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

Moving out of your mind and into your body: Yoga buffers the effects of childhood maltreatment on PTSD symptoms

Objective: Childhood maltreatment has been consistently linked to posttraumatic stress disorder (PTSD) symptoms among college students and yoga may buffer the effects. The current study examined the frequency of college student's yoga practice over the past year as a moderator of childhood maltreatment and PTSD symptoms in the past 30 days. Participants: A sample of 177 college students from a southern university. Methods: Participants competed an online survey in exchange for extra credit or entry into a gift card raffle. Results: Moderation analysis indicated that a more frequent yoga practice buffered the relationship between maltreatment and PTSD symptoms. Conclusion: Clinicians working with college students with a history of maltreatment are encouraged to make referrals to yoga classes. Universities are encouraged to adopt trauma-sensitive yoga programs.

A Systematic Review of Evidence-Based Treatments for Adolescent and Adult Sexual Assault Victims

BACKGROUND

Sexual assault (SA) is a serious crime that is a prevalent mental and public health problem.

AIMS

Addressing the needs of SA victims and providing appropriate treatment are essential to reduce potential adverse short- and long-term outcomes.

METHODS

Our team undertook an extensive systematic literature review (published between January 2006 and July 2021) to provide evidence-based mental health intervention recommendations for adolescent and adult victims of SA. Where SA-specific research was limited, the literature and clinical practice guidelines on treatments for trauma-induced post-traumatic stress disorder (PTSD) were reviewed to provide additional information to formulate recommendations.

RESULTS

Findings strongly support several primary psychotherapy treatments: cognitive behavioral therapy, cognitive processing therapy, eye movement desensitization and reprocessing, narrative exposure therapy, and prolonged exposure therapy. Complementary (aerobic exercise, art, drama, and music therapy) and pharmacological treatments were explored.

CONCLUSIONS

Mental health nurses who provide services for victims of SA can utilize this overview to guide recommendations for treatment of SA trauma and related PTSD symptoms to mitigate the short- and long-term negative impacts after a traumatic event. When victims of SA receive optimal mental health treatments, our communities benefit as victims heal and recover.

The Neurophysiology of Interoceptive Disruptions in Trauma-Exposed Populations

In the aftermath of psychological trauma, many individuals experience perturbations in interoception, a term that broadly references the ability to accurately detect body signals and integrate these signals with emotional states. These interoceptive disruptions can manifest in different ways, including blunting or amplification of sensitivity to internal physiological signals. In this chapter we review extant neurophysiological research on interoception in trauma-exposed populations, with a particular focus on the effects of chronic interpersonal trauma, such as childhood maltreatment and racial discrimination. We explore research that used different types of interoceptive assays, from self-report measures to electrophysiological and neuroimaging tools to characterize the disruptions in pain perception, interoceptive acuity, and physiological responses that may arise after a traumatic event. Finally, we discuss interventions that are designed to target interoceptive mechanisms, from exposure-based therapies to mindfulness-based practices, as well as future directions in trauma interoception research.

The role of interoception in reducing trauma-associated distress: a feasibility study

Background: Altered interoception plays an important role in chronic stress and posttraumatic stress disorder. The aim of this study was to evaluate the feasibility of a Trauma Sensitive Yoga (TSY) intervention for improving emotional distress and psychological discomfort in women living under circumstances of social and gender vulnerability. We assessed the effect of the treatment on the interoceptive mechanisms, and whether the psychological improvements were mediated by the changes in these mechanisms.Methods: The study involved a sample of 62 women who attended public community centres dedicated to supporting women victims of gender-based violence or who were socially and economically disadvantaged because of their gender. Participants underwent a six-week TSY programme. We evaluated dropout rate, adherence, and intervention satisfaction. We measured emotional distress, psychological discomfort, interoceptive mechanisms, and two nonequivalent dependent variables to enhance internal validity. We compared pre-post differences using paired samples t-test and a structural equation model (SEM) analysis was performed to compare the changes in the outcomes with the changes in the nonequivalent dependent variables. Mediation models were adjusted to evaluate the role of changes in interoception on outcome changes.Results: Fourteen (23%) women dropped out, mainly after the first intervention session. Intervention adherence (mean attendance 5.3 over 6 sessions) and acceptability were high (mean satisfaction 3.4 over 4). We observed post-intervention improvements in anxiety, depression, psychological discomfort, body responsiveness, and interoceptive awareness. The changes in the outcomes were larger than the changes in the nonequivalent dependent variables. Additionally, we found that the changes in body responsiveness partially mediated the change in anxiety and psychological discomfort but not in depression.Conclusions: TSY could be an interesting therapeutic approach for women experiencing chronic posttraumatic stress symptomatology. Our findings underscore the role of interoceptive mechanisms in traumatic stress and emphasize the importance of addressing these aspects.

The Multidimensional Assessment of Interoceptive Awareness, version 2 (MAIA-2): psychometric properties in a Dutch non-clinical sample

BACKGROUND

Interoceptive awareness is a multidimensional construct that refers to the sensation, interpretation, and integration of signals within the body. There is increasing evidence that problems with interoceptive awareness form an important component of mental health problems. The Multidimensional Assessment of Interoceptive Awareness 2 (MAIA-2) is presently the most used self-report questionnaire to measure interoceptive awareness. The aim of the present study is to psychometrically evaluate the Dutch version of the MAIA-2.

METHOD

The psychometric properties of the MAIA-2-NL were examined in a non-clinical sample of 1054 participants aged between 18 and 83. Internal consistency and test-retest reliability were investigated. Factor structure was examined by exploratory factor analysis (EFA), followed by confirmatory factor analysis (CFA).

RESULTS

Internal consistency was good, with McDonald's omega (ω) ranging from 0.67 to 0.89. Test-retest reliability was moderate to good, with intraclass correlation coefficients (ICC) ranging from 0.67 to 0.79. Factor analyses suggested a six-factor structure, combining the original subscales Noticing with Emotional awareness and Self-regulation with Body listening. However, a CFA based on the original eight factors showed a somewhat better fit than the CFA based on six factors.

CONCLUSION

The MAIA-2-NL is a reliable and valid instrument to measure interoceptive awareness in healthy Dutch adults. We recommend to maintain the original 37 items.

Mind-body practices, interoception and pain: a scoping review of behavioral and neural correlates

OBJECTIVE

Chronic pain is a significant source of suffering in the United States, and many individuals increasingly turn towards yoga for pain relief. However, little is known regarding how yoga improves pain. Herein we seek to examine the scope of the literature linking mind-body practices, pain and interoception; an emerging mechanism by which yoga may improve chronic pain.

METHODS

This scoping review followed the five-stage methodological framework proposed by Arksey and O'Malley to examine behavioral and neural correlates of interoception in mind-body practices and pain. A broad search of the Pubmed, CINAHL, SportDiscus, Scopus, PsychInfo, and SocIndex databases was conducted, utilizing three clusters of search terms: (1) interoceptive terms, (2) mind-body terms, and (3) pain terms.

RESULTS

A combined total of 690 articles were screened, and 24 findings included for analysis. Sixteen studies examined interoceptive outcomes in response to mind-body practices for chronic pain, and 8 studies examined interoceptive outcomes in response to evoked-pain tasks in experienced mind-body practitioners. Only three studies linked yoga, interoception and pain.

CONCLUSION

This review relied on the broader mind-body literature to inform our analyses as the literature examining yoga, pain and interoception remains limited. Interoceptive techniques including attending to and acceptance of bodily sensations, appear to be key therapeutic mechanisms in mind-body practices for chronic pain. Future yoga-based interventions would benefit examining interoceptive outcomes and integrating interoceptive strategies to facilitate the pain-modulating benefits of yoga.

A scoping review of integrated yoga and psychological approaches for the treatment of eating disorders

BACKGROUND

Eating disorders are serious mental health conditions that significantly impact the social and economic burden of mental ill health in Australia. Best practice treatment for eating disorders includes a multi-axial approach, including medical, psychiatric, and psychological approaches. More recently, complementary and alternative therapy approaches, such as yoga, are used to support eating disorder recovery.

METHODS

This scoping review identified and examined current research exploring the use of yoga alongside psychological approaches for the treatment and management of eating disorders across the lifespan.

RESULTS

Results highlighted the lack of available research, with only four studies identified. Three of these studies piloted programs and identified promising results with a reduction of eating disorder symptomatology. However, these results remain tentative due to methodological limitations and the overall lack of available evidence. In the future, researchers are encouraged to clearly articulate the theoretical concepts that underpin their yoga programs and focus on adequately powered and designed trials, such as RCTs, to accurately compare treatment effects between interventions combining yoga with psychological interventions and standard psychological treatment. Qualitative enquiry is also recommended to provide further insights regarding what makes interventions successful.

CONCLUSIONS

Current evidence suggests further guidance and pragmatic recommendations to guide researchers and clinicians alike are required, ultimately improving outcomes for people experiencing an eating disorder across the lifespan.

Mediators of improved PTSD symptoms in veterans and civilians following a yoga program

OBJECTIVE

Although yoga shows some promise as an intervention for post-traumatic stress disorder (PTSD), little is known about how yoga reduces PTSD symptoms. The current study hypothesised that aspects of interoceptive awareness would mediate the effect of a yoga intervention on PTSD symptoms.

METHODS

We used data from our recently completed randomised controlled trial of a 16-week holistic yoga programme for veterans and civilians diagnosed with PTSD (n = 141) that offered weekly 90-minute sessions. We conducted a mediation analysis using interoceptive awareness and other variables that were associated with PTSD symptom reduction at mid-treatment and treatment end.

RESULTS

Although measures of anxiety, interoceptive awareness, and spirituality were identified in individual mediator models, they were no longer found to be significant mediators when examined jointly in multiple mediator models. When examining the multiple mediator models, the strongest mediator of the yoga intervention on PTSD symptoms was mental well-being at mid-treatment and stigma at the treatment end. The total effect of yoga on CAPS and PCL at the treatment end mediated by stigma was 37.1% (-1.81/-4.88) and 33.6% (-1.91/-5.68), respectively.

CONCLUSION

Investigation of mental well-being and mental illness stigma as potential mediators is warranted in future studies of yoga as a treatment for PTSD as they may prove to be important foci for yoga interventions.

Embodiment-related risk factors for Posttraumatic Stress, Anxiety and Depression in female victims of intimate partner violence

A central notion in the field of embodiment is that body sensorimotor processes and body mental representations influence emotion, cognition and behavior. By affecting the body, intimate partner violence (IPV) can leave victims with a fragile self, and significant physical and mental health problems. In this study, we aim to examine embodiment-related variables and mental health of female victims of IPV, as well as the impact of embodiment on mental health. A total of 38 female victims of IPV (mean age 40.3 ± 10.9 years) were recruited from shelters and the community. The study assessed the levels of Posttraumatic Stress Disorder (PTSD), Anxiety and Depression, and abilities of Movement Imagery, Interoceptive Accuracy, Interoceptive Sensibility, Body Ownership and Bodily Dissociation. Univariate, bivariate and binary regression analysis were used. PTSD, Anxiety and Depression were highly prevalent among our sample, alongside with altered values of body ownership and interoception. All three mental health disorders were significantly correlated with interoceptive self-regulation, interoceptive trusting, and bodily dissociation. For this group of women, each unit rise in the bodily dissociation scale increased two and six times the risk for developing Depression and Anxiety, respectively. The embodiment of female victims of IPV is altered, and higher bodily dissociation can be a risk factor for the development of mental health problems. Restoration of embodiment-related functions could be important for the victims to overcome the negative effects of violent relationships.

Integration of hatha yoga and evidence-based psychological treatments for common mental disorders: An evidence map

BACKGROUND

Interest in the use of yoga to enhance engagement with and augment the benefits of psychological treatment has grown. However, a systematic approach to reviewing existing research examining the use of yoga with psychological treatment is lacking.

MATERIALS AND METHODS

This mapping review identified and synthesised research trialling yoga as an integrated or adjunct therapy with evidence-based psychological interventions for the treatment of anxiety, depression, PTSD, and eating disorders.

RESULTS

Overall, the review identified ten published and three unpublished studies, representing either single group or small quasi-experimental research designs.

DISCUSSION

Limited but promising findings were shown for yoga with CBT for anxiety and depression, and the integration of yoga within intensive treatment models for PTSD.

CONCLUSIONS

Future research is encouraged to focus on controlled trials that enable examination of the component effect of yoga when applied with evidence-based psychological treatment and acceptability and feasibility data to further knowledge regarding a role for yoga in clinical practice.

A Web-Based Cognitive Behavioral Therapy, Mindfulness Meditation, and Yoga Intervention for Posttraumatic Stress Disorder: Single-Arm Experimental Clinical Trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is a debilitating, undertreated condition. The web-based delivery of cognitive behavioral therapy supplemented with mindfulness meditation and yoga is a viable treatment that emphasizes self-directed daily practice.

OBJECTIVE

This study aims to examine the effectiveness of a web-based cognitive behavioral therapy, mindfulness, and yoga (CBT-MY) program designed for daily use.

METHODS

We conducted an 8-week, single-arm, experimental, registered clinical trial on adults reporting PTSD symptoms (n=22; aged 18-35 years). Each participant received web-based CBT-MY content and an hour of web-based counseling each week. Pre-post outcomes included self-reported PTSD symptom severity, depression, anxiety, chronic pain, and mindfulness. Pre-post psychophysiological outcomes included peak pupil dilation (PPD) and heart rate variability (HRV). HRV and PPD were also compared with cross-sectional data from a non-PTSD comparison group without a history of clinical mental health diagnoses and CBT-MY exposure (n=46).

RESULTS

Pre-post intention-to-treat analyses revealed substantial improvements in PTSD severity (d=1.60), depression (d=0.83), anxiety (d=0.99), and mindfulness (d=0.88). Linear multilevel mixed models demonstrated a significant pre-post reduction in PPD (B=-0.06; SE=0.01; P<.001; d=0.90) but no significant pre-post change in HRV (P=.87). Overall, participants spent an average of 11.53 (SD 22.76) min/day on self-directed mindfulness practice.

CONCLUSIONS

Web-based CBT-MY was associated with clinically significant symptom reductions and significant PPD changes, suggesting healthier autonomic functioning. Future randomized controlled trials are needed to further examine the gains apparent in this single-arm study.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03684473; https://clinicaltrials.gov/ct2/show/NCT03684473.

How does yoga reduce stress? A clinical trial testing psychological mechanisms

Yoga interventions can reduce stress, but the mechanisms underlying that stress reduction remain largely unidentified. Understanding how yoga works is essential to optimizing interventions. The present study tested five potential psychosocial mechanisms (increased mindfulness, interoceptive awareness, spiritual well-being, self-compassion and self-control) that have been proposed to explain yoga's impact on stress. Forty-two participants (62% female; 64% White) in a yoga program for stress reduction completed surveys at baseline (T1), mid-intervention (T2) and post-intervention (12 weeks; T3). We measured two aspects of stress, perceived stress and stress reactivity. Changes were assessed with paired t-tests; associations between changes in mechanisms were tested in residual change models. Only stress reactivity decreased, on average, from T1 to T3. Except for self-compassion, all psychosocial mechanisms increased from T1 to T3, with minimal changes from T2 to T3. Except for self-control, increases in each mechanism were strongly associated with decreases in both measures of stress between T1 and T2 and decreases in perceived stress from T1 to T3 (all p's < 0.05). Increased psychosocial resources are associated with stress reduction. Yoga interventions targeting these resources may show stronger stress reduction effects. Future research should test these linkages more rigorously using active comparison groups and larger samples.

Twelve-Week Yoga vs. Aerobic Cycling Initiation in Sedentary Healthy Subjects: A Behavioral and Multiparametric Interventional PET/MR Study

Interventional yoga studies with an active control group remain scarce and are important to clarify the underlying neurobiology. We conducted an interventional study in healthy controls using simultaneous positron emission tomography/magnetic resonance (PET/MR) imaging and psychometric scales. Thirty healthy, female volunteers (28.4 ± 8.4 years) participated and were randomly assigned to a 12-week yoga or indoor cycling intervention. Before and after the intervention, [¹⁸F]FDG and [¹¹C]UCB-J PET was performed on a simultaneous GE Signa PET/MR with volumetric imaging. Psychometric scales were evaluated on affect, mindfulness, stress, worrying, self-compassion, and interoceptive awareness. Yoga subjects scored higher on interoceptive awareness compared to baseline (p < 0.001). Cognitive (P = 0.009) and overall cognitive functioning (P = 0.01) improved after the yoga intervention compared to the cycling group. We did not observe significant differences in glucose metabolism, synaptic density, or gray matter (GM) volume. The indoor cycling group did not show changes in psychometric variables, but significant increases in relative glucose metabolism were observed in the parahippocampal/fusiform gyrus and cerebellum (P < 0.001). In conclusion, 12 weeks of yoga practice has significant effects on interoceptive awareness and perceived cognitive function in starters. Longer interventions and/or higher frequency of yoga practice may be needed to detect cerebral metabolic and/or morphologic effects on the macroscopic level.

A multi-method assessment of interoception among sexual trauma survivors

It is well established that many female sexual trauma survivors experience dissociation, particularly disconnection from the body, in the aftermath of sexual trauma. This study aims to address the open question of how sexual trauma is associated with awareness of inner body sensations (i.e., interoception). Given the important role that interoception has in emotion regulation, a process with which survivors often struggle, it is important to understand the associations between interoception and PTSD symptoms among survivors. Through multi-methods, we assessed associations between interoception, dissociation, and PTSD symptoms among 200 female sexual trauma survivors. We assessed two components of interoception: interoceptive accuracy (IAc: accurately perceiving internal body sensations; via heartbeat perception task) and interoceptive sensibility (IS: self-report perception of sensitivity to interoceptive sensations). We hypothesized that IAc and IS would be positively correlated with PTSD, with interactions between IAc/dissociation and IS/dissociation qualifying those main effects, weakening them for survivors with higher dissociation. Results showed an opposite pattern than was predicted: although IAc did explain significant PTSD variance, as IAc increased, PTSD decreased. Although IAc did explain significant variance in PTSD symptoms, interestingly, IS did not. Consistent with extant literature, dissociation predicted significant variance in PTSD. These correlational results suggest that the ability to more accurately perceive inner body sensations is related to lower PTSD symptoms. Findings provide a foundation for future research that can assess if interventions (such as yoga or exercise) that target increasing interoceptive accuracy lead to decreases in PTSD symptoms. We discuss further clinical implications, limitations and future directions.

Exploring how different types of yoga change psychological resources and emotional well-being across a single session

OBJECTIVES

Yoga demonstrates beneficial effects in many populations, yet our understanding of how yoga brings about these effects is quite limited. Among the proposed mechanisms of yoga are increasing psychological resources (mindfulness, body consciousness, self-transcendence, spiritual peace, and social connectedness) that may bring about salutary effects on emotional wellbeing. Further, yoga is a complex practice comprising meditation, active and restorative postures, and breathwork; however little is known about how different components may affect mechanisms. We aimed to determine how an acute session of yoga (and its specific components) related to pre- to post- session changes in proposed mechanisms (psychological resources) and whether those changes were associated with positive changes in emotions.

DESIGN

144 regular yoga practitioners completed measures of mindfulness, body consciousness, self-transcendence, social connectedness, spiritual peace, and exercise-induced emotions (positive engagement, revitalization, tranquility, exhaustion) immediately before and after a yoga session (N = 11 sessions, each a different type of yoga). Perceived properties of each yoga session, exercise exertion and engagement with the yoga teacher were assessed immediately following the session.

RESULTS

Pre-to post- yoga, levels of positive emotions (engagement, tranquility and revitalization) increased while exhaustion decreased. Further, all psychological resources increased and closely tracked improved emotions. Additionally, aspects of the yoga session correlated with changes in psychological resources (mechanisms) and emotions.

CONCLUSIONS

Yoga may influence multiple psychological mechanisms that influence emotional well-being. Further, different types of yoga may affect different mechanisms. Results can inform yoga interventions aiming to optimize effects through specific mechanisms such as mindfulness or spirituality.