Yoga Pranayama Intervention for PTSD Criteria Symptoms in Veterans

An Interventional, Single Arm Study

Kelly F Doyle, DNP-C, PMHNP

Margaret Knight, PhD, PMHCNS-BCProject Chair

Background Statement

¤ PTSD has been identified by the House Committee on Veterans Affairs as one of the signature wounds of Veterans returning from OEF/OIF

¤ In 2005, 14 years after the Gulf War, Veterans reported PTSD rates of 15.2%

¤ According to the Department of Veterans Affairs Strategic Plan, rates of PTSD are steadily rising within the Veteran population.

(Department of Veterans Affairs Strategic Plan Refresh Fiscal Year 2011-2015, 2011).

Background

¤ In 2012, Department of Defense (DoD) spent approximately $294 million and VA spent approximately $3 billion on PTSD care for service members and veterans (IOM, 2014)

¤ Rates of PTSD per VA diagnostic data are above 30% in Viet Nam and combat veteran populations (U.S. Department of Veteran Affairs, 2012)

¤ First line treatment is currently pharmacological (SSRI, alpha-1 adrenergic blockers, benzodiazepines), but not consistently effective.

¤ Difficult to treat, many resistant symptoms such as criteria D & E (APA, 2012)

Statistics and Epidemiology

¤ alarming rise in MH disorders including PTSD related veteran suicides – est.22/day (U.S. Department of Veteran Affairs, 2012)

¤ OEF/OIF prevalence 13.8% (Tanielian et al., 2008)

¤ Gulf War – 12.1% (Kang, et al., 2003)

¤ *(NVVRS) showed a lifetime PTSD prevalence of 30.9 % among male and 26.9% among female Vietnam theater Veterans.

*Using DSM-IV criteria

IOM & DoD Recommendations

¤ IOM call for more research into forms of contemplative neuroscience interventions for PTSD (IOM, 2014)

¤ VA strategic plan calling for more research for PTSD interventions. (Office of the Secretary: Department of Veterans Affairs Strategic Plan Refresh Fiscal Year 2011-2015., 2011)

Intervention Background

¤ Clinical guidelines for yoga interventions are still in their infancy

¤ Past studies – distinguishing different forms of yoga in a consistent way, combining many types/styles in one intervention

¤ Lack of useful lexicon hampers developing unifying theory (Brown, 2005a)

¤ Recently investigators are making an effort to: ¤ improve study design ¤ increase randomization and generalizability¤ and formally assess comorbidities of participants I screening that

could potentially serve as confounding variables

Intervention Background

¤ Few effective evidence-based options: cognitive processing therapy (CPT) and prolonged exposure therapy (PE) cognitive behavioral therapy (CBT) (Karlin, Ruzek, & Chard, 2010) Eye Movement and Desensitization and Reprocessing (EMDR)¤ 2-3 weeks before any effect detected ¤ Can be iatrogenic - can induce intrusive thoughts, difficult memories,

and emotions. (Raza & Holohan, 2015) ¤ far less effect on the hyper-arousal symptom criteria (E)

¤ Drop out rates from these therapies are as high as 54.0% (Brown, 2012) EMDR better, faster results.

¤ In many studies, yoga with pranayama, has been shown to be more effective than existing EB treatments for residual and resistant symptoms (Pascoe & Bauer, 2015)

Literature Review

¤ Yoga with pranayama (breathing; Sanskrit translation – “Extension of the life force”) shows more significant effect size than mixed forms (Johnston et al., 2015)

¤ Three studies that used only yoga pranayama, all found that: ¤ yoga-breath interventions may help relieve distressing, treatment resistant

symptoms and psychological distress of PTSD¤ reduces the prevalence of PTSD-like symptoms (Descilio et al., 2010; Kim et al., 2013;

Seppala et al., 2014).

¤ Significant decreases in treatment resistant hyper-arousal symptoms on PCL-5 after six week sessions (Mitchell et al. 2014; van der Kolk et al., 2014)

Literature Review

¤ Improvement with autonomic dysfunction, negative affect, sleep, and emotion regulation (Seppala et al., 2014)

¤ Improvement in associated symptoms of anxiety, “re-experiencing,” and depression (Streeter et al., 2010)

¤ Seven recent controlled trials using pranayama showed significant improvements in PTSD symptoms post-intervention.

¤ Body-based contemplative practices used as prescribed therapeutic interventions are highly preferred and indicated for high-trauma populations such as war veterans and torture survivors (Britton et al., 2013)

Problem Statement

¤ As noted, not all symptoms are treated effectively with medication –most will persist.

¤ Resistant symptoms treated with PE, CPT, and EMDR as well as symptom targeted therapies (sleep, anxiety) not effective.

¤ Treating target resistant criteria (D and E) (the negative affect and hyper-arousal symptoms) is a problem in treatment

¤ Poor outcomes with current – PE and CPT 59% of individuals still had PTSD after 12 weeks of treatment, and 78% remained symptomatic at 6-month follow-up (Schnurr, et al., 2007)

Research Question

Does a six-week trauma-sensitive yoga breathing (Ashtanga Pranayama) intervention show a clinically significant

reduction of symptoms in a veteran population diagnosed with PTSD?

Screening Guidelines - Inclusion

Inclusion Criteria:

¤ Veterans

¤ English fluency

¤ Screen positive for PTSD on PC-PCL, PCL-5 or prior diagnosis at VAMC

¤ Able to attend 60 minute group twice a week for six weeks

Screening Guidelines - Exclusion

Exclusion Criteria

¤ unstable medical condition

¤ current or lifetime bipolar I or psychotic disorder

¤ pregnancy or breastfeeding status

¤ active alcohol or substance abuse/dependence in the past 6 months

¤ active suicide risk

¤ 10 or more prior yoga sessions in past year

¤ Medication changes or yoga class in past three months

Framework

Current Data on treatment efficacy

Independent Variables

Intervention

Demographics

Six week-Twelve session Ashtanga Pranayama Yoga

45 minute sessions

Dependent Variables

PCL-5 scores

The State-Trait Anxiety Inventory (STAI)

The Pittsburgh Sleep Quality Index (PSQI)

Screening scores on affect and mood.

Monitor Scores at start,

completion, and one month follow-

up

Does a six-week, trauma-sensitive yoga breathing

intervention show a clinically significant reduction of symptoms in a veteran

population diagnosed with PTSD?

Design

¤Quasi-experimental Design¤ Single arm interventional study¤ No control group

Sample and Setting

¤ Thirty veterans with clinical or sub-clinical PTSD

¤ Two intervention groups – two groups of fifteen

¤ Durham VA Medical Center or nearby CBOC

Instruments

¤ A multimethod approach - self-report symptom measures and psychophysiological testing to assess the effects of Ashtanga Pranayama yoga:

¤ Posttraumatic Stress Disorder Checklist for DSM-5 ¤ MASQ = Mood and Anxiety Symptoms Questionnaire ¤ The Pittsburgh Sleep Quality Index (PSQI) ¤ Salivary cortisol levels (if possible)

Intervention

¤ Ashtanga Pranayama group/class

¤ Two groups of fifteen, run sequentially

¤ Expert consultant design of Ashtanga Pranayama program

¤ 60 minute class, six weeks, two classes a week.

¤ 15 minute home practice program to do twice a week

Data Analysis

¤ Differences in the pre-intervention to post-intervention measurements

¤ Baseline and post data will be assessed

Limitations

¤ Challenges scheduling teaching time for classes

¤ Homogeneity of population

¤ Possible pre-study comorbidities in participants

¤ Small sample size

¤ Recruiting participants – isolation is significant barrier for PTSD population

¤ Drop out rates

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Brown, R., & Gerbarg, P. (2005a). Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: part I --neurophysiologic model [corrected] [published erratum appears in Journal of Alternative & Complimentary Medicine 3005, Apr;11(2): 383-4]. Journal of Alternative and Complimentary Medicine, 11(1), 189-201.

Brown, P. A. (2012). Trauma research and the treatment of combat veterans: An evidence based integrative literature review. (Unpublished doctoral dissertation) California Institute of Integral Studies, San Francisco, CA. Retrieved from http://search.proquest.com/docview/1017861314?accountid=14026

Descilio, T., Vedumurtachar, A., Gerbarg, P. L., Nagaraja, D., Gangadhar, B. N., Damodaran, B., & Brown, R. P. (2010). Effects of a yoga breath intervention alone and in combination with an exposure therapy for posttraumatic stress disorder and depression in survivors of the 2004 South-Easat Asia tsunami. Acta Psychiatrica Scandinavia, 12(4), 289-300. http://dx.doi.org/10.1111/j.1600-0447.2009.01466.x

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Kang, H.K., Natelson, B.H., Mahan, C.M., Lee, K.Y., & Murphy, F.M. (2003). Post-Traumatic Stress Disorder and Chronic Fatigue Syndrome-like illness among Gulf War Veterans: A population-based survey of 30,000 Veterans. American Journal of Epidemiology, 157(2):141-148.

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References Continued

Mitchell, K. S., Mazzeo, S. E., Schlesinger, M., Brewerton, T., & Smith, B. N. (2012). Comorbidity of partial and sub threshold PTSD among men and women with eating disorders in the National Comorbidity Survey Replication study. International Journal of Eating Disorders, 45, 307-315.

Office of the Secretary: Department of Veterans Affairs Strategic Plan Refresh Fiscal Year 2011-2015. (2011). Retrieved from www.va.gov/VA_2011-2015_Strategic_Plan_Refresh_wv.pdf

Pascoe, M. C., & Bauer, I. E. (2015). A systematic review of randomized control trials on the effects of yoga on stress measures and mood. Journal of Psychiatric Research, 68270-282. http://dx.doi.org/10/1016/j.jpsychires.2015.07.013

Raza, G. T., & Holohan, D. R. (2015). Clinical treatment selection for posttraumatic stress disorder: Suggestions for researchers and clinical trainers. Psychological Trauma Theory, Research, Practice, and Policy, 7, 547-554.

Schnurr PP, Friedman MJ, Engel CC, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. JAMA. 2007;297(8):820–830. doi:10.101/jama.297.8.820PubMed

Seppala, E. M., Nitschke, J. B., Tudorascu, D. L., Hayes, A., Goldstein, M. R., Nguyen, D. H., & Davidson, R. J. (2014). Breathing-based meditation decreases posttraumatic stress disorder symptoms in US Military veterans: A randomized controlled longitudinal study.Journal of Traumatic Stress, 27(4), 397-405. http://dx.doi.org/10.1002/jts.21936

Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and posttraumatic stress disorder. Medical Hypotheses, 78(5), 571-579. http://dx.doi.org/10.1016/j.mehy.2012.01.021

Tanielian, T. & Jaycox, L. (Eds.). (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation. (OEF/OIF)

U.S. Department of Veteran Affairs. (2012). Suicide data report. Retrieved from http://www.va.gov/opa/docs/Suicide-Data-Report-2012-final.pdf

van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M., & Slinazola, J. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. The Journal of Clinical Psychiatry, 75(6), E559-E565. http://dx.doi.org/10.4088/JCP.13M08561