Abstract
Background:
Panic disorder is associated with autonomic nervous system dysfunction and reduced heart rate variability (HRV). Enhancing HRV may help mitigate symptoms of panic disorder. This study investigated the effects of Rajyoga mindfulness meditation training on HRV in patients with panic disorder.
Methods:
This prospective randomized controlled trial included 110 patients with panic disorder recruited from a psychiatry department in India. Participants were randomized to either an 8-week Rajyoga meditation intervention (n = 55) or a waitlist control group (n = 55) receiving standard treatment alone. HRV was measured at baseline and after 8 weeks using time domain (SDRR, RMSSD, pNN50) and frequency domain (total power, HF, LF, LF/HF ratio) parameters.
Results:
At baseline, there were no significant differences in demographics or HRV parameters between groups. After 8 weeks, the Rajyoga group showed significant increases in SDRR, RMSSD, pNN50, and total power compared to controls (P < 0.05), indicating improved parasympathetic activity. The LF/HF ratio decreased in the Rajyoga group versus controls, suggesting a shift toward parasympathetic predominance.
Conclusions:
Eight weeks of Rajyoga mindfulness meditation training improved HRV and parasympathetic activity in patients with panic disorder compared to standard treatment alone. Rajyoga meditation may be a beneficial adjunctive intervention for enhancing autonomic regulation in panic disorder.
Keywords: Heart rate variability, meditation, mind–body therapies, panic disorder, Rajyoga
INTRODUCTION
Heart rate variability (HRV) is a measure of the variation in time intervals between heartbeats, providing insights into autonomic nervous system function. For patients with panic disorder, HRV is of particular significance due to its association with autonomic dysfunction and its potential as a biomarker of pathological anxiety.[1,2,3]
Research has consistently shown that individuals with anxiety disorders, including panic disorder, tend to have reduced HRV, which is associated with increased physiological arousal and decreased ability for growth and repair after the body detects a threat.[4]
Therefore, enhancing HRV can be beneficial for patients with panic disorder as it may help mitigate the somatic symptoms of anxiety and contribute to improved autonomic functioning. Additionally, HRV biofeedback devices have been found to be effective in reducing symptoms of anxiety, further highlighting the potential benefits of HRV for this patient population.[1]
The practice of Rajyoga meditation has shown promising potential in influencing cardiovascular health among patients with panic disorder. Research has revealed that individuals who engage in Rajyoga meditation have demonstrated an optimum mean heart rate and blood pressure compared to nonmeditators, indicating its possible role in modulating physiological responses secondary to anxiety.[5,6]
Furthermore, studies have highlighted the hemodynamic effects of Rajyoga meditation on heart rate, blood pressure, and ECG parameters, suggesting a decrease in heart rate and blood pressure among practitioners.[5]
This research topic is of significant importance as it explores a noninvasive and potentially effective adjunctive intervention for managing panic disorder, offering new insights into the potential benefits of meditation practices for individuals struggling with this condition.
The research topic on the effect of Rajyoga meditation on heart rate variability among patients with panic disorder is significant and novel for medical research. Rajyoga meditation has been shown to have a positive impact on HRV, blood pressure, and respiratory rate among individuals who practice it regularly.[5] This suggests that Rajyoga meditation may be an effective adjunctive intervention for managing panic disorder as it can help improve autonomic nervous system activity and contribute to better physiological responses.
Furthermore, research on the effectiveness of Rajyoga meditation as an adjuvant for panic anxiety syndrome is limited,[6] highlighting the novelty of this research topic. Investigating the specific effects of Rajyoga meditation on HRV among patients with panic disorder can offer new insights into the potential benefits of meditation practices for individuals struggling with this condition and contribute to the development of effective interventions for managing panic disorder.
MATERIALS AND METHODS
In this randomized control trial, 110 patients with panic disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, were selected by consecutive sampling from the psychiatry department at the All India Institute of Medical Sciences, Patna.
All the participants were given to fill the preapproved demographic questionnaire and Physical Health Questionnaire-9 (PHQ 9), which were used for the screening purpose. Diagnosis was ascertained by a qualified psychiatric consultant using the DSM-5.
The inclusion criteria encompass patients between 18 and 60 years of age, regardless of gender, who meet the DSM-5 diagnostic criteria for panic disorder. Additionally, eligible participants must have a PHQ 9 score below 20.
The study excludes several groups of patients. These include those with severe depression as indicated by a PHQ 9 score of 20 or higher as well as individuals with a history of severe mental disorders such as schizophrenia, bipolar disorder, or common mental disorders. The exclusion criteria also extend to subjects with any history of neurological trauma, cerebrovascular disease, or organic brain disorder.
All the study subjects have been explained about the study protocol in their language of communication and informed consent obtained from the participants before beginning of the study. Prior ethical approval has been taken from the Institute Ethical Committee vide letter number AIIMS/Pat/IEC/2019/411 dated 30/11/2019. The study has also been registered on the trial registry portal of Government of India vide registration number CTRI/2020/12/029462 prior to starting the study. The sample size calculation equation has been used to determine the number of participants needed per group based on the following statistical parameters: 95% confidence level (Zα/2 = 1.96), 80% power (Zβ = 0.84), standard deviations of 20.3 and 14.65 for Groups A and B, respectively, and an expected mean difference of 8 ms. The calculation yields approximately 55 participants required per group to achieve the desired statistical power and confidence level.
The study participants were randomized into two groups using computer-generated block randomization tables, with the block size of 4. We used sealed envelopes for location concealment. The assessors were blinded to treatment allocation. The study consisted of two groups with 55 participants each. Group A (Experiment) received standard treatment plus Rajyoga meditation, while Group B (Control) received only standard treatment.[7] The standard treatment protocol was identical for both groups, comprising SSRI medication and CBT administered by the same psychiatrist and clinical psychologist to ensure consistency of care across all participants.
Rajyoga meditation
The Rajyoga meditation technique from the Brahma Kumaris school of thought, which emphasizes the cultivation of positive thoughts for oneself and others through guided techniques, was used in the Rajyoga meditation practice in the current study. With a focus on the idea of the ultimate soul, a hypothetical primary source of energy for each and every person particularly emphasizes the intentional transfer of cognitive process from a body-conscious to the soul-conscious state.[6]
The intervention arm of the study population has been subjected to supervised Rajyoga meditation (RM) sessions tailored specifically for the purpose of panic disorder by a team of long-term (>10 years) Rajyoga meditators. The RM session protocol (6 domains) was practiced sequentially by all the intervention group participants 25–30 minutes each morning and evening daily for 5 days or more every week for 8 weeks.
The primary outcome variable was SDRR (ms), which is the primary measure of variation between consecutive R-R intervals indirectly representing HRV. Highly variable HRV indicates better outcome in most of the health conditions. RMSSD (MS) stands for root mean square deviation of N-N interval (normal QRS to QRS interval) in ECG, which is also the measure of HRV in time-domain parameter and interpreted similarly as SDRR. pNN 50 (%) is percentage of consecutive R-R intervals having >50 ms difference in time with relation to the total consecutive R-R intervals recorded. A high proportion of pNN50 highly correlates with hypervariable heart rate. Total power (Ms2) is the frequency domain parameter considered more robust than the time-domain parameter as a marker for HRV. It computes HRV using fast Fourier transformation algorithm for computation of variablility. A high total power associates well with high HRV, which indirectly signifies parasympathetic dominance. LF and HF power (nu) indicates low-frequency modulation and high-frequency modulation of heart rate in a frequency domain algorithm. Low-frequency modulation is mainly due to sympathetic overactivity, whereas high-frequency modulation is due to parasympathetic hyperactivity. The LF/HF ratio is reported to be a good reliable marker of sympathovagal balance; thus, low LF/HF ratio is an indicator of parasympathetic dominance.
Data analysis: The data have been compiled using MS Excel Ver. 2010. The data have been further analyzed using SPSS ver. 22. All the normally distributed continuous variables have been compared using mean and standard deviation and categorical variables using proportions and percentages. Association of continuous variables was done by independent sample t-test, and categorical variables by Chi-square test. Independent sample t-test was used to compare the postintervention HRV measures between the meditation and control groups, controlling for baseline HRV values. A P value of <0.05 has been taken as the level of significance.
CONSORT FLOWCHART:
RESULTS
A total of 110 participants with panic disorder were randomized to either the Rajyoga meditation group (n = 55) or waitlist control group (n = 55). There were no significant differences between groups in baseline demographics or clinical characteristics (all P > 0.05). The two study groups were comparable in terms of mean sleep hours, diagnosis, mean duration of untreated period, family history, and comorbidities (P > 0.05) See [Table 1].
Table 1.
Sociodemographic variables among study groups
| Demographic Variables | categories | Group A (Rajyoga) | Group B (Control) | P |
|---|---|---|---|---|
| Age in years (Mean±S.D.) | 34.49±8.3 | 34.36±11.1 | 0.946 | |
| Gender | Males | 38 (69.1%) | 27 (49.1%) | 0.052 |
| Females | 17 (30.9%) | 28 (50.9%) | ||
| Type of family | Nuclear | 22 (40%) | 22 (40%) | 1 |
| Joint | 33 (60%) | 33 (60%) | ||
| Education | Uneducated | 2 (3.6%) | 5 (9.1%) | 0.215 |
| Elementary school | 4 (7.3%) | 1 (1.8%) | ||
| High school | 17 (30.9%) | 25 (45.5%) | ||
| Graduation | 24 (43.6%) | 19 (34.5%) | ||
| Postgraduation | 7 (12.7%) | 3 (5.5%) | ||
| Higher qualification | 1 (1.8%) | 2 (3.6%) | ||
| Occupation | Unemployed | 13 (23.6%) | 6 (10.9%) | 0.344 |
| Housewife | 12 (21.8%) | 17 (30.9%) | ||
| Self employed | 9 (16.4%) | 8 (14.5%) | ||
| Govt. job | 6 (10.9%) | 5 (9.1%) | ||
| Student | 2 (3.6%) | 0 | ||
| Agriculture | 6 (10.9%) | 10 (18.2%) | ||
| Others | 7 (12.7%) | 9 (16.4%) | ||
| SES | Upper | 4 (7.3%) | 3 (5.5%) | 1 |
| Upper middle | 4 (7.3%) | 4 (7.3%) | ||
| Lower middle | 28 (50.9%) | 29 (52.7%) | ||
| Upper lower | 19 (34.5%) | 19 (34.5%) | ||
| Dietary Pattern | Vegetarian | 12 (21.8%) | 13 (23.6%) | 1 |
| Nonvegetarian | 43 (78.2%) | 42 (76.4%) | ||
| Duration of illness | <6 months | 12 (21.8%) | 14 (25.5%) | 0.873 |
| 6-12 months | 18 (32.7%) | 16 (29.1%) | ||
| 1-2 years | 15 (27.3%) | 14 (25.5%) | ||
| >2 years | 10 (18.2%) | 11 (20.0%) | ||
| Severity | Mild | 18 (32.7%) | 20 (36.4%) | 0.912 |
| Moderate | 25 (45.5%) | 23 (41.8%) | ||
| Severe | 12 (21.8%) | 12 (21.8%) | ||
| Treatment | SSRI only | 15 (27.3%) | 17 (30.9%) | 0.891 |
| SSRI + CBT | 28 (50.9%) | 26 (47.3%) | ||
| SSRI + Benzodiazepines | 12 (21.8%) | 12 (21.8%) | ||
| Comorbidity | None | 31 (56.4%) | 33 (60.0%) | 0.844 |
| Depression | 15 (27.3%) | 14 (25.5%) | ||
| Social Anxiety | 6 (10.9%) | 5 (9.1%) | ||
| Other | 3 (5.5%) | 3 (5.5%) | ||
| Tobacco use | 5 (9.1%) | 5 (9.1%) | 1 | |
| Alcohol use | 0 | 1 (1.8%) | 0.315 | |
Table 2 shows the HRV parameters like SDRR (Ms), RMSSD (Ms), pNN 50 (%), and total power (Ms2) decreased significantly in both groups (P < 0.05).
Table 2.
Heart rate variability among study groups
| Heart rate Variability | Group A (Rajyoga) |
Group B (Control) |
||||
|---|---|---|---|---|---|---|
| Pre | Post | P | Pre | Post | P | |
| SDRR (Ms) | 39±20.3 | 29.9±12.8 | 0.025 | 31.08±14.65 | 27.9±12.9 | 0.004 |
| RMSSD (Ms) | 31.6±20.3 | 27.75±17.1 | 0.001 | 27.4±19.4 | 24.4±18.5 | <0.001 |
| pNN 50 (%) | 13±18.1 | 11±16.6 | 0.001 | 11.6±18.6 | 10.1±17 | <0.001 |
| Total power (Ms2) | 1871.8±2011.6 | 1251.1±1620.6 | 0.002 | 1148.5±1116.8 | 1028.3±1270.9 | 0.036 |
| HF power (nu) | 51.4±19.7 | 52.8±17.7 | 0.231 | 54.7±18.9 | 53.6±16.5 | 0.1 |
| LF power (nu) | 46.6±20.5 | 45.3±18.7 | 0.153 | 42.4±18.7 | 45±16.6 | 0.066 |
| Mean LF/HF | 1.22±1.4 | 1.19±1.7 | 0.868 | 1.04±1.04 | 1.19±0.89 | 0.866 |
Table 3 compares how much the HRV parameters changed between the Rajyoga meditation and control groups after treatment. Most parameters showed improvements in both groups, but the differences were not statistically significant except for HF power (P = 0.048), which showed a larger increase in the control group. The Rajyoga group showed better improvements in pNN50 and total power, while the control group showed larger changes in RMSSD and LF power. The similar changes in many parameters suggest that both standard treatment and Rajyoga meditation were beneficial for autonomic function in panic disorder patients.
Table 3.
Comparison of change scores among study groups
| Heart rate Variability | Group A (Rajyoga) | Group B (Control) | P |
|---|---|---|---|
| SDRR (Ms) | 16.85±20.7 | 17±19.3 | 0.970 |
| RMSSD (Ms) | 10.6±18.7 | 15.04±20.2 | 0.233 |
| pNN 50 (%) | 19.84±12.8 | 6.69±17.2 | 0.434 |
| Total power (Ms2) | 777±1622.2 | 638.4±1268.6 | 0.619 |
| HF power (nu) | 15±31.2 | 27.2±33 | 0.048 |
| LF power (nu) | 18.76±32.9 | 24.9±34.9 | 0.346 |
| Mean LF/HF | 0.56±1.98 | 0.76±1.8 | 0.581 |
DISCUSSION
After 8 weeks of Rajyoga meditation practice, the study participants’ cardiac autonomic function improved as seen by changes in both the frequency and time domains of their HRV measurements. The HRV is the time difference between successive heartbeats as recorded on a typical ECG. It conveys how the parasympathetic and sympathetic nervous systems are balanced.[8] Stress causes the HRV spectrum’s HF component to drop and its LF component and LF/HF ratio to rise, both of which are indicators of increased sympathetic nervous system activity. The primary factor contributing to the development of cardiovascular disease is this increase in sympathetic activity.[9,10]
The goal of the current study was to assess how yoga exercise can improve cardiac autonomic function. Our research showed that while the low-frequency (LF) power spectrum and the LF/HF ratio were reduced and the high-frequency (HF) power spectrum was boosted, time-domain parameters like SDNN, RMSSD, and PNN50 were dramatically increased. Changes in the temporal and frequency domain parameters show sympathetic withdrawal in conjunction with parasympathetic predominance, whereas a decrease in the LF and an increase in the HF value indicate parasympathetic dominance. These modifications are explained by the benefits of Rajyoga meditation for the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal (HPA) axis, which enhance both mental and physical health.
Similar results of increased SDNN, RMSSD, PNN50, and HF and decreased LF and LF/HF ratio were also noted by Vinay et al.[11] in their study following a brief yoga practice on 32 male healthy volunteers. They proposed that variations in HRV values resulted from a switch in autonomic balance between the parasympathetic and sympathetic nervous systems. These findings align with previous research on drug treatments for panic disorder.[7]
Following aerobic training, Selvamurthy W et al.[12] and Tulppo et al.[13] reported an increase in the HRV characteristics as determined by the variance of the NN interval. They came to the conclusion that elevated high-frequency power is indicative of elevated parasympathetic activity, which has previously been shown by other researchers following yoga activities.
Hautala AJ et al.[14] and Billman GE et al.[15] have also found similar findings of lower LF/HF ratio, which alters the sympathovagal balance in favor of parasympathetic components following exercise.
Rajyoga meditation improves an individual’s overall health status and fosters positive health. Given the positive effects of yoga on our study, it makes sense to assume that practicing yoga regularly over an extended period of time will lower the prevalence of noncommunicable diseases and improve quality of life.
Limitations
This randomized controlled trial investigating the effects of Rajyoga meditation on HRV in panic disorder patients demonstrated promising results. After 8 weeks of intervention, both the Rajyoga meditation group and control group showed improvements in HRV parameters, indicating enhanced autonomic nervous system regulation. While most changes were not statistically significant between groups, the Rajyoga group showed notable improvements in several parameters including pNN50 and total power, suggesting increased parasympathetic activity. The findings indicate that Rajyoga meditation could serve as a beneficial complementary intervention alongside standard treatment for panic disorder. However, the study’s limitations, including its single-center design and short intervention period, suggest the need for larger, long-term studies across diverse populations to fully establish the therapeutic potential of Rajyoga meditation in panic disorder management.
CONCLUSION
Based on the study findings, Rajyoga meditation demonstrates potential benefits for patients with panic disorder by modulating cardiac autonomic function. The 8-week intervention showed statistically significant improvements in HRV parameters, particularly in time-domain measurements, suggesting a shift toward parasympathetic nervous system dominance. The results indicate that Rajyoga meditation may be a promising complementary approach to standard treatment for panic disorder, potentially helping to improve autonomic nervous system regulation. However, further research with longer follow-up periods, more diverse populations, and more comprehensive control groups is needed to fully establish the therapeutic potential of this meditation technique for panic disorder patients.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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