Mais conteúdo relacionado Semelhante a Mastercourse Brown & Gerbarg cip2012 (20) Mastercourse Brown & Gerbarg cip20121. 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 College
donderdag 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
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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 26 april 2012
6. Autonomic Nervous System
Sympathetic System Parasympathetic System
Approach (BAS) Emotional Regulation
Avoidance (BIS) (Vagal)
Behavior & Emotion
©2012 RPBrown & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 26 april 2012
9. Vagus Nerve Involved in:
• Social bonding
• Empathy & love
• Gut feelings & instincts
• Perception & observation
(Stephen Porges 2001, 2009)
©2012 RPBrown & PLGerbarg
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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 Brown
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 26 april 2012
20. Mean Scores PTSD Checklist PCL-17
P < .001
©2012 RPBrown & PLGerbarg
donderdag 26 april 2012
21. Mean Scores Beck Depression Inventory
P < .0001
©2012 RPBrown & PLGerbarg ©2010 RPBrown & PLGerbarg
donderdag 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 Queensland
donderdag 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 daily
donderdag 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 0.91
donderdag 26 april 2012
25. Outcomes Over 6 Months: CAPS
Week 6: Effect Size = 0.91
©2012 RPBrown & PLGerbarg
donderdag 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, Canada
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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
change
donderdag 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. Katzman
donderdag 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 & PLGerbarg
donderdag 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 significance0.05/9=.006 n=17 subjects
©2012 RPBrown & PLGerbarg
donderdag 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 significance0.05/5=.01 n=27
©2012 RPBrown & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 26 april 2012
37. Haiti - Gretchen Leads Coherent Breathing
©2012 RPBrown & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
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 & Surgeons
donderdag 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 & PLGerbarg
donderdag 26 april 2012
51. Mean Scores Perceived Stress Scale
compared to norms for women and men
Pre- and 6 Weeks Post- Training
©2012 RPBrown & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 26 april 2012
71. INSULA: Receives interoceptive information;
Integrates sensation and emotion; Subjective
awareness of the condition of the body; Self-
awareness
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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 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 & PLGerbarg
donderdag 26 april 2012