Mindfulness-Based Therapies for PTSD in veterans Kyle Stephenson Clinical Psychology California...
-
Upload
lynette-walton -
Category
Documents
-
view
217 -
download
0
Transcript of Mindfulness-Based Therapies for PTSD in veterans Kyle Stephenson Clinical Psychology California...
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
References1. Amaya-Jackson, L., Davidson, J. R., Hughes, D. C., Swartz, M., Reynolds, V., George, L. K., & Blazer, D. G. (1999). Functional impairment and
utilization of services associated with posttraumatic stress in the community. Journal Of Traumatic Stress, 12, 709-724. 2. Baer, R.A., Smith, G.T., Lykins, E., et al. (2008). Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating
samples. Assessment, 15, 329-342.3. Breh, D. C., & Seidler, G. H. (2007). Is peritraumatic dissociation a risk factor for PTSD?. Journal Of Trauma & Dissociation, 8(1), 53-69. 4. Eftekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., & Karlin, B. E. (2013). Effectiveness of national implementation of
prolonged exposure therapy in veterans affairs care. JAMA Psychiatry, 70(9), 949-955. 5. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research And Therapy, 38(4), 319-345. 6. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20– 35.7. Gates, M. A., Holowka, D. W., Vasterling, J. J., Keane, T. M., Marx, B. P., & Rosen, R. C. (2012). Posttraumatic stress disorder in veterans and
military personnel: Epidemiology, screening, and case recognition. Psychological Services8. Hetzel-Riggin, M. D., & Roby, R. P. (2013). Trauma type and gender effects on PTSD, general distress, and peritraumatic dissociation. Journal
Of Loss And Trauma, 18(1), 41-53. 9. Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic
review. Journal Of Consulting And Clinical Psychology, 78(2), 169-183.10. Kabat-Zinn, J. (1990). Full catastrophe living. Using the wisdom of your body and mind to face stress, pain and illness. New York: Bantam
Doubleday Dell 11. Kramer, M. D., Polusny, M. A., Arbisi, P. A., & Krueger, R. F. (2014). Comorbidity of PTSD and SUDs: Toward an etiologic understanding. In P.
Ouimette, J. P. Read (Eds.) , Trauma and substance abuse: Causes, consequences, and treatment of comorbid disorders (2nd ed.) (pp. 53-75). Washington, DC, US: American Psychological Association.
12. Pacella, M. L., Hruska, B., & Delahanty, D. L. (2013). The physical health consequences of PTSD and PTSD symptoms: A meta-analytic review. Journal Of Anxiety Disorders, 27(1), 33-46.
13. Monson, C. M., Macdonald, A., Vorstenbosch, V., Shnaider, P., Goldstein, E. R., Ferrier‐Auerbach, A. G., & Mocciola, K. E. (2012). Changes in social adjustment with cognitive processing therapy: Effects of treatment and association with PTSD symptom change. Journal Of Traumatic Stress, 25, 519-526.
14. Polusny, M. A., Kumpula, M. J., Meis, L. A., Erbes, C. R., Arbisi, P. A., Murdoch, M., & ... Johnson, A. K. (2014). Gender differences in the effects of deployment-related stressors and pre-deployment risk factors on the development of PTSD symptoms in National Guard Soldiers deployed to Iraq and Afghanistan. Journal Of Psychiatric Research, 491-9.
15. Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M., Chow, B. K., et al. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA: Journal Of The American Medical Association, 297, 820-830.
16. Schnurr, P. P., Lunney, C. A., Bovin, M. J., & Marx, B. P. (2009). Posttraumatic stress disorder and quality of life: Extension of findings to veterans of the wars in Iraq and Afghanistan. Clinical Psychology Review, 29, 727-735.
17. Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of Mindfulness. Journal Of Clinical Psychology, 62(3), 373-386.18. Shin, L. M., Rauch, S. L., & Pitman, R. K. (2006). Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD. In R. Yehuda
(Ed.) , Psychobiology of posttraumatic stress disorders: A decade of progress (Vol. 1071) (pp. 67-79). Malden: Blackwell Publishing. 19. Stander, V. A., Thomsen, C. J., & Highfill-McRoy, R. M. (2014). Etiology of depression comorbidity in combat-related PTSD: A review of the
literature. Clinical Psychology Review, 34(2), 87-98. 20. Thomas, J. L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010). Prevalence of mental health problems and functional
impairment among Active Component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives Of General Psychiatry, 67, 614-623.