yoga therapy for syncope and anxiety

Clinical Application Case Study for Syncope Episode and Anxiety

Can yoga therapy be a cost-effective, low side effect treatment plan for those with anxiety disorders? Syncope Episode, also known as fainting, is a loss of consciousness by a fast onset, short duration, and spontaneous recovery with a cause usually from low blood pressure. Anxiety is a general term for several disorders that cause nervousness, fear, apprehension, and worrying. Anxiety disorders often cause feelings of panic, fear, and intrusive thoughts and may result in interrupted sleep, difficulty function at work, disturbances in relationships, and physical symptoms. Genetic, environmental, psychological, and developmental factors contribute to anxiety disorders. Stress and trauma play roles in the development and triggering of anxiety disorders and symptoms. Dysfunction in stress-response systems manifests anxiety disorders. These imbalances have widespread effects on emotion regulation, perception; cognitive function; social relationships, and the functioning of the cardiovascular, respiratory, gastrointestinal, neuroendocrine, immunological, and other systems. Yoga therapy practices such as pranayama can have rapid normalizing effects on the autonomic nervous system to improve sympathovagal balance and significantly reduced symptoms in stress-related anxiety. Yoga therapy can also increase the release of gamma-aminobutyric acid (GABA), the brain’s primary inhibitory neurotransmitter, can reduce symptoms of anxiety

Introduction

Approximately 40 million American adults have an anxiety disorder. Nearly three-quarters of this approximation will have had their first episode by the age of twenty-one. Those who have anxiety disorders will also frequently co-occur with depressive disorders. (P.nd., 2017) According to a report in the Journal of Health Affairs, the United States spent over $201 Billion on anxiety and depression in 2013. The economic burdens of anxiety are one-third of the mental health costs. Yet, anxiety often goes untreated and undetected. Could yoga therapy be a supplemental treatment? Yoga is an attractive option because of its recent popularity in the west; however, motivation and compliance may be issues to consider with clients experiencing anxiety disorders. (Kirkwood, 2005) Studies suggest that specific changes in neurotransmitters following yoga practice may be responsible for improved psychological states. (Telles, 2011)

Clinical Interview and Red Flags

The client is a 28-year-old single female. With a past medical history of anxiety, trauma, syncope episode with unknown etiology, panic attacks, and poor sleep with reoccurring nightmares. She is taking prescribed Zoloft and is considering a medical leave from her job as a school teacher. The client saw a primary care doctor and was referred to yoga therapy by her primary care doctor with a yoga therapy goal to help support her working with anxiety.

Annamaya Kosha: The yoga therapist (YT) has not done a full musculoskeletal assessment with this client yet. As trust is built in this relationship, it is the YT’s goal to do a complete musculoskeletal assessment. Specific areas of interest would be to look into possible pelvic floor disruption, flexibility, and strength imbalances. Mindfulness and self-regulation of attention teach people to respond to stressful situations more reflectively rather than reflexively. (Hoffmann, 2010) Yoga has demonstrated improvement in quality of life measures related to a sense of well-being. (Balasubramaniam, 2013) In addition, the slow and deep breathing involved in mindfulness meditations may alleviate body symptoms of distress by balancing the sympathetic and parasympathetic responses. (Hoffmann, 2019) Items such as body scan sustained mindfulness practice and progressive muscle relaxation (PMR) in which attention is sequentially directed throughout the body. (Smith, 2006)

Pranayama Kosha: Panic attacks and anxiety are often accompanied by shallow, rapid breath patterns from the upper lung. This breath pattern may lead to hyperventilation and sensations such as dizziness, nausea, shortness of breath, confusion, and tingling in the hands. In addition, the fear of fainting usually brings on her panic attacks.

Manomaya Kosha: The client struggles with rajas mind (fear and anxiety) and at times tamas (rumination of worry that she is going crazy). She has not been diagnosed with PTSD; however, it is notable that she has had childhood trauma. The childhood traumas are the divorce of her parents at the age of 10 and the first report of anxiety, along with a reported history of sexual trauma by an older teenage boy at 12. While I will not point this out to the client, the symptoms that may suggest PTSD are anxiety, isolates (she describes herself as a homebody and does not feel comfortable going far away from her home), panic attacks (around fear of fainting), reports that her world is getting smaller, difficulty participating in life (shown by decreased interests in activities), lack of joy (no longer enjoys going to gym, hiking and walking, reports she has lost motivation), difficulty sleeping, nightmares (someone is hurting her but does not know who), few friends and social engagement (recently ended a relationship because she did not want to overwhelm them with her problems), and intrusive thoughts (worried about going crazy). YT is unaware of the extent of PTSD, and YT cannot diagnose; however, They may consider a trauma-sensitive yoga therapy treatment plan.

Vijnanamaya Kosha and Anandamaya Kosha: She shows an inability to integrate the higher self into everyday living and appears to be trapped in the roller coaster of life with its painful ups and downs with difficulty to see the bigger picture of life.

Potential red flags may be that the doctor recommended the YT session, and she may not be in the right stage of change to take action to alter the circumstances of her situation. Based on past traumas and the current symptoms that the client is presenting, a request with collaboration for consent to work with a mental health professional and primary care doctor may help to develop a collaborative treatment plan that addresses the client’s key concerns.

Description of Condition, Symptoms, Challenges, Allopathic Treatment

While the client reported various disease conditions and could be discussed here, the YT will only address the one need that the client is asking for support with, which is anxiety.

A DSM-5™ diagnosis criterion for Generalized Anxiety Disorder (GAD) is excessive anxiety and worry occurring more days than not for at least six months about several events or activities. In addition, anxiety disorders may share features of extreme fear, anxiety, and panic attacks occurring for no apparent reason.

Causes for anxiety can range from trauma from events such as abuse, victimization, the stress in relationships both intimate and family/friends, stress at work or from an illness, side effects from medication, substance abuse, family history, abnormal levels of neurotransmitters in the brain. The symptoms are as varied as the causes may be, such as difficulty controlling worried thoughts, restlessness, fatigue, irritability, muscle tension, difficulty sleeping, difficulty concentrating, trembling, nausea, diarrhea, headache, backache, heart palpitations, frequent urination, to being easily startled. (Crosta, 2015)

Allopathic treatment of anxiety is an integrative treatment plan of psychotherapy, behavioral therapy, and medications. It can be treated with psychological counseling or independently and is determined by patient preferences. A variety of treatments can be used, such as cognitive-behavioral therapy (CBT), Applied Relaxation, Acceptance and Commitment Therapy (ACT), Mindfulness, Interpersonal Psychotherapy (IPT), Motivational Interviewing (MI), and Exercise. A pharmacological treatment used to be treated with benzodiazepines. However, it is declining because of its addictive qualities and increased rate of dementia as a side effect. Serotonin Reuptake Inhibitors (SSRI) are popular because of fewer side effects. The side effects of SSRIs are jitters, nausea, and sexual dysfunction. Tricyclics have been shown to work well for anxiety as well. You may also see Monoamine Oxidase Inhibitors (MAOIs), beta-blockers and buspirone prescribed. (Crosta, 2015)

Challenges faced in treating anxiety are, anxiety may also be comorbid in up to 50% of patients, leading to problems during diagnosis and treatment. Despite their frequency, the recognition and treatment of anxiety disorders are frequently suboptimal, with as few as 15% of patients obtaining treatment consistent with evidence-based care recommendations. (Coleman, 2008) GAD is often unrecognized or misdiagnosed as a physical condition due to the range of clinical presentations, including somatic symptoms and the frequent occurrence of comorbid conditions. (Davidson, 2010) Screening for GAD can improve detection rates and developing a collaborative care approach. Achieving satisfactory treatment results depends significantly on patient adherence to the treatment plan. Possible non-compliance to treatment plans may be: lack of efficacy, delay in treatment effects, the patient feels cured, stop treatment, the stigma of receiving treatment, and ambivalence. YT may support the client through education, add holistic tools to help with the waxing and waning emotions they feel, and come to peace with an extended treatment plan.

Yoga Therapy Intervention & Rationale

Session one focused on an evening movement routine with breath as a tool to balance emotions. Bo Forbes’s work influences this session. (Forbes, 2011)

PracticeFocusRationale
Supported Child’s PoseFocus would be to breath into the back bodyCalm, ground & soothe the body, imagine being enveloped in calm
Reclining TwistWould focus on one lung breathing, generous inhale hold it and then exhale slides out, Mountain Climb BreathUse the breath to help relax the body & imagine the breath entering any part of the body that needs to let go
Supported Shoulder BridgeFocus would be on a  longer exhale than inhale, allow the exhale to take you deeper into your bodyLet the thoughts move across the surface of awareness, when a challenging thought arises focus on the breath and body & let the thought pass in its own time
Side Lying PoseEqual Ratio BreathSuggested supported sleeping pose, allows for freedom to adjust in a way that suites them
Legs up wall W/ Pelvis LiftedAlternate nostril breath without handsGrounded & soothing pose, inversions help to reset the rumination of the  mind
Restorative CrocodileFocus would be on belly breathingReducing stress, fatiguing the body, teaching patience & self-care can extend from your practice to your life outside of the practice
Yoga Nidra Short for SleepComing home to selfReduce negative emotions & increase positive feelings despite persistent problems including intrusive memories

Homework would be to look up the poem by Rumi “The Guest House.

Session two focused on a morning practice with breath centered movement and mantra. This session is influenced by Amy Weintraub’s work. (Weintraub, 2004)

PracticeFocusRationale
5 minute body check-in, MountainInhale “You are” Exhale “I am not alone”Grounding, union, & sensation into a deeper experience of being in a physical body in the present moment
Cat/cowFlexion/Extension of spineThe spine houses the central nervous system so moving it through all planes of motion brings health to all systems of the body
Wag tail side-to-sideLateral Movement of spineSee cat/cow
Threading needleRotation of spineSee cat/cow
5 minute check-in, Mountain with arms overheadMantra of “I am aligned with the energy of the universe, & the energy of the universe supports and protects me.”Soothes, energizes so there is more room for authentic expression
Jack Kornfield’s forgiveness of self, meditation seatedForgiveness of others, Forgiveness of self, Forgiveness of those that have harmed youFree the self of barriers that have been erected & the emotions that have been carried because of them

Homework is to start a gratitude journal and list three things every day that they are grateful for. It can be as simple as the sun was out or it rained.

Session three focused on a mid-day practice focusing on balance and felt a sense of peace within their inner being. Picking the breath practice that best fits for the day and as needed. Best to do this before lunch or two hours after lunch and if you are feeling resistant to doing the practice consider stepping outside and practicing in the fresh air for a moment.

PracticeFocusRationale
Nadi ShodhanaAre you feeling calmer or more alert? 5-7 roundsStart here to open up the energy channels so the body & brain are functioning in balance
BrahmariFocus on the vibration 10-20 roundsThe longer exhale slows down the nervous system & has a calming effect
Breath of JoyFocus is on filling up & then letting it go, Inhale completely & exhale vigorously 5-7 roundsIncrease energy, feel light & smile
Chandra Bheda-Left Nostril BreathingUseful before sleep too with a  longer exhale, close right nostril, inhale left, close left nostril, exhale right 20 timesSlows down, activating the right hemisphere of the brain & the parasympathetic nervous system
Pala MudraAttune to feelings & sensations while entering inner sanctuary & inviting every body part into this sanctuaryAnxiety relief & cultivating a sense of wholeness

Session four focuses on tools that will support the client as needed such as loving-kindness and bhakti.

PracticeFocusRationale
Journal PracticeWhat did you notice mentally, emotionally and physically? This can be done after any of the practices daily. Use the R.A.I.N. (Recognize, Allow, Investigate, Non-Identify)Exploring self-awareness/ mindfulness self-inquiry
Daily ReadPick one that is based on personal belief system: Daily OM, The Golden Present, Light is the New BlackFocus the mind on a theme
ChantingBased on their beliefs this could be vowels, seed sounds or Gayatri MantraVibration of voice & the rhythm of breath helps to open up the energy system & balance the body
MeditationPMR, Breath Awareness, Loving Kindness, Body Scan, in a bottom-up approachTo establish a connection to self & reestablish a relationship with sensation in the body, exploring opposites of tension & relaxation

Outcome measures to consider for a client experiencing anxiety are MY-MOP (Measure Your Medical Outcome Profile), STPI (State Trait Personality Inventory Subscale anxiety), BAI (Beck Anxiety Inventory) all are self-reporting questionnaires.

Contradictions/ Challenges/ Countertransference

The nervousness of anxiety implies there is a lack of self-esteem, self-awareness, and connectedness, which transfers to a lack of grounding in your being, which creates a nervous fear of others, a wariness that the world is not a safe place to be, and apprehension that may have no discernible cause. This stress can be connected to stress, failure, or loss. Chronic stress and anxiety create a cycle of tension in the body. You often suffer from muscle tension, stiffness, eating disorders, heart palpitations, rapid breath patterns, excessive sweating, and headaches. Learning the life skills of relaxation, breath, and therapeutic movement is key to management. (Shapiro, 2006)

Mindfulness to consider in building a trauma-sensitive space and treatment plan are the language minimize commands use invitations instead (If you like, When you are ready, Be Curious, Just for today, Approach with interest, Allow, Experiment, Feel), assists the key is not imposed only to empower (only guide to develop a sense of empowerment and control over themselves), environment consider the client as your collaborators and offer them some control (straps, yoga walls with apparatus on them, fans and so on may be triggering), and yoga therapist’s qualities you are not a trauma expert only present opportunities for experience (cultivate a safe, stable, predictable space). (Emerson, 2011)

Items that may be contraindicated for anxiety are intense backbends, lateral poses, and breathing techniques such as Kapalabhati, as these may lead to agitation and increased anxiety. You should approach handstand with caution in acute anxiety as it may be overstimulating. Any practice that prolongs inhalation or that focuses on breathing through the right nostril may prompt agitation. Please proceed with caution, even with ujjayi breath. Even though it is a calming pranayama practice, it can be unsettling to some people with anxiety. (Khalsa, 2016)

Self-Care for the Yoga Therapists

Yoga therapists need to continue their self-practice. Personal practice includes physical-based practice, mindfulness practice, meditation, journaling, checking in with some self-inquiry, and so on. It is hard to parent ourselves; therefore, yoga therapists may consider hiring their yoga therapist. Other items to consider are scheduling enough time between sessions to use the restroom, washing your hands, taking a moment to hold a mudra for your self-care before seeing the next client, and taking a shower upon returning home before you start into your personal life.

Discussion

To date, a limited number of yoga studios have been performed focusing on anxiety disorders alone. Those that have been done have been lacking in rigorous methodology. Yoga shows promise as a cost-effective treatment measure. However, yoga researchers and practitioners may consider how they will measure their outcomes for complex interventions. Anxiety does not appear to be decreasing any time soon in our social environment.

Yoga may offer those struggling with anxiety disorders the benefits of balancing the stress-response system, reducing overactivity in the limbic system, increasing the capacity of higher brain centers, improving cognitive functions and correction of misappraisals of threat, activating interoceptive inputs to key brain regulatory centers, improving efficiency and integration in bottom-up and top-down neurophysiological networks, reduce internally generated ruminative anxious thoughts and worries, enhance feelings of connectedness, bonding and safety via interoceptive autonomic pathways and prosocial, antianxiety neurohormones release. (Khalsa, 2016)

References

Balasubramaniam, M., Telles, S., & Doraiswamy, P. M. (2012). Yoga on our minds: a systematic review of yoga for neuropsychiatric disorders. Frontiers in psychiatry3.

Coleman, V. H., Carter, M. M., Morgan, M. A., Schulkin J. (2008) Obstetrician-gynecologists’ screening patterns for anxiety during pregnancy. Depression and Anxiety 25:2, pages 114-123. 

Crosta, P. (2015, August 3). Anxiety: Causes, Symptoms and Treatments. Retrieved July 4, 2017, from http://www.medicalnewstoday.com/info/anxiety

Davidson, J. R. T., Feltner, D. E., & Dugar, A. (2010). Management of Generalized Anxiety Disorder in Primary Care: Identifying the Challenges and Unmet Needs. Primary Care Companion to The Journal of Clinical Psychiatry12(2), PCC.09r00772. http://doi.org/10.4088/PCC.09r00772blu

Emerson, D., Sharma, R., Chaudhry, S., & Turner, J. (2009). Trauma-sensitive yoga: Principles, practice, and research. International Journal of Yoga Therapy19(1), 123-128.

Forbes, B. (2011). Yoga for emotional balance: simple practices to help relieve anxiety and depression. Boston: Shambhala.

Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of consulting and clinical psychology78(2), 169.

Khalsa, S. B.S., Cohen, L., McCall, T. B., & Telles, S. (2016). The principles and practice of yoga in health care. UK: Handspring Publishing Limited.

Kirkwood, G., Rampes, H., Tuffrey, V., Richardson, J., & Pilkington, K. (2005). Yoga for anxiety: a systematic review of the research evidence. British Journal of Sports Medicine39(12), 884-891.

P. (n.d.). Data on Behavioral Health in the United States. Retrieved August 2, 2017, from http://www.apa.org/helpcenter/data-behavioral-health.aspx

Shapiro, D. (2006). Your body speaks your mind decoding the emotional, psychological, and spiritual messages that underlie illness. Boulder, CO: Sounds True.

Smith, C., Hancock, H., Blake-Mortimer, J., & Eckert, K. (2007). A randomized comparative trial of yoga and relaxation to reduce stress and anxiety. Complementary therapies in medicine15(2), 77-83.

Telles, S., Singh, N., & Balkrishna, A. (2012). Managing mental health disorders resulting from trauma through yoga: a review. Depression research and treatment2012.

Weintraub, A. (2004). Yoga for depression: a compassionate guide to relieve suffering through yoga. New York: Broadway Books.

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