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Breathwork and effects on the immune system, brain function, and behaviour

Fahri Saatcioglu, Ph.D. University of Oslo Oslo, Norway

Summary 1. Sympathetic tone is increased during times of stress. It seems that in many of us there is a chronic overactivity of the SNS. 2. Ample evidence exists for a strong and consistent association of acute and chronic psychological stress with various diseases, such as hypertension and insulin resistance, ischaemia, arrhythmia, and cancer. 3. Interventions derived from spiritual traditions, such as yoga, act, at least in part, by directly influencing the breath and the functioning of the ANS. 4. Breath is therefore a unique medium to affect the ANS and other aspects of the physiology, from molecular to systemic levels, to increase health and wellness.

What We Spend – and What it is Worth • U.S. has spent nearly $2,3 trillion on health care in 2007 – approx. 16% of GDP, more than any other major expenditure and more per capita than anywhere else in the world. It is projected that the percentage will reach 20 percent by 2016.


Chronic diseases account for 75% of the $1.4 trillion spent on health care in the US


$245 billion an average of $1,066 per person


$1.4 trillion an average of $5,039 per person


$2.8 trillion an average of $9,216 per person

Mensah: Heffler et al. Health Affairs, March/April 2002.

We Face an Epidemic of Unparalleled Proportions • Noncommunicable diseases cause 86% of deaths and 77% of the disease burden in the WHO European Region. • One-third of the years of potential life lost before age 65 is due to chronic disease. • Four chronic diseases—heart disease, cancer, stroke, and diabetes—cause almost two-thirds of all deaths each year. Mensah:

What We Spend – and What it is Worth • U.S. uses more expensive specialty services – by far – than elsewhere, but studies show more care doesn’t necessarily mean better health.


Percutaneous transluminal coronary angioplasty interventions per 100,000 population in 2002 416

400 300









0 United














Life Expectancy by Health Care Spending

US spends more on health care than any other country in the world, but it does not translate into better health.

Walter C. Willet MD MPH Professor of Medicine Chairman of the Department of Nutrition Harvard School of Public Health

• Moderately easily achieved lifestyle intervention* results in 82% reduction risk of coronary artery disease…. This is much more important than Statins. *No cigarette smoking, moderate physical activity and easy diet changes +Reduction of psychological stress!

“Honest doc--if I had known I was gonna live this long, I’d have taken better care of myself…”


"There are two classes of diseases—bodily and mental. Each arises from the other, and neither can exist without the other. Thus mental disorders arise from physical ones, and likewise physical disorders arise from mental ones." --Ancient epic Mahabarata

"The biggest mistake physicians make is attempting to cure the body without curing the mind. The mind and the body are one." --Plato, ca 400 B.C.

“I would rather know the person who has the disease rather than the disease the person has!" --Hippocrates, the father of modern medicine, ca 400 B.C.

Psychoneuroimmunology (PNI) Stress, Emotions, Individual characteristics

Nervous System

Endocrine System

Immune System Breakdown


Stress-induced hormonal alterations are associated with significant clinical effects, such as: • An increased susceptibility to viral infections • Activation of latent viral infections • Onset and exacerbation of autoimmune diseases • Progression of atherosclerotic heart disease and myocardial infarctions • Stroke • Depression

PNI, Selected findings Cardiovascular Disease ►In a prospective study over 15 yrs of 1800 middle aged men, hostility and anger increased CHD and all cause mortality by 50% and 42%, respectively (Schekelle et al., 1983). ►In a prospective study of 2832 people, depression and extreme hopelessness were associated with an increased risk of ischemic heart disease, 55 and 110%, respectively (Anda et al., 1993).

PNI, Selected findings Cancer ►In 2428 men over six years, moderately and highly hopeless men were at significantly increased risk of all-cause and cause-specific mortality relative to men with low hopelessness scores (Everson et al., 1996). ►Psychosocial treatment significantly increased life expectancy in a cohort of metastatic breast cancer patients (Spiegel et al, 1989).


PNI, Selected findings HIV/AIDS ►In 602 men, over six years, depressive affects were associated with significantly greater mortality (Mayne et al., 1996). ►Faster progression to AIDS was related to stressful life events, denial coping, low social support, and increased cortisol (Leserman et al, 2000).

An example of stress associated dysregulation of the PNI axis

PNAS 2003, vol. 100, p. 9090

► This was a longitudinal (6-year) community study that assessed the relationship between chronic stress and IL-6 production in 119 men and women who were caregiving for a spouse with dementia and 106 noncaregivers, with a mean age at study entry of 70.58 (SD 8.03).

An example of stress associated dysregulation of the PNI axis ► Recent medical literature has highlighted a spectrum of ageassociated diseases whose onset and course may be influenced by proinflammatory cytokines, including cardiovascular disease, osteoporosis, arthritis, type 2 diabetes, certain cancers, Alzheimer’s disease, periodontal disease, and functional decline. ► For example, the link to cardiovascular disease, the leading cause of death, is intriguing as IL-6 plays a central role in promoting the production of C-reactive protein (CRP), an important risk factor for myocardial infarction.


Predicted IL-6 (Log10, pg/ml)

An example of stress associated dysregulation of the PNI axis 1.0

Caregivers Controls

p<0.001 p<0212





65 70 75 Age



90 95

â&#x2013;ş Over the course of the study, caregivers' average rate of increase in IL-6 was about four times as large as that of noncaregivers. Furthermore, caregivers consistently reported significantly more stress and loneliness compared with controls.

An example of stress associated dysregulation of the PNI axis â&#x2013;ş These findings have notable implications for morbidity and mortality.

â&#x2013;ş These data provide important evidence of a key mechanism through which chronic stressors may have potent health consequences for older adults, accelerating risk of a host of age-related diseases.


How to handle stress? ►Stress management skills ►Time management ►Diet ►Exercise ►Yoga, meditation, breathwork ►Prayer ►Massage therapy ►etc.

Summary 1. One of the most effective means to relieve stress is through breathing exercises derived from yoga. 2. In traditional ’spiritual’ exercises, such as meditation, yoga, Qigong, etc., a major component of the effects elicited may be due to changes in respiration rate and/or patterns. 3. Yogic breathing exercises may directly influence the functioning of the ANS.

►’’Of all the techniques that I have investigated for reducing stress and increasing relaxation, it is breathwork that I have found to be most timeefficient, the most cost-effective, and the one that most promotes increased wellness and optimal health.’’ Andrew Weil, M.D. Director, Arizona Center for Integrative Medicine University of Arizona Author, ’Spontaneous Healing’


Slow breathing, heart rate and hypertension ► Slow controlled breathing is coincident with important modifications of cardiovascular function, including a marked enhancement of respiratory sinus arrhythmia and a reduction in blood pressure. Hirsch JA, Bishop B. 1993 Am J Physiol Heart Circ Physiol.

► Slow controlled breathing is normally accompanied by a potentiation of the influences of both heart rate and blood pressure on arterial baroreceptors. Radaelli et al. 2004 Am J Hypert

Slow breathing and traditional practices ► Slow breathing, either controlled or occurring naturally, is a hallmark of most traditional practices that are employed to increase health and wellbeing.

Dipartimento di Medicina Interna, U. of Pavia, Pavia; Departimento di Medicina Interna, Unita Ospedaliera S Maria Nuova, Florence British Medical Journal, 2001


Effect of breath on cardiovascular function, some background 1. Reduced heart rate variability and baroreflex sensitivity are powerful and independent predictors of poor prognosis in heart disease. 2. Slow breathing enhances heart rate variability and baroreflex sensitivity by synchronizing inherent cardiovascular rhythms.

Bernardi et al., BMJ 2001 1. Recitation of the rosary, and also of some yoga mantras (type of meditation), slowed respiration to almost exactly 6/min, and enhanced heart rate variability and baroreflex sensitivity. 2. This frequency (6/min) coincides with the subjects' spontaneous Mayer wave frequency and thus enhanced this cardio-vascular oscillation by synchronising sympathetic and vagal outflow. 3. This even resulted in rhythmic fluctuations in cerebral blood flow, which might directly influence central nervous system oscillations. 4. Thus, the rosary or yoga mantra chanting may be viewed as a health practice!

Bernardi et al., BMJ 2001


Somatic vs. Autonomic Nervous System Somatic • • • •

Voluntary Skeletal muscle Single efferent neuron Axon terminals release acetylcholine • Always excitatory • Controlled by the cerebrum

Autonomic • Involuntary • Smooth, cardiac muscle; glands • Multiple efferent neurons • Axon terminals release acetylcholine or norepinephrine • Can be excitatory or inhibitory • Controlled by the homeostatic centers in the brain – pons, hypothalamus, medulla oblongata

Antagonistic control in the ANS

Is meditation effective against hypertension?

4.7 mm Hg decline on average (95% CI)

Anderson et al., Am J Hyp 2008 Meta-analysis of 9 studies


Is meditation effective against hypertension?

3.2 mm Hg decline on average (95% CI)

Anderson et al., Am J Hyp 2008 Meta-analysis of 9 studies

Is meditation effective against hypertension? The regular practice of meditation has the potential to reduce both systolic and diastolic blood pressure that are clinically meaningful.

Anderson et al., Am J Hyp 2008 Meta-analysis of 9 studies

Slow breathing, heart rate and hypertension â&#x2013;ş Thus, slow breathing may be used to

attenuate the sympathetic overactivity that characterizes several conditions in health and disease. Radaelli et al. 2004 Am J Hypert


Neural mechanisms involved in reflex control of cardiovascular function 1. Baroreceptors blood pressure 2. Chemoreceptors pH, [gases]

Meditation and brain activity Electroencephalographic (EEG) studies of meditative states have been conducted for almost 50 years. While there is no clear consensus about the underlying neurophysiological changes from meditation practice, reliable meditation-related EEG frequency effects, as well as EEG coherence and ERP component changes, have been observed.

Cahn and Polich, 2006 Psychological Bulletin

Buddhist meditation and brain activity â&#x2013;ş The subjects were eight long-term Buddhist

practitioners and 10 healthy student volunteers. Buddhist practitioners underwent mental training in the same Tibetan traditions for 10,000 to 50,000 h over time periods ranging from 15 to 40 years. â&#x2013;ş Long-term Buddhist meditation practitioners had sustained electroencephalographic high-amplitude gamma-band oscillations and phase-synchrony during meditation. These electroencephalogram patterns differed from those of controls, in particular over lateral frontoparietal electrodes. Davidson et al., 2004 PNAS


Increased gamma power during Buddhist meditation Cont.


Color code: Percentage of subjects that had an increase in gamma activity during Meditation. Davidson et al., 2004 PNAS

Meditation and brain activity ► Different meditation practices may have different

effects on the EEG with the general finding of power increases in theta and alpha bands and overall frequency slowing. ► For example, one of the hallmarks of the TM technique is the rapid onset and maintenance of high levels of short- and long-range EEG coherence, in alpha, theta and gamma frequencies, especially in the prefrontal cortex. ► Neuroimaging results indicate that frontal and

prefrontal areas are generally activated. Prospective longitudinal assessments are required. Cahn and Polich, 2006 Psychological Bulletin

Meditation experience is associated with increased cortical thickness ► Hypothesis: Since meditation practice is associated with altered resting EEG patterns, suggestive of long lasting changes in brain activity, it is possible that meditation practice might also be associated with changes in the brain’s physical structure. ► Magnetic resonance imaging was used to assess cortical thickness in 20 participants with extensive insight meditation experience, which involves focused attention to internal experiences. ► Brain regions associated with attention, introspection and sensory processing were thicker in meditation participants than matched controls, including the prefrontal cortex and right anterior insula. Differences in prefrontal cortical thickness were most pronounced in older participants, suggesting that meditation might offset age-related cortical thinning.


Meditation experience is associated with increased cortical thickness

1. 2. 3. 4.

Insula Brodmann area 9/10 Somatosensory cortex Auditory cortex Lazar et al., 2006 Neuroreport

The Yogic Science of Breath:

5000+ year-old system of health promotion, one of the first to recognize the impact of mind and emotions as being pivotal/significant in the restoration and maintenance of vibrant health.

"Breath and mind are linked like body and mind. Breath sorts out the imbalances in the mind and the body. Itâ&#x20AC;&#x2122;s the secret of life we have forgotten." --Sri Sri Ravi Shankar


Art of Living practices ► Yoga-classical, hatha yoga

► Ujjayi (victory) breath, pranayama

► Bhastrika (bellows breath) - forced rapid breathing

Sudarshan Kriya (SK) ► Stress-management and self-development program derived from the Yogic Science of Breath ► Precise physiological procedure utilizing distinct rhythms or patterns of breath ► Taught by certified instructors uniformly around the world, so far to over 2 million people in more than 140 countries

Scientific Research on SK&P


Antidepressant effect of SKY in Melancholia (Janakiramaiah et al., 2000) ► Melancholic depressives (n=45) randomized into 3 groups. A) Electroconvulsive therapy (ECT), B) Imipramine (IMN), C) SKY.

► Significant reductions in depression were observed for all groups (as measured by BDI and HRSD).

Antidepressant effect of SKY

HRSD Score

ECT (n=15) IMN (n=15) SKY (n=15)





Assessment week

Antidepressant effect of SKY

BDI Score

ECT (n=15) IMN (n=15) SKY (n=15)





Assessment week


Antidepressant effect of SKY in Melancholia (Janakiramaiah et al., 2000) â&#x2013;ş IMN and SKY were comparable â&#x2013;ş SKY is a potential alternative to current standard antidepressant treatments. -absence of unwanted side effects -self-empowering -cost-effective

Stress relief in healthy people through SK&P? t=6 wks








Home practice

Days 1-6

Group 1: SK&P, daily practice (n=48) Group 2: Sitting w/eyes closed, <=15 min/day (n=55)

Kjellgren et al., 2007 BMC Complement Altern Med

Decreased anxiety and depression through SK&P

Depression SK&P Cont

Relative Anxiety (HAD)

9 8 7





5 4


Relative Depression (HAD)


SK&P Cont








3 2








Kjellgren et al., 2007 BMC Complement Altern Med


Decreased stress and increased optimism through SK&P


Stress Relative Stress (SE)



* P=0.003





Relative Optimism

25 SK&P Cont

* 20


SK&P Cont

* P=0.002








Kjellgren et al., 2007 BMC Complement Altern Med

Experience of altered states of consciousness during SK&P

Experience of Altered States of Consciousness (EDN)

* 40




* P<0.001

* 0



Kjellgren et al., 2007 BMC Complement Altern Med

Natural Killer (NK) cells

â&#x2013;şKill virally infected and tumor cells â&#x2013;şPrevent tumor growth and metastases


Natural Killer (NK) cells ►Kill virally infected and tumor cells ►Prevent tumor growth and metastases ►NK cell toxicity is down-regulated by stress ►NK-activating cytokine production 25-fold lower in medical students taking exams (e.g. Glaser et al, 1986)

Increase in NK cells through SKY

Flowcytometry: NK Cells 30

p<0.001 25

% of cells

► NK cells significantly higher in SKY practitioners compared with normal and cancer patients (p<0.001).

20 15 10 5 0



Cancer patients




Kochupillai et al., 2005 Ann N Y Acad Sci.

Increase in NK cells through SKY in cancer patients remission, left either untreated (n=6) or practiced SKY (n=21) for a period of 6 months. NK cells significantly higher in SKY group compared with control patients (p<0.05).

► Similar results obtained through use of Nishino breathwork, derived from martial arts/Qigong (Kimura et al. 2005, J Alt Com Med).

Relative NK cell number

► Cancer patients in 20


SKY Cont





1 12 Sampling time (weeks)


Kochupillai et al., 2005 Ann N Y Acad Sci.


Other findings/ongoing studies on SK&P ►Decreased levels of the ’stress’ hormone cortisol. ►Increased levels of the ’wellness’ hormone prolactin. ►In EEG, increased alpha waves, interspersed with beta waves. ► Decreased levels of blood cholesterol. ► Decreased levels of PTSD symptoms. ► Possible effects of SK&P on respiratory function. ► Possible effects of SK&P on gene expression. ► For details:

SUMMARY ►As exemplified by the yogic breathing exercises, the subjective reports of increased health, vitality, well-being, and peace of mind through ‘meditative’ practices are supported by research findings, which suggest an overall strengthening of the mind/body system at all levels. ►Further studies are certainly needed; however, these practices provide a possibility for powerful health restoration and promotion effects. Therefore, they could be incorporated into the current medical practice as a preventive and adjunct regimen.

The need for integrative medicine ►Integrative medicine has been defined as healing-oriented medicine that takes account of the whole person (body,mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative. ►Integrative medicine embraces the concerns of the public and medical profession for more effective, compassionate, patient-centered medicine. Recently,the number of medical schools providing education related to integrative medicine has grown rapidly.


Some Centers for Integrative Medicine in the US academic institutions

Integrative Medicine in the Netherlands?

Focus Altern Complement Ther 2007; 12: 21 Hospital-based integrative medicine in the Netherlands van Duijn RM1, Georgiou M, Koolen R, von Rosenstiel I Slotervaart Hospital, Amsterdam, Louwesweg 6, 1066 EC, the Netherlands

â&#x20AC;&#x153;Then you should do yogic breathing!â&#x20AC;?


Partnerships needed!


Breathwork and effects on the immunesystem, brain function, and behaviour