Running head: YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

Culminating Project Proposal

Use of Yoga to Support Post-Traumatic Stress Disorder (PTSD) and Hypertension Symptom
Reduction
India Caldwell-Cox
Doctor of Behavioral Health
Arizona State University

This culminating project will not be submitted for publication and it does not involve vulnerable
populations as part of the data collection or intervention. It is submitted only for credit for the
requirements for the DBH culminating project.

YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

Table of Contents
Table of Contents...........................................................................................................................2
Use of Yoga to Support Post-Traumatic Stress Disorder (PTSD) and Hypertension
Symptom Reduction......................................................................................................................3
Prevalence Rates of Anxiety Disorders....................................................................................3
Statement of Problem................................................................................................................7
Research Question.....................................................................................................................7
Methods..........................................................................................................................................8
Setting.........................................................................................................................................8
Population...................................................................................................................................9
Procedures..................................................................................................................................9
Measures...................................................................................................................................10
Data Collection.........................................................................................................................11
Research Design.......................................................................................................................11
Data Analysis............................................................................................................................12
References.....................................................................................................................................13
Appendix A...................................................................................................................................17

YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

Use of Yoga to Support Post-Traumatic Stress Disorder

(PTSD) and Hypertension Symptom Reduction
Prevalence Rates of Anxiety Disorders
Veterans diagnosed with PTSD and hypertension may benefit from engaging in yoga,
relaxation, and breathing techniques to regulate blood pressure levels (Walczewska, Rutkowski,
Wizner, Cwynar, & Grodzicki, 2011). Hypertension is a co-occurring disorder that is common
among people exposed to traumatic events such as natural disasters or combat (Wofford,
Hertzberg &Vacchiano, 2012; Spitzer et al., 2009). According to Edmondson, Kronish, Shaffer,
Falzon, & Burg (2013), individuals suffering from PTSD usually complain of symptoms
including intrusive thoughts, flashbacks, and nightmares. The veteran population with PTSD
symptoms has an increased lifetime prevalence rate (7.8%) of developing of chronic physical
issues and increased mortality rates (Beristianos, Yaffe, Cohen & Byers, 2014; Trivedi et al.,
2015; Kemp, Quintana, Felmingham, Matthews, & Jelinek, 2012; Gaderman, Alonso, Vilagut,
Zaslavsky, & Kessle, 2012). Patients with PTSD often engage in unhealthy lifestyle habits such
as drinking, smoking, and use of illicit drugs to deal with depression, paranoia, and to block
unpleasant thoughts and memories (Paulus, Argo & Egge, 2013).
Studies suggest that veterans who had served in Korean and Vietnam wars found it
difficult to adapt after coming back home and had difficulty returning to their previous day-today functioning (Walczewska, Rutkowski, Wizner, Cwynar, & Grodzicki, 2011; Marmar et al.,
2015). Sidney (2013) observed that individuals diagnosed with PTSD were more likely to adopt
unhealthy lifestyles that lead to unfavorable cardiovascular outcomes. Beristianos et al. (2014)
note that cardiovascular dysfunction is associated with the dysregulation of altered pathways in

YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

the autonomic nervous system and the hypothalamus-pituitary-adrenal axis. The result is blood
coagulation, high blood pressure, vascular problems, and the development of calcification in the
arteries that have a strong link with PTSD (Ahmadi et al., 2011; Vaccarino et al., 2013). People
with PTSD are also likely to experience depressive symptoms that can lead to increased blood
pressure levels and cause cardiovascular disease (Kinder et al. 2008; Kinoshita et al., 2012).
According to the Centers for Disease Control and Prevention, over 65 million individuals
are affected by hypertension, and congestive heart disease making this one of the leading causes
of death in Americans (Kinoshita et al, 2012). Eleven and a half percent or 276 adults in the
United States are diagnosed with heart disease. Twelve million patients visit physician offices
with heart disease as a principal diagnosis (U.S. Dept. Health, 2014). Along with prescription
and alternative medications, veterans with PTSD and blood pressure issues have been introduced
to other treatments (McFarlane, 2010) including: visual kinesthetic dissociation, traumatic
incident reduction, music therapy, mindfulness-based stress reduction, mantra-based meditation
(MBM), equine therapy, emotional freedom technique (EFT), canine therapy, acupuncture art
therapy, acceptance and commitment therapy, and yoga.
Furthermore, the links between PTSD, hypertension, and other cardiovascular diseases
may deliver new insights into best practices in primary care interventions for addressing PTSD,
hypertension and cardiovascular ailments (Roy, Foraker, Girton, & Mansfield, 2015; Coughlin,
2011). Alternative and contemporary medical therapies are looked into for the prevention and
treatment of hypertension. Mind-body therapies such as yoga have become more popular
because they provide a substitute for medication (Cohen & Townsend, 2007). Yoga, in this case,
is defined to include meditation, mindfulness, and asana (physical postures). Murugesan et al. (as
cited in Manchada & Madan, 2013) conducted a randomized study that proved that yoga had

YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

similar benefits as drug monotherapy in patients suffering from mild hypertension. Yoga may
also result in an empowered feeling in patients suffering from PTSD, who often feel they have no
control over their emotions. Cohen & Townsend (2007) identify Iyengar Yoga, which is useful
for the regulation of various medical conditions including internal organ disturbances such as
heart disease, diabetes, and hypertension. According to Manchanda & Madan (2013), chronic
stress is a significant cause of high blood pressure. They recommend the incorporation of yoga
into the treatment of hypertension since it has been proved as an excellent tool for stress
management.
Manchanda &Madan (2013) review several articles of literature and find reports of
reduced diastolic and systolic blood pressure in patients practicing yoga. They, however, identify
the need for more studies into the efficiency of the yoga practice in reducing blood pressure.
They explore uncontrolled and controlled trials that exhibit the short term, as well as the longterm effectiveness of yoga in treating hypertension. Noteworthy reduction in blood pressure was
observed in patients who employed the corpse posture, which is a yogic activity intended for
relaxation. They, however, note that many research studies highlighting the benefits of yoga in
hypertensive patients are not scientifically weak due to their limited sample size, lack of
sufficient controls, and irregularities in baseline blood pressure. Manchanda & Madan (2013)
further highlight a meta-analysis including nine properly conducted randomized controlled
studies that looked into the impact of transcendental meditation on blood pressure. The results of
the study suggest that transcendental meditation has the potential to lower moderately the
diastolic and systolic blood pressu
Emerson, Sharma, Chaudry, & Turner (2009) provided evidence-based practices and
principles of teaching trauma survivors how to do yoga. A pilot study conducted by the Trauma

YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

Center Yoga Program in Brookline, Massachusetts demonstrated that yoga is beneficial for
people suffering from PTSD Libby, Reddy, Pilver, & Desai (2012). They observed the increased
use of yoga as an adjunctive treatment for psychological disorders such as PTSD. A review of the
article by Bussing, Michalsen, Khalsa, Telles, & Sherman (2012) shows evidence of the positive
effects of yoga on physical and mental health. Yoga can be used in support of other medical
treatments, but no proof exists that indicates it can be utilized alone. Bussing et al. (2012)
highlights studies that showed that yoga was as effective as other control interventions including
dance, cognitive behavioral therapy, and relaxation in the reduction of perceived stress. One
particular review studied existing literature on yoga for the treatment of PTSD. It revealed that
the practice of yoga had reduced PTSD symptoms significantly after a natural disaster. Yoga
practice was also effective in improving PTSD symptoms in those exposed to terrorism and
combat. The review article encourages further research since yoga is a cost-effective behavioral
treatment that improves self-confidence, self-efficacy, and offers a lifetime behavioral skill
(Bussing et al., 2012).
This literature review sought to provide an evidence-focused review indicating a
correlation between veterans with PTSD and their likelihood to develop blood pressure
complications, which increases their chances of contracting cardiovascular diseases. It also
sought to provide evidence supporting the use of yoga in the treatment of PTSD and
hypertensive symptoms. Based on the findings from the literature review, further research can be
conducted to find out whether patients with PTSD and hypertension will record lower blood
pressure after participating in one hour of yoga, once a week for a month. Early treatment can
lead to lifestyle changes, education, and positive outcomes that will contribute to improved
outcomes for veterans and other individuals suffering from PTSD. The use of substitute options

YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

such as abstinence from hallucinogenic agents or other substances that can lead to dependence,
cognitive behavioral therapy, medication management, and yoga carries a lot of benefit for this
patient population.

Statement of Problem
Post Traumatic Stress Disorder (PTSD) has gained significant scholarly attention over the
recent past, which forms an important part of this objective of this research project. The primary
aim is to illustrate the presence of a positive correlation between individuals suffering from
PTSD and its role in inducing high blood pressure (hypertension. In light of such a correlation,
the research seeks to establish whether behavioral therapies such as yoga may contribute towards
alleviation of PTSD symptoms and hypertension. Research is indicative that intervention
strategies such as incorporation of yoga and methodologies learnt from engagement in hatha
yoga may contribute towards alleviation of hypertension and PTSD symptoms based on PCPTSD scores. Bussing et al. (2012) suggests that behavioral interventions such as yoga are
effective in enabling patients achieve improved quality of life by alleviation of hypertension and
PTSD symptoms.

Research Question
Will patients with hypertension (elevated blood pressure) and symptoms of Post-Traumatic
Stress Disorder (PTSD) experience decreased blood pressure readings and PTSD symptoms after
participating in 1 hour of yoga, every week for 1 month?
Hypotheses

YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

H1: Blood pressure readings will be lower after a 4-week intervention of relaxation and
breathing techniques learned from participating in yoga compared to blood pressure readings
prior to attending yoga.

H2: PC-PTSD scores will decrease as a result of patients with PTSD using calming and focus
techniques learned from participating in yoga

Methods
Setting
The setting for this study will be the Phoenix Veterans Administration Medical Center
(PVAMC) located in Phoenix, Arizona. The Post Traumatic Stress Disorder (PTSD) clinic
located on the first floor of PVAMC and this clinic is staffed with 2 psychiatrists, 2
psychologists, 5 registered nurses (RN), 6 license practical nurses (LPN). There are 2 Licensed
Social Workers (LSW) and 2 nursing assistants (NA). The hospital has a nutritionist, diabetic
educator, addiction therapist, clinical pharmacist, physician assistant and psychologist accessible
to the clinic. The facility offers other groups to include alcoholic anonymous classes held on the
lower level, homeless information and transportation to and from the facility.
A designated area has been identified where the yoga classes will be held. The waiting
area has a southwestern desert landscape and earth tone colors that provide a calming and
relaxing environment. It is in the rear of the clinic, with dark floors, a small window and 3 large
mirrors on the southwest end of the room. There are 2 automatic blood pressure machines and 7
yoga mats not including the mat for the instructor.

YOGA, PTSD, & HYPERTENSION SYMPTOM REDUCTION

Population
Participants of this study are veterans who are currently receiving their care from the
Phoenix Veteran Affairs Medical Center (PVAMC). The population will be made up of veterans
from various branches of the armed forces, various eras of war, veterans that are retired, active
duty, combat and non-combat. Both male and female, from all ethnic backgrounds, religions, and
ages 18 and older along with these requirements, to be eligible for the study. The participants
must meet a number of conditions such as being diagnosed with hypertension for three months or
longer , with the diagnosis being delivered by a primary care physician (PCP); diagnosed with
PTSD for a period of three months or more delivered by a psychiatrist; a Primary Care of PTSD
screen score of three; engaged in active treatment for hypertension with varied levels of semicontrolled hypertension and with adequate literacy skills. Veterans excluded from the study will
be veterans who are active addicts and accustomed to abusing drugs; have not been diagnosed
with hypertension or PTSD and have accrued zero scores on PC-PTSD tool

Procedures
An email and flyer will be sent to the in-house physician and social work mail group that
include hundreds of employees in this area. The email will consist of contacts and information
seeking veterans to participate in the study who meet the requirements. This is the start of how to
identify and recruit participants. All veterans that participate in this study held in the PTSD clinic
will be identified by their diagnoses of PTSD and HTN. After it has been determined which
veterans diagnosed with PTSD and HTN and have agreed to participate in the study and attend
yoga, the veterans will attend yoga classes every Wednesday at 10 am for four one-hour sessions.
Each veteran will be provided with a blood pressure log to monitor their blood pressure levels at

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10

home during their participation in yoga. Each veteran will be asked to arrive 30 minutes prior to
class to take the PC-PTSD tool and to have their blood pressure taken in the clinic at least 15
minutes before the yoga class begins. A post blood pressure will be taken immediately after the
veteran has finished the yoga class. All confidential patient information will be maintained in the
Behavioral Health Coordinator (BHC) secured office with a designated key, locked in a file
cabinet that can only be accessed by the BHC. All documents and patient identifiers will be
disposed of by using a crosscut shredder that is maintained in the BHC office and paper shreds
will be placed in the locked recycle bin located in the copy room that his accessed only by
employees who know the four-digit code.

Measures
The measures used for this study include monitoring blood pressure results of veterans over the
course of time during their participation in the study. TThe systolic measure the pressure in the
arteries when the heart beats and the diastolic, which is the bottom number that measures the
pressure in the arteries between heartbeats. Recording blood pressure readings from home as
well as doctor visits will be collected and included in the overall data. A single high reading
does not mean that someone has high blood pressure however; if readings stay at 140/0 mm Hg
or above overtime you the PCP will likely want to start treatment, which includes lifestyle
changes and possibly prescription medication (American Heart Association, n.d.).
The PC-PTSD is a four-item test developed at a VAMC and uses a presence/absence-scoring
format. It takes less than a minute to administer and each of the four questions can be found in
the Posttraumatic Stress Disorder Checklist-Civilian (PCL-C). There is one question
corresponding to each one of the re-experiencing, behavioral avoidance, and emotional
avoidance and hyperarousal symptoms on the PC-PTSD. A confirmation of any three of four

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questions is considered a positive screen result. It has been found to be the single best screening
test in the primary care setting because of its brevity and diagnostic efficiency. The PC-PTSD
has 78% sensitivity and 87% specificity in the veteran population (Hanley, DeRoon-Cassini, &
Brasel, 2013, p. 723)

Data Collection
A spreadsheet will be created to document the patients information. The first letter of the
veterans last name will be used to identify the participants and the last four digits of their social
security number. There will be color codes to represent male veterans as orange and female
veterans as red. The patients age, pre and post blood pressure scores and the pre-class and
weekly PC-PTSD scores will also be identified on the spreadsheet. The veteran will keep a
journal of home blood pressure scores; am and pm times, if the veteran implements any of the
yoga techniques outside of class they will be asked to share this information along with their
blood pressure (BP) numbers with the BHC on the next visit. This will take place over the course
of three weeks and attending one yoga class each week.

Research Design
The design of this research is a quasi-experimental; it will include pre intervention
measures and repeat post intervention measures. The dependent variables of this study are the
PC-PTSD scores and blood pressure results. The study will examine how patients that participate
in yoga for 3 weeks decrease the symptoms of Post-Traumatic Stress Disorder (PTSD) and their
effects on blood pressure results to prevent the development of cardiac disease. For this study,
there is no control or randomization. No funding was needed for this program. All expenses will
be provided by the VAMC.

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Data Analysis
Data collected will include basic demographic data, age, gender, and site of pain origin
for each veteran participating in the study. Because yoga has several beneficial effects like
control of stress, promotion of physical and emotional well-being and control of risk factors for
cardiovascular disease (CHD) (stress, diabetes, obesity, lipids, smoking), and is beneficial for
secondary prevention of CHD, is cheap and has no side effects. Pre and post PC-PTSD and
blood pressure scores will be collected in order to assess the outcome of the intervention. All
data will be analyzed using SPSS. The mean, standard deviation, and range for the two
dependent variables will be calculated pre- and post-intervention. A paired samples t-tests will be
used to test the hypotheses to determine whether the symptoms of PTSD and HTN scores change
significantly after implementing yoga as an intervention.

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References
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(2011).Post-traumatic stress disorder, coronary atherosclerosis, and mortality. American
Journal of Cardiology, 108(1), 29-33.
Beristianos, M. H., Yaffe, K., Cohen, B., & Byers, A. L. (2016).PTSD and risk of incident
cardiovascular disease in aging veterans. American Journal of Geriatric Psychiatry,
24(3), 192-200.
Bussing, A., Michalsen, A., Khalsa, S. B. S., Telles, S. & Sherman, K. J. (2012). Effects of Yoga
on Mental and Physical Health: A Short Summary of Reviews. Evidence-Based
Complementary and Alternative Medicine, 2012(165410), 1-7.
Cohen, D. & Townsend, R. R. (2007).Yoga and Hypertension. Journal of Clinical Hypertension,
9(10), 800-801.
Coughlin, S. S. (2011). Post-traumatic Stress Disorder and Cardiovascular Disease. Open
Cardiovasc Med J., 5, 164-170.
Edmondson, D., Kronish, I. M., Shaffer, J. A., Falzon, L., & Burg, M. M. (2013). Posttraumatic
stress disorder and risk for coronary heart disease: A meta-analytic review. American
Heart Journal, 166(5), 806-814.
Emerson, D., Sharma, R., Chaudry, S. & Turner, J. (2009).Trauma-Sensitive Yoga: Principles,
Practice, and Research. International Journal of Yoga Therapy, 19(1), 123-128.
Gadermann, A. M., Alonso, J., Vilagut, G., Zaslavsky, A. M., & Kessler, R. C. (2012).
Comorbidity and disease burden in the national comorbidity survey replication (ncs-R).
Depression & Anxiety, 29(9), 797-806.

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Hanley, J., DeRoon-Cassini, T., & Brasel, K. (2013, June 25,2013). Efficiency of a four-item
posttraumatic stress disorder screen in trauma patients. Journal of Trauma Acute Care
Surg, 75(4), 722-727. http://dx.doi.org/10.1097/TA.0b013e3182a53a5f
Kemp, A. H., Quintana, D. S., Felmingham, K. L., Matthews, S., &Jelinek, H. F. (2012).
Depression, comorbid anxiety disorders, and heart rate variability in physically healthy,
unmedicated patients: Implications for cardiovascular risk. Plos One, 7(2)
Kinder, L. S., Bradley, K. A., Katon, W. J., Ludman, E., McDonell, M. B., & Bryson, C. L.
(2008). Depression, posttraumatic stress disorder, and mortality. Psychosomatic
Medicine, 70(1), 20-26 7p.
Kinoshita, L. M., Yesavage, J. A., Noda, A., Jo, B., Hernandez, B., Taylor, J., et al. (2012).
Modeling the effects of obstructive sleep apnea and hypertension in Vietnam veterans
with PTSD. Sleep & Breathing = Schlaf Atmung, 16(4), 1201-1209.
Libby, D., Reddy, F., Pilver, C. & Desai, R. (2012).The Use of Yoga in Specialized VA PTSD
Treatment Programs. International Journal of Yoga Therapy, 22(1), 79-88.
Manchanda, S. C. &Madan, K. (2013).Yoga and hypertension. Preventive Cardiology, 2(4), 361364.
Marmar, C. R., Schlenger, W., Henn-Haase, C., Qian, M., Purchia, E., Li, M., et al. (2015).
Course of posttraumatic stress disorder 40 years after the Vietnam War: Findings from the
national Vietnam veterans longitudinal study. JAMA Psychiatry, 72(9), 875-881.
McFarlane, A. C. (2010). The long-term costs of traumatic stress: intertwined physical and
psychological consequences. World Psychiatry, 9(1), 3-10.

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Niles, A. N., Dour, H. J., Stanton, A. L., Roy-Byrne, P., Stein, M. B., Sullivan, G., et al.
(2015).Anxiety and depressive symptoms and medical illness among adults with anxiety
disorders. Journal of Psychosomatic Research, 78(2), 109-115 7p.
Paulus, E. J., Argo, T. R., &Egge, J. A. (2013). The impact of posttraumatic stress disorder on
blood pressure and heart rate in a veteran population. Journal of Traumatic Stress, 26(1),
169-172.
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J.,
Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2003). The Primary Care PTSD Screen (PCPTSD): Development and operating characteristics (PDF). Primary Care Psychiatry, 9, 914. doi: 10.1185/135525703125002360 PILOTS ID: 26676
Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J.,
Thrailkill, A., Gusman, F.D., Sheikh, J. I. (2004). The Primary Care PTSD Screen (PCPTSD): Corrigendum (PDF). Primary Care Psychiatry, 9, 151.
Roy, S. S., Foraker, R. E., Girton, R. A., & Mansfield, A. J. (2015). Posttraumatic stress disorder
and incident heart failure among a community-based sample of US veterans. American
Journal of Public Health, 105(4), 757-763.
Sidney, S. (2013). Post-traumatic stress disorder and coronary heart disease. Journal of the
American College of Cardiology, 62(11), 979-980.
Spitzer, C., Barnow, S., Vlzke, H., John, U., Freyberger, H. J., & Grabe, H. J. (2009). Trauma,
posttraumatic stress disorder, and physical illness: Findings from the general population.
Psychosomatic Medicine, 71(9), 1012-1017 6p.

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Trivedi, R. B., Post, E. P., Sun, H., Pomerantz, A., Saxon, A. J., Piette, J. D., et al. (2015).
Prevalence, comorbidity, and prognosis of mental health among US veterans. American
Journal of Public Health, 105(12), 2564-2569.
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Vaccarino, V., Goldberg, J., Rooks, C., Shah, A. J., Veledar, E., Faber, T. L., et al. (2013). Posttraumatic stress disorder and incidence of coronary heart disease: A twin study. Journal
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Walczewska, J., Rutkowski, K., Wizner, B., Cwynar, M., &Grodzicki, T. (2011).Stiffness of large
arteries and cardiovascular risk in patients with post-traumatic stress disorder. European
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Appendix A
Primary Care PTSD Screen (PC-PTSD)
The PC-PTSD is a 4-item screen that was designed for use in primary care and other
medical settings and is currently used to screen for PTSD in veterans at the VA. The screen
includes an introductory sentence to cue respondents to traumatic events. The authors suggest
that in most circumstances the results of the PC-PTSD should be considered "positive" if a
patient answers "yes" to any 3 items. Those screening positive should then be assessed with a
structured interview for PTSD. The screen does not include a list of potentially traumatic events.
Scale Instructions:
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that,
In the past month, you:
1.Have had nightmares about it or thought about it when you did not want to? YES / NO
2.Tried hard not to think about it or went out of your way to avoid situations that reminded you
of it? YES / NO
3. Were constantly on guard, watchful, or easily startled? YES / NO
4.Felt numb or detached from others, activities, or your surroundings? YES / NO
Current research suggests that the results of the PC-PTSD should be considered "positive" if a
patient answers "yes" to any three items. (Prins, Ouimette, & Kimerling, 2003)