A Multisite Randomized Controlled Trial of Mindfulness-Based Stress Reduction in the Treatment of Posttraumatic Stress Disorder

Randomized controlled trials of mind-body interventions for posttraumatic stress disorder: a systematic review

Mind-body interventions (MBIs) include mindfulness-based interventions (MiBIs), meditation- and mantra-based interventions (MMIs), and movement-based interventions (MoBIs). These approaches have demonstrated preliminary efficacy in improving posttraumatic stress disorder (PTSD) symptoms. However, previous systematic reviews and meta-analyses have noted that this area of research is limited by inadequate comparator conditions, heterogeneity of measurement, and absence of objective outcome measures. For these reasons, an updated review of the highest-quality evidence available is warranted. We used the Agency for Healthcare Research and Quality (AHRQ)-funded evidence tables for the PTSD-Repository to identify relevant studies and assess the risk of bias as follows: The search was conducted between June 2018 and June 2022, and databases included PTSDpubs (formerly PILOTS), Ovid® MEDLINE®, Cochrane CENTRAL, Embase®, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), SCOPUS, and PsycINFO®. Twenty-six randomized controlled trials met our inclusion criteria. After identifying studies and retrieving risk of bias information from the PTSD-Repository evidence tables, we extracted additional data and synthesized the evidence. The strength of evidence was rated as low for MiBIs and MMIs, largely due to contradicting results, inconsistent use of active versus passive comparators, and high risk of bias. The strength of evidence for MoBIs was rated as moderate due to individual studies consistently favoring the intervention and a relatively large number of studies and participants. Of the 26 included studies, only two included objective outcome measures. Implications for future MBI research and clinical applications for treating PTSD are discussed.

Predictors of Treatment Completion among Women Receiving Integrated Treatment for Comorbid Posttraumatic Stress and Substance Use Disorders

Background: Retention in treatment for individuals with comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is an area of concern in treatment outcome studies. The current study explores key variables related to retention in a group of women with comorbid PTSD and SUD enrolled in community SUD treatment randomized to eight weekly sessions of a trauma adapted mindfulness-based relapse prevention (TA-MBRP) or an integrated coping skills (ICS) group intervention. Methods: Two unadjusted and adjusted logistic discrete failure time (DFT) models were fit to examine associations between participants and the time (in weeks) to treatment completion status. Key covariates of interest, including time-varying PTSD Symptom Scale-Self Report (PSS) total score, time-varying Five Factors Mindfulness Questionnaire (FFMQ) total score, group assignment, baseline endorsements of substance use and demographics such as age, race and employment status were fit into the model. Results: In the adjusted PSS model, increased levels of PTSD symptom severity (PSS) scores at week 5 and 7 (PSS OR: 1:06: OR 1.13, respectively) were associated with higher odds of non-completion. In the FFMQ model, increased levels of FFMQ scores at week 6 (OR: 0:92) were associated with lower odds of non-completion. In both models, assignment to the ICS control group and unemployment were associated with lower odds of completion and baseline use of cocaine and sedatives were associated with higher odds of completion. Conclusion: Monitoring PTSD symptom severity and measures of mindfulness can inform providers on strategies to enhance retention early in treatment for individuals with comorbid PTSD/SUD.ClinicalTrials.gov # NCT02755103.

Who Sticks with Meditation? Rates and Predictors of Persistence in a Population-based Sample in the USA

Objectives

Despite the well-documented psychological benefits of meditation practice, limited research has examined factors associated with meditation practice persistence. Like other health behaviors (e.g., exercise), non-persistence may undermine the effectiveness of meditation.

Methods

We examined rates and correlates of meditation persistence using a population-based sample (n = 953) in the United States. Persistence was operationalized in two ways: number of lifetime practice sessions (i.e., lifetime persistence) and current practice frequency (i.e., current persistence). Consistent with the National Health Interview Survey, we defined meditation as mindfulness meditation, mantra meditation, and spiritual meditation. We examined factors related to the Reasoned Action Approach (RAA), a theory that has been used to explain adherence to health behaviors.

Results

Almost half of the sample (49.3%) indicated lifetime exposure to meditation and a third (35.0%) indicated practice in the past year. Factors positively associated with persistence (lifetime and/or current) included having spoken with a meditation teacher, higher perceived effectiveness of meditation, higher meditation-positive subjective norms, lower perceived barriers, higher conscientiousness, higher wellbeing growth mindset, and retreat experience. Factors negatively associated with persistence included first exposure through various forms of technology and having a mental health motivation for practice. First exposure through a smartphone app and first exposure through friends and family were not associated with lifetime or current persistence. Findings were unchanged after controlling for demographics and applying a false discovery rate p-value adjustment.

Conclusions

These findings provide insights into factors that may promote persistence with meditation which can guide the delivery of meditation training.

Preregistration

This study was preregistered at the Open Science Framework (https://osf.io/4h86s).

The efficacy of mindfulness-based stress reduction intervention 3 for post-traumatic stress disorder (PTSD) symptoms in patients with PTSD: A meta-analysis of four randomized controlled trials

As one of the most widely used mindfulness-based psychotherapeutic intervention techniques, mindfulness-based stress reduction (MBSR) has emerged as an auxiliary or alternative technique for the treatment of post-traumatic stress disorder (PTSD). This study conducted a meta-analysis of the effect of MBSR on the changes in symptoms in PTSD patients. The final search was conducted on 10 December 2021, and 10 eligible randomized controlled trials were identified, including 768 participants. A quality assessment was conducted. Proportional sensitivity analysis and random effects meta-analysis were performed, and the 95% confidence interval was calculated. Subgroup analyses were also conducted to identify moderators (e.g., features of population and intervention). Compared with the control condition, MBSR significantly reduced the symptoms of PTSD patients and had a moderately positive effect (g = 0.46, 95% CI: 0.31-0.62, p < 0.001). This was the case in people who suffer from PTSD for different reasons, indicating that MBSR is an effective treatment for PTSD symptoms in PTSD patients. It was feasible to implement MBSR interventions for PTSD patients caused by different reasons.

Biomarker Response to Mindfulness Intervention in Veterans Diagnosed with Post-traumatic Stress Disorder

Objectives

This study evaluates the effects of treatment with mindfulness-based stress reduction (MBSR) compared to the active control, present-centered group therapy (PCGT), on morning plasma cortisol, interleukin-6 (IL-6), and C-reactive protein (CRP) in veterans diagnosed with post-traumatic stress disorder (PTSD).

Methods

In a post hoc exploratory analysis, we pooled biomarkers and clinical outcomes of mindfulness, PTSD, and depression from two randomized controlled trials comparing MBSR (n = 104) to PCGT (n = 106) in U.S. military veterans diagnosed with PTSD. Linear mixed-effects modeling was used to evaluate associations between changes in biomarkers and clinical outcomes from baseline to 9-week primary endpoint and 16-week follow-up endpoint.

Results

Cortisol levels were inversely related to self-reported PTSD symptoms at baseline (p = 0.02). Cortisol increased from baseline to 9-week endpoint for both groups, but significantly less so in the MBSR group compared to PCGT group (mean difference 1.69 ± 0.8 SE; p = 0.035). Changes in IL-6 and CRP did not differ between groups at either baseline or week 9. From baseline to week 9, increased mindfulness was significantly associated with increased cortisol (p = 0.02) and decreased PTSD and depression severity (p < 0.01). Increased IL-6 and CRP were significantly associated with decreased PTSD severity (p < 0.05), but not depression. Pooled analysis corroborated earlier findings that MBSR is significantly better than PCGT in improving clinical outcomes. Increased mindfulness was strongly associated with improved symptoms.

Conclusions

Increased mindfulness is associated with a recalibration of cortisol levels which may be indicative of therapeutic response, especially in patients with lower baseline cortisol. Furthermore, mindfulness-based practices improve symptoms of PTSD and depression in a significant correlation with self-reported levels of mindfulness.

Clinical Trial Registration clinicaltrialsgov

NCT01532999 and NCT01548742.

Impact of a Mindfulness-Based Stress Reduction Program on Psychological Well-Being, Cortisol, and Inflammation in Women Veterans

BACKGROUND

Women veterans experience higher levels of stress-related symptoms than their civilian counterparts. Psychological stress is associated with greater inflammation and may increase risk for cardiovascular disease (CVD). Mindfulness-based stress reduction (MBSR) has been found to improve psychological well-being in other populations but no randomized controlled trials (RCT) have been conducted examining the impact of MBSR on well-being and inflammation in women veterans at risk for CVD.

OBJECTIVE

Determine the effectiveness of MBSR in improving psychological well-being, cortisol, and inflammation associated with CVD in women veterans.

DESIGN

The design is a RCT comparing MBSR to an active control condition (ACC) consisting of a health education program.

PARTICIPANTS

Women veterans (N=164) with risk factors for CVD from the Chicagoland area participated in the study.

INTERVENTION

An 8-week MBSR program with weekly 2.5-h classes was compared to an ACC consisting of an 8-week health promotion education program with weekly 2.5-h classes.

MAIN MEASURES

The outcomes were psychological well-being [perceived stress, depressive symptoms, loneliness, and post-traumatic stress disorder (PTSD)] symptoms and stress-related markers, including diurnal salivary cortisol and cytokines interleukin-6 (IL-6) and interferon gamma (IFN-γ). Data were collected at baseline, 4 weeks (mid-point of intervention), 8 weeks (completion of intervention), and 6 months after completion of MBSR or ACC.

KEY RESULTS

Compared to the ACC, women who participated in MBSR reported less perceived stress, loneliness, and symptoms of PTSD. Although there were no significant differences between groups or changes over time in IL-6 or IFN-γ, participants in the MBSR program demonstrated a more rapid decline in diurnal salivary cortisol as compared to those in the ACC.

CONCLUSIONS

MBSR was found to improve psychological well-being and decrease diurnal salivary cortisol in women veterans at risk for CVD. Health care providers may consider MBSR for women veterans as a means by which to improve their psychological well-being.

Effectiveness of Mindfulness-Based Stress Reduction Therapy on the Quality of Life of Patients with Lung Cancer

Background

Lung cancer is one of the most common and life-threatening cancers in men around the world. Therefore, it is important to pay particular attention to the psychological status of patients with lung cancer due to their greater vulnerability during treatment. This study aimed to evaluate the effectiveness of mindfulness-based stress reduction therapy on the quality of life of patients with lung cancer.

Materials and Methods

This quasi-experimental study, with a pretest-posttest design and a three-month follow-up, was conducted in the summer of 2019. Thirty patients with lung cancer, who were referred to Masih Daneshvari Hospital in Tehran, Iran, were selected through purposive sampling and randomly assigned to experimental (n=15) and control (n=15) groups. In the pretest stage, the Short-Form Health Survey (SF-36) was completed by both groups. The experimental group received mindfulness-based stress reduction therapy for eight sessions, while the control group did not receive any intervention. In the posttest stage, both groups were examined again, and data were analyzed using SPSS version 21 by repeated measures multivariate analysis of variance (MANOVA).

Results

The findings showed a significant difference between the experimental and control groups after mindfulness-based stress reduction therapy. In other words, the mean score of quality of life increased in the experimental group as compared to the control group (P<0.001).

Conclusion

Based on the results of this study, the effectiveness of mindfulness-based stress reduction therapy in increasing the quality of life of patients with lung cancer was confirmed. Therefore, psychological screening is suggested to improve the quality of life of patients by taking advantage of clinical trials and appropriate intervention models during medical treatment.

The Effects of Mindfulness-Based Stress Reduction on Trauma in Victims of Gun Violence: a Pilot Study

Objectives

Gun violence is a significant problem in the United States of America. Gun violence produces lifelong psychological adversity, trauma, and grief. In the face of this epidemic, efficacious therapies that assuage gun violence-based trauma and negative health are lacking.

Methods

The proposed, longitudinal pilot experiment examined the effects of an 8-week mindfulness-based stress reduction (MBSR) program on traumatized individuals as a direct consequence of gun violence. Twenty-four victims of gun violence (median age = 53 years; 21 female) completed measures of the primary outcome: trauma. Secondary outcomes were characterized as grief, depression, sleep quality, life satisfaction, and mindfulness. All assessments were administered before, after 5, and 8 weeks of MBSR training. It was hypothesized that trauma and other comorbidities would improve following MBSR. It was also predicted that outcomes would be significantly stronger from baseline to 5 weeks of MBSR training than from 5 to 8 weeks of training.

Results

Before MBSR, volunteers exhibited high levels of trauma, depression, sleep difficulty, and grief. Participation in MBSR was associated with improved trauma, depression, sleep difficulty, and life satisfaction. The most pronounced improvements in psychological disposition were exhibited within the first 5 weeks of MBSR. However, these benefits were largely preserved after completion of the course. Importantly, increases in dispositional mindfulness predicted lower trauma, complicated grief, and sleep difficulties.

Conclusions

The present findings should be interpreted with caution because they were derived from an uncontrolled, non-randomized trial. However, said findings suggest that MBSR may reduce trauma and improve overall well-being in gun violence victims.

A Web-Based Cognitive Behavioral Therapy, Mindfulness Meditation, and Yoga Intervention for Posttraumatic Stress Disorder: Single-Arm Experimental Clinical Trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is a debilitating, undertreated condition. The web-based delivery of cognitive behavioral therapy supplemented with mindfulness meditation and yoga is a viable treatment that emphasizes self-directed daily practice.

OBJECTIVE

This study aims to examine the effectiveness of a web-based cognitive behavioral therapy, mindfulness, and yoga (CBT-MY) program designed for daily use.

METHODS

We conducted an 8-week, single-arm, experimental, registered clinical trial on adults reporting PTSD symptoms (n=22; aged 18-35 years). Each participant received web-based CBT-MY content and an hour of web-based counseling each week. Pre-post outcomes included self-reported PTSD symptom severity, depression, anxiety, chronic pain, and mindfulness. Pre-post psychophysiological outcomes included peak pupil dilation (PPD) and heart rate variability (HRV). HRV and PPD were also compared with cross-sectional data from a non-PTSD comparison group without a history of clinical mental health diagnoses and CBT-MY exposure (n=46).

RESULTS

Pre-post intention-to-treat analyses revealed substantial improvements in PTSD severity (d=1.60), depression (d=0.83), anxiety (d=0.99), and mindfulness (d=0.88). Linear multilevel mixed models demonstrated a significant pre-post reduction in PPD (B=-0.06; SE=0.01; P<.001; d=0.90) but no significant pre-post change in HRV (P=.87). Overall, participants spent an average of 11.53 (SD 22.76) min/day on self-directed mindfulness practice.

CONCLUSIONS

Web-based CBT-MY was associated with clinically significant symptom reductions and significant PPD changes, suggesting healthier autonomic functioning. Future randomized controlled trials are needed to further examine the gains apparent in this single-arm study.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03684473; https://clinicaltrials.gov/ct2/show/NCT03684473.

The mediating role of emotion dysregulation in the association between trait mindfulness and PTSD symptoms among trauma-exposed adults

Objectives

Growing evidence of the effectiveness of mindfulness-based interventions for posttraumatic stress disorder (PTSD) warrants greater understanding of factors relevant to the relation between trait mindfulness and PTSD, such as emotion dysregulation (ED). The goal of this study was to examine associations between trait mindfulness, ED, and PTSD symptoms across two samples of trauma-exposed adults.

Methods

Participants for Sample 1 (n = 39, 90% women, 100% Black) and Sample 2 (n = 60, 100% women, 87% Black) were recruited from an urban hospital in the South. Trait mindfulness, ED, and PTSD were assessed.

Results

Across both samples, mindfulness and ED were significantly associated with overall PTSD severity (r = -.49 and r = -.42, ps = .001; r = .53 and r = .51, ps < .001, respectively) in the expected direction. In Sample 1, mindful nonjudgment and difficulty with emotion regulation strategies showed the strongest associations with overall PTSD severity as well as symptom clusters. In Sample 2, mindful acceptance and all ED dimensions (except non-awareness) showed strong associations with overall PTSD severity and particularly with negative cognitions and mood symptoms. In both samples, ED mediated the association between mindfulness and overall PTSD severity (Sample 1: ab = -.15, 95%CI [-.35, -.02]; Sample 2: ab = -.11, 95%CI [-.22, -.04]).

Conclusions

These findings demonstrate the important role of ED in the relation between trait mindfulness and PTSD symptoms among trauma-exposed adults. They highlight the value of examining ED as a mechanism of change in mindfulness-based interventions for PTSD.

Clinical Trials Registration Information

Sample 1: NCT03922581, April 22, 2019; NCT03938350, May 6, 2019; Sample 2: NCT02754557, April 28, 2016.

Does treatment preference affect outcome in a randomized trial of a mindfulness intervention versus cognitive behaviour therapy for social anxiety disorder?

Research suggests that treatment preference may affect outcome of randomized clinical trials, but few studies have assessed treatment preference in trials comparing different types of psychosocial interventions. This study used secondary data analysis to evaluate the impact of treatment preference in a randomized trial of a mindfulness-based intervention adapted for social anxiety disorder (MBI-SAD) versus cognitive behaviour group therapy (CBGT). Ninety-seven participants who met DSM-5 criteria for SAD were randomized. Prior to randomization, twice as many participants expressed a preference for the MBI-SAD over CBGT. However, being allocated or not to one's preferred treatment had no impact on treatment response. Additionally, with the exception of perception of treatment credibility, treatment matching had no impact on treatment-related variables, including treatment initiation, session attendance, homework compliance, satisfaction with treatment and perception that treatment met expectations. In sum, despite the greater preference for the mindfulness intervention in this sample of participants with SAD, we found little evidence of preference effects on our study outcomes. Findings should be viewed as preliminary and require replication.

Transcutaneous Cervical Vagus Nerve Stimulation Lengthens Exhalation in the Context of Traumatic Stress

Transcutaneous electrical stimulation of the vagus nerve is believed to deliver afferent signaling to the brain that, in turn, yields downstream changes in peripheral physiology, including cardiovascular and respiratory parameters. While the effects of transcutaneous cervical vagus nerve stimulation (tcVNS) on these parameters have been studied broadly, little is known regarding the specific effects of tcVNS on exhalation time and the spontaneous respiration cycle. By understanding such effects, tcVNS could be used to counterbalance sympathetic hyperactivity following distress by enhancing vagal tone through parasympathetically favored modulation of inspiration and expiration - specifically, lengthened expiration relative to inspiration. We thus investigated the effects of tcVNS on respiration timings by decomposing the respiration cycle into inspiration and expiration times and incorporating state-of-the-art respiration quality assessment algorithms for respiratory effort belt and electrocardiogram derived respiration signals. This enabled robust estimation of respiration timings from quality measurements alone. We thereby found that tcVNS increases expiration time minutes after stimulation, compared to a sham control (N = 26). This suggests that tcVNS could counteract sympathovagal imbalance, given the relationship between expiration and heightened vagal tone.

Military-related posttraumatic stress disorder and mindfulness meditation: A systematic review and meta-analysis

PURPOSE

Posttraumatic stress disorder (PTSD) is a significant global mental health concern, especially in the military. This study aims to estimate the efficacy of mindfulness meditation in the treatment of military-related PTSD, by synthesizing evidences from randomized controlled trials.

METHODS

Five electronic databases (Pubmed, EBSCO Medline, Embase, PsychINFO and Cochrane Library) were searched for randomized controlled trials focusing on the treatment effect of mindfulness meditation on military-related PTSD. The selection of eligible studies was based on identical inclusion and exclusion criteria. Information about study characteristics, participant characteristics, intervention details, PTSD outcomes, as well as potential adverse effects was extracted from the included studies. Risk of bias of all the included studies was critically assessed using the Cochrane Collaboration's tool. R Statistical software was performed for data analysis.

RESULTS

A total of 1902 records were initially identified and screened. After duplicates removal and title & abstract review, finally, 19 articles in English language with 1326 participants were included through strict inclusion and exclusion criteria. The results revealed that mindfulness meditation had a significantly larger effect on alleviating military-related PTSD symptoms compared with control conditions, such as treatment as usual, present-centered group therapy and PTSD health education (standardized mean difference (SMD) = -0.33; 95% CI [-0.45, -0.21]; p < 0.0001). Mindfulness interventions with different control conditions (active or non-active control, SMD = -0.33, 95% CI [-0.46, -0.19]; SMD = -0.49, 95% CI [-0.88, -0.10], respectively), formats of delivery (group-based or individual-based, SMD = -0.30, 95% CI [-0.42, -0.17], SMD = -0.49, 95% CI [-0.90, -0.08], respectively) and intervention durations (short-term or standard duration, SMD = -0.27, 95% CI [-0.46, -0.08], SMD = -0.40, 95% CI [-0.58, -0.21], respectively) were equally effective in improving military-related PTSD symptoms.

CONCLUSION

Findings from this meta-analysis consolidate the efficacy and feasibility of mindfulness meditation in the treatment of military-related PTSD. Further evidence with higher quality and more rigorous design is needed in the future.

Psychological Impact of COVID-19 Confinement and Its Relationship with Meditation

The objective of this study was to evaluate the psychological impact of confinement due to the COVID-19 pandemic, considering any protective factors, such as the practice of meditation or self-compassion, and their relationship with different lifestyles and circumstances of adults residing in Spain. A cross-sectional study was done using an anonymous online survey in which 412 participants filled out the Depression, Anxiety and Stress Scale-2; the Impact of Events Scale; and the Self-Compassion Scale-Short Form, reporting severe symptomatology of posttraumatic stress and mild anxiety and depression. Quality of cohabitation and age were found to be key variables in the psychological impact of confinement. The impact of confinement was more negative for those who reported very poor cohabitation as opposed to very good (F (3, 405) = 30.75, p ≤ 0.001, d = 2.44, r = 0.054) or for those under 35 years of age compared to those over 46 (F (2, 409) = 5.14, p = 0.006, d = 0.36). Practicing meditation was not revealed as a protective factor, but self-compassion was related to better cohabitation during confinement (F (3, 403) = 11.83, p ≤ 0.001, d = 1.05). These results could be relevant in designing psychological interventions to improve coping and mental health in other situations similar to confinement.

Non-pharmacological and non-psychological approaches to the treatment of PTSD: results of a systematic review and meta-analyses

BACKGROUND

Non-pharmacological and non-psychological approaches to the treatment of post-traumatic stress disorder (PTSD) have often been excluded from systematic reviews and meta-analyses. Consequently, we know little regarding their efficacy.

OBJECTIVE

To determine the effect sizes of non-pharmacological and non-psychological treatment approaches for PTSD.

METHOD

We undertook a systematic review and meta-analyses following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

30 randomised controlled trials (RCTs) of a range of heterogeneous non-psychological and non-pharmacological interventions (28 in adults, two in children and adolescents) were included. There was emerging evidence for six different approaches (acupuncture, neurofeedback, saikokeishikankyoto (a herbal preparation), somatic experiencing, transcranial magnetic stimulation, and yoga).

CONCLUSIONS

Given the level of evidence available, it would be premature to offer non-pharmacological and non-psychological interventions routinely, but those with evidence of efficacy provide alternatives for people who do not respond to, do not tolerate or do not want more conventional evidence-based interventions. This review should stimulate further research in this area.

Maintenance of treatment gains up to 12-months following a three-week cognitive processing therapy-based intensive PTSD treatment programme for veterans

BACKGROUND

Intensive treatment programmes (ITPs) have shown promise for reducing PTSD and depression symptoms. It is still unknown whether treatment gains are maintained following completion.

OBJECTIVE

This study examined whether veterans were able to maintain treatment gains for up to 12 months after an ITP for PTSD and whether reductions in negative posttrauma cognitions predicted treatment gain maintenance.

METHODS

209 veterans (62.7% male, mean age = 40.86 years) completed a 3-week, CPT-based ITP for PTSD. Participants' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, post-treatment, and at 3-, 6-, and 12-month follow-up timepoints.

RESULTS

Despite small symptom increases from post-treatment to 3-month follow-up, significant and clinically meaningful reductions in PTSD and depression symptoms were reported from intake to 12 months follow-up (averaging >18 points on the PCL-5 and >6 points on the PHQ-9; d = 1.28, and d = 1.18, respectively). Greater reductions in negative posttrauma cognitions during treatment were associated with lower PTSD (p <.001) and depression (p =.005) severity at follow-up. Most veterans who completed the aftercare survey followed treatment recommendations and reported seeing a mental health provider at 3-, 6-, and 12-months post-treatment. Aftercare treatment did not significantly predict whether veterans maintained treatment gains at follow-up.

CONCLUSIONS

Overall maintenance of treatment gains long-term suggests veterans may be able to apply skills acquired during the ITP following treatment. These findings further support the feasibility and effectiveness of intensive, trauma-focused, evidence-based therapy delivery.

Dysregulation of inflammation, neurobiology, and cognitive function in PTSD: an integrative review

Compelling evidence from animal and human research suggest a strong link between inflammation and posttraumatic stress disorder (PTSD). Furthermore, recent findings support compromised neurocognitive function as a key feature of PTSD, particularly with deficits in attention and processing speed, executive function, and memory. These cognitive domains are supported by brain structures and neural pathways that are disrupted in PTSD and which are implicated in fear learning and extinction processes. The disruption of these supporting structures potentially results from their interaction with inflammation. Thus, the converging evidence supports a model of inflammatory dysregulation and cognitive dysfunction as combined mechanisms underpinning PTSD symptomatology. In this review, we summarize evidence of dysregulated inflammation in PTSD and further explore how the neurobiological underpinnings of PTSD, in the context of fear learning and extinction acquisition and recall, may interact with inflammation. We then present evidence for cognitive dysfunction in PTSD, highlighting findings from human work. Potential therapeutic approaches utilizing novel pharmacological and behavioral interventions that target inflammation and cognition also are discussed.

Resolution of Dissociated Ego States Relieves Flashback-Related Symptoms in Combat-Related PTSD: A Brief Mindfulness Based Intervention

A novel understanding and therapeutic approach to the treatment of PTSD-related flashback triggers are described. Triggered responses are conceptualized as the result of latent dissociative structures of neural organization and psychodynamic functioning activated by current events. The dissociative structure - here described as a dissociated ego state (DES) - reflects a fracturing of executive functioning resulting in a delimited aspect of self that is not under cognitive control or subject to cognitive inhibition by the self of daily experience, and is the psychological construct behind intrusive PTSD symptoms. Use of a mindful attentional state permits regulated access to the DES (therapeutic engagement without risk of emotional dysregulation) so that dissociated cognitive resources can be recovered and the dissociated structure deactivated. This may relieve maladaptive responses and behaviors associated with the DES in a profound and durable way, without the need for exposure to or recovery of traumatic memories. Based on this understanding, a 9-step intervention is introduced with a case example of a Vietnam veteran suffering PTSD symptoms for 49 years with significant gains maintained at 21 months follow up. These findings demonstrate rapid and durable resolution of chronic PTSD symptoms through a mindfulness-based approach that focused on deactivation of dissociated ego states, in contrast to targeting trauma memories. If proven efficacious, this novel approach may result in reduced treatment costs and improved outcomes for veterans suffering with PTSD.

Increasing Mindfulness Skills of Veterans With PTSD Through Daily Mindfulness Training Incorporated Into an Intensive Treatment Program

Objectives

Mindfulness training is frequently included as part of an integrative care approach to treating PTSD in veterans. However, the utility and acceptability of daily group mindfulness training in an intensive treatment program (ITP) for PTSD have not been explored. The study objectives were to determine: (a) whether mindfulness skills significantly increased from pre- to post-treatment and (b) if daily group mindfulness training was acceptable to veterans.

Methods

Veterans (N = 170 outpatients, age M = 40.7 (SD 9.3), 67.6% male) in this prospective study were consecutively enrolled in a 3-week ITP that included daily mindfulness group sessions. Mindfulness skills were assessed using the Five Facet of Mindfulness Questionnaire (FFMQ) at intake and post-treatment. Acceptability was assessed using an anonymous post-treatment program satisfaction survey.

Results

Paired t tests demonstrated significant increases in overall mindfulness skills from pre- to post-treatment (t(169) = - 6.33, p < 0.001, d = 0.49). Small to medium effect sizes were observed across subscales: describing, (t(169) = - 5.91, p < 0.001, d = 0.38); acting with awareness, (t(169) = - 3.70, p < 0.001, d = 0.29); nonjudging, (t(169) = - 7.54, p < 0.001, d = 0.58); and nonreactivity, (t(169) = - 4.84, p < 0.001, d = 0.41). Most veterans (n = 125, 74.4%) found daily mindfulness training moderately to very helpful.

Conclusions

Veterans' mindfulness skills significantly increased over the course of a 3-week ITP, and mindfulness training was found acceptable. Mindfulness training can be delivered daily as part of an ITP for veterans with PTSD, and mindfulness skills can meaningfully increase over the course of 3 weeks. A significant limitation is the lack of control condition.

Present-centered therapy (PCT) for post-traumatic stress disorder (PTSD) in adults

BACKGROUND

Present-centered therapy (PCT) is a non-trauma, manualized psychotherapy for adults with post-traumatic stress disorder (PTSD). PCT was originally designed as a treatment comparator in trials evaluating the effectiveness of trauma-focused cognitive-behavioral therapy (TF-CBT). Recent trials have indicated that PCT may be an effective treatment option for PTSD and that patients may drop out of PCT at lower rates relative to TF-CBT.

OBJECTIVES

To assess the effects of PCT for adults with PTSD. Specifically, we sought to determine whether (1) PCT is more effective in alleviating symptoms relative to control conditions, (2) PCT results in similar alleviation of symptoms compared to TF-CBT, based on an a priori minimally important differences on a semi-structured interview of PTSD symptoms, and (3) PCT is associated with lower treatment dropout as compared to TF-CBT.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register, the Cochrane Library, Ovid MEDLINE, Embase, PsycINFO, PubMed, and PTSDpubs (previously called the Published International Literature on Traumatic Stress (PILOTS) database) (all years to 15 February 2019 search). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing trials. Reference lists of included studies and relevant systematic reviews were checked. Grey literature searches were also conducted to identify dissertations and theses, clinical guidelines, and regulatory agency reports.

SELECTION CRITERIA

We selected all randomized clinical trials (RCTs) that recruited adults diagnosed with PTSD to evaluate PCT compared to TF-CBT or a control condition. Both individual and group PCT modalities were included. The primary outcomes of interest included reduced PTSD severity as determined by a clinician-administered measure and treatment dropout rates.

DATA COLLECTION AND ANALYSIS

We complied with the Cochrane recommended standards for data screening and collection. Two review authors independently screened articles for inclusion and extracted relevant data from eligible studies, including the assessment of trial quality. Random-effects meta-analyses, subgroup analyses, and sensitivity analyses were conducted using mean differences (MD) and standardized mean differences (SMD) for continuous data or risk ratios (RR) and risk differences (RD) for dichotomous data. To conclude that PCT resulted in similar reductions in PTSD symptoms relative to TF-CBT, we required a MD of less than 10 points (to include the 95% confidence interval) on the Clinician-Administered PTSD Scale (CAPS). Five members of the review team convened to rate the quality of evidence across the primary outcomes. Any disagreements were resolved through discussion. Review authors who were investigators on any of the included trials were not involved in the qualitative or quantitative syntheses.

MAIN RESULTS

We included 12 studies (n = 1837), of which, three compared PCT to a wait-list/minimal attention (WL/MA) group and 11 compared PCT to TF-CBT. PCT was more effective than WL/MA in reducing PTSD symptom severity (SMD -0.84, 95% CI -1.10 to -0.59; participants = 290; studies = 3; I² = 0%). We assessed the quality of this evidence as moderate. The results of the non-inferiority analysis comparing PCT to TF-CBT did not support PCT non-inferiority, with the 95% confidence interval surpassing the clinically meaningful cut-off (MD 6.83, 95% CI 1.90 to 11.76; 6 studies, n = 607; I² = 42%). We assessed this quality of evidence as low. CAPS differences between PCT and TF-CBT attenuated at 6-month (MD 1.59, 95% CI -0.46 to 3.63; participants = 906; studies = 6; I² = 0%) and 12-month (MD 1.22, 95% CI -2.17 to 4.61; participants = 485; studies = 3; I² = 0%) follow-up periods. To confirm the direction of the treatment effect using all eligible trials, we also evaluated PTSD SMD differences. These results were consistent with the primary MD outcomes, with meaningful effect size differences between PCT and TF-CBT at post-treatment (SMD 0.32, 95% CI 0.08 to 0.56; participants = 1129; studies = 9), but smaller effect size differences at six months (SMD 0.17, 95% CI 0.05 to 0.29; participants = 1339; studies = 9) and 12 months (SMD 0.17, 95% CI 0.03 to 0.31; participants = 728; studies = 5). PCT had approximately 14% lower treatment dropout rates compared to TF-CBT (RD -0.14, 95% CI -0.18 to -0.10; participants = 1542; studies = 10). We assessed the quality of this evidence as moderate. There was no evidence of meaningful differences on self-reported PTSD (MD 4.50, 95% CI 3.09 to 5.90; participants = 983; studies = 7) or depression symptoms (MD 1.78, 95% CI -0.23 to 3.78; participants = 705; studies = 5) post-treatment.

AUTHORS' CONCLUSIONS

Moderate-quality evidence indicates that PCT is more effective in reducing PTSD severity compared to control conditions. Low quality of evidence did not support PCT as a non-inferior treatment compared to TF-CBT on clinician-rated post-treatment PTSD severity. The treatment effect differences between PCT and TF-CBT may attenuate over time. PCT participants drop out of treatment at lower rates relative to TF-CBT participants. Of note, all of the included studies were primarily designed to test the effectiveness of TF-CBT which may bias results away from PCT non-inferiority.The current systematic review provides the most rigorous evaluation to date to determine whether PCT is comparably as effective as TF-CBT. Findings are generally consistent with current clinical practice guidelines that suggest that PCT may be offered as a treatment for PTSD when TF-CBT is not available.