Breath-Body-Mind Practices for Stress and Mental Health

Breath-Body-Mind Practices for
Treatment of Stress,
Anxiety Disorders,
PTSD, and Mass Disasters
Richard P. Brown MD
Associate Professor of Clinical Psychiatry
Columbia University
Patricia L. Gerbarg, MD
Assistant Professor of Clinical Psychiatry
New York Medical College

donderdag 26 april 2012

Professional Disclosure: Richard P. Brown, MD
and Patricia L. Gerbarg, MD

With respect to the following presentation, there
has been no relevant (direct or indirect) financial
relationship between the parties listed above
(and/or spouse) and any for-profit company in the
past 24 months which could be considered a
conflict of interest.


“You’ve been fooling around with
alternative medicines, haven’t you?”

How Can We Function Better
Under Stress?
• Increase energy supplies
• Maintain energy supplies
• Learn how to stop wasting energy
• Balance the stress-response system:
shift from sympathetic (energy burning)
to parasympathetic (energy recharging)

©2012 RPBrown & PLGerbarg


Gray’s Motivational Theory

Approach Reward - Fight/Flight/Freeze - Avoidance
Behavioral Activation Behavioral Inhibition
System (BAS) System (BIS)
Dopamine Serotonin/Norepi

Sympathetic Nervous System
(Stress Response; Burns Energy)
(Beauchaine, T. 2001)



Autonomic Nervous System

Sympathetic System Parasympathetic System

Approach (BAS) Emotional Regulation
Avoidance (BIS) (Vagal)

Behavior & Emotion



Vagal Activity
• 20% of vagus regulates heart, lungs,
digestion, glands, immune function
(efferent)
• 80% of vagus nerve carries messages
from the body up to the brain (afferent)



Activation of the
Parasympathetic System (PNS)
• Vagus nerve, main pathway of PNS, is
bidirectional
• Breathing activates afferent pathways that
stimulate vagus nerve
• Voluntary change in pattern of breath can alter
activity of vagus nerve, emotional tone,
attention, and cognitive processes
(Philippot P & Blairy S. 2003)



Vagus Nerve Involved in:

• Social bonding
• Empathy & love
• Gut feelings & instincts
• Perception & observation

(Stephen Porges 2001, 2009)



What is Heart Rate Variability

• HRV is the rate at which the heartbeat
changes. Healthy HRV correlates with
health and well-being.
• HRV diminishes with age, illness, stress,
and lack of exercise.
• Heart Rate Variability (HRV) can be used
as an indicator of parasympathetic and
sympathetic activity


Heart Rhythm Varies With Breathing Rhythm

Heart rhythm at 5 breaths per minute Heart rhythm at 15 breaths per minute

Heart rhythm at 7.5 breaths per minute Heart rhythm at 30 breaths per minute



HRV Biofeedback vs Relaxation for PTSD
• Pilot study
• 38 substance abuse patients with PTSD in
residential facility randomized to Respiratory
Sinus Arrythmia Biofeedback or Progressive
Muscle relaxation 20 min/day
• Both groups ↓ PTSD & insomnia ratings
• HRV group improved more in depression,
HRV indices (correlated with less PTSD)
(Zucker TL et al. Appl Psychophysiol Biofeedback 2009)



What is Coherent Breathing?

• Breathing with comfortable depth at
• 1 breath duration ~ 12 sec with (5 cpm)
– 6 sec inhalation and 6 sec exhalation
• Results in:
– Optimal sympathovagal balance
– Cardiopulmonary resonance
– ↑ coherence of autonomic nervous
system and heart electrical activity


Yoga Breathing Corrects
• Sympathetic and Parasympathetic
imbalance
• How does it do this?

(Brown & Gerbarg, Part I. J Alternative and
Complementary Medicine 2005; Telles &
Desijaru 1992)



How to Increase Vagal Afferent
Stimulation
• Slow breathing 3 – 6 bpm
• ↑ airway resistance – laryngeal
contraction (Ujjayi, Victory, Ocean
Breath) or by pursed lips
• Duration of exhalation > inhalation

(Cappo & Holmes 1984; Telles & Desijaru 1992;
Calabrese 2000; Gozal 1995)



Effects of Yoga-Breath Intervention Alone and with Exposure
Therapy for PTSD and Depression in Survivors of the 2004
Southeast Asia Tsunami. Acta Psychiatr Scand 2010
Teresa Descilo, Patricia Gerbarg, A Vedamurtachar,
D Nagaraja, BN Gangadhar, R Damodaran,
Beth Adelson, Laura Braslow, Sue Marcus,
Richard Brown


Severely Traumatized Population
• Refugees from the most severely
damaged coastal villages in
Nagapattinam
• Living in 5 refugee camps
• Out of all deaths in the state of Tamil
Nadu, 75% occurred in Nagapattinam
district



Study Design
• 183 subjects
• 3 equal groups assigned by camps
• BWS: BWS + 10-minute SK
• B+T: BWS followed 3 days later by
TIR (Traumatic Incident Reduction)
• CON: 6-week wait-list control group



Mean Scores PTSD Checklist PCL-17

P < .001



Mean Scores Beck Depression Inventory

P < .0001

©2012 RPBrown & PLGerbarg ©2010 RPBrown & PLGerbarg


Multi-component Yoga-Breath Based
Program Reduces PTSD in Australian
Vietnam War Veterans
Janis Carter, MD
University of Queensland
Patricia L. Gerbarg, MD
New York College of Medicine
Richard P. Brown, MD
Columbia University
Robert Ware, PhD
University of Queensland


Randomized, Wait-list Controlled Trial

• 32 Australian Vietnam Veterans
• Chronic, treatment resistant PTSD
• Mean age 58 years
• 25 completed study and testing
• Totally disabled due to PTSD
• Previous treatments: individual & group therapies,
medication
• On stable doses of 2 or more psychotropics; all
on sertraline
• Heavy alcohol use daily


Results after 6 Weeks

• Intervention Group Caps scores
(adjusted for baseline CAPs) decreased
14.2 (95% CI: 4.6 to 23.7; P=.007)
• Control Group: no decline
• The Effect Size of the difference in
CAPS scores is 0.91


Outcomes Over 6 Months: CAPS
Week 6: Effect Size = 0.91



Effect of Breath~Body~Mind
Workshop on Symptoms of GAD
with Comorbidities

Martin Katzman, Monica Vermani,
Patricia Gerbarg, Richard P. Brown
START Clinic, Toronto, Canada


Method
• Open preliminary trial
• 24 adults with diagnoses of GAD with
comorbidities (PTSD, social phobia,
OCD, depression)
• Recruited at START Clinic,Toronto
• Measures of anxiety and depression
before and after intervention



Breath~Body~Mind Workshop
Taught over 2 Consecutive days – Total 12 hours
1.Resistance Breathing + Coherence
Breathing (5 bpm) + Breath Moving
2. QiGong: Gentle movements with Resistance Breath
– QiGong breathing: counts & holds 4–4–6–2
3. Open Focus meditation: improves flexibility of
attention (Les Fehmi)
– First focus on internal spaces of the body.
– Connect internal spaces with space in environment.
4. Group Processes



Pre-Workshop, Post-Workshop, 6-Month Follow-Up

Mean + SD Mean + SD Mean + SD
Scale PRE POST 6 Month
ASI - Anxiety 33.80 +12.15 23.24 +11.70* 18.00 ± 18.83ᴺˢ
Sensitivity Index
BAI - Beck Anxiety 26.05 +14.38 7.75 + 7.47* 13.40 ± 16.06ᴺˢ
Inventory
BDI-II -Beck 24.37 +12.35 12.05 + 9.87* 15.05 ± 15.01ᴺˢ
Depression Inventory
II
PSWQ - Penn State 64.45 + 9.25 42.75+23.34* 41.80 ± 32.78ᴺˢ
Worry Questionnaire

* = p < 0.01; ©2012 RPBrown & PLGerbarg
Ns = non-signiﬁcant
change

2 Open Trials of
Breath~Body~Mind for
PTSD, Depression, and
Anxiety Related to
September 11, 2001
New York City World
Trade Centre Attacks.

Richard P. Brown, Patricia
L. Gerbarg,
Monica Vermani,
Martin A. Katzman

Breath~Body~Mind Workshop
Taught over 2 Consecutive days – Total 12 hours

1. Resistance Breathing + Coherence Breathing (5
bpm) + Breath Moving
2. QiGong: Gentle movements with Breath
– QiGong breathing: counts & holds 4–4–6–2
3. Open Focus meditation
4. Group Processes



1st Open Study T-Test Results
Pre vs Post Scores df t Significance

Anxiety Sensitivity Index 16 5.33 .001
Beck Anxiety Inventory 13 4.02 .001
Beck Depression Inventory 16 7.38 .001

Penn State Worry 15 3.18 .006
Questionnaire
Sheehan Disability Index 15 3.44 .004
Social Life
Bonferroni t-tests significance0.05/9=.006 n=17 subjects


2nd Open Study T-Test Results
Pre vs. Post df t Significance

Anxiety Sensitivity Index 21 3.93 .001
Beck Depression Inventory 20 4.01 .001

Beck Anxiety Inventory 21 3.09 .005
Penn State Worry 19 1.95 .066 (ns)
Questionnaire
Treatment Outcome PTSD 18 1.63 .120 (ns)
Scale

Bonferroni t-tests significance0.05/5=.01 n=27


Contraindications
• Pregnancy: Avoid rapid, forceful breathing or
breath holds. Slow, Resistance or Coherence
breathing are helpful
• Acute asthma symptoms or dyspnea (Breath
Moving Technique keeps airways open)
• Seizure disorder
• Recent surgery – Slow, gentle breathing only
• Severe cardiac disease
• Uncontrolled hypertension – no rapid or forceful
breathing



Risks and Precautions
• Bipolar I – rapid breathing can trigger mania.
Yoga courses may be overstimulating
• Rapid Yoga breathing can ↓Lithium levels
• Bipolar II – if stable on medication, compliant,
not prone to rapid cycling or mania may take
yoga breath course. However, avoid rapid
breathing.



• Gretchen Wallace, founder of Global
Grassroots, non-profit provides Academy for
Conscious Change, 2-18 month program
offering social venture development skills,
leadership training, and grants for
disadvantaged women to initiate their own civil
society organizations.
• www.globalgrassroots.org



Haiti - Gretchen Leads Coherent Breathing



South Sudan:
Survivors of War and Slavery
• Tens of thousands of South Sudanese were taken
captive and kept in slavery in North Sudan
• Christian Solidarity International purchases their
freedom: 1 slave = $100,000 in bovine vaccine
• At the border Dr. Luka Deng screens survivors,
newly liberated after 5 to 20 years of slavery while
tribal chiefs identify their lineage before returning
them to their home villages.



Teaching Breath~Body~Mind in
Sudan
• Ellen Ratner began teaching 3 Qigong
movements and Coherent Breathing to some
of the liberated slaves at the Pamela Lipkin
MD Clinic in South Sudan, 30 miles east of the
border with Darfur.
• The results were so positive Ellen asked us to
help her do a program evaluation



Evaluation of Short Breath Practice in
19 Sudanese Women
• Short form of Breath~Body~Mind practices
• 3 Qigong movements and 20 minutes of
Coherent Breathing with the clinic staff 5
days a week for 18 weeks.
• VAS Mood Scale and VAS PTSD Scale.



Program Evaluation Data from Sudan:
Response of Refugees to Breath~Body~Mind

Mean Test Scores Change Mean
Score/
% Change Mean
Baselin 6 wks 18 wks 0-6 wks 0-18
Score
e wks
VAS 49.3 17.2 14.5 32.1 34.8
PTSD 65% 71%
VAS 20.8 10.8 7.1 10.0 13.7
Mood 48% 66%

VAS: Visual Analogue Scale


Dr. Richard Brown Teaching Breath~Body~Mind in Sudan


Breath~Body~Mind Training for
Stress Relief after
the Horizon Gulf Oil Spill (2010)
(British Petroleum funded
Mississippi State DMH Grant)

Patricia L. Gerbarg
New York Medical College
Chris C. Streeter & T. Whitfield
Boston University Medical Center
Richard P. Brown
Columbia University College of Physicians & Surgeons


Breath~Body~Mind Training for Stress
Relief Post Disaster

• Out of 151 health care service providers 80
enrolled in study
– social workers (31%), counselors (15%), teachers
(10%), psychologists (8%), case workers (5%)
• Mississippi counties affected by Gulf Oil Spill
• 3-day 18-hr Train-the-trainer April-June 2011



Mean Scores Perceived Stress Scale
compared to norms for women and men
Pre- and 6 Weeks Post- Training



Exercise Induced Feeling Inventory (EIFI)

Scores on all items significantly
improved
Positive Engagement (p<0.001)

Revitalization (p<0.001)
Tranquility (p<0.001)

Physical Exhaustion (p<0.001)

Among those who returned 6-week follow-up
packets (n=30) significant improvements were
sustained in all subscales except Engagement. At 6-
weeks Engagement sores were higher than at
baseline, but did ©2012 RPBrown & statistical significance.
not reach PLGerbarg


Traumatic Experiences
• Imbalance in stress response systems
• Disturbances in neural networks
• Trauma memories (subsymbolically encoded),
physical sensations, feeling defective, emotion
dysregulation, re-experiencing, numbing,
• Disconnectedness: disruption of
bonding, loss of meaning
Gerbarg PL: Yoga and Neuro-Psychoanalysis, in Bodies in
Treatment: The Unspoken Dimension. Ed. FS Anderson.
The Analytic Press. 2008, pp.127-150.



Bonding and Connectedness
• The capacity to feel meaningful connection
is an essential component of bonding.
• One can feel connected to a person, a deity,
a nation, an institution, or an idea.
• Do bonding and connectedness share the
same neural networks and neurohormones?
• When bonding is enabled, will
disconnectedness be resolved?



Case 1. Disconnection Sept 11, 2001
Cholene, former Air Force U-2 spy plane pilot, was
flying for United Airlines. She was scheduled to be
on Flight #93 on Sept 11, 2001, but her connecting
flight was changed. Her close friend, pilot Leroy
Homer, Jr. died when Flight #93 crashed leaving
her with survivor guilt and feeling helpless, angry,
and disconnected from everyone and everything
she had believed in. Hoping to find a connection to
life, she did 3 tours in Iraq as an embedded
journalist and 2 years of post-Katrina relief work in
Mississippi. She was left feeling drained, joyless
and without meaning.


Reconnection September 26, 2009
NYC 2-day breath workshop
“The breathing and the rhythm of the bells
were like the tide in the Arabian Gulf. The
sound of the tide and the feel of the waves
rolling over me were the only things that
made me feel connected to life. The
breathing was that and much more
powerful because I was physically and
mentally connecting to a larger energy
source.”


“I found myself weeping when Dr. Brown
said,‘think of those you love.’ I came
away with a sense of being reunited with
my life and loved ones. For the first time
in years, I wanted to be connected to
something besides a war or a disaster
zone. After the breathing, during the
meditation, I felt connected to the
universe and to everyone in it.”
(Through the Eye of the Storm by Cholene
Espinoza. Chelsea Green Pub. 2006)


Case 2. PTSD Childhood Sexual Abuse

• Susan entered psychoanalysis with Dr.
Gerbarg at the age of 27
• “I’m depressed and I don’t know why.”
• She had been repeatedly molested from
age 3 to 12 by a middle-aged male cousin.
• c/o paralyzing fear of men and inability to
date



Perception of Body Defect
• She had a feeling that there was
something defective about her buttocks
(the focus of the molestation).
• She worried that people could see what
was wrong with her body.
• Never wore skirts.



Impenetrable Façade
• On the outside well adjusted, excellent
student and athlete.
• Friendships were superficial.
• Appeared poised, aloof while in constant fear
that someone would discover her secret.
• Susan never dated. Attention from eligible
men caused her to freeze and panic. Kept
men at a distance.
• She lavished her love on animals.



Yoga Breathing in 8th Year of Analysis
• Through analysis → Let go of guilt, self-blame
• Bought house with property for animals
• Happy except she wanted intimate relationship,
marriage, and children
• Still paralyzed by fear. Age 35, had never dated.
• If a man showed sexual interest, she froze.
• Suggested yoga breath SKY course to ↓ anxiety



2 Yoga Breath Courses (SKY)

• After the first breath course she felt
unusually calm and relaxed.
• Practiced at home every day and
attended group sessions twice a month
for 8 months.
• Took breath course again.



Transformative Experience

• While doing the SK breathing in group
session, she had a transformative
experience:
“I felt a warm sensation in my uterus and
genitals.” She reflected, “I knew it was good
for me, a healing sensation. And then it felt
like an opening-up and I thought that it was
just what I needed, that what had happened
to me as a child, the molestation, would no
longer have such an affect on my life.”



Resolution of Sexual Trauma Symptoms

• 3 weeks later started dating
• After 2 months steady boyfriend, had 1st
adult sexual experience
• Completely normal. Pleasurable
response. No anxiety or panic.
• Long term relationship developed.



Interoception provides substrate for
emotional awareness
• Interoception is the perception of
“feelings” (eg. visceral, genital, vasomotor,
muscular, air hunger, pain, temperature,
sensual touch) reflecting physiological state
of the body
• Primary representation in dorsal posterior
insula → meta-representation anterior insula
→ map & regulate internal states
(Craig 2003; Critchley 2005; Damasio 1994, 1999)


Interoceptive afferent
pathways project to dorsal
posterior insula
(interoceptive cortex) (R –
SNS; L – PNS) and medial
frontal region (anterior
cingulate cortex, ACC).
(A.D.Bud Craig, Interoception &
Emotion, Ch 16 Handbook of
Emotions 3rd Ed, Ed. M Lewis,
JM Haviland-Jones, LF Barrett,
Builford press 2008, pg 275)



Anatomical Model
The subjective awareness
of feelings from the body is generated
directly from cortical rerepresentations
of the interoceptive image
of the body’s homeostatic condition.
(AD (BUD) CRAIG Interoception and Emotion:
A Neuroanatomical Perspective. Handbook of Emotions, 3rd
Edition, ed M Lewis, J Haviland-Jones, LF Barrett.
Guilford Press. 2008)



Vagal GABA Theory of Inhibition

• Gamma-aminobutyric acid (GABA) is the
brains main inhibitory neurotransmitter.

• (Streeter C, Gerbarg PG, Brown RP,. Medical
Hypotheses. 2012)



Activating GABA Inhibitory Projections to
the Amygdala
Vagal stimulation could reduce activity in regions
thought to have increased activity in PTSD.
Inhibitory GABAergic projections from insular
cortex to the Central Extended Amygdala (CEA)
could correct the over activation seen in PTSD.
(Streeter C, Gerbarg PG, RB Sape, DA Ciraulo, Brown RP.
Effects of yoga on the autonomic nervous system,
gamma-aminobutyric-acid, and allostasis in epilepsy,
depression, and post-traumatic stress disorder Medical
Hypotheses. 2012)



Insular Cortex
• The insular cortex sends inhibitory GABAergic
projections to the Central Extended Amygdala
(CEA), where they modulate the over activation
observed in subjects with PTSD.
• The medial prefrontal cortex cortex sends
inhibitory GABAergic projections to the
amygdala, where they modulate the over
activation observed in subjects with PTSD.
• These inhibitory effects would reduce autonomic
and somatic over reactions



INSULA: Receives interoceptive information;
Integrates sensation and emotion; Subjective
awareness of the condition of the body; Self-
awareness


Reducing Autonomic and Somatic
Reactions
Strong tonic inhibition decreases output
from amygdala to brainstem (dorsal
vagal complex, parabrachial complex,
periaqueductal grey matter, pontine
reticular formation, and ventrolateral
medulla) thereby reducing autonomic
and somatic expression of over
reactions to fear-inducing and aversive
stimuli.


Hypothesis: Breathing stimulates Vagal activation of GABA pathways
from PFC and Insula to inhibit amygdala overactivity.
Prefrontal Cortex GABA-R = gamma aminobutyric acid receptors
GABA-R Autonomic, GABA and other
neurotransmitter pathways
Hypothalamic-pituitary-adrenal axis
neuroendocrine pathways
Thalamus Insula
GABA-R GABA-R
Hypothalamu Pituitary
s

Amygdala Hippocampus
GABA-R GABA-R

Parabrachial
Nucleus
Periaqueductal
Grey Adrenal

Nucleus Tractus Nucleus Dorsal Medial
Solitarius Ambiguus
Brainstem
Nucleus GABA-R
Nuclei
Vagal Efferents
Afferents

Pharynx, Larynx, Lungs Cardiac Gastrointestina
Vagal

(Streeter et al, Med
Hypotheses, 2012)


Why are interoceptive messages
from the respiratory system so
powerful?

Why do interoceptive messages from the
respiratory system cause such rapid and
widespread effects on the mind, emotions,
subjective experiencing of the body,
bonding, and connectedness?



Breathing – Most Vital Function
• Messages about the state of respiration
receive top priority because they are
critical for survival.
• Connections between brain and
respiratory systems are evolutionarily
old, powerful and rapid.
• All central regulatory systems must
coordinate to restore and preserve
respiration.


Polyvagal Theory
• A state in which there is increased vagal
influence on Heart Rate Variability support
social engagement & bonding
• Any stimulus that increases feeling of safety can
recruit neural circuits that support social
engagement system and inhibit defensive limbic
structures

(SW Porges. 2009. The polyvagal theory: New insights into
adaptive reactions of the autonomic nervous system.
Cleveland Clinic J Med 76(3):S86-S90)


Hypotheses: Yoga Breathing
• enables interoceptive communication with
emotion schemas
• ↑ vagal PNS input to networks involved in:
fear conditioning & extinction
emotional memories & responses
bonding & reward (OX, VP, dopamine?)
• ↑ mPFC and Insular Cortex GABAergic
inhibitory control over amygdala



Case 3. 2nd Generation Holocaust
Leah’s father fled alone to Israel as a
teenager during the British blockade. After
the war, he rescued other Jews in Europe.
His own family had died in the gas
chambers. Leah’s mother had also lost
family there.
Leah did BBM and 2 months later, level-2
workshop with new Breath Cycling (3.5, 5,
10, 60 bpm cycles). After breathing, during
quiet rest she had a vivid experience:


Connection and Reunification
I experienced my breath going out towards the gas
chambers. I see my father’s family, my grand-
parents, his 2 brothers, his baby sister. They’re
standing to my left. My breath goes out towards
them and pulls them out of the gas chamber. To
my right I see my father who is dead. As my
breath pulls them out in that moment I hear them
click together. They unite. I feel that happening in
my body. I have this deep sense of something
restored, something so long broken, alienated that
I’ve been carrying inside me.



Being Restored
“It’s 3-fold: them and him coming together
and me, the 3rd piece of it. The feeling
afterwards was a sense of peace, a
feeling of something coming home,
being restored, a sense of freedom, as if
something finally came to its rightful
place.”



Tools for Learning and Practicing

www.haveahealthymind.com
RP Brown & PL Gerbarg - Updates on
Integrative Psychiatry, Workshops, free
Newsletter
The Healing Power of the Breath (Book + CD)
by RP Brown, PL Gerbarg. Teaches breath
practices. (Shambhala, June 2012)
www.coherence.com Respire-1 CD for
Coherent Breathing by Stephen Elliot



Integrative Psychiatry Resources
• How to Use Herbs, Nutrients and Yoga in
Mental Health Care
RP Brown, PL Gerbarg, PR Muskin (Norton 2009)
• Non-Drug Treatments for ADHD
RP Brown & PL Gerbarg (Norton 2012)
• www.ropertpeng.com DVDs and CDs of Qigong
movements with Master Robert Peng
• www.openfocus.com by Les Fehmi, PhD
CDs for Open Focus Meditation



Breath-Body-Mind Practices for Stress and Mental Health

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