Pam Harrison

April 07, 2016

PHILADELPHIA — In a controlled pilot study, mindfulness-based exposure therapy (MBET) has again been shown to favorably modify thought patterns that perpetuate posttraumatic stress disorder (PTSD).

"People with PTSD ruminate, and rumination is all about not being present. It's all about focusing on something terrible that happened in the past or something frightening that will happen in the future, so these patients are stuck in a rut," Anthony King, PhD, assistant research professor, University of Michigan, in Ann Arbor, told Medscape Medical News.

"My personal bias is that mindfulness-based therapy has a big effect on rumination, and decreasing rumination allows people to experience the present moment, which expands their awareness of different possibilities and increases their ability to pay attention to things they have avoided in the past," he said.

The research was presented here at the Anxiety and Depression Association of America (ADAA) Conference 2016.

High Retention Rate

Thirty-seven combat veterans who had recently returned from Afghanistan and Iraq were enrolled in the 16-week program. The program included elements of "mindfulness" — mediation, body scanning, and movement — self-compassion exercises, education about PTSD, and in vivo exposure to avoidance activities. It did not, however, involve overt trauma processing, a technique that has been shown to be effective for PTSD.

Dr King explained that overt trauma exposure does not work in a group setting, and as many as 30% of veterans refuse to participate in trauma exposure therapy, so they would not have participated in the program had it been incorporated into the plan.

The comparator program consisted of present-centered group therapy (PCGT), which is also effective in the treatment of PTSD. Fourteen veterans were randomly assigned to the PCGT group.

At program intake, there was no significant difference between groups regarding scores on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5); the group receiving MBET scored 74.5, and the group receiving PCGT scored 77.8. The CAPS-5 is considered the gold standard for assessing PTSD symptoms.

"The first thing we found that was fairly interesting is that veterans randomized to the mindfulness-based exposure group stayed in the group, so the retention rate was relatively high," Dr King observed. Indeed, at the end of the 16-week program, only 18% of participants had dropped out.

In comparison, the dropout rate among patients assigned to the comparator PCGT group was high, at 65% (P < .005 compared with MBET).

Intent-to-treat analysis showed that by the end of the program, CAPS-5 scores had dropped by an average of 63 points in the MBET group. This was equivalent to an effect size of g = 0.85, which was significant (P = .005). As Dr King pointed out, a decrease in the CAPS-5 score of greater than 10 points is both statistically and clinically significant.

Relapse Prevention

Improvement was also noted in patients participating in the comparator program, but to a lesser degree than that seen in the MBET group, at a decrease in CAPS-5 scores of 7.3 points from baseline. In the PCGT group, the effect size of the intervention was g = 0.44, which was not significant.

Functional MRI studies performed before and after treatment showed that veterans exposed to the mindfulness program experienced changes in the default mode network, manifested as greater connectively to areas of the brain that control executive function and attention. Participants who had a greater reduction in PTSD symptoms also had increased activity in the amygdala in response to images of angry faces.

"What I think is happening here is that participants are engaging more, they are processing that face more activity," Dr King explained.

"So after successful treatment, these patients see an angry face, and they engage with it more. They ask themselves how they feel about it as opposed to what they usually do, which is to refuse to look at the face, or if they look at it, they don't process it. With MBET, people may have more attentional resources on board to bring to bear when their mind wanders."

A mindfulness-based approach was also explored in veterans who had been successfully treated for substance use disorder (SUD) in an effort to help them maintain the gains they had made in recovery.

"Anyone who had worked in this field knows that trauma exposure frequently co-occurs in individuals with severe SUD," Michael Gawrysiak, PhD, Delaware State University, in Dover, told delegates.

"And it's important to be aware of this, because co-occurring trauma exposure greatly interferes with the efficacy of any intervention for substance use or PTSD, and people with co-occurring trauma exposure are also much more likely to relapse."

Growing Evidence

The mindfulness-based relapse prevention (MBRP) program used in the pilot study was specifically designed to increase awareness of internal states, such as craving and negative affect, that could lead to relapse.

"We also trained individuals to sit with their craving states and experience their craving rather than trying to suppress them," said Dr Gawrysiak. "Our goals were to raise awareness of triggers for craving and to change the relationship from one of discomfort to one where patients are more tolerant and accepting of these difficult states."

A total of 37 individuals from the Philadelphia Veterans Administration were enrolled in the 8-week MBRP program. Ten participants had been diagnosed as having depression, and 14 had been diagnosed as having PTSD. All had experienced some trauma in their life.

At the end of the 8-week program, improvements in mindfulness measures were noted, and the severity of PTSD symptoms were surprisingly reduced as well — "an interesting finding," Dr Gawrysiak observed, "as MBRP deals pretty much exclusively with craving states and negative affect, yet we found that PTSD symptoms were significantly reduced, even though this is not a direct focus of our treatment."

Table. Changes Before and After MBRP

  Before MBRP After MBRP
Mindfulness (FFMQ) 117.22 127.89 (P < .05)
PTSD symptoms (PCL) 56.43 47.86 (P < .001)
Resilience (CDRISC) 28.50 30.50 (NS)
Well-being (BHQ) 4.67 5.89 (NS)
Life-functioning (BHQ) 7.00 7.56
Craving (PACS: D+A) 15.28 11.00 (P < .05)

FFMQ, Five Facet Mindfulness Questionnaire; PCL, Post-traumatic Stress Disorder Checklist; CDRISC, Connor-Davidson Resilience Scale; BHQ, Behavioral Health Questionnaire; PACS, Penn Alcohol Craving Scale; NS, not significant.

"With mindfulness therapy in general, there is a lot of discussion about improving attentional control ― being aware of what you are focusing on and being able to disengage from it if it's ruminative or overly negative ― and increasing a person's ability to tolerate negative states, so all this may all help explain what's going on," Dr Gawrysiak said.

"Mindfulness may also help participants 'disidentify' from their diagnosis — they are not only their symptoms sort of thing," he added.

Earlier reports by Medscape Medical News also showed that mindfulness-based therapy led to clinically significant symptomatic improvement over standard interventions for PTSD.

Appropriate Therapy

Commenting on this therapeutic approach for Medscape Medical News, Simon Rego, PsyD, director of psychology training, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, told Medscape Medical News that both studies are preliminary and that more work needs to be done to explore the potential benefits of this particular approach in these patient groups.

Still, he said, the study by Dr King and colleagues was big enough to show that the dropout rate was impressively less than it was for the control group.

Both studies also showed that the mindfulness-based approach did improve symptoms of PTSD, which was of interest.

"The idea of using mindfulness is really appropriate here, as it helps people to redefine their relationship with their private experiences," Dr Rego noted.

"Whether you have people who get very uncomfortable with either memories of the traumatic event or physiological symptoms related to triggers of the event, or whether it's all about cravings ― in this case, it was with substance use, but in other studies, the approach could work for people who engage in binge eating or bodily-focused habits, where people get intense feelings of discomfort," Dr Rego said.

"Mindfulness teaches people not to suppress or fight their feelings but rather allows them to be present and create some space for themselves so they can redefine their relationship with cravings so that the cravings are not pushing them to do things. People can decide what to do in spite of the fact that the carvings are there."

Dr King and Dr Gawrysiak have disclosed no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2016: Symposium 345, presented April 1, 2016.

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