POSTTRAUMATIC STRESS DISORDER (PTSD), MINDFULNESS AND MEDITATION
A Literature Review
Dr Ian Gawler OAM, BVSc, MCounsHS August 2021

INTRODUCTION

Did you know a cancer diagnosis is a very common cause of Posttraumatic Stress Disorder (PTSD)? Most will be aware PTSD is associated with major conflict like war or extreme personal trauma, yet it can also follow on from significant psychological distress.

Stress affects us all differently; some people experience stress as a positive challenge, for others it leads to unwelcome distress. For a large number of people affected by significant trauma, that distress extends into the chronic and debilitating condition now known as Posttraumatic Stress Disorder (PTSD).

1. SPEAKING PERSONALLY

My own introduction to meditation was through Dr Ainslie Meares. Dr Meares was a psychiatrist who helped survivors of World War 2 with what in those days was called “shell shock”. He found hypnotherapy useful, became a world authority and then moved on to become a leading pioneer in the use of therapeutic meditation; helping many people to use intense meditation as an adjunct to healing a wide range of conditions.

Having drawn heavily upon Dr Meares’ meditation techniques during my own recovery from a very difficult cancer, in 1981 I went on to develop what was probably the world’s first lifestyle-based cancer self help group. Meditation was at the heart of what we offered.

Now, most people when they first came to those groups seemed to be in severe distress. In the early eighties we had no name for it, but as the years went on, it was clear that well over half those in our groups were in fact suffering from PTSD. What was wonderful was that after attending either a 10 day residential program or 12 week non-residential program, nearly everyone was free of their PTSD symptoms. It remains one of the major regrets of my working life that we were never able to gather the funding or support to conduct a proper research trial on those groups’ effectiveness with PTSD. My sense is there was more to these consistent recoveries than "just" the mind techniques we taught, but they were very much at the heart of it.

Anyway, here we are in current times when PTSD is a well-recognised and common issue besetting many people. Any event that involves a threat to life or a serious injury has the potential to be traumatic. This includes natural disaster, war, a serious accident, physical or sexual assault. And yes, strong psychological trauma like the diagnosis of cancer can also lead to PTSD.

2. THE SCOPE OF THIS LITERATURE REVIEW

This literature review aims to present key evidence regarding what mindfulness and meditation can offer to those affected by PTSD. Then, given the times we are in, it also examines the evidence base for online mindfulness and meditation programs.

Quite a large body of research has been published in this field, but not surprisingly, it varies in quality. Therefore, while not exhaustive, this review aims to reproduce key research (using many direct quotes from that research) that investigates the efficacy of mindfulness and meditation for people affected by PTSD.

This review includes direct hyper-links to the original scholarly articles as published.

3. INTRODUCTION

Posttraumatic stress disorder (PTSD) affects the lives of 7-8% of adults in the U.S. In Australia, in any given year it is estimated around 4.4% of the population will be suffering from PTSD and around 5 - 10% of the population will suffer from PTSD sometime during their life. PTSD is a commons and devastating disorder.

Although several interventions demonstrate clinical effectiveness for treating PTSD, many patients continue to have residual symptoms and ask for a variety of treatment options.

Both pharmacological and psychological interventions are used in the treatment of PTSD.

Despite empirical support of effectiveness, these interventions have high rates of incompletion (up to 50%) and many patients, both veterans and civilians, continue to have residual symptoms and seek more options.

For this prevalent and devastating disorder, the poor completion rates and relatively poor remission rates of existing, standard PTSD interventions suggest that new, complementary and integrative interventions, whether adjunctive or stand-alone, are likely warranted. Further, both patients and providers have voiced desires for the availability of more PTSD treatment options.

Meditation-based approaches are among the most popular complementary approaches for health promotion used by adults in both the U.S.A. and Australia. Meditation practices have elements of exposure, cognitive change, attentional control, self-management, relaxation, and acceptance, all of which are pertinent to the symptoms of PTSD.

3. WHAT IS PTSD?

– with gratitude to Phoenix Australia

Posttraumatic Stress Disorder (PTSD) is a set of reactions that can develop after someone has been through a traumatic event.

Most people will experience at least one of these types of events during their lives. In the first days and weeks after a traumatic event, people often experience strong feelings of fear, sadness, guilt, anger, or grief. Generally, these feelings will resolve on their own, and with the support of family and friends, the person recovers. However, if the distress continues, it may mean that the person has developed PTSD or another mental health condition.

A person with PTSD has four main types of difficulties:

∙ Re-living the traumatic event

– through unwanted memories, vivid nightmares, flashbacks, or intense reactions such as heart palpitations or panic when reminded of the event.

∙ Feeling wound up

– having trouble sleeping or concentrating, feeling angry or irritable, taking risks, becoming easily startled, or constantly being on the look-out for danger.

∙ Avoiding reminders of the event

– activities, places, people, thoughts or feelings that bring back memories of the trauma.

∙ Negative thoughts and feelings

– feeling afraid, angry, guilty, flat, or numb a lot of the time, losing interest in day-to-day activities, feeling cut off from friends and family.

It is not unusual for people with PTSD to experience other mental health problems like depression or anxiety. Some people may develop a habit of using alcohol or drugs as a way of coping.

4. STANDARD TREATMENT

Almost everyone who goes through a traumatic event will be emotionally affected in some way. For some, the effects can be long lasting. If you are still experiencing problems two weeks after a traumatic event, it is worth talking to your GP or a mental health professional to assess how you are going and to see if treatment would be helpful.

Effective treatments for posttraumatic stress disorder (PTSD) are available, and include counselling, medication, or a combination of both. These treatments can work even if your traumatic experience was a long time ago.

5. WHAT MINDFULNESS AND MEDITATION OFFER TO PEOPLE AFFECTED BY PTSD

– A research-based overview

A recent major review observed mindfulness-based treatments of PTSD have emerged as promising adjunctive or alternative intervention approaches.

The authors reviewed the literature on PTSD treatment studies, including approaches such as mindfulness-based stress reduction, mindfulness-based cognitive therapy and metta mindfulness, and found low attrition with medium to large effect sizes.

This review examined the convergence between neurobiological models of PTSD and neuroimaging findings in the mindfulness literature, where mindfulness interventions may target emotional under- and overmodulation, both of which are critical features of PTSD symptomatology. Recent emerging work indicates that mindfulness-based treatments may also be effective in restoring connectivity between large-scale brain networks among individuals with PTSD, including connectivity between the default mode network and the central executive and salience networks.

Future directions, including further identification of the neurobiological mechanisms of mindfulness interventions in patients with PTSD and direct comparison of these interventions to first-line treatments for PTSD are discussed.

Boyd JE, Lanius RA, McKinnon MC. Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence. J Psychiatry Neurosci. 2018;43(1):7-25. doi:10.1503/jpn.170021

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747539/

6. PTSD IN SPECIFIC SETTINGS

Posttraumatic Stress Disorder (PTSD) can be defined by the inability to recover from a traumatic event. A common misconception is that PTSD can only develop in circumstances of war or acute physical trauma. However, the diagnostic criteria of PTSD were adjusted in the Diagnostic Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) to include the diagnosis and treatment of a life-threatening illness, such as cancer, as a traumatic stressor that can result in PTSD. Here we examine PTSD in specific contexts.

i) PTSD and cancer

It is not unusual or surprising that many people experience a diagnosis of cancer as sudden, catastrophic, and/or life-threatening. Cancer-related PTSD (CR-PTSD) is often claimed to affect around 50% of those diagnosed with cancer. CR-PTSD can negatively affect a person’s psychosocial and physical well-being during treatment and into survivorship. Unfortunately, CR-PTSD often goes undiagnosed and, consequentially, untreated.

This study reflects the commonly held view; it found the prevalence of distress amongst people with cancer was 76% and the incidence of PTSD was 55%.

Pranjic N et al. Distress and PTSD in patients with cancer: cohort study case. Mater Sociomed. 2016 Feb;28(1):12-6. doi: 10.5455/msm.2016.28.12-16.

https://pubmed.ncbi.nlm.nih.gov/27047260/

This next 2019 article provides a general overview of PTSD with cancer as the traumatic event in order to define CR-PTSD, and reviews the growing pool of literature on this topic, including prevalence, risk factors, characterization, and treatment of CR-PTSD. The purpose of this article is to spread awareness of this relatively newly defined and commonly missed disorder among patients with cancer to clinicians and patients alike.

Leano A et al. Are we missing PTSD in our patients with cancer? Part I. Can Oncol Nurs J. 2019;29(2):141-146. Published 2019 Apr 1.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516338/#b31-conj-29-2-141

ii) Mindfulness, PTSD and the military - systematic review and meta-analysis of the benefits

Military veterans report high rates of psychiatric and physical health symptoms that may be amenable to mindfulness-based interventions (MBIs). However, inconsistent prior findings and questions of fit between MBIs and military culture highlight the need for a systematic evaluation of this literature.

The authors

searched five databases and found 20 randomized controlled trials (RCTs) testing MBIs in military veterans to include in their analysis. The findings? MBIs were superior to non-specific controls (e.g., waitlist, attentional placebos) on measures of posttraumatic stress disorder (PTSD), depression, general psychological symptoms (i.e., aggregated across symptom domains), quality of life / functioning, and mindfulness but not physical health. At follow-up (mean length = 3.19 months), MBIs continued to outperform non-specific controls on general psychological symptoms, but not PTSD.

The author’s concluded

MBIs may improve psychological symptoms and quality of life / functioning in veterans. Questionable acceptability and few high-quality studies support the need for rigorous RCTs, potentially adapted to veterans.

Goldberg SB et al. Efficacy and acceptability of mindfulness-based interventions for military veterans: A systematic review and meta-analysis. J Psychosom Res. 2020 Nov;138:110232.

https://pubmed.ncbi.nlm.nih.gov/32906008/

iii) Mindfulness use for PTSD in children

We all know many children are exposed to adverse experiences. The evidence is clear - such adverse childhood exposures may result in stress and trauma, which are associated with increased morbidity and mortality into adulthood.

In general populations and trauma-exposed adults, mindfulness interventions have demonstrated reduced depression and anxiety, reduced trauma-related symptoms, enhanced coping and mood, and improved quality of life. Studies in children and youth also demonstrate that mindfulness interventions improve mental, behavioural, and physical outcomes.

Taken together, this research suggests that high-quality, structured mindfulness instruction may mitigate the negative effects of stress and trauma related to adverse childhood exposures, improving short- and long-term outcomes, and potentially reducing poor health outcomes in adulthood. Future work is needed to optimize implementation of youth-based mindfulness programs and to study long-term outcomes into adulthood.

Ortiz R, Sibinga EM. The Role of Mindfulness in Reducing the Adverse Effects of Childhood Stress and Trauma. Children (Basel). 2017;4(3):16. Published 2017 Feb 28. doi:10.3390/children4030016

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5368427/

7. META-ANALYSES AND MAJOR REVIEWS – Mindfulness, meditation and PTSD

i) 2016 review finds positive but statistically weak benefits

This systematic review and meta-analysis synthesized evidence from randomized controlled trials of meditation interventions to provide estimates of their efficacy and safety in treating adults diagnosed with posttraumatic stress disorder (PTSD). Outcomes of interest included PTSD symptoms, depression, anxiety, health-related quality of life, functional status, and adverse events.

In total, 10 trials on meditation interventions for PTSD with 643 participants met inclusion criteria. Across interventions, adjunctive meditation interventions of mindfulness-based stress reduction, yoga, and the mantra repetition program improve PTSD and depression symptoms compared with control groups, but the findings are based on low and moderate quality of evidence. Effects were positive but not statistically significant for quality of life and anxiety, and no studies addressed functional status.

The authors concluded meditation appears to be effective for PTSD and depression symptoms, but in order to increase confidence in findings, more high-quality studies are needed on meditation as adjunctive treatment with PTSD-diagnosed participant samples large enough to detect statistical differences in outcomes.

Hilton L et al. Meditation for posttraumatic stress: Systematic review and meta-analysis. Psychol Trauma. 2017 Jul;9(4):453-460.

https://pubmed.ncbi.nlm.nih.gov/27537781/

ii) 2017 Meta-analysis finds meditation offers significant help

In this 2017 meta-analysis, 19 randomized control trials with data on 1,173 participants were reviewed. A random effects model yielded statistically significant positive effects in the small to medium range. Interestingly, the study revealed no appreciable differences between intervention types, study population, outcome measures, or control condition.

The authors concluded these findings suggest meditation (and yoga) are promising complementary approaches in the treatment of PTSD among adults and warrant further study.

Gallegos AM et al. Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev. 2017;58:115-124.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5939561/

8. SOME CAUTIONS RE MINDFULNESS and PTSD

While mindfulness has much to offer, there are some cautions and this article from Smiling Minds is worth reading if you are taking up that specific practice…

Mindfulness and traumatic stress - best practice guidelines. Catherin Morey-Nase, March 2021, Smiling Mind Blog.

https://blog.smilingmind.com.au/mindfulness-traumatic-stress-best-practice-guidelines

In my own experience, starting any mindfulness or meditation-based practice with deep relaxation as in the Progressive Muscle Relaxation, significantly mitigates any potential adverse effects. As such, I highly recommend this practice.

9. ONLINE MINDFULNESS AND MEDITATION PROGRAMS FOR PEOPLE WITH PTSD

i) Online programs and their benefits – a meta-analysis

The aim of this meta-analysis of 15 randomised controlled studies was to estimate the overall effects of online MBIs on mental health. Results showed that online MBIs have a small but significant beneficial impact on depression, anxiety, well-being and mindfulness. The largest effect was found for stress, with a moderate effect size.

For stress and mindfulness, analysis demonstrated significantly higher effect sizes for guided online MBIs than for unguided online MBIs. In addition, effect sizes for stress were significantly moderated by the number of intervention sessions.

The researchers concluded their findings indicate online MBIs have potential to contribute to improving mental health outcomes.

Spijkerman MPJ et al. Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clinical Psychology Review Vol 45, 2016, 102-114

https://pubmed.ncbi.nlm.nih.gov/27111302/

ii) App use improves mental health

Previous research has shown one in five Australians (21%) have taken time off work in the past 12 months due to feeling stressed, anxious, depressed or mentally unhealthy. Workers who took part in this 30 day app trial were assessed over 12 months and reported fewer depressive symptoms while scores for workplace performance, resilience and wellbeing had improved.

“This is the first time researchers have ever been able to achieve reductions in depression incidence using an app alone,” claimed the lead author Dr Mark Deady.

https://www.blackdoginstitute.org.au/news/new-app-shows-reduced-rates-of-new-onset-depression-in-workers-by-up-to-50/

PART D : CONCLUSION

There is a solid evidence base for mindfulness and meditation being used to help people affected by PTSD. These same interventions can play a part in reducing associated symptoms of PTSD such as anxiety and depression, as well as assist in recovery.

Also, there is good evidence online mindfulness - based programs have positive benefits and that these benefits are increased with the support of an on-line guide or mentor. Further, the evidence concludes that increasing the number of guided sessions increases the measured benefits.