Striking Poses: Yoga as an Intervention for PTSD in Military Populations

DSM V Criteria A: Traumatic event: threatened death, serious injury or sexual violence; experienced, witnessed, or indirect to close friend or family. B: (beginning with event): Re-experiencing symptoms: intrusive thoughts, nightmares, flashbacks, psychological and physiological reactivity to reminders. C: (beginning with event): Avoidance (can be thoughts, feelings, or people connected to the event, or reminders) D: (worsen after event): Negative alteration in mood or cognition (e.g. negative thoughts about the self and the world; loss of interest in previously enjoyed activities; isolation, negative affect, and difficulty experiencing positive affect; exaggerated sense of blame or responsibility for the event.) E: (worsen after event): Arousal symptoms (difficulties with concentration, startle, anger, hypervigilance, and startle). F: Chronicity (at least one month duration) Specifiers: Dissociation and/or depersonalization (“this isn’t happening to me”), de-realization (“this isn’t real”).

Clinical Vignette The Case of “Joe”

The 8 Limbs of yoga Yama: Ethics and Morals Niyama: Virtuous behavior Asana: Physical postures Pranayama: The regulation of the breath Pratyahara: The discovery of one’s true self through introspection Dharana: One-pointed concentration Dhyana: Non-judgmental attitude toward to object of concentration Samadhi: Absorption and unity with the object of concentration

Research BENEFITS CAVEATS Hyperarousal Few Studies Re-experiencing Small ‘N’ Sleep Few “dual arm” RCTs Resting heart rate High drop out rate Confronting avoidance Different styles of yoga used Improved relatedness Different elements of yoga emphasized Improved self-compassion Brevity of intervention Connection with a sense of wonder No control on quality of instruction

Ideal Benefits of a Yoga Program 1) I am safe in my body and in the world. 2) I am not my thoughts, and not every thought needs immediate response. 3) I have a body that works, and I can and should be a responsible shepherd of its cultivation. 4) Feelings come and go, and I can observe them rather than respond to them. 5) I have a safe physical outlet when I am feeling sluggish or hyper. 6) Through my feeling of enhanced safety, I can know a truer me, and cultivate that true self. I begin to see PTSD as separate from me. I shed PTSD as an identity. 7) Through greater distance from PTSD and connection to myself, I can sustain abiding, trusting connections to others. 8) Through this greater sense of connection to myself and others, I begin to connect to a sense of awe and wonder about our place in the cosmos. I have glimpses of transcendence and joy.

Positive Effects of Yoga on PTSD in military populations by Study Authors (date) Benefits recorded, if any Size of study, type of study Staples (2013) Hyperarousal, sleep quality. No improvements in anger or ‘quality of life’. N=12, single arm Sepala, et al. (2014) Re-experiencing, hyperarousal, reduction in resting heart rate. N=11, single arm Johnston, et al. (2015) Re-experiencing, hyperarousal, avoidance, “resilience”. N=10, single arm Reinhardt, et al. (2017) Did not show hypothesized benefits; high drop-out rate. N(yoga)=9; N(non-yoga)=6; RCT

Positive Effects of yoga on PTSD in non-military populations Authors (year) Benefits Number of participants; type of study. Jindani & Khalsa (2015). Improved feelings of energy and renewal, self-esteem, centeredness, and a connection with a feeling of wonder. N=50; (yoga=29, non yoga=21); RCT. West, Liang, & Spinazzola (2017) Improvements in levels of relatedness, acceptance, centeredness, empowerment, and self-compassion. N=31, all female, single arm.

References   Jindani, F., Khalsa, B.A. 2015. A yoga intervention program for patients suffering from symptoms of posttraumatic stress disorder: A qualitative descriptive study. The Journal of Alternative and Complementary Medicine, 21, 7: 401-408.  Johnston, J. 2015. Yoga for military service with PTSD: A single arm study. Psychological Trauma: Research, Practice, & Policy, vol. 7, no. 6, 555-562.  Reinhardt, et al. 2017. Kripalu yoga for military veterans with PTSD: A randomized trial. Journal of Cliical Psychology, 00: 1-16.  Sepala, et al. 2014. Breathing-Based Meditation Decreases Posttraumatic Stress Disorder Symptoms in U.S. Military Veterans: A Randomized Controlled Longitudinal Study. Journal of Traumatic Stress, 27, 397-405). Staples, J., Hamilton, M., Uddo, M. 2013. A yoga program for the symptoms of post-traumatic stress Disorder in Veterans. Military Medicine, 178,8, 854-860. West, Liang, & Spinazzola. 2017. Trauma Sensitive Yoga as a Complementary Treatment for Posttraumatic Stress Disorder: A Qualitative Descriptive Analysis. International Journal of Stress Management. 173-195. VA Press Release, September 15, 2017: https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2951 van der Kolk, Bessel. 2015. The body keeps the score: brain mind, and body in the healing of trauma. Penguin Books.