Healing Mind and Body: Using Therapeutic Yoga in the Treatment of Schizophrenia

This article offers insight into the causes and nature of schizophrenia, a chronic mental illness, and describes practical ways Yoga can be integrated as an aspect of treatment. Yoga offers a safe, effective intervention to address both the physiological and psychological stress prevalent in this population. With a practice grounded in the movement of the breath, Yoga can create a sense of community, self-awareness, and self-care that traditional psychiatric practice is frequently unable to foster. This article also discusses some of the concerns specific to teaching this population, and to teaching in a psychiatric hospital. Clinical cases are shared to illustrate the benefits individuals with schizophrenia may receive from a practice of Yoga. Some identifying information about patients described in this article has been changed to protect the individuals’ privacy. We imagine that the soul is the body, almost a result and derivation from the body; but it is the body that is the soul and a result and derivation from the soul. — Sri Aurobindo Introduction A 52-year-old man, EF, lives in a state psychiatric hospital. He can frequently be found lying on a couch in the dayroom at the hospital where he will likely spend the rest of his life. EF has the ability to be intelligent and approachable, but he can also be illogical and unreachable. Other clients at the hospital respect him and have elected him secretary of the patient government, but they also fear his angry outbursts, which emerge erratically from this otherwise gentle man. EF exists in a situation all too typical for someone with schizophrenia. He suffers from a disease that is poorly understood and rarely cured. He is routinely medicated, and if he refuses his medication, doctors are legally authorized to force him to take it. Living among others who are struggling with their own version of this powerful illness, EF feels isolated and unable to connect. His perceptions of reality are frequently unreliable and confusing, and he occasionally hears voices, a hallmark of schizophrenia. His family seems to have forgotten about him, and he rarely has visitors to break up the monotony of the hospital schedule. Despite these challenges, EF was able to motivate himself to come to a weekly Yoga class I was teaching on his hospital unit. He frequently requested more challenging postures, and he enjoyed his success at the physical aspect of practice. At the end of class, I ask people to share how they are feeling physically and emotionally compared to when class began. On one particular day, EF did not share anything with the group. But after our closing prânâyâma and chanting, he came directly up to me and said, “After Yoga, I can feel my feet touching the ground more.” A lack of groundedness—the literal disconnection from physical experience—is something EF shares with many others suffering from schizophrenia. Untethered from shared experiences of reality, they suffer from disorganization on multiple levels: uncontrolled thoughts, shifting emotions, unstable social worlds. Their internal reality is frequently confusing and difficult to articulate. But by engaging themselves in the sensations and grounding experience of the body, many are able to become present to a sense of calm which otherwise eludes them. There has been much discussion in the popular press recently about the many uses of Yoga for improved menYOGA FOR SCHIZOPHRENIA 96 tal health: Yoga for depression, Yoga for anxiety, Yoga for insomnia. However, there is little discussion about the possibility of addressing the most severe sorts of mental illness, including schizophrenia, through Yoga. Schizophrenia is one of the most debilitating and chronic forms of mental illness. It affects both the mind and the body in profound ways, and full recovery is almost unheard of. Through its calming effects on the nervous system and its focus on connecting mind and body, Yoga can make a unique contribution to the treatment of people suffering with schizophrenia. In this article, I describe what schizophrenia is, how it affects people’s lives, and the common approaches to managing this chronic illness. I then explore how the practice of breath-based Yoga can offer opportunities for healing otherwise excluded from current treatments. I provide teaching strategies and guidelines for those interested in sharing Yoga with this population, and offer stories from my own experiences teaching Yoga to individuals with schizophrenia. I am a medical doctor training in psychiatry at Montefiore Medical Center in Bronx County, New York. I have been practicing Yoga for over 15 years, and have studied âsana, prânâyâma, and meditation extensively with Prakash Shankar Vyas, a Kriya Yogi in Varanasi, India in the lineage of Lahiri Mahasaya. I have also studied vinyasa krama with Srivatsa Ramaswami, Ashtanga Yoga with Pattabhi Jois, and Hatha Yoga in the Sivananda tradition. Understanding Schizophrenia Schizophrenia is one of the most serious forms of mental illness because it disrupts cognitive, emotional, and social functioning. Qualities we consider most essential to our identity as human beings become deeply disturbed, including thoughts, language, perception of the world around us, feelings, and a sense of ourselves and our bodies. People with schizophrenia in the United States are subject to downward socio-economic drift and frequently become homeless, abandoned by those who were closest to them. Symptoms There are as many manifestations of schizophrenia as there are people with the illness, and the level of function and kinds of symptoms also vary tremendously. As described in the Diagnostic and Statistical Manual of Mental Disorders, schizophrenia consists of two classes of symptoms: positive and negative.1 Positive symptoms involve the presence of experiences and behaviors that are considered abnormal. These include hallucinations (hearing voices or other sensory perceptions not shared by others) and delusions (fixed, false beliefs such as “I am the president of the United States”), and non-goal-oriented, disorganized speech and behavior. In contrast, negative symptoms refer to the absence of typical behaviors. These include apathy, lack of displayed emotion, and poor social functioning. Unfortunately, the medications used to treat the symptoms of schizophrenia can create a wide range of side effects, including tremors, stiffness, confusion, sedation, depression, and both acute and chronic movement disorders. What Causes the Symptoms of Schizophrenia? There is no known cause of schizophrenia; most psychiatrists agree that it is multi-factorial. There is likely a genetic pre-disposition toward the illness, activated by stressors including perinatal viruses, obstetric complications, childhood trauma, and social environment. 2-4 It is frequently speculated that there is a neurodevelopmental component to schizophrenia. Excessive amounts of dopamine, a neurotransmitter, in brain regions such as the hippocampus are believed to be an important cause of schizophrenia.5 Dopamine receptors in these areas appear to function differently, with some taking up too much dopamine and others seeming to be overly sensitive to small amounts. People with schizophrenia frequently have a high baseline level of physiological arousal, in which the body is chronically agitated and on the alert even under normal conditions, as Zahn6 and others describe. Simultaneously, the parasympathetic nervous system—the body’s means of calming itself—has been found to be suppressed in many with schizophrenia.7 This hyperresponsivity to stress can lead to ongoing overactivation of two of the body’s stress-response systems, the hypothalamic-pituitary-adrenal and sympathoadrenalmedullary axes.8 These systems produce cortisol and epinephrine, so-called stress hormones. Stress hormones put the body in a state of alert—ready for action or danger, with increased heart and respiratory rates, increased blood pressure, and many other changes. When these hormones are chronically released, as is often the case in schizophrenia, they strain the entire body and mind, and lead to chronic mental and physical distress. Excess cortisol and epinephrine can worsen the pre-existing problems with dopamine. As the HPA is increasingly activated, more cortisol is released, which interferes with cell function in the part of the brain where dopamine receptors thought to be involved in schizophrenia reside. The end result is exacerbation of excess dopamine’s harmful effects. The unfortunate conclusion is that stress is a trigger of schizophrenic episodes as well as a by-product of schizoINTERNATIONAL JOURNAL OF YOGA THERAPY – No. 17 (2007) 97 phrenia itself, creating a difficult-to-break chain of relapse and suffering. Prognosis In the U.S., fewer than 15 percent of people who experience a first episode of schizophrenia successfully recover social and vocational function with remission of symptoms for over two years.9 While the incidence of schizophrenia is relatively stable throughout populations around the world (approximately one percent), the World Health Organization finds that people living in developing countries have a better prognosis than those in the industrialized nations of Europe and the United States.10-11 No one knows exactly how to account for this difference, but several explanations have been offered. It is clear that developing nations are better able to integrate the mentally ill into society, and fewer people are subjected to long-term hospitalization. Maintaining social connections and having opportunities to perform useful tasks keep people more functional than hospitals and daytreatment programs ever could. Another explanation for the improved course of illness could be the decreased reliance on antipsychotic medications in developing nations.12 Regardless of the explanation, the poor prognosis for individuals with schizophrenia suggests that treatment of this illness in the U.S. can be considered unsuccessful. Current Treatments and Their Limitations Perhaps because there is no single cause of schizophrenia, there is also no single effective treatment. The National Institute of Mental Health identifies several types of psychosocial rehabilitation to help individuals and families cope with schizophrenia, including social and vocational rehabilitation, family education, cognitive behavior therapy, self-help groups, and treatment for substance abuse if indicated.13 Many hospitals and day-treatment programs offer social-skills training, independent-living skills training, and group therapy. Traditional individual and group therapy can create small changes and provoke certain insights after months and years of treatment, but it is acknowledged to be mostly supportive of the client, rather than curative. Talk therapy continually draws attention back to the mind, which has become most comfortable circling familiar themes while avoiding others. “Breakthroughs” out of the illness are rare, if not impossible. Ongoing therapy rarely transforms the face of the illness, and many current treatments emphasize clients’ adherence to medication instead. Medication is considered a critical component of treating schizophrenia. The oldest known antipsychotic medication is an Ayurvedic herb, called Rauwolfia Serpentia, which has been used for thousands of years to treat what traditional Indian medicine understood as “madness.” 14 Many pharmaceutical drugs, some based on this herb, have been developed for schizophrenia. In general, antipsychotic medications aim to reduce the amount of dopamine available in certain parts of the brain, and some also affect activity of other neurotransmitters. Antipsychotic medications are most effective at decreasing hallucinations and delusions. They routinely produce side-effects that worsen the negative symptoms, leading to further functional impairment.15 The drugs often make people more depressed, less interested in doing pleasurable things, and more emotionally cut off. They can also create sleep and eating disturbances. Many people with schizophrenia gain a significant amount of weight because of medication side-effects, which can lead to more inactivity, Type 2 diabetes, high blood pressure, and not feeling at home in their bodies. People taking antipsychotic medications can develop a variety of movement disorders, some of which are lifelong, regardless of whether the medication is stopped. Despite these limitations and the chronic nature of schizophrenia, current trends and pressures in healthcare in general and psychiatry in particular have led to an emphasis on medications and short-term interventions.