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Managing Mental Health Disorders Resulting from Trauma through Yoga: A Review

  • Patanjali Research Foundation

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There are many and varied types of trauma. The extent to which trauma influences the mental health of an individual depends on the nature of trauma, as well as on the individual's coping capabilities. Often trauma is followed by depression, anxiety, and PTSD. As the pharmacological remedies for these conditions often have undesirable side-effects, nonpharmacological remedies are thought of as a possible add-on treatment. Yoga is one such mind-body intervention. This paper covers eleven studies indexed in PubMed, in which mental health disorders resulting from trauma were managed through yoga including meditation. The aim was to evaluate the use of yoga in managing trauma-related depression, anxiety, PTSD and physiological stress following exposure to natural calamities, war, interpersonal violence, and incarceration in a correctional facility. An attempt has also been made to explore possible mechanisms underlying benefits seen. As most of these studies were not done on persons exposed to trauma that had practiced yoga, this is a definite area for further research.
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Hindawi Publishing Corporation
Depression Research and Treatment
Volume 2012, Article ID 401513, 9 pages
Review A rticle
Managing Mental Health Disorders Resulting from
Trauma through Yoga: A Review
Shirley Telles, Nilkamal Singh, and Acharya Balkrishna
Department of Yoga Research, Patanjali Research Foundation, Haridwar, Uttarakhand 249408, India
Correspondence should be addressed to Shirley Telles,
Received 15 October 2011; Revised 5 March 2012; Accepted 13 March 2012
Academic Editor: Rachel Yehuda
Copyright © 2012 Shirley Telles et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
There are many and varied types of trauma. The extent to which trauma influences the mental health of an individual depends
on the nature of trauma, as well as on the individual’s coping capabilities. Often trauma is followed by depression, anxiety, and
PTSD. As the pharmacological remedies for these conditions often have undesirable side-eects, nonpharmacological remedies
are thought of as a possible add-on treatment. Yoga is one such mind-body intervention. This paper covers eleven studies indexed
in PubMed, in which mental h ealth disorders resulting from trauma were managed through yoga including meditation. The aim
was to evaluate the use of yoga in managing trauma-related depression, anxiety, PTSD and physiological stress following exposure
to natural calamities, war, interpersonal violence, and incarceration in a correctional facility. An attempt has also been made to
explore possible mechanisms underlying benefits seen. As most of these studies were not done on persons exposed to trauma that
had practiced yoga, this is a definite area for further research.
1. Introduction
The definitions of trauma are many and varied. One des-
cription states that an event is traumatic if it is extremely
upsetting and at least temporarily overwhelms the individ-
ual’s inner resources [1]. In the United States, surveys of the
general population suggest that at least half of all the adults
have experienced at least one major traumatic stressor [2, 3].
2. Trauma: Types of Trauma and Their
Physiological Consequences
The types of trauma include (i) natural disasters, ( ii) mass
interpersonal violence, (iii) large-scale transportation acci-
dents, (iv) house or other domestic fires, (v) motor vehicle
accidents, (vi) rape and sexual assault, (vii) stranger physical
assault, (viii) partner battery and emotional abuse, (ix)
torture, (x) war, (xi) child abuse, (xii) exposure of emergency
workers to trauma, and (xiii) major accident or illness. In
listing traumas separately there may be an erroneous impres-
sion that such traumas are independent of one another. This
is applicable to noninterpersonal traumas such as natural
disasters or house fires. However, it is also recognized that
vict ims of interpersonal traumas are at greater risk of addi-
tional interpersonal traumas. For example those who have
experienced child abuse are more likely to be victimized as
adults [4, 5].
People respond to trauma in dierent ways. When expos-
ed to the same trauma, some people develop posttraumatic
stress disorder, whereas others are less aected or respond
with symptoms such as depression or generalized anxiety [6].
It is well recognized that severe psychological trauma
causes impairment of the neuroendocrine systems in the
body, with sympathetic activation and suppression of the
parasympathetic nervous system. There is also an increase in
the level of circulating cortisol which has adverse eects on
dierent systems. Severe trauma in early childhood especially
has serious consequences. It can aect all aspects of develop-
ment, including cognitive, social, emotional, physical, psy-
chological, and moral development [7]. This has serious con-
sequences in adolescence and can influence adult life as well.
Van der Kolk et al. (1996) described the long-term eects
of trauma, which were: generalized hyper-arousal and di-
culty in modulating arousal, alterations in neurobiological
processes involved in stimulus discrimination, conditioned
fear responses to trauma related stimuli, loss of trust and
2 Depression Research and Treatment
hope, social avoidance, and lack of interest and participation
in preparing for the future [8]. With these changes, it is
understandable that if the trauma is severe, and if support is
inadequate and hereditar y factors are also present, a person
may develop symptoms of depression.
The pharmacological management of psychological dis-
orders resulting from trauma is best supplemented with non-
pharmacological healing techniques which would allow the
person to regulate their internal states and response to exter-
The Indian science of living, yoga, includes several pra-
ctices such as physical postures (asanas), voluntary regulat-
ed breathing (pranayamas), meditation, conscious sen-
sory withdrawal (pratyahara), and philosophical principles
3. Yoga and the Management of
the Consequences of Trauma
It is often dicult for people who have been subjected to
acute or prolonged trauma to regain a sense of normalcy and
balance in their lives [11]. In many cases, psychiatric help is
sought [12]. Also, since yoga requires involvement and ulti-
mately trains the person to practice on their own, learning
yoga can help a person regain their sense of being in control
of their lives, as well as increase their self-dependence.
Yoga is a nonpharmalogical remedy which has been used
to help in managing trauma related to (i) natural disasters,
(ii) combat and terrorism, (iii) interpersonal violence, and
(iv) being incarcerated in a correctional facility. Studies pub-
lished in journals indexed in PubMed were reviewed. Those
indexed in other bibliographic databases or which did not
use yoga, including meditation as an intervention, were
3.1. Yoga and Coping with Natural Disasters. In December
2004, a tsunami occurred in South East Asia [13]. Two
studies were conducted to assess the eects of yoga on the
survivors. A single group study on 47 tsunami survivors wi th
ages between 28 and 50 years was evaluated to see the eects
ofa7-dayyogaprogram[14]. The yoga program included
loosening exercises, yoga postures, breathing practices, and
guided relaxation for 60 minutes daily. Participants were
assessed for self-rated symptoms of stress (viz., fear, anxiety,
disturbed sleep, and sadness) using linear analog scales. The
electrocardiogram (to assess heart rate variability), breath
rate, and skin resistance were recorded using a portable four-
channel polygraph. Data were analyzed using paired t-tests
and all self-rated symptoms significantly reduced along with
the breath rate. Eect sizes were not calculated. The three
main limitations of the study were (i) the absence of a control
group, (ii) use of scales whose reliability and validity had
not been established, and (iii) the short duration of the
intervention with no long-term foll ow up. To a large extent,
these shor tcomings were overcome in the second study which
evaluated 183 tsunami survivors who were above the age of
18 years and who scored 50 or above on the Posttraumatic
Check List-17 (PCL-17) [15]. They were allocated to three
groups. The groups were (i) yoga breath intervention,
(ii) yoga breath intervention followed by 3 to 8 hours trauma
reduction exposure technique, and (iii) a wait list control
group. The participants were assessed at the beginning and
end of 24 weeks, as well as intermittently usingthe Posttrau-
matic Check List (PCL-17) for PTSD and Beck Depression
Inventory (BDI-21) for depression. The data were analyzed
using a three-way ANOVA. The scores of PCL-17 signif-
icantly reduced with yoga breath intervention and yoga
breath intervention followed by 3–8 hours trauma reduction
exposure technique. This study used scales whose validity
and reliability had been established and the participants were
followed up for 24 weeks. The eect sizes were not calculated.
The only weakness of the study was that the allocation of the
participants to three dierent groups was not random.
A meditation technique called Inner Resources was used
in a single study on 20 health workers (aged between 31 and
67 years) who were involved in relief work, 10 weeks after
Hurricane Katrina [16]. Meditation was taught as a 4 hour
workshop followed by an 8-week home study program. The
participants were assessed using disaster exposure questions,
PTSD Checklist-Specific Version (PCL-S), the Center for
Epidemiological Studies-Depression Scale (CES-D), the 20-
item state portion of the State-Trait Anxiety Inventory
(STAI-S) and a follow up questionnaire. Intention-to-treat
regression analyses and one-sample t-tests showed that the
persons’ PTSD scores assessed by PCL-S and anxiety sym-
ptoms assessed by STAI-S significantly decreased with the
intervention. Treatment eect size based on Cohens d was
calculated for PCL-S total (d
= .38), CES-D (d = .12) and
= .45). The limitations of the study were the small
sample size and absence of a control group.
Both the tsunami and the hurricane were unexpected
natural disasters. In certain cases, natural disasters occur
repeatedly. An example is the floods in the north eastern
Indian state of Bihar caused by seasonal rain and a breach
in a river [17]. In a cross-sectional study 1289 people (aged
between 15 to 85 years) who had been directly exposed to
the floods were screened for PTSD and depression using the
Screening questionnaire for disaster mental health (SQD)
[17]. In this study, no intervention was given. Two factor
ANOVAs showed that people over 60 years of age had higher
scores of PTSD and depression. From the larger sample of
1289 p ersons, a small sample of 22 persons (with an age
range of 20 to 40 years) were selected based on their w illing-
ness to participate in the trial and randomized as two groups,
a yoga group and a control group who continued with
their regular activities [18]. The yoga intervention was for 7
days and included loosening exercises, yoga postures, breath-
ing exercises, and guided relaxation for 60 minutes everyday.
The self-rated symptoms of distress, namely, fear, anxiety,
disturbed sleep, and sadness were assessed with linear analog
scales, the heart rate variability based on the electrocardio-
gram and breath rate were recorded with a four channel
polygraph. The yoga group showed a significant decrease in
sadness while anxiety significantly increased in the control
group (paired t-tests were used for analyses). Eect sizes were
not calculated in this study. Limiting factors were the use of
analog scales which have not been validated and the small
sample size.
Depression Research and Treatment 3
3.2. Yoga and Coping with Exposure to Combat and Terrorism.
In Kosovo, 139 high school students with ages ra nged from
12 to 19 years took part in a single group study in which the 6
week program included meditation, biofeedback, drawings,
autogenic training, guided imagery, genograms, movement,
and breathing techniques [19]. They were trained in the
program in three separate groups. Although there were no
inclusion or exclusion criteria and screening for PTSD was
not done using standardized methods, the children included
in the study were directly exposed to assault and atrocities of
war. The symptoms of PTSD were assessed using the PTSD
Reaction Index and were lower after the program. A paired
t-test was used to analyze pre and posttest dierences in
mean PTSD scores. There was a reduction in PTSD scores
after the program (P<.001). Eect sizes were calculated
using Cohens d with values of 0.6, 2.1, and 2.4 for changes
in pre and posttest measurements of Groups I, II, and
III, respectively, indicating a moderate clinical dierence
= 0.5) in Group I and large clinical dierences (d = 0.8)
in groups II and III. The main limitation of this study was the
absence of a control group. A later study by the same author
randomized 82 adolescents who met the criteria for PTSD
according to the Harvard Trauma Questionnaire [20]. They
were randomly assigned to a 12 session mind body group
program or a wait list control group. Here, again the mind
body program included meditation, guided imagery, breath-
ing techniques, self-expression through words, drawings and
movement, autogenic training, biofeedback, and genograms.
PTSD symptoms were assessed using the Harvard Trauma
Questionnaire. The intervention group had significantly
lower PTSD symptoms compared to the wait list control
group. After the wait list control group received the interven-
tion, their PTSD symptoms were reduced. This study meets
most of the criteria for rigor as the sample size was adequate,
participants were randomized to two interventions and the
assessment tool was standardized for assessment of trau-
A single group study was conducted on 122 preteen
Israeli school children (ages between 8 and 12 years) aected
by the second Lebanon war [21]. Those schools approved for
participation by the school principals were included in this
study. The yoga program consisted of 13 yoga sessions w hich
included yoga postures and breathing practices conducted
for 4 months. The assessments were made using the WHO
Well-Being Index and a satisfaction questionnaire for the
children. The teachers were given the Connor Abbreviated
Questionnaire to assess the behavior of the students. The
significant finding was improvement in attention span,
restlessness and inattention based on Connor Abbreviated
Symptoms rated by the teacher. There was no significant
dierence in the WHO Well-Being measures though the
children expressed satisfaction w ith the yoga training they
had received. The first and third scales are validated w hereas
the second (satisfaction questionnaire) was de veloped by the
authors. The data were analyzed w ith non parametric statis-
tics (i.e., Wilcoxon paired signed ranked test and Kruskall-
Wallis test). Eect sizes were not calculated in this study. The
advantage of the study is that the responses of the children
as well as the observations of the teachers were taken into
account using valid questionnaires. The disadvantages of the
study were that there was no control group.
Children between 6 and 12 years of age (n
= 226) who
experienced the terrorist bomb explosion in Bali in 2002 and
who were subsequently diagnosed with PTSD were studied
[22]. The design was a longitudinal, quasi-exper imental,
single blind, and randomized control design. Forty-eight
children received group Spiritual-Hypnosis Assisted Therapy
(SHAT) while 178 did not. Posttraumatic stress disorder
symptom scores reduced at the two year follow up after
SHAT with 77.1 percent improvement compared to 24 per-
cent in the control group.
In north eastern Sri Lanka, 71 children who were aected
by the civil war and the tsunami participated in a study [23].
They were diagnosed for PTSD through an interview. The
age range was between 8 a nd 14 years. Those with men-
tal retardation, psychosis, or a ny psychological disorder were
excluded from the study. They were randomized as two
groups; one received six-session narrative exposure therapy
for children (KIDNET) while the other group had six ses-
sions of meditation-relaxation (MED-RELAX). Assessments
were made after one and six months using the UCLA PTSD
index for DSM IV in interview form. In addition, a 5-item
scale was used to assess problems in functioning in di erent
areas of childrens lives (e.g., social relationships, family life,
and general life satisfaction). Also children were asked 5
questions related to the tsunami (e.g., “Did you see the
big wave close by?”). The data were analyzed with repeated
measures ANOVA and chi-square tests to compare postval-
ues of the two groups for one and six months. Symptoms
of PTSD were significantly reduced for both groups at one
month and remained stable at six months. Within-group
eect sizes based on Cohens d were calculated, eect sizes for
the KIDNET were 1.76 (CI 0.9–2.5) at one-month posttest
and 1.96 (CI 1.1–2.8) at 6-month follow up while for MED-
RELAX they were 1.83 (CI 0.9–2.6) and 2.20 (CI 1.2–3.0) at
one and six months posttest, respectively. This study used
standardized questionnaires and randomized participants to
two interventions. The only possible limitation is the absence
of a no intervention group. The study is particularly useful as
the children had been traumatized by both war and tsunami
and they improved with the interventions.
3.3. Interpersonal Violence. Usefulness of mindfulness med-
itation was evaluated for 97, fourth grade (mean age of 9.7
years, n
= 55) and fifth-grade (mean age of 10.6 years, n =
42) students from Baltimore city [24]. Most of these child-
ren lived in low-income neighborhoods with high levels of
violence. They were randomized as two groups, one received
mindfulness meditation and yoga (n
= 51) and the other
= 46). Assessments were taken at
the beginning and end of 12 weeks. Both groups were asses-
sed using (i) the response to stress questionnaire (RSQ) from
which the involuntary engagement coping scale was select-
ed, (ii) the short mood and feelings questionnaire-Child
version for depressive symptoms (SMFQ), (iii) the emotion
profile inventory (EPI), and (iv) relations with peers and the
school were assessed with the “People in my Life (PIML)”
self-report measure. Data were analyzed using ANOVA for
4 Depression Research and Treatment
continuous variables and chi-square tests for categorical vari-
ables. The findings suggest that a mindfulness based inter-
vention shows promise in reducing physical and cognitive
ways of responding to stress among youth faced with violence
in their daily life. Eect sizes were calculated for emotional
profile positive aect (d
= .04), Emotional profile negative
aect (d
= .13), SMFQ depression scores (d = .13), PIML
trust in friends (d
= .40), PIML communications with
friends (d
= .17), PIML Teacher Aliation (d = .09), PIML
dissatisfaction with teachers (d
= .08), and RSQ (d = .83).
The limitations include the fact that the recruitment may
have resulted in highly motivated students and/or those with
enthusiastic parents taking part. Also the self-report mea-
sures may have been influenced by various sources of bias.
3.4. Youth Incarcerated in a Correctional Facility. Youthful
oenders are committed to legal custody and interventions
are needed to help them cope with the stress and adjustment
to the environment [25]. A randomized controlled trial was
were living in a community h ome as they had a history of
committing legal oences [26]. The 28 girls were matched
for age
±6 months and duration of stay in the community
±2 months. Participants were then assigned to two
groups randomly, namely, yoga or games. The yoga training
included postures and guided relaxation sessions for 60
minutes daily for 5 days a week. At the end of 6 months,
both groups heart rate, breath rate and skin resistance were
assessed to evaluate their physiological stress levels. Data
were analyzed using Wilcoxon paired-sample test for pre
and postcomparisons. Following 6 months of practice, both
groups significantly reduced their heart rate, but the yoga
group alone showed a decrease in breath ra te. Eect sizes
were not calculated in this study. The findings of the study
were limited by (i) the small sample size, (ii) absence of tests
for self reported stress and wellbeing, and (iii) the objective
variables used were very simple a nd apart from the skin
resistance do not directly relate to physiological stress [27].
The studies cited above have been summar ized in Table 1.
4. Mechanisms Underlying
the Improvement in the Psychological
State Following Trauma with Yo ga
Given the possibility of using yoga to positively modify the
mental state following trauma, it is interesting to speculate
about the mechanisms underlying the benefits seen. The
amygdala is one of the main sites where alterations in the
regulation of the serotonin transporter (5-HTT) may alter
the stress response [28]. Based on a positron emission tomo-
graphy scan, abnormally reduced amygdala 5-HT binding
was found in PTSD and was associated with higher symp-
toms of anxiety and depression in posttrauma patients, parti-
cularly those with diagnosed PTSD. Hence, abnormal 5-HT
signaling within neural systems possibly underlies threat
detection and fear learning.
Whole blood serotonin levels and mood state changes
were assessed before and after focused attention on Tanden
breathing, which is a part of Zen meditation, in 15 healthy
right-handed participants [29]. Recordings were m ade of
the (i) elec tromyogr a phy (EMG) to monitor the abdominal
muscle contraction, (ii) the electroencephalograph (EEG)
from three scalp locations for monopolar recordings, (iii)
electrooculography (EOG) and electrocardiography (ECG),
(iv) near infrared spectroscopy (NIRS) u sing a 24-channel
system, and (v) whole blood serotonin levels measured
within 2 weeks of the experiment using standard high-per-
formance liquid chromatography- (HPLC-) based methods.
Dierent statistical tests were used for the dierent measures
such as two way repeated measures ANOVA for EEG, one-
way repeated measures ANOVA for serotonin levels, paired
t-tests for the mood scores and one way repeated measures
ANOVA for oxy-hemoglobin levels derived from the NIRS
data. Eect sizes were not calculated in this study. During
focused attention on Tanden breathing, there was a signifi-
cant increase in the oxy-hemoglobin level in the anterior pre-
frontal cortex, increased alpha activity with decreased theta
activity, and increase in whole blood serotonin levels cor-
related with increased alpha activity and reduced negative
Apart from changes in serotonin levels, animal models
of depression often use traumatic experiences of pain, isola-
tion, or social defeat to cause changes in mesolimbic and
mesocortical dopamine systems, which alter cortical control
of midbrain defenses [30]. Imbalance within the ascending
dopaminergic tracts may cause rapid fluctuations in the level
of arousal and in the associated mood, drive, and motivation.
Stress reduction, positive aect, and levels of plasma
catecholamines were assessed in 67 regular (range 3–144
months) meditators (aged 18–36 years) and 57 non-medi-
tators (aged 19–37 years). The meditation pract ice was called
“Brain Wave Vibration Mind Body Training” which is con-
sidered to change negative thoughts into positive ones [31].
The technique used natural rhythmic movements and hence
it is a moving meditation. All participants were assessed
using the stress response inventory, Positive Aect Negative
Aect Scale (PANAS), as well as blood samples to estimate
norepinephrine, epinephrine and dopamine levels using
high-performance liquid chromatography (HPLC). Com-
parisons between the two groups were made with t-tests
and Pearsons correlation coecient was used to analyze the
relationship between the two variables. Eect sizes were not
calculated in this study. The meditation g roup had higher
scores on positive aect and lower scores on negative aect
compared with non meditators. Their plasma dopamine
levels were also higher. The control group showed a negative
correlation b etween stress and positive eect. A positive cor-
relation was found between somatization of stress and nore-
pinephrine/epinephrine and dopamine/epinephrine ratios.
Hence in comparison with the control group, the regular
meditators had lower stress, higher positive aect, and higher
plasma dopamine levels.
While changes in serotonin and dopamine levels follow-
ing meditation may explain at least in part the positive aect
and reduction in stress following meditation the explanation
for the anxiety lowering eect of the yoga practices may
be related to another neurotransmitter, namely, Gamma
Aminobutyric Acid (GABA). Two studies demonstrated that
Depression Research and Treatment 5
Table 1: Summary of the twelve studies reviewed
Category of trauma
Sample: (1)
Age, (2)
Gender, (3) n
Study design
Assessment tools and their
Statistics Eect sizes Limitations
Natural disaster (tsunami)
(Location: the Andaman
islands) [14]
(1) 28–50 years
(2) both
(3) n
= 47
Single group
longitudinal design
with before, after (7
(i) Linear analog scales for fear,
anxiety, disturbed sleep, and
sadness (the reliability and
validity has not been
(ii) Heart rate variability from
the electrocardiogram),
(iii) breath rate and,
(iv) skin resistance
(ii), (iii), (iv) were recorded
with a polygraph and were
Paired t-tests Not reported
(i) Absence of a control
group, (ii) use of scales
whose reliability and
validity had not been
established, and (iii)
short duration of the
Natural disaster (tsunami)
(Location: South-east
coast of India) [15]
(1) 18–65 years
(2) Both
(3) n
= 183
Allocation (non
random) to 3 groups
(a) yoga breath
intervention, (b) yoga
breath intervention
followed by trauma
reduction exposure
technique, a nd (c) a
wait list control.
(d) Longitudinal
assessments before,
after (24 weeks) as
well as intermittently
(i) The PTSD check list-17
(ii) Beck depression inventory
(BDI-21) reliability and validity
are established
Three factor
ANOVA, with
post hoc analysis
using Newman
Keuls tests
Not reported
Allocation to the 3
groups was not random
Natural disaster
(Hurricane Katrina)
(Location: New Orleans,
U.S.A.) [16]
(1) 31–67 years
(2) Both
(3) n
= 20
(i) Single group
(ii) longitudinal
assessments before,
after (8 weeks of
(i) PTSD checklist-Specific
version (PCL-S)
(ii) Centre for (CES-D)
(iii) State subscale of STAI
(iv) a follow up questionnaire
(i), (ii), and (iii) are reliable and
treat regression
analysis and one
sample t-tests
PCL-S (d
= .38) CES-D (d = .12)
= .45)
(i) Small sample size
and (ii) absence of a
control group
Natural disaster (floods)
(Location: Bihar, India)
(1) 15–85 years
(2) Both
(3) n
= 1289
Cross sectional single
group study
evaluating r i sk for
PTSD and depression
in dierent age
Screening questionnaire for
disaster mental health (SQD)
with known reliability and
Two fa ctor
followed by
Not reported
Confounding variables
which could influence
susceptibility other
than age and gender
were not reported
6 Depression Research and Treatment
Table 1: Continued.
Category of trauma
Sample: (1)
Age, (2)
Gender, (3)n
Study design
Assessment tools and their
Statistics Eect sizes Limitations
Natural disaster (floods)
(Location: Bihar, India)
(1) 20–40 years
(2) Males
(3) n
= 22
(i) Randomized
controlled study
(ii) Longitudinal with
before, after
assessment after 7
days of intervention
(i) Linear analog scales to assess
fear, anxiety, disturbed sleep and
sadness, (ii) heart rate
variability based on
electrocardiogram, and (iii)
breath rate.
reliability and validity of linear
analog scales are not established
and (ii) and (iii) were recorded
on a polygraph with
standardized methods
Paired t-tests Not reported
(i) Small sample size
(ii) use of analog scales
which are not valid
Exposure to combat and
terrorism (Location:
Kosovo) [19]
(1) 12 to 19
(2) Both
(3) n
= 139
(i) Single group.
(ii) Longitudinal with
before, after (6 weeks)
(i) PTSD reaction Index
With known reliability and
Paired t-tests
one group and
the subset of
another group
Eect size for group 1 (d
= 0.5)
and group II and II (d
= 0.8)
Absence of a control
Exposure to combat and
terrorism (Location:
Kosovo) [20]
(1) 12–19 years
(2) Both
(3) n
= 82
(i) Randomized
control study
(ii) Longitudinal
before, after (3
Harvard trauma questionnaire
(valid and reliable)
Not obtained possibly reported NIL
Exposure to combat and
terrorism (Location:
Israel) [21]
(1) 8–12 years
(2) Both
(3) n
= 122
(i) Single group
(ii) Longitudinal
before, after (4
(i) WHO well being index
(ii) A satisfaction questionnaire.
(iii) Connor abbreviated
questionnaire (rated by the
(i) and (iii) are reliable and valid
(i) Wilcoxon
paired signed
ranked test
(ii) Kruskall
Wallis test
Not reported
Absence of a control
Exposure to combat and
terrorism (Location: Bali)
(1) 6–12 years
(2) Both
(3) n
= 226
(i) Single blind,
randomized control
(ii) Longitudinal
before, after (2 year
follow up)
Not obtained Not obtained Not obtained
Numbers in the 2
groups were unequal
(i.e., 48 in the SHAT
in the control) this is
not usual in a
randomized control
Exposure to combat and
terrorism as well as
tsunami (Location: Sri
Lanka) [23]
(1) 8–14 years
(2) Both
(3) n
= 71
Randomized to 2
interventions, before,
after (1, 6 months)
(i) (UCLA PTSD index for
(ii) 5 item scale for satisfaction.
(iii) 5 item scale related to the
(i) and (ii) had established
reliability and validity
chi-square tests
Eect Sizes (i) KIDNET 1.76 (one
month post test), 1.96 (6 months
post test) (ii) MED-RELAX 1.83
(one month post test), 2.20 (6
month post test)
(i) Absence of a no
intervention control
(ii) The third
questionnaire (related
to the tsunami) was not
Depression Research and Treatment 7
Table 1: Continued.
Category of trauma
Sample: (1)
Age, (2)
Gender, (3)n
Study design
Assessment tools and their
Statistics Eect sizes Limitations
Interpersonal violence
(Location: Baltimore City,
U.S.A.) [24]
(1) 9–11 years
(2) Both
(3) n
= 97
Randomized control
before, after (12
weeks) assessments
(i) Response to stress
questionnaire. (ii) The short
mood and feelings
questionnaire: Child version for
depressive symptoms.
(iii) Emotional profile inventory
(iv) “People in my life self report
(i) ANOVA for
(ii) chi-square
tests for
Eect sizes were calculated for
Emotional profile positive aect
= .04), Emotional profile
negative aect (d
= .13), SMFQ
depression scores (d
= .13),
PIML Trust in Friends (d
= .40),
PIML Communications with
Friends (d
= .17), PIML Teacher
Aliation (d
= .09), PIML
Dissatisfaction with Teacher
= .08) and RSQ (d = .83)
Recruitment may have
involved highly
motivated students
with enthusiastic
parents (the self-report
measures may have
been influenced by bias
Yo uth i n a co r r e c t i onal
facility (Location:
Bangalore, India) [26]
(1) 12–16 years
(2) Females
(3) n
= 28
Matched pair
allocation to
intervention and
control g roups (pairs
were matched for age
and duration of stay
in the community
home), before, after
(6 months)
(i) Heart rate from the
(ii) Breath rate from a
(iii) Skin resistance. The 3
variables were recorded with a
polygraph using standard
Not reported
(i) The small sample
size. (ii) absence of tests
for self reported stress,
and (ii) simplistic
variables used are
inadequate to assess
physiological stress
8 Depression Research and Treatment
GABA-ergic activity increased after yoga practice. In the ear-
lier study, 8 experienced yoga practitioners were compared
with 11 non practitioners [32].Allsubjectswereevaluated
using the Structural Clinical Interview for DSM-IV Axis I
Disorders: Patient Edition (CID) and the Addiction Severity
Index (ASI). Persons with contraindications for magnetic
resonance evaluation were excluded from the study. The
yoga group completed a 60-minute session which included
yoga postures while the comparison subjects read periodicals
and popular fiction during a 60-minute session. GABA-
to-creatine ratio was measured using magnetic resonance
spectroscopy imaging (MRSI) immediately before and after
the intervention. The GABA levels increased by 27 percent
in the yoga practitioners after the yoga session while the
comparison group showed no change. In this study, eect
size was not calculated. The second study by the same authors
addressed the question of whether changes in GABA levels
are specific to yoga or related to physical activity [33].
Participants were randomized to a yoga group (n
= 19) or
a metabolically matched physical exercise group (n
= 15)
for 60 minutes, 3 times a week for 12 weeks. The age range
of the participants was 18–45 years. Magnetic resonance
spectroscopy scans demonstrated that thalamic GABA levels
increased in the yoga group and were positive ly correlated
with improved mood. The acute changes in GABA levels
in the yoga group approached significance (P
= 0.09, t-
test). In this study, also eect sizes were not calculated. The
thalamic GABA level was associated with improved mood
and decreased anxiety. These changes are usually obtained
by pharmacological agents designed to improve mood and
alleviate anxiety. Hence, this study was the first report of a
behavioral intervention producing the same eect.
These studies suggest that certain changes in neurotrans-
mitters following yoga practice may be responsible for the
improved psychological state in trauma victims who prac-
ticed yoga. However, neurotransmitters have not been mea-
sured in any of the studies on trauma victims who improv-
ed with yoga. Hence, this is a speculation.
For this review, we examined in detail eleven studies
(indexed in PubMed) on people exposed to trauma who
received yoga including meditation as an intervention. There
was also a single group cross-sectional study conducted prior
to one of the intervention studies. Hence, 12 studies were
reviewed. Among them, there were 7 randomized controlled
trials (RCTs), 4 single group studies, and the one cross-
sectional single group survey referred to above. Even where
RCTs were conducted studies were limited by factors such as
small sample sizes and in a few cases use of assessment tools
whose reliability and validity were not established. Hence,
though yoga and other mind body interventions appear to be
useful in reducing mental health disorders following trauma
there is as yet no systematic randomized control trial which
meets all the requirements to state that these interventions
conclusively are useful in trauma management.
The last part of the article attempts to consider possible
mechanisms underlying the improvement with yoga. How-
ever, since none of these studies were conducted in trauma
survivors, they remain speculative, and a possible direction
for future study.
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... Yoga is a broad term that encompasses a set of breathing, movement, and meditation practices that were first developed in India thousands of years ago (Khanna & Greesen, 2013). The practice seeks to foster a state of consciousness that balances physical, emotional, and spiritual health and encourages mindful focus on the present moment (Salmon, Lush, Jablonski, & Sephton, 2009;Telles, Singh, & Balkrishna, 2012). Yoga is a stand-alone intervention that may serve as a complementary or alternative therapy when used in addition to, or in place of, conventional health care (Blacher & Rundio, 2014). ...
... 2007) to control groups. Systematic review of the random clinical trials about yoga have recognized these positive results and raise methodological questions about the research, including inadequate randomization, small sample sizes, high attrition rates, and lack of information about adverse effects (Kirkwood, Rampes, Tuffrey, Richardson, & Pilkington, 2005;Posadzki et al., 2014;Telles et al., 2012). In spite of these limitations, reviews describe the existing literature as "encouraging" and call for rigorous studies that more definitively measure the impact of yoga on health outcomes (Kirkwood et al., 2005, p. 890;Posadzki et al., 2014, p. 7). ...
... Telles and colleagues report that yoga was effective at improving mental health and alleviating anxiety in instances of severe trauma and loss, where symptoms of anxiety, sadness, and PTSD abated, attention span improved, and restlessness decreased among the subjects of the trials that were examined (Telles et al. 2012). Heart rates were additionally reduced when elevated, negative emotions were limited, and sleep quality was improved by sustained practice (ibid.). ...
Full-text available
This article examines the efficacy of the postures, breath control techniques, and meditative states of yoga, specifically Haṭha Yoga, in promoting overall mental and physical health. It then examines whether this form of yoga could be effective in reducing morbidity or serious illness during the COVID-19 pandemic. We assess the potential efficacy of three claims made for Haṭha Yoga. They are the following: (1) breathing exercises associated with yoga may help maintain pulmonary health and protect the upper respiratory tract, the portal of entry for the SARS-CoV-2 virus infection; (2) improved immunity resulting from sustained yoga practice may help prevent COVID-19 contraction; (3) stress reduction of yoga may be effective in maintaining the mental well-being needed to combat the extra stress of living during a pandemic. Related to this claim, we examine testimony to the effect that yoga also gave people meaning and purpose in their lives during the isolating lockdown period. While exploring these beneficent advantages, we further address a serious health-related counterclaim that the community practice of yoga has the potential to create conditions that facilitate disease transmission due to heavy breathing in small, enclosed spaces. This balanced analysis introduces an interesting tension relevant to public health policy, namely that well-intended attempts to minimize indoor interaction for the sake of reducing the spread of infection may impact the effectiveness of yogic therapies and impede the freedom to practice the spiritual discipline of yoga. They may also not reduce the spread of infection enough to warrant their damaging effects on yoga practice. We suggest ways for resolving this tension and conclude with some concrete recommendations for facilitating yoga practice in future pandemics. These include (1) that public health policymakers consider programs that provide access to yoga by ensuring hospital prayer rooms appropriate in size and that, where feasible, yoga studios conduct their lessons outside in open areas; (2) that resources be devoted to providing therapeutic access to virtual yoga as a federal program, despite potential resistance to this idea of government involvement due to concerns that yoga has its origins in heterodox religious practice.
... It also removes posttraumatic stress disorder. Studies have shown that it has helps in diminishing stress, sadness, disturb sleep and anxiety 17 . ...
... It is generally believed that yoga reduces anxiety, but systematic studies in this area are surprisingly scarce. A review that looked at the use of yoga in managing trauma-related depression, anxiety, PTSD, and physiological stress concluded that these problems could be managed through yoga and meditation (Telles et al., 2012). ...
Full-text available
This chapter is divided into four subsections: the first section of the chapter provides an update on current evidence for yoga therapy in common mental health disorders, the second section provides brief overview on neurophysiological abnormalities in psychiatric disorders and their relationship with psychological stress, the third section deals with summary of evidence for neurophysiological effects of yoga in mental health disorders, and the last section emphasizes on practical aspects of yoga therapy with details of clinically useful yoga practices for common mental health disorders. The mental health disorders covered in this chapter include depression, anxiety, schizophrenia, child and adolescent psychiatric disorders, substance use disorders, and geriatric psychiatric disorders.
... Research have investigated the effects of yoga on anxiety, depression, mood disturbance, performance anxiety, mental and physical stress, schizophrenia, addictive behavior, attention deficit disorder, autism, and obsessive compulsive disorder; and found it as an effective additional treatment for these conditions. It possibly treat symptoms that are left untreated by psychological and pharmacological interventions [36,[38][39][40]. ...
... [11][12][13] Besides, this yoga has also been proven beneficial in alleviating the mental trauma arising from testing conditions such as natural calamities. [14,15] Owing to these benefits, postulates for the inclusion of yoga into mental health crisis arising due to COVID-19 are on the rise. [7][8][9][10][16][17][18] Based on the compelling literature, we evaluated whether a modified yoga protocol along with aromatherapy a naturopathic intervention alongside the standard care is effective in reducing depression, anxiety, and stress among mild-to-moderate COVID-19 patients. ...
In recent years, interest in the therapeutic potential of yoga for people recovering from trauma has flourished. To date, much of this research on yoga for trauma adopts a quantitative methodology that positions yoga as a medicalised intervention to understand if yoga is ‘effective’ for trauma recovery for adults. This paper seeks to contribute to an emerging body of qualitative literature by drawing on the voices of eight Iyengar yoga teachers with experience teaching adult students with trauma. It reveals that the teachers do not hold themselves out to be specialists in trauma, nor do they rely on formulistic principles or knowing a person’s trauma narrative. Rather, they draw on the pedagogic skills they have developed more generally through their considerable experience of teaching yoga as an embodied practice to tailor their approach for their students. Of central interest is the way the teachers use their own bodies, particularly their sensory perceptions, to ‘read’ the bodies and emotional capacities of their students within each teaching session. The teachers also reflect on the way they use adjustments as part of their embodied pedagogic skills in nuanced ways that challenge the dominant no-touch discourse on teaching students with trauma. These pedagogic approaches offer important insights for movement teachers more generally, particularly those teaching vulnerable students.
Yoga has been demonstrated to improve well-being and mental health in diverse populations; however, understanding of the mechanisms of action is still developing. This chapter explores the impact of yoga-based interventions on psychological and/or biological mechanisms related to mental health. This chapter highlights that yoga-based interventions decrease stress reactivity, influence physiological markers of stress reactivity, resulting in overall improved health and well-being, in diverse populations of adults. Yoga-based interventions influence psychological processes important in the regulation of mood and emotion, including dispositional mindfulness, self-compassion, rumination, attention, metacognition, and memory. Finally, yoga-based interventions result in structural and functional changes in several brain regions. Yoga-based interventions impact several processes relevant to mental health and maybe a useful complementary intervention for a number of mental health concerns.
It is not uncommon for youth (ages 2–19) to experience trauma. There are various types of traumatic events that may lead to adverse effects on youths’ emotional, cognitive, social, physical, and spiritual health. It is important that youth receive support and resources to address the negative impacts trauma may have on their minds and bodies. Yoga is a holistic practice that may address these negative effects in all 5 health domains. However, there are many inconsistencies and gaps in the literature regarding the use of yoga with youth who have experienced trauma. The purpose of this descriptive survey research study was to address these inconsistencies by describing the approaches of 56 practitioners who utilize yoga with youth who have experienced trauma, and their perceptions of how and why they use yoga with these youth. Findings highlighted the importance of implementing trauma-specific adaptations when facilitating yoga with youth who have experienced trauma, such as increasing participant autonomy, providing a safe environment, and developing a therapeutic rapport. Results also indicated that the most common use of yoga among these practitioners was to address emotional and physical needs of youth who have experienced trauma. Implications of study findings and opportunities for future research are discussed.
Full-text available
The progressive escalation in military suicides, along with a substantial increase in post-traumatic stress diagnosis among active military personnel and veterans, has become a significant humanitarian, societal, and cultural concern. Such a defining moment illuminates the need for timely and innovative treatment approaches for combat-related post-traumatic stress. This research explored depth psychological practices within short-term, group-based treatment programs. Using a phenomenological research method, interviews were conducted with six former combat veteran alumni of these programs to gather new insights and understanding into their lived experience. Informants described meaningful reductions in post-traumatic stress, moral injury, and treatment-resistance, while treatment completion rates increased significantly. Research findings suggest depth psychological practices do exhibit compelling potential as valuable, or formidable treatment approaches, alongside current evidence-based treatments. Based on the findings of this preliminary exploration future research is warranted on depth psychological treatments and group-based programs for combat-related post-traumatic stress.
Full-text available
To examine the role of perceived stressfulness of trauma exposure and economic, social, occupational, educational, and familial adaptation after trauma in posttraumatic stress disorder (PTSD) and depression in displaced war survivors. A cross-sectional survey was conducted between March 2000 and July 2002 with a sample of 173 internally displaced persons or refugees and 167 matched controls in Croatia. Clinical measures included Structured Clinical Interview for DSM-IV and Clinician-Administered PTSD Scale. Displaced war survivors reported the exposure to a mean±standard deviation of 13.1±8.3 war stressors, including combat, torture, serious injury, death of close persons, and loss of property. Compared to controls, they reported higher rates of marked to severe impact of war on family (16.2% vs 51.6%), social (7.2% vs 43.5%), economic (12.6% vs 55.4%), occupational (1.8% vs 15.9%), and educational (2.4% vs 8.8%) adaptation. In two logistic regression analyses, the strongest predictor of PTSD and depression was high level of perceived distress during trauma exposure. PTSD but not depression was associated with economic, social, occupational, educational, and familial adaptation after trauma. Displaced survivors who experienced multiple war events perceived greater negative impact of war on their life domains compared to individuals who lived in a war setting but had no trauma exposure. The most important determinant of psychological outcomes was perceived stressfulness of war stressors. Although post-trauma adaptation in different life spheres had an impact, its effect was not robust and consistent across disorders. These findings suggest that it would be effective to use a trauma-focused approach in rehabilitation of war survivors.
To ascertain the prevalence of posttraumatic stress disorder (PTSD) and risk factors associated with it, we studied a random sample of 1007 young adults from a large health maintenance organization in the Detroit, Mich, area. The lifetime prevalence of exposure to traumatic events was 39.1%. The rate of PTSD in those who were exposed was 23.6%, yielding a lifetime prevalence in the sample of 9.2%. Persons with PTSD were at increased risk for other psychiatric disorders; PTSD had stronger associations with anxiety and affective disorders than with substance abuse or dependence. Risk factors for exposure to traumatic events included low education, male sex, early conduct problems, extraversion, and family history of psychiatric disorder or substance problems. Risk factors for PTSD following exposure included early separation from parents, neuroticism, preexisting anxiety or depression, and family history of anxiety. Life-style differences associated with differential exposure to situations that have a high risk for traumatic events and personal predispositions to the PTSD effects of traumatic events might be responsible for a substantial part of PTSD in this population.
Conference Paper
A random sample of 724 individuals across the United States were mailed a questionnaire containing demographic information, an abridged version of the Traumatic Events Survey (D. M. Elliott, 1992), and questions regarding memory for traumatic events. Of these, 505 (70%) completed the survey. Among respondents who reported some form of trauma (72%), delayed recall of the event was reported by 32%. This phenomenon was most common among individuals who observed the murder or suicide of a family member, sexual abuse survivors, and combat veterans. The severity of the trauma was predictive of memory status, but demographic variables were not. The most commonly reported trigger to recall of the trauma was some form of media presentation (i.e., television show, movie), whereas psychotherapy was the least commonly reported trigger.
Background: Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated lifetime prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.Methods: Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.Results: The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.Conclusions: Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
This cross-sectional study examined whether previous life stressors are associated with current traumatic stress symptoms in women who were sexually abused in childhood. Fifty-eight treatment-seeking women, sexually abused in childhood and meeting criteria for current posttraumatic stress disorder (PTSD) in response to their childhood sexual abuse, participated in this study. Participants were administered a structured interview to assess PTSD as well as selfreport measures to assess acute stress reactions, other trauma-related symptoms, sexual revictimization as an adult, and recent stressful life events. Recent stressful life events were shown to be associated with PTSD symptoms, acute stress disorder (ASD) symptoms, and other trauma-related symptoms. Sexual revictimization was associated with trauma-related symptoms but not PTSD symptoms or ASD symptoms. Implications for clinical intervention and future research are discussed.
Despite important advances in and growing applications of psychophysiology, there has existed no single book that covers the diverse elements of psychophysiology at a level of scholarship that is informative to the specialist while also covering these topics at a level of discourse that is accessible to the nonspecialist. A major objective in creating this book, therefore, was to provide sufficiently comprehensive discussions of physical, social, and inferential elements of psychophysiology to interest and inform the specialist; and sufficiently clear and explicit coverage that the potential and excitement of psychophysiology becomes apparent, and its principles and methods become more accessible, to graduate students and scientists interested but not yet well-versed in psychophysiology. Part I is divided into two sections. it begins with a description of the psychophysiological enterprise, a brief history of the field, and conceptual frameworks for linking psychophysiological data and psychological/behavioral constructs. The chapters in Part II elaborate upon these foundations by highlighting principles of human behavior that have emerged from psychophysiological analyses. The chapters in Part III provide detailed overviews of the major physiological systems that are currently actively investigated in the psychophysiological literature. Although each chapter on physiological systems discusses issues related to the extraction, analysis, and interpretation of physiological data, there are several important issues in psychophysiology that are sufficiently complex and general that they warrant tutorials of their own. Part IV, on issues in the analysis of psychophysiological signals, is included for this purpose. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Research on increased medical care costs associated with posttraumatic sequelae has focused on posttraumatic stress disorder (PTSD). However, the provisional diagnosis of Disorders of Extreme Stress Not Otherwise Specified (DESNOS) encompasses broader trauma-related difficulties and may be uniquely related to medical costs. We investigated whether DESNOS severity was associated with greater nonmental health medical care costs in veterans receiving mental health care. Participants were 106 men and 105 women receiving VA outpatient mental health treatment. A standardized interview assessed DESNOS severity. The dependent variables consisted of primary and specialty medical treatment costs. Sequential zero-inflated negative binomial regression was used to evaluate the variance in medical costs accounted for by DESNOS severity, controlling for PTSD severity and established predisposing, enabling, and need-based health care factors. Contrary to our hypothesis, in fully adjusted models, DESNOS severity independently added a significant amount of variance to lower specialty medical care costs, whereas PTSD did not consistently account for significant variance in medical care costs. Greater DESNOS severity appears to be associated with lower specialty medical care costs but not primary care costs. These findings may indicate that patients with DESNOS symptoms are at risk for being underreferred for specialty care.
The amygdala is a key site where alterations in the regulation of the serotonin transporter (5-HTT) may alter stress response. Deficient 5-HTT function and abnormal amygdala activity have been hypothesized to contribute to the pathophysiology of posttraumatic stress disorder (PTSD), but no study has evaluated the 5-HTT in humans with PTSD. On the basis of translational models, we hypothesized that patients diagnosed with PTSD would exhibit reduced amygdala 5-HTT expression as measured with positron emission tomography and the recently developed 5-HTT-selective radiotracer [(11)C]AFM. Fifteen participants with PTSD and 15 healthy control (HC) subjects without trauma history underwent a resting-state positron emission tomography scan. [(11)C]AFM binding potential (BP(ND)) within the combined bilateral amygdala region of interest was significantly reduced in the PTSD group compared with the HC group (p = .027; 16.3% reduction), which was largely driven by the between-group difference in the left amygdala (p = .008; 20.5% reduction). Furthermore, amygdala [(11)C]AFM BP(ND) was inversely correlated with both Hamilton Rating Scale for Anxiety scores (r = -.55, p = .035) and Montgomery-Åsberg Depression Rating Scale scores (r = -.56, p = .029). Our findings of abnormally reduced amygdala 5-HTT binding in PTSD and its association with higher anxiety and depression symptoms in PTSD patients support a translational neurobiological model of PTSD directly implicating dysregulated 5-HTT signaling within neural systems underlying threat detection and fear learning.
On 26 December 2004, a large earthquake in the Indian Ocean and the resulting tsunami created a disaster on a scale unprecedented in recorded history. Thousands of foreign tourists, predominantly Europeans, were affected. Their governments were required to organize rapid rescue responses for a catastrophe thousands of miles away, something for which they had little or no experience. The rescue operations at three international airports in Sweden, the UK, and Finland are analyzed with emphasis on "lessons learned" and recommendations for future similar rescue efforts. This report is based on interviews with and unpublished reports from medical personnel involved in the rescue operations at the three airports, as well as selected references from an electronic literature search. In the period immediately following the tsunami, tens of thousands of Swedes, Britons, and Finns returned home from the affected areas in Southeast Asia. More than 7,800, 104, and approximately 3,700 casualties from Sweden, the UK, and Finland, respectively, received medical and/or psychological care at the temporary medical clinics organized at the home airports. Psychiatric presentations and soft tissue and orthopedic injuries predominated. All three airport medical operations suffered from the lack of a national catastrophe plan that addressed the contingency of a natural or disaster due to a natural or man-made project occurring outside the country's borders involving a large number of its citizens. While the rescue operations at the three airports functioned variably well, much of the success could be attributed to individual initiative and impromptu problem-solving. Anticipation of the psychological and aftercare needs of all those involved contributed to the relative effectiveness of the Finnish and Swedish operations.