Breath, Body, Mind Techniques for Stress, Depression, Anxiety, Post Traumatic Stress Disorder, and Disaster Relief Richard P. Brown, MD Associate Professor

Breath, Body, Mind Techniques for Stress, Depression, Anxiety, Post

Traumatic Stress Disorder, and Disaster Relief

Richard P. Brown, MDAssociate Professor in Clinical Psychiatry

Columbia University College of Physicians and Surgeons

Patricia L. Gerbarg, MDAssistant Professor in Clinical Psychiatry

New York Medical College

Presenter Disclosures

The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose.

Richard P. Brown, MDPatricia L. Gerbarg, MD

Evolving Roles for Mind-Body Practices in Public Health

• stress, anxiety, insomnia, depression• Prevent/relieve effects of mass disasters• Military service related stress and PTSD• Stress-related medical illness: eg.

cardiovascular, Inflammatory Bowel Disease• Children: stress, trauma, ADHD, emotion

regulation• Health care provider and care giver stress• Cost of health care and accessibility of care

Gray’s Motivational Theory

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

Norepinephrine

Sympathetic Nervous System(Stress Response: Burns Energy)

(Beauchaine, T. 2001. Vagal tone, development, and Gray's motivational theory: toward an integrated model of autonomic nervous system functioning in psychopathology Dev Psychopathol 13:183-214.)

Autonomic Nervous System

Sympathetic System Parasympathetic System

Approach (BAS) Emotional RegulationAvoidance (BIS) (Vagal Nerves)

Behavior & Emotion

Breath and Emotion

• Bi-Directional• Specific emotions induce breath patterns• Voluntary changes in breath patterns

induce specific emotions

(Philippot P, Chapelle G & Blairy S. Respiratory feedback in the generation of emotion. Cognition and Emotion, 2003, 16(5):605-627)

Vagus Nerves are Involved in:• Social bonding• Empathy & love• Gut feelings & instincts• Perception & observationCarter, CS. 1998. Neuroendocrine perspectives on social

attachment and love. Psychoneuroendocrinology, 23 (8), 779–818; Porges, SW. 2001. The polyvagal theory: phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42(2), 123-46.

VagusNerve

Parabrachial Nucleus

Nucleus Tractus Solitarius

Limbic SystemAmygdalaHippocampus

Corpus Callosum

SlowsHeart Rate

Calms and slowsGastrointestinal

Tract

Thalamus

Cerebral Cortex

Slows Respiratory

Rate

Hypothalamus

Brown RP, Gerbarg PL. 2009. How to Use Herbs, Nutrients, and Yoga in Mental Health Care. NY; WW Norton. P79.

Vagal Nerve Pathways

Copyright 2007 S. Elliott. Used with Permission.

Heart Rate Variability

at 5 breaths per minute

at 7.5 breaths per minute



“The purpose of breathing practices is to induce the

tenderness of a new-born babe.”

Lao Tzu, Tao Te Ching

Clinical Studies: Breath-Centered Programs

1.Generalized Anxiety Disorder2.Schizophrenia3.Inflammatory Bowel Disease4.Southeast Asia Tsunami Survivors5.Australian Vietnam Veterans6.9/11 World Trade Center Attacks7.Mississippi Healthcare Providers8.South Sudanese Survivors of War & Slavery

Effects of a Yoga-Breath Intervention Alone and in Combination with an Exposure Therapy for PTSD and Depression in Survivors of the 2004 Southeast Asia Tsunami. Acta Psychiatr Scand 2010. 121(4):289-300.

Teresa Descilo, Patricia Gerbarg, A Vedamurtachar, D Nagaraja, BN Gangadhar, R Damodaran, B Adelson, L Braslow, S Marcus, Richard P Brown

Severely Traumatized Population

• Refugees from the most severely damaged coastal villages in India

• Living in 5 refugee camps 9 months after the tsunami

• In the state of Tamil Nadu, 75% of the deaths occurred in this small district: Nagapattinam

Study Design183 subjects: 3 equal groups, assigned by camps1.Breath Water Sound (BWS) + 10-minute

Sudarshan Kriya: 2 hours/day, 4 consecutive days = total 8 hours

2.B+T: BWS followed 3 days later by TIR (Traumatic Incident Reduction, client-driven exposure therapy) 3-5 sessions

3.CON: 6-week wait-list Control GroupCollaboration: National Institute of Mental Health and Neurosciences of India, The Trauma Center of Dade County Florida, The International Association of Human Values

P < .001

Mean Scores PTSD Checklist PCL-17

Mean BDI Scores

P < .0001

Multi-component Yoga Breath Program for Vietnam Veteran PTSD: Randomized controlled

trial. J Carter, PL Gerbarg, RP Brown, et al.

• 25 Australian Vietnam Veterans with chronic, treatment resistant PTSD disabled

• Clinician Administered PTSD Scale (CAPS) • Mini-Plus, AUDIT, PCLM, CES-D• baseline, pre, 6 week-post, 6-month post

J Traumatic Stress Disorders & Treatment. 2013.2(3):1-10.

Outcomes Over 6 Months: CAPS

Minimizing Rapid or Forceful Breathing Reduces the Following Risks

• Panic Disorder - panic attacks• Generalized Anxiety Disorder - anxiety• Post Traumatic Stress Disorder – flashbacks• Seizure disorder - seizure• Acute asthma or dyspnea - exacerbation• Uncontrolled hypertension - BP• Bipolar disorder – manic episodes• Pregnancy

Breath-Body-Mind includes the following breathing practices

• Coherent Breathing– Rate: 3.5 to 6 breaths per minute– Equal inhalation and exhalation– Like natural breathing: quiet and gentle

• Breath Moving: imaginative• Resistance Breathing on exhalation• “Ha” Breath (briefly 2 to 5 minutes)• 4-4-6-2 Counts Breathing(RP Brown & PL Gerbarg (2012). The Healing Power of the Breath.

Book + CD. Boston: Shambhala Press.)

1st & 2nd Trials of Breath~Body~Miond for relief of PTSD, Depression, and Anxiety Related to

September 11th NYC WTC Attacks.

RP Brown, PL Gerbarg, M Vermani, MA Katzman

1st Trial: Breath~Body~Mind Workshop

12 hour workshop taught over 2 days1. Resistance + Coherence Breathing (5 bpm) + Breath

Moving2. QiGong: Gentle movements with Resistance Breath

– QiGong breathing: counts & holds 4–4–6–23. Open Focus meditation: improves flexibility of

attention (Les Fehmi)– First focus on internal spaces of the body. – Connect internal spaces with space in environment.

Increases alpha brain wave synchrony. 4. Group Processes

Presented at American Psychiatric Association Annual Meeting May 2013, San Francisco, CA

©2012 RPBrown & PLGerbarg

1st Trial: 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 Questionnaire

15 3.18 .006

Sheehan Disability Index Social Life

15 3.44 .004

Bonferroni t-tests significance 0.05/9 = .006 n = 17 subjects ©2012 RPBrown & PLGerbarg

2nd Trial: Breath~Body~Mind Workshop12 hour workshop taught over 2 days

1.Coherence (5 bpm), Resistance Breath, Breath Moving

2.QiGong: Gentle movements1. counts 4–4–6–2

3. Open Focus meditation: trains flexibility of attention (Les Fehmi)– First focus on internal spaces of the body. – Connect internal spaces with space in environment.

Increases alpha brain wave synchrony. 4. Group Processes

(Presented American Psychiatric Association Annual Meeting May 2013, San Francisco, CA)


September 11th ExperienceTotal N = 27 participants NFirst Responder 6Firemen 4Worked with or affected by 9/11 4Emergency Health Care Provider 2Worker at Ground Zero (post attack) 6Resident Living near World Trade Center

10

Witnessed Attack 8Family member of a first responder 1Escaped from World Trade Center 2

Clinical Disorder N

Major Depressive Disorder 12

Generalized Anxiety Disorder 14

Post Traumatic Stress Disorder 23

Panic Disorder 16

Agoraphobia 9

Number of Participants Meeting Criteria for a Clinical Disorder

Note: Total N = 27 participants

2nd Trial: T-Test ResultsPre 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 Questionnaire

19 1.95 .066 (ns)

Treatment Outcome PTSD Scale

18 1.63 .120 (ns)

Bonferroni t-tests significance 0.05/5 = .01

Adapting Mind/Body Practices for Mass Disasters

• Few teachers serve large groups• Simple techniques, easy to learn and teach• Rapid relief • Safe for all, regardless of age, trauma, illness• Understood and accepted by diverse cultures• No equipment, electricity, buildings, or supplies• Lower cost• Sustainability: train community leaders to teach(RP Brown & PL Gerbarg (2012). The Healing Power of the

Breath. Book + CD. Boston: Shambhala Press.)

Breath~Body~Mind Training for Stress Relief after Gulf Oil Spill

(Mississippi State DMH Grant)Assisted by Mississippi Cares & Serving Those Who Serve

Chris StreeterBoston University Medical Center

Patricia GerbargNew York Medical College

Richard P BrownColumbia University College of Physicians & Surgeons

Breath~Body~Mind Training-the-Trainer for Stress Relief Post Disaster

• 153 service providers: 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• Exercise Induced Feeling Inventory (EIFI)• Perceived Stress Scale (PSS)(Poster presented at SYTAR (Symposium of yoga Therapy

and Research), Stockbridge, MA. Sept. 23-25, 2011.

Mean Scores Perceived Stress Scale compared to norms for women and men

Pre- and 6 Weeks Post- Training

(Gerbarg PL, Streeter CC, Whitfield T, Brown RP. Poster presented at SYTAR, Stockbridge, MA. Sept. 23-25, 201).

Exercise Induced Feeling Inventory (EIFI)

• post tests at 6 weeks showed statistically significant improvements in mean scores for:

• Revitalization: mean (p < 0.001)• Tranquility: mean (p < 0.001)• Physical Exhaustion: (p < 0.04)• Positive Engagement showed trend toward

improvement but not of statistical significance

(Gerbarg PL, Streeter CC, Whitfield T, Brown RP. Poster presented SYTAR, Stockbridge, MA.Sept.23-25, 2011)

• Gretchen Wallace, founder/director Global Grassroots, supports conscious social change, for vulnerable women at the grassroots level.

• Brief (30 minutes) work with 50 women 1 week after the Earthquake: relief of stress symptoms, back pain, worry, insomnia

• 1 month later the women continued to practice together and brought friends – 80 women

• The Academy for Conscious Change, a 12-18 month incubator offering social venture development skills, leadership training, and grants for disadvantaged women to initiate their own civil society organizations. www.globalgrassroots.org

2012 Haiti Earthquake

War and Slavery in Sudan

It is estimated tens of thousands of South Sudanese captured during the last two decades of war remain in slavery in North Sudan.$100,000 worth of bovine vaccine purchases freedom for one of these slaves.

Independence Day Flag S.Sudan July, 2011 photo by G Weibach

Sudanese Survivors of War and SlaveryProgram Evaluation

• 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.• 19 South Sudanese women

(Drs. Luka Deng, PL Gerbarg & RP Brown, 2011; Gerbarg, Wallace, Brown. 2011. Mind-body solutions for mass disasters: challenges and field experience. Int. J. Yoga Therapy. No. 21: 23-34.)

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

Mean Test Scores Change Mean Score/% Change Mean Score

Baseline 6 wks 18 wks 0-6 wks 0-18 wks

VASPTSD

49.3 17.2 14.5 32.1 65%

34.8 71%

VAS Mood

20.8 10.8 7.1 10.0 48%

13.7 66%

VAS: Visual Analogue Scale n = 19 women(Gerbarg, Wallace, Brown. Int J Yoga Therapy. 2011. 21:23-34)

600 Liberated Slaves

• Walked for 1 week and crossed the border into S. Sudan July 4, 2011

• Dr. Luka Deng and clinic staff evaluated• Relief workers provide grain and utensils• Dr. Richard Brown taught Breathing Practices

for 30 minutes• Village chiefs identified and helped return

their people to villages of origin

2011 RPBrown & PLGerbarg

Traumatic Experiences• Disturbances in neural networks• Leave impressions on the mind: trauma

memories (subsymbolically encoded), physical sensations, emotion dysregulation

• Difficult to access with verbal therapies• Disruption of bonding, disconnectedness, loss of

meaning, emotional numbing

(RP Brown, PL Gerbarg. 2012. The Healing Powerof the Breath. Book + CD. Boston:Shambhala Press)


Interoception provides substrate for emotional awareness

• Interoception: the perception of ‘feelings’ (eg. gut, viscera, genital, vasomotor, muscular, air hunger, pain, temperature, sensual touch) reflecting internal state of the body

• Primary representation in dorsal posterior insula meta-representation anterior insula map & regulate internal states

(Craig AD. Interoception: The sense of the physiological condition of the body. Curr Opin Neurobiol, 2003.13(4):500–505; Critchley HD. J Comp Neurol. 2005; Damasio RR. The Feeling of What Happens: Body and Emotion in the Making of Consciousness. NY: Harcourt Brace 1999)

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


Polyvagal Theory • Physiological state characterized by ↑ vagal influence

on HRV supports social engagement & bonding • Any stimulus that ↑s feeling of safety can recruit

neural circuits that support social engagement system and inhibit defensive limbic structures

• Interoception enables social behavior by distinguishing safe from dangerous

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


Vagal-GABA Theory of Inhibition

• Gamma-aminobutyric acid (GABA) is the brain’s main inhibitory neurotransmitter.

• Evidence suggests that vagal nerve stimulation can increase GABAergic activity

• GABAergic activity from insular cortex and prefrontal cortex could inhibit overactivity in amygdala as 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)


Prefrontal Cortex

(PFC) GABA-R Prefrontal Cortex

(PFC) GABA-R

InsulaGABA-R

InsulaGABA-R

AmygdalaGABA-R

AmygdalaGABA-R

HippocampusGABA-R

HippocampusGABA-R

Parabrachial NucleusGABA-R

Parabrachial NucleusGABA-R

Nucleus Tractus SolitariusGABA-R

Nucleus Tractus SolitariusGABA-R

Dorsal Medial Nucleus GABA-R

Dorsal Medial Nucleus GABA-R

Nucleus AmbiguusGABA-R

Nucleus AmbiguusGABA-R

Periaqueductal Grey

GABA-R

Periaqueductal Grey

GABA-R

Pharynx, Larynx, LungsPharynx, Larynx, Lungs GastrointestinalGastrointestinalCardiacCardiac

AdrenalAdrenal

ThalamusGABA-R

ThalamusGABA-R

Vagal Efferents

HypothalamusGABA-R

HypothalamusGABA-R

Brainstem Nuclei

Pituitary

GABA-R = gamma aminobutyric acid receptorsAutonomic, GABA and other neurotransmitter pathwaysHypothalamic-pituitary-adrenal axis neuroendocrine pathways

Hypothesis: Breathing Stimulates Vagal Activation of GABA Pathways from PFC and Insula to Inhibit Amygdala Overactivity, as Occurs in PTSD.

(Streeter et al, Med Hypotheses, 2012)


Hypothesis: Oxytocin/Vasopressin

• Electrical vagal nerve stimulation (VNS) is known to increases oxytocin and prolactin release

• Respiratory interoceptive feedback via vagal afferent stimulation could also induce:→ hypothalamus PVN to Oxytocin release leading to→ feelings of safety, bonding, love

PVN = paraventricular nucleus(CS Carter. Psychoneurooendocrinology 1998,23:779-818; CS

Carter. Biological perspectives on social attachment and bonding: a new synthesis. 2005 MIT Press)

Yoga and Oxytocin• 1-month yoga program RCT in 43 stabilized

medicated patients with schizophrenia • The yoga (with breathing practices) group had

significant (p= 0.01) elevations in endogenous plasma oxytocin levels compared to wait-list control group.

• The yoga group had significant improvement in recognition of facial expressions of emotion vs control.

(Jayaram N, Varambally S, Behere RV, et al. Effect of yoga therapy on plasma oxytocin and facial emotion recognition deficits in patients of schizophrenia. Indian J Psychiatry 2013.55(Suppl 3):S409-13)

2nd Generation Holocaust Survivor

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 Breath-Body-Mind Level-1 workshop and 2 months later, Level-2 B-B-M workshop. After breathing, during quiet rest she had a transformative experience of reunification:


Disconnection Sept 11, 2001

A former Air Force U-2 spy plane pilot was flying for United Airlines. She was scheduled to be on Flight #93 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.


Resources for Further Learning

www.HaveAHealthyMind.com RP Brown & PL Gerbarg

Updates & Integrative Mental Health Free Newsletter

www.Coherence.com Stephen Elliotwww.OpenFocus.com Les Fehmi, PhDwww.RobertPeng.com Qigong Master

Robert Peng


Recommended Reading - 1

1. Brown, RP, Muench F, Gerbarg, PL. Breathing practices for treatment of psychiatric and stress-related medical conditions. In Complementary and Integrative Therapies for Psychiatric Disorders, Ed. PR Muskin, PL Gerbarg, RP Brown. Psychiatric Clin NA. March 2013, 36(1):121-140.

2. RP Brown & PL Gerbarg (2012). The Healing Power of the Breath. Book + CD. Boston: Shambhala Press.

3. RP Brown & PL Gerbarg (2012). Non-Drug Treatments for ADHD. NY: WW Norton.

Recommended Reading - 24. RP Brown, PL Gerbarg, PR Muskin (2009). How to Use

Herbs, Nutrients and Yoga in Mental Health Care. NY: WW Norton.

5. Brown RP and Gerbarg PL. Yoga breathing, meditation, and longevity. In Longevity, Regeneration, and Optimal Health, Integrating Eastern and Western Perspectives, Ed. C. Bushness, E. Olivo, and N Theise. Annals NY Acad Sci. 2009, 1172:54-62.

6. Gerbarg PL: Yoga and Neuro-Psychoanalysis, in Bodies in Treatment: The Unspoken Dimension. Ed. FS Anderson. The Analytic Press, Inc. Hillsdale, NJ. 2008, pp.127-150.


5. Brown RP and Gerbarg PL. Yoga breathing, meditation, and longevity. In Longevity, Regeneration, and Optimal Health, Integrating Eastern and Western Perspectives, Ed. C. Bushness, E. Olivo, and N Theise. Annals NY Acad Sci. 2009, 1172:54-62.

6. Descilo T, Vedamurtachar A, Gerbarg PL, Brown RP, et al. Effects of a Yoga-Breath Intervention Alone and in Combination with an Exposure Therapy for PTSD and Depression in Survivors of the 2004 Southeast Asia Tsunami. Acta Psychiatr Scand Aril 2010, 121(4):289-300.


Recommended Reading - 47. Gerbarg PL, Wallace GS, Brown RP. Mass disasters and

mind-body solutions: Evidence and field insights. Journal of the International Association of Yoga Therapists. 2011. 2(21):23-34.

8. Streeter CC, Gerbarg PL, Saper MD, Ciraulo DA, and 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 May;78(5):571-9.



9. Gerbarg, P & Brown, RP (2011). Mind-Body Practices for Recovery from Sexual trauma. In T. Bryant-Davis (Ed.) A Guide to Recovery and Empowerment, Rowman & Littlefield, 199-216.

10. Descilo T, Vedamurtachar A, Gerbarg PL, Brown RP, et al. Effects of a Yoga-Breath Intervention Alone and in Combination with an Exposure Therapy for PTSD and Depression in Survivors of the 2004 Southeast Asia Tsunami. Acta Psychiatr Scand Aril 2010, 121(4):289-300.


11. Gerbarg P, Brown RP. Nutrients, Phytomedicines, and Mind-body treatments for Substance Abuse. In N El-Guebaly, M Galanter, G Carr (eds.). Textbook of Addiction Treatment: International Perspectives. Springer Milan Heidelberg NY, London [in press].

12. Elliot, Stephen, Dee Edmonson. 2008. Coherent Breathing, the Definitive Method, Theory and Practice. Allen, Tx: Coherence Press.


13. Fehmi, L. G. , & McKnight, J. T. (2001). Attention and neurofeedback synchrony training: clinical results and their significance. Journal of Neurotherapy, 5(1/2).

14. Fehmi, L. and Robbins, C. Dissolving Pain: Simple Brain-Training Exercises for Overcoming Chronic Pain. Trumpeter Press, Boston.

15. Fehmi, L. and Robbins, C. (2007). The Open Focus Brain, Trumpeter Press.

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Breath, Body, Mind Techniques for Stress, Depression, Anxiety, Post Traumatic Stress Disorder, and Disaster Relief Richard P. Brown, MD Associate Professor