Yoga for PTSD and the role of interoceptive awareness: A preliminary mixed-methods case series study

Abstract

Introduction

A growing body of literature suggests yoga is a promising adjunct or standalone treatment for Posttraumatic Stress Disorder (PTSD). The mechanism behind these improvements in physical and mental health outcomes is less understood. Interoceptive awareness, the ability to perceive internal bodily sensations, is proposed to be a crucial factor behind yoga, yet research investigating interoception in PTSD is limited.

Objective

This study extends current research by investigating the role of interoceptive awareness, and improved mental health outcomes, using a self-report measure of interoceptive awareness at baseline, during, and post a Trauma Sensitive Yoga intervention, in addition to qualitative interviews.

Method

The outcomes of an eight-week Trauma Sensitive Yoga intervention for people with PTSD (n = 3) were examined using a case series design.

Results

Overall, the results indicate participants experienced significant increases in interoceptive awareness and significant decreases in PTSD symptoms, depression, anxiety, and stress.

Conclusion

These preliminary findings suggests that increased interoceptive awareness may be a mechanism producing the beneficial outcomes of yoga for those affected by trauma. The implications of these findings for the effectiveness and development of PTSD treatment, as well as the use of yoga treatment, is discussed.

Introduction

Posttraumatic Stress Disorder (PTSD) can develop after exposure to a traumatic event/s and significantly impairs everyday functioning and quality of life (American Psychiatric Association, 2013). Evidence based therapies, such as Cognitive Behavioural Therapy and Eye Movement Desensitization and Reprocessing, have shown beneficial effects in reducing PTSD symptoms (e.g. Bradley et al., 2005, Foa et al., 1995, Van der Kolk et al., 2007), and are recommended in the Australian National Health and Medical Research Council guidelines as having the most robust body of evidence that can be trusted to guide practice (National Health and Medical Research Council, 2013). Prolonged Exposure Therapy has been extensively researched and can be viewed as the most efficacious treatment to date, linked to significantly greater reductions in PTSD symptoms from pre-post treatment compared to treatment as usual (Nacasch et al., 2011), supportive counselling (Schnurr et al., 2007), and waitlist control (Foa et al., 2005).

These existing therapies, however, have limitations including high dropout rates, worsening of symptoms, and residual symptoms post treatment. In response well-controlled trials of novel and developing interventions for PTSD or adjunctive treatments have been proposed to address some of these difficulties with treatment (National Health and Medical Research Council, 2013).

A growing body of research has investigated yoga interventions for the treatment of trauma populations with preliminary, yet promising results. Much of the research includes studies with small sample sizes, both randomised and non-randomised, as well as larger non-randomised studies. Following yoga interventions lasting 6 weeks and up to 6 months, reductions in PTSD symptoms have been shown for a number of populations, including war veterans (Carter et al., 2013, Johnston et al., 2015, Staples et al., 2013, McCarthy et al., 2017)., tsunami survivors (Descilo et al., 2010), and those with current full or subthreshold PTSD symptoms (Mitchell et al., 2014). However, a recent systematic review and meta-analysis (Cramer et al., 2018) reports low quality evidence and high dropout rates in yoga studies.

Using more rigorous methods, two studies used randomized controlled methods with larger sample sizes. Following an 8 session Kundalini yoga intervention, participants with PTSD experienced significantly greater improvements on measures of PTSD, sleep, positive and negative affect, anxiety, stress, and resilience, compared to a waitlist control (n = 80, 30% dropout; Jindani et al., 2015). Additionally, Van der Kolk et al (2014) investigated a 10-week Trauma Sensitive Yoga (TSY) intervention for 64 women experiencing chronic PTSD compared to supportive women’s health education. From pre to post treatment, the yoga group had significantly greater reductions in PTSD symptoms compared to the control.

To explore the mechanisms behind these yoga interventions qualitative studies have been conducted. Following the research by Van der Kolk et al (2014), two qualitative studies investigated participant’s experiences of the yoga in the randomised control trial (Rhodes, 2015, West et al., 2017). Via interviews, Rhodes (n = 39; 2015) found the women reported increased ownership, control, and connection to their bodies, emotions, and thoughts after the yoga. Key themes identified included greater interoceptive awareness, emotion regulation abilities, self-care capacities, connection with others, and sense of control and hope over their lives, compared to before the yoga intervention. Similarly, West, Liang, and Spinazzola (n = 31; West et al., 2017) identified main themes from interviews, including increased gratitude and compassion, relatedness, acceptance, centeredness, and empowerment compared from pre- to post-yoga.

Improvements in interoceptive capabilities have been proposed as crucial in the effectiveness of yoga in treating those with trauma (Caplan et al., 2013, Van der Kolk et al., 2014, Emerson, 2015). Interoceptive awareness can be understood in a number of ways, for the purpose of this paper interoceptive awareness refers to the ability to perceive internal physiological sensations of the body, including heart beat, hunger, and autonomic nervous system sensations related to emotions (Mehling et al., 2012), and is compromised subsequent to a traumatic event. Neuroimaging studies of trauma demonstrate decreased activation in the prefrontal cortex, and brain areas related to interoceptive awareness (Herringa et al., 2012, Van der Kolk, 1994). Following trauma, survivors commonly experience a sense of disconnection between their mind and body (Herman, 2015, Van der Kolk et al., 2014). Most trauma involves physical violation of the body, and individuals exposed to trauma can develop fear of their own emotions and bodily sensations. Those with PTSD can fluctuate between intrusive reliving of trauma symptoms in their bodies and minds, and avoidance of bodily sensations or thoughts (Herman, 2015). Engagement in yoga may increase interoceptive abilities such as increased awareness, recognition, and acceptance of internal sensations and emotional reactions, and in turn improve the ability to regulate affect and impulsive behaviours.

A randomised controlled trial of integrative exercise (IE) with yoga postures compared to a waitlist control for military veterans with PTSD investigate changes in interoceptive awareness (n = 47; Mehling et al., 2017). Following three IE classes per week for 12 weeks, those in the IE group showed an increases in (with large effect sizes) on two interoceptive awareness scales: body listening the ability to use emotion-related signals from the body for insight and decision making. And self-regulation, the capacity to regulate psychological distress via non-judgmental attention to body sensations. These changes in interocpetive awareness were hypothesised to be a mechanism behind reductions in PTSD symptoms and increases in quality of life associated with the intervention.

Although increased interoceptive awareness is proposed as a core mechanism of yoga in reducing trauma symptoms, current research on interoceptive awareness is limited. This research, therefore, aims to address the gap in the literature and further explore yoga’s impact on interoceptive awareness for people with trauma symptoms. A mixed-methods design was utilised with repeated measurement of interoceptive awareness (body awareness, attention regulation, and emotion regulation) during a TSY intervention for a trauma population. In addition, this study assessed changes in depression, anxiety, stress, PTSD symptoms, and participants subjective experience of the effects of TSY.

Three hypotheses were proposed regarding pre to post, and pre to follow-up, yoga intervention effects. First, it was hypothesised there would be a significant increase in interoceptive awareness on all three subscales. Second, it was hypothesised there would be a significant decrease in PTSD symptoms. Third, it was hypothesised there would be a significant decrease in anxiety, depression, and stress.