Vol. 4, No. 10 / October 2005 Current Psychiatry Online

Yoga: A breath of relief for Hurricane Katrina refugees

Stress-reducing programs relieve trauma symptoms, perhaps by stimulating the vagus nerve.

Patricia L. Gerbarg, MD

Assistant professor in clinical psychiatry, New York Medical College, Valhalla, NY

Richard P. Brown, MD

Associate professor in clinical psychiatry, Columbia University College of Physicians, New York, NY

Hurricane Katrina survivors need help rebuilding their mental health as well as their homes and lives. That’s why 17 teachers trained in a disaster-specific yoga breathing intervention traveled South just days after the storm.

Yoga-based trauma relief programs are a cost-effective way to rapidly relieve posttraumatic stress symptoms and depression in populations affected by disasters. Experience from the 2001 World Trade Center attacks and December 2004 tsunami show these programs can help patients of all ages, with minimal risk.

This article describes two programs shown to ameliorate anxiety, depression, insomnia, hyperarousal and re-experiencing (flashbacks) in survivors of war, terrorism, and natural disasters. We present a neurophysiologic model to explain how yoga breathing could have these effects.

Box 1

Yoga breathing: Disaster teams aid hurricane victims, many others

Two world-wide, nonprofit, humanitarian organizations that originated in India—the Art of Living Foundation (AOLF) and International Association for Human Values (IAHV)—have provided disaster and stress relief programs in 146 countries.

Among Hurricane Katrina survivors, AOLF volunteers were offering courses for adults and children in Baton Rouge, LA, Houston and Austin, TX, when this article went to press in mid-September. Child evacuees who took a yoga breath course Sept. 7 at the Austin convention center said they felt less tense and less aggressive by the second or third day of the course. Their sleep and energy improved, and their writings reflected a more positive self-image.

Sudarshan Kriya yoga (SKY) and Breath Water Sound (BWS) teachers are setting up programs in other cities receiving large numbers of evacuees, including San Antonio, TX, Miami, FL, Washington, DC, Perth Amboy, NJ, and St. Louis, MO.

A history of helping. SKY and BWS courses are taught by yoga instructors trained and certified by the AOLF, which offers programs in most major U.S. cities. Fees for regular courses and private donations support the free programs offered to disaster survivors and impoverished populations.

Before Hurricane Katrina, the AOLF and IAHV (which are United Nations nongovernmental organizations) have offered emergency trauma relief in other recent disasters:

In Russia, they offered programs for Russian soldiers with PTSD after more than 300 hostages were killed in the September 2004 Beslan school terrorist attack (Photo 1). Many Beslan civilians also participated in the yoga breath courses.

In Southeast Asia, AOLF and IAHV volunteers delivered supplies, set up refugee camps and orphanages, and provided BWS trauma relief to more than 15,000 survivors of the December 2004 tsunami (Photo 2).

Other countries and disasters where AOLF and IAHV trauma programs have been offered include:

· floods in Jakarta (Indonesia), Poland, and Dresden (Germany)

· earthquakes in Gujurat (India) and Bam (Iran)

· terrorist train bombing in Madrid (Spain)

· war or civil strife in Chechnya, Kosovo, Serbia, Croatia, Armenia, Azerbaijan, Kashmir, India, Pakistan, Iraq, Kabul (Afghanistan), Ramallah (Palestine), Gaza Strip (Palestine), South Africa, Kenya, Botswana, Sudan, and Malawi.

SKY and BWS programs

Art of Living Foundation. www.artofliving.org International Association for Human Values. www.iahv.org; for information on BWS courses, contact relief@iahv.org

Research information

Art of Living Foundation Research Committee. Contact researchcommittee@artofliving.org

Source: Photographs reproduced with permission of the Art of Living Foundation

Yoga breath programs

Yoga programs often combine stretches, breath practices, meditation, and group discussions with psychoeducation. All are valuable, but we will focus on four breath forms.

Victorious breath (Ujjayi) creates a sound like ocean waves by a slight contraction of the laryngeal muscles and partial closure of the glottis to increase airway resistance and breath control. At 2 to 4 breaths per minute, Ujjayi is physically and emotionally calming. Three-stage Ujjayi is an advanced form using specific breath cycle ratios, postures, and breath-holds for more powerful effects.

Bellows breath (Bhastrika) is a high-frequency (30 breaths per minute) exercise using the arms to increase the force of inhalation and exhalation.

‘Om.’ Chanting “om” very slowly creates vibrations in the abdomen, chest, throat, and jaw stimulating vagal and sensory afferents.

Purifying breath (Sudarshan Kriya) is an advanced cyclical breathing at slow, medium, and fast rates.

All four breath forms are taught in Sudarshan Kriya Yoga (SKY), a 22-hour course that includes yoga postures, guided meditation, group processes, service, and psychoeducation in stress reduction and human values. Breath Water Sound (BWS)—an 8-hour version of SKY adapted for immediate disaster relief—uses three-stage Ujjayi, Bhastrika, and “om” with or without Sudarshan Kriya breathing.

SKY and BWS are offered by the nonprofit Art of Living Foundation (AOLF) and International Association for Human Values (IAHV), which provide disaster relief worldwide (Box 1).

Lessons from 9/11

More than 1,000 New Yorkers received free yoga breathing courses beginning 2 weeks after the September 11, 2001 World Trade Center terrorist attack and continuing for 6 months. Although retrospective analysis has questioned the efficacy of conventional psychotherapy in treating mass trauma within the first weeks of a disaster,¹ SKY and BWS teachers and participants reported that trauma symptoms improved dramatically. Three sample cases follow:

Case 1: Persistent fear. Ms. P, age 28, suffered constant panic attacks after witnessing the twin towers’ collapse and having her apartment engulfed in the toxic cloud. She was afraid to be alone, afraid to go out, and felt “numb, depressed, and paralyzed.” Twelve weeks after the terrorist attack, she took the SKY course on the advice of her therapist.

The first Sudarshan Kriya gave her a feeling of lightness and clarity. During the second, she felt happy and peaceful, as though “purified.” The course relieved her symptoms and helped her get on with life.

Ms. P is a recovering alcoholic who was sober for 2 years before 9/11. When interviewed in 2005, she said the yoga programs helped her stay sober and quit smoking. She still practices SKY and is taking advanced courses. She has no posttraumatic stress disorder (PTSD) or depression symptoms.

Case 2: Sleepless nights. Ms. M, age 48, did not sleep more than 1 hour a night for 2 weeks after 9/11. She was so groggy that she could not return to work as a waitress.

During the first Sudarshan Kriya she cried with fear every time she got to the fast breath cycles because they reminded her of how she was breathing while running from the dust cloud, terrified that she would die. The next day, however, she felt peaceful during Kriya and finished it feeling happy. That night she slept 12 hours.

Case 3: Inability to eat. Ms. L was so nauseated after 9/11 that she could not eat. For 3 weeks, she vomited every time she tried to eat. The night after her first Sudarshan Kriya she was able to hold down a meal. After the second Kriya, she felt hungry for the first time in weeks.

Box 2

Advantages of yoga breathing programs for emergency trauma relief

1. Well-tolerated by recently traumatized survivors of mass disasters

2. Rapidly improve psychological and physiological symptoms of post-traumatic stress, including insomnia, nightmares, anxiety, depression, hyperarousal, overreactivity to triggers, re-experiencing, emotional numbing, social withdrawal, loss of appetite, angry outbursts

3. Cost-effective group treatments (one teacher can lead three classes of 30 persons every day)

4. Acceptable to survivors who do not want to be stigmatized by seeking “psychiatric” treatment

5. Enhance group bonding, group support, and the empowerment of survivors to take responsibility for projects for the good of their communities

How effective?

Immediately after mass disasters, many obstacles impede the study of mental health interventions:

· Immediate relief efforts must focus on rescue and acute physical care, and conditions are too chaotic for controlled studies.

· One-on-one interventions are impractical as the sheer number of victims overwhelms health care providers.

· The sudden, unexpected nature of disasters denies researchers the time needed to develop protocols, obtain grants, and mobilize teams.

· Researchers cannot follow subjects during massive population displacement.

· Ethical concerns about exploiting disaster victims have discouraged research.

As a consequence, most literature contains retrospective data or studies done months or years after the disaster. For data on the effect of SKY and BWS programs, we have drawn on pilot studies; reports from first responders, relief workers, and news reporters; and government documents.² Our review shows that SKY and BWS programs have advantages over traditional psychotherapy (Box 2) and are effective in relieving survivors’ depression, stress, and anxiety.

Depression. An open study of 46 patients with dysthymia³ (mean illness duration 3.15 years) showed significant improvement on Beck Depression Inventory (BDI) and Clinical Global Impression scales 1 and 3 months after SKY breath training. Among the 37 patients who completed the program, 67.5% achieved remission. After SKY training, small but significant prolactin elevation occurred.⁴

In a randomized, controlled study, 45 hospitalized patients with severe melancholic depression received SKY; imipramine, 150 mg/d; or electroconvulsive therapy (ECT) three times a week. SKY was as effective as imipramine and almost as effective as ECT, as shown by reductions in BDI and Hamilton Rating Scale for Depression total scores. Significant prolactin elevations were noted after SK cyclical breathing.⁵

Tsunami survivors. A wait-list controlled study of survivors of the December 2004 Southeast Asian tsunami found dramatic improvements in test scores for PTSD and depression after 8-hour BWS training (Descilo et al, manuscript in preparation).

Anxiety and PTSD. Studies of anxiety and PTSD using similar breath techniques document benefits in anxiety,^6,7 student exam stress,⁸ and in Australian Vietnam veterans with PTSD.⁹

SKY reduced chronic PTSD symptoms in a pilot study of Australian Vietnam veterans (Carter et al, manuscript in preparation). A 6-week study using breath techniques and other mind-body interventions significantly reduced PTSD symptoms in high school students traumatized by war in Kosovo.¹⁰

Children and adolescents. In a pilot study of ART Excel (a BWS course adapted for children), atrisk children showed rapid reduction in measures of anxiety and depression (Descilo et al, manuscript in preparation). A pilot study found significant reductions in measures of anxiety, depression, and anger in inner-city youth participating in a Youth Empowerment Seminar, a SKY course adapted for adolescents (Sageman et al, manuscript in preparation).

How does yoga breathing work?

Anxiety, depression, and PTSD are associated with sympathetic nervous system (SNS) overactivity or erratic activity and parasympathetic nervous system (PNS) underactivity.^11-15 Evidence suggests yoga breathing normalizes SNS activity and increases PNS tone as indicated by heart rate variability.^8,16

The autonomic nervous system (ANS) regulates respiration, and emotional states affect respiratory rate, depth, and pattern. Conversely, voluntary manipulation of breath patterns can account for up to 40% of the variance of feelings such as anger, fear, joy, and sadness.¹⁷

Yoga breathing is an example of peripheral feedback eliciting an emotional response.¹⁸ Evidence suggests that voluntary control of breath patterns can affect ANS functions via vagal afferents to brainstem nuclei (nucleus tractus solitarius, parabrachial nucleus, and locus coeruleus). Yoga breathing also can influence the thalamus, cortex, and limbic system, inducing changes in emotion, cognition, and consciousness.¹⁹ Our neurophysiologic model (Figure) postulates that vagal afferents activate hypothalamic vigilance areas and enhance attention and alertness, whereas pathways through the thalamus quiet frontal cortical activity and reduce anxious worrying. Vagal afferents stimulate the limbic system and forebrain reward systems, releasing prolactin (and possibly oxytocin) while inducing joy, pleasure, and bonding. Thus:

· Ujjayi produces a state of calm alertness and well-being.

· Bhastrika stimulates the SNS and, over time, enhances autonomic flexibility, reducing overreactivity to stress.

Among more than 200 persons using Sudarshan Kriya for PTSD symptoms, we have seen that many experience relief from trauma-related memories, emotions, sensations, and physiologic reactions. Most feel calmer, lighter, less worried, happier, and more hopeful. Combined effects on the limbic system, thalamus, and cortex may cause this response.²

Figure
Neurophysiological model of vagus nerve afferent pathways

VNS=vagal nerve stimulation; NTS=nucleus tractus solitarius; PBN=parabrachial nucleus; MRS=mesolimbic reward system; SMR=sensori-motor rhythm; PRS=post-reinforcement synchronization (Adapted and reproduced with permission from John Wiley & Sons, Ltd.)¹⁹

Referral and precautions

SKY and BWS courses are available in most major U.S. cities (Box 1) and are considered safe for most trauma survivors. Some precautions and contraindications apply, however.

Pregnancy. Pregnant women should not do breath-holds or any rapid or forceful yoga breathing. Slow, gentle basic Ujjayi without breath-holds is safe and soothing.

Comorbid medical illness. Patients with uncontrolled hypertension; migraine headaches; severe COPD; acute asthma symptoms; recent neck, shoulder, or chest injuries; or recent major surgery or myocardial infarction should not do Bhastrika or any strenuous yoga breathing. Yoga breathing is contraindicated in persons with seizure disorders.

Comorbid psychiatric illness. Yoga breathing—particularly Bhastrika and rapid cycle breathing—may trigger manic episodes in patients with bipolar disorder. Those with type II bipolar disorder whose mood swings are well-controlled may do yoga breathing under supervision if they avoid Bhastrika and rapid cycle breath forms.

Patients with chronic PTSD from childhood abuse can benefit from SKY if they do not have significant dissociative symptoms. The psychotherapist should contact the yoga teacher, prepare the patient, and help process early trauma-related material that may emerge.

Psychosis is a contraindication for yoga breathing. Some psychotic patients benefit from gentle basic Ujjayi under supervision.

Related resources

· National Alliance on Mental Illness. Hurricane Katrina resource guide.

Disclosures

The authors receive no remuneration other than reimbursement for travel expenses for their work with the Art of Living Foundation and the International Association for Human Values.

Acknowledgment

Jim Farrow, MD, who taught SKY and BWS to hundreds of New Yorkers after 9/11, contributed cases 1 and 3 to this article.

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