By David Kiefer, MD
Clinical Assistant Professor, Department of Family Medicine, University of Wisconsin; Clinical Assistant Professor of Medicine, Arizona Center for Integrative Medicine, University of Arizona, Tucson
Dr. Kiefer reports he is a consultant for WebMD.
Synopsis: A 10-week “trauma-informed” yoga practice, more than health education classes, aided women with chronic, treatment-resistant PTSD.
Source: van der Kolk BA. Yoga as an adjunctive treatment for posttraumatic stress disorder: A randomized controlled trial. J Clin Psychiatry 2014;75:e559-565.
Summary Points
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This study compared the effects of “trauma-informed” yoga practice to health education classes over 10 weeks in women with chronic, treatment-resistant post-traumatic stress disorder (PTSD).
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Sixty-four women were included in the intention-to-treat analysis, showing more benefits in the yoga group for the Clinician Administered PTSD Scale and two sub-analyses of the self-reported Inventory of Altered Self-Capacities.
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In the Davidson Trauma Scale, the yoga group maintained benefits for the entire study, whereas the control group showed regression during the latter half.
Yoga is often known as a body-based therapy, as anyone who has tried to hold a warrior pose for more than 30 seconds can attest. But, often overlooked is the mind component, the stillness and calm that can be achieved when breathing, focus, spirit, and body meet in a yoga practice. This effect was not lost on this research team, who postulated that weekly yoga might be of benefit for a difficult-to-treat psychological condition, post-traumatic stress disorder (PTSD). The authors cited proven components of a successful elimination of conditioned fear responses associated with PTSD, including being able to manage intense emotions and keep one’s attention focused on conditioned stimuli. Such effects are often exactly what yoga can provide.
From community sources, the researchers enrolled women with chronic PTSD, resistant to at least 3 years of PTSD-focused treatment. As part of the telephone screening, a trauma history was also elicited, and women were randomized to either yoga classes or women’s health education classes, each lasting 1 hour, once weekly for 10 weeks. A total of 101 participants were assessed for enrollment, but 18 were excluded because they lacked a PTSD diagnosis, were unstable medically, were breastfeeding or pregnant, had alcohol or other drug abuse in the last 6 months, were actively suicidal, had five or more prior yoga sessions, or had a Global Assessment of Functioning score < 40. Another 19 withdrew prior to randomization or treatment, leaving 64 to be included in the trial and analyzed as intention-to-treat.
The women in the treatment arm participated in yoga that was considered hatha and involved breathing, postures, and meditation. The particular class was specifically created as a “trauma-informed” yoga program (citation for this was provided in the article) by consultation with certified yoga instructors who had graduate degrees in psychology. What was considered the control group utilized interactive women’s health education classes designed to help attendees use medical services and terminology, discuss health issues with health professionals, improve the ability to discuss “uncomfortable” issues, and improve self-care. Assessments were done at time zero, 5 weeks, and 10 weeks, and included the Clinician Administered PTSD Scale (CAPS), the self-reported Inventory of Altered Self-Capacities (IASC), and the Davidson Trauma Scale (DTS). The IASC was reported out in two sub-categories, the affect dysregulation scale and the tension reduction sub-scale.
An impressive total of 60 people completed the 10-week study; there were no statistically significant differences between the people who dropped out of the yoga arm (n = 1) and the control arm (n = 3). Of the results presented, the change in the CAPS test pre- and post-treatment in the two groups was the most interesting and clinically significant; at the end of the trial 16/31 participants in the yoga group no longer met the criteria for having PTSD, whereas only 6/29 in the control group had a resolution of their PTSD symptoms (P = 0.013). In addition, the measurements over time showed that both groups had improvements in the CAPS, though it was more pronounced in the yoga group (see Table 1).
Table: Change in Assessments over Time for Yoga vs Control Group |
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|
CAPS pre- |
CAPS post- |
IASC TR pre- |
IASC TR post- |
IASC AD pre- |
IASC AD post- |
|
Yoga |
73.94 |
49.48*** |
73.66 |
67.17* |
76.69 |
68.88** |
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Control |
76.66 |
63.49** |
67.97 |
68.51 |
75.50 |
69.48* |
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* = P < 0.05; ** = P < 0.01; *** = P < 0.001 for trend CAPS: Clinician Administered PTSD Scale; IASC: self-reported Inventory of Altered Self-Capacities; DTS: Davidson Trauma Scale; AD: affect dysregulation scale; TR: tension reduction sub-scale |
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The results for the DTS were depicted in a figure showing improvements in both groups from time = 0 to 5 weeks, but only with the yoga group maintaining benefits; the control group regressed in its symptomatology by the DTS from weeks 5 to 10.
Commentary
For the specific demographic studied, these results show impressive effects and the use of women’s health education control group provided a contrast to help explain the results. For instance, the researchers portend that the supportive nature of the control group conveyed a psychological benefit that led to some of the observed improvements, but it was the added “physical and interoceptive aspects” of the yoga practice that maintained decreased PTSD symptomatology, even as regression occurred in the control group. This is truly an endorsement of the mind-body approach that can be an important component of healing for people of all health conditions, but arguably especially so for those difficult-to-treat diagnoses. In this case, one can’t ignore the fact that a significant proportion of the study participants in the yoga group failed to meet the PTSD definition at the 10-week mark. These women were deemed chronic and treatment resistant — an extraordinary finding.
With any new treatment approach, it is important to put the intervention into context of known, accepted, standard-of-care treatments. In this case, the authors point out that the effect sizes seen compare with pharmaceutical and psychological interventions well-studied in the medical literature. Many of us in clinical practice can attest to the difficulties of treating PTSD, as well as to the treatments’ cost or adverse safety profile, so the yoga intervention studied here is a welcome addition to our armamentarium. Missing, though, is to know whether the effects persist; that is, will a 10-week yoga class convey benefits 6 months, 12 months, 5 years down the road? And, is it necessary to continue a daily or weekly yoga practice to continue the positive effects? Clearly, topics for future research studies.
How relevant is this demographic to our own clinical practices? It is a select group, women with chronic, treatment-resistant PTSD. And excluded were any women who had attended five or more yoga classes (ever) or had alcohol or other drug abuse issues in the last 6 months. Yoga is becoming more and more available, so it might be difficult to find people who haven’t attended less than a handful of classes, casting into question the generalizability of these results. Similarly with the lack of recent alcohol or other drug abuse, given the common co-existence of alcohol or other drug abuse with PTSD. The 60/64 completion rate, too, speaks to a very motivated population; if not the norm, it might be difficult to replicate these results in real life.
Overall, these results are promising, and there appears to be no reason, other than cost perhaps, not to implement yoga classes as adjunctive therapy for patients with PTSD. Yoga is a unique, mind-body approach that addresses many aspects of the symptomatology of a complex condition.
A 10-week “trauma-informed” yoga practice, more than health education classes, aided women with chronic, treatment-resistant PTSD.
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