Complementary Therapies in Medicine 42 (2019) 145–148

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Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

Effectiveness of yoga in eating disorders – A case report T

a,⁎ a b c
Thomas Ostermann , Hannah Vogel , Christina Starke , Holger Cramer
a
Department of Psychology and Psychotherapy, Witten/Herdecke University, Alfred-Herrhausen-Str. 50, 58448 Witten, Germany
b
Parkland-Hospital for Psychosomatics and Psychotherapy, Im Kreuzfeld 6, 34537 Bad Wildungen-Reinhardshausen, Germany
c
Department of Internal and Integrative Medicine, Faculty of Medicine, University of Duisburg-Essen, 45276 Essen, Germany

A R T I C LE I N FO A B S T R A C T

Keywords: Eating disorders are among the most common psychosomatic diseases and are often associated with negative
Yoga health consequences. The use of yoga as a treatment method in eating disorders is controversial discussed. The
Eating disorders interviewee was a 38 year old female patient suffering on anorexia nervosa and various psychosomatic-psy-
Case report chiatric diagnoses in her medical history. The patient reported that yoga recovered the soul contact which she
lost and she had learned to perceive and feel herself again. She stated that yoga helped her to find access to her
body and its needs and to cope with her traumatic experiences. She also reported that attitudes have changed in
relation to her stomach in the treatment of her anorexia. The case report confirmed the positive effect of yoga on
eating disorders. Research should pay particular attention to taking into account the influence of individual’s co-
morbidities, as eating disorders usually occur in association with co-morbidities.

1. Background using food substitutes) or extreme weight control behaviors (i.e. med-
ication use or purging to lose weight) among yoga practitioners.8,9
Eating disorders are among the most common psychosomatic dis- Epidemiological studies in contrast have shown that regular yoga use is
eases in Western developed countries.1 Due to its high prevalence, as associated with a decreased risk of developing eating disorders 10,11 and
well as several serious health consequences, they represent a serious that yoga users are more satisfied with their body weight and shape
social problem. Diverse research efforts aim to address this issue with than non-yoga users.12
regard to the investigation of effective low-threshold forms of therapy Preliminary clinical trials have demonstrated a positive influence of
for the treatment of eating disorders. yoga interventions on symptoms of eating disorders, including reduced
Yoga has gaining increased acceptance and wide acclaim by the symptoms of eating disorders and increased body satisfaction.13–19 An
company as a possible treatment approach, and meets the requirements early systematic review reported decreased risk for eating disorders and
of a low-threshold treatment due to its low costs, accessibility and po- related symptoms after yoga interventions.10 This was corroborated by
pularity.2 Yoga derives from traditional Indian spiritual, self-care, and a recent meta-analysis that demonstrated reduced drive for thinness as
medical practice,3,4 and has now become a popular practice to promote well as body dissatisfaction in patients with eating disorders after yoga
physical and mental well-being worldwide.3–5 While modern yoga interventions.20
mainly comprises physical postures (asanas), breathing techniques The present work investigates the subjective experiences of yoga use
(pranayama), and meditation (dyana),3 traditional yoga also includes in eating disorders from a personal perspective.
advice to achieve an ethical and healthy lifestyle such as consciously Due to the scarcity of the study landscape of qualitative research to
making healthy and ethical food choices.3,4,6 However, experts in the the examining of individual cases with regard to the topic of eating
field of eating disorders have therefore expressed concerns about yoga disorders a patient with long-standing eating disorder, namely of an-
use amongst eating disorders patients to suppress hunger suggesting orexia nervosa, and experience with a yoga-based therapy was inter-
this may result in their illness going undetected by health professionals; viewed.
leaving doubts on whether yoga has a positive or detrimental effect in Anorexia nervosa, known popularly as 'Anorexia', is characterized
those with eating disorders.7 Accordingly, pilot studies suggest a con- by the refusal, to maintain a size- and age-adequate body weight or the
siderable high prevalence of orthorexia nervosa (i.e., fixation on fear of weight gain, a significant body perception disturbance and the
righteous eating), and trends for using unhealthy (i.e. skipping meals or absence of menstruation for more than three cycles. The weight loss is

⁎
Corresponding author.
E-mail address: [email protected] (T. Ostermann).

https://doi.org/10.1016/j.ctim.2018.11.014
Received 8 August 2018; Accepted 9 November 2018
Available online 13 November 2018
0965-2299/ © 2018 Elsevier Ltd. All rights reserved.
T. Ostermann et al. Complementary Therapies in Medicine 42 (2019) 145–148

achieved through disordered eating behavior, such as restricting the traumatic experiences, so the patient described, had been possible only
amount of food or a selective food choices and increased physical ac- through the practice of yoga in the treatment. Thus, in the course of
tivity and purging behavior. treatment, if consent with the patient was given, lying meditation po-
sitions instead of sitting meditation was practiced, with no occurrence
2. Material and methods of flashbacks.
With regard to the symptoms of anorexia, the patient reported to eat
The interview with the patient took place in June 2015 in a spe- little to nothing and to exercise excessively during phases. She had run
cialist clinic for Psychosomatic Medicine and psychotherapy. In ad- up to 60 km daily. In addition, she has taken thyroid hormones as well
vance an interview guide had been designed and developed, based on as diuretics to reduce her weight. Through this behavior she wanted to
the 'CARE Guidelines’ by Gagnier et al.,21 after consultation with the stifle and avoid all feelings evoked by the trauma in order to stop
treating physician. The consensus-based CARE guidelines provide feeling her body.
structuring and organization tools for the systematic documentation of She reported that she perceived weighing little as a protection
a case report regarding the collection and structuring of relevant in- against her traumatic memories. She referred to the eating disorder as
formation. her survival strategy to deal with the traumatic experiences and to live
The focus of interest of the interview was to gain an insight into the on. In addition, the patient reported to suffer from disordered body-
subjective perception and experience of yoga as a treatment for eating schema. Being confronted with her appearance, for example during
disorders. The questions addressed to the patient included the topics of mirror therapy at her hospital stays was perceived as a serious chal-
the drive for thinness and a dissatisfaction with the own body. After lenge.
obtaining informed consent, files, as well as medical documentation of In the course of the integration of a yoga-based treatment into the
the various hospital stays of the patient were investigated after the therapy concept, the patient has noted some personal developments.
interview and taken into consideration during the evaluation of the She reported that yoga helped her "to come down again". Through the
consideration. The bottom line of the interview is presented below. practice of yoga, she had recovered the soul contact which she lost both
at a physical and at a mental level and she had learned to perceive and
3. Case feel herself again. Previously she "did everything to not perceive her
body" by her dysfunctional movement and eating behavior. The patient
The interviewee was a 38 year old female patient with various asserted that she could not “run away from herself” during the Yoga
psychosomatic-psychiatric diagnoses in the medical history, among units, but had to work with herself and her feelings. As a result she felt
others: Anorexia nervosa since the eighth year of life, post-traumatic an inner peace, as well as a decrease of the motion urge, without per-
stress disorder due to repeated sexual abuse in childhood and youth, ceiving the need to counteract this. Participating in the Yoga Group had
abuse of diuretics and thyroid hormone, and hypokalemia. given her a sense of security and certainty, as if nothing could happen
The patient reported repeated and diverse stays in acute hospitals to her even if she would let this calmness happen. Through this, as well
and rehabilitation facilities focusing on eating disorders in adolescents as through the yoga-mediated access to her own body, for the first time
and adults, obesity in adults, psychotraumatology and acute-psycho- she realized her traumatic memories, which she had experienced since
somatic treatment. The first hospital stay of the patient had been in her early childhood. Through the practice of yoga, she had become able
2003, the patient reported that this was followed by several more to uncover her traumas and to work with them. The patient reported
hospitalizations. In 2016 a yoga-based therapy as additional treatment that there still were days when she felt forced to counteract the emer-
had been implemented at the treating hospital, in which the patient ging memories by running for miles, despite of years of treatment.
regularly took part during the following stays. However, also in those moments, yoga represented a resource to listen
Yoga treatment based on the style of the Hatha-yoga took place once to herself and to feel and perceive her body. The patient reported
a week in a group of 8 women. Considering her medical history the having gained body awareness and later a degree of acceptance of the
therapy was patient specific consisting of Yoga postures (Asanas) body through yoga. She was able to perceive herself and her own body,
combined with breathing techniques (Pranayama). One session ex- without the urge to having to counteract this sensing and perceiving.
emplary included This was also reflected in the gain of body weight during her hospital
stay. Starting with a weight of 43.4 kg which at a given height of 1.66 m
1 Sitting meditation (Dhyana): 5–10 minutes: relaxed breath aware- was equivalent to a Body Mass Index (BMI) of 15.75 her weigh in-
ness with focused concentration (Dharana) on the present moment creased over the course of time and finally went up to 46.4 kg (BMI:
and non-judging acceptance especially of the body perception 16.91). At the time of the interview half a year later she had a weight of
(Santosha) and sense withdrawal (Pratyahara) 55.6 yielding to a normal BMI of 20.2. The detailed time series of
2 Cross-legged seated position, breath coordinated with arm move- weight increment together with expected set points is shown in Fig. 1.
ments, sidebend In addition it had been possible for the patient to allow feelings and
3 Cat and cow pose (Marjaryasana – Bitilasana), coordinated with to perceive herself through yoga. Although the initial perceptions often
breath rhythm were trauma-related emotions, the patient described the mere ability of
4 Sidestep perceiving as positive, because she otherwise was unable to feel herself
5 Standing forward bend (Uttanasana), movement to mountain pose at all. Through yoga she became able to pay attention to her body and
(Tadasana) its signals and limits. She could better respond to her physical needs,
6 Mountain pose (Tadasana) such as hunger, and satisfy them. Also with regard to her disordered
7 Banana pose (Bananasana) body-schema the patient reported positive effects yoga. She now was
8 Tree pose (Vrksasana) able to face situations such as a confrontation with her appearance
9 Sitting meditation (Dhyana): 15–20 minutes (see above) rather than completely avoiding them as before. The patient described
the effect of yoga as: “You have a different approach to yourself, and
Both, the patient and her group were guided closely by an experi- you can track and perceive yourself on another level, without this being
enced yoga therapist working on various aspects of her psycho-social- negative as it was before.”
physical constraints. Initially, the primary therapeutic goal of the pa- With regard to the symptoms of her eating disorder, the patient
tient was the treatment of anorexia. However, in the further course of reported that attitudes have changed in relation to her stomach in the
therapy coping with traumatic memories from childhood and early treatment of her anorexia. She could now respect this part of her body.
youth had come to the fore. The memory of and the work with the Body regions like pelvic, hip and leg however still were areas that she

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T. Ostermann et al. Complementary Therapies in Medicine 42 (2019) 145–148

Fig. 1. Detailed time series of weight increment (blue line) together with expected set points (red bars). Measurements were recorded with an interval of two days.
(For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

clearly rejects. She could not confirm a change of their attitude through but she does not speak of satisfaction in the context. She still rejects
yoga towards the mentioned areas of her body because these areas were parts of the body such as the pelvic, buttocks or legs, because they are
linked too close to her traumatic memories. In terms of the drive for linked too closely to the experienced trauma.
thinness, the patient reported that she previously did not explicitly The report of the patient thus highlights limitations of research on
think about food or diet plans, rather she was not thinking about food assessing the efficacy of yoga in eating disorders. Eating disorders
or eating at all. The awareness of vital bodily needs had only emerged usually not occur isolated but frequently in association with one or
in her in the course of her yoga practice. more co-morbidities. According to the current study literature, frequent
During her inpatient treatment she learned various forms of physical co-morbidities of eating disorders are anxiety disorders,22 substance
therapy, such as Pilates, progressive muscle relaxation or autogenic abuse,23 mood disorders,24 attention - deficit hyperactivity disorders,25
training, in addition to the Yoga therapy. In comparison to yoga none of personality disorders26 and post-traumatic stress disorder.27 It is often
mentioned forms of therapy showed a similar positive effect on body difficult to determine which of the diseases is the main disorder and
awareness, inner peace and relaxation with her. As an example, the which is the concomitant one. With regard to the clinical picture of
patient explained that Pilates affected her pelvic floor, an area of the post-traumatic stress disorder, which was diagnosed with the present
body she did not want to feel at all due to the trauma. Therefore she patient, Mitchel et al. 27 showed that the experience of trauma, in
could not profitably use this method for herself. On the other hand, the particular sexual trauma has a direct influence on the body image of the
patient experienced yoga as positive, because there always was at least person and can strongly foster the development of an eating disorder.
one aspect in the practice on which she could focus. Also within the Their study demonstrated that between 21% and 36.9% of the in-
framework of yoga treatment there sometimes were exercises with dividuals with an eating disorder additionally meet the criteria of a
which she was unable to cope due to the trauma. However, in these post-traumatic stress disorder. According to Swanson et al. 28 the life-
situations she still could focus on the breathing techniques, helping her time-prevalence developing at least one further concomitant disease in
to perceive and become calm. She appreciates in Yoga that there always individuals with anorexia nervosa, Bing-eating disorder, and Bulimina
are elements that could help her “to pull out again” from difficult nervosa was 55.2%, 88.0% and 83.5%, respectively. These concomitant
moments. It was important for the patient to practice yoga in a pro- diseases can also influence the effectiveness of therapeutic measures
tected and small group of women. The meditative form of yoga applied and confound the resulting effects. If an eating disorder develops in
in the clinic was very profitable for her. She also tried more exercise- order to cope with a severe trauma, such as in the presented case, it
based forms of yoga, however these forms triggered the well-known becomes more difficult to make conclusions about the effectiveness of
urge to move and admitted any relaxation. Since then she practiced therapeutic intervention for the treatment of eating disorders. Occur-
yoga at home for herself. ring effects as well as lack of effects can thus be referred to the effec-
tiveness of the treatment as well as to co-existing co-morbidities, their
4. Discussion symptoms and effects.
In this respect the presented case report can confirm the positive
In conclusion, the patient reported that yoga initially helped her to effect of yoga. Prior clinical trials have shown that yoga can reduce
find an access to her body and its needs regardless of her anorexia. It drive for thinness, body dissatisfaction and symptoms of eating dis-
helped her to remember her traumatic experiences and to cope with orders and increase body satisfaction.10,13–20 This is in line with trials
them and contrary to the memories to come back again and again in the on other mind-body medical intervention such as mindfulness that also
‘here and now’ and not to give up in dealing with their fate. can positively influence eating disorders.29–32 At the same time more
Thus, the consideration of the case confirms a predominantly posi- effects of yoga on the symptoms of eating disorders are revealed, in-
tive picture of yoga and its effectiveness on the symptoms of an eating cluding reduced of the excessive movement urge or the development of
disorder. The patient confirmed to have access to her body and to gain the ability to perceive and allow emotions. It is clear that the isolated
body awareness and ultimately body acceptance, because of practicing investigation and treatment of eating disorders can fail to take the
yoga. According to reports of the patient, yoga can make a contribution patient’s reality into account, because other diseases with their own
to the remission of eating disorder-related symptoms. Nevertheless, the symptoms and dynamics can co-exist, which should not be disregard in
patient reported discrepant results with regard to her body satisfaction. the framework of the evaluation of a therapeutic intervention. Based on
She could better accept selected areas of the body like her belly now, the preceding consideration, it is relevant for research purposes to

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