Emerging evidence suggests that mindfulness-based stress reduction (MBSR) training may be another nonpharmacologic therapy option for veterans with posttraumatic stress syndrome (PTSD).
A new randomized controlled pilot study found reduction of PTSD symptoms in Iraq-serving veterans after 8 weeks of MBSR training. The effects lasted at least 6 months after treatment ended. The results are preliminary, given the small population, but they pave the way for broader research.
“Any time we tell someone we have a treatment for them that doesn’t involve drugs or talking about their trauma, it can be compelling,” lead author James Douglas Bremner, MD, a professor of psychiatry and director of the Clinical Neuroscience Research Unit at Emory University School of Medicine, Atlanta, Georgia, told Psychiatry Advisor.
Previous research has already identified benefits for MBSR in areas of chronic pain, hot flashes, asthma, depression, fibromyalgia, psoriasis, and anxiety, notes the study’s background information.
Current Standard of Care
Current PTSD treatment recommendations include a prescription for a selective serotonin reuptake inhibitor and exposure-based cognitive behavioral therapy. Although only Paxil and Zoloft have been approved by the US Food and Drug Administration for treating PTSD, any selective serotonin reuptake inhibitor would be considered first-line treatment, Dr Bremner told Psychiatry Advisor.
“Many clinicians may go on to add a mood stabilizing agent or an antipsychotic, depending on the symptoms,” he added, but even polypharmacy has modest effects.
“Pharmacological treatment results in improvement in only a portion of PTSD patients and in others there is only a partial response to treatment,” Dr Bremner’s team writes in the study. Exposure therapy and cognitive behavioral therapy have shown effectiveness, but 30% to 60% of patients show no clinical improvement, the authors wrote in Frontiers in Psychiatry.
“The problem is that it’s fairly aversive to have to talk about traumatic memories, and a lot of people drop out of treatment or avoid treatment in the first place,” Dr Bremner told Psychiatry Advisor. “It may be that the most symptomatic people aren’t even getting treatment. Overall, that’s not a very good playing field.”
The inadequacy of current treatments led Dr Bremner’s team to explore MBSR. No research into its use for PTSD existed when they began their research, and the handful of studies published since then is mixed, with uncontrolled studies or reliance only on self-reported outcomes. In their small pilot study, Dr Bremner’s team relied on the “Clinician-Administered PTSD Scale (CAPS), mindfulness with the Five Factor Mindfulness Questionnaire (FFMQ), and brain imaging using positron-emission tomography PET during exposure to neutral and Iraq combat-related slides and sound” to assess outcomes.
Pilot Study Procedures
The study began with 26 veterans who had served in Operation Enduring Freedom and/or Operation Iraqi Freedom and had clinical diagnoses of PTSD. Block randomization assigned half to 8 sessions of MBSR and half to patient-centered group therapy (PCGT). Of these, 9 patients in the MBSR group and 8 in the PCGT group completed the study with all assessments. Reasons for attrition included lack of interest, lack of transportation, work-related issues, and relocation.
The participants, recruited through fliers and public bulletins in Atlanta, Georgia, and at the Atlanta VA Medical Center, had all returned from deployment within the past year and had not taken psychotropic medications during the previous 4 weeks. The researchers excluded participants with significant head trauma, loss of consciousness for at least 2 minutes, current alcohol or substance abuse, diagnosis of psychotic illness, or a PTSD diagnosis before entering the military.
The MBSR intervention included 8 weekly sessions of 2.5 hours that provided “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.” The instructors, trained by the Center for Mindfulness at the University of Massachusetts, aimed to help participants increase relaxation and awareness of their mind/body experiences related to their sense of self and thoughts and emotions related to PTSD. The MBSR also included a 6-hour all-day session during week 6.
“The MBSR expert on the study team…tailored the MBSR teaching materials to veterans, using metaphors that they could relate to, such as using analogies of attending to one’s breathing to training in sniper fire,” the authors wrote. Specific MBSR exercises included body scan meditation, sitting meditation, mindful hatha yoga, home practice, and study with assessment, as well as discussion of the psychology and physiology of stress.
The PCGT control group involved the same total hours as MBSR with a “here-and-now” focus that did not involve discussing their trauma.
“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,” the authors wrote. “[T]he 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.” The program concluded with a barbecue to match the MBSR’s all-day mindfulness retreat.
What the Study Found
Assessment involved the CAPS, the Structured Clinical Interview for DSM-IV, the FFMQ, and four 60-second positron emission tomography scans while the participants were exposed to both neutral (city scenes, birds tweeting, etc) and Iraq combat-related images and sounds.
Total scores on the CAPS dropped from a mean 56 before to 28 after MBSR compared with a drop from 51 to 43 in the PCGT control group (P =.016). The measure of mindfulness with the FFMQ, meanwhile, increased from 121 to 139 in the MBSR group compared with an increase from 121 to 127 in the control group (P =.04). Improvement was seen in both groups on the Functional Assessment of Cancer Illness Therapy-Spirituality Subscale, but the difference was not statistically significant.
“You can use the brain as almost an analogy for the stress response and recovery,” Dr Bremner explained to Psychiatry Advisor. “The amygdala is the part that learns fear memory, and the prefrontal cortex inhibits the fear response. We’ve shown that PTSD patients have dysfunction in the prefrontal cortex, so if we can enhance that brain area’s response to reminders, we expected that will correlate with improvement in symptoms, and that’s what we found.”
Both groups showed increased activation in several frontal and temporal cortical brain regions after the interventions and decreased activation in subcortical areas, insula, and cerebellum.
“PTSD patients treated with MBSR also showed a differential brain response to combat-trauma-related slides, and sounds when compared to the PCGT group, with an increased activation in the right anterior cingulate, and right inferior parietal lobule, and decreased activation in the right insula and precuneus,” the authors reported.
Application and Generalizability
This study is too small to draw broad conclusions, but if future studies in veterans pan out, it suggests MBSR could help those with PTSD from other causes, particularly as veterans tend to be the most challenging population to treat for PTSD.
“If we can get it to work in veterans, this Eastern-based philosophical approach based on Buddhism, there’s no reason it shouldn’t apply to other populations who may be even more receptive to the concept,” Dr Bremner told Psychiatry Advisor, acknowledging that some veterans may be skeptical of a program that involves yoga or may sound “flaky” to them. “Anecdotally, it seems the people who are enthusiastic about the concept seem more responsive,” he added.
The involvement of participants who had just recently returned from Iraq revealed possible strengths and limitations to the MBSR approach. On one hand, it may explain the dropout rate. On the other hand, the early intervention may be the reason the veterans had a good response. In a later study not yet published, Dr Bremner’s team found effectiveness at 2 of 3 sites but no significant effect at the third site. That study involved all comers, including people with chronic PTSD that had previously not responded to drugs or therapy.
Still, the authors proposed an explanation for how MBSR might work.
“Specific to PTSD, MBSR could potentially increase participants’ overall sense of control through a positive accepting mode of control, which is associated with greater [quality of life] and emotional well-being,” the authors wrote. “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. 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.”
The research was funded by the Veterans Administration, the National Institutes of Health, and the Atlanta Clinical and Translational Sciences Institute. The authors reported having no financial conflicts of interest.
Bremner JD, Mishra S, Campanella C, et al. A pilot study of the effects of mindfulness-based stress reduction on post-traumatic stress disorder symptoms and brain response to traumatic reminders of combat in operation enduring freedom/operation iraqi freedom combat veterans with post-traumatic stress disorder [published online August 25, 2017]. Front Psychiatry. doi:10.3389/fpsyt.2017.00157