Introduction
Yoga is an experiential psycho-philosophical system that can enhance physical and mental health. Yoga means “to unite” the individual life energy, prâna, with the universal energy, Brahman. The methods to achieve this union increase awareness of the mind and body through self-observation, enhance the capacity to control the mind (fluctuations of consciousness) and physiological processes, increase energy, reduce the influence of negative emotions and experiences, uncover the true self, and free the individual to improve the quality of life.
The history, philosophy, and practices of the many schools of yoga have been reviewed elsewhere . Variations of basic techniques are used by most yoga practitioners. These include asanas (postures and stretching), pranayama (yoga breathing), meditation, and relaxation. The ancient rishis knew that each practice enhances the others. Our focus will be on pranayama and asanas. Derived from wisdom as ancient as 5000 B.C.E., yoga ideas and practices were systematized in the Patanjali Sutras (200 C.E.) as “The Eight Limbs of yoga.” These can be briefly summarized.
Western psychiatry has struggled to comprehend yoga science since Freud admitted his discomfort with the subject in Civilization and its Discontents: “…it is very difficult for me to work with these almost intangible qualities. Another friend of mine…has assured me that through the practices of yoga, by withdrawing from the world, by fixing the attention on bodily functions and by peculiar methods of breathing, one can in fact evoke new sensations…which he regards as regressions to primordial states of mind which have long ago been overlaid. He sees in them a physiological basis, as it were, of much of the wisdom of mysticism…” .
Had Freud delved deeply into yoga science, he would have discovered that despite its exotic appearance, many principles of yoga were based on neuro-psychological concepts corresponding to modern science. Around 200 C. E. Patanjali attributed the neuroses (depression, tremor, languor, doubt, heedlessness, sloth, dissipation, false vision, and instability) to “fluctuations in the state of consciousness.” To restrict the fluctuations of consciousness, he prescribed a list of remedies including yoga breathing and dream analysis: “the expulsion and retention of breath [prâna] according to the yoga rules” and “[restriction is achieved when consciousness] rests on insights [arising from] dreams and sleep” .
Although yoga is steeped in tradition, it is remarkably innovative. Yoga masters who develop fresh insights, techniques, and approaches to the problems of modern life are deeply honored, particularly if their contributions benefit mankind. Love of creativity and adaptability to our changing world has kept yoga alive and relevant.
The Clinical Uses of Yoga
Anxiety, Phobias and Stress Overreactivity
Asanas, meditation and pranayama, particularly slow ujjayi, unilateral, and alternate nostril breathing, increase PNS activity, reduce SNS activity, and produce a state of physical and mental calmness. In 22 medical patients with anxiety disorders, 8-weeks of mindfulness meditation, asanas, and relaxation techniques significantly improved anxiety and reduced panic attacks. At 3-year follow up, 18 subjects maintained the practice and their improvements on scales of depression and anxiety .
In a 3-month randomized study of 50 first-year medical students 25 were given 3 one-hour sessions per week of yoga postures, pranayama, and meditation. The control group used the time for reading. The yoga program significantly reduced anxiety levels on the day of exams . Six-sessions of meditation, Hatha-Yoga, pranayama, and imagery significantly reduced anxiety and depression and improved self-efficacy in the caregivers of 12 demented patients .
Individuals with severe anxiety or panic attacks may need extra preparation and reassurance before starting a yoga course. Sometimes when patients with panic disorders attempt rapid breath practices, they become worried about hyperventilating. This anxiety can trigger a panic attack. The problem can be prevented by explaining the differences between controlled rapid breathing and uncontrolled hyperventilation. In addition anxious patients can be instructed to reduce the frequency of respirations if they begin to feel anxious until they become more comfortable.
Obsessive Compulsive Disorder
Kundalini Yoga using 8 yoga practices including asanas, meditation, and slow (1 cpm) left-nostril breathing with breath holds improved symptoms of OCD in a pilot study and in a 12-month randomized trial. Subjects in the Kundalini program showed significantly greater improvement than the control group given relaxation and mindfulness training .
Posttraumatic Stress Disorder
Although no formal studies have been done yet, SKY is known to relieve symptoms of PTSD. Dr. Sharon Sageman has found that patients with PTSD benefited from SKY training (Sageman, personal communication 2002). The SKY course includes aspects of cognitive-behavioral therapy and psychoeducation in human values of acceptance, social responsibility, and community service . SKY breathing sometimes evokes trauma-related sensations, movements, and affects in a safe, supportive setting. The authors, Dr. Gerbarg and Dr. Brown, have observed that many patients with PTSD experience improvement in physical and psychological symptoms. The overall effect is amelioration of feelings of fear, neglect, abuse, rejection, depression, isolation, and worthlessness. Patients with PTSD should be told in advance about what occurs in SKY courses and the possibility of physical or emotional reactions. The therapist should monitor the patient during and after the course to help process intense emotions that may emerge.
Mood and Depression
A nonrandomized study of 87 healthy college students found that both swimming and Hatha Yoga (postures, stretches, and breathing) significantly improved depression scores and reduced indices of stress (anger, confusion, and tension) compared to the control group who just attended lectures. In male students, yoga produced a greater mood elevation than swimming . Compared to visualization and relaxation, 30-minutes of asanas and pranayama significantly improved perceptions of increased mental and physical energy, alertness, enthusiasm, and positive mood in a group of 71 normal adults .
Three open studies found that SKY significantly improve depression and in a randomized comparison study of 45 hospitalized patients with severe melancholic depression, SKY was as effective as high dose imipramine (225mg/day) and almost as effective as ECT, but SKY had no adverse side effects . SKY also normalized P300 event related evoked potential amplitude in depressed patients .
In a randomized wait-list control study of 28 mildly depressed young adults two one-hour Iyengar yoga classes per week for 5 weeks (using postures only) significantly reduced depression, fatigue, and trait anxiety scores .
Bipolar Disorder
Yoga should be used with caution in Bipolar I patients or unstable rapid cyclers. Some Bipolar patients overuse the practices for self-stimulation. This can exacerbate mania. However, Bipolar-II patients whose hypomania is well-controlled on mood-stabilizers other than lithium (yogic breathing can lower lithium levels by increasing lithium excretion) and antipsychotic medication have benefited from SKY. Patients taking lithium may be considered for yoga breathing if serum lithium levels are monitored and doses adjusted. Avoiding rapid cycle breathing and in some cases Bhastrika will reduce the possibility of overstimulation. Bipolar patients with predominantly depressive symptoms often respond well to pranayama and asanas.
Schizophrenia and Psychoses
General yoga classes are not recommended for psychotic patients. A letter to the editor of Lancet reported that after two months of pranayama, 60 hospitalized schizophrenic patients become calmer and more relaxed . A non-verbal expressive group therapy study compared four patient groups: psychotic, psychosomatic, heterogeneous, and control. The program included deep-breathing yoga and movement. All patients responded well with decreased anxiety and improved sociability. Medication requirements were reduced .
Dr. Sagemen introduced ujjayi breathing to a therapy group for women with severe chronic mental illness, predominantly schizophrenia. Most were Latino or African Americans living below the poverty line with histories of abuse, childhood trauma, and repeated psychiatric hospitalizations. The patients learned ujjayi quickly and responded with rapid improvement in mood, energy, and attention. “The effect of the breathing exercises on the group members' affect and behavior was a transition from sad, tense, or withdrawn to more cheerful, alert, and interactive” .
Schizophrenic patients may benefit from modified nonstimulating yoga techniques in a supportive setting with skilled mental health professionals.