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Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
Mastercourse Brown & Gerbarg cip2012
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Mastercourse Brown & Gerbarg cip2012

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Slides van de mastercourse van Brown & Gerbarg tijdens Congres Integrale Psychiatrie 2012

Slides van de mastercourse van Brown & Gerbarg tijdens Congres Integrale Psychiatrie 2012

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  • 1. Breath-Body-Mind Practices for Treatment of Stress, Anxiety Disorders, PTSD, and Mass Disasters Richard P. Brown MD Associate Professor of Clinical Psychiatry Columbia University Patricia L. Gerbarg, MD Assistant Professor of Clinical Psychiatry New York Medical Collegedonderdag 26 april 2012
  • 2. Professional Disclosure: Richard P. Brown, MD and Patricia L. Gerbarg, MD With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the parties listed above (and/or spouse) and any for-profit company in the past 24 months which could be considered a conflict of interest.donderdag 26 april 2012
  • 3. “You’ve been fooling around with alternative medicines, haven’t you?”donderdag 26 april 2012
  • 4. How Can We Function Better Under Stress? • Increase energy supplies • Maintain energy supplies • Learn how to stop wasting energy • Balance the stress-response system: shift from sympathetic (energy burning) to parasympathetic (energy recharging) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 5. Gray’s Motivational Theory Approach Reward - Fight/Flight/Freeze - Avoidance Behavioral Activation Behavioral Inhibition System (BAS) System (BIS) Dopamine Serotonin/Norepi Sympathetic Nervous System (Stress Response; Burns Energy) (Beauchaine, T. 2001) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 6. Autonomic Nervous System Sympathetic System Parasympathetic System Approach (BAS) Emotional Regulation Avoidance (BIS) (Vagal) Behavior & Emotion ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 7. Vagal Activity • 20% of vagus regulates heart, lungs, digestion, glands, immune function (efferent) • 80% of vagus nerve carries messages from the body up to the brain (afferent) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 8. Activation of the Parasympathetic System (PNS) • Vagus nerve, main pathway of PNS, is bidirectional • Breathing activates afferent pathways that stimulate vagus nerve • Voluntary change in pattern of breath can alter activity of vagus nerve, emotional tone, attention, and cognitive processes (Philippot P & Blairy S. 2003) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 9. Vagus Nerve Involved in: • Social bonding • Empathy & love • Gut feelings & instincts • Perception & observation (Stephen Porges 2001, 2009) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 10. donderdag 26 april 2012
  • 11. What is Heart Rate Variability • HRV is the rate at which the heartbeat changes. Healthy HRV correlates with health and well-being. • HRV diminishes with age, illness, stress, and lack of exercise. • Heart Rate Variability (HRV) can be used as an indicator of parasympathetic and sympathetic activity ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 12. Heart Rhythm Varies With Breathing Rhythm Heart rhythm at 5 breaths per minute Heart rhythm at 15 breaths per minute Heart rhythm at 7.5 breaths per minute Heart rhythm at 30 breaths per minute ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 13. HRV Biofeedback vs Relaxation for PTSD • Pilot study • 38 substance abuse patients with PTSD in residential facility randomized to Respiratory Sinus Arrythmia Biofeedback or Progressive Muscle relaxation 20 min/day • Both groups ↓ PTSD & insomnia ratings • HRV group improved more in depression, HRV indices (correlated with less PTSD) (Zucker TL et al. Appl Psychophysiol Biofeedback 2009) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 14. What is Coherent Breathing? • Breathing with comfortable depth at • 1 breath duration ~ 12 sec with (5 cpm) – 6 sec inhalation and 6 sec exhalation • Results in: – Optimal sympathovagal balance – Cardiopulmonary resonance – ↑ coherence of autonomic nervous system and heart electrical activity ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 15. Yoga Breathing Corrects • Sympathetic and Parasympathetic imbalance • How does it do this? (Brown & Gerbarg, Part I. J Alternative and Complementary Medicine 2005; Telles & Desijaru 1992) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 16. How to Increase Vagal Afferent Stimulation • Slow breathing 3 – 6 bpm • ↑ airway resistance – laryngeal contraction (Ujjayi, Victory, Ocean Breath) or by pursed lips • Duration of exhalation > inhalation (Cappo & Holmes 1984; Telles & Desijaru 1992; Calabrese 2000; Gozal 1995) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 17. Effects of Yoga-Breath Intervention Alone and with Exposure Therapy for PTSD and Depression in Survivors of the 2004 Southeast Asia Tsunami. Acta Psychiatr Scand 2010 Teresa Descilo, Patricia Gerbarg, A Vedamurtachar, D Nagaraja, BN Gangadhar, R Damodaran, Beth Adelson, Laura Braslow, Sue Marcus, Richard Browndonderdag 26 april 2012
  • 18. Severely Traumatized Population • Refugees from the most severely damaged coastal villages in Nagapattinam • Living in 5 refugee camps • Out of all deaths in the state of Tamil Nadu, 75% occurred in Nagapattinam district ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 19. Study Design • 183 subjects • 3 equal groups assigned by camps • BWS: BWS + 10-minute SK • B+T: BWS followed 3 days later by TIR (Traumatic Incident Reduction) • CON: 6-week wait-list control group ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 20. Mean Scores PTSD Checklist PCL-17 P < .001 ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 21. Mean Scores Beck Depression Inventory P < .0001 ©2012 RPBrown & PLGerbarg ©2010 RPBrown & PLGerbargdonderdag 26 april 2012
  • 22. Multi-component Yoga-Breath Based Program Reduces PTSD in Australian Vietnam War Veterans Janis Carter, MD University of Queensland Patricia L. Gerbarg, MD New York College of Medicine Richard P. Brown, MD Columbia University Robert Ware, PhD University of Queenslanddonderdag 26 april 2012
  • 23. Randomized, Wait-list Controlled Trial • 32 Australian Vietnam Veterans • Chronic, treatment resistant PTSD • Mean age 58 years • 25 completed study and testing • Totally disabled due to PTSD • Previous treatments: individual & group therapies, medication • On stable doses of 2 or more psychotropics; all on sertraline • Heavy alcohol use dailydonderdag 26 april 2012
  • 24. Results after 6 Weeks • Intervention Group Caps scores (adjusted for baseline CAPs) decreased 14.2 (95% CI: 4.6 to 23.7; P=.007) • Control Group: no decline • The Effect Size of the difference in CAPS scores is 0.91donderdag 26 april 2012
  • 25. Outcomes Over 6 Months: CAPS Week 6: Effect Size = 0.91 ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 26. Effect of Breath~Body~Mind Workshop on Symptoms of GAD with Comorbidities Martin Katzman, Monica Vermani, Patricia Gerbarg, Richard P. Brown START Clinic, Toronto, Canadadonderdag 26 april 2012
  • 27. Method • Open preliminary trial • 24 adults with diagnoses of GAD with comorbidities (PTSD, social phobia, OCD, depression) • Recruited at START Clinic,Toronto • Measures of anxiety and depression before and after intervention ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 28. Breath~Body~Mind Workshop Taught over 2 Consecutive days – Total 12 hours 1.Resistance Breathing + Coherence Breathing (5 bpm) + Breath Moving 2. QiGong: Gentle movements with Resistance Breath – QiGong breathing: counts & holds 4–4–6–2 3. Open Focus meditation: improves flexibility of attention (Les Fehmi) – First focus on internal spaces of the body. – Connect internal spaces with space in environment. 4. Group Processes ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 29. Pre-Workshop, Post-Workshop, 6-Month Follow-Up Mean + SD Mean + SD Mean + SD Scale PRE POST 6 Month ASI - Anxiety 33.80 +12.15 23.24 +11.70* 18.00 ± 18.83ᴺˢ Sensitivity Index BAI - Beck Anxiety 26.05 +14.38 7.75 + 7.47* 13.40 ± 16.06ᴺˢ Inventory BDI-II -Beck 24.37 +12.35 12.05 + 9.87* 15.05 ± 15.01ᴺˢ Depression Inventory II PSWQ - Penn State 64.45 + 9.25 42.75+23.34* 41.80 ± 32.78ᴺˢ Worry Questionnaire * = p < 0.01; ©2012 RPBrown & PLGerbarg Ns = non-significant changedonderdag 26 april 2012
  • 30. 2 Open Trials of Breath~Body~Mind for PTSD, Depression, and Anxiety Related to September 11, 2001 New York City World Trade Centre Attacks. Richard P. Brown, Patricia L. Gerbarg, Monica Vermani, Martin A. Katzmandonderdag 26 april 2012
  • 31. Breath~Body~Mind Workshop Taught over 2 Consecutive days – Total 12 hours 1. Resistance Breathing + Coherence Breathing (5 bpm) + Breath Moving 2. QiGong: Gentle movements with Breath – QiGong breathing: counts & holds 4–4–6–2 3. Open Focus meditation 4. Group Processes ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 32. 1st Open Study T-Test Results Pre vs Post Scores df t Significance Anxiety Sensitivity Index 16 5.33 .001 Beck Anxiety Inventory 13 4.02 .001 Beck Depression Inventory 16 7.38 .001 Penn State Worry 15 3.18 .006 Questionnaire Sheehan Disability Index 15 3.44 .004 Social Life Bonferroni t-tests significance0.05/9=.006 n=17 subjects ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 33. 2nd Open Study T-Test Results Pre vs. Post df t Significance Anxiety Sensitivity Index 21 3.93 .001 Beck Depression Inventory 20 4.01 .001 Beck Anxiety Inventory 21 3.09 .005 Penn State Worry 19 1.95 .066 (ns) Questionnaire Treatment Outcome PTSD 18 1.63 .120 (ns) Scale Bonferroni t-tests significance0.05/5=.01 n=27 ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 34. Contraindications • Pregnancy: Avoid rapid, forceful breathing or breath holds. Slow, Resistance or Coherence breathing are helpful • Acute asthma symptoms or dyspnea (Breath Moving Technique keeps airways open) • Seizure disorder • Recent surgery – Slow, gentle breathing only • Severe cardiac disease • Uncontrolled hypertension – no rapid or forceful breathing ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 35. Risks and Precautions • Bipolar I – rapid breathing can trigger mania. Yoga courses may be overstimulating • Rapid Yoga breathing can ↓Lithium levels • Bipolar II – if stable on medication, compliant, not prone to rapid cycling or mania may take yoga breath course. However, avoid rapid breathing. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 36. • Gretchen Wallace, founder of Global Grassroots, non-profit provides Academy for Conscious Change, 2-18 month program offering social venture development skills, leadership training, and grants for disadvantaged women to initiate their own civil society organizations. • www.globalgrassroots.org ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 37. Haiti - Gretchen Leads Coherent Breathing ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 38. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 39. South Sudan: Survivors of War and Slavery • Tens of thousands of South Sudanese were taken captive and kept in slavery in North Sudan • Christian Solidarity International purchases their freedom: 1 slave = $100,000 in bovine vaccine • At the border Dr. Luka Deng screens survivors, newly liberated after 5 to 20 years of slavery while tribal chiefs identify their lineage before returning them to their home villages. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 40. Teaching Breath~Body~Mind in Sudan • Ellen Ratner began teaching 3 Qigong movements and Coherent Breathing to some of the liberated slaves at the Pamela Lipkin MD Clinic in South Sudan, 30 miles east of the border with Darfur. • The results were so positive Ellen asked us to help her do a program evaluation ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 41. Evaluation of Short Breath Practice in 19 Sudanese Women • Short form of Breath~Body~Mind practices • 3 Qigong movements and 20 minutes of Coherent Breathing with the clinic staff 5 days a week for 18 weeks. • VAS Mood Scale and VAS PTSD Scale. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 42. Program Evaluation Data from Sudan: Response of Refugees to Breath~Body~Mind Mean Test Scores Change Mean Score/ % Change Mean Baselin 6 wks 18 wks 0-6 wks 0-18 Score e wks VAS 49.3 17.2 14.5 32.1 34.8 PTSD 65% 71% VAS 20.8 10.8 7.1 10.0 13.7 Mood 48% 66% VAS: Visual Analogue Scale ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 43. donderdag 26 april 2012
  • 44. Dr. Richard Brown Teaching Breath~Body~Mind in Sudandonderdag 26 april 2012
  • 45. donderdag 26 april 2012
  • 46. donderdag 26 april 2012
  • 47. donderdag 26 april 2012
  • 48. Breath~Body~Mind Training for Stress Relief after the Horizon Gulf Oil Spill (2010) (British Petroleum funded Mississippi State DMH Grant) Patricia L. Gerbarg New York Medical College Chris C. Streeter & T. Whitfield Boston University Medical Center Richard P. Brown Columbia University College of Physicians & Surgeonsdonderdag 26 april 2012
  • 49. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 50. Breath~Body~Mind Training for Stress Relief Post Disaster • Out of 151 health care service providers 80 enrolled in study – social workers (31%), counselors (15%), teachers (10%), psychologists (8%), case workers (5%) • Mississippi counties affected by Gulf Oil Spill • 3-day 18-hr Train-the-trainer April-June 2011 ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 51. Mean Scores Perceived Stress Scale compared to norms for women and men Pre- and 6 Weeks Post- Training ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 52. Exercise Induced Feeling Inventory (EIFI) Scores on all items significantly improved Positive Engagement (p<0.001) Revitalization (p<0.001) Tranquility (p<0.001) Physical Exhaustion (p<0.001) Among those who returned 6-week follow-up packets (n=30) significant improvements were sustained in all subscales except Engagement. At 6- weeks Engagement sores were higher than at baseline, but did ©2012 RPBrown & statistical significance. not reach PLGerbarg donderdag 26 april 2012
  • 53. Traumatic Experiences • Imbalance in stress response systems • Disturbances in neural networks • Trauma memories (subsymbolically encoded), physical sensations, feeling defective, emotion dysregulation, re-experiencing, numbing, • Disconnectedness: disruption of bonding, loss of meaning Gerbarg PL: Yoga and Neuro-Psychoanalysis, in Bodies in Treatment: The Unspoken Dimension. Ed. FS Anderson. The Analytic Press. 2008, pp.127-150. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 54. Bonding and Connectedness • The capacity to feel meaningful connection is an essential component of bonding. • One can feel connected to a person, a deity, a nation, an institution, or an idea. • Do bonding and connectedness share the same neural networks and neurohormones? • When bonding is enabled, will disconnectedness be resolved? ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 55. Case 1. Disconnection Sept 11, 2001 Cholene, former Air Force U-2 spy plane pilot, was flying for United Airlines. She was scheduled to be on Flight #93 on Sept 11, 2001, but her connecting flight was changed. Her close friend, pilot Leroy Homer, Jr. died when Flight #93 crashed leaving her with survivor guilt and feeling helpless, angry, and disconnected from everyone and everything she had believed in. Hoping to find a connection to life, she did 3 tours in Iraq as an embedded journalist and 2 years of post-Katrina relief work in Mississippi. She was left feeling drained, joyless and without meaning. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 56. Reconnection September 26, 2009 NYC 2-day breath workshop “The breathing and the rhythm of the bells were like the tide in the Arabian Gulf. The sound of the tide and the feel of the waves rolling over me were the only things that made me feel connected to life. The breathing was that and much more powerful because I was physically and mentally connecting to a larger energy source.” ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 57. “I found myself weeping when Dr. Brown said,‘think of those you love.’ I came away with a sense of being reunited with my life and loved ones. For the first time in years, I wanted to be connected to something besides a war or a disaster zone. After the breathing, during the meditation, I felt connected to the universe and to everyone in it.” (Through the Eye of the Storm by Cholene Espinoza. Chelsea Green Pub. 2006) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 58. Case 2. PTSD Childhood Sexual Abuse • Susan entered psychoanalysis with Dr. Gerbarg at the age of 27 • “I’m depressed and I don’t know why.” • She had been repeatedly molested from age 3 to 12 by a middle-aged male cousin. • c/o paralyzing fear of men and inability to date ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 59. Perception of Body Defect • She had a feeling that there was something defective about her buttocks (the focus of the molestation). • She worried that people could see what was wrong with her body. • Never wore skirts. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 60. Impenetrable Façade • On the outside well adjusted, excellent student and athlete. • Friendships were superficial. • Appeared poised, aloof while in constant fear that someone would discover her secret. • Susan never dated. Attention from eligible men caused her to freeze and panic. Kept men at a distance. • She lavished her love on animals. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 61. Yoga Breathing in 8th Year of Analysis • Through analysis → Let go of guilt, self-blame • Bought house with property for animals • Happy except she wanted intimate relationship, marriage, and children • Still paralyzed by fear. Age 35, had never dated. • If a man showed sexual interest, she froze. • Suggested yoga breath SKY course to ↓ anxiety ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 62. 2 Yoga Breath Courses (SKY) • After the first breath course she felt unusually calm and relaxed. • Practiced at home every day and attended group sessions twice a month for 8 months. • Took breath course again. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 63. Transformative Experience • While doing the SK breathing in group session, she had a transformative experience: “I felt a warm sensation in my uterus and genitals.” She reflected, “I knew it was good for me, a healing sensation. And then it felt like an opening-up and I thought that it was just what I needed, that what had happened to me as a child, the molestation, would no longer have such an affect on my life.” ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 64. Resolution of Sexual Trauma Symptoms • 3 weeks later started dating • After 2 months steady boyfriend, had 1st adult sexual experience • Completely normal. Pleasurable response. No anxiety or panic. • Long term relationship developed. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 65. Interoception provides substrate for emotional awareness • Interoception is the perception of “feelings” (eg. visceral, genital, vasomotor, muscular, air hunger, pain, temperature, sensual touch) reflecting physiological state of the body • Primary representation in dorsal posterior insula → meta-representation anterior insula → map & regulate internal states (Craig 2003; Critchley 2005; Damasio 1994, 1999) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 66. Interoceptive afferent pathways project to dorsal posterior insula (interoceptive cortex) (R – SNS; L – PNS) and medial frontal region (anterior cingulate cortex, ACC). (A.D.Bud Craig, Interoception & Emotion, Ch 16 Handbook of Emotions 3rd Ed, Ed. M Lewis, JM Haviland-Jones, LF Barrett, Builford press 2008, pg 275) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 67. Anatomical Model The subjective awareness of feelings from the body is generated directly from cortical rerepresentations of the interoceptive image of the body’s homeostatic condition. (AD (BUD) CRAIG Interoception and Emotion: A Neuroanatomical Perspective. Handbook of Emotions, 3rd Edition, ed M Lewis, J Haviland-Jones, LF Barrett. Guilford Press. 2008) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 68. Vagal GABA Theory of Inhibition • Gamma-aminobutyric acid (GABA) is the brains main inhibitory neurotransmitter. • (Streeter C, Gerbarg PG, Brown RP,. Medical Hypotheses. 2012) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 69. Activating GABA Inhibitory Projections to the Amygdala Vagal stimulation could reduce activity in regions thought to have increased activity in PTSD. Inhibitory GABAergic projections from insular cortex to the Central Extended Amygdala (CEA) could correct the over activation seen in PTSD. (Streeter C, Gerbarg PG, RB Sape, DA Ciraulo, Brown RP. Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder Medical Hypotheses. 2012) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 70. Insular Cortex • The insular cortex sends inhibitory GABAergic projections to the Central Extended Amygdala (CEA), where they modulate the over activation observed in subjects with PTSD. • The medial prefrontal cortex cortex sends inhibitory GABAergic projections to the amygdala, where they modulate the over activation observed in subjects with PTSD. • These inhibitory effects would reduce autonomic and somatic over reactions ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 71. INSULA: Receives interoceptive information; Integrates sensation and emotion; Subjective awareness of the condition of the body; Self- awarenessdonderdag 26 april 2012
  • 72. donderdag 26 april 2012
  • 73. Reducing Autonomic and Somatic Reactions Strong tonic inhibition decreases output from amygdala to brainstem (dorsal vagal complex, parabrachial complex, periaqueductal grey matter, pontine reticular formation, and ventrolateral medulla) thereby reducing autonomic and somatic expression of over reactions to fear-inducing and aversive stimuli. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 74. Hypothesis: Breathing stimulates Vagal activation of GABA pathways from PFC and Insula to inhibit amygdala overactivity. Prefrontal Cortex GABA-R = gamma aminobutyric acid receptors GABA-R Autonomic, GABA and other neurotransmitter pathways Hypothalamic-pituitary-adrenal axis neuroendocrine pathways Thalamus Insula GABA-R GABA-R Hypothalamu Pituitary s Amygdala Hippocampus GABA-R GABA-R Parabrachial Nucleus Periaqueductal Grey Adrenal Nucleus Tractus Nucleus Dorsal Medial Solitarius Ambiguus Brainstem Nucleus GABA-R Nuclei Vagal Efferents Afferents Pharynx, Larynx, Lungs Cardiac Gastrointestina Vagal (Streeter et al, Med Hypotheses, 2012)donderdag 26 april 2012
  • 75. Why are interoceptive messages from the respiratory system so powerful? Why do interoceptive messages from the respiratory system cause such rapid and widespread effects on the mind, emotions, subjective experiencing of the body, bonding, and connectedness? ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 76. Breathing – Most Vital Function • Messages about the state of respiration receive top priority because they are critical for survival. • Connections between brain and respiratory systems are evolutionarily old, powerful and rapid. • All central regulatory systems must coordinate to restore and preserve respiration. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 77. Polyvagal Theory • A state in which there is increased vagal influence on Heart Rate Variability support social engagement & bonding • Any stimulus that increases feeling of safety can recruit neural circuits that support social engagement system and inhibit defensive limbic structures (SW Porges. 2009. The polyvagal theory: New insights into adaptive reactions of the autonomic nervous system. Cleveland Clinic J Med 76(3):S86-S90) ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 78. Hypotheses: Yoga Breathing • enables interoceptive communication with emotion schemas • ↑ vagal PNS input to networks involved in: fear conditioning & extinction emotional memories & responses bonding & reward (OX, VP, dopamine?) • ↑ mPFC and Insular Cortex GABAergic inhibitory control over amygdala ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 79. Case 3. 2nd Generation Holocaust Leah’s father fled alone to Israel as a teenager during the British blockade. After the war, he rescued other Jews in Europe. His own family had died in the gas chambers. Leah’s mother had also lost family there. Leah did BBM and 2 months later, level-2 workshop with new Breath Cycling (3.5, 5, 10, 60 bpm cycles). After breathing, during quiet rest she had a vivid experience: ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 80. Connection and Reunification I experienced my breath going out towards the gas chambers. I see my father’s family, my grand- parents, his 2 brothers, his baby sister. They’re standing to my left. My breath goes out towards them and pulls them out of the gas chamber. To my right I see my father who is dead. As my breath pulls them out in that moment I hear them click together. They unite. I feel that happening in my body. I have this deep sense of something restored, something so long broken, alienated that I’ve been carrying inside me. ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 81. Being Restored “It’s 3-fold: them and him coming together and me, the 3rd piece of it. The feeling afterwards was a sense of peace, a feeling of something coming home, being restored, a sense of freedom, as if something finally came to its rightful place.” ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 82. Tools for Learning and Practicing www.haveahealthymind.com RP Brown & PL Gerbarg - Updates on Integrative Psychiatry, Workshops, free Newsletter The Healing Power of the Breath (Book + CD) by RP Brown, PL Gerbarg. Teaches breath practices. (Shambhala, June 2012) www.coherence.com Respire-1 CD for Coherent Breathing by Stephen Elliot ©2012 RPBrown & PLGerbargdonderdag 26 april 2012
  • 83. Integrative Psychiatry Resources • How to Use Herbs, Nutrients and Yoga in Mental Health Care RP Brown, PL Gerbarg, PR Muskin (Norton 2009) • Non-Drug Treatments for ADHD RP Brown & PL Gerbarg (Norton 2012) • www.ropertpeng.com DVDs and CDs of Qigong movements with Master Robert Peng • www.openfocus.com by Les Fehmi, PhD CDs for Open Focus Meditation ©2012 RPBrown & PLGerbargdonderdag 26 april 2012

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