Mindfulness-Based Therapies for PTSD in veterans

Kyle StephensonClinical PsychologyCalifornia State University Monterey Bay

Overview• Definition of PTSD• Prevalence of PTSD in veterans

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of PTSD▫ Emotional Processing Theory ▫ Factors that maintain PTSD symptoms

• Mindfulness-based therapies▫ Mindfulness Based Stress Reduction (MBSR)▫ Example

• Efficacy▫ Efficacy▫ Treatment moderators▫ Treatment mediators

What is PTSD?• Criterion A – Traumatic event• Criterion B – Re-experiencing symptoms• Criterion C – Avoidance symptoms• Criterion D – Alterations in mood/cognition• Criterion E – Hyperarousal • For PTSD:

▫ All criteria need to be met ▫ At least 6 months▫ Cause significant distress or dysfunction

Overview• Definition of PTSD• Prevalence of PTSD in veterans

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of PTSD▫ Emotional Processing Theory ▫ Factors that maintain PTSD symptoms

• Mindfulness-based therapies▫ Mindfulness Based Stress Reduction (MBSR)▫ Example

• Efficacy ▫ Efficacy▫ Treatment moderators▫ Treatment mediators

Prevalence of PTSD in veterans

•10-15% of Vietnam vets (Gates et al., 2012)

•Up to 30% of returning OIF/OEF vets have significant symptoms (Thomas et al., 2010)

Impact of PTSD

•Quality of life (Schnurr et al., 2007)

•Work function (Amaya-Jackson et al., 1999)

•Relationships (Monson et al., 2012)

•Course of PTSD is fairly chronic if not treated

Risk factors for PTSD

•Being female (Polusny et al., 2014)

•Interpersonal trauma vs. disaster, etc. (Hetzel-Riggin & Roby, 2013)

•Dissociation during trauma (Breh & Seidler, 2007)

Comorbidities

•Physical health conditions ▫including chronic pain, cardiovascular, and

gastrointestinal problems (Pacella et al., 2013)

•Depression (Stander et al., 2014)

•Substance abuse - 4.5X more likely (Kramer et al., 2014)

•80% of those with PTSD also have another mental health dx

Overview• Definition of PTSD• Prevalence of PTSD in veterans

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of PTSD▫ Emotional Processing Theory ▫ Factors that maintain PTSD symptoms

• Overview of mindfulness-based therapies▫ Mindfulness Based Stress Reduction (MBSR)▫ Mindfulness Based Cognitive Therapy (MBCT)▫ Example

• Efficacy of MBSR and MBCT▫ Efficacy▫ Treatment moderators▫ Treatment mediators

Emotional Processing Theory•Foa & Kozak, 1986

▫Fear structures: Schemas regarding threat▫Fear structure is problematic when:

Likelihood or severity of threat is overestimated

Threat perceptions are maintained through avoidance behaviors

Emotional Processing Theory: PTSD

•Trauma Structures▫Very heavily sensory based▫Fragmented and poorly organized▫Often contain unrealistic information

Stimuli dangerous: “Always swerve from a bag on side of road”

Responses are incompetent: “I am weak because I can’t handle this”

▫Trauma structures “brought home” with a service member served a survival purpose during

deployment

Trauma Structure

DarkYell

Helpless Incompetent

Hide

Afraid

I - Me

Uncontrollable

Combat IED

Crowd

Noise

Cry

Driving

Dangerous

Fire

PTSDSymptoms

Trash

A cognitive model of PTSD

Ehlers & Clark, 2000

Factors that maintain PTSD symptoms•Inaccurate fear networks (classical

conditioning)▫Things that are similar to trauma have

been connected to fear response▫Memories have been connected to fear

response•Avoidance (operant conditioning –

negative reinforcement)▫When I get reminded of the trauma, I feel

bad. When I avoid that reminder, I immediately feel less bad – thus, avoidance has been reinforced.

•Unprocessed nature of trauma memory (Shin et al., 2006)

Overview• Definition of PTSD• Prevalence of PTSD in veterans

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of PTSD▫ Emotional Processing Theory ▫ Factors that maintain PTSD symptoms

• Mindfulness-based therapies▫ Mindfulness Based Stress Reduction (MBSR)▫ Example

• Efficacy▫ Efficacy▫ Treatment moderators▫ Treatment mediators

What is Mindfulness?

•“Mindfulness is paying attention on purpose, in the present moment, and non-judgmentally”▫-John Kabat Zinn

•Not past or future, but now•Not auto-pilot, but with purpose•Not judging, but accepting

Theories of mindfulness

•Shapiro model (Shapiro et al., 2006)

▫Intention, attention, and attitude are basic axioms of mindfulness

▫These axioms give rise to mechanisms which induce increased well being: “reperceiving” (meta-cognitive awareness) improved self-regulation emotional/cognitive/behavioral flexibility values clarification exposure

Mindfulness Based Stress Reduction (MBSR)• Structure (Kabat-Zinn, 2005)

▫Taught in groups, weekly 2.5 hour sessions for 8 weeks, one 7-hour retreat

▫Experiential practice is primary component▫Lots of homework (30-45 min/day) using audio

recordings and assigned readings• Components / “interventions”

▫Breathing meditations▫Body scan meditations▫Active meditations (walking, yoga)▫Loving-kindness meditation

Goals of Mindfulness-Based interventions•Greater intentional awareness of one’s

own present experience•Decreased judgment (i.e., greater

acceptance of experience and self)▫Acceptance

•Meta-cognitive awareness

Sample meditation

•Breathing meditation

Addressing symptoms and maintaining factors of PTSD•Avoidance of traumatic memories and

emotions▫Openness to all of present experience

•Inaccurate fear network▫New learning that traumatic memories and

emotions are not dangerous

•Negative alterations in mood▫Self-compassion, non-judging

Overview• Definition of PTSD• Prevalence of PTSD in veterans

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of PTSD▫ Emotional Processing Theory ▫ Factors that maintain PTSD symptoms

• Mindfulness-based therapies▫ Mindfulness Based Stress Reduction (MBSR)▫ Example

• Efficacy▫ Efficacy▫ Treatment moderators▫ Treatment mediators

Efficacy of mindfulness for PTSD•4 studies•Study #1: Niles et al., 2011

▫Randomized-controlled trial▫33 veterans with PTSD randomized to

mindfulness intervention based on MBSR or psychoeducation

▫Participants received 2 in-person sessions, followed by 6 (20-min) telephone sessions

Efficacy of mindfulness for PTSD•Study #2: Kearney et al., 2012

▫Non-controlled open trial with 94 veterans at large VA hospital

▫High-quality MBSR▫PTSD, depression, and quality of life all

improved significantly (48% showed clinically significant reductions in PTSD symptoms)

▫BUT, many were engaging in additional treatments – can’t say it was mindfulness alone that helped

Efficacy of mindfulness for PTSD•Study #3: King et al., 2013

▫Open trial with 37 veterans ▫Treatment was Mindfulness-Based

Cognitive Therapy (MBCT) adapted for PTSD 8 weekly 1-hour sessions

▫Participants receiving MBCT (vs. treatment as usual) showed significant decreases in PTSD symptoms, especially emotional numbing

▫73% of treatment completers reported clinically significant decreases in PTSD symptoms

Efficacy of mindfulness for PTSD•Study #4: Kearney et al., 2013

▫Randomized trial of 47 veterans▫Treatment was MBSR vs. TAU▫No significant difference in PTSD

symptoms between groups at post-treatment

▫However, significantly lower PTSD symptoms in MBSR group at 4-month follow-up

Initial & follow-up results

TAU Post-treatment MBSR Post-treatment TAU 4-month follow-up MBSR 4-month follow-up

75

64

74

61

25

36

26

39

Treatment Outcome - PTSD

Small/no improvement Significant improvement

Initial & follow-up results

TAU Post-treatment MBSR Post-treatment TAU 4-month follow-up MBSR 4-month follow-up

90 91100

73

10 90

27

Treatment Outcome – PTSD & depression

Small/no improvement Significant improvement

So, does it work?•Probably, but not as well as exposure

treatments•Effect sizes on PTSD symptoms: .54 - .64

▫Smaller than effects of formal exposure-based treatments: 1.08 (Powers et al., 2010)

•Hard to say how many benefit significantly▫Percentages reporting significant

decreases in PTSD symptoms range from 39% to 73%

▫Compared to 70% no longer meeting criteria for PTSD following Prolonged Exposure (Eftekhari et al., 2011)

If it’s not as good as exposure, why should we care?•Because patients and providers are often

unwilling to engage in exposure treatments▫Up to 38% patient drop-out rate, even after

agreeing to begin treatment (Schnurr et al., 2007)

▫Providers often feel uncomfortable having patients engage in exposures (Becker et al., 2004)

•So, mindfulness may represent an efficacious alternative or first-line treatment

Overview• Definition of PTSD• Prevalence of PTSD in veterans

▫ Prevalence▫ Risk factors▫ Comorbidities

• Theory of PTSD▫ Emotional Processing Theory ▫ Factors that maintain PTSD symptoms

• Mindfulness-based therapies▫ Mindfulness Based Stress Reduction (MBSR)▫ Mindfulness Based Cognitive Therapy (MBCT)▫ Example

• Efficacy ▫ Efficacy▫ Treatment moderators▫ Treatment mediators

Treatment moderators•???•Little good evidence available to predict

who will benefit most from Mindfulness

Treatment mediators

•What are the active ingredients of mindfulness-based interventions?

•A lot of theoretical work, with little empirical research

•Shapiro and others suggest:▫Meta-cognitive awareness▫Exposure▫Increased engagement in valued activities

Treatment mediators•Which aspects of mindfulness are most

helpful?•Stephenson et al., under review:

▫Increases in “non-reactivity” & “acting with awareness” were strongest predictors of improvements in PTSD symptoms

▫Both are likely related to patients allowing for exposure to previously avoided cognitive and emotional content

▫So, mindfulness have be efficacious in treating PTSD to the degree that it serves as a de-facto exposure

Take-Home• Mindfulness-based therapies seem helpful in

treating PTSD in veterans in some cases• The treatment effects are generally smaller than

for exposure-based treatments• While there is some initial evidence regarding

which aspects of mindfulness are most helpful, we have limited information regarding treatment moderators and mediators

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