significantly mediate the relationship between trauma exposure and PTSD. These findings .. a useful definition as it lends itself to assessment and generalization. Non- . importance of examining mindfulness as it relates to trauma. Particular. Posttraumatic stress disorder is associated with a myriad of symptoms, including of and relationships with thoughts, promoting a “decentred” perspective (i.e., .. Evaluation of the evidence for mindfulness-based treatments of PTSD. examining specific avoidance strategies that have an established research base within . ness and PTSD; thus, the relationship between mindfulness and. PTSD symptoms ity and experiential avoidance rated on 7-point Likert scale from 1.
Mindfulness-based stress reduction MBSR is a promising non-pharmacologic approach to the treatment of anxiety and pain disorders. MBSR-treated patients had increased anterior cingulate and inferior parietal lobule and decreased insula and precuneus function in response to traumatic reminders compared to the PCGT group.
Furthermore, MBSR treatment is associated with changes in brain regions that have been implicated in PTSD and are involved in extinction of fear responses to traumatic memories as well as regulation of the stress response.
Introduction Post-traumatic stress disorder PTSD is an important clinical problem in populations exposed to traumatic experiences such as war, sexual assault, and natural disasters.
Increasing awareness and an increase in research in the field have furthered our understanding of this disorder, which is reflected in the revisions of the diagnostic criteria for PTSD and its reclassification from a form of anxiety disorder to its current place in trauma- and stressor-related disorders in the DSM-V criteria 2.
Thirteen percent of soldiers deployed to Iraq were reported to have PTSD, and many of these soldiers did not seek mental health care 3 — 7. For those who do seek treatment, the available treatments are not always effective.
Pharmacological treatment results in improvement in only a portion of PTSD patients and in others there is only a partial response to treatment 8. Psychological treatments involve either trauma-based and non-trauma-based interventions 9. These limitations have led to the search for alternative treatments for PTSD, such as mindfulness-based stress reduction MBSR and other mindfulness-based training approaches 14 — Mindfulness may be defined as intentionally paying attention to present-moment experience physical sensations, affective states, thoughts, and imagery in a non-judgmental way and thereby cultivating a stable and non-reactive awareness 17 Mindfulness is one of eight qualities cultivated in Buddhism to reduce psychic angst.
In that system, relief comes through recognition of distress being created moment by moment through conditioned mental processes and behavior. A thought gives rise to a feeling, that gives rise to a sensation, which reminds again of the thought, and on it goes.
International Society for Traumatic Stress Studies
Mindfulness training exercises are designed to cultivate recognition of these processes in real time. Attention is used to notice whichever thoughts, sensations, and feelings are appearing in awareness, while at the same time retaining the capacity to maintain the focus on these contents, or to redirect attention elsewhere. By providing a sense of control in stressful situations and encounters, this less-reactive response reduces the likelihood of being overwhelmed by thoughts and feelings and leaves mental space for more creative and less habitual responses.
Mindfulness training found its way into Western clinical settings largely through the work of Kabat-Zinn, who developed the manualized MBSR program The program classes also provide education in applying those recognitions to habitual and reactive patterns in everyday situations as they are occurring 19 — The program has been found to promote attention processes 23 and feelings of well-being, as well as reducing stress and worry 24 — In the context of the present study, mindfulness training appears to target reactivity and experiential avoidance, key factors in the development and maintenance of PTSD Because it is not based on processing the content of traumatic experience, it potentially circumvents problems related to treatment compliance related to symptoms of avoidance.
Mindfulness-based stress reduction has been shown to be effective for a variety of conditions, including chronic pain 14153031hot flashes 32asthma 33depression 1618202134 — 38 fibromyalgia 39psoriasis 40and anxiety 1415173041 — MBSR is also helpful as an adjunctive intervention in patients with complex medical conditions, including promoting cancer recovery 1635reducing psychological distress and depression, and promoting well-being and health-related quality of life QOLand sense of well-being 17182136 — 38404145 — 47 with positive effects persisting well beyond the initial treatment period 1547 This less reactive mode of coping with difficulties may provide a way for PTSD patients to experience a greater sense of control in relation to their trauma-related thought and memories and to be less emotionally reactive to their presence 21 This process may also prevent the rehearsing and replay of traumatic memories, which may modify the way they are stored and make them indelible, or resistant to further modification.
A number of studies demonstrated the utility of MBSR for the promotion of well-being and mental health 14 — 17213034 — 36404145 — 4853 — Studies have assessed the effect of mindfulness-based programs on symptoms of PTSD 4357 — Increases in mindfulness with MBSR, especially mindful awareness and non-reactivity, were associated with a decrease in PTSD symptoms when data from this study were combined with other data from the same group in a re-analysis Previous studies have outlined a network of brain regions involved in symptoms of PTSD 63 — 65 that show functional responses to successful treatment Brain imaging studies have identified a network of brain regions involved in the symptoms of PTSD that includes the amygdala, prefrontal cortex, hippocampus, parietal cortex, and insula 63brain regions that play an important role in both memory, fear learning, and the physiological response to threat The amygdala signals other parts of the brain to initiate the fight or flight response and in conjunction with hippocampus to convert this experience into a long-term memory.
The suppression of the amygdala during extinction of fearful memories is mediated by the prefrontal cortex. The parietal cortex is involved in evaluating the self and other in space and time, which is an important facet of the stress response 68and the insula serves as a gateway to peripheral responses to stress as well as regulating sense of time 69 Other brain areas implicated in PTSD include the parietal cortex 79 — 83precuneus 8184and insula 84 — These brain areas are involved memory, spatial attention, and coordination of peripheral physiological responses to stress.
A hypoactive frontal lobe leads to impairment in the differentiation of benign stresses from true stresses, consequently leading to reduction in the suppression of the amygdala manifesting as a hypervigilant state that is seen in PTSD Fear learning paradigms have shown an increase in amygdala function in PTSD, and studies have shown both smaller hippocampal volume 91 — 93 and decreased function with memory tasks in PTSD patients.
Smaller hippocampal volume and decreased medial prefrontal cortical function has been shown to reverse with both pharmacotherapy 94 — 99 and psychotherapies including eye movement desensitization reprocessingand cognitive-behavioral therapy CBT — Psychotherapy for PTSD also led to changes in parietal cortex function Imaging studies suggest that MBSR may affect brain areas and physiological systems involved in the fear response in a beneficial way 31— A recent study showed an increased connectivity between default mode network brain regions and frontal brain regions involved in executive control in PTSD patients treated with a novel therapy called mindfulness-based exposure therapy Studies have used functional brain imaging to study neural correlates of MBSR.
MBSR has also been associated with changes in brain function and structure in normal individuals In social anxiety disorder patients, MBSR increased recruitment of posterior parietal and occipital cortical attention-related brain regions This is significant since studies in animals show that early intervention before memories become indelible may have a positive effect on the long-term course of PTSD Understanding neural correlates of successful treatment response could improve understanding of the mechanisms by which successful treatments effects symptom improvement in the brain.
This could be useful in guiding the development of new treatments. Brain imaging of neural correlates of response also provides an objective, quantifiable measure of treatment response that may be related to changes in the core pathophysiology. PCGT involves weekly group sessions with a therapist that emphasize problem solving, being in the here and now, and health education.
It was selected to control for the non-specific effects of attending weekly group sessions with other veterans with PTSD and participating in a treatment program.
Subjects were assessed before and after treatment with brain imaging during exposure to neutral and combat-trauma-related slides and sounds. Brain imaging was performed with high-resolution positron-emission tomography HR-PET which is minimally invasive requires insertion of an intravenous catheter but offers superior anatomical resolution, a closer approximation to actual brain blood flow, and improved ease of presentation of visual and auditory materials compared to other imaging techniques such as fMRI.
We hypothesized that MBSR but not PCGT would result in increased medial prefrontal and parietal cortex function and decreased insula and precuneus function with exposure to trauma-related stimuli. All veterans had returned from deployment in the past year, had not been treated with psychotropic medications in the previous 4 weeks, and had the diagnosis of combat-related PTSD. All participants were recruited through fliers and public bulletins distributed within the community and the Mental Health Assessment Team at the Atlanta VA Medical Center.
This study was approved by the Investigational Review Board of Emory University, and all enrolled subjects provided written informed consent. All participants spoke fluent English and had at least an eighth grade reading ability.
Participants were considered ineligible if they had experienced significant head trauma or loss of consciousness for at least 2 min, or if they reported significant medical histories, current alcohol or substance abuse, or psychotic illness as identified by DSM-IV criteria in the Structured Clinical Interview for DSM-IV SCIDor the diagnosis of PTSD preceding military service Before attending the first class, three MBSR subjects dropped out because of lack of interest, and five because of lack of transportation and work-related issues.
There were no differences in age, race, or years of education between the two groups Table 1. The 8-week, 9-session MBSR intervention provides systematic and intensive training in mindfulness through formal meditation and mindful hatha yoga exercises, as well as application of their principles to everyday life and the range of challenges arising from real-life stressors and chronic diseases.
In this way, participants were supported in becoming more aware of their internal resources and in acquiring skills that could be flexibly applied to cope more effectively with stress and PTSD symptoms. Formal mindfulness training was through: Subjects were assessed to determine the degree to which they followed homework assignments.
In-class didactic material emphasized the systematic development of mindfulness awareness and its application in everyday life. Additional discussion focused on the psychology and physiology of stress reactivity and suggestions for the application of mindfulness as a method for responding positively to stress. Mindfulness-based stress reduction instructors were trained by the Center for Mindfulness at the University of Massachusetts. All instructors and therapists did not participate in the research assessments.
Recordings were made of sessions which were reviewed by the supervisor to ensure adherence to treatment integrity. In this study, PCGT was used as a control for the non-specific effects of a group-based intervention. PCGT was initially developed for use as a control group in a VA multisite study that tested the effects of trauma-focused group therapy in veterans with combat-related PTSD no difference between the two groups was found for the treatment of PTSD The primary elements of PCGT include expectations of symptom reduction, normalization of PTSD symptoms though education, decreasing isolation, the opportunity to both give and receive support, and have positive experiences with others who also suffer from similar symptoms.
PCGT also offers an atmosphere of safety and support where subjects can have an increased awareness of how PT SD affects their daily lives and those of other group members, and can gain more perspective and objectivity about the effects of PTSD on their lives. The initial phase of PCGT treatment was psycho-educational. After this phase, the primary content of PCGT was discussion of everyday problems of group members and coming to a better understanding of how PTSD creates or intensifies these problems.
At the end of the program, there was a barbecue to balance the mindful retreat of the active group. The CAPS includes indices measuring reexperiencing, avoidance and numbing, and hyperarousal symptoms. The CAPS has a coefficient alpha of 0. This instrument was derived from a factor analysis of questionnaires measuring a trait-like general tendency to be mindful in daily life. What is the greatest lesson life has taught you recently? That the things you love the most are also the things that are the sources of the most extraordinary pain possible.
And there is no greater joy or pain life can deliver than that you get from your children. Sweet and sad, poured from the same vessel in equal measure.
What motivates you to inspire self-care in others? I lost my eldest brother Randy in to suicide. Since then, I lost my brother David in to a cerebral haemorrhage, and my baby brother Michael into a heart attack. In I was given a head and neck cancer diagnosis. How would you describe ACT in a nutshell? They are in touch with their personal values so that they are geared toward living life to its fullest. What are your most inspired actions?
I think the time I truly felt the most inspired simply in terms of output was writing my most recent book, Inside This Moment. I was in a zone for the entire time that I was writing it, it was coming from the heart. It was actually quite an amazing experience. The book zeroes in on how to use the present moment in therapy to inspire people to live their lives to the fullest, and not to run from their own demons, but rather cradle them.
So that was enjoyable. Not the term, not the popular concept, but understanding exactly what goes into it. How are we going to populate these concepts into public health models and work with lay people, primary care providers and teachers, for example? I think the other area that is going to become bigger and more important is values-based behaviour change. There are measurement issues that are going to have to be dealt with, as well as creating more efficient ways of talking to people about motivating factors in their lives.
These two things go hand in hand in mindfulness — this ability to pay attention in a particular way and then to act with intention inside of your own space.
There are hidden properties of treatments, and then there are the observable properties of treatments. In ACT the observable properties are quite different, with an emphasis on values. ACT uses values as a foundation for addressing that. I am also uncomfortable with the message that effective therapy can be delivered in 15 minutes.
I am sure it sells well in behavioral health settings or in neoliberal societies where the goal is to underfund mental health services, but claim to offer them broadly.
But strong claims with such potentially socially pernicious implications need very strong evidence. I have searched and can find none. Could you give a picture of what you might focus on in a session, say for diabetes or depression? The goal of focused ACT is to get patients to make direct contact with the unworkable results of their current life strategies.
Usually, these strategies involve avoiding dealing with important life issues — such as maintaining social health, managing diet or other health risk behaviours in the case of diabetes. The counter-weight in focused ACT is to get the patient to make direct contact with what matters to them in their life, and whether their avoidance behaviours are helping them move in that direction.
Change comes from within, not from without. So focused ACT is a very humanising approach in which we readily agree that making important changes in life might likely trigger painful emotional consequences or distressing memories of past failures, et cetera. Pain is inevitable, but suffering is optional.
mindfulness | Quick Thoughts
There is no difference really between us. How do your ideas connect with your values? I get more excited in my personal work about supporting the work of others. So my value is being of use and building a community that can profoundly be of use — trying to bring science into alignment with what society needs and wants from us. Surely, you jest, Steve. Garrett is a kind of a meditation or mindfulness person, a wise adult.
It talks about seeing and feeling, and watching the thought. We can do something a lot wiser than that. When I teach brand new students, say, research methods, the very first thing I get across is this: