mindfulness-based therapies for ptsd in veterans kyle stephenson clinical psychology california...
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Mindfulness-Based Therapies for PTSD in veterans
Kyle StephensonClinical PsychologyCalifornia State University Monterey Bay
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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
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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
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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
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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)
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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
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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)
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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
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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
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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
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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
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Trauma Structure
DarkYell
Helpless Incompetent
Hide
Afraid
I - Me
Uncontrollable
Combat IED
Crowd
Noise
Cry
Driving
Dangerous
Fire
PTSDSymptoms
Trash
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A cognitive model of PTSD
Ehlers & Clark, 2000
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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)
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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
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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
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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
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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
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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
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Sample meditation
•Breathing meditation
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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Treatment moderators•???•Little good evidence available to predict
who will benefit most from Mindfulness
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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
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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
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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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