Post Traumatic Stress Disorder [PTSD] is a body/mind illness diagnosed in military and civilian populations worldwide. It develops in the aftermath of many kinds of traumatic events including military combat, physical or sexual assault, and natural disaster. PTSD symptoms cluster into four separate categories: 1] recurrent distressing memories of the traumatic event, including nightmares and flashbacks; 2] avoidance of stimuli associated with the event, including physical environments, thoughts and emotions; 3] exaggerated negative beliefs and feelings about oneself, others and the world; and 4] a set of aversive physiologic states including hypervigilance, physical tension and disturbed sleep.
I and my colleagues developed an integrative PTSD treatment protocol that combines two evidence-based practices, Kundalini Yoga and cognitive-behavioral therapy [CBT] to address both the physical and psychological expressions of PTSD. Our pilot study found the protocol significantly reduced PTSD symptoms in all four symptom clusters, and that these gains were maintained at follow-up.1
Integrative Medicine: Healing The Body/Mind
Language differentiates “body” from “mind.” And while these two are distinct they are never separate. Psychological experience always has correlates throughout our physical structure. When we think a stressful thought or have a distressing memory our bodies participate in such activities every bit as much as our minds. Our emotions too occur not only in such brain structures as the amygdalae but throughout our bodies. It is impossible to experience feelings like fear, anger or joy “from the neck up.” Our psychological lives are intimately bound up with activity in our endocrine, cardiac, respiratory and immune systems.
So too the state of our physical structure gains expression in our thought patterns, emotions and memory processes. Research has demonstrated that the body’s incline,2 temperature3 and muscle tonus4 influence such things as our perception of others, our altruism, and orientation toward either the past or the future. Seeing a person walk timidly or confidently into a roomful of people we understand much about their psychological state. And this body/mind sphere of influence is always bidirectional: how we are in one dimension impacts how we are in the other. Body and mind comprise a reciprocal feedback loop that creates our total experience of ourselves, other people and the world.
Thus integrative medicine is not adding one thing [body-based practices] to “something else” [psychological approaches]. It is, rather, skillfully utilizing both pathways to healing, with an appreciation that each offers complete access to the suffering and wellness of the whole person. Working with the body, by means of yoga therapy, we heal the mind. Working with cognitive-behavioral therapy tools we sooth and restore the body to a state of vitality, equilibrium and wellness.
CBT has roots in humanity’s earliest written records. A twelfth-century account of Buddha’s enlightenment quotes the sage as declaring that all people are already enlightened, “Yet simply because of their delusions and preoccupations they cannot bear witness to this endowment.” 5 The Greek Stoic philosophers wrote at length about how negative thinking is the root of all emotional suffering. Arrian, a second-century disciple of the Stoic philosopher Epictetus, quoted his teacher as saying that people “are disturbed not by what happens to them, but by the principles and notions they form concerning what happens to them.”
Since the 1950’s clinicians and researchers worldwide have been building a modern science of the mind based on these ancient teachings. We now understand in a more granular way than ever before the relationships between different aspects of our mental, emotional and physical lives. And while CBT references cognition and behavior, both are grounded in our beliefs about ourselves, other people and the world at large. Resetting faulty beliefs is the ultimate aim of CBT.
Post trauma a person’s belief structure may experience a hard reset. A woman who has been sexually assaulted may begin to believe that most men are dangerous predators. Approaching an unknown man walking the opposite direction up the street this belief might be triggered and produce the thought “That man wants to hurt me.” This thought will produce a fear response with expressions in both body and mind. The fear will likely drive an avoidant behavior – crossing to the other side of the street – that reinforces the belief. This woman would not be avoiding men if they were simply other human beings like herself. Her avoidant behavior reminds her she must maintain physical and emotional hypervigilance in a world that is very dangerous at all moments. And her safe arrival home will register as data that confirms her entire belief/thought/behavior structure.
As this example makes clear, dealing only with cognition, emotion, or behavior we miss the root of an illness like PTSD. It is only by bringing into awareness the faulty beliefs that give rise to negative thoughts, feelings and behaviors – and providing patients the tools to reset these beliefs – that CBT opens the doorway to healing, peace, self confidence and joy.
Sometimes referred to as the “yoga of awareness” Kundalini yoga utilizes physical posture, pranayama, mudra and mantra to unify the practitioner’s body and mind – with the final goal of yoking the human and the divine. Kundalini Yoga kriyas are being investigated by modern medical science to understand the physical and psychological effects of these practices. Our research and that of colleagues is creating a body of data in support of these kriyas efficacy in addressing sleep disorders,6 PTSD,7,8 addiction, 9 anxiety 10 and other parameters of mental health.11
Mantra, a key component of Kundalini practice, has been shown to decrease physical risk factors including high blood pressure, chemoreflex sensitivity and low brain oxygen saturation.12 In PTSD veteran populations mantra practice has correlated with significant reductions in hyperarousal symptoms and disturbed sleep.13 Kundalini Yoga’s Kirtan Kriya, which includes a mantra component, decreased depression symptoms and improved mental health and cognitive function in family caregivers of dementia patients.14
Over the last two decades yoga of many schools has been studied better to understand the cognitive effects of this ancient practice. In our clinical work we see the kriyas resetting patients’ negative thoughts and the negative feelings that flows from them. While we also offer CBT tools to effect these changes, yoga in and of itself appears capable of producing such healing in PTSD patients. Colleagues’ research has demonstrated that yoga practice correlates with overall improvement in a number of cognitive functions. These include working memory,15 long term memory,16 visual attention17 and executive function.18 This data strongly recommends yoga practice as both a stand-alone and a complementary approach to PTSD treatment.
Physiologic Effects of PTSD
PTSD is correlated with structural and functional changes throughout the brain and body. These changes are often coequal with changes in belief, cognition and emotion in producing patients’ experience of illness. Our outline above of the interdependence of body and mind explains how this will likely be the case. PTSD is also comorbid with a wide range of disease states including cardiovascular, respiratory and autoimmune illness. PTSD is correlated with changes in the immune response19 and gut biome20 and many of these comorbidities may be driven by inflammation. A number of inflammatory markers are significantly increased in PTSD patients relative to controls.21
The amygdalae are twin structures that together comprise the seat of emotional processing in the brain. The amygdalae are overactive in PTSD which may account for the hypervigilance found in many patients.22 The hippocampi are twin structures associated with memory formation and processing of long-term memories. Hippocampal volume is reduced in PTSD and this reduction is likely implicated with the memory disturbances [both memory loss and intrusion of unwanted memories] experienced by patients.22 The anterior cingulate cortex [ACC] is another brain structure affected by PTSD. The ACC helps regulate emotion and the stress response and is reduced both in size23 and activity24 in PTSD patients.
PTSD-related structural and function changes are not limited to the brain. FKBP5 is a gene that helps moderate the stress response; the expression of FKBP5 is reduced in PTSD.25 PTSD is associated with increased pro-inflammatory and decreased anti-inflammatory cytokines.26 Heart rate variability [HRV], the variance in time intervals between heartbeats, is a marker for nervous system balance and health; higher variability correlates with better health. PTSD is correlated with decreased HRV,27 an indication of sympathetic nervous system dominance, a state sometimes referred to as “fight or flight.”
Physiologic Effects of Yoga and CBT
Yoga and CBT have been shown to produce effects that lie opposite the structural and functional changes that travel with PTSD, restoring physical wellness right down to the molecular level. CBT increases FKBP5 expression in PTSD patients 28 and decreases overactivity of the amygdala.29 Both CBT28 and yoga30 increase hippocampal volume and CBT improves memory.28 CBT31 and yoga32 also raise heart rate variability in PTSD patients to the level of healthy controls and regulate genes associated with the inflammatory response.33-35
In reviewing the literature my colleagues and I are struck by the similar structural and functional repair produced by such apparently divergent therapies as yoga and CBT. We hypothesize that there are as-yet-unrecognized mechanisms common to both therapies. Discovering these underlying mechanisms – and better understanding the interactive effects of an integrative approach – constitute promising areas for further research.
PTSD is a mind/body illness that our research and that of colleagues suggests can be healed by patients’ skillful use of their own bodies and minds. The combination of CBT and Kundalini yoga offers an evidence-based approach that is drug-free, low-tech and suitable for either individual or group treatment. Via self-help books like Reclaiming Life After Trauma, this protocol can be made available to remote or displaced populations without access to financial resources, medical facilities or even electricity. It is our hope that this combination of ancient Eastern wisdom and modern cognitive science will bring healing to PTSD patients worldwide and further our understanding of the essential unity of the human body, mind and spirit.
- Staples JK, Mintie D, Khalsa SBS. Evaluation of a combined yoga and cognitive behavioral therapy program for posttraumatic stress disorder. J Altern Complement Med 2016;22:A94.
- Miles LK, Nind LK, Macrae CN. Moving through time. Psychol Sci 2010;21:222-223.
- Williams LE, Bargh JA. Experiencing physical warmth promotes interpersonal warmth. Science 2008;322:606-607.
- Hung IW, Labroo AA. From firm muscles to firm willpower: understanding the role of embodied cognition in self-regulation. J Consum Res 2011;37:1046-1064.
- Aitken R. The Morning Star:New and Selected Zen Writings. Berkeley, CA: Counterpoint, 2003.
- Khalsa SB. Treatment of chronic insomnia with yoga: a preliminary study with sleep-wake diaries. Appl Psychophysiol Biofeedback 2004;29:269-278.
- Jindani F, Turner N, Khalsa SBS. Ayoga intervention for posttraumatic stress: a preliminary randomized control trial. Evid Based Complement Alternat Med 2015;351746.
- Jindani FA, Khalsa GFS. A yoga intervention program for patients suffering from symptoms of posttraumatic stress disorder: A qualitative descriptive study. J Altern Complement Med 2015;21:401-408.
- Khalsa SB, Khalsa GS, Khalsa HK, Khalsa MK. Evaluation of a residential Kundalini yoga lifestyle pilot program for addiction in India. J Ethn Subst Abuse 2008;7:67-79.
- Khalsa MK, Greiner-Ferris JM, Hofmann SG, Khalsa SB. Yoga-enhanced cognitive behavioural therapy (Y-CBT) for anxiety management: a pilot study. Clin Psychol Psychother 2015;22:364-371.
- Sarkissian M, Trent NL, Huchting K, Singh Khalsa SB. Effects of a kundalini yoga program on elementary and middle school students’ stress, affect, and resilience. J Dev Behav Pediatr 2018;39:210-216.
- Bernardi NF, Bordino M, Bianchi L, Bernardi L. Acute fall and long-term rise in oxygen saturation in response to meditation. Psychophysiology 2017;54:1951-1966.
- Bormann JE, Thorp SR, Wetherell JL, Golshan S, Jang A. Meditation-based mantram intervention for Veterans with posttraumatic stress disorder: a randomized trial. Psychol Trauma 2013;213:259-267.
- Lavretsky H, Epel ES, Siddarth P et al. A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity. Int J Geriatr Psychiatry 2012;10.
- Gothe N, Pontifex MB, Hillman C, McAuley E. The acute effects of yoga on executive function. J Phys Act Health 2013;10:488-495.
- Rocha KK, Ribeiro AM, Rocha KC et al. Improvement in physiological and psychological parameters after 6 months of yoga practice. Conscious Cogn 2012;21:843-850.
- Narayana NVVS. The effect of yoga on visual reaction time. Indian J Soc Sci Res 2009;6:63-70.
- Manjunath NK, Telles S. Improved performance in the tower of London test following yoga. Indian J Physiol Pharmacol 2001;45:351-354.
- Neigh GN, Ali FF. Co-morbidity of PTSD and immune system dysfunction: opportunities for treatment. Curr Opin Pharmacol 2016;29:104-10.
- Leclercq S, Forsythe P, Bienenstock J. Posttraumatic stress disorder: does the gut microbiome hold the key? Can J Psychiatry 2016;61:204-213.
- Gill JM, Saligan L, Woods S, Page G. PTSD is associated with an excess of inflammatory immune activities. Perspect Psychiatr Care 2009;45:262-277.
- Shin LM, Rauch SL, Pitman RK. Amygdala, medial prefrontal cortex, and hippocampal function in PTSD. Ann N Y Acad Sci 2006;1071:67-79.
- Karl A, Schaefer M, Malta LS, Dörfel D, Rohleder N, Werner A. A meta-analysis of structural brain abnormalities in PTSD. Neurosci Biobehav Rev 2006;30:1004-1031.
- Shin LM, Whalen PJ, Pitman RK et al. An fMRI study of anterior cingulate function in posttraumatic stress disorder. Biol Psychiatry 2001;50:932-942.
- Levy-Gigi E, Szabo C, Kelemen O, Keri S. Association among clinical response, hippocampal volume, and FKBP5 gene expression in individuals with posttraumatic stress disorder receiving cognitive behavioral therapy. Biol Psychiatry 2013;74:793-800.
- Passos IC, Vasconcelos-Moreno MP, Costa LG et al. Inflammatory markers in post-traumatic stress disorder: a systematic review, meta-analysis, and meta-regression. Lancet Psychiatry 2015;2:1002-1012.
- Chalmers JA, Quintana DS, Abbott MJ, Kemp AH. Anxiety disorders are associated with reduced heart rate variability: a meta-analysis. Front Psychiatry 2014;5:80.
- Szabó C, Kelemen O, Kéri S. Changes in FKBP5 expression and memory functions during cognitive-behavioral therapy in posttraumatic stress disorder: a preliminary study. Neurosci Lett 2014;569:116-120.
- Felmingham K, Kemp A, Williams L et al. Changes in anterior cingulate and amygdala after cognitive behavior therapy of posttraumatic stress disorder. Psychological Science 2007;18:127-129.
- Hariprasad VR, Varambally S, Shivakumar V, Kalmady SV, Venkatasubramanian G, Gangadhar BN. Yoga increases the volume of the hippocampus in elderly subjects. Indian Journal of Psychiatry 2013;55:S394-S396.
- Nishith P, Duntley SP, Domitrovich PP, Uhles ML, Cook BJ, Stein PK. Effect of cognitive behavioral therapy on heart rate variability during REM sleep in female rape victims with PTSD. J Trauma Stress 2003;16:247-250.
- Markil N, Whitehurst M, Jacobs PL, Zoeller RF. Yoga Nidra relaxation increases heart rate variability and is unaffected by a prior bout of Hatha yoga. J Altern Complement Med 2012;18:953-958.
- Black DS, Cole S, Irwin MR et al. Yogic meditation reverses NF-kappaB and IRF-related transcriptome dynamics in leukocytes of family dementia caregivers in a randomized controlled trial. Psychoneuroendocrinology 2013;38:348-355.
- Bower JE, Greendale G, Crosswell AD et al. Yoga reduces inflammatory signaling in fatigued breast cancer survivors: a randomized controlled trial. Psychoneuroendocrinology 2014;43:20-29.
- Antoni MH, Lutgendorf SK, Blomberg B et al. Cognitive-behavioral stress management reverses anxiety-related leukocyte transcriptional dynamics. Biol Psychiatry 2012;71:366-372.