अशा ज्ञानाला अखिल मानव जातीचा आणि म्हणूनच प्रत्येक व्यक्तीचा सर्वश्रेष्ठ धर्म असे म्हणतात.
ह्या धर्माविषयी संभ्रम होऊ नये म्हणून आपल्या सर्वांच्या वतीने महाराज युधिष्ठीर हा प्रश्न विचारतात. याअगोदर जे चार प्रश्न विचारले गेले आहेत, त्याना अनुरोधून पाहिले तर, अंतरीचा निर्गुण देव, म्हणजेच योग्य स्तुती आणि पूजेचे अचूक स्थान ह्या सर्वश्रेष्ठ धर्माच्या आचरणानेच प्राप्त हितात आणि आपले जीवन सर्वतोपरी कृतार्थ होत होत; सच्चिदानंद अनुभूतीमध्ये परिणत होते.
प्रश्न ६.
किं जपन्मुच्यते जन्तुर्जन्मसंसार बंधनात?
याअगोदर विचारात घेतलेल्या धर्माचे एक उन्नत, अत्यावश्यक आणि अविभाज्य अंग म्हणजे स्मरण. ह्यालाच जप असेही म्हणतात.
सुरवातीला जन्म-मृत्त्युचे बंधन आणि त्यातून मुक्ती हे शब्दप्रयोग आणि ह्या कल्पना आपल्याला अनैसर्गिक (आणि काहीजणांना तर विकृत) वाटू शकतात. परंतु आपण जसे जसे; जीवनाच्या गाभ्याच्या नजीक पोचतो, तसे तसे हे शब्द प्रयोग आणि ह्या कल्पना समजू लागतात. त्यांच्यातील मर्म ध्यानात येऊ लागते. जन्म आणि मृत्युच्या अर्थात संसाराच्या बंधनातून मुक्ती म्हणजे आंतरिक सामाधानापासून पुन्हा पुन्हा फरफटत दूर जावे लागण्यापासून मुक्ती असते; ह्याची कल्पना येऊ लागते.
पण हे सारे नामस्मरणाच्या आचरणानेच अधिकाधिक स्पष्ट होऊ लागते!
पण म्हणूनच महाराज युधिष्ठीर आपल्या सर्वांच्या वतीने हा प्रश्न उपस्थित करीत असताना दिसत आहेत, की कोणत्या जपाच्या साह्याने जंतू म्हणजे मनुष्य प्राणी जन्म आणि मृत्यू ह्यांच्या; अर्थात संसाराच्या बंधनातून मुक्त होईल?


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Sep18
लेखांक १०. श्री विष्णुसहस्रनाम स्तोत्रातì
श्री विष्णुसहस्रनाम स्तोत्रातील वैश्विक चैतन्य: डॉ. श्रीनिवास कशाळीकर
लेखांक १०.
प्रश्न ४.
(अशुभ म्हणजेच सच्चिदानंदाच्या आड येणारे सर्व नष्ट होण्यासाठी) कंमर्चंत: म्हणजे अर्चना करण्यायोग्य वा पूजा अर्चा करण्यायोग्य कोण आहे? अर्चना किंवा पूजा अर्चा कुणाची करावी?
आईला आपल्या नवजात बाळाला किती जपू आणि कसे जपू असे होते. त्याला कुठे ठेवू आणि कुठे नको असे होते. त्याच्यावरून सर्वस्व, अगदी जीव देखील ओवाळून टाकावा असे होते. त्याच्यासाठी काय करू आणि काय नको असे होते. त्याचे कोड कौतुक किती आणि कसे करू आणि कसे नको असे होते. त्याचे सर्व काही करण्यामध्ये काही उणे पडू नये आणि काही चुकू नये असे तिला वाटते!
महाराज युधिष्ठीर यांची (प्रत्यक्षात आपली सर्वांची जरी आपल्याला काळात नसली तरी) वास्तवात अवस्था, आईसारखीच आहे.
ज्याची आंतरिक ओढ लागते, जे अत्यंत महत्वाचे वाटते, जे सर्वाधिक महत्वाचे वाटते त्याची पूजा अर्चा करण्यात काही गफलत होऊ नये असे वाटते.
ज्याप्रमाणे बाळाचे सर्व काही यथायोग्य व्हावे; आणि ते बाळालाच पोचावे यासाठी आई; अनुभवी मातांकडून मार्गदर्शन मागते, त्याचप्रमाणे अर्चना म्हणजेच पूजा-अर्चा योग्य व्हावी आणि योग्य तिथे पोचावी ह्यासाठी हा प्रश्न विचारलेला आहे.


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Sep18
लेखांक ९. श्री विष्णुसहस्रनाम स्तोत्रातीë
श्री विष्णुसहस्रनाम स्तोत्रातील वैश्विक चैतन्य: डॉ. श्रीनिवास कशाळीकर
लेखांक ९.
प्रश्न ३.
(अशुभ म्हणजेच सच्चिदानंदाच्या आड येणारे सर्व नष्ट होण्यासाठी) स्तुवन्त: कं म्हणजे स्तुती करण्यायोग्य कोण आहे किंवा कुणाची स्तुती करावी? ह्या अगोदर वर्णन केलेली सद्गती म्हणजेच सर्वांच्या अंतरंगातील हे स्थान; निराकार, अदृश्य म्हणजेच निर्गुण असल्यामुळे त्याविषयी कल्पना करता येत नाही. एका बाजूने सर्वांना उत्कट आणि अनामिक ओढ तर लागते, पण दुसऱ्या बाजूने त्याविषयी गोंधळ निर्माण होण्याची दाट शक्यता असते. विपरीत कल्पना निर्माण होण्याची शक्यता देखील असते.
अशी विपरीत कल्पना होऊ नये, म्हणून आत्मज्ञानी आणि आत्मसाक्षात्कारी सदगुरूंकडे धाव घेणे आणि त्यांना प्रश्न विचारणे वा सांकडे घालणे गरजेचे आणि योग्य असते. आपल्याला योग्य ज्ञान मिळावे, आपली इच्छा योग्य दिशेला वळावी आणि आपल्याकडून योग्य क्रिया घडावी ह्यासाठी सद्गुरुंचे अंतरंग आणि आपले अंतरंग जोडले जाणे आवश्यक असते. ह्यालाच सद्गुरुकृपा म्हणतात. अशा सद्गुरुकृपेने आपला जिव्हाळा (जो दुधावरील सायीप्रमाने किंवा ताकावरील लोण्याप्रमाणे आपल्या जीवनाचे सर्वस्व असतो, तो अनुचित प्रकारे अनुचित ठिकाणी न जाता) योग्य शब्दातून आणि योग्य ठिकाणी पोचावा म्हणून आर्ततेने विचारलेला हा प्रश्न आहे.
आत्मज्ञानी जगद्गुरू महर्षी वेदव्यास यांनी विश्वकल्याणासाठी आपणच हा प्रश्न महाराज युधिष्ठीर यांच्याद्वारे भीष्म पितामह यांना विचारून आपणच भीष्मचार्यांच्याद्वारे त्याचे समर्पक उत्तर पुढे दिले आहे.


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Sep17
लेखांक ८ .श्री विष्णुसहस्रनाम स्तोत्रातीë
श्री विष्णुसहस्रनाम स्तोत्रातील वैश्विक चैतन्य: डॉ. श्रीनिवास कशाळीकर
लेखांक ८.
प्रश्न २. किंवाप्येकं परायणम् ह्याचा आशय असा आहे की विश्वनियंत्रक अशी शक्ती ही कुणी व्यक्ती नाही. ती वस्तू नाही. ती एकादे स्थान नाही. ती वीज किंवा उष्णता यासारखी उर्जा नाही. ती अवकाश व काल देखील नाही. ती वासना, भावना, कल्पना, विचार, प्रेरणा, इच्छा इत्यादी काही नाही. ती एकादी निव्वळ मानसिक अवस्था देखील नाही. परंतु, ती शब्दातीत शक्ती आपल्या अंतर्यामी आणि खोलवर असल्याचे जसे अस्पष्टपणे जाणवते, तसेच ती संपूर्ण विश्वातील अणुरेणु व्यापून आहे असे देखील भासते. अंतर्यामी असल्यामुळे शरीराने तिथे पोचण्याचा प्रश्नच नाही. परंतु जाणीवेने तिथे पोचण्यासाठी देखील ती अत्यंत दूर भासते.
वर्णन करण्यास अशक्य असल्यामुळे ह्या सद्गतीचे वर्णन आपापल्या परीने संकेताने केले जाते. आपण तिला जाणीवेची सद्गती म्हणू. ह्या सद्गतीलाच; परंधाम, ईश्वराचे चरण कमल, ईश्वरी साक्षात्कार, सद्गुरुभेट, मोक्ष, निर्वाण, मुक्ती म्हणतात. जाणीवेच्या ह्या सद्गतीमध्ये पूर्णत्व येत असल्या तिला शाश्वत समाधानाची किंवा सच्चिदानंदाची अनुभूती म्हणतात. ती जाणीवेच्या पलीकडे असलेली सर्वांच्या अस्तित्वाची आणि जाणीवेची सद्गती असल्यामुळे आणि ह्या सद्गतीमध्ये सुरक्षितता अनुभवाला येत असल्यामुळे तिला कालातीत आश्रयस्थान म्हणतात. तिचे स्वरूप धूसरपणे जाणवत असल्यामुळे असा प्रश्न निर्माण होतो, की सर्वांचे अंतीम गंतव्य असे ते जडत्वहीन आणि म्हणूनच पवित्रतम असलेले असे स्थान कोणते?


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