Yoga for Military Service Personnel With PTSD: A Single Arm Study
Jennifer M. Johnston
Boston University Medical Cente
Takuya Minami
University of Massachusetts Boston
Deborah Greenwald and Chieh Li
Northeastern University
Kristen Reinhardt
University of Oregon
Sat Bir S. Khalsa
Brigham and Women’s Hospital, Boston, Massachusetts
This study evaluated the effects of yoga on posttraumatic stress disorder (PTSD) symptoms, resilience,
and mindfulness in military personnel. Participants completing the yoga intervention were 12 cu
ent o
former military personnel who met the Diagnostic and Statistical Manual for Mental Disorders-Fourth
Edition-Text Revision (DSM–IV–TR) diagnostic criteria for PTSD. Results were also benchmarked
against other military intervention studies of PTSD using the Clinician Administered PTSD Scale
(CAPS; Blake et al., 2000) as an outcome measure. Results of within-subject analyses supported the
study’s primary hypothesis that yoga would reduce PTSD symptoms (d � 0.768; t � 2.822; p � .009)
ut did not support the hypothesis that yoga would significantly increase mindfulness (d � 0.392;
t � �0.9500; p � .181) and resilience (d � 0.270; t � �1.220; p � .124) in this population.
Benchmarking results indicated that, as compared with the aggregated treatment benchmark (d � 1.074)
obtained from published clinical trials, the cu
ent study’s treatment effect (d � XXXXXXXXXXwas visibly lower,
and compared with the waitlist control benchmark (d � 0.156), the treatment effect in the cu
ent study
was visibly higher.
Keywords: yoga, posttraumatic stress disorder, PTSD, military service personnel, complementary and
integrative medicine
Posttraumatic stress disorder (PTSD) is a mental health condi-
tion that may result from experiencing traumatic events. PTSD,
particularly in the military, is a focus of much research investiga-
tion (e.g., Foa, Keane, Friedman, & Cohen, 2009) and military
service men and women are particularly at risk for PTSD. Fo
example, interpersonal violence, such as front-line combat, which
many troops experience, is more highly co
elated with PTSD than
other, noninterpersonal types of trauma, such as natural disasters
and motor vehicle accidents (Diagnostic and Statistical Manual fo
Mental Disorders-Fourth Edition-Text Revision [DSM–IV–TR];
American Psychological Association, 2000), and military person-
nel not involved in combat are also exposed to a variety of
psychosocial and physical stressors and other military-specific
situations to which the general population would not normally be
exposed.
Recent studies have evaluated the impact of yoga on PTSD
symptoms in a civilian population, including a protocol of yogic
eathing with exposure treatment, which reduced anxiety and
depressive symptoms in survivors of the South-East Asia tsunami
(Descilo et al., XXXXXXXXXXTwo yoga studies (van der Kolk, 2006; van
der Kolk et al., 2014) included women with PTSD. These studies
found that the yoga interventions significantly improved PTSD
e-experiencing and avoidance symptoms.
Thus far, two studies (Mitchell et al., 2014; Staples, Hamilton,
& Uddo, 2013) assessing yoga for PTSD symptoms have included
military service personnel. Mitchell et al XXXXXXXXXXconducted an
RCT of 38 women, some of whom were military veterans, with
full or subthreshold PTSD and found that both the yoga group and
control group had significant reductions in re-experiencing and
hyperarousal symptoms after a 12 session program. Staples et al.
(2013) conducted a single-arm trial with military veterans with
military-related PTSD and found that the 12 veterans who partic-
ipated in the 12 session yoga intervention had a significant im-
This article was published Online First May 25, 2015.
Jennifer M. Johnston, Department of Psychiatry, Boston University
Medical Center; Takuya Minami, Department of Counseling and School
Psychology, University of Massachusetts Boston; Deborah Greenwald and
Chieh Li, Department of Counseling and Applied Educational Psychology,
Northeastern University; Kristen Reinhardt, Department of Psychology,
University of Oregon; Sat Bir S. Khalsa, Departments of Medicine and
Neurology, Brigham and Women’s Hospital, Boston, Massachusetts.
This study was supported by US Department of Defense Awards
W81XWH XXXXXXXXXXand W81XWH XXXXXXXXXXto S.K. at Brigham and
Women’s Hospital from the Telemedicine & Advanced Technology Re-
search Center (TATRC) of the US Army Medical Research and Material
Command (USAMRMC) and by the Institute of Extraordinary Living of
the Kripalu Center for Yoga and Health.
Co
espondence concerning this article should be addressed to Jennife
M. Johnston, Boston University School of Medicine–Psychiatry, 85 East
Newton Street, Solomon Carter Fuller Building, Room 918, Boston, MA
02115. E-mail: XXXXXXXXXX
T
hi
s
do
cu
m
en
t
is
co
py
i
gh
te
d
y
th
e
A
m
e
ic
an
Ps
yc
ho
lo
gi
ca
l
A
ss
oc
ia
tio
n
o
on
e
of
its
al
lie
d
pu
l
is
he
s
.
T
hi
s
a
tic
le
is
in
te
nd
ed
so
le
ly
fo
th
e
pe
s
on
al
us
e
of
th
e
in
di
vi
du
al
us
e
an
d
is
no
t
to
e
di
ss
em
in
at
ed
oa
dl
y.
Psychological Trauma: Theory, Research, Practice, and Policy © 2015 American Psychological Association
2015, Vol. 7, No. 6, 555– XXXXXXXXXX/15/$12.00 http:
dx.doi.org/10.1037/tra0000051
555
mailto: XXXXXXXXXX
http:
dx.doi.org/10.1037/tra0000051
provement in PTSD hyperarousal symptoms and overall sleep
quality as well as a reduction in sleep-related daytime dysfunction.
This empirical evaluation of contemplative practices such as
yoga to manage PTSD symptoms for people with PTSD is under-
standable given the evidence base for yoga in other populations,
and also because PTSD is a psychophysiological condition (Telles,
Singh, & Balkrishna, 2012) wa
anting interventions that address
oth the physical and psychological symptoms of PTSD. Yoga is
an integrative system of practices geared toward self-understanding,
self-regulation, and psychological and physical well-being (Garfinkel
& Schumacher, 2000; Khalsa, XXXXXXXXXXYoga has also been shown to
increase an inhibitory neurotransmitter gamma amino butyric acid
(GABA; Streeter et al., 2007, 2010), which is relevant to people
with PTSD as this group of people has been shown to be low in
GABA system activity and to experience reduction in anxiety and
depressive symptoms when prescribed pharmacological agents
which increase activity of the GABA system (Streeter, Ge
arg,
Saper, Ciraulo, & Brown, XXXXXXXXXXYogic practices include compo-
nents that may reduce, inte
upt, or reframe re-experiencing, stress,
arousal, and avoidance symptoms of PTSD by eliciting the relax-
ation response (Benson, 1975), which counte
alances the “fight
or flight response” by down regulating the stress system and
increasing present-moment nonjudgmental awareness and accep-
tance, which is often challenging for people with PTSD. The
mindfulness and psychophysiological stress reduction skills in a
yoga practice provide the practitioner with tools to manage triggers
and symptoms with acceptance rather than avoidance. This may
educe reactivity and ensuing learned avoidance behaviors, and
may help counteract trauma-relevant avoidance in these individu-
als.
Yoga contains within its system not only mental practices but
also physical poses (asanas) that have been shown to reduce
musculoskeletal and mental tension, increase cognitive attentive-
ness or mind-body awareness and mindfulness, and improve phys-
ical flexibility and strength (Netz & Lidor, 2003; Se
er, 2000).
Yogic
eathing exercises (pranayama) modify respiratory fre-
quency and tidal volume, which elicits psychological and physio-
logical changes (Brown & Ge
arg, 2009; Pal, Velkumary, &
Madanmohan, XXXXXXXXXXKulkarni and Bera XXXXXXXXXXpropose that mod-
ulation of
eath, via its impact on the central nervous system
(CNS), plays a critical role in maintaining balance or allostasis and
educing cognitive and emotional reactivity. Thus, Kulkarni and
Bera XXXXXXXXXXpropose that modulation of
eath results in psycho-
logical and physiological change, including increasing mindful-
ness and reducing stress.
Mindfulness, or present-moment nonjudgmental awareness, is
an integral dimension in yoga practice, and yoga has been shown
to increase mindfulness (Shelov, Suchday, & Friedberg, XXXXXXXXXXIt
has been negatively co
elated with physical and psychiatric symp-
toms and positively co
elated with well-being; Carmody and Bae
(2008) indicate that various psychological and physical complaints
have been reduced through a mindfulness practice, as have previ-
ous studies (Baer, 2003; Kabat-Zinn, 2003).
Resilience is an individual’s ability to adjust or cope with change o
misfortune (Rutter, XXXXXXXXXXYoga has been seen to improve resilience
in other populations by reducing oxidative stress (Martarelli & Pom-
pei, 2009) and reducing and preventing inflammation (Olivo, 2009),
as well as by reducing anxiety (Su
amanya & Telles, 2009),
perceived stress, and depressive symptoms (Simard & Henry,
2006), and by increasing meaning and promoting dynamic coping
(Chan, Chan, & Ng, XXXXXXXXXXResilience may be critical in creating
an optimal healing environment (OHE; Osuch & Engel, 2004),
which includes a multicomponent (i.e., social, psychological, spir-
itual, physical, and behavioral) approach (Jonas & Chez, 2004)
toward optimizing healing. Based on their research, Osuch and
Engel explicitly recommend mind
ody practices as a means to
heal trauma. Frueh et al XXXXXXXXXXnoted the necessity for the U.S.
Department of Veterans Affairs to update policies to include
empirically supported concepts of resilience.
The theoretical focus of the yoga intervention in the cu
ent
protocol was to help participants increase awareness, release
chronic tension and decrease maladaptive automatic reactions,
develop a nonjudgmental attitude, and induce a state of relaxation
to optimally manage cu
ent symptoms and metabolize previous
experiences. The cu
ent study extends prior research and is unique
in that it uses a manualized Kripalu yoga intervention to explore
whether the physical, cognitive, and psychological practices used
in the intervention are an effective means of decreasing PTSD
symptoms as assessed by the CAPS, and evaluates whether yoga
may increase mindfulness as demonstrated by the Five Facet
Mindfulness Questionnaire (FFMQ; Baer et al., 2006), and resil-
ience, as measured by the Resilience Scale (RS; Wagnild, 2009;
Wagnild & Young, 1990), in military service men and women.
Also unique is that the data for the participants in the study were
enchmarked against other interventions used to treat the military
men and women with PTSD. This enabled the authors to contex-
tualize the results of the cu
ent yoga intervention with other PTSD
treatments used for the military population given the study’s lack
of control group.
Method
After all protocol materials were approved by the Institutional
Review Boards (IRB) from the Department of Defense Telemedi-
cine and Advanced Technology Research Center, the Brigham and
Women’s Hospital, and Northeastern University, recruitment of
participants took place via posting flyers in the local area as well
as advertisements in the newspaper and on trains through the
Massachusetts Bay Transportation Authority. Potential partici-
pants underwent a telephone screening to preliminarily assess
eligibility, and, when deemed potentially eligible, came in for an
in-person interview. During this meeting, informed consent was
obtained and an interview was then performed to ensure inclusion
criteria were met. After screening into the study, participants
underwent a baseline CAPS assessment and then completed base-
line questionnaires before undertaking the 10-week yoga interven-
tion. At the final yoga class, they completed