Change in Cortisol Awakening Response in a Randomized Controlled Trial of Yoga

and Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Paul Busser, MD1, Violaine Guerin, MD2, XXXX, Eric Bui, MD, PhD1,3,4,

1
Centre Hospitalier Universitaire Caen Normandie, Caen, France
2
XXXXX
3
Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of

Neurological Disorders", NEUROPRESAGE Team, (Institut Blood and Brain @ Caen-

Normandie), Cyceron, Caen, France

4
Massachusetts General Hospital, Boston, MA

Word count: XXX

Corresponding Author:

Eric Bui, MD, PhD

Professor of Psychiatry

University of Caen Normandy & Caen University Hospital

14000 Caen, FRANCE

bui-th@chu-caen.fr
Dear Editor,

In a recent publication of the European Journal of Psychotraumatology, Auren et al. (2022)

reported effectiveness data from a two-week intensive program for PTSD, combining

prolonged exposure therapy, EMDR, and physical activity. They found that between half to

two third of patients exhibited a clinically significant PTSD symptom improvement, with large

effect sizes on a range of psychiatric outcomes (d = 1.38–1.52), and quasi non-existent

dropout. Their results, in line with prior data (van Woudenberg et al., 2018), suggest that

delivering physical activity in a group setting might improve the efficacy and/or acceptability

of evidence-based trauma focused therapies. In fact, another recent paper (van Toorenburg

et al., 2020) found that difficulties in regulating emotions did not predict poorer outcome

among patients undergoing an intensive trauma-focused treatment, delivered alongside

group physical activity. The authors concluded that emotion regulation difficulties was not

associated with worse trauma-focused treatment outcomes for PTSD, however, another

explanation is that group physical activity may improve emotion regulation, as suggested by

others (Bahmani et al., 2020). In further support of this, we would like to report the

preliminary results of a fencing program developed for female trauma victims, on emotion

regulation outcomes.

Methods

Six female sexual assault victims (Mean age = XX, SD = XX; mean time since trauma = XX,

SD = XX) completed a fencing program over 10 months. The fencing program included one

monthly X-hour sessions that were instructed by certified Master of Arms, X, X. The program

also included Xput the different components of the programXX (ADD citation of the book).

This retrospective study was approved by the institutional ethical committee of the Caen

University Hospital (put number here). At baseline, month 2, 4, 6, 8, and 10, participants

were assessed for PTSD symptoms using the 20-item PTSD checklist for DSM5 (PCL5;

range: 0–80; Weathers et al. XXXX), Depressive Symptom severity using the 16-item Quick

Inventory of Depressive Symptomatology (QIDS; range: 0–XX; XXXX et al. XXXX)), and
trouble regulating emotions using the XX-item Difficulties in Emotion Regulation Scale

(DERS; range: 0–XX; XXXX et al. XXXX)) that included XX subscales (XX, range 0-xx; XX,

range 0-xx; XX, range 0-xx; XX, range 0-xx; XX, range 0-xx;). Change over time was

modeled using a series of repeated measures analysis of variance.

Results

Results are reported in Table 1. Briefly, we found a statistically significant effect of time for

the DERS total score and two DERS subscales: XX. No other change was significant.

**ADD TABLE 1***

Discussion

Results are the first examination of the potential effects of a fencing program tailored to the

needs of female victims of sexual assaults. Our very preliminary results suggest that fencing

as a group physical activity might improve emotion regulation. We did not find any change in

PTSD no depressive symptom severity, but this is unsurprising as evidence based treatment

for PTSD rely on trauma-focused therapies (citation), and this fencing program did not have

a specific trauma focus. This highlights even more the significant and large improvements in

emotion regulation we report, following the participation to the 10 fencing sessions among

female trauma victims with elevated PTSD symptom severity. Our data are in line with prior

research suggesting that group physical activity may improve emotion regulation (Bahmani et

al., 2020). Because the fencing program included some component of XXX, it is related to

mind-body interventions, and our results are also consistent with data suggesting that mind-

body interventions may improve emotion regulation (**citation***). Recently, many have

proposed to deliver trauma-focused therapy in intensive programs that often include some

form of physical activity including yoga of mind-body interventions (e.g., Harvey et al. XXX;

XXX). Taken together, our results suggest that group fencing sessions might also be used in

conjunction with trauma-focused psychotherapies, to improve their efficacy and/or

acceptability.
Despite interesting results, our pilot study is obviously limited by the small sample size, the

lack of clinician-administered measure of PTSD, and XXXX.

Future research investigating the efficacy of physical activity and mind-body interventions,

including fencing, on emotion regulation, and their potential to enhance the delivery of

evidence-based therapies for PTSD is warranted.

Auren, Trude Julie Brynhildsvoll, et al. "Intensive outpatient treatment for PTSD: an open trial

combining prolonged exposure therapy, EMDR, and physical activity." European Journal of

Psychotraumatology 13.2 (2022): 2128048.

Bahmani, Dena Sadeghi, et al. "Physical activity interventions can improve emotion

regulation and dimensions of empathy in persons with multiple sclerosis: An exploratory

study." Multiple sclerosis and related disorders 37 (2020): 101380.

Van Toorenburg, M. M., et al. "Do emotion regulation difficulties affect outcome of intensive

trauma-focused treatment of patients with severe PTSD?." European Journal of

Psychotraumatology 11.1 (2020): 1724417.

van Woudenberg, C., Voorendonk, E. M., Bongaerts, H., Zoet, H. A., Verhagen, M., Lee, C.

W., van Minnen, A., & De Jongh, A. (2018). Effectiveness of an intensive treatment

programme combining prolonged exposure and eye movement desensitization and

reprocessing for severe post-traumatic stress disorder. European Journal of

Psychotraumatology, 9(1), 1487225–1487225.

https://doi.org/10.1080/20008198.2018.1487225