There are many and varied types of trauma. The extent to which trauma influences the mental health of an individual depends on the nature of trauma, as well as on the individual's coping capabilities. Often trauma is followed by depression, anxiety, and PTSD. As the pharmacological remedies for these conditions often have undesirable side-effects, nonpharmacological remedies are thought of as a possible add-on treatment. Yoga is one such mind-body intervention. This paper covers eleven studies indexed in PubMed, in which mental health disorders resulting from trauma were managed through yoga including meditation. The aim was to evaluate the use of yoga in managing trauma-related depression, anxiety, PTSD and physiological stress following exposure to natural calamities, war, interpersonal violence, and incarceration in a correctional facility. An attempt has also been made to explore possible mechanisms underlying benefits seen. As most of these studies were not done on persons exposed to trauma that had practiced yoga, this is a definite area for further research.
The definitions of trauma are many and varied. One description states that an event is traumatic if it is extremely upsetting and at least temporarily overwhelms the individual's inner resources [
The types of trauma include (i) natural disasters, (ii) mass interpersonal violence, (iii) large-scale transportation accidents, (iv) house or other domestic fires, (v) motor vehicle accidents, (vi) rape and sexual assault, (vii) stranger physical assault, (viii) partner battery and emotional abuse, (ix) torture, (x) war, (xi) child abuse, (xii) exposure of emergency workers to trauma, and (xiii) major accident or illness. In listing traumas separately there may be an erroneous impression that such traumas are independent of one another. This is applicable to noninterpersonal traumas such as natural disasters or house fires. However, it is also recognized that victims of interpersonal traumas are at greater risk of additional interpersonal traumas. For example those who have experienced child abuse are more likely to be victimized as adults [
People respond to trauma in different ways. When exposed to the same trauma, some people develop posttraumatic stress disorder, whereas others are less affected or respond with symptoms such as depression or generalized anxiety [
It is well recognized that severe psychological trauma causes impairment of the neuroendocrine systems in the body, with sympathetic activation and suppression of the parasympathetic nervous system. There is also an increase in the level of circulating cortisol which has adverse effects on different systems. Severe trauma in early childhood especially has serious consequences. It can affect all aspects of development, including cognitive, social, emotional, physical, psychological, and moral development [
Van der Kolk et al. (1996) described the long-term effects of trauma, which were: generalized hyper-arousal and difficulty in modulating arousal, alterations in neurobiological processes involved in stimulus discrimination, conditioned fear responses to trauma related stimuli, loss of trust and hope, social avoidance, and lack of interest and participation in preparing for the future [
The pharmacological management of psychological disorders resulting from trauma is best supplemented with nonpharmacological healing techniques which would allow the person to regulate their internal states and response to external stress [
The Indian science of living, yoga, includes several practices such as physical postures (
It is often difficult for people who have been subjected to acute or prolonged trauma to regain a sense of normalcy and balance in their lives [
Yoga is a nonpharmalogical remedy which has been used to help in managing trauma related to (i) natural disasters, (ii) combat and terrorism, (iii) interpersonal violence, and (iv) being incarcerated in a correctional facility. Studies published in journals indexed in PubMed were reviewed. Those indexed in other bibliographic databases or which did not use yoga, including meditation as an intervention, were excluded.
In December 2004, a tsunami occurred in South East Asia [
A meditation technique called Inner Resources was used in a single study on 20 health workers (aged between 31 and 67 years) who were involved in relief work, 10 weeks after Hurricane Katrina [
Both the tsunami and the hurricane were unexpected natural disasters. In certain cases, natural disasters occur repeatedly. An example is the floods in the north eastern Indian state of Bihar caused by seasonal rain and a breach in a river [
In Kosovo, 139 high school students with ages ranged from 12 to 19 years took part in a single group study in which the 6 week program included meditation, biofeedback, drawings, autogenic training, guided imagery, genograms, movement, and breathing techniques [
A single group study was conducted on 122 preteen Israeli school children (ages between 8 and 12 years) affected by the second Lebanon war [
Children between 6 and 12 years of age
In north eastern Sri Lanka, 71 children who were affected by the civil war and the tsunami participated in a study [
Usefulness of mindfulness meditation was evaluated for 97, fourth grade (mean age of 9.7 years,
Youthful offenders are committed to legal custody and interventions are needed to help them cope with the stress and adjustment to the environment [
The studies cited above have been summarized in Table
Summary of the twelve studies reviewed
Sl. Number | Category of trauma | Sample: (1) Age, (2) Gender, (3) |
Study design | Assessment tools and their reliability/validity | Statistics | Effect sizes | Limitations |
---|---|---|---|---|---|---|---|
(1) | Natural disaster (tsunami) |
(1) 28–50 years |
Single group longitudinal design with before, after (7 day yoga program) | (i) Linear analog scales for fear, anxiety, disturbed sleep, and sadness (the reliability and validity has not been established), |
Paired |
Not reported | (i) Absence of a control group, (ii) use of scales whose reliability and validity had not been established, and (iii) short duration of the intervention. |
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(2) | Natural disaster (tsunami) (Location: South-east coast of India) [ |
(1) 18–65 years |
Allocation (non random) to 3 groups (a) yoga breath intervention, (b) yoga breath intervention followed by trauma reduction exposure technique, and (c) a wait list control. |
(i) The PTSD check list-17 (PCL-17). |
Three factor ANOVA, with |
Not reported | Allocation to the 3 groups was not random |
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(3) | Natural disaster (Hurricane Katrina) (Location: New Orleans, U.S.A.) [ |
(1) 31–67 years |
(i) Single group |
(i) PTSD checklist-Specific version (PCL-S) |
Intention-to-treat regression analysis and one sample |
PCL-S |
(i) Small sample size and (ii) absence of a control group |
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(4) | Natural disaster (floods) (Location: Bihar, India) [ |
(1) 15–85 years |
Cross sectional single group study evaluating risk for PTSD and depression in different age groups | Screening questionnaire for disaster mental health (SQD) with known reliability and validity | Two factor ANOVAs followed by |
Not reported | Confounding variables which could influence susceptibility other than age and gender were not reported |
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(5) | Natural disaster (floods) (Location: Bihar, India) [ |
(1) 20–40 years |
(i) Randomized controlled study |
(i) Linear analog scales to assess fear, anxiety, disturbed sleep and sadness, (ii) heart rate variability based on electrocardiogram, and (iii) breath rate. |
Paired |
Not reported | (i) Small sample size and |
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(6) | Exposure to combat and terrorism (Location: Kosovo) [ |
(1) 12 to 19 years |
(i) Single group. |
(i) PTSD reaction Index |
Paired |
Effect size for group 1 |
Absence of a control group |
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(7) | Exposure to combat and terrorism (Location: Kosovo) [ |
(1) 12–19 years |
(i) Randomized control study |
Harvard trauma questionnaire (valid and reliable) | Repeated measures ANOVA | Not obtained possibly reported | NIL |
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(8) | Exposure to combat and terrorism (Location: Israel) [ |
(1) 8–12 years |
(i) Single group |
(i) WHO well being index |
(i) Wilcoxon paired signed ranked test |
Not reported | Absence of a control group |
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(9) | Exposure to combat and terrorism (Location: Bali) [ |
(1) 6–12 years |
(i) Single blind, randomized control design. |
Not obtained | Not obtained | Not obtained | Numbers in the 2 groups were unequal (i.e., 48 in the SHAT group compared to 178 in the control) this is not usual in a randomized control design |
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(10) | Exposure to combat and terrorism as well as tsunami (Location: Sri Lanka) [ |
(1) 8–14 years |
Randomized to 2 interventions, before, after (1, 6 months) | (i) (UCLA PTSD index for DSM-IV. |
Repeated measures ANOVA and chi-square tests | Effect Sizes (i) KIDNET 1.76 (one month post test), 1.96 (6 months post test) (ii) MED-RELAX 1.83 (one month post test), 2.20 (6 month post test) | (i) Absence of a no intervention control group. |
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(11) | Interpersonal violence (Location: Baltimore City, U.S.A.) [ |
(1) 9–11 years |
Randomized control before, after (12 weeks) assessments | (i) Response to stress questionnaire. (ii) The short mood and feelings questionnaire: Child version for depressive symptoms. |
(i) ANOVA for continuous variables. |
Effect sizes were calculated for Emotional profile positive affect |
Recruitment may have involved highly motivated students with enthusiastic parents (the self-report measures may have been influenced by bias |
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(12) | Youth in a correctional facility (Location: Bangalore, India) [ |
(1) 12–16 years |
Matched pair allocation to intervention and control groups (pairs were matched for age and duration of stay in the community home), before, after (6 months) assessments | (i) Heart rate from the electrocardiogram. |
Wilcoxon paired—sample tests | Not reported | (i) The small sample |
Given the possibility of using yoga to positively modify the mental state following trauma, it is interesting to speculate about the mechanisms underlying the benefits seen. The amygdala is one of the main sites where alterations in the regulation of the serotonin transporter (5-HTT) may alter the stress response [
Whole blood serotonin levels and mood state changes were assessed before and after focused attention on Tanden breathing, which is a part of Zen meditation, in 15 healthy right-handed participants [
Apart from changes in serotonin levels, animal models of depression often use traumatic experiences of pain, isolation, or social defeat to cause changes in mesolimbic and mesocortical dopamine systems, which alter cortical control of midbrain defenses [
Stress reduction, positive affect, and levels of plasma catecholamines were assessed in 67 regular (range 3–144 months) meditators (aged 18–36 years) and 57 non-meditators (aged 19–37 years). The meditation practice was called “Brain Wave Vibration Mind Body Training” which is considered to change negative thoughts into positive ones [
While changes in serotonin and dopamine levels following meditation may explain at least in part the positive affect and reduction in stress following meditation the explanation for the anxiety lowering effect of the yoga practices may be related to another neurotransmitter, namely, Gamma Aminobutyric Acid (GABA). Two studies demonstrated that GABA-ergic activity increased after yoga practice. In the earlier study, 8 experienced yoga practitioners were compared with 11 non practitioners [
These studies suggest that certain changes in neurotransmitters following yoga practice may be responsible for the improved psychological state in trauma victims who practiced yoga. However, neurotransmitters have not been measured in any of the studies on trauma victims who improved with yoga. Hence, this is a speculation.
For this review, we examined in detail eleven studies (indexed in PubMed) on people exposed to trauma who received yoga including meditation as an intervention. There was also a single group cross-sectional study conducted prior to one of the intervention studies. Hence, 12 studies were reviewed. Among them, there were 7 randomized controlled trials (RCTs), 4 single group studies, and the one cross-sectional single group survey referred to above. Even where RCTs were conducted studies were limited by factors such as small sample sizes and in a few cases use of assessment tools whose reliability and validity were not established. Hence, though yoga and other mind body interventions appear to be useful in reducing mental health disorders following trauma there is as yet no systematic randomized control trial which meets all the requirements to state that these interventions conclusively are useful in trauma management.
The last part of the article attempts to consider possible mechanisms underlying the improvement with yoga. However, since none of these studies were conducted in trauma survivors, they remain speculative, and a possible direction for future study.