LONGEVITY, REGENERATION, AND OPTIMAL HEALTH

Yoga Breathing, , and Longevity Richard P. Browna and Patricia L. Gerbargb aAssociate Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, USA bAssistant Professor of Clinical Psychiatry, New York Medical College, Valhalla, New York, USA

Yoga breathing is an important part of health and spiritual practices in Indo-Tibetan traditions. Considered fundamental for the development of physical well-being, med- itation, awareness, and enlightenment, it is both a form of meditation in itself and a preparation for deep meditation. Yoga breathing () can rapidly bring the mind to the present moment and reduce stress. In this paper, we review data indicat- ing how breath work can affect longevity mechanisms in some ways that overlap with meditation and in other ways that are different from, but that synergistically enhance, the effects of meditation. We also provide clinical evidence for the use of yoga breathing in the treatment of depression, anxiety, post-traumatic stress disorder, and for victims of mass disasters. By inducing stress resilience, breath work enables us to rapidly and compassionately relieve many forms of suffering.

Key words: yoga; breathing; meditation; depression; post-traumatic stress; anxiety

Mindfulness of in-and-out breathing, when developed and as increased insulin resistance), oxidative dam- pursued, brings the four frames of reference to their culmina- age by free radicals, and neural degeneration. tion. Is there evidence that these ancient practices Sutta can ameliorate stress and the process of aging? If so, how can we understand such effects in Peace in our world can only start with peace in our minds. Western scientific terms? Sri Sri Ravi Shankar

Historical Context Introduction Awareness and training of breath are fun- When we think of aging, we worry about damental to Indo-Tibetan yoga and medi- loss of energy, vigor, mental functions, sexual tation. While Transcendental Meditation has capacity, independence, and the ability to deal been studied in research institutions since 1963, with physical or emotional stress. Yoga breath- the scientific study of Tibetan Buddhist and ing and meditation have been an integral part yoga breath practices is relatively new. In of the spiritual practices used for thousands of the past this has been due to the protective years by Eastern cultures to deal with these con- secrecy surrounding these techniques. There cerns. Neuro-immuno-endocrine changes asso- have been concerns that if the practices are not ciated with stress and aging include inflamma- taught properly, they could cause harm. More- tion, dysregulation of energy utilization (such over, religious leaders and devotees are reluc- tant to see treasured traditions taught piece- meal without their spiritual and philosophical Address for correspondence: Patricia L. Gerbarg, M.D., 86 Sherry Lane, Kingston, NY 12401. Voice: 845-331-8881; fax: 845-331-3562. underpinnings. Nevertheless, interest in East- [email protected] ern healing and spiritual practices is growing

Longevity, Regeneration, and Optimal Health: Ann. N.Y. Acad. Sci. 1172: 54–62 (2009). doi: 10.1111/j.1749-6632.2009.04394.x C 2009 New York Academy of Sciences. 54 Brown & Gerbarg: Yoga Breathing, Meditation, and Longevity 55 and their techniques are being adapted to di- tence, rapture not-of-the-flesh, serenity (calm- verse cultures and medical settings. As more of ness of mind and body), concentration, and the previously hidden techniques become ac- equanimity. The seven factors bring clear cessible, they provide new areas of research that knowing and release. Thus the process of awak- will enrich Western medicine and science. ening begins with mindfulness of breathing.3 Yoga breathing, called pranayama, is one of Paintings on the walls of the Secret Temple the Eight Limbs of Yoga that were systematized of the in Lhasa depict ancient Ti- in Patanjali’s yoga sutras (circa 200 B.C.). The betan yoga poses of trul-khor.TwoformsofTi- life-force or in is the life-air, vi- betan trul-khor movement and breath practices tal breath, or srong- in Tibetan. Life-force- are being taught in the West: Trul-khor and energy is called chi in Chinese and ki in Japanese Yantra Yoga. The aim of these practices is to traditions. Pranayama translates from Sanskrit clear away all unwanted obstructions, imbal- as “control of energy” or “expansion of en- ances (drowsiness and agitation), distractions ergy.”1 Yoga teachings are found throughout and negative emotions to enable the practi- . In the 7th century A.D. Ayurvedic tioner to experience “the natural mind” and Medicine and Buddhism from reached remain in the meditative state. In Tibetan the Tibet. These traditions were further enriched word for yoga, nejor, can mean “union.” Nejor by pre-Buddhist Shamanic, Chinese, and Per- can also mean “original” or “authentic knowl- sian influences. Yogic Science and Buddhism edge” or “understanding.” This deeper mean- seek to understand the nature of the mind in ing alludes to our original, never-changing con- order to develop awareness, compassion, and dition.4 Western psychology would call this enlightenment. Both traditions teach the same the “true self.” Although these practices were basic precept, that there is a bi-directional re- believed to enhance physical and emotional lationship between the mind and the breath, health as well as to reverse the process of ag- such that one can affect the mind and con- ing, they were primarily used to develop med- sciousness through manipulation of the breath. itative practices and to bring awareness of the Breath practices are believed to eliminate tox- “natural state” of the mind. Trul-khor move- ins and negative “karmic airs,” to clear the ments and breath practices are used when the “subtle pathways” of the “” (the mind is unclear, unstable, or weak to stabilize energy body), and to increase oxygenation to and clarify meditation. Exhalation with sounds strengthen the physical body. Breathing, visu- of Ha and Phat breaks through mental obsta- alization, , and movement are used to cles while sustaining the natural state of mind. control the forces of the mind and body to clear Yantra Yoga was originally taught in the 8th a path to enlightenment or the realization of century A.D. in Tibet by Vairocana, a student Buddhahood.2 of Guru . According to Lama In Thai Buddhism, the emphasis is on the Lobsang Palden Rinpoche who escaped Tibet Mindfulness of Breathing as taught in the Ana- after the Chinese authorities closed the Tashi panasati Sutta, part of the Tipitaka or Pali Kyil Monastery, Yantra Yoga techniques are canon (250 B.C.), the compiled teachings of healing movements with corresponding breath Buddha. According to the Tipitaka, the pursuit practices that put the whole body into and development of mindfulness of in-and-out to circulate and rejuvenate energy. This serves breathing leads to the culmination of the four to purify karma, eliminate negativity, and en- frames of reference: focus on the body, the feel- gender peace.5 ings, the mind, and mental qualities. The four Yoga philosophy considers the greatest stress frames of reference bring the seven factors for to come from fluctuations of the mind as it awakening: mindfulness, analysis and compre- movestowardthethingsitwantsoraway hension of the quality of mindfulness, persis- from things it dislikes, as it runs towards future 56 Annals of the New York Academy of Sciences worries, or becomes mired in past mistakes. that when subjects became angry their risk Even as you read this paper or attend a lecture of further heart attacks doubled compared to your mind is in constant motion, shifting into those who remained calm.7 In a study of 5,716 future obligations or past frustrations. When middle-aged people, those with the best self reg- the mind is 100% in the present we experience ulatory abilities were 50 times more likely to be the calmness, peace, and joy that minimize the alive and without chronic disease 15 years later effects of stress. Most people agree that being than those with poor scores on measures of in the present moment is desirable, but they self regulation.8 As the only autonomic func- cannot find the way to get there. Yoga breath- tion easily controlled through voluntary effort, ing rapidly quiets the fluctuations of the mind breathing serves as a portal through which im- bringing us into the present moment.6 balances in the stress-response system can be What do these diverse breath traditions corrected. have in common? How might they increase For most people, the quality of life is even longevity? What is the research evidence and more important than longevity. The quality of what more needs to be done? one’s life depends upon the quality of one’s mind. Stress, overstimulation, excess expecta- Research Evidence tions, and mental turmoil drain our energy and our capacity to enjoy life. Mind-body and Western scientists and researchers have been spiritual practices offer the sense of peace, studying Buddhist meditation, but there is very joy, and relatedness that sweeten our lives little research on Tibetan movement and breath and the lives of those closest to us. Unfortu- practices. However, the developing evidence on nately, many people who try to learn medita- yoga breath techniques can be used to draw tion cannot focus their minds. Some find the inferences and guide research on Buddhist practices difficult and austere. Most lack the practices. patience to persist. Trying to meditate while un- Yoga breathing can be considered a form der severe stress sometimes magnifies the sub- of meditation. Moreover, certain breath prac- jective sense of distress. In our clinical practices, tices prepare the mind for deeper meditation. we find that starting with breath practices gives Both yoga breathing and meditation can acti- immediate benefits that most people can ex- vate the parasympathetic nervous system and perience, lays the ground work for meditation, induce altered states of consciousness. There and prepares the mind for deeper meditation. are many patterns of breathing and specialized Many scientific studies have shown that techniques that enhance breath practices such mind-body interventions derived from yoga (in- as breathing deeply into the abdomen, breath- cluding breathing, meditation, physical pos- ing against airway resistance, physical postures, tures, centering, and visualization) ameliorate holding the breath at different parts of the stress-related mental and physical disorders in- breath cycle, or breathing alternately through cluding asthma, high blood pressure, cardiac both nostrils, or only one nostril. Extracting illness, elevated cholesterol, irritable bowel syn- the common elements within this diversity and drome, cancer,insomnia, multiple sclerosis, and studying the separate and combined effects of fibromyalgia.9–11 Reducing sympathetic and in- yoga practices enriches our understanding of creasing parasympathetic nervous system tone the impact of yoga practices on the self-repair are integral to such therapeutic action. Car- and self-regulatory systems that may increase diac vagal (parasympathetic) tone has been longevity, resilience, and quality of life. associated with emotional regulation and em- Our ability to deal with stress has an impact pathic response.12,13 on how we age. A Harvard Medical School Western research confirms the Indo- study of 1,623 heart attack survivors found Tibetan teaching that the relationship between Brown & Gerbarg: Yoga Breathing, Meditation, and Longevity 57 breathing and emotion is reciprocal.14 Emo- parasympathetic, activity through numerous tional states can affect respiratory rate, depth, mechanisms, including slow breath rate, con- and pattern. On the other hand, voluntarily traction of the laryngeal musculature, inspira- changing the pattern of breath can account tion against airway resistance, prolonged ex- for at least 40% of the variance in feelings piration against airway resistance and breath of anger, fear, joy, and sadness.15 Breathing is holds. Slow breathing with prolonged expira- controlled by both voluntary and involuntary tion was shown to reduce psychological and mechanisms with complex feedback involving physiological arousal in an anxiety provoking autonomic networks, brain stem nuclei, limbic situation in a randomized study of 70 college system, cortex, and the neuroendocrine system. students.22 The voluntary control of breath can modulate While simple slow breathing increases autonomic nervous system functions including parasympathetic activity, Ujjayi breathing am- cardiac vagal tone as measured by heart plifies these effects through vagal afferent rate variability,1,16 vigilance and attention,17 inputs to the brain and improves heart rate chemoreceptor and baroreflex sensitivity,18,19 variability (HRV).23 Numerous disorders are as well as the level of central nervous system associated with impairment of HRV and res- excitation.20 piratory sinus arrhythmia (RSA).24 Low RSA AyogabreathprogramcalledSudarshan is found in depressed, timid, or fearful infants. (SKY) has been taught to over Low HRV and low RSA have been associated 6 million people in 150 countries by the Art of with anxiety, panic disorder, depression, irri- Living Foundation (a non-profit service orga- table bowel syndrome, early Alzheimer’s, and nization). The reproducible sequence of SKY obesity.25,26 breath practices has been found to alleviate The second breath practice in the SKY stress, anxiety, and depression in clinical prac- program is (bellows breath), a high tice and in research studies. Evidence suggests frequency, forceful technique similar to Kapal- that SKY acts via mechanisms that are funda- abati. High frequency breathing induces au- mental to increased longevity. tonomic sympathetic activation and CNS ex- The effects of SKY breath practices that citation.27 The third component of the SKY have been observed physiologically and clini- program, the “om” chant, improves vagal tone, cally cannot be attributed simply to either hy- decreases sympathetic activation, and increases perventilation or increased oxygenation. Read- mental alertness in the setting of physiologic ers interested in a detailed discussion of the relaxation.28 neurophysiology and clinical effects of the SKY The fourth SKY component is Sudarshan program on stress and psychiatric disorders are Kriya (SK), a cyclical breath form, believed to referred to our previous reviews.20,21 Here we harmonize the nervous system. The translation will briefly mention some plausible mechanisms of Sudarshan Kriya is “clear vision through for the action of breath practices, the benefits purifying action.” This embodies the Indo- for longevity, and some of the evidence for clin- Tibetan principal that the purification of the ical efficacy. subtle and physical bodies through breath prac- The SKY program has four breath com- tices leads to mental clarity, awareness, and ponents: three-stage slow resistance breath- wisdom. In our clinical experience, this highly ing, bellows breath, chanting “om,” and advanced breath practice often evokes deep in- Sudarshan Kriya (cyclical breathing). Slow re- sight, resolution of emotional conflict, and a sistance breathing, known as Ujjayi in San- subjective sense of new found mental clarity. It skrit, means victorious breath (sometimes called also has a strong impact on stress reduction in ocean breath). Previous research indicates clinical conditions such as post-traumatic stress that Ujjayi breathing increases vagal, that is disorder, anxiety, and depression. 58 Annals of the New York Academy of Sciences

A significant increase in β-1 and β-2 ac- ten uses awareness of breath as an entry point) tivity in the left frontal, midline, and occip- including yoga, Zen Buddhist, , and ital regions was noted on EEGs of 19 regu- QiGong.33–39 lar SKY practitioners at rest when compared Our hypothesis is that yoga breathing pro- with 15 healthy age-matched controls.29 An- vides a neurophysiological “work-out” that other study of EEGs in 12 volunteers dur- leads to greater flexibility and plasticity in the ing Sudarshan Kriya followed by meditation nervous system. Experienced SKY practition- showed heightened alertness in all participants ers achieved a remarkable degree of synchrony as indicated by increased spectral power of and coherence on EEG. Hankey39 noted that α-rhythm in the middle band (10–10.5 cps) increased EEG coherence has been associ- in O1 and O2 montages (P < 0.005). Sig- ated with experiences of “pure consciousness” nificant inter-hemispherical asymmetry disap- and greater brain processing capacity. Expe- peared with highest α-activity at the end of SK rienced Tibetan Buddhist meditators showed in the centrencephalic mediobasal structures greater coherence and synchrony in gamma and occipital cortex (P < 0.05), suggesting im- frequencies (25–43 Hz) during the contem- proved inter-hemispheric communication and plative practice of “Compassion.”40 High am- integrative function (P < 0.05).30 plitude synchronous alpha and theta waves, We are currently analyzing neurophysio- most pronounced in advanced practitioners, logical data (EEG, EKG, HRV, respirometry, but also found in novices during post-SK rest galvanic skin response, and temperature) on resembled those found in studies of long-term beginning and experienced SKY breath practi- adepts from other traditions.41 Greater syn- tioners.31 Preliminary findings suggest that Su- chrony has been associated with improved inte- darshan Kriya (SK) breathing temporarily dis- grative brain functioning and problem-solving. rupts the routine patterns (EEG) of the nervous These studies are of interest not only for system, taking it through a range of activity, the optimization of brain function, but also for leading to increasingly synchronized rhythms their potential anti-aging effect. Finding prac- followed by a period of reorganization into a tices that alter brain function, neuroplasticity, state similar to deep meditation or a dream- and even the volume of brain tissue42 raises the like reverie. During SK the EEGs showed in- possibility that specific mental practices could creasingly coherent and synchronous alpha (8– be found to preserve brain tissue and slow the 10 Hz), more pronounced posteriorly and then process of brain aging. spreading over the whole brain cortex. These In yogic terms, Ujjayi quiets the mind. It may observations are similar to studies of long-term also stabilize the cortex through an increase of Transcendental MeditationTM practitioners in gamma-aminobutyric acid (GABA), a testable whom alpha waves spread forward from the hypothesis. This could protect the brain from occipital lobes and dominated the entire cor- possible adverse effects (e.g., seizures) from the tex.32 During the rest period that followed SK, faster forms of breathing which may induce the alpha waves showed even more regular- high amplitude synchronous brain waves. High ization and slowing as they merged into theta frequency breathing activates the sympathetic frequencies (6–8 Hz) while retaining the con- branch of the autonomic nervous system and figuration of alpha waves. These synchronous probably prepares the brain for increased rapid waves showed high amplitudes (30–60 micro- information processing. SK cyclical breath- volts) with the highest amplitudes occurring in ing may disrupt rigid patterns of communi- the most advanced practitioners (4–5 years ex- cation and function within neural networks, perience). Such findings are consistent with pre- the legacy of accumulated stress, for example, vious studies of aniconic meditation (a state of unresolved emotional conflicts or trauma- mental quiescence or transcendence that of- related emotional schemas.43,44 Cyclical Brown & Gerbarg: Yoga Breathing, Meditation, and Longevity 59 breathing increases heart rate variability and of breath practices on lipid profile, antioxidant synchronizes different areas of the brain to systems, and indicators of stress. communicate more effectively. Yogic tradition The aim of yoga, according to ancient Vedic describes this as “harmonizing the layers of texts, was to “cut the seed of sorrow before it the being.” Although some people have in- sprouts.” This is true not only for the individual tense physical or emotional experiences asso- enhancing his or her personal development, vi- ciated with stress release during SKY, it usu- tal energy, stress resilience, and longevity, but ally leads to deep relaxation, a sense of peace also for the compassionate relief of suffering and joy, and other spiritual experiences. The throughout our world community. SKY breath breath forms that precede SKY seem to pre- practices have been used to relieve suffering pare the mind to tolerate and benefit from such among masses of civilians and military person- experiences. nel in the wake of natural and man-made disas- Brain-derived neurotrophic factor (BDNF) ters such as floods, earthquakes, wars, and ter- is involved in neurogenesis, neuronal repair, rorist attacks.52 In a wait-list controlled study of and neuroplasticity. Interventions that increase 180 village survivors of the 2004 Asian Tsunami BDNF, such as exercise and antidepressant who had been living for nine months in refugee treatment, may help preserve brain function.45 camps in Nagapattinam, a short program Conversely, stress and depression suppress neu- of Sudarshan Kriya breath techniques dra- rogenesis through processes that probably in- matically reduced symptoms of post-traumatic volve BDNF.46 In Phase I of an ongoing study, stress disorder (PTSD) and depression on stan- SKY practice increased serum levels of BDNF dardized measures, PTSD Checklist-Civilian in a group of normal individuals.47 If repli- (PCL-C) and Beck Depression Inventory (BDI) cated in larger studies, this data would support in four days and the benefits were sus- the theory that SKY breathing enhances neu- tained at 6-week, 3-month, and 6-month rogenesis and neuroplasticity,processes that are follow-ups.53 essential for maintenance of brain functions as In a series of four small open studies of dis- we age, recovery from trauma, emotional adap- abled Australian veterans of the Vietnam War tation, and learning. with PTSD, Iyengar Yoga improved symptoms Preliminary data from several small stud- of depression, but the addition of pranayama ies suggests additional pro-longevity effects of (particularly Ujjayi) and meditation signifi- SKY practice: improved lipid profile48;en- cantly reduced symptoms of PTSD, includ- hanced immune system function49;andin- ing anxiety, insomnia, and rage.54 A subse- creased antioxidant defense enzymes, glu- quent wait-list controlled study of the SKY tathione (GSH) and superoxide dismutase Program for 30 disabled Australian Vietnam (SOD), and reduced serum lactate (stress in- veterans found that Iyengar Yoga (postures) sig- dicator).50 Moreover, in a 30-day controlled nificantly reduced scores for depression on the study of 190 menopausal women, 40 were given Center for Epidemiological Studies-Depression an 8 mg estradion patch (hormone replace- Test (CES-D). However, SKY was significantly ment therapy HRT), 40 received 500 mg vi- more effective in relieving symptoms of PTSD tamin E/day, and 60 were given SKY only. on standardized measures, including the Clin- Significantly greater decreases in serum mal- ician Administered PTSD Scale (CAPS) and onic dialdehyde (MDA) (a marker of membrane the self-administered PTSD Checklist–Military lipid peroxidation) and significantly greater in- (PCL-M).55 creases in GSH-px and erythrocyte SOD oc- We have found that patients with PTSD from curred in the women given SKY than in those sexual abuse benefit when SKY breathing is given either HRT or vitamin E.51 Further stud- combined with traditional psychiatric and psy- ies are needed to confirm the positive effects chological therapies.56,57 60 Annals of the New York Academy of Sciences

Three studies, two open and one controlled, baby becomes immortal.62 Research on breath found SKY to be effective in treating depres- practices from many traditions will yield new sion and dysthymia.58 In the controlled study insights for neurophysiology, longevity, and the of 45 hospitalized patients with severe depres- clinical treatment of stress-related physical and sion, SKY was equivalent to treatment with emotional disorders. 150 mg/day of imipramine (tricyclic antide- Senescence is feared when it is associated pressant). Electroconvulsive Therapy (ECT) with helplessness, dependency, and loss of the was only slightly more effective than SKY or quality of life. Further research may confirm imipramine.59 that it is possible to enhance our well being and longevity by learning early in life to cul- tivate and sustain the vital qualities of youth, The Circle of Knowledge: Future as Lao Tzu suggests, by cultivating the tender- Directions from the Past ness of the babe, learned most easily through breathing. The application of modern methodologies to study Indo-Tibetan practices raises many Conflicts of Interest tantalizing questions. For example, what is the relationship of the massive increase in EEG The authors declare no conflicts of interest. synchrony, coherence, and amplitude observed during breath practices to improved emotional References regulatory and cognitive functions? How do breath practices affect mitochondrial function, 1. Sovik, R. 2000. The science of breathing–the yogic gene transcription, and DNA repair? Could in- view. Prog. Brain Res. 122: 491–505. creasing BDNF prevent age-associated shrink- 2. Clifford, T. 1990. Tibetan Buddhist Medicine and Psychi- age of the hippocampus and other brain struc- atry: 84. Samuel Weiser, Inc. York Beach, ME. tures while improving mood and memory? 3. Anapanasati Sutta [Mindfulness of Breathing] How does the increase in antioxidant enzyme MN118. In: Tipitaka. Translated by Bhikkhu. 2006. Access to Insight. http://www.accesstoinsight. systems impact longevity? Do breathing prac- org/tipitaka/mn/mn.118.than.html viewed 3/ tices increase cortical GABA as measured on 17/07. magnetic resonance spectroscopy? What is the 4. Chaoul-Reich, A. 2001. Spinning the Magi- potential role of yoga breath training in the cal Wheel. The Snow Lion Newsletter. N53: 1–5. treatment of neuro-psychiatric disorders? Snow Lion Publications. www.snowlionpub.com/ Due to space limitations, this paper has fo- pages/N53_1.php viewed 3/18/07. 5. Giles, D. 2004. Yantra Yoga with Lama cused on research on yoga breath techniques in Lobsang Palden. http://www.lamalobsang.com/ relation to Buddhist practices. However, these yogachicago.htm viewed 3/16/01. findings are fundamental to all forms of yoga, 6. Feuerstein, G. 1998. The Yoga Tradition: It’s History, meditation, and mind-body-spirit practices, in- Literature, Philosophy, and Practice. Hohm Press. Prescott, cluding Qigong, Tai Chi, Zen, Aikido, and AZ. et al breath practices of Native Americans, Hawai- 7. Mittleman, M.A., M. Maclure, J.B. Sherwood, . 1995. Triggering of acute myocardial infarction onset ians, and others. In Sufism, control of breath by episodes of anger. Determinants of Myocardial is crucial to clearing, directing, and preparing Infarction Onset Study Investigators. Circulation 92: the mind for action as well as for conserving 1720–1725. energy.60 In the Tao Te Ching, Lao Tzu em- 8. Frentzel-Beyme, R. & R. Grossarth-Maticek. 2001. phasizes breath control to strengthen the spirit The interaction between risk factors and self- regulation in the development of chronic diseases. and to induce the tenderness of becoming “like Int. J. Hyg. Environ. Health 204: 81–88. 61 a newborn babe.” It was also said by ancient 9. Becker, I. 2000. Uses of yoga in psychiatry and Taoists that he who learns to breathe like a medicine. In Complementary and Alternative Medicine and Brown & Gerbarg: Yoga Breathing, Meditation, and Longevity 61

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