Yoga and meditation research in psychiatry

Presenter: dr Namrata bhatiModerator: dr nimmi

HISTORICAL ASPECTS• Yoga is derived from Sanskrit root yuj • Union of individual soul , atama with parmata, universal soul• integration of mind ,body and spirit• earliest written account - RIG VEDA • 1st yoga texts dates - 2nd BC by PATANJALI • ASHTANGA YOGA -adherence to 8 limbs ashtanga yoga to

quite’s one mind to unite with infinite

History of yoga and origin and pioneer of yoga and meditation• Yoga-”Family of ancient spiritual practices that originated in India• 4 main types –• Karma yoga ,• bhakti yoga• jnana yoga and • raja yoga • Eastern world-path to spiritual enlightenment • central to Hinduism, Sikhism, Buddhism, Jainism • western world yoga -asana (postures) of hath yoga , fitness exercises

Definition of yoga • most schools of yoga incorporate elements of Asanas (physical postures and movements) including relaxation, Pranayama (breathing practices), and dhyana (meditation and mindfulness)cultivation of positive values, thoughts and attitudes & lifestyle

factors multi-dimensional intervention tailored to needs of each

individual.

Schools of yoga• Patanjali Yoga Sutras and focus on unification of body, mind

and spirit to promote health and well-being.• Sudarshan Kriya Yoga (SKY) focuses almost exclusively on

pranayama, • Iyengar's yoga focuses on asanas and • Vinyasa yoga focus on breath-linked movement.

• Yoga Sutras of Patanjali, :‘‘Yoga is the suppression of the modifications of the mind’’ • goal of Meditation :• elimination/ reduction of thought processes,• cessation / slowing of the internal dialogue of the mind -‘‘mental

clutter’’.• thoughtless awareness :• sustained focused attention (concentration),• self-monitoring (preventing the attentional focus to wander off) • cognitive interference control ( inhibit interference / disruption

from unwanted thoughts/ irrelevant external events

MEDITATION• Meditation is essentially a physiological state of demonstrated reduced metabolic activity – different from sleep physical and mental relaxation enhance psychological balance and emotional stability

(Jevning et al., 1992; Young and Taylor, 2001).

• In Western psychology, 3 states of consciousness : sleep, dream and wakefulness.• In Eastern philosophy & Western religious & mystical traditions, ‘

‘‘higher /fourth state of consciousness’’:• the state of ‘‘thoughtless awareness’’ (Ramamurthi, 1995).

• Elimination of incessant thinking processes • experiencing a state of deep mental silence

• Mindfulness Meditation involves focussed attention on internal and external sensory stimuli with ‘‘mindfulness’’, a specific non-judgemental awareness of present-moment stimuli without cognitive elaboration.

Schools of yoga• Patanjali Yoga Sutras and focus on unification of body, mind

and spirit to promote health and well-being.• Sudarshan Kriya Yoga (SKY) focuses almost exclusively on

pranayama, • Iyengar's yoga focuses on asanas and • Vinyasa yoga focus on breath-linked movement.

why could it be a useful adjunct toachieve mental health? long-term trait effects of Meditation : (1) physical level: feelings of deep relaxation , stress relief; (2) cognitive level: enhanced concentrative attention skills, improved self-control a, self- monitoring , ability to inhibit irrelevant interfering external & internal activity; (3) emotional level: positive mood, emotional stability ,resilience to stress ,negative life events (detachment);(4) psychological level: personality changes - enhanced overall psycho-emotional balance.

Reasons for growing interest in yoga

• appealing to people concerned with stigma associated with conventional mental health treatments • recent uncertainties on the effectiveness& long-term benefits of

psychopharmacological treatments - antidepressants and psychostimulants (Jensen et al., 2007; Kirsch et al., 2008)• Current treatment : narrow focus of a diagnosis-treatment

approach • Yoga : broader focus on mind-body or lifestyle interventions, for

living a healthier, happier and flourishing life

Reasons for growing interest in yoga• Free of side effects , preferred by pregnant women • assist people in treatment or recovery from injury, illness or disability• adjunct to current treatment• Cost effective

NEUROENDOCRINOLOGICAL CHANGES DURING MEDITATION• regulatory effect on two axis• hypothalamic-pituitary-adrenal (HPA) axis • sympathetic nervous system (SNS) • repeated exposure to stressors over time,• Dysregulation of axis

Peripheral physiological changes during Meditation

• WAKEFUL HYPOMETABOLIC STATE : • decreased sympathetic nervous activity, • increased parasympathetic activity• heart, respiratory , pulse rates, of systolic blood pressure and oxygen

metabolism, and of urinary vanyl mandelic acid (VMA), increases of skin resistance (Rai et al., 1988)• Prevents stress-related illness.

(Cahn and Polich, 2006; Jevning et al., 1992; Rai et al., 1988; Young and Taylor, 2001).

PERIPHERAL PHYSIOLOGICAL CHANGES DURING MEDITATION

WAKEFUL HYPOMETABOLIC STATE• Decreased sympathetic• Increased parasympathetic

• heart, respiratory , pulse rates, of SBP, oxygen metabolism,• urinary vanyl mandelic acid (VMA), increase skin resistance

• Prevents stress-related illness

(Cahn and Polich, 2006; Jevning et al., 1992; Rai et al., 1988; Young and Taylor, 2001).

Neurophysiological effects during MeditationEEG WAVES EFFECTS

increased low frequency activation of theta and alpha bands

sustained attention to internal events Cahn and Polich, 2006

theta activity over left frontal regions feelings of happiness

Frontal theta activity emotion processing sustained attention

• Asada et al., 1999; Deiber et al., 2007; Gevins and Smith, 2000; Rachbauer et al., 2003; Sauseng et al., 2007).

Neurophysiological effects during MeditationEEG WAVES EFFECTS

alpha power range sustained attention to internal events

fronto-parietal theta bands reduction in the chaotic dimensional complexity,

attentional networks enforcement decreased task-irrelevant processes

Frontal theta activity emotion processing sustained attention

RESULTS IN REDUCED ANXIETY• Asada et al., 1999; Deiber et al., 2007; Gevins and Smith, 2000; Rachbauer et al., 2003; Sauseng et al., 2007).

Neurophysiological changes in yoga• Functional magnetic resonance imaging (fMRI) was conducted in a

small number of five Meditators with at least 4 years of Kundalini Yoga experience with subjects silently generated a random list of animals and did not observe their breathing .• There was increased activation during late versus early Meditation

in dorsolateral prefrontal and parietal cortex, limbic and paralimbic regions (amygdala, hypothalamus, hippocampus and anterior cingulate) and the basal ganglia (Lazar et al., 2000).• Indicationg increased activation of brain regions that mediate

sustained attention and autonomic control.• Given the very small subject numbers a replication in larger

samples will be necessary to corroborate the findings.

Neurophysiological changes in yogaFunctional magnetic resonance imaging (fMRI) changes: Increased activation during late Vs early Meditation in:1. dorsolateral prefrontal and parietal cortex,2. limbic & paralimbic regions (amygdala, hypothalamus, hippocampus and anterior cingulate) 3. basal ganglia increased activation of brain regions mediating sustained attention and autonomic control (Lazar et al., 2000)

sustained attention & autonomic

control

dorsolateral prefrontal

Parietal cortex

basal ganglia

limbic & paralimbic

regions

Neurophysiological changes in yogafMRI changes in late Vs early meditators (Lazar et al., 2000)

Long term plastic effects of Meditation on brain structure• Lazar et al. (2005) compared 20 Buddhist Meditators who

practised insight/ Mindfulness Meditation for an average time of 9 years to age and demographically matched controls.• The Meditators compared to controls had significantly increased

cortical thickness in right middle and superior frontal cortex and the insula• Normal age-related cortical thinning is delayed in right fronto-

limbic brain regions (Lazar et al., 2005).

Clinical effectiveness of Meditation in psychiatric disorders• growing evidence for short and long term effects of Meditation on

physiological indicators of stress, personality and cognitive functions,• on functional and structural plasticity of brain regions that are

important for attention and emotion regulation,• mental disorders with affective and cognitive-attentional problems

are the target

Role of yoga and meditation in depression and anxiety• a recent meta-analysis on antidepressant medication has raised

serious concerns about its clinical efficacy (Kirsch et al., 2008)• Use in Teenagers has been controversial due to side effects and

suicide risk (Vitiello and Swedo, 2004).

• Sahaja Yoga Meditation over 6 weeks showed a significant reduction in the symptoms of anxiety, depression and general mental health in 24 patients with major depression compared to a control group and a group receiving CBT (Morgan, 2001).• the effect sizes were high, ranging from Cohen’s d of 1.2–2.1• replication in a larger sample is needed

• Sudarshan Kriya Yoga, has shown effectiveness in patients with depression on symptoms of anxiety and depression in a randomised controlled trial (Janakiramaiah et al., 2000)• Meditation was as good as Imipramine, an antidepressant, but

inferior to electroconvulsive therapy

• A small study investigated the effect of Mindfulness Meditation based cognitive behavioural therapy in patients with depression with high relapse risk, randomized to either MBCT or treatment as usual (Barnhofer et al., 2007).• results showed that treatment with MBCT significantly reduced

self-reported symptoms of depression from severe to mild levels, while levels of depression remained unchanged in the group that received TAU only.

Meditation studies conducted inobsessive-compulsive disorder (OCD)• Open trial of 12 months Kundalini Yoga practice, consisting of

posture and breathing exercises, in five medicated patients showed significant reduction in OCD symptoms and severity of about 50% (Shannahoff-Khalsa, 1997).• Blinded RCT with 12 months of Kundalini Yoga as the active

condition and relaxation response and mindfulness based Meditation as active control condition (Shannahoff-Khalsa et al., 1999).• Only the Kundalini Yoga group improved in OCD symptoms (38%) .

mood and anxiety measures.

Mindfulness Meditation with bingeeating problems• Mindfulness Meditation based stress-reduction interventions on

18 women with binge eating problems over 6 weeks.• The MBSR treatment showed a significant improvement in binge

eating frequency and severity PLUS symptoms of anxiety and depression after 6 weeks that persisted 3 weeks after treatment (Kristeller et al., 2004).• Though effect size was large (with a Cohen’s d of 2), this study

isconsidered preliminary as it lacked control group.

Meditation studies conducted for adhd• The escalating stimulant prescription rates have caused growing

concern :• Side effects ,the unknown long-term effecTS on brain development. • Waning of superiority of medication treatment over behavioural

treatments after several years, raising worrying questions over potential sensitisation effects (Jensen et al., 2007).• Sahaja Yoga Meditation helps reduce symptoms of hyperactivity

through the reduction of sympathetic activity (Rai et al., 1988; Manocha et al., 2002).

• inattention and impulse control would be counteracted with Meditation• Meditation training induced improvement of cognitive functions

of sustained attention, inhibitory control and self-monitoring (Brown et al., 1984; Jha et al., 2007; Slagter et al., 2007),• Neuroimaging evidence for activation of fronto-parietal attention

networks with Sahaja Yoga Meditation• These are under-activated in children with ADHD during tasks of

inhibitory control and attention (Rubia et al., 1999, 2001, 2005, 2008, 2009; Smith et al., 2006)

• Significant reduction in symptoms of ADHD within 6 weeks of sahaj yoga • It was equally observed in medicated and nonmedicated patients

(Harrison et al., 2004).• The effect size was high (Cohen’s d of 1.2)• 50% of children either stopped or reduced their medication, and

still improved in symptoms.• further explorations in larger samples of medication-naı¨ve

children and including an active control group are required

• 25 adults and adolescents with ADHD were enrolled in an 8-week MCBT• pre–post-improvements in self reported ADHD symptoms and

performance on tasks of selective attention and cognitive inhibition.• The effects sizes for symptom reduction were relatively high

(Cohen’s d 1.8).• Lack of control group and use of self-reported measures of ADHD

symptoms, could have been influenced by placebo effects. (Zylowska et al., 2008)

YOGA STUDIES IN schizophrenia• In schizophrenia patients with several years of illness and on stabilized

pharmacological therapy, one-month training followed by three months of home practices of yoga as an add-on treatment offered significant advantage over exercise or treatment as usual. • Improvement in negative symptoms on PANNS and social dysfunction

ratings was observed in yoga group and only social dysfunction rating in exercise group as compared to treatment only (N Gangadhar Bangalore and Shivarama Varambally, NIMHANS , 2012)

Yoga studies in BPAD• hatha yoga may be a powerful positive practice for some people with

bipolar disorder• increased mindfulness—i.e., increased nonjudgmental focus on the

present moment—and an increased sense of calm or relaxation.• physical activity to reduce weight (side effects of antipsychotics and

mood stabalisers)• hatha yoga is not without risks, and, like many treatments for bipolar

disorder, should be used with care.

Yoga studies in BPAD• hatha yoga is not without risks, and, like many treatments for bipolar

disorder, should be used with care.• Extreme practices— rapid breathing, heated rooms, or very slow and

meditative practice• heat intolerance in people taking antipsychotic medication• Heat causing dehydration can increase the risk for lithium toxicity,

Yoga and meditation studies in PTSD• Yoga has been shown to have a regulatory effect on two key

neurobiological systems: • the hypothalamic-pituitary-adrenal (HPA) axis and• the sympathetic nervous system (SNS)• repeated exposure to stressors makes them “hypervigilant” and

“dysregulated• Downregulation benefit of yoga helps in PTSD((Ross & Thomas,

2010))

Yoga and meditation for substances use• problems of impulsivity, poor self-regulation, and

craving/compulsive states found in substance use disorder • different forms of Buddhist meditation may strengthen the ability

of long-term practitioners to dampen their stress responses • to control the automatic cascade of semantic associations and

thoughts, • increase attentional capacity and preserve cortical integrity and

plasticity.

Yoga and meditation for substances use• In-mates in a correctional facility were offered a choice between

treatment as usual and a ten-day course of Vipassana meditation• This RCT study showed the group choosing meditation showed• decreases in alcohol-related problems and psychiatric symptoms

upon discharge, • increases in positive psychosocial outcomes• Lack of randomization makes it diificult to draw conclusions

Precipitation of psychosis by yoga and medittaion• Some studies have suggested that meditation can actually raise

dopamine levels and exacerbate psychosis. • However, these studies were not randomized, controlled trials, and,

therefore, more research is needed to assess possible negative effects of meditation for individuals with mental illness.

Concerns in reviews for yoga• considerable heterogeneity and lack of detail, rationale and

consistency of approach in the types of yoga-based interventions between the various studies• very difficult to draw generalizable conclusions of the benefits of

yoga and identification of effectiveness of key components of interventions.• Crosssectional studies, however, are confounded by cohort effects.• Meditation practices are often associated with lifestyle changes that

could also affect health and personality.• Longitudinal studies using well-controlled study groups will be

needed to establish long-term effects on personality.

Concerns in research studies in yoga and meditation• considerable heterogeneity and lack of detail, rationale and

consistency of approach in the types of yoga-based interventions between the various studies• very difficult to draw generalizable conclusions of the benefits of yoga

and identification of effectiveness of key components of interventions.

• Longitudinal study designs testing for structural changes before and after years of Meditation practices or• randomised controlled trials will be more informative an convincing

with respect to causality than cross-sectional designs, where it cannot be excluded that brain changes are related to psychological traits or more healthy lifestyles in people who are drawn to practice Meditation.

Take home message

refernces• Kitamura, M. (2013). Harvard yoga scientists find proof of meditation benefit.

Retrieved from http://www.bloomberg.com/news/2013-11-22/harvard-yoga-scientists-find-proof-ofmeditation-benefit.html. • Van der Kolk, B. (2009). Yoga and post-traumatic stress disorder: An interview

with Bessel van der Kolk, MD. Integral Yoga Magazine, 12-13.• Bowen S, Witkiewitz K, Dillworth TM, et al. Mindfulness meditation and

substance use in an incarcerated population. Psychol Addict Behav. 2006; 20:343–347. [PubMed: 16938074] • Bangalore, N. G., & Varambally, S. (2012). Yoga therapy for

Schizophrenia.International Journal of Yoga, 5(2), 85–91. http://doi.org/10.4103/0973-6131.98212

refernces• Yorston G.A. Mania precipitated by meditation: a case report and

literature review. Ment Health Relig Cult. 2001;4(2):209–213.• Walsh R, Roche L. Precipitation of acute psychotic episodes by

intensive meditation in individuals with a history of schizophrenia. Am J Psychiatry. 1979;136(8):1085–1086. [PubMed]• 17. Lazarus A.A. Psychiatric problems precipitated by transcendental

meditation. Psychol Rep.1976;39(2):601–602. [PubMed]

refernces• Hermesh H, Shiloh R, Epstein Y, et al. Heat intolerance inpatients with

chronic schizophrenia maintained with antipsychotic drugs. Am J Psychiatry 2000;157:1327–9.