Mindfulness Meditation and Combat-Related Post-Traumatic Stress Disorder: A Psychological,...

7/29/2019 Mindfulness Meditation and Combat-Related Post-Traumatic Stress Disorder: A Psychological, Philosophical, and Ne

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MindfulnessMeditationandCombat-RelatedPost-

TraumaticStressDisorder:APsychological,

Philosophical,andNeuroscientificPerspective

MelissaT.Greene

LehighUniversityCognitiveScienceProgram

SeniorThesis:Spring2012


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I.EMOTIONANDAFFECTIVECONTROL:ANINTRODUCTIONINCONTEXT

Emotionandaffectiveregulationstrategiesarecoreprinciplesincognitivescience,

clinicalpsychology,neuroscience,andarangeofotherfieldsthatseektounderstandthe

complexrelationshipbetweenmindandbrain.Whiletherichemotionallivesweleadas

humanbeingsarecertainlyinvaluable,theyalsolendthemselvestoanever-expandinghost

ofquestionsthatattempttoidentifytheroots,purposes,andnuancesinvolvedinand

pertainingtosuchauniquelycomplicatedexperience.Theexperienceofemotionis

inextricablylinkedtobothneurological/physiologicalandpsychologicalprocesses,andthe

actofaffectiveregulationhassimilarfoundationsinbothneuroscienceandpsychology.

Additionally,thereexistsavarietyofexceptionalphilosophicalandculturaltenetsthat

influencethemethodsdifferentindividualschooseinattemptingtomoderateemotion,and

thesefactorscombinedproduceaverydenseandveryinvolvedtopicofstudy.

Whileemotionandaffectivecontrolareinandofthemselvesprofoundlyinteresting

topics,perhapsmoreintriguingstillistheuniquecircumstanceofemotionandemotional

regulationwithinthecontextofpsychiatricillnessandmentaldisorders.Dueto

disruptionsinbothneurologicalandpsychologicalfunctioningwhichemotionand

emotionregulationstrategiesdependuponemotionregulationpresentsanewand

unusualchallengetodisorderedpatients.Effectivelycontrollingaffectisdifficultfor

anyone;therefore,theadditionalimpedancesexperiencedbypsychiatricpatientscertainly

provetofurthercomplicatethetask.Ofparticularrelevancetoday(althoughsignificantly

underrepresentedinthecurrentliterature)isthisissueasitpertainstocombatveterans

sufferingfrompost-traumaticstressdisorder:theongoingconflictsintheMiddleEasthave

resultedinunprecedentednumbersofindividualsexperiencingintensepsychological


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trauma,yetrelativelylittleattentionhasbeendevotedtodevisingathoroughandeffective

solutiontothispervasiveissue.

Returningwarveteransoftenexperienceintenseanddebilitatingpsychological

injuriesthatareextremelydifficulttotreatcomprehensively.Manyveteransgrapplewith

transitioningbackfromcombatmodetheadaptationsthemindmakestohandletokill

orbekilledrealityofwarzonesbacktocivilianlife,andsevereconflictresultsasthe

demandsonthepsycheworsen.Insuchinstances,theexperienceofaffectis

overwhelminglynegative,neurologicaldamagehindershigh-levelcognitiveprocessing

involvedinexecutivecontrol,andpsychologicalcopingstrategiesareoftenexhausted,

renderingemotionregulationanextraordinarilydifficultanddauntingtask.Thebestway

tomanagesuchpsychologicalinjuriesthenisunderstandablyyettobedeterminedas

treatmentforpost-traumaticstressdisorderisbroad;becausethedisorderpresentssucha

challengetobothpatientsandclinicians,variousinterventionoptionsarestillbeing

explored.

Furthercomplicatingtheissuearethephilosophicalandculturalideologiespresent

withinthestructureofthemilitaryitself.Psychologicalresilienceishighlyvalued,

admissionofmentalillness(PTSDinparticular)ishighlystigmatized,andoutsiders

(includingpsychologists,psychiatrists,andothermedicalprofessionals)aremetwith

significantsuspicionandhostility.ThismeansthatmanyindividualsexperiencingPTSD

symptomsmayrefusetoseektreatment(Gould,2007),addingyetanotherlayertoan

alreadycompoundedproblem.Inadditiontoattemptingtoregulateseriouslypowerful

negativeaffectdirectlyassociatedwiththetraumatheyhaveexperienced,veteransarealso


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limitedinwhichcopingstrategiesandtreatmentoptionstheymayimplementbasedupon

thevaluesandbeliefsofthelargersystemofwhichtheyareapart.

Thispurposeofthispaperisthenfourfold.First,anoverviewofthepsychological

experienceofaffectandcognitiveregulationtechniqueswillbeprovided;thenthe

neurologicalandphysiologicalexperienceofemotionandstresswillbedescribedalong

withtheirrelatedinterventions;next,thesetopicswillbedescribedintermsoftheir

relationshiptocombat-relatedpost-traumaticstressdisorder;andfinally,thecurrent

researchandhypothesisregardingeffectiveemotionregulationtechniquesforuseinthe

treatmentofcombat-relatedPTSDwillbedescribed.

II.THEPSYCHOLOGICALEXPERIENCEOFAFFECTANDCOGNITIVEMANAGEMENTTECHNIQUES

Whilethetermemotionhasbeengenerallyapplieduptothispoint,itisimportant

tonowspecifythatnegativeaffectandstressinparticularwillbethemorenarrow

andappropriatetermsinwhichregulatorystrategiesaredescribed.Whilethehuman

stressresponseissimilarinbothcasesofgoodstressandbadstress,itisrarelythecase

thatemotionalregulationstrategiesarerequiredintheexperienceofgoodstress.

Likewise,post-traumaticstressdisorder(asitsnameimplies)involvesextremelynegative

affect;therefore,stresswillbeusedtocomprehensivelydescribenegativeaffectfromthis

pointforward,andemotionalregulationwillbedescribedasitpertainstocopingstrategies

implementedtoreducetheeffectsofstress.

Psychologicallyspeaking,stressexistsintwodistinctformsacuteandchronic.

Acuteandchronicstressdifferinthedomainsofphysicalandphysiologicalsymptomsas

wellaspsychologicalsymptoms,andasaresultaremanagedviadifferentcoping


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strategies,althoughthereareoverlapsineachoftheseareasaswell.Beforecontinuing,it

isnecessarytoemphasizethepreviouspointthatoverlapsbetweenacutestressand

chronicstressareverycommon.Forthisreason,typesofstressexistmoreasdifferent

componentsofthestressprocessratherthandistinctcategories.Therearenohardand

fastlinesthatdeterminewhatcountsasorcausesacuteversuschronicstress;sympathetic

nervoussystemactivationcanattendchronicrolestrain,forexample,anddailyhassles

typicallyconsideredacutestressorscaninsomecasesbecomechronic(Aldwin,2009).

Forthepurposeofthispaper,workingdefinitionsofthetermsacutestressandchronic

stresswillbeestablishedandthevariancesinsymptomsandcopingstrategieswillbe

understoodthroughtheselenses.

Thefirsttypeofstressacutestressseemstobethemorecommonofthetwo,as

itincludesdailyhasslesthatoftentimesdonotleadtopersistingpsychologicalorphysical

symptoms(again,thisisnottosaythatthisneveroccurs).Acutestressisperhapsbest

differentiatedfromchronicstressbasedontemporalcharacteristics;thatis,whileacute

andchronicstresstypicallysharemanyfeatures(neuroendocrineresponses,immune

responses,theexperienceofnegativeaffect,etc.),acutestressgenerallyoccursasrapid-

onsetandisintenseforashortperiodoftime,whereastheoppositeistrueforchronic

stress(Aldwin,2009).Similarly,becauseintensityismoderateanddurationisshort,

lastingphysicalandpsychologicalconsequencesarenotusuallyobservedinacutestress

situations.Toprovideanexample,studentsexaminations(andparticularlyimportant

examinations,suchastheLSATorbarexam)areoftendescribedastheprototypicalacute

stressor.Theyareassociatedwithanticipatorystress,althoughforthemostpart,stress

peaksafewdaysbeforetheexamanddropsoffrapidlyinthedaysfollowingtheexam.


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Chronicstress,asitsnameimplies,referstostressexperiencedpersistentlyforan

extendedperiodoftime(weeks,months,oryears).Chronicstressdoesnotfollowthe

normalcyclicalpatternofarousalandreturntobaselineobservedwithacutestress,andis

insteadrepresentedbyaflatteningofnormaldiurnalpatternsofhormonesecretion,which

resultsinpersistentpsychologicalandphysicalsymptoms.Post-traumaticstressdisorder

qualifiesaschronicstress:thisstressissevere,unwavering,andpervasive,andlastslong

aftertheinitialtraumahaspassed.

Negativeaffectisassociatedwithbothacuteandchronicstress,althoughagain,

symptomsassociatedwithacutestressdonotpersistforanysignificantlengthoftime.

Negativeaffectasitpertainstochronicstressismarkedlydifferent:psychological

symptomsnotonlypersist,butleadtoconditionssuchaschronicmoodandanxiety

disorders,includingPTSD(McEwen,2005).Acutestressisalsomorecommonlyassociated

withsymptomssuchassituation-specificanxiety(asopposedtogeneral),negativemood,

orpanic,whereaschronicstressislinkedtogeneralizedanxietydisordersanddepression.

Again,itisapparentthatmanydifferencesbetweenacuteandchronicstresspertainto

temporalfactors,particularlywithintherealmofpsychologicalsymptoms:abadmood

willsubsideeventually,butdepressionmayendureindefinitely.

Becauseofthesetemporaldifferences,differentcopingstrategiesareemployed

accordingly.LazarusandFolkman(1980)definecopingstrategiesascognitions

(thoughts)andbehaviorsthatapersonusestoreducestressandmoderateitsemotional

impact,whichsuggeststhatwecananddoconsciouslyimplementpsychological

techniquestocombatourownpsychologicalexperienceofstress.AsLazarusandFolkman


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explain,thisoccursattwolevelscognitiveandbehavioralandthechoiceofstrategy

dependslargelyononesappraisalofthetypeofstresstheyareexperiencing.Ultimately,

thisresultsinthechoicebetweenproblem-focusedandemotion-focusedcoping.However,

somechronicstresssituationsandPTSDisaparticularlypoignantexamplenon-

copingmaybeemployedinstead,resultinginexacerbatedstressexperiencesthatmay

requireprofessionalormedicalintervention.

Problem-focusedcopingisacognitivecopingstrategyalsoknownasactivecoping,

andistypicallyimplementedwhenthesourceofthestressiseasilyidentifiableand

appraisedasmanageable.Problem-focusedcopingtypicallyinvolvesacquiringresources

thatwillaidinthedirectmanagementofthestress;inotherwords,problem-focused

copingistheactofdirectlysolvingormanagingtheproblemthatisdeemedthesourceof

thestress(Kilburn&Whitlock,2011).Thistypeofcopingisdonebygatheringinformation,

makingdecisions,makingplans,andresolvingconflicts,anditincludessituation-specific,

instrumental,andtask-orientedbehaviors(Kilburn&Whitlock,2011).Thistypeofcoping

istypicallyimplementedinacutestresssituations.

Emotion-focusedcopingfocusesonthemanagementofemotionrelatedtostress

andistypicallyemployedinchronicstresssituationsinwhichthestressorisnotdirectly

manageable.Cognitivestrategiesareprimarilyrelieduponinemotion-focusedcoping(as

opposedtothebehavioralstrategiesdescribedinproblem-focusedcoping),andinclude

positivereappraisal,seekingemotionalsupport,andmeaning-focusedcopinginwhichan

individuallooksforpositivemeaningwithinthestress.Additionally,thereareafew


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behavioraltechniquesthatfallundertheumbrellaofemotion-focusedcoping,suchas

regulatedbreathingforexample(Kilburn&Whitlock,2011).

Tobrieflyelaborateuponbehavioralmethods,techniquessuchasregulated

breathingandcognitivereappraisalarehelpfulintheshort-termwherestressorscanbe

reevaluatedincontext,assumingthatunderstandingthecontextwillhelprelievethe

stress.Inotherwords,ifastudenttakingthebarexamintwohourscanrelax,breathe

deeply,andcognitivelyreappraisetheirstresssuchthattheyseeitashavingaforeseeable

end,theymaybebetterequippedtohandleitandmayobserveareductioninstress

experienced.Thisdoesnotworkinchronicstresssituations,asthestresstypicallyhasno

foreseeableend.InthecontextofPTSD,thepresentstressactuallyresultsfromsituations

thathaveoccurredinthepast,presentingarathercomplicatedproblem.Thefuturedoes

notprovideanescapefromthepresentstressasitmightintheacutestressexample

becauseitinvolvesanindeterminateperiodofre-experiencingthetrauma,which

introducesacompletelynew(andarguablymuchworse)stressexperience;intheacute

stresssituation,thefutureisrelativelystress-freeandprovidessomethingtolookforward

to.Becauseofthis,strongerinterventionsthancognitiveproblem-oremotion-focused

coping(specificallyprofessionalormedicalinterventions)areoftennecessaryinchronic

stresssituations,anditsimilarlyexplainswhynormalemotionregulationstrategiesfail

withinthecontextofpsychiatricdisorderssuchasPTSD.

Avoidancecoping,ornon-coping,isamaladaptivecopingstrategyinwhichthe

individualattemptstoescapefromastressorwithoutdirectlyorindirectlydealingwithit.

Unfortunately,avoidancecopingissadlyverycommonincasesofpost-traumaticstress


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disorder,particularlywithinthecontextofthemilitary,andPTSDsymptomshaveactually

beendescribedastheprecursortoavoidancecoping(Zeidner,2005).Avoidancecopingis

markedbystrategiessuchasavoidance(theactofdeliberatelyavoidingaddressingthe

trauma),numbing(refusaltoacknowledgeanysortofphysicaloraffectiveresponse),

repressionofdetailsaboutthestressor,andtheuseofdrugsoralcoholasameansof

escapefromthestressor(Vijanovic,2011).

III.THENEUROLOGICAL/PHYSIOLOGICALFOUNDATIONSOFAFFECT:EXPERIENCEANDREGULATION

Thereexistsasignificantneurologicalandphysiologicalcomponenttostressin

additiontotheemotionalandcognitiveelementspreviouslydescribed,whichpresentsa

uniqueinteractionandacompoundedchallengewithinthedomainofstressandcoping.It

isundeniablethattheinterconnectivitybetweenmindandbodyplaysasignificantrolein

theexperienceofemotionandtheprocessofemotionregulation.Obviously,thetwoare

closelylinked;ourthoughtsandconsciousexperiencesarenotonlyathomeinamaterial

brain,butarealsoengagedinauniquecausalrelationshipwiththematerialworldinwhich

weoperate.Therefore,whenexaminingthepsychologicalcausesandimplicationsofthe

experienceofemotionandstress,itiscriticaltoalsoexploretheneurologicaland

physiologicalexperiencessimultaneously.

Becausestressitselfisasubjectivementalstatewithrootsinamaterialbrain,itis

oftenthecasethatstressmanifestsitselfasphysiologicalchanges,disruptions,or

malfunctions.Stressmaybebothpsychologicalandphysiologicalinnature,andthus,the

relationshipissuchthatpsychologicalprocessesaffectphysiologicalonesandviceversa.


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Beforedelvingintothespecificsofthebidirectionalrelationshipofpsychological

andphysiologicalprocesses,itisimportanttounderstandwhythisconnectionis

particularlystrongwithinthecontextofstressandcoping.Astoucheduponpreviously,

psychologicalstress(whichincludestheexperienceofnegativeaffect)isoneofthefew

mentalphenomenathatmayultimatelyleadtophysicalconsequencesorrepercussions

overtime;similarly,physicalorphysiologicalchangescanalsoleadtopsychologicalstress.

Thisisconsistentwiththeconceptoftransactionism;itisdifficulttodeterminewhether

psychologicalorphysiologicalchangesinitiatethiscomplexfeedbackloopbecauseonceit

begins,eachcomponentcontinuestoinfluencetheother(Aldwin,2009).

Nowthatthisrelationshiphasbeenexploredincontextanditisunderstoodhow

psychologicalprocessesaffectphysiologicalones,itisusefultoinvestigatethespecific

waysinwhichphysiologyaffectspsychology.Perhapsthebestplacetostartinthis

discussionisthegeneraladaptationresponseitself,whichisexploredindepthbySelyein

his1956paper.Thegeneraladaptationsyndromeconsistsofthreedistinctphasesin

whichthebodyrespondstostress;thefirstthealarmstageincludestheactivationof

thehypothalamus-pituitary-adrenalaxis(HPA)andprovidesaverygooddemonstrationof

themutualinfluenceofpsychologicalandphysiologicalprocesses.

Thismodelpositsthatthecomplicatedfeedbackloopbetweenpsychological

processesandphysiologicalprocessesbeginswiththreatdetection.Furtheremphasizing

thetransactionistmodelthatAldwindescribesinthefirstchapterofherbook,thenotionof

threatdetectionisaperfectplacetobeginwhenattemptingtounraveltheconnection

betweenpsychologyandphysiology;interestingly,ithighlightsthefactthattheonecannot


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beparsedintermsoftheother.Threatdetectionisassociatedwithheightenedactivityin

theamygdala,whichleadstoactivationofthehypothalamusintheHPAaxisa

physiologicalresponseyetitisalsoassociatedwiththeexperienceoffearandother

negativeaffect.ItisunclearwhetherthephysiologicalactivationoftheHPAaxisleadsto

theexperienceoffearorwhethertheexperienceoffearleadstotheactivationoftheHPA

axis,whichisfurtherevidenceoftheintricaterelationshipbetweenpsychologicaland

physiologicalresponsesinthecontextofstressandcoping.AsAldwinpointsoutinher

book,thebrainandmindmutuallyaffectoneanother,anditisinadequatetoattemptto

reduceonetoanepiphenomenalpropertyoftheother,orspeakofthetwointermsof

causalrelationships(Aldwin,2009,p.6).Itiscrucialtohavethisconceptfirmlyestablished

beforecontinuing:whiletherearedistinctwaysinwhichpsychologyaffectsphysiologyand

viceversa,itisimperativetounderstandthatwhichcausestheotherisdifficult(ifnot

impossible)todetermine.

Followingtheactivationofthehypothalamusistheactivationofthepituitarygland,

whichcausesanumberofendocrineresponses(Aldwin,2009).Oncethepituitaryglandis

activated,vasopressin,oxytocin,andadrenocorticotropichormones(ACTH)arereleased,

againproducingsimultaneouspsychologicalandphysiologicalchanges.Vasopressinisa

vasoconstrictorandanantidiurectic;theseareimportantphysiologicalresponsestostress

astheypreparethebodyforfightorflight.However,vasopressinisalsoclosely

structurallyrelatedtooxytocin,whichproducesincreasedfeelingsofcontentmentanda

decreaseinanxietyandothernegativeaffects,andpreparesthemindtotendand

befriend(apsychologicalprocess).Oxytocinservesasanantagonisttovasopressin,

essentiallybyusingpsychologicalprocessestoregulatephysiologicalones.


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ThethirdstageintheHPAactivationisthereleaseofepinephrineand

norepinephrine,catecholaminesthatincreaseheartrateandbloodpressure,releasestored

energy,andinitiateanimmuneresponse.Becausecatecholaminesaretoxictothebody,the

stresshormonecortisolissimultaneouslyreleasedinordertocounteractthesepotentially

harmfuleffects;herewiththereleaseofcortisoldoweagainseeconcurrentpsychological

effects.Followinganormaldiurnalpattern,cortisolpeaksinthemorninganddecreases

throughouttheday.Inindividualswhoexperiencechronicstress,however,cortisolpeaks

earlierandfailstodrop.Heightenedlevelsofcortisol(andthuslowerlevelsof

norepinephrine)interferewithserotoninproductionandthusmayleadtodepression.This

conceptisreferredtoasthecatecholaminehypothesisofaffectivedisordersandis

describedbyJosephSchildkrautina1995paper(Schildkraut,1995).Cortisolmayalso

interruptthesleepcycle,leadingtorumination,impairedmemory,andnegativemood,

whichinturnerodessocialsupportandexacerbatesstress.ThelinktoPTSDisclearinthis

case,andasonecouldeasilypredict,individualssufferingfromPTSDshowhighlevelsof

secretionofcatecholaminesandlowlevelsofcortisol(whichexplainstheirinabilityto

counteractthedamagingeffectsofthecatecholamines),aswellasthesubsequent

psychologicalsymptomsofdepression.IndividualswithPTSDtypicallyexperience

heightenedphysiologicalarousalandanexaggeratedadrenalineresponse,whichovertime

resultsindeepneurologicalpatternsthatindicateamarkedabnormalityintheHPAaxis

(Geracioti,2001).

Thesecondandthirdphasesofthegeneraladaptationsyndromeinvolveresistance

andexhaustion,andfocusonvariousmethodsofcopingandthepsychologicalandphysical

consequencesofafailuretocope.Onpage96,Aldwindescribescopingascognitionsand


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behaviorsthataredirectedatmanagingaproblemanditsattendantnegativeemotional

consequences(Aldwin,2009,pg.96).Thebodyproducesthestressresponsesdescribed

abovewhichthemselvesleadtophysicalailmentssuchasulcersandothergastrointestinal

problems,headaches,cardiovascularproblems,andgeneralpain(Selye,1956).By

implementingcognitivecopingmethods,onehopestodelayorpreventtheonsetofthese

physicalmaladiesusingpreventativepsychologicalmeasuressuchasreappraisal,support

seeking,activecoping,problem-focused/emotionfocusedcoping,etc.InthecaseofPTSD,

however,individualsexperienceallostaticoverloadandaninabilitytocope.Thus,these

physicalsymptomsoftenmanifestasaresultofPTSD.

TherealsoexistsanamygdalocentricmodelofPTSD,whichsuggeststhatpost-

traumaticstressdisorderresultsfromhyperarousaloftheamygdalaandinsufficienttop-

downcontrolfromthemedialprefrontalcortexandthehippocampus(Milad2009).Itis

clearincasesofPTSDthatthefunctioningofavarietyofbrainregionsisseriously

impaired,whichislikelyaresultof(and,interestingly,acauseof)theprolongedstress

responseandhyperarousaloftheHPAaspreviouslydescribed.Areasaffectedincludethe

amygdala,hippocampus,andsubregionsofthemedialprefrontalcortex(including

ventromedialprefrontalcortexanddorsalanteriorcingulatecortex),andtheimplications

andconsequencesofthedamagearequiteextensive(Milad2009).

Theseareas(theamygdalaspecifically)arelargelyresponsibleforthefear

response,andarealsoinvolvedinavarietyofmemoryprocesses(includinglearning,

localizedwithinthehippocampus).Thus,hyper-orhypoactivityintheseareasultimately

resultsinaninabilitytodiminishthefearresponseandalsocausesseriousimpairmentin


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fearextinctionlearninganditsrecall(Milad2009).Fearextinctionlearningreferstothe

gradualreductionoftheconditionedfearresponse,andextinctionrecallreferstothe

retrievalandexpressionofthelearnedextinctionresponse.Thisisimportantwithinthe

contextofPTSDbecausethedisorderismarkedbyheightened,exaggerated,andpersistent

fearresponsestomemoriesandremindersofthetraumaticeventwithaninabilityto

regulateorotherwisemanagesuchaneffect.Thus,disruptionofextinctionabilitiesresults

inrepeatedandexacerbatedarousalinresponsetofearmemories,whicharepervasivein

sufferersofPTSD.Theamgydalocentricmodelexplainsthisintermsofneurobiology,

whichspeakstothecomplexityoftheissue;PTSDcanbeconsiderednotonlyamental

disorderbutalsoaneurobiologicalmalfunction,meaningthattreatingitisparticularly

challenging.Currentneurologicalsolutionsincludetranscranialmagneticstimulation,

whichstimulatesthedorsolateralprefrontalcortex(responsibleforaffectiveregulation),

andadultneurogenesis,whichinvolvesthecreationofneuronsinthehippocampusfrom

neuralstemandprogenetorcells.Neurogenesisaidsintheregulationofstressbothby

augmentingtheroleofthehippocampusinthenegativefeedbackmechanismoftheHPA

axis(whichagainisextremelyhyperactiveincasesofPTSD)andmayalsoinhibitthe

amygdala(responsibleforfear),althoughthistheoryisyettobeexploredinanyextensive

detail(Santarelli2003).

IV.AFFECTIVEEXPERIENCEANDREGULATIONWITHINTHECONTEXTOFCOMBAT-RELATEDPOST-

TRAUMATICSTRESSDISORDER

Post-traumaticstressdisorder(PTSD)presentsaverygravechallengetotheUnited

Statesmilitary.Estimatedtoaffectabout33%oftroopsreturningfromoperations


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overseas,PTSDisatragicpsychologicalinjurythatisdifficulttotreatandvirtually

impossibletoeradicate;oftentimes,conventionalsolutionssuchasmedicationor

traditionalpsychotherapyareseenasincompleteandinsufficientanddolittletoresolve

underlyingissueswithcomplexpsychologicalandneurologicalroots.Becauseofthis,

variousavenuesforinterventionhavebeenexploredrecently,withthemostcommon

beingcognitivebehavioraltherapy(specifically,cognitiveprocessingtherapy),socialand

familybasedinterpersonaltherapies,andmeditationtherapies.Thesetreatmentsareall

implementedwiththegoalofeffectivelyregulatingaffectwithouttheuseof

antidepressants,antipsychotics,orotherpsychopharmacologicalsolutions,whichhave

beenlinkedtoariseindrugdependency,suicide,andfatalaccidentswithinthearmed

forces(Dao,2011).

Beforeexploringthevariousinterventionsavailableinthemanagementofpost-

traumaticstressdisorder,itisfirstnecessarytoreiterateboththepsychologicaland

neurologicalsymptomsofcombat-relatedPTSDaswellasthemaladaptivecoping

strategiescommonlyimplementedbycombatveterans.Aspreviouslydescribed,veterans

experiencetraditionalsymptomsofPTSD(whichincludeavoidance,numbing,and

repressedmemory)andtypicallyengageinavoidancenon-coping.Also,therehasbeena

markedincreaseindrugabuseanddependencyamongcombatsoldiersandveteransdue

totheparticularlytroublingandpersistentqualityoftheillness.Thesocialstigmaattached

tootherformsoftreatment(includingpsychotherapy)maycontributetorampantdrug

abuseaswell(Dao,2011).Forthosewhodoseektraditionalandclinicalpsychotherapy,

manyoptionsareavailable,eachwithvaryingdegreesofeffectiveness.


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Cognitivebehavioraltherapy(CBT)isatalkingtherapythatseekstochangethe

traumavictimsfeelingsandactionsbychangingpatternsinthevictimsthinkingand

behavior.Itworksbyidentifyingthedysfunctionalcognitive-affective-behavioralprocess

andfocusingoncorrectingsuchprocessessothatthevictimmayhavemoreaccurate

beliefsaboutthecausesandrepercussionsofthetrauma.Ofparticularimportanceis

understandingandcontextualizingthetrauma;oftentimes,avoidance(theactof

deliberatelyavoidingaddressingthetrauma)preventsvictimsfromrealistically

understandingitanddealingwiththesubsequentfeelings.Cognitivebehavioraltherapy,

andcognitiveprocessingtherapyinparticular,isusedtoconquerthedefensemechanism

ofavoidanceandtreatPTSDbyformallyprocessingthetraumasuchthatthefeelings

associatedwithitandthemeaningattributedtoitarenolongeroverlynegativeor

personal.

Cognitiveprocessingtherapy,asubdivisionofcognitivebehavioraltherapy,has

beenusedspecificallyforthetreatmentofPTSD.Becauseitaddressesthemanysymptoms

ofPTSD(includinganxiety,depression,anger,etc.),cognitiveprocessingtherapyis

empiricallyproventobehighlyeffective,clinicallyimprovingabout80%ofpatientswith

PTSD(Eftekhari,2006).Cognitiveprocessingtherapytypicallyconsistsoftwocomponents:

thetraditionalcognitive-behavioralcomponentsdiscussedpreviously,whichinclude

identifyingandchangingdetrimentalthoughtpatternsandbeliefs,andaprolonged

exposurecomponent,whichallowsfordirectengagementwithandanultimate

desensitizationtotraumaticstimuli.


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Theinitialsessionsofcognitiveprocessingtherapy,whichmaybeconductedin

eitheragrouporprivatesession,involvefirstexplainingPTSD,itssymptoms,howitis

addressed,andhowtherapywillproceedandultimatelysucceed.Thegoalhereistobegin

thetherapybyrationalizingthedisorderinmuchthesamewasasthepatientwill

ultimatelybeabletorationalizethethoughts,feelings,andbehaviorsassociatedwiththe

disorderinsubsequentsessions;bydemonstratingthetechniquesandskillsthatwillbe

taughtlater,thetherapistdevelopsrapportwiththepatientandalsoasksthepatientto

thinklogicallyandrationallyveryearlyon.Asthepatientbeginstoviewthedisorderand

itssymptomsandtreatmentfromacalmandobjectiveperspective,thefoundationisset

forviewingandconsideringmorepersonalandemotionallyloadedstuckpointsatalater

time(Monson,2006).

Thenextstepfocusesprimarilyondirectlyconfrontingandformallyprocessingthe

traumabybreakingavoidancepatternscommoninmanysufferersofPTSD.Atthispoint,

exposuretherapyisimplemented,andpatientsareaskedtofirstwriteabouttheir

traumaticexperiences(theirimpactstatements)andlaterreadthemaloud.Asavoidance

patternsarebroken,strongemotionsaredispelled;asaresult,thepatientisbetterableto

addressthetraumafromarationalandobjectiveperspectivelateron(Monson,2006).

Asitsnameimplies,prolongedexposurereliesonvariousmethodsofexposingthe

patienttotraumaticmemoriesandtriggerstheywouldotherwiseavoid.AsPTSDistypified

bytheconstantrecurrenceofintrusivethoughts,memories,nightmares,andexternal

triggersassociatedwiththetrauma,itisnotunusualthatpatientswithPTSDseektoavoid

suchtriggersatallcosts;theproblemherelieswiththefactthatthesetriggersmightnotbe


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inherentlyharmfulandmaybeencounteredfrequentlyineverydaylife.Inordertorestore

apatientsabilitytoleadanormal,productivelife,itisimperativetofirstdesensitizethem

tocommontriggers;thisisdoneviaanintensivetwo-partinterventionthatincludes

imaginativeandin-vivoexposure(Williams,2010).Imaginativeexposureoccursfirstand

involvestheimpactstatementsdescribedpreviously:traumavictimsconfronttheirmost

traumaticexperiencesdirectlybywritingandspeakingaboutthembothintherapy

sessionsandashomework.Thegoalhereistoaddressnaturalemotionsthathavebeen

previouslyrepressed;similarly,astheexposureisrepeated,patientsareaskedtowrite

specificallyaboutthoughtsandfeelingsassociatedwiththetrauma,thoughtsaboutthose

thoughtsandfeelings,and,asthetherapyconcludes,waysinwhichtheymaychallenge

thosemaladaptivebeliefs(Monson,2006).

Thetherapyproceedsbyultimatelyunravelingthedisorder:firstbyaddressingthe

feelingsexperienced,thenbyaddressingthethoughtsaboutthosefeelings,andthenby

questioningthevalidityofsuchbeliefs.Itisatthispointthatthetraditionalelementsof

cognitivetherapiescanbeseenasthetherapistusesaSocraticstyleofquestioningtoto

ask[patients]questionsregardingtheirassumptionsandself-statementsinordertobegin

challengingthem(Monson,2006).

Thebenefitsofacognitiveprocessingapproacharereadilyapparent;notonlydoes

thepatientlearntoconfrontthoughtsandtriggersthathavepreviouslybeenavoided,but

thepatientalsosimultaneouslylearnstomanagesuchfeelingsanddevelopskillsthatlead

tofeelingsofempowerment.Cognitiveprocessingtherapyisconsideredtobethemost

effectivetreatmentforPTSDtodate,addressingmanyofthemorecomplexsymptomssuch


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asdepressionandgeneralanxiety,affectfunctioning,guiltdistress,andsocialadjustment,

whichmanytraditionalpsychotherapiesneglect(Monson,2006).

Itisimportanttonotethatcognitiveprocessingtherapyissignificantlymore

effectivethanprolongedexposuretherapyalone;whilecognitiveprocessingtherapyand

prolongedexposuretherapyareequallyeffectiveintreatingdepressioninPTSDsufferers,

cognitiveprocessingtherapyhasbeenproventomoreadequatelytreattrauma-related

guilt(Monson,2006).SuchstatisticsagainservetohighlightthecomplexityofPTSD;

cliniciansaredealingwithadangerouslymultifacetedissueandneedtoexploretreatment

optionsthatsuccessfullymanageallsymptoms.

Asecondapproachtothetreatmentofpost-traumaticstressdisorderinvolves

interpersonalpsychotherapy,orIPT.BecausePTSDhaslongbeenassociatedwith

difficultiesinmarriage,families,andfriendships,interpersonalpsychotherapymaybe

implementedwiththegoaloffixingtheindividualbyfixinghisrelationshipswithhis

lovedones.Inotherwords,theunderlyingbeliefisthatimprovingsocialfunctioning

shouldleadtoanoverallimprovementinothersymptoms(Cukor,2009).

IPTtreatmentstypicallyfocusonthedevelopmentoftrustandinterpersonal

difficultiesthatariseasaresultofthetraumaexperienced.Becauseofthis,social

relationshipsaretypicallyimproved,leadingtoreduceddepressionandsocialanxietyand

abettergeneralsenseofwellbeing;however,other,moreintricatenegativeemotions

remainunchanged(Cukor,2009).

IPTproceedsinstages,withtheinitialstagesresemblingthoseofCPT.Thepatientis

assessed,diagnosed,andthemajorproblemareasareidentified(thestuckpointsofCPT),


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andastatementisdrawnupinwhichthepatientexpresseshishopesandgoalsintherapy.

ThenextstagesworkthroughthemainproblemareasviathefourcommonthemesofIP:

grief,roledispute,roletransition,andinterpersonaldeficits(Frank,2010).

Thefirsttheme,grief,addressestherepressedormisrepresentedfeelingsofgrief

associatedwithPTSD.SimilartoCPT,thepatientisencouragedtoovercomeavoidance

defensesbyacceptingtheirpersonalgriefandotherstrongemotions;thetherapistaidsin

thefacilitationofthisprocessbyfocusingonthepresentandtalkingthroughcurrent

understandingsofthetrauma.Oncethegrievingprocesshasbeencompleted,patients

moveontoaddressthesecondthemeofroledispute,whichiswheretheinterpersonal

aspectofIPTisfirstobserved.

Roledisputeoccurswhenapatienthasexpectationsaboutrelationshipsthatarenot

reciprocated.InthecaseofPTSD,patientsmayexpectthattheirfriendsandfamily

understandtheirunwillingnesstotalkorengageinotherpreviouslyenjoyableactivities;

naturally,thisisnottheinclinationofmostlovedonesandthediscrepancyinrelationship

expectationsneedstobeaddressed.IPTaddressesroledisputebyfocusingfirston

understandingthenatureofthedisputeandthenatureofthecommunicationdifficulties

(hereagainwenotesimilaritiestoCPTasaccurateandrationalperceptionsareimperative

intreatment).Oncethesituationisunderstood,thetherapistworkswiththeclientto

improvetheirabilitytocommunicatewhilestillcateringtothepatientspersonalneeds.

Oncecommunicationhasbeenimproved,roletransitioncanbeaddressed.Because

traumaticexperiencestendtochangetheindividualswhoexperiencethem,itcanbe

assumedthattheirroleinlovedonesliveschangeaswell.Asaresult,patientswhosuffer


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fromPTSDmustacceptsuchatransitionandlearntocopewithboththelossoftheoldrole

aswellastheadoptionofanewone.Therapyatthisstagefocusesonemotions

experiencedasaresultofbothofthesestepsanddevelopingtheskillsnecessarytofulfill

thenewrole.

ThefinalstepinIPTisacknowledging,accepting,andovercominginterpersonal

deficits.Throughrole-playingandotheractivities,clientsadopttheperspectiveofother

individualsintheirlifeandattempttoidentifytheirowninterpersonalshortcomings.In

otherwords,patientslookatthemselvesfromtheperspectiveofalovedoneandthrough

thatlensidentifypatternsofisolation,failuresincommunication,andothersimilar

interpersonaldeficitsthattheymayhave(Frank,2010).

Aprimarycritiqueofinterpersonalpsychotherapyisthatitfocusespredominantly

ontreatingdepressivesymptomsandforthatreasoncannotbeconsideredcomprehensive,

especiallyinthecaseofPTSD.WhilePTSDpatientsshowedimprovementinresponseto

IPTwhencomparedtoPTSDpatientswhoreceivednotreatmentatall,merelytreatingthe

socialaspectsofPTSDmayfailtoaddressothersymptomssuchasre-experiencingand

hyperarousal(Cukor,2009).

Similarly,post-traumaticstressdisorderhasbeenknowntohaveaveryhigh

remissionratewhentreatedwithoutanytypeofexposure;becauseinterpersonal

psychotherapyfocusesonrelationshipswithothersratherthantheindividuals

relationshipwithhisownmaladaptivebeliefs,theuseofexposureislimitedornon-

existentandpatientsoftencontinuetoexperiencesymptoms.Whileinterpersonal

psychotherapyiseffectiveinaidingpatientsinimprovingrelationshipswiththeirfriends


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andfamilies(aseriousconsequenceofPTSD),itmaynotbeeffectiveinallowingthe

individualtoovercomehisownpersonalstruggles.Forthisreason,IPTmaynotbethe

beststand-alonetreatmentforPTSD;however,whencoupledwithothertherapies,itmay

provetobeeffective.

Itisimportanttonotethatpsychotherapy,whilesurelyuseful,failstocorrectthe

neurologicalabnormalitiespresentinsufferersofPTSD.Few(ifany)ofthesestrategies

resultinphysiologicalorneurobiologicalchangesorimprovement,whichisimperativein

eradicatingPTSD.Thus,itisclearthatother,morecomprehensiveavenuesneedtobe

explored;specifically,asynthesisofneurologicalandpsychologicalapproachestoemotion

regulationarecrucialinthecomprehensivetreatmentofPTSD.

V.MEDITATIONASANAFFECTIVEANDATTENTIONALREGULATIONSTRATEGY

Whileitmayseemthattheonlystrategiesthataddresstheneurologicaland

physiologicalrootsofstressarethosethatdirectlyintervenewiththewetware(suchas

TMSandneurogenesis),therearecognitivecopingstrategiesthathavebeenshownto

resultindirectphysiologicalchanges.Fascinatingly,meditationasastress-management

techniqueisonesuchexample.

MeditationhasrootsinfundamentalBuddhistteachings,andisbestunderstoodin

theclinicalsenseasacomplex,connectedgroupofemotionalandattentionalregulatory

trainingmethodsdevelopedandpracticedforavarietyofpurposes.Amongthese,the

creationofasenseofoverallwell-beingandemotionalbalanceareoftentheprimarygoals

inmeditativepractices,andthesestatesareachievedviatwodistinctformsofpractice

(Lutz,2008).Thefirst,focusedattentionmeditation(FA),requiresthatthepractitioner


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directandsustainattentiononasingleselectedprocess(suchasbreathsensation)while

disengagingfromallotherdistractors.Thepractitionertypicallytriestobecomefully

cognizantofmindwanderingand,whensuchdeviationsfrompracticearedetected,the

practitionercognitivelyreappraisesthedistractoranddirectsattentionbacktothe

selectedprocess.Thesecondmethodofmeditationisknownasopenmonitoring(OM)and

isratherdifferentfromFA;itinvolvesnonreactivemeta-cognitivemonitoringand

awarenessofmentalandemotionalexperiencefrommomenttomoment.Thereisno

specifictaskorprocessthatattentionisfocusedon,and,onthecontrary,fluidityof

sensory,perceptual,andendogenousstimuliisembracedwithoutjudgment(Lutz,2008).

Bothofthesemethodsactasemotionalandattentionalregulatorystrategies,and,similarly,

bothofthesemethodshavelong-termimpactsonthebrainandbehavior(Lutz,2008).

Becauseeachmethoddiffersfundamentally,itfollowsthattheywouldinvoke

differentneurologicalandpsychologicalprocessesandresultindifferentchangesand

effects.However,itisimportanttonotethatalthoughthetwopracticesaredifferent,they

areoftenusedinconjunctionwithoneanother.Whetherthetwoareusedwithinone

trainingsessionoroverthelongercourseofthepractitionerstraining,FAandOM

meditationpracticesareintegratedinordertomaximizeneurologicalandpsychological

benefits.Infact,itisoftenthecasethatapractitionerbeginswithFAmeditationinorderto

calmthemindandreducedistractions,andlatertransitionsintoOMmeditation(Lutz,

2008).Theneurologicalandpsychologicalbenefits,aspreviouslydescribed,includeboth

attentionalandemotionalregulationviathestrengtheningofskillsnecessaryinhigher-

orderfunctioning.


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Attentioniscriticalinsuccessfullycompletinggoal-directedbehaviors,and

interestingly,thereareanumberofparallelsbetweentheprocessesinvolvedinFA

meditationandtheprocessesdescribedwithinrecentcognitiveneuroscienceframeworks

ofattention.BothBuddhistscholarsandWesterncliniciansandscientistsrecognizethat

focusingonadesiredobject,goal,orintentionrequiresastrongabilitytodirectattention,

recognizeandblockoutdistractors,andredirectfocustothedesiredobjectwhen

concentrationisbroken.Theseprocesseshaveallbeenlinkedtoclearanddistinctpartsof

thebrain;therefore,thecurrentassumptionisthattheneuralsystemsinvokedinconflict

monitoring,selectiveattention,andsustainingattentionareallsimilarlyinvolvedinthe

inductionandmaintenanceofFAmeditation(Lutz,2008).Thesesystemsincludethe

dorsalantetiorsingularcortex,dorsolateralprefrontalcortex,ventro-lateralprefrontal

cortex,temporal-parietaljunction,andthethalamus,amongothers.Itiscrucialatthispoint

topointoutthelinkbetweenthesebrainareasandtheareasaffectedbyPTSDaccordingto

theamygdalocentricmodel:manyofthebrainregionsaffectedbyPTSDarealsoinvolved

inandstrengthenedbyFAmeditation,suggestingthatFAmeditationmayservetocorrect

thedeficienciesintop-downprocessingevidentinpatientswithpost-traumaticstress

disorder.AsLutzandcolleaguessuggest,theneurophysiologicalchangesinducedbyFA

meditationshouldcausesimilarimprovementsinbehavioralmeasuresofsustained

attention,whichhasbeenidentifiedasaseriouschallengeinpatientswithcombat-related

PTSD(Lutz,2008&Vujanovic,2011).Likewise,long-termchangesincognitiveandbrain

functionmaybeobservedasaresultofFAmeditation,providingapromisingfuturefor

treatingPTSDneurologicallythroughcognitivepractice.BuddhistteachingsdescribeFA

meditationasvoluntarysustainandcontrolofattention,althoughtheyalsoindicatethat


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thispracticebecomesinvoluntaryandautomaticovertime.Therefore,itcanbeassumed

thatastheprocessesinvolvedindirectingandsustainingattentionstrengthen,the

activationofandwithinneuralsystemswillbereduced,optimizingperformanceinother

attentionaltasks(Lutz,2008).

Whilethismayseemtobelargelytheoretical,studiesinvolvingexpertpractitioners

haveprovidedpreliminaryevidenceforthesehypotheses.WorkbyCarteretal.(2005)has

demonstratedthatTibetanBuddhistmonksexhibitchangesinnotonlyattentional

processing,butalsoinbrainstructures:brainregionsinvolvedinmonitoring,engaging

attention,andattentionorientingshowedlessactivationinexpertmeditatorsthanin

novices.Similarly,expertmeditatorsshowedlessactivationintheamygdaladuringFA

meditation.Again,itiscriticaltohighlightthelinktoPTSDinsuchaninstance;because

PTSDismarkedbyhypersensitivityandheightenedarousaloftheamygdala,meditative

practicethatreducesactivityintheregionseemstoclearlyaddresstheneurologicalrootof

theissue.Additionally,traininginFAisassociatedwithasubstantialdecreasein

emotionallyreactivebehaviors,indicatingthatthepsychologicalrootoftheproblemis

simultaneouslyaddressed(Lutz,2008).

WhilemuchofthediscussionhasthusfarfocusedonFAmeditationandattention,

OMmeditationisvaluableforitsimplicationsonemotionalregulationaswellas

attentionalregulationinsomeinstances.OMdiffersfromFAinthatitdoesnotinvolve

brainregionsresponsiblefordirectingandsustainingattentiononaspecificobject;

instead,OMmeditationinvolvesmonitoringanddisengagingattentionfromstimuliwhich

distractattentionfromthestreamofconsciousness(Lutz,2008).Aninterestingstudy


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revealedsupportforthisconceptualization.WorkbyValentineandcolleagues(1999)

showedthatOMmeditatorsperformedbetterthanFAmeditatorsinasustainedattention

taskwherethestimuluswasunexpected,indicatingamoredistributedfocusofattentionin

OMmeditators.Similarly,anotherstudybyTangandcolleagues(2007)indicatedthatafter

justfivedaysofOMmeditation,theexperimentalgroupshowedagreaterimprovementin

conflictmonitoringthandidacontrolgroupassignedtoarelaxation-basedmeditation

program.

PerhapsthemoreinterestingaspectofOMmeditationisitsrelationshipwithaffect

andaffectiveregulation.OMmeditationreliesheavilyupontheideaofawarenessofthe

featuresofanygivenmoment,andincludesaspectssuchasthatmomentsemotionaltone.

Thus,processesinvokedinOMmeditationaremoredirectlyrelatedtointernalbodily

sensations,termedinteroception,asopposedtoattentionalprocesses,andrelyonmental

representationsofphysicalstates(Lutz,2008).Becausetheseprocessesrelyonmental

representations,italsostandstoreasonthatOMmeditationmaybeusefulinregulating

limbicresponsesbyinvokingtheprefrontalcortexinprocessingandcognitively

reappraisingthesementalrepresentations.ThisisdoneinOMthroughtheactoflabeling

emotions,whichisacentraltenetofthepracticeandalsoakeycomponentofmanyclinical

interventionsbasedonOM(Lutz,2008).

TheprominentbrainregioninvolvedinOMmeditationistheinsula,whichisnot

onlyresponsibleforemotionalprocessingbutisalsospecificallyinvolvedinprocessing

sightsofmutilation,normviolation,andempathy.Theconnectionwithcombat-related

PTSDisveryobviousinsuchanexample.Fascinatingly,theinsulasofindividualswho


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meditatearesignificantlylargerthanthoseofindividualsdonot,furthersuggestingthat

meditationtherapiessuchasOMmaybeclinicallyusefulinthemanagementofcombat-

relatedPTSD(Lutz,2008).Whiletheneuroscientificbasisofmeditationisstillinits

infancy,thepreliminaryfindingsandhypothesesarepromising,andfurtherresearchis

necessarytoconfirmthebenefitsofsucheffects.

VI.MINDFULNESSMEDITATIONANDMINDFULNESS-BASEDSTRESSREDUCTION(MBSR)AS

INTERVENTIONSFORPOST-TRAUMATICSTRESSDISORDER

MeditationandrelaxationtherapiesareperhapsthenewestinterventionsinPTSD

managementandarelargelyempiricallyunderexplored.Believedtohavegreatpotentialto

treatPTSDandcomorbiddisorders,meditationtherapiesprimarilyfocusonmindfulness,

anOMpracticeinwhichanindividualishighlycognizantofsensationsandbeing.Contrary

totheconventional(andseeminglymechanical)processofdesensitizationtotraumatic

stimuli,mindfulnessstressesacceptancewithoutjudgmentandactingwithawareness

asimperativeinovercomingsymptomsassociatedwithPTSD(Cukor,2009).

Thedrawofmeditationtherapiesisthattheyfocusprimarilyonteachingcoping

skills;becausemanyveteransdonotreportsymptomsofPTSD,donotseektreatment,or

dropoutoftreatment(treatmentreferringtoconventionaloptionssuchasCPT),

meditationtherapyisameansofteachingsimilarcopingstrategieswithoutraisingthe

typicallyassociatedstigmaoftherapyamajorconcernforveterans(Vujanovic,2011).

Similarly,veteransmayexperienceotherdifficultieswithexposure-basedtherapies:they

oftenlackcommunicationskillsinthefirstplace,inhibitingthemfromsuccessfully

participatingintherapy,ordonotfeelableorreadytoparticipateinintenselyemotional


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exposuretheories.Thus,mindfulnessmeditationtrainingcanbeusedtoequipveterans

withtheskillstheyneedinordertosuccessfullybeginothertreatments(Vujanovic,2011).

Thelatestempiricalevidencefailstoaddressif,how,andwhichmindfulness-based

approachesarebestintreatmentofPTSD,althoughtherearetwodistinctgoalsof

mindfulness.Thefirstgoalisintentionalredirectionofattentiontothepresentmoment,

andthesecondistoapproachtraumaticexperiencesandtheirsubsequentemotions,

actions,thoughts,andfeelingswithnonjudgmentalacceptance(Vujanovic,2011).

Currently,mindfulnesstherapyhasbeenusedinconjecturewithothertherapies

andseemstobesuccessfulwhenutilizedinsuchaway.Usedindependently,mindfulness

therapymaycauseproblemsincertainindividualswithacutePTSDsymptoms,whichis

currentlyitsbiggestcriticism.Mindfulnessisconsideredilladvisedforveteranswhohave

significanttroubleregulatingemotion,forexample;clientswhotendtoexperiencevery

painfulre-experiencingsymptomsaretypicallynotabletofocusonthepresent,acentral

tenetofmindfulnessmeditationtherapies.Similarly,patientswithaninabilitytotolerate

painfulmemorieswhensubjectedtolongperiodsofsilence(commoninmeditation

practices)mayalsonotbefitforsuchtreatmentoptions.Whilesuchindividualsmaynot

bepreparedforlongmindfulnessmeditationtherapysessions,theycanparticipatein

shortersessionsandbuilduptolongerones;thus,despiteitsapparentlackofgeneral

suitability,mindfulnesstrainingcanbescaledtofittheneedsofmostindividuals

(Vujanovic,2011).Anothercriticism,mentionedearlierinregardstoIPT,isthatremission

ratesofPTSDtendtobehighwithoutexposure;whilemindfulnesstherapiesemphasize


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acceptance,itisunclearwhetherornotacceptanceisequivalenttoexposureandthus

PTSDtreatedwithmindfulnesstrainingmayhavesimilarlyhighrecurrencerates.

VII.HYPOTHESIS

Becausemindfulnesshasbeenshowntohaveaninverserelationshipwithmanyof

thesymptomsofPTSD,includinganxiety,depressivesymptoms,substanceabuse,and

chronicpain,itstandstoreasonthatmindfulnessmaybesuccessfulintreatingPTSD,

althoughcurrentresearchislimited(Vujanovic,2011).Nonetheless,empiricalevidence

suggeststhatmindfulnesstrainingisclinicallyusefulinfourdifferentways:(1)itfosters

nonjudgmentalacceptanceofpreviouslytroublinginternalstates(includingtrauma-

relatedtriggers);(2)itenablesindividualstosuccessfullyengageinothertreatments;(3)it

decreasesphysiologicalarousalandstressactivity;and(4)itfosterspsychological

flexibility(Vujanovic,2011).Psychologicalflexibilityisakintotheconceptof

psychologicalresilience,whichhasbeenlinkedtoadaptiverespondingtostressand

traumainawidevarietyofsituations(Bonanno,Westphal,&Mancini,2011).Similarly,

preliminarystudiesrevealthatmindfulnesstrainingisverysuccessfulinreducingmany

associatedPTSDsymptoms,particularlyavoidance/numbing(Vujanovic,2011).Forthese

reasons,wehypothesizethatpreemptivemindfulnessmeditationtrainingmaybeusefulin

preventingordelayingtheonsetofpost-traumaticstressdisorderfollowingtraumatic

experiences.Ifmindfulnessskillsaretaughtandperfectedbeforetraumaisexperienced,it

ispossiblethatattention,focus,andemotionmayberegulatedandredirectedfromthe

traumaticstimuliandtothetaskathand.Thebenefitscouldbetwofold,reducingthe

incidenceofPTSD,andimprovingtask-relatedperformance(therebyreducingcostly

errors).


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VIII.METHODS

Participants

Participantswere70LehighUniversityundergraduatesrecruitedfromthePSYC1

ParticipantPool.Themale-to-femaleratiowasapproximately1:1.Participantscompleted

theexperimentforonefullparticipationcreditfortheclass,andeachparticipantreceiveda

copyofthemindfulnesstrainingmaterialsuponcompletionofthestudyregardlessoftheir

assignedcondition.

Design

Thegoalofthisstudywastodeterminewhetherpreemptivemindfulness

meditationtrainingissuccessfulinpreventingordelayingtheonsetofpost-traumatic

stressdisorderfollowingtraumaticexperiences;thecurrentstudysoughttoprovideafirst

testofthisbasichypothesisinasampleofnormallyfunctioningyoungadults.Weexamined

performanceandemotionalreactivityduringanemotionallyevocativetaskattwopointsin

time(separatedbyapproximately8-10weeks).Betweenthesetwoassessments,halfofthe

participantscompletedeightweeksoftraininginmindfulness-basedstressreduction

(MBSR;Kabat-Zinn,1990),amindfulnesstrainingprogramdevelopedbycliniciansand

supportedbyahostofempiricalstudiesandclinicaltrials(e.g.,Kabat-Zinn,Massion,

Kristeller,Peterson,Fletcher,Pbert,Linderking,&Santorelli,1992).Thetrainingwasa

combinationofCD-guidedtrainingandself-guidedtrainingbasedinthetechniqueofopen

monitoring(non-reactivemonitoringofthecontentofexperiencefrommomentto

moment),averagingapproximately20minutesperday.Theotherhalfoftheparticipants

wereaskedtoengageinacontroltaskthatrequiredthesamedailytimeinvestment;they


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completedareflectivewritingtaskinwhichtheywereaskedtokeepajournaloftheir

stressfulexperiencesday-to-day.

TheemotionallyevocativetaskwasadaptedfromaparadigmdevelopedbyCorrell

andcolleagues(2002)toassessracialbias.Theoriginaltask,designedtomimicavideo

game,presentedparticipantswithaseriesofphotographsofurbansettings.Occasionally,a

photographofablackorwhitemalewouldappearinascene,holdingeitheragunora

neutralobject.Participants'objectivewastocorrectlyidentifywhethertheindividualwas

threatening(ifhewasholdingagun)orbenign(ifhewasholdinganeutralobject).Our

adaptationremovestheracialcomponentandcreatesascenarioclosertothatfacedby

moderncombatsoldiers.Inourtask,thebackgroundimageswerephotographsofMiddle

EasternandCentralAsiansettings,andthetargetindividualswereyoungmenfromthe

sameregions.Thesemenwereholdingmilitaryweaponsorneutralobjects,andthe

participants'taskwastocorrectlyclassifythemenasthreateningornot.Beforeeachtarget

appears,theparticipantwasprimedwithastimulusfromtheInternationalAffective

PicturesSystem(IAPS)withtheintentionofelicitinganemotionalresponseanddistracting

theparticipantfromcompletingthetasksuccessfully.TheIAPScontainsawiderangeof

emotionallyevocativestimuli,whichhavebeenextensivelystudiedandnormed(Bradley&

Lang,2007).Forourpurposes,theemotionallyevocativestimuliwereonesthatdepicted

graphicviolenceorinjuriestopeople,suchasvictimsofbeatings,caraccidents,or

homicide,thatarenormativelydescribedashighinarousalandnegativity.Theneutral

stimulialsodepictedpeople,butwerechosenfornormativeratingsoflowarousaland

neutralvalence.


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Theprogressionofeachtrialwasasfollows(consistentwithCorrelletal.,2002):

Participantsviewedbetween1and4backgroundimagesonagiventrial(eachpresented

forarandomtimebetween500and1000ms).Justpriortothepresentationofthefinal

backgroundofthetrial(inwhichthetargetindividualappears),aneutraloremotional

primefromtheIAPSappearedfor275ms.Afterthefinalbackgroundandtargetappeared,

participantshad650msinwhichtorespond.Ifthistimeelapsedwithoutaresponse,

participantsweregivenamessageencouragingthemtorespondmorequicklyon

subsequenttrials.Theprimaryoutcomesofinterestwereparticipants'abilitytocorrectly

andquicklyclassifythetargetsasthreateningornotasafunctionofprimetype,andtheir

physiologicalreactivityasafunctionofprimeandtargettype.Physiologicalresponsesto

thestimuli(includingheartrate,respiration,andskinconductance)weremonitoredusing

theBioPacMP150system.Heartratewasmeasuredviaelectrodesattachedtothechest

(justbelowthecollarboneoneitherside),skinconductancewasmeasuredviaelectrodes

attachedtothetipsofadjacentfingersonthenon-dominanthand,andrespirationwas

measuredbyastraingaugebeltaroundthechest.Beforebeginningtheemotionally

evocativetaskateachsession,participantswerealsoaskedtocompletethePerceived

StressScale(PSS;Cohen,1983),theLifeOrientationTest-Revisedoptimismquestionnaire

(LOT-R;Scheier,Carver,&Bridges,1994),theBerkeleyExpressivityQuestionnaire(BEQ;

Gross&John,1997),andtheEmotionRegulationQuestionnaire(ERQ;Gross&John,2003).

Whilewedidnothavespecificpredictionsfortheseindividualdifferencevalues,these

measureswereincludedsothattheireffectsoncompliancemaybeobserved.


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IX.RESULTS

Theanalysesperformedonthedatacollectedexaminedavarietyofvariables

includingprimetype,targettype,effectsofcondition,accuracyofresponse,reactiontime

oncorrecttrials,percentageofgunresponse,skinconductanceresponseheartrate,and

individualdifferencevariables,amongothers.Wealsoexaminedtheseeffectsasthey

changedacrosssessions.Weaskedavarietyofquestionsaboutthesevariables;wewere

interestedspecificallyinwhichvariables(bothbehavioralandphysiological)wereaffected

bythetask(primeandtargettype),whichvariableswereaffectedbytheintervention,

whichindividualdifferencevariableswererelatedtotaskperformance,whichfactors

predictaccuracy,whichfactorspredictfasterreactiontimesoncorrecttrials,andwhich

factorspredictedtheprobabilityofagunresponse.

Wehadafewgeneralpredictionsaboutthesequestions.Weexpectedthat

emotionalreactivity,reactiontime,anderrorrateswouldallbehigheronemotionalprime

andtargettrialsthanneutralprimeandtargettrials,butthattheseeffectswouldbe

reducedinthemindfulnessgroupspost-trainingpoint.Essentially(onaconceptuallevel),

webelievedthatmindfulnesstrainingwouldimproveperformanceandemotional

reactivityonalaboratory-basedstresstask.Wedidnothaveanyspecificpredictionsfor

theindividualdifferencevariables,althoughwedidrunstatisticalanalysesonthese

variablestogainabetterunderstandingofwhatcharacteristicsmayaffectcompliance

ratesandtaskperformance.

Theresultsindicatedawiderangeofinteractionsandmaineffects.Itisperhaps

besttobeginwiththemostbasicmaineffectsobserved;inlookingatreactionsatSession1


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only,wefoundthataccuracy,reactiontimeoncorrecttrials,gunresponse,andGSR

showedvarianceasafunctionofprimeandtargettype(theheartratemeasuredidnot

showanysignificanteffectsandwasthusleftoutofthesubsequentanalyses).Inthe

accuracyanalysis,wefoundasignificantmaineffectoftargettypebutnotprime,indicating

thatparticipantsweremoreaccurateinguntrialsregardlessofprimetype.Whilewedid

notseeasignificantinteractionbetweenprimeandtargettype,wedidseeatrend:

participantsseemedtogetmorecorrectanswersonemotionalprime/guntrialsthanother

trials.ThisisillustratedinFigure1,AppendixA.

AtSession1,wealsonoticedtwosignificantmaineffectsandasignificant

interactionbetweenprimetypeandtargettypeforreactiontimeoncorrectresponsetrials.

Thisindicatesthatparticipantswererespondingmorequicklyonguntrialsregardlessof

primeandemotionaltrialsregardlessoftarget,andthattheywererespondingparticularly

quicklyontrialsthatpairedanemotionalprimewithaguntarget.Thisisdepictedin

Figure2,AppendixA.

Therewerealsosignificantmaineffectsofprimeandtargettypeongunresponses

atSession1,althoughtherewasnointeraction.Participantsweremorelikelytorespond

gunonguntrials,butwerealsomorelikelytorespondgunonemotionallyprimedtrials

regardlessoftargettype.SeeFigure3,AppendixA.

Itisimportantnowtopointoutthattheseresultsindicateacertainresponsebiasin

ourparticipants.Peoplewerebiasedtowardsrespondinggunasaresultofemotional

primes,whichhassignificantimplicationsforourresults.


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Theskinconductanceresponsesdemonstratedasimilarpattern(andasimilar

responsebias)oftwosignificantmaineffectsofprimeandtargettype,butnointeraction.

Skinconductancewashigherinemotionallyprimedtrialsregardlessoftargettype,and

wasalsohigheringuntrialsregardlessofprime.ThispatterncanbeseeninFigure4,

AppendixA.

Thevariableofgreatestinterestinthisstudywascondition,andthechangesinour

measuresasafunctionofconditionprovedtobeinterestingdespitelowcompliancerates

fortheintervention.Toaccountforthisissue,welimitedouranalysestoonlyinclude

participantsabovethemediantotaltimespentontheintervention.

Thefirstchangeweexaminedwaschangeinaccuracyasafunctionofcondition

(observableinFigure5,AppendixA).Here,wenotedanimprovementinperformanceon

neutralprimeguntrialsasafunctionofthemindfulnessintervention,butitislikelythat

thisissignificantonlybecausethisgroupperformedpoorlyinthisareainSession1.Itis

importanttonotethatwasadegreeofinconsistencybetweenthemindfulnessgroupand

thecontrolatSession1,whichmayaccountforsomeofthefollowingsignificantresults.

Nevertheless,wedidseeamarginalinteractionbetweenprimetype,targettype,condition,

andsessionfortheaccuracymeasure.

Thesecondchangeweobservedyieldsperhapsthebestresult:therewasa

significantmaineffectofsessiononresponsetimesforcorrecttrials(seeFigure6,

AppendixA).ParticipantswerefasteratrespondinginSession2thanSession1,but

fascinatingly,thespeed-upinthecontrolgroupisconsistentwiththeresponsebias

demonstratedintheSession1results(theseparticipantsshowedthegreatestincreasein


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speedonemotionalprimedguntrials).Weobservedasignificantfour-wayinteraction

betweenprimetype,targettype,condition,andsessionforthismeasure.

Thegunresponsemeasuredidnotyieldanysignificantmaineffectsorinteractions

(seeFigure7,AppendixA).Everybodyimprovedregardlessofcondition:gunresponses

increasedonguntrialsanddecreasedonneutraltargettrials.Itisnotclearthatthereis

anythingworthnotinggoingonhere,orthatthetwoconditionsdifferedinresponseto

emotionalprimeorguntrials.

Similarly,therewerenosignificantchangesinskinconductanceasafunctionof

condition.ThiscanbeseeninFigure8,AppendixA.

Wenextexaminedindividualdifferencevariablesandobservedsomeinteresting

effects:first,allsix-wayinteractionsweresignificant(emotionalprime*gun*session*

condition*totaltime*individualdifferencevariables),andsecond,wenotedthateach

individualdifferencevariablehadimplicationsforthemeasuresofaccuracy,responsetime,

gunresponsepercentage,andskinconductanceresponse.Toreiterate,weexamined

individualdifferencevariablesinfourareas:perceivedstress,emotionalexpressivity,

optimism,andemotionregulationability.

Therewasasignificantinteractionbetweentheperceivedstressmeasureand

accuracyonguntrials:individualswhoreportedhighermeasuresinperceivedstresswere

lesslikelytobecorrectonguntrials.Thiseffectwasalsoobservedinemotional

suppression:individualshigherinemotionalsuppressionwerealsolessaccurateongun

trials.


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Foremotionalexpressivity,wenoticedthatindividualswithahighercomposite

scorewerelessaccurateonemotionaltrials.Wealsonotedamarginalinteractionbetween

emotionalexpressivity,emotionalprimes,andguntargets,indicatingthatpeoplehigherin

emotionalexpressivityareexhibitingtheresponsebiasparticularlystronglyascompared

toothers.

Therewerealsoeffectsofcognitivereappraisal,whichisasubscaleintheemotional

regulationquestionnaire.Individualswhoreportedhigherscoresincognitivereappraisal

wereslowertorespondonguntrials.Therewasamarginaltendencyinthesamedirection

withemotionalsuppression,anotherERQsubscale.

Aswecansee,theindividualdifferencevariablesyieldedcomplexresults.Further

analysisisnecessarytodeterminetheimplicationsoftheseresults.

X.DISCUSSION

Itisimportanttounderstandthatwhileourmaineffectsandinteractionswere

significant,atleastsomeofthissignificancecanbeattributedtotheinductionofaresponse

bias.Toclarify,wefoundthatparticipantsweresignificantlyquickerandmoreaccurateat

respondingtoguntrialsprimedwithemotionalstimuli;howevertheemotionalprimemay

itselfcauseparticipantstoanswergunsimplyduetoitsnature.Thereisaclear

associationbetweenemotionallyupsettingdepictionsofviolenceandguns,andthus,the

emotionalprimesmayinvokementalassociationswithgunsandleadtosucharesponse

bias.


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Whilewemighttakethisasareasontodownplaythesignificanceofourresults,its

implicationsforreal-worldsituationsshouldnotbeignored.Theexistenceofaresponse

biasinacombatsituationcouldbeapotentiallygraveconsequenceofwar:iftheresultsof

thestudycarryandthiseffectisobservedincombat,thissuggestsaninnatemechanismby

whichterriblemistakescanhappen.Ifviolencemakespeoplemisperceivethreatorpull

thetriggerinspiteoftheirperceptionsfordefensepurposes,costlyerrorsmaybemade.

Thus,itiscrucialthatthismechanismisunderstoodandstepsaretakentocounteractits

effects.

Inreflectinguponthenarrowerscopeofthisstudy,themostreadilyidentifiable

difficultyencounteredindesignandimplementationwascomplianceamongparticipants,

whichcanbecontributedlargelytothemethodofrecruitment.Becausetheparticipants

weregatheredfromthePSYC1participantpool,theircommitmenttothestudywas

seriouslylacking;participantsreceivedcoursecreditaslongastheyshowedupatthe

laboratoryforbothsessions,regardlessofwhetherornottheycompletedtheintervention

betweensessionsasdirectedornot.

Duetotheease,accessibility,andspeedofrecruitingfromtheparticipantpool,this

sourcewasultimatelydeterminedtobethebestplacetofindparticipants.Unfortunately,

thishadimplicationsforthequalityofparticipation:noparticipantscompletedthetraining

fortheentireeightweeksasinstructed,fewcompletedsometraining,andothers

completednotrainingatall.AccordingtotheworkdonebyKabat-Zinn(1982),the

programrequiressignificantdedication,withobservableeffectsemergingaftereight

weeksoftrainingfor45minutesperday,sixorsevendaysperweek.Noneofour


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participantscompletedthisamountoftrainingandthereforeourfindingswerenotrobust.

BasedontheresultsofKabat-Zinnsstudy,itislikelythatourresultswouldhavebeen

betterhadtheparticipantscompletedthetrainingasinstructed.Whilethiscouldbe

remediedbycarryingoutthestudyinapreexistingmeditationclinic,theresultswould

thenlackgeneralizabiltiy:itislikelythatwewouldseedifferentresults,butitwouldbe

difficulttoapplythemtosoldiers,whoareregularpeopleratherthanexpertorparticularly

willingmeditators.

Continuingwiththeconceptofgeneralizability,itisalsoimportanttonotethatthe

resultsofthecurrentstudyeveniftheyhadbeensignificantwouldhavebeendifficult

toapplywithinthebroadconceptualframeworkdescribed.Whileemotionalregulation

mayhaveimprovedandphysiologicalarousalmayhavedecreasedwithinthecontextof

theIAPSphotographs,itislikelythattheextentofthetraumaexperiencedinawarinvokes

afarmorecomplicatedemotionalandphysiologicalresponse.Likewise,thedurationof

exposuretotraumaticstimuliinawarisfargreaterthanthe325mspresentationofthe

photographsintheexperiment;suchlongexposuretosuchseverelydisturbingstimuli

seemsinmanywaysimpossibletocounteract.Nevertheless,theeffectivenessof

mindfulnessmeditationasatreatmentforpost-traumaticstressdisorder(andcombat-

relatedPTSDinparticular)stillhasmerit,andadditionalresearchshouldseektoexplore

thisrelationshipandtailorthepracticesuchthatitbetterfitstheneedsofsoldiers.

Insummation,thoroughlyassessingtheoverarchinghypotheseswasdifficultgiven

theavailableresources.Nonetheless,thisstudywasagoodfirststep.Ifmoreresearchcan

becompletedtobetterunderstandmindfulnessanditsclinicalbenefits,perhapsmore


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individualscanbeconvincedtocomplywiththetrainingandexperiencesucheffects.As

mindfulnessbecomesmoremainstream,itislikelythatmorepeoplewillsubscribetothe

practice,makingstudieslikethisoneeasierandtheresultsmorerobust.Hopefully,theuse

ofsuchatherapeuticpracticewillbecomemorecommon,andthesignificantadvantages

gainedfromitcanbeputtouseinavarietyofcontextstobetterensurethesafetyand

psychologicalwellbeingofamultitudeofpopulations.


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APPENDIXA

FIGURE1:TIME1REACTIONS/ACCURACYASAFUNCTIONOFPRIMEANDTARGETTYPE

FIGURE2:TIME1REACTIONS/REACTIONTIMEONCORRECTRESPONSESASAFUNCTIONOFPRIME

ANDTARGETTYPE

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-.+/$

012/$

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1230$


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FIGURE3:TIME1REACTIONS/PERCENTOFGUNRESPONSESASAFUNCTIONOFPRIMEANDTARGET

TYPE

FIGURE4:TIME1REACTIONS/SKINCONDUCTANCERESPONSEASAFUNCTIONOFPRIMEANDTARGETTYPE

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FIGURE5:CHANGEINACCURACYFROMSESSION1TOSESSION2ASAFUNCTIONOFCONDITION

FIGURE6:CHANGEINREACTIONTIMEONCORRECTRESPONSESASAFUNCTIONOFCONDITION

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FIGURE7:CHANGEINPERCENTAGEOFGUNRESPONSESASAFUNCTIONOFCONDITION

FIGURE8:CHANGEINSKINCONDUCTANCERESPONSEASAFUNCTIONOFCONDITION

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