Breath, Body, Mind Techniques for
Stress, Depression, Anxiety, Post
Traumatic Stress Disorder,
and Disaster Relief
Richard P. Brown, MD
Associate Professor in Clinical Psychiatry
Columbia University College of Physicians and Surgeons
Patricia L. Gerbarg, MD
Assistant Professor in Clinical Psychiatry
New York Medical College
Presenter Disclosures
Richard P. Brown, MD
Patricia L. Gerbarg, MD
The following personal financial relationships
with commercial interests relevant to this
presentation existed during the past 12
months: No relationships to disclose.
Evolving Roles for Mind-Body Practices
in Public Health
 stress, anxiety, insomnia, depression
Prevent/relieve effects of mass disasters
 Military service related stress and PTSD
Stress-related medical illness: eg. cardiovascular,
Inflammatory Bowel Disease
• Children: stress, trauma, ADHD, emotion
regulation
•  Health care provider and care giver stress
•  Cost of health care and  accessibility of care
•
•
•
•
Gray’s Motivational Theory
Approach Reward
Fight/Flight
Behavioral Activation
System (BAS)
Dopamine
Freeze
Avoidance
Behavioral Inhibition
System (BIS)
Serotonin
Norepinephrine
Sympathetic Nervous System
(Stress Response: Burns Energy)
(Beauchaine, T. 2001. Vagal tone, development, and Gray's motivational
theory: toward an integrated model of autonomic nervous system
functioning in psychopathology Dev Psychopathol 13:183-214.)
Autonomic Nervous System
Sympathetic System Parasympathetic System
Approach (BAS)
Avoidance (BIS)
Emotional Regulation
(Vagal Nerves)
Behavior & Emotion
Breath and Emotion
• Bi-Directional
• Specific emotions induce breath patterns
• Voluntary changes in breath patterns
induce specific emotions
(Philippot P, Chapelle G & Blairy S. Respiratory feedback in the
generation of emotion. Cognition and Emotion, 2003,
16(5):605-627)
Vagus Nerves are Involved in:
• Social bonding
• Empathy & love
• Gut feelings & instincts
• Perception & observation
Carter, CS. 1998. Neuroendocrine perspectives on social
attachment and love. Psychoneuroendocrinology, 23 (8),
779–818; Porges, SW. 2001. The polyvagal theory:
phylogenetic substrates of a social nervous system.
International Journal of Psychophysiology, 42(2), 123-46.
Vagal Nerve
Pathways
Brown RP, Gerbarg PL.
2009. How to Use Herbs,
Nutrients, and Yoga in
Mental Health Care. NY;
WW Norton. P79.
Heart Rate Variability
at 5 breaths per minute
at 15 breaths per minute
at 7.5 breaths per minute
at 30 breaths per minute
Copyright 2007 S. Elliott. Used with Permission.
“The purpose of breathing
practices
is to induce the tenderness
of a new-born babe.”
Lao Tzu, Tao Te Ching
Clinical Studies: Breath-Centered Programs
1.
2.
3.
4.
5.
6.
7.
8.
Generalized Anxiety Disorder
Schizophrenia
Inflammatory Bowel Disease
Southeast Asia Tsunami Survivors
Australian Vietnam Veterans
9/11 World Trade Center Attacks
Mississippi Healthcare Providers
South Sudanese Survivors of War & Slavery
Effects of a Yoga-Breath Intervention Alone and in
Combination with an Exposure Therapy for PTSD and
Depression in Survivors of the 2004 Southeast Asia
Tsunami. Acta Psychiatr Scand 2010. 121(4):289-300.
Teresa Descilo, Patricia Gerbarg, A Vedamurtachar,
D Nagaraja, BN Gangadhar, R Damodaran, B Adelson,
L Braslow, S Marcus, Richard P Brown
Severely Traumatized Population
• Refugees from the most severely damaged
coastal villages in India
• Living in 5 refugee camps 9 months after
the tsunami
• In the state of Tamil Nadu, 75% of the
deaths occurred in this small district:
Nagapattinam
Study Design
183 subjects: 3 equal groups, assigned by camps
1. Breath Water Sound (BWS) + 10-minute
Sudarshan Kriya: 2 hours/day, 4 consecutive
days = total 8 hours
2. B+T: BWS followed 3 days later by TIR
(Traumatic Incident Reduction, client-driven
exposure therapy) 3-5 sessions
3. CON: 6-week wait-list Control Group
Collaboration: National Institute of Mental Health and
Neurosciences of India, The Trauma Center of Dade County
Florida, The International Association of Human Values
Mean Scores PTSD Checklist PCL-17
P < .001
Mean BDI Scores
P < .0001
Multi-component Yoga Breath Program for Vietnam
Veteran PTSD: Randomized controlled trial.
J Carter, PL Gerbarg, RP Brown, et al.
• 25 Australian Vietnam Veterans with chronic,
treatment resistant PTSD disabled
• Clinician Administered PTSD Scale (CAPS)
• Mini-Plus, AUDIT, PCLM, CES-D
• baseline, pre, 6 week-post, 6-month post
J Traumatic Stress Disorders & Treatment. 2013.2(3):1-10.
Outcomes Over 6 Months: CAPS
Minimizing Rapid or Forceful Breathing
Reduces the Following Risks
•
•
•
•
•
•
•
•
Panic Disorder - panic attacks
Generalized Anxiety Disorder - anxiety
Post Traumatic Stress Disorder – flashbacks
Seizure disorder - seizure
Acute asthma or dyspnea - exacerbation
Uncontrolled hypertension -  BP
Bipolar disorder – manic episodes
Pregnancy
Breath-Body-Mind includes the following
breathing practices
• Coherent Breathing
– Rate: 3.5 to 6 breaths per minute
– Equal inhalation and exhalation
– Like natural breathing: quiet and gentle
• Breath Moving: imaginative
• Resistance Breathing on exhalation
• “Ha” Breath (briefly 2 to 5 minutes)
• 4-4-6-2 Counts Breathing
(RP Brown & PL Gerbarg (2012). The Healing Power of the Breath.
Book + CD. Boston: Shambhala Press.)
1st & 2nd Trials of Breath~Body~Miond
for relief of PTSD, Depression, and Anxiety Related to
September 11th NYC WTC Attacks.
RP Brown, PL Gerbarg, M Vermani, MA Katzman
1st Trial: Breath~Body~Mind Workshop
12 hour workshop taught over 2 days
1. Resistance + 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.
Increases alpha brain wave synchrony.
4. Group Processes
Presented at American Psychiatric Association Annual Meeting
May 2013, San Francisco, CA
©2012 RPBrown & PLGerbarg
1st Trial: 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
Questionnaire
Sheehan Disability Index
Social Life
15
3.18
.006
15
3.44
.004
Bonferroni t-tests significance 0.05/9 = .006 n = 17 subjects
©2012 RPBrown & PLGerbarg
2nd Trial: Breath~Body~Mind Workshop
12 hour workshop taught over 2 days
1.Coherence (5 bpm), Resistance Breath, Breath
Moving
2.QiGong: Gentle movements
1. counts 4–4–6–2
3. Open Focus meditation: trains flexibility of attention
(Les Fehmi)
– First focus on internal spaces of the body.
– Connect internal spaces with space in environment.
Increases alpha brain wave synchrony.
4. Group Processes
(Presented American Psychiatric Association Annual
Meeting May 2013, San Francisco, CA)
©2012 RPBrown & PLGerbarg
September 11th Experience
Total N = 27 participants
First Responder
Firemen
Worked with or affected by 9/11
Emergency Health Care Provider
Worker at Ground Zero (post attack)
Resident Living near World Trade Center
Witnessed Attack
Family member of a first responder
Escaped from World Trade Center
N
6
4
4
2
6
10
8
1
2
Number of Participants Meeting
Criteria for a Clinical Disorder
Clinical Disorder
N
Major Depressive Disorder
12
Generalized Anxiety Disorder
14
Post Traumatic Stress Disorder
23
Panic Disorder
16
Agoraphobia
9
Note: Total N = 27 participants
2nd Trial: 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
Questionnaire
Treatment Outcome PTSD
Scale
19
1.95
.066 (ns)
18
1.63
.120 (ns)
Bonferroni t-tests significance  0.05/5 = .01
Adapting Mind/Body Practices for Mass Disasters
•
•
•
•
•
•
•
•
Few teachers serve large groups
Simple techniques, easy to learn and teach
Rapid relief
Safe for all, regardless of age, trauma, illness
Understood and accepted by diverse cultures
No equipment, electricity, buildings, or supplies
Lower cost
Sustainability: train community leaders to teach
(RP Brown & PL Gerbarg (2012). The Healing Power of the
Breath. Book + CD. Boston: Shambhala Press.)
Breath~Body~Mind Training for Stress
Relief after Gulf Oil Spill
(Mississippi State DMH Grant)
Assisted by Mississippi Cares
& Serving Those Who Serve
Chris Streeter
Boston University Medical Center
Patricia Gerbarg
New York Medical College
Richard P Brown
Columbia University College of Physicians & Surgeons
Breath~Body~Mind Training-the-Trainer
for Stress Relief Post Disaster
• 153 service providers: 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
• Exercise Induced Feeling Inventory (EIFI)
• Perceived Stress Scale (PSS)
(Poster presented at SYTAR (Symposium of yoga Therapy
and Research), Stockbridge, MA. Sept. 23-25, 2011.
Mean Scores Perceived Stress Scale
compared to norms for women and men
Pre- and 6 Weeks Post- Training
Normed Female
20
18
Normed Male
16
Trainees
14
12
10
8
6
4
2
0
Pre
6 weeks
(Gerbarg PL, Streeter CC, Whitfield T, Brown RP. Poster
presented at SYTAR, Stockbridge, MA. Sept. 23-25, 201).
Exercise Induced Feeling Inventory (EIFI)
• post tests at 6 weeks showed statistically
significant improvements in mean scores for:
• Revitalization: mean (p < 0.001)
• Tranquility: mean (p < 0.001)
• Physical Exhaustion: (p < 0.04)
• Positive Engagement showed trend toward
improvement but not of statistical significance
(Gerbarg PL, Streeter CC, Whitfield T, Brown RP. Poster
presented SYTAR, Stockbridge, MA.Sept.23-25, 2011)
2012 Haiti Earthquake
• Gretchen Wallace, founder/director Global
Grassroots, supports conscious social change,
for vulnerable women at the grassroots level.
• Brief (30 minutes) work with 50 women 1 week
after the Earthquake: relief of stress symptoms,
back pain, worry, insomnia
• 1 month later the women continued to practice
together and brought friends – 80 women
• The Academy for Conscious Change, a 12-18 month incubator offering social
venture development skills, leadership training, and grants for
disadvantaged women to initiate their own civil society organizations.
www.globalgrassroots.org
War and Slavery
in Sudan
It is estimated tens of
thousands of South
Sudanese captured
during the last two
decades of war remain
in slavery in North
Sudan.
$100,000 worth of
bovine vaccine
purchases freedom for
one of these slaves.
Independence Day Flag S.Sudan July, 2011 photo by G Weibach
Sudanese Survivors of War and Slavery
Program Evaluation
• 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.
• 19 South Sudanese women
(Drs. Luka Deng, PL Gerbarg & RP Brown, 2011; Gerbarg, Wallace,
Brown. 2011. Mind-body solutions for mass disasters: challenges
and field experience. Int. J. Yoga Therapy. No. 21: 23-34.)
Program Evaluation Data from Sudan: Response of
Refugees to Breath-Body-Mind Practices
Change Mean Score/
% Change Mean Score
Mean Test Scores
Baseline 6 wks 18 wks 0-6 wks
VAS 49.3
PTSD
VAS 20.8
Mood
17.2
14.5
10.8
7.1
 32.1
 65%
 10.0
 48%
0-18 wks
 34.8
 71%
 13.7
 66%
VAS: Visual Analogue Scale n = 19 women
(Gerbarg, Wallace, Brown. Int J Yoga Therapy. 2011. 21:23-34)
600 Liberated Slaves
• Walked for 1 week and crossed the border
into S. Sudan July 4, 2011
• Dr. Luka Deng and clinic staff evaluated
• Relief workers provide grain and utensils
• Dr. Richard Brown taught Breathing Practices
for 30 minutes
• Village chiefs identified and helped return
their people to villages of origin
2011 RPBrown & PLGerbarg
Traumatic Experiences
• Disturbances in neural networks
• Leave impressions on the mind: trauma
memories (subsymbolically encoded), physical
sensations, emotion dysregulation
• Difficult to access with verbal therapies
• Disruption of bonding, disconnectedness, loss of
meaning, emotional numbing
(RP Brown, PL Gerbarg. 2012. The Healing Power
of the Breath. Book + CD. Boston:Shambhala Press)
2012 RPBrown & PLGerbarg
Interoception provides substrate for
emotional awareness
• Interoception: the perception of ‘feelings’ (eg.
gut, viscera, genital, vasomotor, muscular, air
hunger, pain, temperature, sensual touch)
reflecting internal state of the body
• Primary representation in dorsal posterior insula
 meta-representation anterior insula  map
& regulate internal states
(Craig AD. Interoception: The sense of the physiological condition of the
body. Curr Opin Neurobiol, 2003.13(4):500–505; Critchley HD. J Comp
Neurol. 2005; Damasio RR. The Feeling of What Happens: Body and
Emotion in the Making of Consciousness. NY: Harcourt Brace 1999)
Interoceptive afferent
pathways project to
dorsal posterior insula
(interoceptive cortex) (R –
SNS; L – PNS) and medial
frontal region (anterior
cingulate cortex, ACC).
(Used with permission. A.D. Bud
Craig. Interoception & Emotion,
Ch 16 Handbook of Emotions 3rd
Ed, Ed. M Lewis, JM HavilandJones, LF Barrett, NY: Guilford
press 2008, pg 275)
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. NY: Guilford Press. 2008)
2012 RPBrown & PLGerbarg
Polyvagal Theory
• Physiological state characterized by ↑ vagal influence
on HRV supports social engagement & bonding
• Any stimulus that ↑s feeling of safety can recruit
neural circuits that support social engagement system
and inhibit defensive limbic structures
• Interoception enables social behavior by
distinguishing safe from dangerous
(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 & PLGerbarg
Vagal-GABA Theory of Inhibition
• Gamma-aminobutyric acid (GABA) is the brain’s
main inhibitory neurotransmitter.
• Evidence suggests that vagal nerve stimulation
can increase GABAergic activity
•  GABAergic activity from insular cortex and
prefrontal cortex could inhibit overactivity in
amygdala as seen in PTSD
(Streeter C, Gerbarg PG, RB Sape, DA Ciraulo, Brown RP. Effects of
yoga on the autonomic nervous system, gamma-aminobutyricacid, and allostasis in epilepsy, depression, and post-traumatic
stress disorder Medical Hypotheses. 2012)
©2012 RPBrown & PLGerbarg
Hypothesis: Breathing Stimulates Vagal Activation of GABA Pathways from PFC
and Insula to Inhibit Amygdala Overactivity, as Occurs in PTSD.
Prefrontal Cortex
GABA-R = gamma aminobutyric acid receptors
Autonomic, GABA and other
neurotransmitter pathways
Hypothalamic-pituitary-adrenal axis
neuroendocrine pathways
(PFC) GABA-R
Thalamus
Insula
GABA-R
GABA-R
Pituitary
Hypothalamus
GABA-R
Amygdala
GABA-R
Vagal Afferents
Periaqueductal
Grey
GABA-R
Hippocampus
GABA-R
Parabrachial
Nucleus
GABA-R
Adrenal
Nucleus Tractus Solitarius
GABA-R
Nucleus Ambiguus
GABA-R
Dorsal Medial Nucleus
GABA-R
Brainstem Nuclei
Vagal Efferents
Pharynx, Larynx, Lungs
Cardiac
Gastrointestinal
(Streeter et al, Med
Hypotheses, 2012)
©2012 RPBrown & PLGerbarg
Hypothesis: Oxytocin/Vasopressin
• Electrical vagal nerve stimulation (VNS) is known
to increases oxytocin and prolactin release
• Respiratory interoceptive feedback via vagal
afferent stimulation could also induce:
→ hypothalamus PVN to  Oxytocin release
leading to
→  feelings of safety, bonding, love
PVN = paraventricular nucleus
(CS Carter. Psychoneurooendocrinology 1998,23:779-818; CS Carter.
Biological perspectives on social attachment and bonding: a new
synthesis. 2005 MIT Press)
Yoga and Oxytocin
• 1-month yoga program RCT in 43 stabilized
medicated patients with schizophrenia
• The yoga (with breathing practices) group had
significant (p= 0.01) elevations in endogenous
plasma oxytocin levels compared to wait-list
control group.
• The yoga group had significant improvement in
recognition of facial expressions of emotion vs
control.
(Jayaram N, Varambally S, Behere RV, et al. Effect of yoga
therapy on plasma oxytocin and facial emotion
recognition deficits in patients of schizophrenia.
Indian J Psychiatry 2013.55(Suppl 3):S409-13)
2nd Generation Holocaust Survivor
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 Breath-Body-Mind Level-1 workshop
and 2 months later, Level-2 B-B-M workshop.
After breathing, during quiet rest she had a
transformative experience of reunification:
©2012 RPBrown & PLGerbarg
Disconnection Sept 11, 2001
A former Air Force U-2 spy plane pilot was flying
for United Airlines. She was scheduled to be on
Flight #93 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.
©2012 RPBrown & PLGerbarg
Resources for Further Learning
www.HaveAHealthyMind.com
RP Brown & PL Gerbarg
Updates & Integrative Mental Health Free
Newsletter
www.Coherence.com Stephen Elliot
www.OpenFocus.com Les Fehmi, PhD
www.RobertPeng.com Qigong Master
Robert Peng
©2012 RPBrown & PLGerbarg
Recommended Reading - 1
1. Brown, RP, Muench F, Gerbarg, PL. Breathing
practices for treatment of psychiatric and stressrelated medical conditions. In Complementary and
Integrative Therapies for Psychiatric Disorders, Ed.
PR Muskin, PL Gerbarg, RP Brown. Psychiatric Clin
NA. March 2013, 36(1):121-140.
2. RP Brown & PL Gerbarg (2012). The Healing Power
of the Breath. Book + CD. Boston: Shambhala Press.
3. RP Brown & PL Gerbarg (2012). Non-Drug
Treatments for ADHD. NY: WW Norton.
Recommended Reading - 2
4. RP Brown, PL Gerbarg, PR Muskin (2009). How to Use
Herbs, Nutrients and Yoga in Mental Health Care. NY:
WW Norton.
5. Brown RP and Gerbarg PL. Yoga breathing, meditation,
and longevity. In Longevity, Regeneration, and Optimal
Health, Integrating Eastern and Western Perspectives,
Ed. C. Bushness, E. Olivo, and N Theise. Annals NY Acad
Sci. 2009, 1172:54-62.
6. Gerbarg PL: Yoga and Neuro-Psychoanalysis, in Bodies in
Treatment: The Unspoken Dimension. Ed. FS Anderson.
The Analytic Press, Inc. Hillsdale, NJ. 2008, pp.127-150.
Recommended Reading - 3
5. Brown RP and Gerbarg PL. Yoga breathing,
meditation, and longevity. In Longevity, Regeneration,
and Optimal Health, Integrating Eastern and Western
Perspectives, Ed. C. Bushness, E. Olivo, and N Theise.
Annals NY Acad Sci. 2009, 1172:54-62.
6. Descilo T, Vedamurtachar A, Gerbarg PL, Brown RP, et
al. Effects of a Yoga-Breath Intervention Alone and in
Combination with an Exposure Therapy for PTSD and
Depression in Survivors of the 2004 Southeast Asia
Tsunami. Acta Psychiatr Scand Aril 2010, 121(4):289300.
©2012 RPBrown & PLGerbarg
Recommended Reading - 4
7. Gerbarg PL, Wallace GS, Brown RP. Mass disasters and
mind-body solutions: Evidence and field insights.
Journal of the International Association of Yoga
Therapists. 2011. 2(21):23-34.
8. Streeter CC, Gerbarg PL, Saper MD, Ciraulo DA, and
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 May;78(5):571-9.
©2012 RPBrown & PLGerbarg
Recommended Reading - 5
9. Gerbarg, P & Brown, RP (2011). Mind-Body Practices
for Recovery from Sexual trauma. In T. Bryant-Davis
(Ed.) A Guide to Recovery and Empowerment,
Rowman & Littlefield, 199-216.
10. Descilo T, Vedamurtachar A, Gerbarg PL, Brown RP,
et al. Effects of a Yoga-Breath Intervention Alone
and in Combination with an Exposure Therapy for
PTSD and Depression in Survivors of the 2004
Southeast Asia Tsunami. Acta Psychiatr Scand Aril
2010, 121(4):289-300.
Recommended Reading - 6
11. Gerbarg P, Brown RP. Nutrients, Phytomedicines, and
Mind-body treatments for Substance Abuse. In N ElGuebaly, M Galanter, G Carr (eds.). Textbook of
Addiction Treatment: International Perspectives.
Springer Milan Heidelberg NY, London [in press].
12. Elliot, Stephen, Dee Edmonson. 2008. Coherent
Breathing, the Definitive Method, Theory and Practice.
Allen, Tx: Coherence Press.
Recommended Reading - 6
13. Fehmi, L. G. , & McKnight, J. T. (2001). Attention and
neurofeedback synchrony training: clinical results
and their significance. Journal of Neurotherapy,
5(1/2).
14. Fehmi, L. and Robbins, C. Dissolving Pain: Simple
Brain-Training Exercises for Overcoming Chronic
Pain. Trumpeter Press, Boston.
15. Fehmi, L. and Robbins, C. (2007). The Open Focus
Brain, Trumpeter Press.