Yoga For Psychosis New Promise From An Ancient Science · Yoga is restraining the mind from taking...

Yoga For Psychosis– New Promise

From An Ancient Science

Prof. B N Gangadhar

Department of Psychiatry,

National Institute of Mental Health and

Neurosciences, Bangalore

10/1/2015 Yoga for Schizophrenia (84 Slides)

Acknowledgements

Shivarama Varambally

Jagadisha Thirthalli

Rashmi Arasappa

Venkatasubramanian Ganesan

Rishikesh Behere/ Aarti Jagannathan

Urvakhsh Mehta

Staff NIMHANS Integrated Centre for

Yoga 10/1/2015 Yoga for Schizophrenia (84 Slides) 2

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Presentation Layout

Psychosis and its impact

Why Yoga?

Review of previous studies

Summary and Conclusions

Future directions

Yoga for Schizophrenia (84 Slides) 3

Schizophrenia..

Current Diagnosis

> 1 month Active Phase Symptoms

Positive symptoms

Delusions

Hallucinations

Disorganised speech

Grossly disorganised behaviour

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Current Diagnosis...

Negative Symptoms

Affective blunting

Alogia

Avolition

Anhedonia

> 6 months illness

Impairment,

Exclusion: substance-induced, organic


Psychosis - What…. Differential Diagnoses

Schizophrenia (spectrum)

Affective disorders with psychosis

Other primary psychotic disorders

Drug induced

Amphetamines

? Cannabis

Hallucinogens

Alcohol10/1/2015 Yoga for Schizophrenia (84 Slides) 6

Schizophrenia.. Who, when, where

Epidemiology

1% worldwide (M=F )

Men earlier onset illness (late teens) than women (early twenties)

Natural course after first episode:

1/3rd 1-2 episodes;

1/3rd multiple episodes

but mild-moderate impairment;

1/3rd chronic, severe illness


Schizophrenia causes BurdenDALY/Person (NIMHANS Study 2005)

0

5

10

15

20

25

Depression Schizophrenia Tuberculosis Diabetes


Schizophrenia.. Why

Aetiology

Biological: genetics, structural changes, functional changes, dopamine hypothesis, obstetric complications, neurological soft signs, developmental, ?drug abuse

Psychological: expressed emotion, parenting

Social: Impoverished, rural & migrant populations, global studies


Schizophrenia – Mx (How)

Pharmacotherapy: Antipsychotic medications

Typicals: dopamine (D2) antagonists

Atypicals: serotonin dopamine antagonists

Novel: Clozapine, Aripiprazole

Depot preparations (long-acting)


Psychosocial Mx

Psychosocial interventions: Family interventions, assertive community treatment, vocational rehabilitation, social skills training, CBT

Multidisciplinary teams important

Mx of Comorbidity especially substance use and medical complications.


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Presentation Layout


Why Yoga?



Future directions


योगस्थः कुरु कर्मणि

सङं्ग त्यक्त्वा धनञ्जय ।

णसद्धि अणसद्ध्ोः सर्ः भूत्वा

सर्त्वं योग उच्यते ।।

Perform action, O Dhananjaya,

being fixed in yoga, renouncing attachments,

being even-minded in success & failure;

equilibrium is verily yoga

(Bhagavad Gita Chapter 2 - Samkhya Yoga - Sloka 48)


Definition of yoga

“yogah cittah vritti nirodhah”

Patanjala Yoga Sutra Chp 1/verse 2

Yoga is restraining the mind from taking various forms.

“manah prashamanopayah yoga ityabhidhiyate”

Yoga Vasista

Processes by which Calming the mind is known as Yoga


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Rationale - Why Yoga?

Yoga has been found effective in stress management

Yoga has proven positive effects on:

Blood glucose and lipid levels

Cognitive performance (including memory and

executive functions) and motor functioning

Neurophysiological markers of stress

Sleep patterns


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Schizophrenia and Yoga…

Rationale:

Presence of depressive and anxiety symptoms in many patients with schizophrenia causing disability

Presence of significant cognitive and executive function deficits in schizophrenia

Proven benefits of Yoga in all these areas in normals (Naveen et al 1997, Manjunath et al 2001)

Limitations of current treatments for schizophrenia and significant adverse effects.


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Schizophrenia and Yoga… ‘Metabolic Syndrome’ – secondary to antipsychotic

treatment (2nd generation)

Abdominal obesity

Blood glucose

Triglycerides

↓ HDL Cholesterol

Reported improvements in these parameters with yoga therapy (Jain et al 1993; Bijlani et al 2005; Manjunatha et al 2005; Malhotra et al 2005)


Why yoga for schizophrenia...?

‘Schizo’ ‘phrenia’, Splitting the mind

Schism between thought & affect

And between Individual & Society

Connectopathy (functional & structural)

Frontal and cerebellar (Cognitive Dysmetria)

Right and Left hemispheres (Corpus Callosum)

Yoga means to connect/unite (Yuj )


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Presentation Layout


Why Yoga?



Future directions


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Studies

SVYASA (2000):

- Random allotment of 26 chronic schizophrenia

patients to yoga therapy and physical exercise

- Benefits at the end of one year:

Yoga Therapy Group

• Blunted affect

• Somatic concern

• Attention

• Anxiety

• Social avoidance

Physical Exercise Group

• Anxiety

• Social avoidance


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Studies…

A single blind randomized crossover trial in a group of 28 chronic schizophrenia patients

Patients received either Yoga and Physical training

Assessments at baseline and three months, followed by a crossover.

The final assessment was at 6 months.

Reported greater reduction in symptoms and better neuropsychological performance with yoga(Naveen et al 2003)


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Studies in NIMHANS – I


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Screening

SCIDDSM-IV Diagnosis

Moderately ill or worse (CGI>3)

Recruited after Consent = 61; Baseline Assessments

Randomized

Yoga Therapy (21/31) Physical Exercise (20/30)

Training: atleast 15 sessions; Practice at home for months

Follow-up after 4 months: Follow up assessments

Analysis of Covariance: Controlling for baseline scores

Yoga for Schizophrenia (84 Slides)

Ten patients in each group

dropped out

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Methods Rater:

Psychiatrist trained in administering the tools

Blind to the group status

Therapist:

Trained in both Yoga and Physical Exercise

Both groups taught by the same teacher for same time period

Compliance:

Ensured by regular letter and telephone contact; log kept by informants


Yoga Group

Yoga package (1 hour)

- 1. Loosening exercises

- 2. Asanas - Sitting posture

- Prone posture

- Supine posture

- 3. Breathing exercises

- 4. Quick Relaxation Technique

Instant Relaxation Technique


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Yoga for Schizophrenia (84

Slides) 26

Physical Exercise Group

Physical Exercises package (1 hour)

- Standard Physical Training for high school students (National Fitness Corp)

-Brisk walking

-Jogging

-06 Exercises (Standing)

-10 Exercises (Sitting)


Symptoms of Schizophrenia improved better with Yoga (YT) than exercise (PT)

Duraiswamy, et al, Acta Psychiatrica Scandinavica, 2007; 116:226-32.10/1/2015 Yoga for Schizophrenia (84 Slides) 28

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Conclusions from study-I

Yoga is a useful add-on treatment for schizophrenia:

Improvement across several dimensions of outcome:

symptoms, functioning ability and quality of life

No serious adverse effects

Needs to be replicated with additional ‘placebo’ arm


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NIMHANS Study II - RCT

Randomized controlled trial - similar to Study I (AYUSH funded research project)

Modifications:

- Addition of control group (waitlist)

- Larger sample size – 40 x 3 groups (Yoga, physical exercise, and waitlist)

- Assessment of social cognition using a novel instrument – Tool for Recognition of Emotions in Neuropsychiatric DisorderS (TRENDS)

(Behere et al 2009)


Screening

SCIDDSM-IV Diagnosis

Moderately ill or worse (CGI>3)

Recruited after Consent = 120; Baseline Assessments

Randomized

Yoga Therapy (N=46) Physical Exercise (N=36)

Training: 1 month; practice at home for 3 months

Follow-up after 4 months: Follow up assessments

Analysis

Waitlist (N=38)


Positive And Negative Syndrome Scale (PANSS)

Social and Occupational Functioning Scale (SOFS)

Abnormal Involuntary Movements Scale (AIMS)

Extrapyramidal Side-effects Scale (SAS)

Hamilton Depression Rating Scale (HDRS)

Quality of Life scale (WHOQUOL)

Clinical Global Impressions Scale (CGI)

Tool for Recognition of Emotions in Neuropsychiatric DisorderS (TRENDS)

Assessments


Total number of patients screened : 941

Total number of patients randomized :120

Patients who completed 4 months follow up : 95

Majority of patients on atypical antipsychotics (mostly

risperidone), only 6 on typical antipsychotics, and

10 patients on both

Three groups were comparable at baseline on socio-

demographic profile, psychopathology scores, and

side-effect profile

Some details of the patients


Higher Percentage of Schizophrenia patients were improved at 4 months after Yoga


Varambally et al Ind J Psychiatr 2012

An analysis of the odds ratio between yoga and waitlist-group showed that:

- likelihood of improvement in yoga group in terms of negative symptoms (13/39) was about 5 times greater than the waitlist group [3/34; Odds ratio = 5.167 (95% CI = 1.32 - 20.1)],

- and the exercise group [2/22; Odds ratio = 5.000 (95% CI = 1.01 – 24.74)]

Analysis – Odds Ratio


Higher Percentage of Schizophrenia patients were improved at 4 months after Yoga

As regards Social Functioning


Varambally et all Ind J Psychiatr 2012

Indian J Psychiatry 2012;54:227-32

• This research was recognized as “high quality evidence” by the NICE

(UK) guidelines for Psychosis (2014)

• These studies from NIMHANS, formed the basis for recommending Yoga

as an intervention in Schizophrenia for the first time.

10/1/2015Yoga for Schizophrenia (84 Slides) 37

Combined data

Data was pooled from the above two

randomized trials

For analysis, subjects were classified into two

interventional groups – yoga or non-yoga

Baseline demographics and clinical data were

comparable across groups


Combined data….2


(Higher effect size; 0.6)

Combined data…..3


Summary of the two RCT’s

Data from two independent randomized controlled trials with similar methodology done at a specialty neuroscience hospital in India

Yoga as an add-on therapy reduces negative symptoms and improves socio-occupational functioning in patients with schizophrenia


Usefulness of yoga for inpatients with psychosis at onset (inpatients)


Yoga introduced in acute Psychosis (2 weeks) significantly bettered outcome at 6 weeks (assessment 3) (p<0.01)

10/1/2015 Yoga for Schizophrenia (84 Slides) #

Other recent studies

A randomized, controlled pilot study included 18 (12 males) clinically stable schizophrenia inpatients residing at a state psychiatric facility

10 patients were randomized to an eight-week supervised yoga program (2 sessions/week) and the rest were wait-listed.

The yoga module included postures, breathing exercises, and relaxation.

Visceglia et al 2012


Other recent studies, contd…

Psychopathology and quality of life was measured using the PANSS and WHOQOL-BREF respectively, at baseline and after 8 weeks.

Subjects who received yoga therapy achieved significant improvements in PANSS total and subscale scores and quality of life

Visceglia et al 2012


Does yoga ‘improve’ Social Cognition?


Effect of Yoga on facial emotion recognition deficits (FERD)

FERD are very important indicators of social

cognition and socio-occupational functioning

in patients with schizophrenia

FERD measured using TRENDS showed

significantly more improvement in TRENDS

Accuracy Score [TRACS] in the Yoga group

than exercise or waitlist (Behere et al, 2011)


Yoga improves social cognition in schizophrenia

Behere et al, Acta Psychiatrica Scandinavica, 2011; 123:147-53


Yoga benefits in cognition…


Change in scores

Yoga = +6

Exercise = +2

Waitlist = –4

Emotion recognition ability improved in Yoga compared to exercise or waitlist groups

Does Yoga improve Neuro-Cognition?


Yoga for cognitive remediation

A non-randomized study compared adjunctive Yoga therapy (YT) with treatment as usual (TAU) for improving cognitive domains in Schizophrenia

YT (n=65) was compared with TAU (n=23)

YT was also evaluated in Bipolar Disorder (n=40) Major Depression (n=37), and in cardiology outpatients (n=68) Bhatia et al 2012


Results

YT group showed significantly greater improvement with regard to measures of attention; the changes were more prominent among the men.

In the other diagnostic groups, differing patterns of improvements were noted with small to medium effect sizes.


Yoga for combating stress in caregivers of schizophrenia


Yoga for caregivers of patients with Schizophrenia

Caregivers suffer significant stress and burden

Yoga has been shown to decrease stress in caregivers of patients with other neuropsychiatric disorders such as Alzheimer’s Dementia

Some recent studies using Yoga modules for caregivers of patients with schizophrenia


A short Yoga course (6 Sessions) did not reduce burden in caregivers of schizophrenia inpatients


Jagannathan et al 2012

58

Yoga for caregivers of outpatients Burden scores dropped and

Quality of life increased in the Yoga groupVarambally et al, Asian J Psychitry 2012


10

12

14

16

18

20

22

24

26

28

30

Case

Control

BAS mean baseline score

BAS mean last f/u score

of 68

Yoga for OP Caregivers


Barriers to receive yoga therapy


Schizophrenia & add-on Yoga: Summary

Yoga is better than exercise in outpatients

Both are better than waitlist in negative symptoms

Yoga also improves social & neuro cognition

Acutely ill inpatients: Yoga better than exercise

Barriers limit routine use of Yoga in schizophrenia

Inpatients’ caregivers: No benefit from yoga course

Longer course benefited caregivers of outpatients


HOW DOES YOGA WORK?


Yoga Mechanisms in Schizophrenia

One learns Yoga from a teacher

Postures have to be imitated

Performing them with mindfulness

Attention to synchronizing breathing with the movements leading to the postures

Remain physically relaxed except the posture

Focus on the experiences with each posture

Specific breathing practices (Pranayama)


THE MIRROR NEURONS


What benefits from Yoga?


The negative symptoms & Social Cognition

Schizophrenia has Low MNA


0.55

0.65

0.75

0.85

0.95

1.05

DRUGNAÏVE MEDICATED CONTROLS

F(df)=4.74(2,95),p=0.011 Observing ‘rest’

Observing ‘action’

Mehta UM et al., Schizophrenia Bulletin 2014

m

V

o

l

t

M

E

P

Negative Symptoms & Low MNA

10/1/2015 Yoga for Schizophrenia (84 Slides) 69Lee et al., Schizophrenia Research 2013

Social Cognition & MNA


r=0.413,p=0.002

Mehta UM et al., Schizophrenia Bulletin 2014

Oxytocin & Social Cognition


(A) Healthy Comparison Group

Log Oxytocin (pg/ml)

3 4 5 6 7 8

Pe

rce

nt C

orr

ect E

mo

tio

n

Re

co

gn

itio

n (

%)

40

50

60

70

80

90

100(B) Schizoprehania Probands and Relatives

Log Oxytocin (pg/ml)

3 4 5 6 7 8

Pe

rce

nt C

orr

ect E

mo

tio

nR

eco

gn

itio

n (

%)

40

50

60

70

80

90

100

r=0.40, p<0.01r=0.03

r=-0.04

Figure. Raw correlations showing: (A) Higher serum levels of oxytocin are associated with better performance on a facial emotion recognition test in the healthy comparison group but not in (B) schizophrenia probands and their first-degree relatives.

Proband

Relative

Figure-6: Associations between oxytocin levels and emotion recognition in healthy subjects (A),

schizophrenia patients and their relatives (B) Rubin et al., 2014

Oxytocin & MNA

Twenty-four students were administered 24 IU of OT or placebo intranasally in a double-blind within-subject design

After 45 minutes mu wave suppression was significantly enhanced in the OT versus the placebo conditions while viewing biological motion

Perry et al., Psychoneuroendocrinology (2010)


Yoga improved imitation skills in autism (? MNA/OXT mediated)


Radhakrishna S, International Journal Of Yoga (2010)

Mindful Imitation & Yoga


In infants OXT nebulization increased gesture-imitation

10/1/2015 Yoga for Schizophrenia (84 Slides) 75Simpson et al, PNAS, 2014, Vol 111

The ‘cuddle hormone’ oxytocin is elevated by Yoga in schizophrenia

Jayaram et al Ind J Psychiatry 201310/1/2015 Yoga for Schizophrenia (84 Slides) 76

Schizophrenia & Yoga: Mechanisms

Oxytocin-Mirror Neuron facilitation

(Indirect brain mechanism)

Direct neurophysiological observations?


Yoga facilitated brain mechanisms in neurocognition and mirror neuro activityin healthy practitioners


Preliminary data

6 Healthy Subjects (3 Men)

Age: 35.0±9.4 Years

Yoga sessions: 4 weeks (7-24 sessions)

fNIRS studies were performed at baselineand after completion of the yoga training.

The fNIRS experiments involved:

Executive Function Task:

Tower of London (Scarborough Adaptation)

Mirror Neuron Activation Task

Neurohemodynamic Effects of Yoga Practice:Functional Near-Infrared Spectroscopy (fNIRS) Studies


fNIRS Probe geometry

DLPFC

Ventral Pre-

Motor Cortex


Effect of Yoga: Tower of London Task (DLPFC)

Pre-Yoga Post-Yoga

Significantly increased activation following Yoga

([S5-D3] ~ Right DLPFC; t = 3.0; p = 0.03)

Following Yoga, subjects performed greater number of multiple

moves [27.3±5.4 vs. 32.0±4.9; t = 2.0; p = 0.04]


Effect of Yoga: Mirror Neuron Activation Task (PMC)

Pre-Yoga Post-Yoga

Significantly increased activation following Yoga

([S7-D4] ~ Right Ventral Pre-Motor Cortex; t = 3.8; p = 0.01)


Proposed Mechanism of Yoga


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