Ann sbv 2014 vol 3 iss 1

SRI BALAJI VIDYAPEETH ACADEMY OF HEALTH PROFESSIONS EDUCATION AND ACADEMIC DEVELOPMENT

ANNALS OF SBV Volume 3 - Issue 1 Jan - Jun 2014

Theme

Mind-Body Medicine

Annals of SBV Editorial Advisor

Editor-in-Chief

K R. Sethuraman

N.Ananthakrishnan Core Committee

T.R. Gopalan

V.N. Mahalakshmi

K.A. Narayan

Karthiga Jayakumar

Usha Carounanidy

R. Pajanivel

S. Kamalam

R. Jagan Mohan

M. Ravishankar Issue Editor Sivaprakash B Statistical Consultant G.Ezhumalai

Editorial and Production Consultant A.N. Uma Editorial Assistance M. Shivasakthy

A. Kripa Angeline Technical Assistance George Fernandez

Published, Produced and Distributed by Sri Balaji Vidyapeeth

Editorial correspondence to Editorial and Production Consultant

Annals of SBV Sri Balaji Vidyapeeth

(Deemed to be University, Declared Under Section 3 of the UGC Act, 1956) Mahatma Gandhi Medical College & Research Institute Campus Pillaiyarkupam, Puduchery - 607 402 INDIA E.mail:annals@sbvu.ac.in | Phone : +91 413 2615449 to 58 | Fax : +91 413 2615457 Visit Annals of SBV Online at http://www.annals.sbvu.ac.in

Index 1. From the editor’s desk An Introduction to the issue on Mind-Body Medicine

05

- Sivaprakash B

2. Understanding music therapy - Clearing misconceptions

08

- Sumathy Sundar

3.

Music and health

12

- Sivaprakash B, Srinivasan AR

4. A review of the anxiolytic effect of music and its clinical applications

16

- Sivaprakash B

5.

Physiology & neurobiology of stress & the implications for physical health

25

- Sukanto Sarkar, Sivaprakash B

6. Yoga and mind body therapies in health and disease - A brief review

29

- Ananda Balayogi Bhavanani , Meena Ramanathan Bhavanani , Madanmohan

7. A yogic perspective on health & disease

42

- Meenakshi Devi Bhavanani

8. Yogic perspectives on mental health

47

- Ananda Balayogi Bhavanani

9.

The yoga of interpersonal relationships

53

- Ananda Balayogi Bhavanani

10. Spirituality & health - Concepts & controversies - Avudaiappan S

61

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From the Editor’s Desk An Introduction To Mind-Body Medicine Dr. Sivaprakash B *

The World Health Organization defines health as “a state of complete physical, mental and social well-being”. Mental health is an integral & essential part of health; indeed, there is no health without mental health. Scientific research has now established that the mind is basically a manifestation of complex electrical & chemical activities within the neural circuits of the brain.

In simple words, the mind is a group of complex functions of the brain. The main components of the mind include consciousness, thought, emotion, & behaviour. Other important dimensions of the mind include memory, intelligence, attitudes, motivation, & character. Mental health is a state of well-being characterized by the ability to successfully regulate thoughts, emotions, & behaviour, understand the feelings of others & respond appropriately, have healthy relationships with other people, feel enthusiastic & motivated, work productively & fruitfully, adapt to change, & cope with stress & realize one’s full potential.

Mental health is the foundation for the well-being & effective functioning of individuals, families, society, and humanity as a whole.

Psychosomatic medicine is a speciality that seeks to advance the scientific understanding & multidisciplinary integration of biological, psychological, behavioral & social factors in human health & disease & to incorporate this understanding into health care.1 Related fields include mind-body medicine, behavioral medicine, integrative medicine, & health psychology. The boundaries of all these disciplines are not clearly defined, and there is significant overlap.1 Mind-body medicine focuses on research and practices pertaining to the interrelationships of the mind, brain, bodily organ systems and behavior (Lane, 2009).1 According to the Center for Mind-

Body Medicine, USA, mind-body medicine focuses on the interactions between mind and body and the powerful ways in which emotional, mental, social and spiritual factors can directly affect health.

How does the mind influence physical health?

The pathways from mind to body can be classified into the following levels: (A) mental / psychological / behavioral states & traits, (B) brain, (C) information transfer systems (ANS, endocrine, immune) & (D) body proper (end-organs).2 The mind (A) can influence the body (D) only through levels B & C.2 Introducing the brain into psychosomatic research may identify causal mechanisms that link thoughts & emotions to the regulation of peripheral biological phenomena.3 This is the basis of the new field called “brain-body medicine”.3 The concept of mind-body medicine can actually be subsumed under brainbody medicine. Brain-body medicine focuses on interactions between the brain, peripheral pathways & bodily end-organs.1 The prefrontal cortex, limbic system & hypothalamus play a critical role in the interactions between the mind & brain-body pathways. Brain-body pathways are the physical substrates that mediate the association between the mind & physical health.The main brain-body information transfer systems are the autonomic nervous system, the hypothalamic-pituitary-adrenal (HPA) axis & the neuro-immune pathway. Extensive scientific research over several decades has clearly established the powerful influence of emotions on these brain-body information transfer systems.

In addition, mental health influences physical health through the “health behaviour pathway” too.

Health behaviour covers a range of activities such as maintaining personal hygiene, eating sensibly, sleeping well, avoiding smoking & alcohol, exercising regularly, following medical prescriptions etc.

* Dr. Sivaprakash B, Professor of Psychiatry Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India.

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Mind-body therapies such as meditation, prayer, yoga, relaxation therapy, etc., produce health benefits mainly through the brain-body information transfer systems.4 For example, functional neuroimaging has shown that music can modulate activity of limbic, paralimbic brain structures & hypothalamus. Music therapy can thus influence peripheral physiological processes through the brain-body information transfer systems.5,6

All these interesting concepts are covered in this issue of the Annals of SBV. The physiological effects & health benefits of music therapy & yoga are explored in a series of reviews. In addition, this issue also contains special articles on stress medicine & the association between spirituality & health.

Figure 1: This picture illustrates how the emotions & stress influence physical health through the brain-body information transfer systems. The brain regulates the immune system through the autonomic and neuroendocrine systems. The figure depicts sympathetic innervation of the adrenal medulla, which secretes epinephrine, and sympathetic and parasympathetic innervation of lymph nodes. The HPA axis, prolactin, and growth hormone, together with epinephrine, influence the immune cells that secrete cytokines. (PFC = Prefrontal cortex)

Figure 2: Mind-body therapies such as meditation, prayer, yoga & music therapy act on the brain, where they generate positive emotions, reduce negative emotions, & reduce stress. This translates into health benefits through the brain-body information transfer systems.

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References

1. Lane RD, Wager TD. Introduction to a special issue of Neuroimage on Brain-Body Medicine. Neuroimage 2009; 47:781–4.

2. Lane RD, Waldstein SR, Chesney MA, Jennings JR, Lovallo WR, Kozel PJ, Rose RM, Drossman DA, Schneiderman N, Thayer JF, Cameron OG.The rebirth of neuroscience in psychosomatic medicine, Part I: historical context, methods, and relevant basic science. Psychosom Med 2009; 71:117–34.

3. Lane RD, Waldstein SR, Critchley HD, Derbyshire SWG, Drossman DA, Wager TD, Schneiderman N, Chesney MA, Jennings JR, Lovallo WR, Rose RM, Thayer JF, Cameron

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OG.The rebirth of neuroscience in psychosomatic medicine, Part II: clinical applications and implications for research.

Psychosom Med 2009; 71:135–51.

4. Taylor AG, Goehler LE, Galper DI, Innes KE, Bourguignon C. 2010. Top-down and bottom-up mechanisms in mindbody medicine: development of an integrative framework for psychophysiological research. Explore (NY ) 2010; 6:29–41.

5. Menon V, Levitin DJ. 2005. The rewards of music listening: response and physiological connectivity of the mesolimbic system. Neuroimage 2005; 28:175–84.

6. Koelsch S. A neuroscientific perspective on music therapy.

Ann. N. Y. Acad. Sci. 2009; 1169:374–84.

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Understanding music therapy - Clearing misconceptions Dr. Sumathy Sundar *

Introduction

While there is a growing interest in the field of music therapy among medical professionals and students, and allied health care professionals and students in India, there are deep rooted misconceptions and a lack of clarity about this field. It is a matter of concern that though there is a lot of interest shown by these people in learning about how to offer clinical music therapy services, their knowledge is limited to theexistence of music healing practices in Indian history and culture and they struggle to integrate these practices into clinical services. The confusion is about identifying what is healing and what is music therapy and understanding the difference between healing and music therapy. Also there is a strong belief that there are readymade general prescriptions of music available for curing various diseases. There is also an enigma around music medicine (music being used as therapy by medical professionals) and music therapy in which music is being used as therapy. The practices are based on belief systems using history as a tool. The various music therapy techniques apart from the receptive listening experiences are not still known due to lack of training. This article attempts to clear all these misconceptions and also explain what is music therapy, the theoretical background and the therapeutic processes involved in clinical music therapy sessions.

What is Music Therapy?

According to World Federation of Music Therapy, the definition of music therapy is as follows. Music therapy is the professional use of music and its elements as an intervention in medical, educational and everyday environments with individuals, groups, families or communities who seek to optimize their quality of life and improve their physical, social, communicative, emotional, intellectual, and spiritual health and well being. Research, practice, education and clinical training in music therapy are based on professional standards according to cultural, social and political

contexts.1 Music therapy is an interpersonal process in which the therapist uses music and all of its facets-physical, emotional, mental, social, aesthetic, and spiritual-to help clients to improve or maintain their health. In some instances, the client’s needs are addressed directly through music; in others they are addressed through the professional relationship between the client and therapist.2

Healing and Music Therapy

What is a healing practice? Healing is deepened and inherited not so much with words but by “feeling in one’s body, heart and soul” and “belief“.3 and music therapy is something observable and measurable. It is an evidencebased practice as indicated by many Cochrane reviews. “In some culturesthe drive for theory is not sointense. Things are just known. Explanations are not always required for practices to be accepted. Understandings are transferred across the generations through action. Indeed, in some societies in which traditional healing practices are maintained, healing is contingent on not questioning the how’s, why’s, what’s, when’s, where’s of the experience. In these societies, the value is on belief more than description or explanation.”3 This situation holds true for Indian situations. The local resources by way of healing practices like Raga Chikitsa, Vedic Chanting and Chakra activation exist as a strong belief system as a curative solution and the lastdecade of development in the music therapy field was based only on this premise. Now, new horizons have emerged. The unquestionable is being questioned. There is a shift from using the static-history as a tool for explaining the practice of art of healing to the dynamic music therapy workings which explain how music, therapy, cultural, spiritual and social context work in a clinical set upare rationalized. 4, 5 Further, we can question now how traditional practices located in a past that has its own validity can be transposed in time to the present.6 However, there is another understanding that music therapy in general is

* Dr. Sumathy Sundar, Head, Center for Music Therapy Education and Research Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India Page 8

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a rational science as well as an art with irrational aspects and anthropological, cultural and personal dispositions playing an important role in reception of music.7 By culture, we mean belief systems, philosophical orientations, tradition, religion, art, values and societal norms for behavior. In a country like India where there is a rich tradition and culture and philosophy of life is linked strongly to religion and spirituality, during the therapy process, when we want to connect to the client, the musical experiences which are closer to these aspects play a more important role than the drive for theory.

The local healing resources which are available throughout history cannot be ignored completely as they strongly form the basis for the clients’ actual needs. The principle function of music in these healing practices is at times healing, at times spiritual, at times religious, and sometimes a combination of these three elements. 5 Hence, ways and means to integrate these resources become primarily important in practice, education and research. The unquestionable is questioned, also at the same time keeping in mind that the local resources should be transferred wherever possible with a need for explaining the processes involved. 5 Methods and Responses

Also, the musical experiences that the therapists use in the music therapy sessions range widely from the methods of passive listening tothe active recreative experiences, song writing, improvisation, playing of musical instruments and engaging in verbal discussion methods.

Sometimes, the therapist sings and at other times, the clients sing. The therapist play both tuned and untuned musical instruments and also engage the clients with baseline, prompted, collaborative andindependentmusical tasks in singing, moving, rhythmicand playing musical instruments.8 The musical responses for engagement, pleasure, selfconfidence and creativity levels are recordedduring initial assessment to find out the musical profile of the client and for planning the therapy protocol.8The therapist selects musical experiences depending on the needs of the clients and also the goals set for therapy.

The responses range from developing sensorimotor skills, learning adaptive behaviours, developing spontaneity, creativity and freedom of Page 9

expression and also developing communication and interpersonal skills. Individual singing exercises can help individuals who have speech impairments to help improve their articulation or fluency.

Group singing builds reality orientation in elderly individuals, or help mentally retarded people develop adaptive behavior, or build cohesiveness in a dysfunctional family or group. Playing instruments can help physically disabled clients to develop gross and fine motor coordination.1 Music Therapy Process and Outcome

The different stages of music therapy, a systematic process of intervention are 1) Referral, 2) A first session: Building Rapport, 3) Assessment, 4) Setting up Goals, Objectives and Targets, 5) Observation, 6) Music Therapy Strategies, 7) MT Treatment plan, 8) Implementation 9)Evaluation and 10)Termination8 During these stages the therapist works on modulating eitherthe client’s communication or the behavior, emotions, attention or cognition. The neuro biological outcome of the therapeutic musical dialoging depends on 1) the therapist recognizing the needs of the client and the client recognizing the intention of the therapist to help him 2) the therapist’s ability to get into emotional resonance with the client 3) engaging in musical activities that result in shared attention between the therapist and the client 4) the therapist understanding the motivation and the intention of the client and 5) the cooperative action between the therapist and the client.9 The mind, a product of the brain, influences physical health through three brain-body information

transfer systems namely the autonomic nervous system (ANS), neuroendocrine pathways and Annals of SBV

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neuroimmune pathways and the health behavior pathways.10

Music therapy being a mind body medicine, the therapeutic musical dialoguing outcome during the music therapy process depend on how the brain transfers the information to the ANS, Endocrine and Immune pathways and the Health Behaviour pathway influencing the physical health.

Researchers have indicated that there are many major computational centres for processing music in the brain which get influenced by appropriate musical inputs to transfer positive information to the ANS, Endocrine and Immune pathways to achieve physical health.

Music as Medicine Versus Music Therapy

Use of recorded music by medical professionals who may not be skilled musicians or music therapists in order to achieve desired biological effects is a regulatory approach called music medicine approach. which depends on the inherent quality of music to reach the desired goal. Music therapy is both a regulatory and a relational approach which has a interpersonal component working as a dynamic force within the therapeutic process between the therapist and the client. The following table indicate the

difference and the research designs between music in medicine and music therapy approaches. 11

Conclusion

Music therapy is both an art and science of healing and an evidence-based practice.

The scientific aspect of this field is yet to be established firmly in India due to lack of adequate trainingfacilities across the country.Pioneering efforts are being taken by medical universities such as Sri Balaji Vidyapeeth to launch professional training programs and introduce music therapy as a medical discipline not only to create awareness about the field but also to integrate music therapy into clinical practice based on education and research. The Centre for Music Therapy Education and Research, a unit of Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth has commenced a one year Post Graduate Diploma Program in March 2014. This initiative is surely an important milestone in India for the development of music therapy as a profession and an academic discipline.

TABLE 1.   Therapeutic concepts and their research designs Music medicine

Music therapy in medicine

Positivistic scientific tradition

Hermeneutic scientific tradition

Biomedical concept

Relational-medical concept

Music has therapeutic potential by itself

Emphasis on relation: therapist-client; music-client

Symptom orientation

Health orientation

Starting-point: illness

Starting-point: health (resources)

Music as medicine

Artistic-creative activity

Desired biological effects

Improved quality of life through creative expression of self

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References

1. Bruscia, K E (1993). Music Therapy Brief. Barcelona Publishers. Available from www.temple.edu/musictherapy/ home/program/faq/htm 2. Definition of music therapy. Available at www. musictherapyworld.net/WFMT/About_WFMT.html

3. Kenny, C. B. (2001). Review of: Constructing Musical Healing: The Wounds That Sing, by June Boyce-Tilman. The Arts in Psychotherapy, 28, 265- 269.

4. Sundar, S. (2012). Music Therapy Training in India: New Horizons. Proceedings of International Seminar on Current Trends in Music Therapy Practices: Methodology, Techniques and Implementation. Benares Hindu University. Page 57-58 5. Sundar, S. (2014). In press. (Ed) Goodman, KD. Music Therapy Education in India: Developmental Perspectives in International Perspectives in Music Therapy Education and Training: Adapting to a Changing World. Charles C Thomas Ltd. Illinois. US. 6. Aldridge, D. (2006) Performative Health - a commentary

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on Traditional Oriental Music Therapy. Music Therapy Today (Online) Vol.VII (1) 65-69. available at http:// musictherapyworld.net

7. Tucek et al. (2006). The revival of Traditional Oriental Music Therapy discussed by cross cultural reflections and a pilot scheme of a quantitative EEG-analysis for patients in Minimally Responsive State. Music Therapy Today(online) Vol. VII (1), (March) 39-64. available at http://musictherapyworld.net.

8. Hanser SB. (2000). The New Music Therapist’s Hand book.

Berkeley Press. US. 9. Tucek, G. (2006) Traditional oriental music therapy – a regulatory and relational approach. Music Therapy Today (Online 1st October) Vol.VII (3) 623-647.

10. Sivaprakash, B. (2014). (Ed) Mind & Medicine. Newsletter.

Department of Psychiatry. Mahatma Gandhi Medical College. Pondicherry. Volume 1 Issue 1 July-Sep 2013 11. Krautschick (2003) Relationship between music in medicine and music therapy in medicine. http://www.hisf.no/sts/ Musikkterapi/hovudfag/semv01_Krautschick.html

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Music and health : An overview of music therapy & music medicine Dr. Sivaprakash B * Dr. Srinivasan A R **

Abstract

This review attempts to provide a brief overview of the role of music in health and disease.

The review starts with a brief introduction to complementary/alternative medicine & mindbody medicine. The differences between music therapy & music medicine are highlighted next.An overview of the effects & clinical applications of music therapy is provided. Numerous randomized controlled trials & systematic reviews have elucidated the clinical benefits of music. Some of the salient published findings are presented in this review. Music therapy is postulated to have beneficial effects on health by reducing negative emotions & stress, inducing mental well-being, & harnessing the power of brain-body information transfer systems (neuroendocrine system, autonomic nervous system and the neuroimmune pathway). Neuroscience research on the brain’s processing areas for music has revealed interesting facts. Some of these are described in this review.

Experts have emphasized that musical preferences of the patient / client need to be taken into account while planning music therapy. The review ends with a note on the significance of musical characteristics & genre in the context of music therapy and music medicine.

Complementary/alternative medicine & mindbody medicine

The term “mind” refers to the totality of mental functions related to consciousness, thought, mood, and behavior, derived from activities within the brain.1 Mental health is a key determinant of overall health.2 The influence of the mind on the body and the effect of psychological factors in health and disease are well known.2 Complementary and alternative medicine (CAM) refers to the various disease-treating or disease-preventing practices whose methods and efficacy differ from conventional biomedical treatment.3 Some of these CAM approaches can

be used in conjunction with allopathic medicine.3 Mind-body medicine is a domain within CAM that focuses on the interactions between mind and body, and the ways in which emotional and behavioral factors can directly affect health.4 Mindbody practices use the mind to affect physical functioning and promote health.4 Music therapy is classified as a mind-body intervention, along with yoga, meditation, biofeedback etc.3 The PubMed MeSH database5 classifies music therapy under “Sensory Art Therapies” (therapies using arts or directed at the senses), within the broad category of complementary therapies.

Music therapy & music medicine

Music therapy is the clinical and evidencebased use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.6 It is an established health service similar to occupational therapy and physical therapy and consists of using music therapeutically to address physical, psychological, cognitive and/or social functioning for patients of all ages.6 Music therapy requires no prior musical knowledge/skill on the part of the patient.7 Interventions are categorized as ‘music medicine’ when passive listening to pre-recorded music is offered as an ancillary therapy, by medical personnel who are not necessarily specialized in the field of music therapy.7,8 In contrast, music therapy requires the implementation of a music intervention by a trained/qualified music therapist.7,8 In active music therapy, the patient makes music either alone, with a therapist or within a group.7 Typical intervention techniques include singing, playing with rhythm, improvisation, and the composition of music or songs.7 In receptive music therapy, therapeutic goals are pursued by listening to recorded or live music.7 An overview of the effects & applications of music therapy

A substantial body of literature exists to

* Dr. Sivaprakash B , Professor of Psychiatry, ** Dr. Srinivasan A R, Professor of Biochemistry Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India.

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support the effectiveness of music therapy.6 Healthy individuals can use music for stress reduction via active music making, as well as passive listening for relaxation.6 Music is often a vital support for physical exercise.6 Music therapy may be used to facilitate labor and delivery.6 Effects of music for stress reduction have been documented in physiological (e.g. heart rate, blood pressure, hormonal levels), neurological (e.g. EEG readings) and psychological (e.g. self-report, the Spielberger State-Trait Anxiety Inventory) domains.8 Music is used in hospitals to alleviate pain in conjunction with anesthesia or pain medication: elevate patients’ mood and counteract depression; promote movement for physical rehabilitation; calm or sedate, often to induce sleep; counteract apprehension or fear; and lessen muscle tension for the purpose of relaxation.6 Anxiety and stress reduction is one of the primary outcomes investigated in music medicine and music therapy research with medical patients.8 The effects of both music and music therapy interventions have been documented in a range of medical patients, for example, pre-surgical, oncology, pediatric, and preprocedural patients.8 Published research on music therapy

RCTs have documented the effect of music therapy on postoperative pain,9,10 preoperative anxiety,9,11 and the stress response to cardiac surgery.12 RCTs have been conducted to study the impact of music on anesthesia,13-15 and the role of music in the management of cerebrovascular disease,16 and obstructive sleep apnea syndrome.17 In addition, RCTs have explored the effects of music on preterm infants18 and ventilatordependent patients.19 A systematic review of 42 randomized controlled trials showed that music intervention reduced perioperative anxiety and pain, in approximately half of the reviewed studies.20 A Cochrane review of 51 studies on the effect of music on pain concluded that listening to music reduces pain intensity levels and opioid requirements.21 A Cochrane review of 23 randomised controlled trials concluded that music listening may have a beneficial effect on blood pressure, heart rate, respiratory rate, anxiety, Page 13

and pain in persons with coronary heart disease.8 A meta-analysis of 8 randomized controlled trials concluded that music improves patients’ overall experience with colonoscopy.22 A Cochrane review stated that 4 of the 5 studies reviewed reported greater reduction in symptoms of depression among those randomised to music therapy than to those in standard care conditions.23 A Cochrane review of 4 randomised controlled trials of music therapy for schizophrenia concluded that music therapy as an addition to standard care may improve symptoms.24 A review of 13 studies observed that music therapy reduced agitation in patients with dementia, in a majority of the studies.25 The adjunctive role of music therapy has been studied in several clinical conditions such as coronary heart disease, chronic obstructive pulmonary disease, breast cancer, skin diseases, dementia, traumatic brain injury, and perioperative scenarios.In the realm of obstetric & gynecologic practice, the supportive role of music therapy has been studied in normal & high-risk pregnancy, labor, cesarean section delivery, and postpartum women.

Additionally, research data is available on the role of music in clinical procedures such as bronchoscopy, gastroscopy, colonoscopy and dental procedures.The effect of music on patients undergoing procedures such as radiation therapy, chemotherapy, burn dressing changes, and bone marrow biopsy has been documented.

How does music influence health?

Factors that contribute to the effects of music therapy include attention modulation, emotion modulation, cognition modulation, behavior modulation and communication modulation.26 These processes can have beneficial effects on psychological & physiological health.26 Music can evoke strong emotions & reliably affect mood.27 Music-evoked emotions can modulate activity in all limbic & paralimbic brain structures.27 Functional magnetic resonance imaging shows that listening to music modulates activity in a network of mesolimbic structures of the brain, including the nucleus accumbens, ventral tegmental area, hypothalamus & insula, which regulate autonomic & physiological Annals of SBV

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responses to rewarding & emotional stimuli.28 It is well known that the hypothalamus exerts control over several vital bodily functions through the brain-body information transfer systems such as the hypothalamic-pituitary-adrenal axis & the autonomic nervous system. Therefore, hypothalamic activation induced by music is of special interest.

Positron emission tomography has been used to demonstrate that pleasant emotional responses to music are associated with changes in cerebral blood flow in brain regions thought to be involved in reward/motivation, emotion, and arousal, including ventral striatum, midbrain, amygdala, orbitofrontal cortex, and ventral medial prefrontal cortex.29 The brain’s major computational centers for music30 Region Auditory cortex

Significance / task The first stages of listening to sounds; the perception and analysis of tones Visual cortex Reading music; looking at a performer’s movements (including one’s own) Cerebellum Movements such as foot tapping, dancing and playing an instrument; also involved in emotional reactions to music Prefrontal cortex Creation of expectations; violation and satisfaction of expectations Motor cortex Movement; foot tapping; dancing; playing an instrument Sensory cortex Tactile feedback from playing an instrument and dancing Hippocampus Memory for music, musical experiences and contexts Amygdala Emotional reactions to music Nucleus accumbens Emotional reactions to music Musical preferences of the patient / client

An individual’s musical preference is highly Page 14

subjective.31 Music that feels soothing to one may feel unpleasant to others.31 Some factors that influence musical preference & taste include age & gender, familiarity with the music, culture, community & peer influences, intelligence & education, socioeconomic status, musical training, mood & personality and current situation & circumstances.31 An important prerequisite for effective music therapy is that the patient enjoys what he or she is hearing.7 The individual’s preferences, circumstances and need for treatment, and the client or patient’s goals help to determine the types of music a therapist may use.32 Further research is required to clarify the differential effects of therapist/researcher-selected music versus patient-selected music.8 Therapeutic significance characteristics & genre

of

musical

There is no particular style of music that is more therapeutic than the rest.32 An eclectic and unbiased approach is recommended while selecting music for therapy. Regardless of subjective factors, there are some sound characteristics which move us in certain emotional, physical or psychological directions.31 Certain sound patterns motivate us, while others tend to evoke peace or relaxation.31 Musical elements that affect a listener include rhythm, volume, complexity, variation in pitch, repetition within the tune, & the type of music.31 Musical mode (major/minor mode) may play a role in the type of emotion triggered by music. It has been noted that major mode music conveys/ induces happiness.33,34 Although researchers have extensively investigated the effects of specific musical characteristics such as tempo, melody, harmony and timbre, on emotional responses in non-medical populations, such research is still needed with medical patients.8 More controlled trials are needed with medical patients to further examine which specific musical characteristics enhance the psychological and physiological benefits of music.8 There exists a popular view that certain special “ragas” of Indian classical music have specific therapeutic indications and possess unique therapeutic efficacy in the context of specific disorders/diseases/symptoms. However, there is insufficient evidence in the published research Annals of SBV

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literature to support this concept of “therapeutic specificity of selective ragas”. The scientific validity of this widely held notion needs to be formally tested and documented through rigorous, welldesigned randomized controlled trials.

References

1. U.S.Department of Health and Human Services. Mental health: A report of the Surgeon General - Executive summary. U S Department of Health and Human Services [ 1999 [cited 2010 Oct. 1]; Available from: URL:http://www. surgeongeneral.gov/library/mentalhealth/home.html

2. World health organization. The world health report 2001 - Mental health: New understanding, new hope. Geneva: World health organization; 2001.

3. Sadock BJ, Sadock VA. Complementary and alternative medicine in psychiatry. In: Sadock BJ, Sadock VA, editors.

Kaplan & Sadock’s synopsis of psychiatry. 10th ed.

Philadelphia: Lippincott Williams & Wilkins; 2009. 839-856.

4. National center for complementary and alternative medicine.

What is complementary and alternative medicine? National center for complementary and alternative medicine [ 2010 [cited 2010 Oct. 21]; Available from: URL:http://nccam.nih. gov/health/whatiscam/

5. National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health. MeSH. National Center for Biotechnology Information [ 2010 [cited 2010 Nov. 9]; Available from: URL:http://www.ncbi.nlm.nih. gov/mesh 6. American Music Therapy Association. Music therapy and medicine. American Music Therapy Association [ 2007 [cited 2007 Sept. 7]; Available from: URL:www.musictherapy.org

7. Rose J, Bartsch HH. Music as therapy. Karger Gazette 2009; 70:5-7.

8. Bradt J, Dileo C. Music for stress and anxiety reduction in coronary heart disease patients. Cochrane Database Syst Rev 2009;(2):CD006577.

9. Good M, Albert JM, Anderson GC, Wotman S, Cong X, Lane D et al. Supplementing relaxation and music for pain after surgery. Nurs Res 2010; 59(4):259-269.

10. Nilsson U, Rawal N, Unosson M. A comparison of intraoperative or postoperative exposure to music--a controlled trial of the effects on postoperative pain. Anaesthesia 2003; 58(7):699-703.

11. Padmanabhan R, Hildreth AJ, Laws D. A prospective, randomised, controlled study examining binaural beat audio and pre-operative anxiety in patients undergoing general anaesthesia for day case surgery. Anaesthesia 2005; 60(9):874877.

12. Nilsson U. The effect of music intervention in stress response to cardiac surgery in a randomized clinical trial. Heart Lung 2009; 38(3):201-207.

13. Lepage C, Drolet P, Girard M, Grenier Y, DeGagne R. Music decreases sedative requirements during spinal anesthesia.

AnesthAnalg 2001; 93(4):912-916.

14. Szmuk P, Aroyo N, Ezri T, Muzikant G, Weisenberg M, Sessler DI. Listening to music during anesthesia does not reduce the sevoflurane concentration needed to maintain a

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constant bispectral index. AnesthAnalg 2008; 107(1):77-80.

15. Zhang XW, Fan Y, Manyande A, Tian YK, Yin P. Effects of music on target-controlled infusion of propofol requirements during combined spinal-epidural anaesthesia. Anaesthesia 2005; 60(10):990-994.

16. Sarkamo T, Tervaniemi M, Laitinen S, Forsblom A, Soinila S, Mikkonen M et al. Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain 2008; 131(Pt 3):866-876.

17. Puhan MA, Suarez A, Lo CC, Zahn A, Heitz M, Braendli O. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. BMJ 2006; 332(7536):266-270.

18. Lubetzky R, Mimouni FB, Dollberg S, Reifen R, Ashbel G, Mandel D. Effect of music by Mozart on energy expenditure in growing preterm infants. Pediatrics 2010; 125(1):e24-e28.

19. Wong HL, Lopez-Nahas V, Molassiotis A. Effects of music therapy on anxiety in ventilator-dependent patients. Heart Lung 2001; 30(5):376-387.

20. Nilsson U. The anxiety- and pain-reducing effects of music interventions: a systematic review. AORN J 2008; 87(4):780-807.

21. Cepeda MS, Carr DB, Lau J, Alvarez H. Music for pain relief.

Cochrane Database Syst Rev 2006;(2):CD004843.

22. Bechtold ML, Puli SR, Othman MO, Bartalos CR, Marshall JB, Roy PK. Effect of music on patients undergoing colonoscopy: a meta-analysis of randomized controlled trials.

Dig Dis Sci 2009; 54(1):19-24.

23. Maratos AS, Gold C, Wang X, Crawford MJ. Music therapy for depression. Cochrane Database Syst Rev 2008;(1):CD004517.

24. Gold C, Heldal TO, Dahle T, Wigram T. Music therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database Syst Rev 2005;(2):CD004025.

25. Wall M, Duffy A. The effects of music therapy for older people with dementia. Br J Nurs 2010; 19(2):108-113.

26. Koelsch S. A neuroscientific perspective on music therapy.

Ann N Y AcadSci 2009; 1169:374-384.

27. Koelsch S. Towards a neural basis of music-evoked emotions.

Trends CognSci 2010; 14(3):131-137.

28. Menon V, Levitin DJ. The rewards of music listening: response and physiological connectivity of the mesolimbic system.

Neuroimage 2005; 28(1):175-184.

29. Blood AJ, Zatorre RJ. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. ProcNatlAcadSci U S A 2001; 98(20):1181811823.

30. Levitin D. This is your brain on music - Understanding a human obsession. London: Atlantic Books; 2006.

31. Ortiz JM. Choosing one’s music. In: Ortiz JM, editor. The Tao of music. Dublin: Newleaf; 1997. 355-359.

32. American Music Therapy Association. Frequently asked questions about music therapy. American Music Therapy Association [ 2010 [cited 2010 Oct. 23]; Available from: URL:http://www.musictherapy.org/faqs.html 33. Khalfa S, Schon D, Anton JL, Liegeois-Chauvel C. Brain regions involved in the recognition of happiness and sadness in music. Neuroreport 2005; 16(18):1981-1984.

34. Suda M, Morimoto K, Obata A, Koizumi H, Maki A. Emotional responses to music: towards scientific perspectives on music therapy. Neuroreport 2008; 19(1):75-78.

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A review of the anxiolytic effect of music and its clinical applications Dr. Sivaprakash B *

Introduction

Neuroscience has established beyond doubt that the mind is a product of the brain. It is also known that the central and peripheral nervous systems extend their cells and synapses throughout the body.1 The mind exerts a profound influence on physical health through intricate and widespread neuro-endocrine and neuro-immune pathways.

Mental health is a key determinant of overall health. Anxious and depressed moods, for example, initiate a cascade of adverse changes in endocrine and immune functioning, and create increased susceptibility to physical illnesses.2 The field of psychosomatic medicine emphasizes the unity of mind and body and the significance of psychological factors in all disease states.3 Concepts derived from psychosomatic medicine influenced the emergence of complementary and alternative medicine (CAM).3 CAM refers to the various disease-treating or disease-preventing practices whose methods and efficacy differ from traditional or conventional biomedical treatment.4 Some of these approaches can be and are used in conjunction with traditional/allopathic medicine.4 According to the National Center for Complementary and Alternative Medicine, USA, CAM is a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine. Mind-body medicine is a domain within CAM that focuses on the interactions among the brain, mind, body, and behavior, and the powerful ways in which emotional, spiritual, and behavioural factors can directly affect health. Mind-body interventions include music therapy, yoga, meditation, biofeedback etc.4 Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship.5 Music therapy has been shown to be an efficacious and valid adjunctive treatment option for patients with a variety of diagnoses.5

Bradt and Dileo6 have explained the concepts of music medicine and music therapy.

Interventions are categorized as music medicine when passive listening to pre-recorded music is offered by medical personnel. In contrast, music therapy requires the implementation of a music intervention by a trained music therapist, the presence of a therapeutic process, and the use of personally tailored music experiences. These music experiences include listening to live, improvised or pre-recorded music, performing music on an instrument etc. Music therapy provides opportunities for anxiety and stress reduction, non-pharmacological management of pain and discomfort, and positive changes in mood and emotional states.5 Systematic research on the effects of music and music therapy on patients has burgeoned during the past 20 years. A substantial body of literature exists to support the effectiveness of music therapy.

In a recent review, Lake7 notes that anxious adult patients randomly assigned to music-assisted reframing experienced greater reductions in overall anxiety than patients who received conventional cognitive therapy. Frequent listening to music probably has beneficial effects on endorphins and other neurotransmitters that mediate improvements in depressed mood7. Music alone or in combination with guided imagery improves mood in depressed cancer patients7. Depressed outpatients reported significant improvements in mood and beneficial changes in heart rate and blood pressure soon after listening to tranquil music7. Regular singing, engaging in dance therapy, listening to music, and participating in musical games improve cognitive and behavioural functioning in individuals with severe dementia, who experience reduced agitation, reduced wandering, enhanced social interaction, improved mood, reduced irritability or fear, and increased cooperative behavior7. Calming background music significantly reduces irritable behavior, anxiety, and depressed mood in nursing home patients with dementia7.

* Dr. Sivaprakash B, Professor of Psychiatry Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India.

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Music therapy can help to relieve pain and reduce stress and anxiety for the patient, resulting in improved respiration, lower blood pressure, improved cardiac output, reduced heart rate, relaxed muscle tension.5 Music therapy has been shown to have a significant effect on a patient’s perceived effectiveness of treatment, self-reports of pain reduction, relaxation, respiration rate, anxiety levels, and amount of analgesic medication.5 There are a number of individual factors that influence responses to music. These include age, gender, cognitive function, severity of stress, anxiety, discomfort and pain, training in music, familiarity with and reference for the music, culture, and personal associations with the music.6 The response of patients/subjects to music therapy is thus highly subjective. Published Indian research literature on music therapy appears to be meagre and elusive. Given the promising results of music therapy research performed in other countries and the fact that culture and socioeconomic factors significantly influence response to music therapy, it may be worthwhile for the scientific community of our nation to start building a repository of indigenous research on music therapy.

Research reports on the impact of music on normal human physiological processes in healthy individuals are not as abundant as research data on the therapeutic effects on music in the context of human illness. It stands to reason that the precise nature of the physiological impact of music needs to be elucidated in through systematic research on healthy subjects, before music can be routinely prescribed with confidence in the clinical setting.

In addition, rigorous randomized controlled trials involving the exposure of healthy subjects to music will help to clarify and establish the role of music in disease prevention, health promotion, and positive psychology. Existing research data pertaining to these issues needs to be replicated in the Indian context, for reasons mentioned earlier.

This review starts with a brief overview of fundamental physiological correlates relevant to the theme of this study, including the neurobiology of anxiety. Salient aspects of the autonomic nervous system are discussed, followed by the relationship between anxiety and the autonomic nervous Page 17

system. The physiological impact of anxiety on the cardiovascular and respiratory systems is reviewed, in brief. Recent research findings pertaining to the neurophysiology of music are highlighted. A brief sketch of the physiological effect of music on healthy subjects is provided, followed by an elaborate review of research on the anxiolytic effect of music in diverse clinical scenarios. Health implications of anxiety, elevated heart rate and blood pressure are discussed briefly. The review ends with an emphasis on the need for further research on the impact of music on human physiology.

Overview of basic physiological correlates Neurobiology of anxiety

Anxiety is a reaction to stress that has both psychological and physical features. The feeling is thought to arise in the limbic system, a brain region that governs many intense emotional responses.

The prevailing neurocircuitry models of anxiety disorders emphasize interactions among limbic structures, especially the amygdala, hippocampus, hypothalamus, and periaqueductal gray, and cortical regions within the sensory association areas and the medial and orbital portions of the prefrontal cortex.8 Autonomic nervous system

It is well known that the hypothalamus is a crucial component of the neural circuitry regulating not only emotions, but also autonomic, endocrine and some somatic functions.9 The limbic system integrates the highly processed sensory and cognitive information content of the cerebral cortical circuitry with the hypothalamic pathways that control autonomic and endocrine systems.9 Stimulation of the lateral nucleus of the hypothalamus via afferent projections from the central nucleus of the amygdala, bed nucleus of the stria terminalis, or ventral striatum activates the sympathetic nervous system, producing increases in blood pressure and heart rate, sweating, piloerection, and pupillary dilation.8 During stress, the secretion of CRH from the PVN of the hypothalamus increases peripheral ACTH levels, which stimulates the adrenal glands to secrete cortisol.8 Annals of SBV

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Emotions, autonomic nervous system and the cardiovascular system

Autonomic nervous system activity is viewed as a major component of the emotion response in many recent theories of emotion.10 Anxiety is characterized by sympathetic activation and vagal deactivation, a pattern of reciprocal inhibition.10 Peripheral manifestations of anxiety include hypertension and tachycardia.11 The autonomic nervous system of some patients with anxiety disorder exhibit increased sympathetic tone.11 There are descending tracts to the medullary vasomotor area from the cerebral cortex (particularly the limbic cortex) that relay in the hypothalamus.

These fibres are responsible for the blood pressure rise and tachycardia produced by emotions such as sexual excitement and anger.12 Anxiety and the respiratory system

One common symptom associated with anxiety is hyperventilation. Abnormal respiratory behavior has been identified in anxiety disorders, particularly panic disorder.13 Dyspnoea can coexist with anxiety.14 Anxiety is often a component of dyspnoea experienced by patients with chronic respiratory illness.14 Neurophysiology of music

Music is capable of evoking exceptionally strong emotions and of reliably affecting the mood of individuals.15 Koelsch16 reviewed the functional imaging studies conducted on the investigation of emotion with music. These studies showed involvement of limbic and paralimbic cerebral structures (such as amygdala, hippocampus, parahippocampal gyrus, temporal poles, insula, ventral striatum, orbitofrontal, as well as cingulate cortex) during the processing of music with emotional valence (such as pleasant or unpleasant). These studies imply that musicevoked emotions can modulate activity in virtually all limbic and paralimbic brain structures. These structures are crucially involved in the initiation, generation, detection, maintenance, regulation and termination of emotions that have survival value for the individual and the species.

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Menon and Levitin17 used functional magnetic resonance imaging and functional/effective connectivity analyses to show that listening to music strongly modulates activity in a network of mesolimbic structures involved in reward processing including the nucleus accumbens (NAc) and the ventral tegmental area (VTA), as well as the hypothalamus and insula, which are thought to be involved in regulating autonomic and physiological responses to rewarding and emotional stimuli. Responses in the NAc and the VTA were strongly correlated pointing to an association between dopamine release and NAc response to music. Responses in the NAc and the hypothalamus were also strongly correlated across subjects, suggesting a mechanism by which listening to pleasant music evokes physiological reactions.

Findings showed significant VTA-mediated interaction of the NAc with the hypothalamus, insula, and orbitofrontal cortex.

Physiological effect of music on healthy subjects

Knight and Rickard18 demonstrated that relaxing music prevents stress-induced increases in subjective anxiety, systolic blood pressure, and heart rate in healthy subjects. Undergraduate students were exposed to a cognitive stressor task involving preparation for an oral presentation either in the presence of music, or in silence. Measures of subjective anxiety, heart rate, blood pressure, cortisol, and salivary IgA were obtained during rest and after presentation of the stressor. The stressor caused significant increases in subjective anxiety, heart rate, and systolic blood pressure in male and female controls. These stress-induced increases were each prevented by exposure to music. Music also enhanced baseline salivary IgA levels in the absence of any stress-induced effects. These findings provide experimental support for claims that music is an effective anxiolytic treatment.Miller et al19 evaluated the extent to which music may affect endothelial function. Endothelial function was assessed by brachial artery flow-mediated dilation (FMD). Self-selected joyful music was associated with increased FMD to a magnitude previously observed with aerobic activity or statin therapy. The authors concluded that listening to joyful music may be an adjunctive life-style intervention for the promotion of vascular health.

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Anxiolytic effect of music in clinical scenarios Coronary heart disease

White20 examined the effects of relaxing music on elevated state anxiety in patients with a confirmed medical diagnosis of acute myocardial infarction. Statistically significant reduction in heart rate, respiratory rate, and state anxiety scores were found in the group that listened to relaxing music. Elliott21 conducted a randomized, controlled trial to test the efficacy of music and muscle relaxation techniques in reducing the anxiety of patients admitted to a coronary care unit with unstable angina pectoris or acute myocardial infarction. No significant reductions in anxiety were achieved for patients using music or muscle relaxation interventions when compared with the control group. Barnason22 studied the effects of music interventions on anxiety in the patient after coronary artery bypass grafting. No significant differences were reported for anxiety ratings. There were significant effects over time for heart rate and systolic and diastolic blood pressure, which indicated a generalized physiologic relaxation response.

A recent Cochrane review6 concluded that music listening may have a beneficial effect on blood pressure, heart rate, respiratory rate, anxiety, and pain in persons with coronary heart disease.

This review stated that that the quality of the evidence is not strong and the clinical significance unclear.

Perioperative scenarios

Several researchers have studied the role of music in the control of patients’ anxiety in perioperative scenarios. Music can reduce the anxiety and stress of patients in the surgical holding area.23 Augustin and Hains24 demonstrated that music can be more beneficial than preoperative instruction alone in reducing ambulatory surgery patients’ preoperative anxiety. Patients who listened to their choice of music before surgery in addition to receiving preoperative instruction had significantly lower heart rates than patients in the control group who received

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only preoperative instruction. Differences in experimental and control group patients’ blood pressure measurements and respiratory rates approached significance. In a controlled study25, it was observed that music produced a significant reduction in anxiety and respiratory rates of women awaiting breast biopsy. Wang et al26 evaluated the role of music in the management of preoperative anxiety through a randomized, controlled study.

Patients who listened to music before surgery reported lower levels of state anxiety. Physiological outcomes (electrodermal activity, blood pressure, heart rate, cortisol, and catecholamine data) did not differ, however, between the study groups. A recent randomized controlled trial27 demonstrated that exposure to music resulted in a statistically significant reduction of preoperative anxiety in patients undergoing day surgery.

Patients who listened to their choice of music during surgery with local anaesthesia experience significantly lower anxiety levels, heart rates, and blood pressure than patients who did not listen to music.28 Allred et al29 studied the effect of music on postoperative pain and anxiety following total knee arthroplasty. The music group’s decrease in pain and anxiety was not significantly different from the comparison rest group’s decrease in pain or anxiety. However, statistical findings within groups indicated that the sample had a statistically significant decrease in pain and anxiety over time. In a systematic review of 42 randomized controlled trials of the effects of music interventions in perioperative settings30, it was observed that music intervention had positive effects on reducing patients’ anxiety and pain in approximately half of the reviewed studies. The authors of this review stated that further research into music therapy is warranted in light of the low cost of implementation and the potential ability of music to reduce perioperative patient distress.

Ventilatory assistance

Chlan31 noted that a single music therapy session was found to be effective for decreasing anxiety and promoting relaxation, as indicated by decreases in heart rate and respiratory rate, in patients receiving ventilatory assistance. Wong et

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al32 studied the effects of music therapy on anxiety in ventilator-dependent patients. Findings indicated that music therapy was more effective in decreasing state anxiety than was an uninterrupted rest period.

However,blood pressure and respiratory rate showed no significant differences in the 2 conditions over time. A randomized controlled trial33 indicated that patients on mechanical ventilation who listened to a single 30-minute session of music appeared to show greater relaxation as manifested by a decrease in physiological indices and an increase in comfortable resting behaviours. Recently, Han et al34 confirmed that short-term therapeutic effects of music listening results in substantial reduction in physiological stress responses arising from anxiety, in mechanically ventilated patients.

Clinical procedures

Colt et al35 observed that relaxation music administered through headphones to patients during flexible bronchoscopy does not decrease procedure-related state anxiety. Kotwal et al36 demonstrated that the background Indian classical music is efficacious in reducing psychological distress during a gastroscopic examination. Smolen et al37 examined the effects of music therapy on selfreported and physiological signs of anxiety among ambulatory patients undergoing colonoscopy.

Their findings indicate that music therapy has the potential to reduce physiological indicators of anxiety and the need for sedation among individuals undergoing a colonoscopy. Listening to music during ambulatory colonoscopies decreases the level of anxiety that is inherent to the process without other anxiolytic methods38.

Studies on the anxiolytic effects of music in the context of cardiac catheterization have yielded mixed results. Hamel39 observed that patients waiting for their cardiac catheterization benefit from music therapy. Anxiety and the heightened physiological values elicited by the stress response are reduced. In contrast, Taylor-Piliae and Chair40 demonstrated that the use of music therapy or sensory information did not significantly reduce anxiety, improve mood state, decrease heart or respiratory rate among subjects undergoing cardiac catheterization. Music therapy results in a statistically significant reduction in

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anxiety scores in patients undergoing angiography procedures.41-43

Obstetrics &Gynaecology

A randomized controlled study44 has demonstrated that exposure to music resulted in significantly less pain and lower anxiety during colposcopy examination. A controlled trial by Chang et al45 provides evidence that two-week music therapy during pregnancy provides quantifiable psychological benefits. Carefully selected music that incorporates a patient’s own preferences may offer an inexpensive and effective method to reduce anxiety for antepartum women with high risk pregnancies who have been prescribed bedrest.46 A recent randomized controlled trial47 provides good evidence for the use of music as an empirically based intervention of women for labour pain and anxiety during the latent phase of labour.

Music therapy can reduce anxiety and create a more satisfying experience for women undergoing caesarean delivery.48 Postoperative use of patientselected music in caesarean section surgery alleviates pain and reduces the need for other analgesics, thus improving the recovery and early contact of mothers with their children.49 A recent study by Tseng et al50 does not provide evidence that preselected designer music reduced stress and anxiety levels among postpartum women.

Dementia

Results of studies on the impact of music on patients with dementia are controversial. According to Sung et al51, preferred music listening has a positive impact by reducing the level of anxiety in older adults with dementia. In contrast, Cooke et al52 have demonstrated that music does not significantly affect agitation and anxiety in older people with dementia.

Dental procedures

Soothing music reduces anxiety in patients undergoing root canal treatment.53 Newton54 demonstrated that relaxing music administered through headphones to subjects during root canal treatment decreased the procedure-related anxiety of the patients, but does not significantly

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affect blood pressure and heart rate over the procedure.

illnesses, including heart disease, chronic respiratory disorders, and gastrointestinal conditions.62

Miscellaneous scenarios

Anxiety can produce disturbances in GI function.3 Research indicates an association between high anxiety levels and the development of IBS following a bowel infection.62 A high level of anxiety symptoms raises the risk of further coronary events in patients after MI by two to five times that for non-anxious comparison patients. 3 High anxiety levels are associated with a tripling of risk of sudden cardiac death.3 In asthmatic individuals, high levels of anxiety are associated with increased rates of hospitalization and asthmaassociated mortality.3

Music has been shown to be effective in reducing anxiety and dyspnoea along with physiologic measures such as systolic BP, pulse rate and respiratory rate in COPD patients hospitalized with exacerbation.14 Guetin et al55 confirmed the usefulness of music therapy in the treatment of anxiety-depression and mood in patients with traumatic brain injury.

The role of music as a therapeutic intervention for anxiety in patients receiving radiation therapy was studied by Smith et al.56 No significant difference existed between the music group and control groups to suggest that music moderated the level of anxiety during radiotherapy. However, post-hoc analyses identified changes and trends in state anxiety scores, suggesting a possible benefit of music therapy during radiotherapy. Yilmaz et al57 have demonstrated that music decreases anxiety and provides sedation in patients undergoing extracorporeal shock wave lithotripsy. Ferrer58 investigated the effects of familiar music on the anxiety levels of patients undergoing chemotherapy treatment. Results of the study showed statistically significant improvement for the experimental group on the measures of anxiety, fear, fatigue, relaxation, and diastolic blood pressure. No significant differences between groups were found for heart rate and systolic blood pressure. Shabanloei et al59 demonstrated positive effects of music therapy on pain and anxiety in patients undergoing bone marrow biopsy and aspiration. Music therapy significantly decreases the acute procedural pain, anxiety, and muscle tension levels associated with daily burn dressing changes.60 Music can improve depression, anxiety, and relationships in psychiatric patients.61 Clinical implicationhs of anxiety, elevated heart rate and blood preshsure

Evidence suggests that people with anxiety disorders are at greater risk for developing a number of chronic medical conditions.62 Anxiety has now been implicated in several chronic physical

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Elevated resting heart rate is a known, independent cardiovascular risk factor in healthy men and women.63;64 Epidemiological studies have reported that a high heart rate is associated with a higher risk of all-cause mortality and cardiovascular events.65 Resting heart rate and BP proportionally raise the risk for type-2 diabetes mellitus.66 Blood pressure of young individuals shows a significant association with cardiovascular risk variables and the occurrence of metabolic syndrome in young adult life.67 Studies have demonstrated a continuous and graded relationship between ‘normal’ systolic blood pressure (SBP) and cardiovascular disease.68 There is a linear relationship between normotensive SBP and risk of heart failure.68 Conclusions

Music-evoked emotions modulate activity in the limbic system and hypothalamus, and can thus have a profound impact on autonomic and physiological responses.The anxiolytic effect of music in various clinical scenarios has been documented by several researchers. However, results are inconsistent across studies. Some studies on the anxiolytic effect of music in clinical settings have indicated dissociation between changes in the psychological and peripheral correlates of anxiety in response to music.Research on the impact of music on physiological processes in healthy individuals is not as abundant as research data on the therapeutic effects on music in the context of illness.Research on the role of music in disease prevention, health

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promotion, and positive psychology is meagre.

There is a definite shortage of published Indian research on the physiological effects of music.

There are a number of individual and sociocultural factors that influence responses to music. Existing research data pertaining to the impact of music on health needs to be systematically replicated in the Indian context.

Recommendations for research

Rigorous randomized controlled trials need to be conducted on large samples to clarify and establish the role of music in disease prevention, health promotion, and positive psychology, in the Indian context.Existing research data pertaining to the therapeutic role of music in various clinical settings needs to be systematically replicated in Indian subjects, through randomized controlled trials.Prospective, controlled, follow-up studies are essential to test the long-term impact of music on health.Controlled trials are needed to compare the therapeutic efficacy of patient-preferred music with researcher-selected music.Future research on music therapy needs to specifically address issues such as music preference of the subjects, subjects’ personal associations with the music, musical background (“musicality”) of the subjects, and sociocultural variables. Studies on the anxiolytic or stress-relieving effects of music should routinely include objective biochemical measures of stressinduced autonomic arousal such as neuroendocrine variables.Functional neuroimaging studies on the neurophysiology of music need to be reproduced on a larger scale. Such studies would serve to elucidate and establish the neural pathways that mediate the impact of music on health.

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39. Hamel WJ. The effects of music intervention on anxiety in the patient waiting for cardiac catheterization. Intensive Crit Care Nurs 2001;17:279-285.

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40. Taylor-Piliae RE, Chair SY. The effect of nursing interventions utilizing music therapy or sensory information on Chinese patients’ anxiety prior to cardiac catheterization: a pilot study.

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42. Moradipanah F, Mohammadi E, Mohammadil AZ. Effect of music on anxiety, stress, and depression levels in patients undergoing coronary angiography. East Mediterr Health J 2009;15:639-647.

43. Weeks BP, Nilsson U. Music interventions in patients during coronary angiographic procedures: A randomized controlled study of the effect on patients’ anxiety and well-being. Eur J CardiovascNurs 2010.

44. Chan YM, Lee PW, Ng TY, Ngan HY, Wong LC. The use of music to reduce anxiety for patients undergoing colposcopy: a randomized trial. GynecolOncol 2003;91:213-217.

45. Chang MY, Chen CH, Huang KF. Effects of music therapy on psychological health of women during pregnancy. J Clin Nurs 2008;17:2580-2587.

46. Yang M, Li L, Zhu H et al. Music therapy to relieve anxiety in pregnant women on bedrest: a randomized, controlled trial.

MCN Am J Matern Child Nurs 2009;34:316-323.

47. Liu YH, Chang MY, Chen CH. Effects of music therapy on labour pain and anxiety in Taiwanese first-time mothers. J Clin Nurs 2010;19:1065-1072.

48. Chang SC, Chen CH. Effects of music therapy on women’s physiologic measures, anxiety, and satisfaction during cesarean delivery. Res Nurs Health 2005;28:453-461.

49. Ebneshahidi A, Mohseni M. The effect of patient-selected music on early postoperative pain, anxiety, and hemodynamic profile in cesarean section surgery. J Altern Complement Med 2008;14:827-831.

50. Tseng YF, Chen CH, Lee CS. Effects of listening to music on postpartum stress and anxiety levels. J Clin Nurs 2010;19:1049-1055.

51. Sung HC, Chang AM, Lee WL. A preferred music listening intervention to reduce anxiety in older adults with dementia in nursing homes. J Clin Nurs 2010;19:1056-1064.

52. Cooke ML, Moyle W, Shum DH, Harrison SD, Murfield JE. A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia.

Aging Ment Health 2010;1-12.

53. Lai HL, Hwang MJ, Chen CJ, Chang KF, Peng TC, Chang FM. Randomised controlled trial of music on state anxiety and physiological indices in patients undergoing root canal treatment. J Clin Nurs 2008;17:2654-2660.

54. Newton JT. Music may reduce anxiety during invasive procedures in adolescents and adults. Evid Based Dent 2009;10:15.

55. Guetin S, Soua B, Voiriot G, Picot MC, Herisson C. The effect of music therapy on mood and anxiety-depression: an observational study in institutionalised patients with traumatic brain injury. Ann PhysRehabil Med 2009;52:30-40.

56. Smith M, Casey L, Johnson D, Gwede C, Riggin OZ. Music as a therapeutic intervention for anxiety in patients receiving radiation therapy. OncolNurs Forum 2001;28:855-862.

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Ann. SBV, Jan - Jun 2014;3(1) 57. Yilmaz E, Ozcan S, Basar M, Basar H, Batislam E, Ferhat M. Music decreases anxiety and provides sedation in extracorporeal shock wave lithotripsy. Urology 2003;61:282-286.

63. Cooney MT, Vartiainen E, Laatikainen T, Joulevi A, Dudina A, Graham I. Simplifying cardiovascular risk estimation using resting heart rate. Eur Heart J 2010.

59. Shabanloei R, Golchin M, Esfahani A, Dolatkhah R, Rasoulian M. Effects of music therapy on pain and anxiety in patients undergoing bone marrow biopsy and aspiration.

AORN J 2010;91:746-751.

65. Perret-Guillaume C, Joly L, Benetos A. Heart rate as a risk factor for cardiovascular disease. ProgCardiovasc Dis 2009;52:6-10.

58. Ferrer AJ. The effect of live music on decreasing anxiety in patients undergoing chemotherapy treatment. J Music Ther 2007;44:242-255.

60. Tan X, Yowler CJ, Super DM, Fratianne RB. The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: a prospective randomized crossover trial. J Burn Care Res 2010;31:590-597.

61. Choi A-N, Lee MS, Lim H-J. Effects of group music intervention on depression, anxiety, and relationships in psychiatric patients: a pilot study. J Altern Complement Med. 2008 Jun;14(5):567–70.

62. Harvard University. Anxiety and physical illness. Harvard Health Publications [serial online] 2010; Available from: Harvard Health Publications. Accessed August 15, 2010.

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64. Cooney MT, Vartiainen E, Laatikainen T, Juolevi A, Dudina A, Graham IM. Elevated resting heart rate is an independent risk factor for cardiovascular disease in healthy men and women. Am Heart J 2010;159:612-619.

66. Nagaya T, Yoshida H, Takahashi H, Kawai M. Resting heart rate and blood pressure, independent of each other, proportionally raise the risk for type-2 diabetes mellitus. Int J Epidemiol 2010;39:215-222.

67. Campana EM, Brandao AA, Pozzan R et al. Blood pressure in young individuals as a cardiovascular risk marker. The Rio de Janeiro study. Arq Bras Cardiol 2009;93:608-665.

68. Britton KA, Gaziano JM, Djousse L. Normal systolic blood pressure and risk of heart failure in US male physicians. Eur J Heart Fail 2009;11:1129-1134.

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Physiology and neurobiology of stress and the implications for physical health Dr. Sukanto Sarkar * Dr. Sivaprakash B **

Stress is a word used to describe experiences that are emotionally and physiologically challenging. “Good stress,” or eustress, generally refers to those experiences that a person can master and which leave a sense of accomplishment, whereas “bad stress”, “distress” or “being stressed out,” refers to experiences where a sense of control and mastery is lacking and which are often prolonged or recurrent, emotionally draining, and physically exhausting and detrimental to health(1).

A hallmark of the stress response is the activation of the sympathetic-autonomic nervous system (SAM) and hypothalamic-pituitary-adrenal (HPA) axis(2). The“fight-or-flight” response is the classical behavioral and physiological response to a threat from a dangerous situation. This is an evolutionary response and is mediated by the autonomic nervous system(3).

Stress, a response to aversive stimuli, is a concept that is difficult to define fully because its interpretation tends to vary according to individual disciplines. Hans Selye, a pioneer in addressing general principles of physiology and pathophysiology in the exploration of stress, defined stress as ‘‘the non-specific response of the body to any demand ’’ (4). He emphasized the role of an integratedresponse of multiple systems rather than isolated reflexes. He gave the concept of general adaptation syndrome (GAS). It involves three stages i.e. the Alarm Reaction, the Stage of Resistance and the Stage of Exhaustion (5). Although virtually all organs are affected by exposure to stress, the neuroendocrine, cardiovascular, immune and gastrointestinal systems are the first to experience functional changes.

Neuroendocrine response to stress

Exposure to variousstressors results in a series of coordinated responses often referred to as ‘‘stress responses,’’ and are composed of alterations in behaviour, autonomic function and the secretion of multiple hormones including adrenocorticotropin

hormone (ACTH) and cortisol/corticosterone, adrenal catecholamines, oxytocin, prolactin and renin(5). Some of the physiological changes associated with the stress response include: (a) mobilization of energy to maintain brain and muscle function; (b) sharpened and focused attention on the perceived threat; (c) increased cerebral perfusion rates and local cerebral glucose utilization; (d) enhanced cardiovascular output and respiration, and redistribution of blood flow, increasing substrate and energy delivery to the brain and muscles; (e) modulation of immune function; (f ) inhibition of reproductive physiology and sexual behaviour; (g) decreased feeding and appetite(6).

There is general agreement regarding the role of the hypothalamic–pituitary–adrenal axis and adrenal catecholamines in maintaining energy balance, as well as the role of the renin–angiotensin system in redistributing blood flow towards the brain and other vital organs(6, 7). Many brain structures are involved in the response to psychologically and physically stressful stimuli. Activation of the hypothalamic–pituitary–adrenal axis leads to a rapid secretion of ACTH from corticotrophs in the anterior pituitary and increase in circulating glucocorticoids(7). Initially, it was thought that corticotropin- releasing factor (CRF) is the sole means of releasing ACTH from the pituitary gland but other factors also contribute to regulate ACTH release from the pituitary gland(8). CRF plays a prominent role in mediating the effect of stressors on the hypothalamic–pituitary adrenocortical axis, and in coordinating the endocrine, autonomic, behavioral and immune responses to stress(6).

Oxytocin and prolactin isalso secreted in both males and females in response to aversive stimuli implicating them as ‘‘stress hormones,’’ thus suggesting that they play other important roles that are important for survival. Oxytocin has been reported to play a role in sodium balance and in a

* Dr. Sukanto Sarkar, Assistant Professor of Psychiatry, ** Dr. Sivaprakash B, Professor of Psychiatry Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India.

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central anxiolytic circuit(9), whileprolactin has been reported to modulate immune function(10).

Neuroanatomy of the stress response

Various brain circuits participate in the regulation of the neuroendocrine responses to various stressors.Among these are the hypothalamus, septohippocampal system, amygdala, cingulate and prefrontal cortices, hindbrain regions such as the brainstem catecholamine cell body groups (A2/C2 cell groups in the nucleus of the tractus solitarius; A1/C1 cell groups in the ventrolateral medulla; A6 cell groups in the locus coeruleus), the parabrachial nucleus, cuneiform nucleus and dorsal raphe nucleus(11). During a stressful event, sensory inputs from peripheral sense organs pass through either the reticular activating system or the thalamus, which function as relay stations, to the amygdala and sensory cortex(12). The sensory cortex communicates to the hippocampus and with the lateral amygdala through the perirhinal cortex (13). The lateral and the basolateral nuclei of the amygdala play a major role by integrating sensory inputs from the thalamus, and cognitiveinformation from the cortex and hippocampus(6). The amygdala also stimulates the dorsal raphe nucleus andadrenergic nuclei located in the brainstem, which, in turn innervate CRF neurons in the hypothalamic paraventricular nucleus (5) . Thus, the hypothalamic pathway is believed to play a key role in the adrenocortical response via a complex pathway. Glucocorticoids play a key regulatory role in the neuroendocrine control of the hypothalamic–pituitary–adrenocortical axis and it terminates the stress response by exerting negative feedback at the levels of hypothalamus and pituitary(14). Also, by stimulating the GABAergic neurons, mineralocorticoid receptors in the hippocampusinhibit the activity of the hypothalamic–pituitary–adrenocortical axis, thus regulating this pathway (15).

Neuroimmune mechanism of Stress

Stressors in various forms at various intensities dysregulates the immune system. The interaction between the CNS, endocrine and the immune system forms the broad interdisciplinary research field known as psychoneuroimmunology (16). Dysregulation ofthe immune system leads to susceptibility to

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infections, physical ill-health and to a spectrum of stress-related disorder such as diabetes, asthma, hypertension etc. The release of cortisol perhaps plays the final role to provoke various immunological changes like the release of cytokines (IFN), interleukins and TNFs. The SAM axis also innervates the lymphoid organs that produce NK cells and other T lymphocytes(17).

Impact on immune cells: Stress increases monocytes, neutrophils and B cells in the spleen and causes redistribution of myeloid and lymphoid cells from the bone marrow(18). There is impaired function of thymus, spleen and lymph nodes under severe stress. Of these,the thymus is very sensitive to stress and thus uncontrolled stress can suppress cellular immunity(17).

Impact on cytokines: Chronic stress elevates serum glucocorticoids which leads to an increase in serum interferonsand interleukins.

Glucocorticoids can influence the growth and maturation of leukocytes, downregulates cytokines such as IFN-γ, TGF-β, TNF-α, IL-12 mediated by cell immunity while upregulating the expression of various interleukins (IL-4,10,13) mediated by humoral immunity(19, 20).

Stress and Physical disorders

Chronic diseases like diabetes, obesity, cardiovascular diseases are the leading cause of death and disability (Centre for Disease Control).

Psychosocial factors including stress are implicated as etiological factors, maintenance factors and factors that hinder recovery from these disorders.

Mind-body medicine deals with such areas exploring the interaction between brain, mind, body and behaviour(21).

Cardiovascular diseases (CVD) are the leading cause of death worldwide. Apart from various psychosocial factors such as emotional distress, Type D personality, depressive symptoms, stressors play an important role in the etiology of CVD(22). Acute stress causes vasoconstriction and vasospasm, mechanical straining, endothelial tearing and plaque rupture. Chronic stress leads to thrombogenesis causing increased platelet aggregation. Elevated cytokines and IL-6 are also Annals of SBV

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associated with chronic stress which is strongly associated with platelet instability(22, 23).

visceral perception and increased permeability,leading to IBS(31,32).

Metabolic Syndrome has increased alarmingly over the last two decades and it includes three major disorders viz. obesity, hyperlipidaemia and diabetes. Glucose intolerance, insulin resistance and hypertension are also associated with this syndrome(24, 25). Evidence shows that chronic psychological stress correlates with the metabolic syndrome, particularly abdominal obesity. Cortisol hypersecretion in chronic stress increases visceral obesity as cortisol binds to glucocorticoid receptors in the fat cells and activates the enzyme lipoprotein lipase which converts triglycerides to free fatty acids(26). Cytokines and other interleukins increase insulin resistance through an inflammatory response,leading to diabetes(27).

Stress management techniques

Rheumatoid Arthritis (RA) is an autoimmune disorder of the joints and stress is recognised as a key risk factor in the pathogenesis of RA. Immune dysregulation triggered by stress via cytokine amplification and other complex mechanism leads to an autoimmune process that produces RA(28).

The treatment of RA currently focuses on stress reduction, life-style modification and improving quality of life.

Asthma is often triggered by stress. Findings suggest that acute stressors activate the sympathetic nervous system that leads to bronchospasm and subsequent attacks of asthma. Emotional distress can constrict the smooth muscles of the airways in the lungs producing wheezing, coughing and chest tightness. Chronic stressors cause immune system activation and can exacerbate asthma via inflammatory pathways(29).

Functional gastrointestinal (GI) disorders are very common in the general population and are one of the most prevalent disorders in patients attending gastroenterology clinics. Irritable Bowel Syndrome, a prototypical functional GI disorder has symptoms of abdominal pain associated with alteration of bowel habits in absence of identifiable organic disease to explain the above symptoms(30).

Stress alters the neuroendocrine and the immune system causing the release of various neuropeptides and interleukins that affects the GI motility, Page 27

intestinal

Various stress management techniques are used to tackle stress in different settings. The most common methods supported by research evidenceinclude progressive muscle relaxation, meditation, biofeedback, cognitive-behavioral skills, stress inoculation techniques and cognitive Mindfulness-based behavioural therapy(33). stress reduction (MBSR) is a new and clinically standardized meditation that has shown consistent efficacy for many mental and physical disorders(33, 34) . A recent article exploring systematic review on yoga in reducing stress (based on eight randomised control trials and clinical controlled trials) indicated a positive effect of yoga in reducing stress levels or stress related symptoms(35). Also Sudarshan Kriya yogic breathing has shown to reduce stress and anxiety symptoms significantly(36).

To conclude, stress has a major impact on our life and its pathological form can contribute to the etiology of various physical disorders. As a health care provider, we should broaden our horizons and consider psychological stress as an etiological factor in various conditions and include stress management as a part and parcel of the treatment of such disorders. Let us keep in mind Sir William Osler’s (1849-1919) famous lines “It is much more important to know what sort of patient has a disease than what sort of disease the patient has” (21).

References

1. McEwen BS. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 2007;87(3):873-904.

2. Ulrich-Lai YM, Herman JP. Neural regulation of endocrine and autonomic stress responses. Nat Rev Neurosci 2009; 10(6):397-409.

3. Koob GF. Corticotropin-releasing factor, norepinephrine, and stress. Biol. Psychiatry 1999; 46:1167–80.

4. Seyle H. Stress and the general adaptation syndrome. Br Med J 1950;1(4667):1383-92.

5. Carrasco GA, Van de Kar LD. Neuroendocrine pharmacology of stress. Eur J Pharmacol. 2003;463(1-3):235-72.

6. Van de Kar LD, Blair ML. Forebrain pathways mediating stress induced hormone secretion. Front Neuroendocrinol 1999; 20: 1- 48.

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Ann. SBV, Jan - Jun 2014;3(1) 7. Aguilera G, Rabadan-Diehl C, Nikodemova M. Regulation of pituitary corticotropin releasing hormone receptors. Peptides 2001; 22:769-74.

8. Levens NR. Control of renal function by intrarenal angiotensin II in the dog. J Cardiovasc Pharmacol 1990; 16: S65– S69.

9. Gimpl G, Fahrenholz F. The oxytocin receptor system: structure, function, and regulation. Physiol Rev 2001; 81:629–83.

10. Neidhart M. Prolactin in autoimmune diseases. Proc Soc ExpBiol Med 1998; 217: 408– 19.

11. Herman JP, Cullinan WE. Neurocircuitry of stress: central control of the hypothalamo-pituitary-adrenocortical axis.

Trends Neurosci 1997;20(2):78-84.

12. Pezzone, MA, Lee WS, Hoffman GE, Rabin BS. Induction of c-fos immunoreactivity in the rat forebrain by conditioned and unconditioned aversive stimuli. Brain Res 1992; 597: 41– 50.

13. LeDoux JE. Emotion: clues from the brain. Annu Rev Psychol 1995;46: 209-35.

14. De Kloet ER. Steroids, stability and stress. Front Neuroendocrinol 1995;16: 416-25.

15. Gesing A, Bilang-Bleuel A, Droste, S.K, Linthorst ACE, Holsboer F, Reul JMHM. Psychological stress increases hippocampal mineralocorticoid receptor levels: involvement of corticotropin-releasing hormone. J Neurosci 2001; 21: 4822-29.

16. Schneiderman N, Ironson G, Siegel SD. Stress and health: psychological, behavioral, and biological determinants. Annu Rev Clin Psychol 2005;1:607-28.

17. Yan W. Impact of prenatal stress and adulthood stress on immune system: A review.Biomedical Research 2012; 23 (3): 315-320.

18. Engler H, Bailey MT, Engler A, Sheridan JF. Effects of repeated social stress on leukocyte distribution in bone marrow, peripheral blood and spleen. J Neuroimmunol 2004; 148 (1-2): 106-15.

19. Carpentier PA, Palmer TD. Immune influence on adult neural stem cell regulation and function. Neuron 2009;64(1): 79-92.

20. Segerstrom SC, Miller GE. Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychol Bull 2004;130(4):601-30.

21. Purdy J. Chronic physical illness: a psychophysiological approach for chronic physical illness. Yale J Biol Med 2013; 86(1):15-28.

22. Hamer M. Psychosocial stress and cardiovascular disease risk: the role of physical activity. Psychosom Med 2012;74(9):896-903.

23. Herman JP, McKlveen JM, Solomon MB, CarvalhoNetto E, Myers B. Neural regulation of the stress response:

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glucocorticoid feedback mechanisms. Braz J Med Biol Res 2012;45(4):292-8.

24. Alberti KG, Zimmet P, Shaw J. Metabolic syndrome-a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med 2006;23(5):469-80.

25. Edwards EM, Stuver SO, Heeren TC, Fredman L. Job strain and incident metabolic syndrome over 5 years of follow-up: the coronary artery risk development in young adults study. J Occup Environ Med 2012;54(12):1447-52.

26. Koch FS, Sepa A, Ludvigsson J. Psychological stress and obesity. J Pediatr. 2008;153(6):839-44.

27. Chang JS, You YH, Park SY, Kim JW, Kim HS, Yoon KH, Cho JH. Pattern of Stress-Induced Hyperglycemia according to Type of Diabetes: A Predator Stress Model. Diabetes Metab J 2013;37(6):475-83.

28. Cutolo M, Straub RH.Stress as a risk factor in the pathogenesis of rheumatoid arthritis. Neuroimmunomodulation 2006;13(56):277-82.

29. Chen E, Miller GE. Stress and inflammation in exacerbations of asthma. Brain Behav Immun 2007; 21(8):993-9.

30. El-Salhy M, Gundersen D, Gilja OH, Hatlebakk JG, Hausken T. Is irritable bowel syndrome an organic disorder? World J Gastroenterol 2014; 20(2):384-400.

31. Barbara G, Cremon C, Carini G, Bellacosa L, Zecchi L, De Giorgio R, Corinaldesi R, Stanghellini V. The immune system in irritable bowel syndrome. J Neurogastroenterol Motil 2011;17(4):349-59.

32. Sugaya N, Izawa S, Kimura K, Ogawa N,Yamada KC, Shirotsuki K, Mikami I, Hirata K, Nagano Y, Nomura S, Shimada H. Adrenal hormone response and psychophysiological correlates under psychosocial stress in individuals with irritable bowel syndrome. Int J Psychophysiol 2012; 84(1):39-44.

33. Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: a review and metaanalysis. J Altern Complement Med 2009; 15(5):593-600.

34. Praissman S. Mindfulness-based stress reduction: a literature review and clinician’s guide. J Am Acad Nurse Pract 2008;20(4):212-6.

35. Chong CS, Tsunaka M, Tsang HW, Chan EP, Cheung WM. Effects of yoga on stress management in healthy adults: A systematic review. Altern Ther Health Med 2011;17(1):32-8.

36. Brown RP, Gerbarg PL. Sudarshan Kriya Yogic breathing in the treatment of stress, anxiety, and depression. Part II-clinical applications and guidelines. J Altern Complement Med 2005; 11(4):711-7.

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YOGA AND MIND BODY THERAPIES IN HEALTH AND DISEASE: A BRIEF REVIEW Ananda Balayogi Bhavanani *, Meena Ramanathan **, Madanmohan ***

Introduction

“Oh, East is East, and West is West, and never the twain shall meet,” said Rudyard Kipling. This dichotomy however seems to have been overcome in recent times, as many eastern healing traditions have slowly and steadily percolated the health care system worldwide. This is especially true of mind– body therapies that focus on the health promotive intrinsic connections that exist between the human brain, mind, body, and individual behaviour.

This includes techniques of meditation (mantra meditation, mindfulness meditation, and others), qi gong, tai chi, and yoga.1 In the USA, reported use of deep breathing, meditation, and yoga increased between 2002 and 2007 with 12.7% of adults using deep-breathing exercises, 9.4% practicing meditation, and 6.1% taking up yoga.2,3 Pain related issues were the top usage statistics while more than 40% of adults with neuropsychiatric symptoms were drawn to the usage of various mind–body therapies.4

Yoga As A Therapy

Yoga as a mode of therapy (yoga chikitsa) has become extremely popular, and a great number of studies and systematic reviews offer scientific evidence of its potential in treating a wide range of psychosomatic conditions. Yoga understands health and well-being as a dynamic continuum of human nature and not merely a ‘state’ to be reached and maintained. Yoga helps the individual to establish “sukha sthanam”, which may be defined as a dynamic sense of physical, mental, and spiritual well-being.

Yogamaharishi Dr. Swami Gitananda Giri Guru Maharaj, the visionary founder of Ananda Ashram at the ICYER, Pondicherry (www.icyer.com) and one of the foremost authorities on Yoga in the past century exclaimed lucidly, “Yoga chikitsa is virtually as old as yoga itself, indeed, the return of mind that feels separated from the Universe in which it exists

represents the first yoga therapy. Yoga chikitsa could be termed as man’s first attempt at unitive understanding of mind-emotions-physical distress and is the oldest wholistic concept and therapy in the world.” 5 To achieve this yogic integration at all levels of our being, it is essential that we take into consideration the all encompassing multi dimensional aspects of yoga that include the following: a healthy life-nourishing diet, a healthy and natural environment, a wholistic lifestyle, adequate bodywork through asana, mudra-bandha and kriya, invigorating breath work through pranayama and the cultivation of a healthy thought process through jnana yoga and raja yoga.

The International Association of Yoga Therapists (IAYT), USA has taken this idea into account in defining Yoga therapy as follows6: “Yoga therapy is the process of empowering individuals to progress toward improved health and well-being through the application of the philosophy and practice of yoga.” This has been further elabourated by the IAYT in its “Recommended Educational Standards for the Training of Yoga Therapists”, published on 1 July, 2012.7 This is one of the best documents on standards in yoga therapy and is a path breaking effort covering comprehensively all aspects of yoga as a holistic therapy.

The need of the hour is for a symbiotic relationship between yoga and modern science. To satisfy this need, living, human bridges combining the best of both worlds need to be cultivated. It is important that more dedicated scientists take up yoga and that more yogis study science, so that we can build a bridge between these two great evolutionary aspects of our civilization. The process as well as the goal of yoga is all about becoming “one” with an integrated state of being.8

* Ananda Balayogi Bhavanani , Deputy Director, E mail: yognat@gmail.com ** Meena Ramanathan, Co-ordinator and Yoga therapist, E mail: saineema@yahoo.com *** Madanmohan, Director, Prof & Head, Dept. of Physiology, E mail: drmadanmohan999@rediffmail.com Centre for Yoga Therapy, Education and Research (CYTER) Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India Page 29

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Promotes Positive Health

Healthy life can be considered as a by-product of practicing yogic techniques since it has been observed that Yoga practitioners are physically and mentally healthier and have better coping skills to stressors than the normal population. Knowledge of inexpensive, effective and easily administrable yogic techniques by health professionals will go a long way in helping us achieve the goal of the World Health Organisation to provide “physical, mental, spiritual and social health” for all sections of human society.

Some of the important documented health promoting benefits of mind-body practices such as yoga and meditation include:

1. Improvement in cardio-respiratory efficiency 9, 10, 11, 12

2. Improvement in exercise tolerance 13, 14, 15, 16 3. Harmonious balance of autonomic function 17, 18, 19, 20

4. Improvement in dexterity, strength, steadiness, stamina, flexibility, endurance, and neuromusculo-skeletal coordination 13, 21, 22, 23, 24, 25, 26 5. Increase in alpha rhythm, inter-hemispheric coherence and homogeneity in the brain 27, 28, 29, 30

6. Improved sleep quality 31 7. Improved cognitive functions 9, 32, 33, 34, 35, 36, 37, 38 8. Alteration in brain blood flow and brain metabolism 39, 40, 41, 42 9. Modulation of the neuro-endocrine axis 43, 44, 45, 46, 47, 48

We can say that the eastern mind-body techniques affect every cell of the human body. They bring about better neuro-effector communication, improve strength, and enhance optimum functioning of all organ-systems while increasing resistance against stress and diseases with resultant tranquillity, balance, positive attitude and equanimity.

Figure1: Possible Factors Responsible For Physical Performance Improvement By Yoga (Ray US, Pathak A, Tomer OS. Hatha Yoga Practices: Energy Expenditure, Respiratory Changes And Intensity Of Exercise. Evid based complement alternat med. 2011; 2011: 241294.)

Managing Stress

It is well established that stress weakens our immune system. Scientific research in recent times has shown that the physiological, psychological and biochemical effects of yoga are of an anti-stress nature.

A majority of studies have described beneficial effects Page 30

of yoga interventions in stress with an Agency for Healthcare Research and Quality (AHRQ) report stating that “Yoga helped reduce stress.”49 Reductions in perceived stress following yoga are reported to be as effective as therapies such as relaxation, cognitive behavioural therapy and dance therapy.

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Mechanisms postulated include the restoration of autonomic balance as well as an improvement in restorative, regenerative and rehabilitative capacities of the individual. A healthy inner sense of wellbeing produced by a life of yoga percolates down through the different levels of our existence from the higher to the lower levels producing health and wellbeing of a holistic nature. Streeter et al recently proposed a theory to explain the benefits of yoga practices in diverse, frequently co-morbid medical conditions based on the concept that yoga practices reduce allostatic load in stress response systems so that optimal homeostasis is restored.50 They hypothesized that stress produces an:

• I mbalance of the autonomic nervous system with decreased parasympathetic and increased sympathetic activity, • Under activity of the gamma aminobutyric acid (GABA) system, the primary inhibitory neurotransmitter system, and • Increased allostatic load.

They further hypothesized that yogabased practices i) correct under activity of the parasympathetic nervous system and GABA systems in part through stimulation of the vagus

nerves, the main peripheral pathway of the parasympathetic nervous system, and ii) reduce allostatic load.

According to the theory proposed by them, decreased parasympathetic nervous system and GABAergic activity that underlies stress-related disorders can be corrected by yoga practices resulting in amelioration of disease symptoms. A review by Bhavanani concluded that heart rate variability (HRV) testing has a great role to play in our understanding of the intrinsic mechanisms behind such potential autonomic balancing effects of yoga.51 Innes et al had earlier postulated two interconnected pathways by which yoga reduces the risk of cardiovascular diseases through the mechanisms of parasympathetic activation coupled with decreased reactivity of sympathoadrenal system and HPA axis.52 It is notable that one of the newer applications of yoga has been in managing the aftermaths of natural disasters. Studies have shown that yoga significantly reduces symptoms of posttraumatic stress disorder (PTSD), self-rated symptoms of stress (fear, anxiety, disturbed sleep, and sadness) and respiration rate.53

Figure 2: Impact Of Stress On Hypothalamic–Pituitary–Adrenal (Hpa) Axis And Sympathetic Nervous System.

(Sengupta P. Health Impacts of Yoga and Pranayama: A State-of-the-Art Review.Int J Prev Med 2012; 3:444–58. * Yoga has significant beneficial effects at these levels) Page 31

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Mental Health

Yoga can enhance one’s spiritual life and perspective beyond the physical life regardless of one’s particular religion.54 It enables people to attain and maintain a balance between exertion and relaxation, and this produces a healthy and dynamic state of homeostatic equilibrium.5 Recent studies have shown that yoga improves mood and reduces depression scores.55,56 These changes have been attributed to an increased secretion of thalamic GABA with greater capacity for emotional regulation.56,57 Even a 10 day yoga-based lifestyle modification program has been reported to improve subjective wellbeing scores of patients.20 There has been extensive work done on Sudarshan Kriya Yoga and depression at the National Institute of Mental Health and Neuro Sciences (NIMHANS) in India. This technique has been recommended as a potential alternative to drugs for melancholia as a first-line treatment.58 A review by Carim-Todd et al on yoga and smoking cessation, reported positive benefits of mind–body interventions.59 These interventions produced changes in smoking behaviour/in predictors of smoking behaviour such as abstinence, decreased number of cigarettes smoked, lower intensity of cravings and attitudinal changes regards smoking. However, definite conclusions

on their benefits for smoking cessation couldn’t be drawn due to scarcity of papers, low quality of some publications, and numerous limitations of these studies like inadequate sample size, limitations of study design, lack of adherence monitoring, lack of objective measures, inadequate or absent control conditions and absence of blinding.

A large number of studies show that the practice of yoga can produce significant decrease in the basal anxiety scores in different populations.

60, 61, 62, 63, 64, 65 These reports have shown significant improvements in perceived stress, state and trait anxiety, subjective well-being, vigour and decrease in salivary cortisol, fatigue and depression. Physical well-being also increased, and those subjects suffering from headache or back pain reported marked pain relief. We can conclude that yoga and other mind body therapies do have a potential role in management of depressive and anxiety disorders.

In addition to its benefits for patients themselves, yoga also has a great role for managing depression manifesting in family caregivers of patients with dementia.66 Researchers also support the promising role of yoga as an intervention for depression because it is cost-effective and easy to implement.61 However a point to consider is that all the mind-body interventions do seem to be effective when compared to passive controls but reports are less conclusive when compared with active controls.67

Figure 3: Interconnections Between Inner Correspondence / Peaceful Harmony (Icph), Mindful Acceptance & Mental /Emotional Stabilization In Response To Mind-Body Interventions Such As Yoga.

(Arndt B¨ussing et al. Inner Correspondence and peacefulness with practices among participants in Eurythmy Therapy & Yoga: A Validation Study. Evid Based Complement Alternat Med 2011; 2011: 329023.)

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Cardiovascular Conditions

Many studies have tried to explore the mechanisms by which yoga modifies coronary artery disease risk factors. Manchanda et al68, Ornish et al69 and Yogendra et al70 have conducted prospective, randomized and controlled trials on angiographically proven coronary artery disease patients with yoga intervention and demonstrated that yoga based lifestyle modification helps in regression of coronary lesions and improvement in myocardial perfusion. The effect of yogic lifestyle on some of the modifiable risk factors could probably explain the preventive and therapeutic beneficial effect observed in coronary artery disease.

A review of 70 eligible studies investigating the effects of yoga on risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with yoga, reported that most had a reduction of systolic and/or diastolic pressure. However, the reviewers also noted that there were several noted potential biases and limitations that made it difficult to detect an effect specific to yoga.52 Another literature review reported significant improvements in overall cardiovascular endurance of young subjects who were given varying periods of yoga training.71 Physical fitness increased as compared to other forms of exercise and longer duration of yoga practice produced better cardiopulmonary endurance. In fact a detailed review of yoga in cardiac health concluded that it can be beneficial in the primary and secondary prevention of cardiovascular disease and that it can play a primary or a complementary role in this regard.72

Respiratory Disorders

Scientific basis of using yoga as an adjunct therapy in chronic obstructive pulmonary diseases is well established with significant improvements in lung function, quality of life indices and bronchial provocation responses coupled with decreased need for regular and rescue medicinal usage.73,74 Behera reported perceptible improvement in dyspnea and lung function in patients of bronchitis after 4 weeks of yoga therapy that used a variety of postures and breathing techniques.75 Yogic cleaning techniques such as dhautikriya (upper gastrointestinal cleaning Page 33

with warm saline or muslin cloth) and netikriya (warm saline nasal wash) remove excessive mucous secretions, decrease inflammation and reduce bronchial hypersensitivity thereby increasing provocation threshold while kapalabhati through forceful exhalations improves the capacity to exhale against resistance.76 A nonspecific broncho protective or broncho relaxing effect has been also postulated77 while improved exercise tolerance has been reported following yoga therapy in patients of chronic severe airways obstruction.78 It has been reported that well-performed slow yogic breathing maintains better blood oxygenation without increasing minute ventilation, reduces sympathetic activation during altitude-induced hypoxia79 and decreased chemoreflex sensitivity to hypoxia and hypercapnia80. These help bring about both objective and subjective improvements in the condition of patients with bronchitis. Yoga as a therapy is also cost effective, relatively simple and carries minimal risk and hence should be advocated as an adjunct, complementary therapy in our search for an integrated system of medicine capable of producing health and wellbeing for all.

Metabolic/Endocrine Conditions

A few RCTs have suggested that yoga and meditation practices act on the hypothalamic– pituitary–adrenal axis (HPA) axis to reduce cortisol levels in plasma, 81, 82, 83, 84 as well as reduce sympathetic nervous system tone, increase vagal activity, 85,86 and elevate brain GABA levels62.

Major systematic reviews of the effects of yoga on risk indices associated with insulin resistance syndrome and risk profiles in adults with type 2 diabetes have been done in recent times.52,87 They reported post-intervention improvement in various indices but with results varying by population and study design. Another systematic review addressed the management of type 2 diabetes and concluded that the reviewed trials suggest favourable effects of yoga on short-term parameters related to diabetes but not necessarily for long-term outcome.88 The AHRQ cites two studies comparing yoga versus medication which reported a large and significant reduction of fasting glucose in individuals with type 2 diabetes in one, and a smaller but still significant improvement in the other.49 Annals of SBV

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Figure 4: Proposed Relationships Among Dyspnea, Benefits of Yoga, and Outcomes of Participation In A Yoga Program. (Donesky-Cuenco D, Nguyen Hq, Paul S, Carrieri-Kohlman V. Yoga Therapy Decreases Dyspnea-Related Distress and Improves Functional Performance In People With Chronic Obstructive Pulmonary Disease: A Pilot Study.

J Altern Complement Med 2009; 15: 225–234).

Figure 5 Postulated Mechanisms By Which Yoga Can Help Reduce Risk For Type 2 Diabetes Mellitus And Its Complications (Innes Ke, Vincent Hk. The Influence Of Yoga-Based Programs On Risk Profiles In Adults With Type 2 Diabetes Mellitus: A Systematic Review. Ecam 2007; 4: 469-86.)

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A recent systematic review of yoga on menopausal symptoms reported small effects on psychological symptoms with no effects on total menopausal symptoms, somatic symptoms, vasomotor symptoms, or urogenital symptoms.89

Musculoskeletal Conditions

A review by Posadzki et al90 found that 10 of 11 RCTs reported significantly greater effects in favor of Yoga when compared to standard care, self-care,

therapeutic exercises, relaxing yoga, touch and manipulation, or no intervention. Yoga was more effective for chronic back pain than the control interventions such as usual care or conventional therapeutic exercises though some studies showed no between group differences.91 Recently two well designed trials of yoga for back pain reported clinically meaningful benefits over usual medical care but not over an intensive stretching intervention.92,93

Figure 6: Mechanisms Underlying Effectiveness Of Yoga For Chronic Low Back Pain. (Sherman et al., Comparison of yoga versus stretching for chronic low back pain: protocol for the Yoga Exercise Self-care trial. Trials 2010; 11:36

Cancer

According to the findings of a comprehensive meta-analysis of role of yoga in cancer, improvements in psychological health were seen in yoga groups when compared to waitlist or supportive therapy groups.94 With respect to overall quality of life, there was a trend towards improvement. To explain the positive outcomes, Smith and Pukall suggested various complex pathways which may involve relaxation, coping strategies, acceptance, and self-efficacy.95 Kochupillai et al reported increase in natural killer cells in cancer patients who had completed their standard therapy after practicing Sudarshan Kriya Yoga and pranayam breathing techniques.96 Page 35

A systematic review and meta-analysis of RCTs on the physical and psychosocial benefits of yoga in cancer patients and survivors by Buffart and colleagues concluded that yoga may be a feasible intervention as beneficial effects on several physical and psychosocial symptoms were reported.97 They showed that it has strong beneficial effects on distress, anxiety and depression, moderate effects on fatigue, general HRQoL, emotional function and social function, small effects on functional well-being, and no significant effects on physical function and sleep disturbances. It was suggested that yoga can be an appropriate form of exercise for cancer patients and survivors who are unable or unwilling to participate in other traditional aerobic or resistance exercise programs.

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Pregnancy

Preliminary evidence from various scientific studies supports yoga’s potential efficacy, particularly if started early in the pregnancy. Women practicing yoga in their second trimester reported significant reductions in physical pain from baseline to post intervention compared with women in the third trimester whose pain increased.98 Women in their third trimester showed greater reductions in perceived stress and trait anxiety. Another study reported significantly fewer pregnancy discomforts at 38-40 weeks of gestation.99 Subjects who participated in the yoga programme exhibited higher outcome and self-efficacy expectancies during active and second stage of labour. Provision of booklets and videos on yoga during pregnancy may contribute to a reduction in pregnancy discomforts and improved childbirth self-efficacy.

Satyapriya et al concluded that yoga reduces perceived stress and improves adaptive autonomic response to stress in healthy pregnant women100 while Chuntharapat et al101 concluded that yoga

produced higher levels of maternal comfort during labour and 2 hour post-labour with a decrease in subject evaluated labour pain. They also reported shorter duration of the first stage of labour, as well as total time of labour in subjects practicing yoga.

A study by Narendran et al reported a lower trend in the occurrence of complications of pregnancy such as pregnancy-induced hypertension, intrauterine growth retardation and pre-term delivery in subjects who practiced yoga.102 They concluded that an integrated approach to yoga during pregnancy is safe and that it improved birth weight, decreased preterm labour, and reduced IUGR either in isolation or associated with PIH, with no increased complications.

A review by Field reported that alternative therapies have been found effective for reducing pregnancy-related back and leg pain and nausea and for reducing depression and cortisol levels and the associated prematurity rate.103 It also noted that alternative therapies reduce pain and thereby the need for medication.

Figure 7: Postulated Mechanisms of Benefits of Yoga In Pregnancy. Chuntharapat S, Petpichetchian W, Hatthakit U. Yoga during pregnancy: effects on maternal comfort, labor pain and birth outcomes. Complement Ther Clin Pract 2008; 14(2): 105-15.

Paediatric Population

Clinical applications of Yoga have been studied in paediatric and young adult populations with focus on physical fitness, cardio-respiratory effects, mental health, behaviour and development, irritable bowel syndrome, eating disorders, and prenatal effects on birth outcomes. Though a large majority of studies Page 36

are positive, due to methodological limitations, evidence provided is still in its infancy.104 Yoga has been suggested as an option for children to increase physical activity and fitness and that yoga may be a gateway for adopting a healthy active lifestyle in sedentary children who are intimidated by more vigorous forms of exercise. They recommended Annals of SBV

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that further research is necessary to identify clinical applications of yoga for children and that such research needs to be conducted with rigorous methodology in RCTs with detailed description of protocols and reporting of results. Methodological issues specific to mind-body interventions should be addressed including adequate description of the intervention and control group, and single blinding of the outcome assessor.

A review by Galantino et al concluded that “the evidence shows physiological benefits of yoga for the paediatric population that may benefit children through the rehabilitation process, but larger clinical trials, including specific measures of QOL are necessary to provide definitive evidence.”105 They rightly suggested that the type and intensity of yoga, the specific postures for the intended outcome, and the measurement of adherence beyond the clinic have to be determined. Their review showed that yoga may benefit children with mental challenges by improving their mental ability, along with motor coordination and social skills and that restoration of some degree of functional ability is possible in those having physical disabilities.

It was suggested that physical therapists might apply these findings in the neuromuscular areas of learning, motor control, and coordination.

A notable point mentioned by them was that, “Regardless of the goal, yoga appears to be a multitasking modality that simultaneously treats both physical impairments as well as more global issues such as stress, anxiety, or hyperactivity.”

In Conclusion

All of the above studies and reviews suggest a number of areas where mind-body therapies such as yoga may be beneficial, but more research is required for virtually every one of them to establish their benefits conclusively. This is true in the process of introducing any new therapy into the modern health care system and is not surprising when we realize that the proper studies on yoga as a therapeutic modality are not older than a few decades.

Some of the major issues highlighted by these studies and reviews include: 1.

Individual studies on yoga for various Page 37

conditions are small 2. Poor-quality trials in general with multiple instances for bias 3. Substantial heterogeneity with regards to the • populations studied, • yoga interventions, • duration and frequency of yoga practice, • comparison groups, and • outcome measures.

4.

Compliance was not routinely noted, thus preventing an understanding of the apt ‘dosage’ requirements with regard to the mind-body interventions 5.

Yoga requires active participation and motivation that requires active efforts from both the researcher as well as the participants.

6. Changes in attitudes and behavior need to be documented and understood better, especially in the lifestyle, stress induced psychosomatic conditions.

7.

It is not clear which patients may benefit from the mind-body interventions, and which aspects of the interventions or which specific styles were more effective than others.

It has been suggested that yoga may help improve patient self-efficacy, self-competence, physical fitness, and group support, and may well be effective as a supportive adjunct to mitigate medical conditions. Büssing et al concluded that yoga may have potential to be implemented as a safe and beneficial supportive/adjunct treatment that is relatively cost-effective, may be practiced at least in part as a self-care behavioral treatment, provides a life-long behavioral skill, enhances selfefficacy and self-confidence, and is often associated with additional positive side effects.106 It is important to develop objective measures of various mind-body therapies and their techniques while including them in intervention trials. It has also been suggested that the publication of specific interventions used in future studies in manual form can allow reliable replication and future implementation. It is also important to develop tools to monitor objectively the participants’ self-practice, compliance, and adherence to the interventions. Yoga has preventive, promotive as well as curative potential and a yogic lifestyle confers many advantages to Annals of SBV

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the practitioner. Since lifestyle related diseases are alarmingly on the rise in our modern society, yogic lifestyle should be given a special place in preventing and managing these diseases.

As suggested by Bussing et al, “Yoga may well be effective as a supportive adjunct to mitigate some medical conditions, but not yet a proven stand-alone, curative treatment. Larger-scale and more rigorous research with higher methodological quality and adequate control interventions is highly encouraged because yoga may have potential to be implemented as a beneficial supportive/adjunct treatment that is relatively cost-effective, may be practiced at least in part as a self-care behavioural treatment, provides a life-long behavioural skill, enhances self-efficacy and self-confidence and is often associated with additional positive side effects.”106

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97. Buffart LM, van Uffelen JG, Riphagen I, Brug J, van Mechelen W, Brown WJ, Chinapaw MJ. Physical and psychosocial benefits of Yoga in cancer patients and survivors, a systematic review and metaanalysis of randomized controlled trials.

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A YOGIC PERSPECTIVE ON HEALTH AND DISEASE Smt. Meenakshi Devi Bhavanani*

“Health and happiness are your birthright! Claim them!” thundered the “Lion of modern yoga” Yogamaharishi Dr. Swami Gitananda Giri Guru Maharaj. “You are born to be healthy and happy.

But, the goal of life is moksha – freedom!”

We live in “topsy-turvy times”, when ancient values have been flipped onto their heads. One rarely meets a truly “healthy” or “happy” person.

In fact, for the vast majority of the human race, health and happiness are distant dreams. Illness, depression, conflict, sorrow, stress, tension and frustration are the “birthright” even of young children in modern times. Billions of dollars are expended by the health industry. Medical science can put pig valves into human hearts and transplant vital organs. Super specialty hospitals abound. The pharmaceutical industry produces a huge amount of life-saving drugs. Why, then, is a truly healthy, happy person such a rarity?

Modern man, like the Biblical Essau, has sold his birthright for a “mess of porridge”. Like Judas, he has betrayed his Christ consciousness, his cosmic consciousness, for less than “30 pieces of silver”.

Swami Gitananda has put before us a simple reason for this sad state of affairs. He advised. “If you want to be healthy, do healthy things. If you want to be happy, do happy things.” People cry, “I want to be healthy.” Then, they indulge in bad habits like tobacco and alcohol, spend late-hours watching television, do not exercise properly, do not drink enough water. Others moan, “I want to be happy!” but they fight, they gossip, they quarrel, they criticize, they delight in conflict, in violence, in defeating others, and crushing competition under their feet. It is irrational to expect that by doing unhealthy things, one can be healthy. It is irrational to believe that by doing unhappy things, one can be happy. Yes, man is an irrational animal indeed!

Yoga is the ancient science of India which shows man not only how to claim his birthright

of health and happiness, but also to obtain the goal of life – moksha. Any scientist worth his salt begins his career by studying the laws of nature and the basic theorems and tenets of his science.

The yogic scientist is no exception to this rule.

The physicist studies the physical laws of nature - gravity, momentum, etc. The chemist studies the chemical properties of matter. The biologist studies life forms, the doctors, anatomy and physiology of the human body. This is the “field” within which they will work, observing the laws of action and reaction, the laws of cause-effect relationship, within that limited spectrum.

For the yogi, the entire universe and everything in it is his “field of research.” He studies the Universal laws which operate within this field. The law of karma, the law of cause-effect, is an important Law for him. The yogi knows that the laws which govern the microcosm also govern the macrocosm, and so, he understands that by studying himself, his “small self,” his “own self ”, his own body, mind and emotions, he can understand the “big self ’, the Atman, Brahman.

This process in yoga is called “swadhyaya” or “self study” and it is the fourth niyama of Patanjali’s Ashtanga Yoga. The rishis, cosmic scientists, have taught, “Without moving out of one’s own cave, one can comprehend the universe.” They realized that universal truths lay within one’s very own heart. “Man, know Thyself ” is the admonition which was written on the entrance to the Greek temple at Delphi. This is the starting point of all endeavors. This is the starting point in the long journey to claim one’s birth right.

Alexander Pope, the great 18th century English poet, wrote, “Man, know thy self / presume not god to scan / the proper study of mankind / is man.”

Through this “self study” the yogi discovers that human nature is governed by an inexorable law and the very law which governs his nature - is the very law which governs the universe. This law is called “Sanatana Dharma” or “the eternal law” and is unbreakable. One has no choice but to discover it, and then, live in harmony with that eternal

* Smt. Meenakshi Devi Bhavanani, Ashram Acharya and Director, ICYER and Yoganjali Natyalayam, Puducherry, www.icyer.com and www.rishiculture.org.

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law. Only then will one be entitled to enjoy one’s birthright - health and happiness. The Christian Bible teaches, “The wages of sin is death.” “Sin” is nothing more than defiance, rebellion and disobedience to the eternal law. Yogamaharishi Dr. Swami Gitananda Giri taught his students: “you cannot break the law. You can only break yourself over the law.” How do we know if we are “breaking the law”? The results are there for all to see: sickness, suffering, unhappiness, conflict, stress, and tension.

One might retort: “But I am unhealthy! I am unhappy! I am not breaking law! I am not an outlaw!” Look again! Indeed, such a person must be breaking the law, whether knowingly or unknowingly. Remember, even in human jurisprudence, “Ignorance of the law is no excuse.”

No court on earth will excuse a law-breaker who pleads “ignorance of the law”. All citizens are expected to not only know the law, but also, to abide by it, so that the society may flourish in a harmonious manner. But, who wants to be unhealthy? Who wants to be unhappy? If these are the result of breaking natural law, then why do people do it? The answer is pure and simple: ignorance. The Sanskrit word for “ignorance” is “avidya”. Patanjali, the sage who codified the principles of yoga 2500 years ago in 196 magnificently concise sutras, calls “avidya” or “ignorance” as the “Mother klesha”. A klesha is a hindrance, an obstacle to spiritual growth. Basically, klesha is the root cause of all human problems.

There are pancha klesha or “five hindrances”.

Sometimes “klesha” is translated as “a knot of the heart”. It prevents the human being from further spiritual advancement and drags the human into the mire of misery. The other four kleshas are: asmita (egoism), the sense of separation, the sense of I, raga (attraction due to pleasure), dwesha (aversion due to pain) and abinivesha (clinging to life, the survival instinct). These are the “obstacles” which stand between man and his desire to claim his birthright of health and happiness. But the root of all obstacles is avidya (ignorance), ignorance of the law, and hence, the constant attempt to “break the law”.

What is ignorance? Look at the word. It is composed mostly of the word “ignore”. “Ignore” implies “a refusal to see”. If we “ignore” someone, it implies a deliberate attempt to cut this person Page 43

out of the field of our awareness. If we attend a gathering and find someone we have aversion towards (dwesha) present, we usually “ignore” that person, literally, turning “our back on them” so that we do not have to “see” or “acknowledge” them.

But, if ignorance of the universal law causes us to break the law, and hence, results in disease and unhappiness, why do we as humans continue on this path to death and destruction? Because we are taught, and we willingly accept this falsehood, that we are not responsible for our own health and happiness. We have given over the responsibility for our own health to the doctor, and have asked him to find us a pill, or cut something out of our body, or stick something into it, and make us healthy again. We have given the responsibility of our happiness to the government, the society, to the media, to the entertainment industry, to antidepressant medicines, and asked them to “please us, to give us about we want, to make us happy.”

We have sold the most precious quality we possess as humans, “manas” or conscious awareness, and its twin virtues, independence and self–initiative, to the various powerful lobbies which govern our lives. And they in turn, most benevolently “put us to sleep”, sedate us, put us under anesthesia, so we no longer feel the pain inherent in breaking the law. We are hypnotized into a fitful sleep from our childhood to our old age, and into the funeral pyre itself. We are lulled into a somnolent state in order to make our life’s journey bearable, with a minimum of pain – we are neither healthy nor happy, but blissfully numb and anesthetized.

Why should our entire social, political, educational, business, commercial, media and entertainment structure be geared to keeping us numb and dumb? For a simple reason: there’s plenty of money and power in unhappiness and disease. But, there’s no money in health and happiness. How would doctors and the huge drug industry support themselves if all were healthy?

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commercial interests that the five billion people on the planet are kept sick and unhappy, in a state of unfulfilled desire and thus, in constant frustration.

As an example close to home, look at the field of dentistry. When I came to Pondicherry in 1968, there was one dentist in town. I did not know anyone who had problems with their teeth. Cavities were rare.

On the contrary, I was struck by the beautiful, white healthy teeth of our Indian people. Even villagers had dazzling smiles! Life was simple. Processed foods were a luxury. Natural food was the norm.

Cut to the present scenario. The number of dentists in Pondicherry numbers more than 500! Children as young as four years of age have cavities and dental problems. I don’t have to tell you professionals where the problem lies. It is obvious! The abundance of refined foods, sugars, sweets, soft drinks, ice creams, lack of oral hygiene has destroyed the nation’s teeth! The good old neem stick has been discarded as “old fashioned” and we now spend Rs.20 on a toothbrush and Rs.50 on toothpaste which is not one-hundredth as effective as the old neem twig! Is this progress?

Is this the obedience to natural law? Is this health?

The villager cannot afford to buy toothbrush and toothpaste – this would cost him one day’s wages.

This “progress” has not only taken his health, but also his happiness. He will “become unhappy because he does not have the money to buy such items!” Should not the emphasis in social dentistry be on spreading awareness of the horrendous damage caused to the teeth by these modern junk foods and drink? But, emphasis seems to be more focused on cure, rather than prevention. Lip service is given to these ideas but the powerful commercial lobbies are quick to squelch any effective activism on these subjects. This is not only in the field of dentistry. It is the fact in every single aspect of life.

There is no money or glory or power in prevention, but plenty of it in cure! Instead of educating people to “obey natural law”, the modern trend is to repair people who have “broken themselves over that law.”

Avidya, ignorance! It is a disease, which is more deadly than an atomic bomb. It has already burst upon the earth and is enveloping all mankind in its black, poisonous mushroom cloud. It is the root cause of all unhappiness and disease.

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“Vidya” – wisdom, knowledge – is the opposite of “avidya” or ignorance. It basically means “to see”.

The rishis were “Men who saw Reality as It Is.” If we wish to claim our birthright of health and happiness, we must “Arise and Awake.” We must open our eyes to see and our ears to hear. When this “Awakening” occurs, one will be drawn to the yogic science. It is the start of the long spiritual journey.

The “Core Concept” in accepting yoga as a way of life is embedded in the word “responsibility”. One must be prepared to accept “total responsibility” for one’s own life, total responsibility for one’s thoughts, words and deeds, total responsibility for one’s own health and happiness. This is, in essence, obedience to the “eternal law” which states, “all karma – all action – has its reaction and that re-action will always rebound on the one who committed the action.” Just as the sudarshan chakra (celestial discus) of Lord Vishnu followed the sage Durvasa wherever he ran as he tried to hide until he made amends to King Ambarish for harming him, so also the “reaction” of our “action” will follow us wherever we go, until we “pay out” the karma in consciousness. In short, if we do unhappy things, we will be unhappy. If we do unhealthy things, we will be unhealthy. There is no “breaking” this law and even the best doctor, the best dentist or the best entertainer cannot keep our karma forever at bay. The sign on the yogi’s door (whether the door leads to his palace or the door leads to his cave) reads. “The buck stops here.” That is, the yogi takes total and complete responsibility for himself and everything which happens to him and makes a conscious choice to “live within the law”, rather than choosing to be an “outlaw.”

The word “responsibility” also has another aspect. Broken into two parts it reads “respondability”, or “the ability to respond”. The yogic way of life cultivates and values consciousness and awareness. Hence the yogi develops the “ability to respond” correctly to any given situation. The correct “response” will produce a “positive effect” and the result of such a positive action-choice is overall health, harmony and happiness.

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thought, word and deed. Obedience to the law produces health and happiness. Disobedience produces disease and suffering. As a scientist, the yogi employs all the tools of any great science: he possesses an elaborate terminology which helps him define and understand the problem; he possesses equipment and tools for his search – asanas, pranayama, concentration practices, mantras, cleansing techniques, etc.

He/she enjoys access to a great body of theoretical concepts, accumulated through hundreds of generations of “spiritual experiments” conducted by the great rishis who have preceded him. This “theory” is recorded in the Vedas, the Upanishads, the Bhagavad Gita, the Yoga Sutras, the Gheranda Samhita, the Hatha Yoga Pradipika and other ancient scriptures. His laboratory, his field of research, is his own body, emotions and mind and his relationship and correspondence to the Universe. The yogi is a detached observer who carefully records his data and comes to his own conclusions based on his own direct observation and experiences.

He begins with this primary hypothesis – the universe is cosmos, it is not chaos. “Cosmos” implies “order”, and “order” implies “laws”. He sets out to discover those laws and to observe the working of those laws in his own life and in the lives of others. The yogi then attempts to “apply” his findings in a practical manner – in his own life, coming to the same “realizations” as those enjoyed by the rishis of old. Health and happiness manifest automatically in such a life, which attunes itself to cosmic law. Health and happiness are automatic byproducts when avidya or ignorance is dispelled and vidya, seeing reality for what it is develops.

The yogi follows the “great law of virtue” which is elaborated in the yogic tradition as the pancha yamas or moral restraints and the pancha niyamas, the ethical observances. These maha vratas, the mighty vows of virtue, reflect the Sanatana Dharma or the eternal law. The yogi develops a love for virtue, a love for the law. He realizes “virtue is its own reward.” He attunes his own microcosm to the rhythm of the macrocosm. He moves with Nature, not against it. Nature is his friend, with whom he lives in harmony, and not an enemy to be conquered or exploited.

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“Sanatana Dharma” is difficult to translate.

It can be called “the eternal law”, “the cosmic law”, even “the structure of the universe as it is”.

“Sanatana” means “eternal” – That which was, which is, and which shall always be – unchanging, self-created, unborn, undying. “dharma” takes its root meaning from “dhar” which means “stability, even-ness, balance.” The English word “durable” has come from “dhar” – that which endures. “Dharma” is hence that which gives stability. Stability is an essential component of health. As any good doctor knows, the best news he can give anxious relatives is that the patient has “stabilized.” Stability is also an essential component of happiness. Nothing creates more misery than an unstable family, unstable romantic relationships, unstable work or social environments. Sanatana Dharma sometimes is more loosely defined as “the law of virtue”. Virtue creates stability. Clean, pure, restrained, controlled, conscious aware living is the basis of all virtue.

Such qualities create personal, interpersonal and intrapersonal stability. Hence, one becomes aware of the necessity of obeying “the law of virtue”, if one wishes to be qualified to claim one’s birthright as health and happiness. As Yogamaharishi Dr. Swami Gitananda put it so succinctly: “Following yama–niyama, obeying the cosmic law is “NoOption Yoga” for those who wish to spiritually evolve themselves in health and happiness.”

Our ancients linked particular diseases to certain lapses in character. These linkages can be found in many Puranas. Arthritis is linked to greed, refusal to let go, or to share. Digestive problems were linked to hoarding, excessive, selfish accumulation. The old idea that diseases were caused by a moral lapse had much truth. Interestingly enough, modern medicine is also coming to a similar conclusion, though by a different route. Research findings have enabled medical men to draw up “personality profiles” for cancer patients, heart attack patients, diabetics, AIDS patients and so on. Character creates circumstances. Character is composed mostly of the word “act”. The manner in which we habitually “act” forms our “character.”

Our actions determine whether we are healthy or unhealthy, happy or unhappy. This is the essence of Sanatana Dharma. We create our own destiny by our thoughts, our words and our actions. There is no such thing as an “innocent victim” in the universal Scheme of Things.

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The yogi grows in consciousness and spirit till he becomes an “adhikarin” a “fit person” for “realizing reality”. He becomes competent to “claim his birthright of health and happiness.”

But, that is only the beginning of his journey. He has arisen! He has been awakened! And now it is his duty to “stop not till the goal of moksha” is reached. But, though the pilgrimage is long and arduous, the universe herself/himself/itself grants him his birthright – health and happiness as the reward for obeying natural law. He has the health, strength and good cheer to make

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his cosmic journey and he has the happiness to enjoy his travels in space and consciousness.

Buoyed by this spiritual legacy, the yogi now has a raft to cross the ocean of samskara. “Avidya” or ignorance of universal law is banished by “vidya”, the light of conscious awareness. His eyes are opened. He sees! Happily and healthily he realizes that he lives not on a small planet, in a small galaxy, tiny as a grain of sand. He is a universal being, a universal citizen obeying the laws of the cosmos. And the Universe is his own, his native land!

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YOGIC PERSPECTIVES ON MENTAL HEALTH Dr Ananda Balayogi Bhavanani *

Introduction:

Yoga is first and foremost a moksha shastra meant to facilitate the individual to attain the final freedom, liberation or emancipation. One of the important by-products of the Yogic way of living is attainment of health and well being. This is brought about by right-use-ness of the body, emotions and mind with awareness and consciousness. This must be understood to be as healthy a dynamic state that may be attained in spite of the individual’s sabija karma that manifests as their genetic predispositions and the environment into which they are born. Yoga also helps maintain and sustain this dynamic positive state of health after it has been attained through disciplined self effort.

The central theme of Yoga is the golden mean, finding the middle path, a constant search for moderation and a harmonious homoeostatic balance. Yoga is the “unitive impulse” of life, which always seeks to unite diverse streams into a single powerful force. Proper practice produces an inner balance of mind that remains stable and serene even in the midst of chaos. This ancient science shows its adherents a clear path to the “eye of the storm” and ensures a stability that endures within, even as the cyclone rages externally.

Causation of Psychosomatic Disorders:

Yogamaharishi Dr Swami Gitananda Giri, founder of Ananda Ashram at Pondicherry (www.icyer. com) has written extensively about the relationship between health and disease. He says, “Yoga views the vast proliferation of psychosomatic diseases as a natural outcome of stress and strain created by desire fostered by modern propaganda and abuse of the body condoned on all sides even by religion, science and philosophy. Add to this the synthetic “junk food” diet of modern society and you have the possibility of endless disorders developing… even the extinction of man by his own ignorance and misdeeds”.

He explains the root cause of disease as follows.

“Yoga, a wholistic, unified concept of oneness, is adwaitam or non-dual in nature. It suggests happiness, harmony and ease. Dis-ease is created when duality or dwaitam arises in the human mind. This false concept of duality has produced all conflicts of human mind and the vast list of human disorders. Duality (dis-ease) is the primary cause of man’s downfall. Yoga helps return man to his pristine, whole nature.

All diseases, maladies, tensions, are manifestations of divisions of what should be man’s complete nature, the atman or ‘Self ’. This ‘Self ’ is “ease”. A loss of “ease” creates “dis-ease”. Duality is the first insanity, the first disease, the unreasonable thought that “I am different from the whole…. I am unique. I am me.” The ego is a manifestation of disease. Only a distorted ego could feel alone, suffer from “the lonely disease”, in a Universe, a Cosmos totally filled with the ‘Self ’.

Interestingly, he points out that one of the oldest words for man is “insan”. Man is “insane”. A return to sanity, “going sane,” is the subject of real Yoga Sadhana and Yoga Abhyasa. Yoga Chikitsa is one of the methods to help insane man back onto the path of sanity. A healthy man or woman may be known by the term-Yogi”. A very strongly worded yet very true statement indeed from the Lion of Pondicherry!

Yogic Perspective of Depression:

According to the Yoga Darshan codified by Maharishi Patanjali, depression or rather daurmanasya is one of the four vikshepa sahabhuvah that are the manifestations that accompany the obstacles to yoga sadhana, the nava antaraya. The other sahabhuvah are duhkha or suffering, angamejayatva or tremors and shvasaprasvasa or irregular respiration. (duhkhadaurmanasya angamejayatva shvasaprasvasa vikshepasahabhuvah Yoga Darshan -1:31). When we analyze this sutra deeply we find that they are very true reflections of our inner state.

* Dr Ananda Balayogi Bhavanani, Deputy Director, CYTER, Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India, Email: yognat@gmail.com Page 47

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Duhkha or painful suffering at the physical, emotional and mental level can drive us to despair.

Suffering is an excellent trick our mind plays as very few can overcome the ‘moment’ of suffering.

Very few are capable of realizing what is really happening in the process of their evolutionary journey. The moment ‘suffering’ is felt, most people give up, and the lower mind survives to fight another day.

Daurmanasya refers to dejection and despair.

We must remember that depression is not just in the mind but has many physical aspects too. A state of depression is another tool by which the lower mind tries to halt the spiritual progress of a sadhaka. However we must realise that the greatest teachings are often given at moments of great despair. The art and science of Yoga understands that this may be the best ‘teachable’ moment and hence we find the highest teachings of the Bhagavad Gita and Ramayana coming at this point.

Our Guru Swami Gitananda Giri Guru Maharaj used to say, “A nervous breakdown is actually an opportunity for a spiritual breakthrough if we can realise the positive implications in our moment of despair and dejection”. The teachings of the Yoga Vasishtha and the Bhagavad Gita which may be said to be the first and second recorded ‘psychological counseling’ sessions in human history were delivered when both Lord Rama and Arjuna respectively were at the depths of their depression. If we realise that this is indeed a window of opportunity for growth, success will come to us the soonest. But if we miss this golden chance, then even the Divine will struggle to help us out of our own deep pit of self pity.

Angamejayatva are the physical tremors of the body. The practice of asana helps us to attain to a state of physical control over our body. This enables us to go beyond the dwandwa, the pair of opposites that are the cause of these tremors. Tremors are an externalized manifestation of internal imbalances of our emotions and mind. Imbalance at the higher level causes the imbalance in the neuro-chemical transmitters and psycho-physiological pathways of the body, resulting in these physical tremors. When confronted with such a frightening manifestation,

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many aspirants get scared whether they are harming themselves and stop their Sadhana out of fear.

Shvasaprasvasa refers to the irregularity in breathing patterns. One of the main physical manifestations of mental and emotional upsets is the haphazardness of respiration. Ancient Yogis contemplated this deeply and found that mental disturbances cause irregularity and instability of respiration. Though their jnana drishti (perspective of wisdom) they realised that by stabilizing the breath, we can conversely produce a stability of emotions and mind. This knowledge is used even today in the practice of pranayama, when it is used as a means of altering the higher (mind) through the lower (body). This is one of the best examples of the numerous somato-psychic applications found in the practices of hatha yoga, the physical science of balancing equal and opposite energies.

Yogic Methods To Attain and Maintain Health:

The science of Yoga has numerous practical techniques as well as advice for proper life style in order to attain and maintain health and well being.

Bahiranga practices such as yama, niyama, asana and pranayama help produce physical health while antaranga practices of dharana and dhyana work on producing mental health along with pratyahara.

Yoga works towards restoration of normalcy in all systems of the human body with special emphasis on the psycho-neuro-immuno-endocrine axis.

In addition to its preventive and restorative capabilities, Yoga also aims at promoting positive health that will help us to tide over health challenges that occur during our lifetime. Just as we save money in a bank to tide over financial crises, so also we can build up our positive health balance to help us manage unforeseen health challenges with faster recovery and recuperation. This concept of positive health is one of Yoga’s unique contributions to modern healthcare as Yoga has both a preventive as well as promotive role in the healthcare of our masses. It is also inexpensive and can be used in tandem with other systems of medicine in an integrated manner to benefit patients.

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Becoming One With The Breath:

In the science of Yoga, body movement and breath must be synchronized. The breath pattern is important. Particularly in the use of kriya or structured movements like Surya namaskar, the body is normally lifted on an incoming breath and lowered on an outgoing breath. Some of the breath patterns such as the bhastrika strengthen the whole solar plexus area as well as the diaphragm, building up stamina while producing internal cleansing of organs and the blood stream. Kapalbhathi is another dynamic technique that enables us to break out of the deep hole of depression by creating a sense of activation. Surya nadi and ujjayi pranayama can also help in activating those who need the activation for healthy well being. The bandha trayam as well as the aswini mudra are both a God-send for those suffering from depression as they revitalise the entire psycho-neuro-endocrine system. The pranava and bhramari pranayama work towards creating an inner harmony that results in the attainment of a state of mental calmness.

According to Dr Swami Gitananda Giri, one of the foremost exponents of Yoga in the 20th century, the inherent message of Pranayama can be summarised as follows: • Th ere is an absolute and direct correlation between the way an organism breathes and its energy level.

• There is an absolute and direct correlation between the way a man breathes and the length of his life span.

• There is an absolute and direct correlation between the way a man breathes and the state of mind and clarity of thought, which he enjoys.

• There is an absolute correlation between the way a man breathes and the quality of emotions, which he experiences.

• There is an absolute and direct correlation between the way a man breathes and the subtlety of the thoughts, which pass through his mind.

Shifting From Individuality To Universality:

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personal. The ego which is fixated only on its own shallow self will soon run into the blank wall of depression and despair, overwhelmed by its own superficiality. That striving spirit which looks within at the universal aspect of its own nature and sees the oneness of the whole of creation will find an endless fountain of inspiration and joy. In short it may be safely said that the practice of Yoga as a unified whole helps the individual shift from an ‘I”-centric approach to a “we”-centric approach.

The Srimad Bhagavad Gita says, “yogaha karmasu koushalam” meaning thereby that Yoga is skill in action (BG 2:50). The real Yogi, immensely conscious and aware at the physical, mental and emotional levels gains great control through that consciousness over all aspects of life thus developing a real skill in living. Part of that skill springs from his cultivated detachment, his ability to work for “work’s sake,” and not for the sake of the reward. He realizes that his duty is to do his best but that the ultimate result is not in his hands. The Yogi performs the needed action not for the sake of the fruits of that action, but because it is good and necessary to do so.

Such an attitude of mind produces consummate skill in whatever action the Yogi undertakes.

Consummate concentration, consummate controls are all offshoots of good Yoga Sadhana. This belies the age-old belief that the competitive spirit produces the highest skill. To this the Yogic answer is: detachment from the fruits of the action produces the greatest efficiency, for one is then emotions connected with “goal-oriented”, competitive thinking. The beauty of Yoga is that these abstract principles become concrete in the daily practice of the techniques available in the Yoga system. Once the “seed of Yoga” finds fertile soil, these concepts grow naturally, slowly but surely taking root in all aspects of life.

Wholistic Approach of Yoga:

The Yogic wholistic approach to life that ‘everything is important and everything has its effect’ could do much to improve the mind, body and emotional states of well being. These practical approaches to health include: • Th e use of early morning sunlight for healing and rejuvenative activities

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• Th e use of water for internal and external cleansing • Careful attention to diet of a sattvic nature • Realising the necessity for balance between exertion and relaxation as all tension must be balanced using concept of spanda nishpanda or “exertion-relaxation-exertion-relaxation” in an alternating rhythm of activity, • Learning how to “unwind” through the many relaxation techniques available in the Yoga science which can balance the immense amount of stress and strain that are part and parcel of day to day life • Realising the need for clean air, water and food • Becoming aware of the effect of modern modes of entertainment and addictive habits in general debilitation of the physical, emotional and mental nature • Providing a “working philosophy” which will sustain one in triumph and defeat • Learning to be sensitive to one’s own biorhythms, one’s own physical, mental and emotional cycles • Being aware of the effects of the seasons and the various unnatural life styles to which the modern man is exposed In short, all of these aspects of Yoga as a way of natural living can provide relief for many of the psychosomatic ailments affecting humankind today.

Cultivation of Positive Health:

According to Yogacharini Meenakshi Devi Bhavanani, Director ICYER at Ananda Ashram in Pondicherry, Yoga has a step-by-step method for producing and maintaining perfect health at all levels of existence. She explains that social behaviour is first optimized through an understanding and control of the lower animal nature (pancha yama) and development and enhancement of the higher humane nature (pancha niyama).

The body is then strengthened, disciplined, purified, sensitized, lightened, energized and made obedient to the higher will through asana.

Universal pranic energy that flows through bodyPage 50

mind-emotions-spirit continuum is intensified and controlled through pranayama using breath control as a method to attain controlled expansion of the vital cosmic energy. The externally oriented senses are explored, refined, sharpened and made acute, until finally the individual can detach themselves from sensory impressions at will through pratyahara.

The restless mind is then purified, cleansed, focused and strengthened through concentration (dharana). If these six steps are thoroughly understood and practiced then the seventh, dhyana or meditation (a state of union of the mind with the object of contemplation) is possible. Intense meditation produces samadhi, or the enstatic feeling of Union, Oneness with the Universe. This is the perfect state of integration or harmonious health.

Yogic Tools For Positive Mental Health:

In order to create an environment conducive to the development of positive mental health as also to prevent and manage the psychosomatic lifestyle disorders that are threatening humankind, Yoga offers us many practical ‘day-to-day’ methods of action. Some of these tools for positive health are as follows.

1. Become aware of your body, emotions and mind: Without awareness there cannot be health or healing. Awareness of body implies conscious body work that needs to be synchronized with breath to qualify as a psychosomatic technique of health and healing. Psychosomatic disorders cannot be tackled without awareness.

2. Improve your dietary habits: Most disorders are directly or indirectly linked to improper dietary patterns that need to be addressed in order to find a permanent solution to health challenges. One of the most important lifestyle changes that needs be implemented in management of any lifestyle disorder is diet.

3. Relax your whole body: Relaxation is most often all that most patients need in order to improve their physical condition. Stress is the major culprit and may be the causative, aggravating, or precipitating factor in so many psychosomatic Annals of SBV

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disorders. Doctors are often found telling their patients to relax, but never tell them how to do it!

The relaxation part of every Yoga session is most important for it is during it that benefit of practices done in the session seep into each and every cell producing rest, rejuvenation, reinvigoration and reintegration.

other thorns continue falling or choose to wear a pair of shoes and walk through the forest. The difference is in attitude. Choosing the right attitude can change everything and bring about a resolution of the problem by healing the core. Stress is more about how you react to the stressor than about the nature of the stressor itself !

4. Slow down your breath making it quiet and deep: Rapid, uncontrolled, irregular breathing is a sign of ill health whereas slow, deep and regular controlled breathing is a sign of health. Breath is the link between body and mind and is the agent of physical, physiological and mental unification.

When breath is slowed down, metabolic processes are also slowed and anabolic activities begin the process of healing and rebuilding. If breath is calm, mind is calm and life is long!

8. Increase your self reliance and self confidence: Life is full of challenges that are there only to make us stronger and better. The challenges should be understood as opportunities for change and faced with confidence. We must understand we have the inner power to overcome each and every challenge that is thrown at us by life. The Divine is not a sadist to give us challenges that are beyond our capacity!

5. Calm down your mind and focus it inwardly: The mind is as disturbed as a drunken monkey bitten by a scorpion say our scriptures. To bring that wayward agitated mind under control, and take it on a journey into our inner being is fundamental in finding a way out of the ‘disease maze’ in which we are entangled like a fly in the spider’s web. Breath work and sensory control are the base on which mind training can occur; hence much importance is given to pranayama and pratyahara. It is only after this that concentration practices leading to meditation can have any use.

Just sitting and thinking about something is not meditation!

6. Improve the flow of healing ‘Pranic Life Energy’: Improve the flow of healing ‘Pranic Life Energy’ to all parts of the body, especially to those diseased parts, thus relaxing, regenerating and reinvigorating ourselves. Prana is life and without it there cannot be healing. The different prana and upa prana vayu that are energies driving different physiological functions of the body need to be understood and applied as per needs of the patient.

7. Fortify yourself against omnipresent stressors: Decrease your stress level by fortifying yourself against the various omnipresent stressors in your life. When face to face with the innumerable thorns in a forest, one may either choose to spend all their time picking them up one by one while Page 51

9. Facilitate natural emanation of wastes: Facilitate natural emanation of waste from the body by practicing shuddi kriyas like dhauti, basti and neti.

Accumulation and stagnation of waste materials either in inner or outer environment always causes problems. Yogic cleaning practices help wash out impurities (mala shodhana) thus helping the process of regeneration and facilitating healing.

10. Take responsibility for your own health: Remember that ultimately it is “YOU” who are responsible for your own health and well being and must take the initiative to develop positive health to tide you over challenging times of ill health.

Yoga fixes responsibility for our health squarely upon our own shoulders. If we do healthy things we are healthy and if we do unhealthy things we become sick. No use complaining that we are not well when we have been the cause of our problem.

As Swamiji Gitananda Giri would say, “You don’t have problems-you are the problem!”

11. Health and happiness are your birthright: Health and happiness are your birthright, claim them and develop them to your maximum potential.

This message of Swamiji is a firm reminder that the goal of human existence is not health and happiness but is moksha (liberation). Most people today are so busy trying to find health and happiness that they forget why they are here in the first place.

Yoga helps us regain our birthright and attain the goal of human life.

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Conclusion:

The dedicated practice of Yoga as a way of life is no doubt a panacea for problems related to psychosomatic, stress related physical, emotional and mental disorders and helps us regain our birthright of health and happiness. It is only when we are healthy and happy that we can fulfil our destiny.

Recommended Reading: 1. Yoga Chikitsa: The application of Yoga as a Therapy.

Dr. Ananda Balayogi Bhavanani. Dhivyananda Creations, Iyyanar Nagar, Pondicherry. 2013.

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2. Ancient Yoga and Modern Science. TR Anantharaman. Mushiram Manoharlal Publishers Pvt Ltd, New Delhi. 1996 3. Back issues of International Journal of Yoga Therapy.

Journal of the International Association of Yoga Therapists, USA. www.iayt.org 4. Back issues of Yoga Life, Monthly Journal of ICYER at Ananda Ashram, Pondicherry. www.icyer.com 5. Four Chapters on Freedom. Commentary on Yoga Sutras of Patanjali by Swami Satyananda Saraswathi, Bihar School of Yoga, Munger, India. 1999 6. Srimad Bhagavad Gita by Swami Swarupananda.

Advaita Ashrama, Kolkata. 2007 7. Yoga and Sport. Dr Swami Gitananda Giri and Meenakshi Devi Bhavanani. Satya Press. Pondicherry. 1991. www.icyer.com

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THE YOGA OF INTERPERSONAL RELATIONSHIPS Dr Ananda Balayogi Bhavanani *

Introduction:

All aspects of our human personality are cultured through the process of Yoga helping us evolve towards perfection until we are “One” with the Divine Self. Yoga helps destroy the Kleshas, the psychological afflictions that warp our vision, as well as eradicates Karma Bandha that prevents us from realizing our potential Divinity. Our great Rishis like Veda Vyasa and Maharishi Patanjali have given us a clear road map for this evolutionary journey with vital clues towards understanding both the internal and external culturing processes of Yoga.

The cultural teachings of Yoga help us become “All One” by losing our sense of individuality to gain an unparalleled sense of universality.

In our day-to-day personal and inter-personal social life, Yoga has given us multitudes of tools, concepts,attitudes and techniques through which we can attain inner contentment leading to happiness and spiritual realization while simultaneously creating harmony in all relationships. All psychosocial qualities essential for healthy inter-personal relationships are cultivated when we live a life of Yoga that is in tune with the eternal Dharma. These humane qualities include loving understanding, innate sensibility that sees other’s perspectives, compassion, empathy, respect, gratitude, fidelity and responsibility. In fact the Srimad Bhagavad Gita delineates very similar qualities of a spiritually healthy person in Chapter XVI. These include: fearlessness (Abhayam), purity of inner being (Sattva Samshuddhih), steadfastness in the path of knowledge ( Jnanayoga Vyavasthitih), charity (Danam), self control (Dama), spirit of sacrifice (Yajna), self analysis (Svadhyaya), disciplined life (Tapa), uprightness (Arjavam), non violence (Ahimsa), truthfulness (Satyam), freedom from anger (Akrodhah), spirit of renunciation (Tyagah), tranquility (Shanti), aversion to defamation (Apaishunam), compassion to all living creatures (Daya Bhutesv), non covetedness (Aloluptvam),

gentleness (Maardavam), modesty (Hrir Acaapalam), vigor (Tejah), forgiveness (Kshama), fortitude (Dhritih), cleanliness of body and mind (Saucam), freedom from malice (Adroho), and absence of pride (Naa Timaanita). One who is blessed with these qualities is indeed a divine blessing to the social life of their immediate family, friends, relatives and their society itself.

The Four Pronged Approach:

Our ancient Indian culture, a vibrant living culture till even today, has a lot to offer in every sphere of life. The elevated spiritual, psychological and metaphysical concepts of our great Maharishis hold true even today and it is up to us to delve into them and reap benefits of psycho-physiological health, happiness as well as intra-personal and inter-personal social harmony. Our Rishis were visionary seers who codified innumerable concepts that produce physically, emotionally and mentally healthy individuals who are valuable for betterment of society.

Our ancients in their infinite wisdom realised that we need to deal with different people differently.

Some people can be held close whereas with others an arm’s length or often a six feet pole’s length is required. Sensitive, sensible people may respond to a soft carrot approach while the arrogant who are usually dull and inert may only respond to a heavy and strong stick. The Rishis have codified a four pronged approach to deal with different types of human personalities at different times and in different ways. Saint Thiyagaraja in his composition “sarasa sama dana bheda danda chatura” describes Lord Rama as the perfect example of a human possessing these qualities of Kingship and kinship.

The first of these four methods is known as Sama and is the dealing with people using a sense of equanimity and treating them as equals in the search for truth. This can only be applied with the noble ones and will be misused by others as seen in

* Dr Ananda Balayogi Bhavanani, Deputy Director, CYTER, Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India and Chairman: International Centre for Yoga Education and Research, and Yoganjali Natyalayam Puducherry. www.rishiculture.org and www.icyer.com Page 53

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today’s chaotic environment. The second method is Dana, which implies the affording of concessions towards those who are truly needy. This may be in the material, physical, mental or emotional form and is the giving of a bit of leeway that can help those who are in trouble to come up to par with others and then slowly develop into one who can be treated at the Sama level. Bheda is the third method and is a separation from troublesome elements in order to reduce the extent of the problem. When used in a proper and judicious manner this can help many situations to normalize and prevent them from going from “bad to worse”.

When things get really bad or worse, then Danda or minimal deterrent action through judicious punishment can be of use when we considering the holistic picture.

In modern times the “spare the rod” mentality is prevalent and we do seem to end up spoiling our children and youth by making them weaker in all aspects. We take away their ability to be responsible citizens by teaching then indirectly that “anything that happens is not your fault- you are the victim”. I reiterate clearly that I am not a supporter of any form of corporal punishment, but I do realize the need for a determent in order for the betterment of the whole. One rotten apple is all that we need to spoil a barrel and the same can be said of the repeated offenders. Such situations need to be nipped in the bud and the Danda method has its uses too in such situations. Of course this requires a lot of Viveka on the part of the parent, teacher or person in authority and also needs safety precautions so that it is not misused by ignorant egotistical persons who want to be the “star of the show” at the cost of the others. The most basic qualities required for a good parent, teacher and leader in any field of endeavor are intelligence and empathy. Yet how many of our people have these qualities today?

Evolutionary Quirks of the Human Brain:

Ammaji, Kalaimamani Meenakshi Devi Bhavanani often talks about the five quirks of the human brain and quotes the Ken Keyes Jr who in his book “Your Road Map to Lifelong Happiness” argues that there is an essential “lack of communication”

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between the “old” (reptilian - mammalian) and the “new” (conscious, neo-cortex) parts of the human brain. As the “old brain” developed over 60 to 375 million years it is powerful and well-set in its ways.

Its habitual responses to environmental survival challenges are strong and automatic – “kill or be killed”. On the other hand, the “New Brain” of human consciousness is only 40 to 100 thousand years old and hence the new boy on the block.

The lack of communication between the old and new brains produces the “Five Quirks” that are the major causes behind innumerable problems we face in all interpersonal relationships. These quirks are: 1. The Object Quirk – the animal brain sees objects only in a very vague, hazy, general sense and not in a specific sense. It views objects and classifies them as to how they may fulfill its needs or in what way they may threaten its safety. Thus, it confuses different people and things. It sees everything generally as friend or foe, provider of food or as a sexual possibility. It does not need to see any object with specific characteristics. For example, it does not choose a mate on personal charm or elevated character but simply as a means to gratify sex drive.

Other objects and other creatures are important only as means to satisfy basic needs.

2. The Time Quirk – Keyes says the “Old Brain” has no time sense. It does not perceive past or future. It lives only in the present moment. It “eats or is eaten.” There is no sense of tomorrow or yesterday. Everything is immediate, now, urgent.

At that lower level of life, every experience is in the “Now” of survival.

3. The Unsafe Stranger Quirk – The “Old Brain” views all strangers with suspicion. The “unknown stranger” is a possible threat to survival or a competitor for resources. Any creature “different” from oneself and one’s species is a potential threat.

4. The Unchanging Entity Quirk – To the “Old Brain” incapable of perceiving subtleties, everything remains the same – a tree is always a tree. It does not perceive the various changes, which all things pass through. It sees all things as “unchanging” as the perception of intricate subtleties of change is not necessary for survival.

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5. Adaptable Memory Quirk – The animal does not need memory. The only memory necessary is what enables it to survive. Hence, what it remembers can be “adjusted” to whatever best helps it to survive. There is no objective truth. The only “Truth” to the animal brain is “survival of the fittest.”

The manner in which animals and reptiles perceive the world is a much dimmer, less precise, less clear, survival-oriented perception totally geared to survival. This is much less than that available to the conscious mind. The “Old Brain” is fuelled by emotional responses. The basic motivating emotion is fear. The other important drives-sex, survival instinct, herd mentality, dominance, power struggles, nurturing and being nurtured-are all tied to the organism’s basic need to survive at all costs and fear of death or extinction.

For example, the “Object Quirk” manifests in human experience when a person in the past was abused by a red-haired woman and hence, in future, always has a dislike for red-haired women.

The “Old Brain” cannot see the possibility that all red-haired women will not abuse it. Similarly the Time Quirk manifests itself in human behavior in this manner: when one experiences unhappiness, one feels one is “always unhappy.” This may cause one to perceive another person as “always angry”, even though the person may only be angry at that moment. Witness how many husband-wife or parent-child quarrels begin with the words… ‘You always do this…”

The “Unsafe Stranger Quirk” is evidenced in the suspicion that people feel when a foreigner enters their circle, or someone of a different religion a different race, a different culture etc comes into their social circle. There is an instinctual fear, even though that person may be perfectly harmless. This is highly visible in today’s society where everyone wants “their” country, state, language, religion etc to be the “best”. Linguistic, religious and regional fanaticism springs forth from such “old” conditioned responses that are so deeply ingrained in the animal brain that people lose all ‘sense’ and do things that they would never do in even their wildest dreams.

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The “Unchanging Entity Quirk” manifests when people cannot see that those around them are constantly changing, that they are not what they were yesterday. A thief may have reformed himself, but others may always perceive him as “a thief.” The husband may have overcome his bad habit, but the wife cannot see him anew. This is carried further by the “Adjustable Memory Quirk” that occurs when people deliberately or unconsciously “re-arrange” their memories to support or justify their emotions or desires. For example, a couple who wish to divorce may “adjust their memories’ to “remember” only the “bad times” or the “bad characteristics” of their partners. This is very common in most relationships and cannot be overcome without awareness and consciousness that springs from introspectional self analysis of Swadyaya.

Animals are prisoners of their genes. They are incarnated into a conditioned, stimulus-response programming and they have no choice, but to follow their instincts. Man, the new being, the first “Conscious Organism” has the power of choice.

He / she may now act, and choose to respond in a dignified and adequate manner, rather than react in an uncontrolled and totally inappropriate manner. The human being has the power to think, to recall past situations and compare them to the present reality. Man has the power of reason which frees him from the instinctive responses to challenge which is the mode of behavior of the reptilian and mammalian kingdom. But the power of the unconscious emotions and instincts rising from the “Old Brain” in a kind of “evolutionary lag” sometimes overpowers the “Rational Brain” and causes “The New Being” to react in an irrational manner. Man as a social, conscious being has lifted himself from the jungle environment with its moment to moment dangers and constant life and death challenges. He no longer faces challenges to his very survival on a constant basis. His life is relatively secure on the physical level (barring wars and other unusual circumstance). Yet, his “Old Brain” is hard wired to react as though every threat (physical or psychological) is a life and death matter. Hence, even psychological challenges, or innocuous frictions trigger off “Old Brain” extreme responses, especially on the emotional level.

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We can witness in so many human relationships that the old, animal and reptilian autonomic responses and reactions cloud the “human” or conscious perception. The “Old Brain” reacts out of past conditioning. It is heavily “loaded” with emotions which are part of the mammalian complex, and hence, “unconscious.” The animal-reptile (Pashu) is not “free” to choose as it is bound by the tight noose (Pasha) of its conditioned stimulusresponse mechanism. If it is threatened, it will flee or fight. These are the only options open to it. We must remember that on the other hand, the “New Brain” has the power to act after considering the reality of the present situation. We have the choice of using discernment, rationality and deliberation to choose consciously our actions and responses in any given circumstance. This power of choice is concomitant to the event of consciousness. The multiple million dolor question is however, “Are we ready and willing to be real human beings?”

for they are the “sarvabhauma mahavratam” of Maharishi Patanjali. If we want to grow, to evolve out of our reptilian – mammalian past into the truly human, humane and divine nature, we must restrain the primordial instincts through Yama and consciously reinforce our Divine nature through the observances and practice of Niyama.

Importance of Adhikara Yoga:

The Pancha Niyamas are Soucha (cleanliness), Santhosha (contentment), Tapa (discipline), Swadyaya (study of one’s-self ) and Ishwar Pranidhana (gratitude to the Divine). The Pancha Niyamas guide us with “DO’S” - do be clean, do be contented, do be disciplined, do self - study (introspection) and do be thankful to the divine for all of his blessings. They help us to say a big “YES” to our higher self and the higher impulses.

Definitely a person with such qualities is a Godsend to humanity.

The Pancha Yama and Pancha Niyama are considered as Adhikara Yoga by Dr TR Anantharaman as they give us the self resplendent authority and inner resolve for spiritual realizations. They provide a strong moral and ethical foundation for our personal and social life. They guide our attitudes with regard to the right and wrong in our life and in relation to our self, our family unit and the entire social system.

The higher,conscious power to reflect,to perceive the current situation freed of all past conditioning, and then to consciously choose an appropriate response is the essence of Yama-Niyama, the moral and ethical system of Rishiculture Ashtanga Yoga. Yama may be understood to be a conscious restraint of primitive instincts and impulses rising from the “Old Brain.” Yama is thus the control of our unconsciousness tendencies, our Vasanas and the deeply ingrained habitual patterns of our Samskaras. Niyama may be on the other hand said to be a positive and conscious reinforcement of the higher consciousness, those Divine characteristics that propel one’s evolution into more advanced states of being. Niyama is the cultivation of consciousness. Pujya Swamiji, Gitananda Giri called the Yama and Niyama as “No-Option Yoga” Page 56

The Pancha Yamas are Ahimsa (Non – violence), Satya (truthfulness), Asteya (non-stealing), Brahmacharya (control of the creative impulse) and Aparigraha (non – covetedness). These are the “DO NOT’S” in a Yoga Sadhaka’s life. Do not kill, do not be untruthful, do not steal, do not waste your god given creativity and do not covet that which does not belong to you. These guide us to say a big “NO” to our lower self and the lower impulses of violence etc. When we apply these to our life we can definitely have better personal and social relationships as social beings.

We must remember that even if we are unable to live the Yama-Niyama completely, the attempt by us to do so will bear fruit and make us a better person, of value to those around us and a valuable person within our family and society.

These are values which need to be introduced to our children and youth, making them aware and conscious of these wonderful concepts of daily living. These are indeed qualities that are to be imbibed in a natural and Sahaja manner and not learnt under the threat of fear or compulsion.

The parents and teachers can by example show their children the importance of these qualities and when the children see the good examples of their parents and teachers living there principles they will surely follow suit sooner than later.

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Other Important Yogic Concepts:

There are many important Yogic concepts that help guide us in shaping our personal lives as well as helping us to create harmonious interpersonal relationships that make up our daily social life.

Some examples of these spiritually uplifting concepts that transform all aspects of our social life include: • Vasudeiva Kudumbakam: The whole world is one family. This is an excellent concept which helps one to understand that division on the basis of class, creed, religion and geographical distribution are all ‘man made’ obstructions towards oneness. One can then look upon all as his own and can bond with everyone irrespective of any barrier. All the great Yogic saints such as Tirumoolar, Tiruvalluvar, Basava, Periyalvar and Tirunavukkarasar have reminded us again and again in so many lovely verses of the singular teachings that there is only “One Humanity and One God”.

• Chaturvidha Purusharthas: The four legitimate goals of life tell us how we can set legitimate goals in this life and work towards attaining them in the right way, following our dharma to attain Artha (material prosperity), Kama (emotional prosperity) and finally the attainment to the real goal of our life, Moksha (spiritual prosperity). These four are termed as Aram, Porul, Inbam and Veedu respectively in Nannool, an ancient Dravidian text and the great life enhancing teachings in the Tirukkural of Tiruvalluvar deal directly with the first three and hints at the fourth.

• Pancha Klesha: Avidya (ignorance), Asmita (ego), Raaga (attraction), Dwesha (repulsion) and Abinivesha (urge to live at any cost) are the five Kleshas or mental afflictions with which we are born into this human life. Through Yoga we can understand how these control our life and see their effects on our behavior. These ‘Kleshas’ hinder our personal and social life and must be destroyed through the practice of Patanjali’s Kriya Yoga which is Tapa, Swadyaya and Ishwar Pranidhana.

• Jiva Karunya: Empathic compassion towards all living beings is extolled in the teachings of Tirumoolar, Tiruvalluvar and Vallalar Page 57

Ramalinga Adigalar. Tirumoolar says that the most important aspects of right living are the devoted loving offering to the Divine while in daily life the feedings of other human beings and animals with loving compassion. He also stresses the need of speaking good and kind words to others as the means to spiritual upliftment. Tiruvalluvar asks us the poignant question, “Of what use is intelligence if one cannot empathize with the pain of others and help them” • Chatur Bhavana: The four attitudes that Patanjali advises us to cultivate are given in the 33rd Sutra of the Samadhi Pada. These attitudes that help us to control our mental processes are: friendliness towards those who are happy (Maitri – Sukha); compassion towards those who are miserable (Karuna – Dukha); cheerfulness towards the virtuous (Mudhita – Punya); and indifference towards the wicked (Upekshanam – Apunya).

These help us create a Yogic attitude of Sama Bhava or equal mindedness in all situations. They also help us to overcome the Kleshas, and provide us with answers on how to live a Yogic life. They make us humane and help us to live within the social structure in a healthy and happy manner.

• Pratipaksha Bhavanam: The concept of Pratipaksha Bhavanam is an amazing teaching and must be inculcated in our Sadhana of dayto-day living as we face it so many times each day. Even if we cannot replace negative thoughts with emotion-laden positive reinforcements, we must at least make an attempt to stop them in their troublesome track! I have personally found that a strong ”STOP” statement works wonders in helping block out the negative thoughts that otherwise lead us into the quicksand-like cesspool of deeper and greater trouble. Tiruvalluvar advises us to repay negative actions done to us by others with positive selfless actions towards them.

• Karma Yoga: Selfless action and the performance of our duty without any motive are qualities extolled by the Bhagavad Gita which is one of the main Yogic texts. Performing one’s duty for the sake of the duty itself and not with any other motive helps us to develop detachment (Vairagya) which is a quality vital for a good life. Karma Yoga includes important concepts of Annals of SBV

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action-reaction and teaches us the importance of right action. This includes the concepts of selfless action (Nishkama Karma) as well as skill in action (Karmasu Koushalam). Selfless action and the performance of our duty without any motive are qualities extolled by the Bhagavad Gita which is one of the main yogic texts. Performing one’s duty for the sake of the duty itself and not with any other motive helps us to develop detachment (Vairagya) which is a quality vital for a good life. Yoga is skill in action according to Yogeshwar Krishna in the Bhagavad Gita. ‘To do our best and leave the rest’ is how Pujya Swamiji Gitananda Giri Guru Maharaj used to describe the best way of life. Even if we don’t practice the other aspects of Yoga, we can be ‘living’ Yoga, by performing all our duties skill fully and to the best of our ability. A great teacher can be a true Yogi by performing doing their duty to perfection and without care for the rewards of the action, even if they do not practice any Asanas or Pranayama.

• Samatvam: ‘Yoga is equanimity’ says the Bhagavad Gita. Development of a complete personality who is neither affected by praise nor blame through development of Vairagya (detachment) leads to the state of “Stitha Prajna” or “Sama Bhava”. This is a state of mind which is equally predisposed to all that happens, be it good or bad. Such a human is a boon to society and a pleasure to live and work with.

• Bhakti Yoga: The self effacing, loving path of Bhakti enables us to realize the greatness of the Divine and understand our puniness as compared to the power of the Divine or nature. We realize that we are but ‘puppets on a string’ following his commands on the stage of the world and then perform our activities with the intention of them being an offering to the Divine and gratefully receive HIS blessings. “It is only with the blessings of the Divine, that we can even worship his holy feet (avanarulal avan thal vanangi)” says the Shiva Puranam, a Shaivite Dravidian classic.

Shifting From Individuality To Universality:

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personal. The ego which is fixated only on its own shallow self will soon run into the blank wall of depression and despair, overwhelmed by its own superficiality. That striving spirit which looks within at the universal aspect of its own nature and sees the oneness of the whole of creation will find an endless fountain of inspiration and joy. In short it may be safely said that the practice of Yoga as a unified whole helps the individual shift from an ‘I”-centric approach to a “we”-centric approach.

Tirumoolar stresses the importance of cutting the ego sense (Anava Mala) in countless verses of the 3000 versed classic Tirumandiram.

Yoga not only considers the importance of attaining a dynamic state physical health but also more importantly mental health. Qualities of a mentally healthy person (Stitha Prajna) are enumerated in the Bhagavad Gita as follows: • B eyond passion, fear and anger (veeta raga bhaya krodhah- II.56) • Devoid of possessiveness and egoism (nirmamo nirahamkarah- II.7) • Firm in understanding and un bewildered (sthira buddhir asammudhah- V.20) • Engaged in doing good to all creatures (sarva bhutahiteratah- V.25) • Friendly and compassionate to all ( maitrah karuna eva ca- XII.13) • Pure hearted and skilful without expectation (anapekshah sucir daksah- XII.16) Maharishi Patanjali tells us that we can gain unexcelled happiness, mental comfort, joy and satisfaction by practicing and attaining a state of inner contentment (santoshat anuttamah sukha labhah- PYS II: 42). This link is quite apparent once we think about it, but not too many associate the need for contentment in their greed for anything and everything in this material world. The Srimad Bhagavad Gita says, “yogaha karmasu koushalam” meaning thereby that Yoga is skill in action (II.50).

The real Yogi, immensely conscious and aware at the physical, mental and emotional levels gains great control through that consciousness over all aspects of life thus developing a real skill in living. Part of that skill springs from his cultivated detachment, his ability to work for “work’s sake,” Annals of SBV

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and not for the sake of the reward. He realizes that his duty is to do his best but that the ultimate result is not in his hands. The Yogi performs the needed action not for the sake of the fruits of that action, but because it is good and necessary to do so. Such an attitude of mind produces consummate skill in whatever action the Yogi undertakes. Consummate concentration, consummate controls are all offshoots of good Yoga Sadhana. This belies the age-old belief that the competitive spirit produces the highest skill. To this the Yogic answer is: detachment from the fruits of the action produces the greatest efficiency, for one is then emotions connected with “goal-oriented”, competitive thinking. The beauty of Yoga is that these abstract principles become concrete in the daily practice of the techniques available in the Yoga system. Once the “Seed of Yoga” finds fertile soil, these concepts grow naturally, slowly but surely taking root in all aspects of life.

Regaining Our Health And Happiness Through Yoga:

“Health and happiness are your birthrights, Moksha is your goal. Reclaim your birthrights and attain your goal though Yoga” roared the Lion of Modern Yoga, Yogamaharishi Dr Swami Gitananda Giri. Living a happy and healthy life on all planes is possible through the unified practice of Hatha Yoga Asanas and Pranayamas, Dharana, Dhyana and Bhakti Yoga especially when performed consciously and with awareness.

Asanas help to develop strength, flexibility, will power, good health, and stability and thus when practiced as a whole give a person a “stable and unified strong personality”. Pranayama helps us to control our emotions which are linked to breathing and the Pranamaya Kosha (the vital energy sheath or body). Slow, deep and rhythmic breathing helps to control stress and overcome emotional hangups. Dharana and Dhyana help us to focus our mid and dwell in it and thus help us to channel our creative energy in a wholistic manner towards the right type of evolutionary activities. They help us to understand our self better and in the process become better humans in this social world.

The true Yogic life involves a sustained struggle against past conditioning, an attempt to control Page 59

one’s inner environment in order to focus inward.

Yoga is isometric, pitting one part of the body against the other and the Yogi strives to be “more perfect today, than he/she was yesterday”. It is practically impossible for classical Yoga Sports, Pranayamas and other Yoga practices to harm the practitioner when they are performed in the proper manner.

Yoga is not just performing some contortionist poses or huffing and puffing some Pranayama or sleeping our way through any so-called meditation.

It is an integrated way of life in which awareness and consciousness play a great part in guiding our spiritual evolution through life in the social system itself and not in some remote cave in the mountains or hut in the forest. Yoga can be rightly said to be the science and art of right-useness of body, emotions and mind.

Tiruvalluvar says, “The loving ones live for the sake of others while the unloving live only for themselves”. Yogis have immense love and compassion for all beings and wish peace and happiness not only for themselves, but for all living beings. They are not “individualists” seeking salvation for themselves but on the contrary are “universalists” seeking to live life in the proper evolutionary manner to the best of their ability and with care and concern for their fellow human brethren and those beings living at all planes of existence. This is well exemplified by Yogic prayers such as, “Om, loka samasta sukhino bhavanthu sarve janaha sukhino bhavanthu Om shanti, shanti, shanti Om”.

May we all become true Yogis as extolled by Yogeshwar Sri Krishna when he says, “tasmad yogi bhavarjuna –become thou a Yogi, Oh Arjuna”. Hari Om Tat Sat- May that be the reality!

Suggested Reading: 1. A Primer of Yoga Theory. Dr. Ananda Balayogi Bhavanani.

Dhivyananda Creations, Iyyanar Nagar, Pondicherry. 2008.

2. A Yogic Approach to Stress. Dr Ananda Balayogi Bhavanani.. Dhivyananda Creations, Iyyanar Nagar, Pondicherry. (2nd edition) 2008.

3. Ancient Yoga and Modern Science. Dr. TR Annals of SBV

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Anantharaman. Mushiram Manoharlal Publishers Pvt Ltd, New Delhi. 1996

Ramanathan, Aarogya Yogalayam, Venkateswara Nagar, Saram, Pondicherry-13.2007

5. Culturing one’s self though Yoga. Ananda Balayogi Bhavanani. Yoga Mimamsa 2011; 43 (1): 84-94.

11. Understanding the Yoga Darshan. An Exploration of the Yoga Sutras of Maharishi Patanjali by Ananda Balayogi Bhavanani. Dhivyananda Creations, Pondicherry. 2011

4. Ashtanga Yoga of Patanjali. Dr Swami Gitananda Giri. Edited by Meenakshi Devi Bhavanani. Satya Press, Pondicherry.1995

6. Evolutionary quirks, yama – niyama & the human brain. Meenakshi Devi Bhavanani. Yoga Vijnana 2009; 2 (3 &4): 1-8.

7. Frankly speaking. Dr Swami Gitananda Giri. Edited

by Meenakshi Devi Bhavanani. Satya Press, Pondicherry.1995

8. Srimad Bhagavad Gita. Swami Swarupananda.

Advaita Ashrama, Kolkata. 2007 9. Thiruvalluvar

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on

Yogic

Concepts.

Meena

10.

Tirumandiram: A Tamil Scriptural Classic.

Translated by Dr. B. Natarajan, Sri Ramakrishna Math, Chennai. 2006

12. Yoga for Health and Healing. Dr Ananda Balayogi Bhavanani. Dhivyananda Creations, Iyyanar Nagar, Pondicherry. 2007 13. Yoga Therapy Notes. Dr Ananda Balayogi Bhavanani.

Dhivyananda Creations, Iyyanar Nagar, Pondicherry. 2007

14. Yoga: Step by Step. Dr Swami Gitananda Giri.

Satya Press, Pondicherry. 1975

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Spirituality & health - Concepts & controversies Dr. Avudaiappan S *

Introduction

A long historical tradition connects religion, medicine, and health care. Religious groups built the first hospitals in Western civilization during the fourth century for care of the sick unable to afford private medical care. For the next thousand years until the Reformation and to a lesser extent until the French Revolution, it was the religious establishments that built hospitals, provided medical training, and licensed physicians to practice medicine. By the end of the 17th century, however, the scientific profession of medicine had nearly completely separated away from its religious beginnings.(1) Early Psychiatrists like Charcot and Freud linked religion to neurosis.(2) According to Moreira-Almeida et al, some scholar seven predicted that religiosity would tend to decrease and disappear by late 20th century.(3) But the latter half of the twentieth century has witnessed a manifold increase in the scientific enquiry into spirituality and health. According to Weaver et al, the rate of articles addressing spirituality rose steadily from an average of 56 per 100,000 during 1965–1969 to 463 per 100,000 between 1996 and 2000. Articles addressing both religion and spirituality occurred at an average rateof 64 per 100,000 in 1965–1969, and increased to an average rate of 362 per100,000 between 1996 and 2000. (4) Even the World Health Organization has incorporated spirituality in their definition of “palliative care”.(5) Recent research reports strongly suggest that to many patients, religion and spirituality are resources that help them to cope with the stresses in life, including those of their illness.(2) It has been suggested that spiritual enquiry should be made as a part of medical curriculum and interns training. (6)(7) But the integration of spirituality into medical care is not without detractors.(8) Objections have been made in terms of significant methodological flaws or misrepresented claims in published

research.(9)Ethical and practical considerations are still being debated. (10)(11) In this article, a review of progress made in spirituality research so far and the problems being encountered, is presented. The controversies surrounding integrating spirituality and medical care are also reviewed. Finally, attempt has been made to suggest future areas of research in this topic.

Defining spirituality

The definition of spirituality is a continuing controversy.(12) The Oxford English dictionary defines spirituality as “the quality or condition of being spiritual” and “attachment to or regard for things of the spirit as opposed to material or worldly interests.”(13) In 1912, James Leuba identified 48 different ways to define religion.(14) Early in the 20th century religiosity and spirituality were considered one and the same. The latter half of the 20th century has witnessed a rise of secularism and a growing disillusionment with the religious institutions of the western society. The effect of these changes during the 1960s and 1970s was that spirituality began to acquire a more distinct meaning and more favorable connotations separate from religion.(15) For most social scientists “spirituality” appears to be the favored term to describe individual experience and is identified with such things as personal transcendence, supra-conscious sensitivity and meaningfulness.(15) Religion is defined as an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (God, higher power, or ultimatetruth/reality).(16) Broad as well as narrow definitions of spirituality exist in the literature. An example of a broad definition was put forward by Myers et al., who defined spirituality as “personal and private

* Dr. Avudaiappan S, Assistant Professor of Psychiatry Mahatma Gandhi Medical College and Research Institute, Puducherry 607402, India Page 61

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beliefs that transcend the material aspects of life and give a deep sense of wholeness, connectedness, and openness to the infinite”. According to this conception, spirituality includes (a) belief in a power beyond oneself, (b) behavior in relation to the infinite such as prayer, (c) meaning and purpose of life, (d) hope and optimism, (e) love and compassion, (f ) moral and ethical guidelines (g)transcendental experience. Another broad definition has been given by Lewis who conceived spirituality as the life affirmed in a relationship with God, self, community, and environment which leads to the nurturance and celebration of wholeness. Within this context, spiritual needs include meaning, purpose and hope, transcendence circumstances, integrity and worthiness, religious participation, loving and serving others, cultivating thankfulness, forgiving and being forgiven, and preparation for death and dying.(17) As cited by Hill et al,(15) Spilka (18) has concluded in his 1993 review that the current understanding of spirituality fall into one of three categories: 1) a God oriented spirituality where thought and practices are premised in theologies either broadly or narrowly conceived; 2) a world oriented spirituality stressing one’s relationship with nature or ecology and 3) a humanistic (or people oriented) spirituality stressing human achievement or potential. Thus, according to Spilka, spirituality should be viewed as a multidimensional concept. This view is shared by a number of researchers who have proposed various multidimensional frameworks.(19)(20)(21) Similarly Worthington et al also identified four types of spirituality, with the first one more related to religion: religious spirituality (closeness and connection to the sacred defined by religion), humanistic spirituality (closeness and connection to mankind), nature spirituality (closeness andconnection to nature), and cosmos spirituality (closeness and connection to the whole of creation).

(22) An integration of the literature shows that several elements are commonly employed in the definition of spirituality. These include meaning and purpose of life, meaning of and reactions to limits of life such as death anddying, search for the sacred or infinite, including religiosity, hope and hopelessness, forgiveness, and restoration of health. Lau pointed out that three key elements of spirituality had been identified in the literature.

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The first element is horizontal as well as vertical relationships in human existence. While horizontal relationships are related to oneself, others, and nature, vertical relationship involves a transcendental relationship with a higher being.

The second element is beliefs and values which are integral to answers to spiritual questions such as life and death. The third elementis the meaning of life.(17) Analyzing each element individually and all elements collectively within a multidimensional framework would be a fruitful way forward to approach the study of spirituality.(23)

Instruments to measure spirituality

Shek identifies two broad strategies to assess the construct of spirituality: quantitative approach and qualitative approach. In the quantitative approach, either single items or scales are used to assess spirituality. For example, researchers have used single items to assess a respondent’s ranking of the importance of things in life, such as wealth, family, health, friends, social status, and peace of mind.

Also, researchers use a few items to assess religiosity and religious involvement. Obviously, both singleitem measure and multiple-item measures are problematic because their reliability and validity have not been examined. To overcome such problems, psychological scales have been developed to measure the construct of spirituality. Some examples include the Spiritual Well-BeingScale, Purpose in Life Questionnaire, Templer’s Death Anxiety Scale, Enright Forgiveness Inventory, and Herth HopeIndex.(17) Qualitative methods (such as open-ended questions, drawing, verbal commentary techniques, and case studies) are also employed to examine spirituality, particularly in the clinical settings. The common features of qualitative research include naturalistic inquiry, inductive analysis, holistic perspective, qualitative data, personal contact and insight, dynamic system, unique case orientation, empathetic neutrality, and design flexibility. For example, children have been invited to draw pictures about their attitudes towards death and dying. While qualitative study can capture the perspectives of the informants and is a more naturalistic form of research, it is often criticized as biased and polluted by ideological preoccupations.(17) Annals of SBV

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Monod et al, in a systematic review of instruments to assess spirituality, identified a twostep process in development of instruments to assess spirituality.(24) The first step would be the definition of the conceptual aspect of spirituality that the instrument intends to assess. The second step would be the definition of items that operationalize the spirituality concept inquestion.

They also proposed a classification of instruments that follows this line of reasoning in instrument development.(24) 1. Conceptual Classification

This classification is based on the underlying concept of spirituality that the instrument mainly intends to capture from the point of view of the authors who developed the instrument. Four common categories of measures are described: general spirituality, spiritual well-being, spiritual support or coping, and spiritual needs.(24) 2. Functional Classification

This classification is based on the examination of all items within the instrument. Three categories of items are proposed, according to the expression of

spirituality they intend to capture: a. Measures of cognitive expressions of spirituality: These items intend to measure attitudes and beliefs toward spirituality (e.g., “Do you believe meditation has value?”). These measures have been shown to be relatively stable within individuals over time. b. Measures of behavioral expressions (public or private practices) of spirituality (e.g., “How often do you go to church?”). These measures are also supposed to be stable over time. c. Measures of affective expressions of spirituality: These items intend to capture feelings associated with spirituality (e.g., “Do you feel peaceful?”).These measures illustrate the patient’s spiritual state, which is not necessarily stable over time. Spiritual states might change over time along a hypothesized spectrum of wellness ranging from spiritual well-being to spiritual distress. A spiritual state might be worse because of external stressors such as illness or bereavement, or improved by

Figure 1 Process generally used to develop instrument to assess spirituality.

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spiritual intervention.(24)

Health Benefits of Spirituality

Many of those faced with illness turn to faith traditions and spiritual beliefs for aid and comfort.

This is seen among hospitalized patients, 94% of which believe spiritual health to be as important as physical health.(25) Thus spirituality and religion are major target areas for holistic health care of patients. Koenig et al, have reviewed 1200 scientific articles demonstrating an association between various physical and mental health benefits and spirituality, in 2001.(16) Since then, there had been a growing body of research in this aspect. However, most studies have not made a distinction between religiosity and spirituality and often use these terms interchangeably and with varying definitions.

(8) Measurement of spiritual variables are also ambiguous, with many studies utilizing crude, single-item indices of global religious involvement (e.g., How often do you attend church or religious services?), which do not assess for specific aspects or positive and negative dimensions of spirituality.

Consequently, findings have been inconsistent, and functional relationships between spirituality and health, including directions and mechanisms of effect, remain largely unclear.(26) A majority of the nearly 350 studies of physical health and 850 studies of mental health that have used religious and spiritual variables have found that religious involvement and spirituality are associated with better health outcomes.(27)During the past 3 decades, at least 18 prospective studies have shown that religiously involved persons live longer.(27) Studies have found that religious/ spiritual involvement is associated with lesser risk of cardiovascular disease,(27) rheumatoid arthritis,(28) lower blood pressure, with health-promoting behaviors such as more exercise, proper nutrition, more seat belt use, smoking cessation, and greater use of preventive services.(27) In addition, religious involvement predicts greater functioning among disabled persons.(27) Finally, religious involvementis associated with fewer hospitalizations and shorter hospital stays.(27) Spirituality/religiosity plays a major role in end of life care by giving strength and hope to terminally Page 64

ill patients.(29) In patients with HIV, higher levels of spirituality/religion have been associated with better immune function, survival, health-related quality of life, life satisfaction, treatment success, medication adherence, and overall well-being.(30) Spirituality is also a powerful coping mechanism providing older adults with the ability to adapt to changing individual needs.(31) Spirituality is recognized as an important aspect of mental health.(2) Role of spiritual well-being in mental health has been examined in relationship to depression, anxiety, schizophrenia. But most investigators use religiosity and spirituality as interchangeable terms, making it difficult to separately estimate the effect of spirituality on mental health. One study found that placing high importance on spiritual values is associated with higher lifetime depression, mania, and social phobia.(32) Smith and colleagues conducted a metaanalysis of 147 studies that involved nearly 100,000 subjects. The average inverse correlation between religious involvement and depression was 20.1, which increased to 0.15 in stressed populations.

Religion has been found to enhance remission in patients with medical and psychiatric disease who have established depression. The vast majority of these studies have focused on Christianity; there is a lack of research on other religious groups.

(33) Studies on anxiety and religion have yielded mixed and often contradictory results that may be attributed to a lack of standardized measures, poor sampling procedures, and failure to control for threats to validity, limited assessment of anxiety, experimenter bias, and poor operationalization of religious constructs.(34) Research on schizophrenia & spirituality is still infantile; Mohr et al found that for some patients, religion instilled hope, purpose, and meaning in their lives, whereas for others, it induced spiritual despair. Most reported that religion lessened psychotic and general symptoms, increased social integration, reduced the risk of suicide attempts, reduced substance use, and fostered adherence to psychiatric treatment.(35) In individuals with substance abuse, spirituality has been shown to be a significant and independent predictor of recovery and/or improvement in Annals of SBV

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indices of treatment outcome. Levels of spirituality increase between treatment entry and subsequent recovery, and levels of spirituality may be greater in individuals whose recovery is successful compared to those who have relapsed. Length of sobriety has also been positively associated with spirituality, while commitment to a higher power may lessen the severity of relapse episodes.

Criticisms to inclusion of spirituality into mainstream medicine

There have been number of criticisms to above findings.(8,9,37) These can be viewed in two aspects – methodological and ethical objections.

Methodologically, first objection would be that most of the studies done in spirituality are simple observational studies that link a spiritual variable to physical or mental health. But, as pointed out

by Sloan et al, these results are to be controlled for confounders such as age, sex, education, ethnicity, socioeconomic status and health status.

Failure to do so, as is the case in many studies, may point to seemingly important findings where none exist.(8)The second methodological objection would be the operationalization of the concept of spirituality. Though various authors have tried to clarify the concept,(38) still there is a great deal of overlap between the definitions of religiosity and spirituality, which makes any meaningful extrapolation of data concerning health benefits difficult. Also most studies take into account only “outward” religious or spiritual activities such as going to church, mass prayers etc., but fail to consider “inward” Spiritual practices like praying at home, reading scriptures etc., which are also very common among religiously inclined. Finally there is a great deal of inconsistencywithin published data. Effects which have been shown in some studies have not be replicated in other samples.(8) Most of these studies also have poor inter-cultural comparability. Spirituality being a culturally varying concept, this needs to be addressed.

Ethically, the first objection would be that, most physicians are ill-trained and ill-suited to discuss spiritual issues with the patients and are prone to misguiding patients.(39) Also, the physician-patient relationship is asymmetric: physicians expect patients to comply with their recommendations, Page 65

and patients generally accede to this authority.

Recommending religion to patients in this context may be coercive.(37) Linking religious activities and better health outcomes can be harmful to patients, who must confront age-old folk wisdom that illness is due to their moral failure.(8) If, as advocated by proponents of spirituality, we distinguish discreet patient groups for whom religion and spirituality are important from those for whom they are not, physicians run the risk of discriminating by encouraging only the former group to engage in religious activity.(37) Conclusion

To conclude, even though there is a great deal of evidence suggesting a link between spirituality and health, the lack of conclusive evidence in the form of randomized controlled trials make it difficult to assess the true clinical benefit of spirituality. But as it is asked, how can we measure faith, which is a radical opposite of the method of scientific enquiry with scientific tools. Also, the ethical objections pointed out by experts should be taken into account. Till these concerns are addressed, it would be premature to formally include spirituality in the current clinical model.

References

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2. Verghese A. Spirituality and mental health. Indian J Psychiatry.

2008 Oct;50(4):233–37.

3. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: areview. Rev Bras Psiquiatr. 2006 Sep;28(3):242-50.

4. Weaver AJ, Pargament KI, Flannelly KJ, Oppenheimer JE. Trends in the Scientific Study of Religion, Spirituality, and Health: 1965–2000. J Relig Health . 2006 Mar;45(2):208–14.

5. World Health Organization. WHO Definition of Palliative Care [Internet]. [cited 2014 Feb 24]. Available from: www. who.int/cancer/palliative/definition/en

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9. Sloan RP, Bagiella E. Claims about religious involvement and health outcomes. Ann Behav Med. 2002 Jan ;24(1):14–21.

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Ann. SBV, Jan - Jun 2014;3(1) 10. Poole R, Cook CCH. Praying with a patient constitutes a breach of professional boundaries in psychiatric practice. Br J Psychiatry. 2011 Aug;199(2):94–8.

11. Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional boundaries, competency, and ethics.

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15. Hill PC, Pargament KI, Hood RW, McCullough J. ME, Swyers JP, Larson DB, et al. Conceptualizing Religion and Spirituality: Points of Commonality, Points of Departure. J Theory Soc Behav. 2000 Mar;30(1):51–77.

16. Koenig HG, McCullough M LD. Handbook of religion and health: a century of research reviewed. New York: Oxford university Press; 2001.

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19. Beck C. Education for spirituality. Interchange. 1986;148–56.

20. Elkins D, Hedstrom L. et al Toward a humanisticphenomenological spirituality definition, description, and measurement. J Humanistic Psychology. 1988; 28(4), 5-18

21. Lapierre LL. A model for describing spirituality. J Relig Health. 1994 Jun;33(2):153-61.

22. Worthington EL Jr, Hook JN, Davis DE, McDaniel MA. Religion and spirituality. J Clin Psychol. 2011 Feb;67(2):20414.

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26. Rosmarin DH, Wachholtz A, Ai A. Beyond descriptive research: advancing the study of spirituality and health. J Behav Med. 2011 Dec;34(6):409–13.

27. Mueller PS, Plevak DJ RT. Religious Involvement, Spirituality, and Medicine: Implications for Clinical Practice. Mayo Clin Proc. 2001;76(December):1225–35.

28. Bartlett, S. J., Piedmont, R., Bilderback, A., Matsumoto, A. K. and Bathon, J. M. (2003), Spirituality, well-being, and quality of life in people with rheumatoid arthritis. Arthritis & Rheumatism, 49: 778–783.

29. Cartwright A. Is religion a help around the time of death?

Public Health. 1991 Jan;105(1):79-87.

30. Szaflarski M, Kudel I, Cotton S, Leonard AC, Tsevat J, Ritchey PN. Multidimensional assessment of spirituality/religion in patients with HIV: conceptual framework and empirical refinement. JRelig Health. 2012 Dec;51(4):1239–60.

31. Manning LK. Navigating Hardships in Old Age: Exploring the Relationship Between Spirituality and Resilience in Later Life. Qual Heal Res. 2013;23(4):568–75.

32. Baetz M, Bowen R, Jones G, Koru-Sengul T. How spiritual values and worship attendance relate to psychiatric disorders in the Canadian population. Can J Psychiatry. 2006 Sep;51(10):654–61.

33. Dein S. Religion, Spirituality, and Mental Health. Psychiatric Times. 2010. Available from: http://www.psychiatrictimes. com/articles/religion-spirituality-and-mental-health

34. Shreve-Neiger AK, Edelstein BA. Religion and anxiety: a critical review of the literature. Clin Psychol Rev. 2004 Aug;24(4):379–97.

35. Mohr S, Brandt P-Y, Borras L, Gilliéron C, Huguelet P. Toward an integration of spirituality and religiousness into the psychosocial dimension of schizophrenia. Am J Psychiatry.

2006Nov;163(11):1952–9.

36. Heinz AJ, Disney ER, Epstein DH, Glezen LA, Clark PI, Preston KL. A focus-group study on spirituality and substance-user treatment. Subst Use Misuse. 2010 Jan;45(12):134–53.

37. Sloan RP, Bagiella E. Spirituality and medical practice: a look at the evidence. Am Fam Physician. 2001 Jan;63(1):33–4.

38. Zinnbauer BJ, Pargament KI, Cole B, Rye MS, Eric M, Belavich TG, et al. Religion and Spirituality : Unfuzzying the Fuzzy. 2010;36(4):549–64.

39. Sloan RP, Bagiella E, VandeCreek L, Hover M, Casalone C, Jinpu Hirsch T, et al. Should physicians prescribe religious activities? N Engl J Med. 2000 Jun;342(25):1913–16.

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Annals of SBV Sri Balaji Vidyapeeth (Deemed to be University, u/s 3, UGC Act, 1956)