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A Pilot Study Of Group Mindfulness???Based Cognitive Therapy (Mbct) For Combat Veterans With Posttraumatic Stress Disorder (Ptsd)

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Background: "Mindfulness-based" interventions show promise for stress reduction in general medical conditions, and initial evidence suggests that they are accepted in trauma-exposed individuals. Mindfulness-based cognitive therapy (MBCT) shows substantial efficacy for prevention of depression relapse, but it has been less studied in anxiety disorders. This study investigated the feasibility, acceptability, and clinical outcomes of an MBCT group intervention adapted for combat posttraumatic stress disorder (PTSD). Methods: Consecutive patients seeking treatment for chronic PTSD at a VA outpatient clinic were enrolled in 8-week MBCT groups, modified for PTSD (four groups, n = 20) or brief treatment-as-usual (TAU) comparison group interventions (three groups, n = 17). Pre and posttherapy psychological assessments with clinician administered PTSD scale (CAPS) were performed with all patients, and self-report measures (PTSD diagnostic scale, PDS, and posttraumatic cognitions inventory, PTCI) were administered in the MBCT group. Results: Intent to treat analyses showed significant improvement in PTSD (CAPS (t(19) = 4.8, P < .001)) in the MBCT condition but not the TAU conditions, and a significant Condition × Time interaction (F[1,35] = 16.4, P < .005). MBCT completers (n = 15, 75%) showed good compliance with assigned homework exercises, and significant and clinically meaningful improvement in PTSD symptom severity on posttreatment assessment in CAPS and PDS (particularly in avoidance/numbing symptoms), and reduced PTSD-relevant cognitions in PTCI (self blame). Conclusions: These data suggest group MBCT as an acceptable brief intervention/adjunctive therapy for combat PTSD, with potential for reducing avoidance symptom cluster and PTSD cognitions. Further studies are needed to examine efficacy in a randomized controlled design and to identify factors influencing acceptability and efficacy.
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DEPRESSION AND ANXIETY 00:1–8 (2013)
Research Article
A Pilot Study of Group Mindfulness-Based Cognitive Therapy
(MBCT) for Combat Veterans with Posttraumatic Stress
Disorder (PTSD)
Anthony P. King, Ph.D.,1,2 Thane M. Erickson, Ph.D.,3Nicholas D. Giardino, Ph.D.,1,2, 4
Todd Favorite, Ph.D.,1,2, 5 Sheila A.M. Rauch, Ph.D., ABPP,1,2, 4 Elizabeth Robinson, Ph.D., MSW,1Madhur
Kulkarni, Ph.D.,6and Israel Liberzon, M.D.1,2, 4
Background: “Mindfulness-based” interventions show promise for stress reduc-
tion in general medical conditions, and initial evidence suggests that they are
accepted in trauma-exposed individuals. Mindfulness-based cognitive therapy
(MBCT) shows substantial efficacy for prevention of depression relapse, but it
has been less studied in anxiety disorders. This study investigated the feasibil-
ity, acceptability, and clinical outcomes of an MBCT group intervention adapted
for combat posttraumatic stress disorder (PTSD). Methods: Consecutive pa-
tients seeking treatment for chronic PTSD at a VA outpatient clinic were en-
rolled in 8-week MBCT groups, modified for PTSD (four groups, n =20) or
brief treatment-as-usual (TAU) comparison group interventions (three groups,
n=17). Pre and posttherapy psychological assessments with clinician admin-
istered PTSD scale (CAPS) were performed with all patients, and self-report
measures (PTSD diagnostic scale, PDS, and posttraumatic cognitions inventory,
PTCI) were administered in the MBCT group. Results: Intent to treat analyses
showed significant improvement in PTSD (CAPS (t(19) =4.8, P <.001)) in the
MBCT condition but not the TAU conditions, and a significant Condition ×Time
interaction (F[1,35] =16.4, P <.005). MBCT completers (n =15, 75%) showed
good compliance with assigned homework exercises, and significant and clinically
meaningful improvement in PTSD symptom severity on posttreatment assess-
ment in CAPS and PDS (particularly in avoidance/numbing symptoms), and
reduced PTSD-relevant cognitions in PTCI (self blame). Conclusions: These
data suggest group MBCT as an acceptable brief intervention/adjunctive ther-
apy for combat PTSD, with potential for reducing avoidance symptom cluster
and PTSD cognitions. Further studies are needed to examine efficacy in a ran-
domized controlled design and to identify factors influencing acceptability and
efficacy. Depression and Anxiety 00:1–8, 2013. C2013 Wiley Periodicals, Inc.
Key words: clinical trials; life events; meditation; mindfulness; posttraumatic
stress disorder (PTSD); stress; treatment
1Department of Psychiatry, University of Michigan, Ann Arbor,
Michigan
2Post-Traumatic Stress Disorder Clinical Team, VA Ann Arbor,
Ann Arbor, Michigan
3Department of Psychology, Seattle Pacific University, Seattle,
Washington
4Department of Psychology, University of Michigan, Ann
Arbor, Michigan
5Institute for Human Adjustment, University of Michigan, Ann
Arbor, Michigan
6Mental Health Service, VA Palo Alto Health System, California
Grant sponsor: Mind & Life Institute, Varela Award to Anthony King;
TATRC; Grant number: W81XWH0820208.
Correspondence to: Anthony King, Department Psychiatry, Uni-
versity of Michigan, 4250 Plymouth Rd, Ann Arbor, Michigan 48105
email: samadhi@med.umich.edu.
Received for publication 6 September 2012; Revised 28 January
2013; Accepted 2 March 2013
DOI 10.1002/da.22104
Published online in Wiley Online Library (wileyonlinelibrary.com).
C2013 Wiley Periodicals, Inc.
2
King et al.
INTRODUCTION
Stress-reduction groups involving mindfulness med-
itation techniques delivered as classes in health-
care settings (e.g. mindfulness-based stress reduction,
MBSR) and psychotherapies incorporating mindfulness
techniques (e.g. mindfulness-based cognitive therapy,
MBCT) have shown promise for reducing emotional
distress and symptom severity across a number of psy-
chiatric conditions with anxious and depressive symp-
tomatology. MBSR has demonstrated durable, albeit
moderate sized, effects on mental health measures of de-
pression, anxiety, and stress when performed in “health-
related” class settings.[1] MBCT was designed to pre-
vent the recurrence of depressive episodes in patients
with chronic recurrent depression, and is associated
with substantial reduction in depression recurrence over
2 years of followup.[2–4] A subsequent version of the
MBCT group-based intervention adapted for gener-
alized anxiety disorder (GAD) has also shown signifi-
cant symptom improvement,[5] as have individual inter-
ventions for GAD integrating mindfulness meditation
techniques.[6,7]
There are theoretical reasons to expect that
mindfulness-based interventions may be similarly use-
ful in treatment of posttraumatic stress disorder
(PTSD),[8,9] and combat-related PTSD in particular.[10]
Mindfulness-based interventions strive to entrain sus-
tained mindful attention to and acknowledgment of even
unpleasant emotions or memories in a nonjudgmental
manner.[11] As previously suggested,[9] such techniques
stand diametrically opposed to the psychological pro-
cesses of avoidance and suppression of painful emotions
and memories, which are thought to contribute to symp-
tom maintenance in PTSD.[12] Accordingly, mindful-
ness practice in patients with anxiety disorders was con-
ceptualized as providing a form of exposure to experience
of feared thoughts and bodily states.[6] Interestingly, in
contrast to “refuting” or changing the content of neg-
ative cognitions that is typical of traditional cognitive-
behavioral therapies, MBCT appears to alter one’s re-
lationship to negative cognitions.[13] Additionally, from
a purely behavioral perspective, MBCT involves tech-
niques similar to relaxation, and non-MBCT relaxation
therapies have been commonly studied in PTSD, albeit
usually as an “active control” therapy delivered individu-
ally. Most studies have found these relaxation techniques
having small effect sizes (0.5) when compared to indi-
vidual exposure-based PTSD therapies (often with effect
sizes >1.5).[14, 15 ] However, as reported in a recent meta-
analysis[16] published studies of group therapies for com-
bat PTSD, including exposure-based group therapy,[17]
have shown much smaller effect sizes (0.3) than indi-
vidual exposure-based therapies.
Preliminary studies among trauma-exposed persons
support the notion that mindfulness-based therapies may
be useful in PTSD treatment. Preliminary evidence sug-
gests that Mind–Body group interventions with civilians
with war-related trauma reduced PTSD symptoms.[18]
A case study of acceptance and commitment therapy
(ACT), which includes some mindfulness exercises, also
suggested potential efficacy for combat PTSD.[19] An
adaptation of MBSR for adults with a history of child-
hood sexual abuse, was well accepted and led to decreased
symptoms of self-reported depression and PTSD.[20] A
recent study at a VA hospital offered MBSR classes to
interested veterans (about a third of whom had a his-
tory of PTSD on their computerized charts) as an ad-
junct to their current treatment, and also found a sig-
nificant decrease in self-reported PTSD and depression
symptoms.[21] Another recent study from the same re-
search group randomly assigned patients with charted di-
agnoses of PTSD to either “standard” MBSR groups (i.e.
with majority patients in the group without PTSD), or
no additional treatment/treatment-as-usual (TAU).[22]
MBSR was associated with improvement in self-report
measures of PTSD (PCL-C), depression, quality of life,
and mindfulness skills, although improvement in PCL-C
was not different between the MBSR and control TAU
condition. Taken together, these studies suggest that
mindfulness techniques found in MBSR might be ac-
ceptable to persons with PTSD and/or trauma history,
and may lead to meaningful improvements in mental
health functioning. However, to our knowledge the use
of mindfulness-based therapies such as MBCT, targeted
to treat chronic combat-related PTSD, has not been
reported.
Exposure-based therapies have been highly effective
in the treatment of PTSD,[15] and do not show higher
rates of adverse events or premature dropout than other
forms of PTSD therapy.[23] Nonetheless, a significant
minority of combat PTSD patients still decline this form
of therapy (Liberzon et al., unpublished data). In light of
this, the development of additional effective therapeu-
tic approaches will be highly useful, and initial reports
of treatment benefits of MBSR with trauma-exposed
individuals[20–22 ] warrant further testing of mindfulness-
based interventions tailored for the treatment of PTSD.
Mindfulness-based interventions may serve as an adjunc-
tive preparation for exposure (e.g. by increasing ability
to tolerate experiencing emotions), an aid to cognitive
therapies (e.g. by increasing engagement and develop-
ing cognitive skills), or possibly a stand-alone interven-
tion to modulate emotional reactivity. The present pi-
lot study examined the acceptability and effectiveness of
a brief mindfulness-based group intervention (MBCT)
adapted for treatment of combat-related PTSD.
METHODS
PARTICIPANTS
Participants were consecutive patients recruited from the PTSD
Outpatient Clinic of the Ann Arbor VA Health Care System based
upon referral by treating clinician. Patients were recruited for a total
of seven groups (four MBCT, one PTSD psychoeducation and skills
group (psychoed), and two Imagery Rehearsal Therapy groups (IRT))
over a 4-year period. Assignment to groups was not randomized, but
Depression and Anxiety
Research Article: Mindfulness-Based Cognitive Therapy for Combat PTSD
3
only a single group was recruited for at a time. Inclusion criteria were
long-term (>10 years) PTSD (as assessed by Clinician Administered
PTSD Scale (CAPS),[24] or PTSD in partial remission. Exclusion cri-
teria included diagnoses of psychosis (e.g. schizophrenia, bipolar, and
schizoaffective disorders) and current substance dependence, or active
suicidal intent, as assessed using the Mini International Neuropsychi-
atric Interview (MINI).[25] All participants endorsed combat-related
traumas (DSM-IV A criteria) from military service in conflicts includ-
ing World War II, Korea, Vietnam, and Operation Desert Storm (Iraq
and Kuwait). We report pre and posttherapy interview data for all sub-
jects; complete self-report measures were not available for four patients
completing MBCT. Psychiatric medication regimens were unchanged
over the course of the study for veterans completing the study except
for one patient with comorbid MDD in the MBCT condition, who
received a new prescription of citalopram during the study. No patient
in any treatment group started new psychotherapy during the study.
Three patients in MBCT and four patients in TAU continued ongoing
group therapy in long-term process groups during the study.
PROCEDURE
Therapists and Raters. Clinical team members included five
doctoral or masters level clinicians. MBCT sessions were audio taped,
and a doctoral-level clinical psychologist provided weekly supervision
to promote treatment integrity and fidelity; the fidelity for each of the
manualized groups was also supported using therapist “checklists” used
in the session. Each of the four MBCT groups had at least one clinician
with formal training in MBCT and/or MBSR and previous experience
with facilitating mindfulness group interventions; and at least one clini-
cian in each group also had training in psychotherapies for treatment of
PTSD. The Psychoed and IRT groups were each coled by a doctoral-
level and a masters level clinical psychologist. Pre and posttreatment
PTSD interview assessments (CAPS) were performed by PTSD clinic
clinicians trained on CAPS not involved in the treatment delivery and
not informed of the treatment status of patients.
Treatments. The MBCT treatment protocol was adapted for
combat-related PTSD from MBCT for the prevention of depres-
sion relapse.[26] The main adaptation was substitution of psychoed-
ucation about depression with psychoeducation geared toward PTSD
and stress physiology, discussion of patients PTSD symptoms in ses-
sion, and encouraging patients to use a formal mindfulness exercise (the
“3-Minute Breathing Space”) as well as informal mindfulness when dis-
tressing situations arose during the week. We also shortened the length
of the mindfulness meditation in session and at home from 45 min
to 15–20 min, and increased attention to distress from trauma mem-
ories during in-session and at-home exercises. The adapted MBCT
consisted of eight, weekly 8-hr group sessions, which included skills
training and in-class practice in: (1) mindfulness techniques; (2) psy-
choeducation regarding PTSD and stress responses; and (3) feedback
and supportive group discussion of exercises. Specific in-class mindful-
ness exercises included: (a) “mindful eating” (the “raisin exercise”), (b)
the “body-scan” exercise, (c) “mindful stretching,” (d) sitting “mindful-
ness” meditation exercises with various objects (breath, body, sounds,
emotional states, thoughts), and (e) the “3-Minute Breathing Space” (a
brief mindfulness of breath exercise). The program incorporated daily
assignments of “formal” home practice of mindfulness techniques (us-
ing 15–20 min audio-recordings) as well as “informal” exercises to
integrate mindfulness into everyday experiences (e.g. eating, walking,
and showering), and use of the MBCT “3-Minute Breathing Space”
at pre-ordained times and also when confronted with upsetting situa-
tions, including trauma memories, anxiety, and other PTSD symptoms
throughout the day. Participants were instructed to practice mindful-
ness exercises aided by audio recordings at least 5 days a week, and the
3-Minute Breathing Exercise daily after week 4, as well as practicing
mindfulness thoughout the day (e.g. while walking, eating, showering,
etc.), for an additional 10–15 min a day, for a total of 25–40 min of total
practice per day. Patients recorded daily practice times in homework
logs that were collected weekly, in which they checked which audio
recording(s) they had listened to that day, and how much time they
had spent doing other mindfulness practice throughout the day.
The comparison interventions were intended as brief, plausible
“treatment-as-usual” (TAU) group interventions for PTSD to control
for nonspecific effects of group therapy (social support, normalization,
expectancy, therapist contact), but did not exactly match contact hours
or forms of homework. PTSD psychoeducation and skills (psychoed)
was developed at VA Ann Arbor and consisted of eight weekly 1-hr ses-
sions with psychoeducation about PTSD symptoms, anger, emotions,
sleep, forms of coping with symptoms, PTSD psychotherapy, medica-
tions, and other services. Imagery rehearsal therapy group (IRT) was
based on previous work with Vietnam veterans,[27, 28 ] and consisted of
six weekly 1.5-hr group sessions as previously described. The rationale
of imagery rehearsal was explained as using alterations to the content
of a recurrent nightmare that promote mastery or control nightmare
(e.g. changing a violent scene to a alternate nonviolent version) as a
method to decrease distress to nightmares. Potential changes to each
patients nightmares were discussed in group, and each patient selected
alternate forms of their own nightmare, rewrote a script that was dis-
cussed by the group, and rehearsed this script in imagination each night
prior to sleep.
Measures. Treatment responses were assessed at intake and
posttreatment in all patients using a semistructured clinician-
administered interview (CAPS),[24] Patients in the MBCT condition
also completed the self-report PTSD diagnostic scale (PDS)[29] and
the posttraumatic cognitions inventory (PTCI),[30] which measures
negative posttraumatic cognitions including negative (incompetent)
self, negative (dangerous) world, and self blame.
Statistical Analyses. Both intention-to-treat and completer
analyses were performed. Within-group effects on PTSD symptoms
in the MBCT and TAU groups were examined with two-tailed paired
samples t-tests of pre and posttherapy total CAPS scores (and intru-
sive, avoidant, and hyperarousal subscales), and within group effect
sizes (Hedge’s g) were calculated. Between group effects were ex-
amined using repeated-measures analyses of variance (RM-ANOVA),
and between group effect sizes calculated from the posttherapy CAPS
scores. Independent sample t-tests and chi-squared analyses were used
to examine differences between demographics, previous treatment, and
symptom measures at intake.
RESULTS
At the time of recruitment, patients enrolled in the
MBCT or TAU groups (Psychoed and IRT) did not
differ in terms of PTSD symptom severity (CAPS), co-
morbidity, age, marital, or employment status, time from
combat trauma, or psychistaric service-connected dis-
ability. Table 1 shows patient demographic and clinical
characteristics. All of the patients had long-term PTSD
(>10 years) associated with military deployment trau-
mas, and the majority reported experience of symptoms
of PTSD for >30 years. Most of the patients enrolled
in this study had extensive previous psychiatric treat-
ments, including medications and individual and group
psychotherapies. There was a considerable range in pa-
tient retrospective report of psychiatric treatment his-
tory, with two patients reporting no previous treatment.
Given the problems of patient retrospective report, we
examined history of previous psychiatric treatment at
Depression and Anxiety
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King et al.
TABLE 1. Demographics and clinical characteristics of
PTSD patients at intake
MBCT TAU tor χ2P
Total N 20 17
Age 60.1 9.7 58.3 8.3 0.9 .33
Years from trauma 37.3 11.3 35.7 8.7 0.5 .61
Completed therapy 15 75% 13 77% 0.0 .97
Military deployment
Korea or WWII 3 15% 1 6% 0.8 .67
Vietnam 15 75% 14 82%
Desert Storm (Iraq) 2 10% 2 12%
Married 14 70% 14 82% 0.7 .38
Employed 8 40% 6 35% 0.1 .79
Service-connect psychiatric
disability 50%
14 70% 9 53% 1.1 .29
Comorbidity
Current MDD 13 65% 13 76% 0.6 .44
Alcohol depend in remission 12 60% 9 62% 0.2 .76
# patients with previous
weekly psychotherapy >
1 year
14 70% 10 59% 0.5 .47
Years in Psychiatric
Treatment at VA Ann
Arbor
4.9 5.1 3.5 3.3 0.9 .36
Current Medications
Antidepressant 13 65% 11 65% 0.0 .99
Benzodiazepine 5 25% 4 24% 0.5 .50
Trazadone 7 35% 2 12% 2.7 .11
Antipsychotic 3 15% 4 24% 0.4 .51
Prazocin 2 10% 0 0% 1.8 .18
None 4 20% 3 18% 0.0 .93
this VA. The overall years of any form of treatment
(e.g. medication, group and individual psychotherapy,
inpatient and high-intensity outpatient program) were
not different between the treatment groups. In terms
of previous psychotherapy, the majority of patients had
long-term group (and/or individual) psychotherapy, and
others fewer than eight previous mental health encoun-
ters, (not different between treatment groups). Patients
did not start new individual or group therapy during the
study period. Three patients in MBCT and four patients
in the IRT group were also in concurrent group thera-
pies (remained in their long-term process groups). The
majority of patients were taking psychiatric medications
for PTSD, depression, and/or pain, there were no dif-
ferences in medications between treatment groups.
COMPLIANCE AND RETENTION
We report behavioral evidence of acceptability as re-
flected in session attendance and homework comple-
tion. Treatment “completion” was defined as attend-
ing at least five sessions of MBCT or Psychoed, and
at least four sessions of IRT. Five (25%) patients en-
rolled in MBCT groups and four (29%) patients enrolled
in TAU groups discontinued treatment within the first
three sessions. MBCT noncompleters endorsed several
reasons for their decision not to continue with treat-
ment: two cited low expectations/interest, three cited
scheduling/transportation difficulties, and two endorsed
increased anxiety during mindfulness exercises involv-
ing attending to bodily states; one, a survivor of sexual
trauma, reported that the “body scan” exercise triggered
traumatic memories of his assault. Reasons for drop out
in the TAU groups were not specified.
Of the seven homework sheets, MBCT treatment
completers turned in an average of 4.6 (SD =1.4)
sheets, in which they reported listening to at least one
15–20 min audio recording on average 5.5 (SD =1.3)
days per/week, amounting to an average self-report of
102.3 (SD =20.4) min/week of audio-guided mindful-
ness practice. There was wide variation of self-report of
mindfulness throughout the day (i.e. while eating, walk-
ing, showering, etc.), which was further skewed by three
older retired veterans who each reported >60 min of
informal practice per day, 7 days a week in which they
included time spent doing daily physical therapy exer-
cises or other routines “mindfully.” Exclusion of these
three participants found self-report of an average of 12.2
(SD =6.6) additional minutes of “informal” mindfulness
practice on days practice is reported.
TREATMENT RESPONSE
Intent-to-treat analyses found that patients who were
enrolled in MBCT showed a significant reduction in
total CAPS score (pre versus post MBCT t(19) =4.8,
P<0.001, average 11-point decrease in total CAPS, ef-
fect size Hedges g=0.54). In contrast, patients enrolled
in the TAU did not show a significant reduction in CAPS
(t(16) =0.2, P=.83, g =−0.04)). In between condition
analyses, RM-ANOVA found a significant Condition ×
Time interaction (F[1,34] =11.4, P=0.002) in total
CAPS scores, with between condition posttherapy CAPS
scores Hedges g=0.67.
Differences in demographics, symptoms severity, and
treatment history were not detected at intake between
treatment completers (N=32) and noncompleters
(N=9). Patients who completed MBCT (N=15)
showed significant improvement in PTSD symptoms
(Table 2 and Figure 1), with effect size g=0.67 for pre-
post CAPS total score. The improvement in the MBCT
condition appeared to be explained by a significant re-
duction in the CAPS-avoidant subscale. A single patient
in the MBCT condition received a new prescription of
citalopram during the group. This patient had among
the highest intake CAPS, and also showed the least im-
provement at posttherapy assessment. Exclusion of this
subject from the MBCT completer analysis did not af-
fect reduction in total CAPS score findings (t(13) =5.6,
P<0.001); nor did exclusion of the three older veter-
ans with reports of very high home practice (t(11) =5.7,
P<0.001). In contrast, patients who completed the TAU
interventions (Psychoed and IRT) did not show reduc-
tion in total CAPS (t(12) =0.5, P=0.622) or any CAPS
subscale (Table 2, Figure 1). Between treatment condi-
tion comparisons in completers also found a significant
condition ×time interaction in total CAPS scores and
Depression and Anxiety
Research Article: Mindfulness-Based Cognitive Therapy for Combat PTSD
5
TABLE 2. PTSD symptoms (CAPS) prepost and condition effects
Intention-to-treat analysis (MBCT N =20, TAU N =17)
Pre-therapy Post therapy Prepost Btw group Group* ×Time
Outcome Mean SD Mean SD Delta t df P g g F[1,35] P
CAPS Total MBCT 74.5 19.3 62.6 23.1 11.8 4.8 19 <0.001 0.55 0.77 14.7 0.001
TAU 76.8 15.1 78.4 15.5 1.6 0.7 16 0.518 0.10
Intrusive MBCT 20.5 7.2 18.8 9.2 1.7 1.4 19 0.183 0.20 0.77 1.2 0.290
TAU 24.5 5.5 24.9 5.7 0.4 0.3 16 0.786 0.07
Avoidance MBCT 29.2 10.3 20.9 11.2 8.3 4.6 19 <0.001 0.76 0.67 11.9 0.001
TAU 27.0 8.6 27.8 9.6 0.8 0.4 16 0.673 0.09
Hyperarousal MBCT 24.7 6.9 22.9 7.9 1.7 1.7 19 0.100 0.24 0.37 0.6 0.461
TAU 26.3 5.1 25.6 5.9 0.6 0.6 16 0.554 0.12
Completer analysis (MBCT N =15, TAU N =13)
Pre therapy Post therapy Prepost Btw group Group ×Time
Outcome Mean SD Mean SD Delta t df P g g F[1,26] P
CAPS total MBCT 73.5 21.7 57.7 24.3 15.7 6.2 14 <0.001 0.67 1.01 16.2 0.001
TAU 77.2 16.3 79.4 16.7 0.8 0.2 12 0.838 0.05
Intrusive MBCT 19.3 6.9 17.1 9.4 2.2 1.3 14 0.621 0.26 0.86 1.2 0.290
TAU 24.4 9.1 24.9 6.4 0.5 0.3 12 0.780 0.06
Avoidance MBCT 30.5 10.1 19.5 11.1 11.0 5.6 14 <0.001 1.01 0.76 14.7 0.001
TAU 27.1 9.9 28.2 11.1 1.1 0.4 12 0.680 0.10
Hyperarousal MBCT 23.7 7.8 21.3 8.5 2.5 1.9 14 0.151 0.29 0.67 0.7 0.407
TAU 27.2 4.0 26.3 5.3 0.8 0.6 12 0.560 0.19
CAPS, clinician administered PTSD scale; MBCT, mindfulness-based cognitive therapy; TAU, treatment as usual; SD, standard deviation; g,
Hedge’s g (bias corrected effect size).
the CAPS-avoidant subscale. The number of treatment
completers with “clinically meaningful” improvements
in PTSD symptoms (reduction of 10 points on the total
CAPS scale) was significantly greater in the MBCT com-
pleters (11 of 15, 73%) compared to TAU completers (4
of 13, 33%), chi squared =4.2, Fisher’s exact P<0.05.
Decrease in PTSD intrusive symptoms (CAPS intru-
sive subscale) in MBCT completers was correlated with
reported average time per week spent on mindfulness
practice using audiorecordings (r(15) =0.53, P=0.03).
Additional self-report measures were available for
MBCT completers only (Table 3). Similar to CAPS,
self-report of PTSD symptoms (PDS) were significantly
reduced following MBCT, and appeared to be due to de-
crease in PDS “numbing” subscale. Negative cognitions
(PTCI) also improved significantly following MBCT,
with significant reductions in total PTCI score and self-
blame cognitions, as well as marginally significant de-
creases in negative self and world cognitions.
DISCUSSION
The results of this pilot trial of a brief mindfulness-
based group therapy suggest that an MBCT group
therapy targeted for combat-related PTSD is accept-
able and a potentially effective novel therapeutic ap-
proach for PTSD symptoms and trauma-related nega-
tive cognitions. The majority of veterans enrolled in the
mindfulness group showed good engagement in the “in
session” exercises, and were also compliant with daily
Figure 1. PTSD symptom severity before and after the 8-week mindfulness training group. Shown are plots of changes in PTSD
symptoms (Clinician-Administered PTSD Scale) total and intrusive, avoidant, and hyperarousal subscales.
Depression and Anxiety
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King et al.
TABLE 3. Self-report measures (MBCT group only)
Pre therapy Post therapy
Outcome Mean SD Mean SD Delta tdfPPrepost g
PDS
PDS total 34.8 9.6 29.7 12.6 5.1 2.3 12 0.014 0.59
Re-experiencing 9.1 4.1 7.8 3.7 1.3 2.6 12 0.119 0.30
Numbing 13.6 4.5 11.0 5.3 2.6 1.0 12 0.029 0.69
Hyperarousal 12.1 3.1 10.8 5.2 1.2 2.6 12 0.267 0.25
PTCI
Negative self 4.0 1.3 3.4 1.5 0.6 1.94 10 0.081 0.48
Negative world 5.3 1.0 4.4 1.9 0.9 2.07 10 0.065 0.61
Self blame 3.6 1.3 2.3 1.3 1.3 2.86 10 0.017 1.04
MBCT, mindfulness-based cognitive therapy; PDS, PTSD diagnostic scale; PTCI, posttraumatic cognitions inventory; SD, standard deviation; g,
Hedge’s g (bias corrected effect size).
mindfulness practice; several reported an unexpectedly
high level of engagement and compliance with home
mindfulness practice. There was a 25% dropout rate of
veterans discontinuing MBCT (all within the first three
weeks), a dropout rate that was not different from the
TAU groups and similar with typical dropout rates in
outpatient treatment studies of PTSD.[27] However, it
is important to note that two patients who dropped re-
ported increased anxiety during the mindfulness exer-
cises as a factor contributing to dropping the group.
This suggests that great attention should be paid to
“body-focused” exercises such as the body scan, which
may be especially challenging for veterans with a his-
tory of sexual assault. Delivering such interventions in
modified form and/or only after establishment of ap-
propriate rapport and safety, might be useful for these
patients.
The MBCT group showed significant reduction in
PTSD symptoms pre- versus post MBCT as assessed by
clinician-administered interview (CAPS) in both intent-
to-treat and completer analyses. MBCT also showed sig-
nificantly greater reduction in CAPS than a comparison
“TAU” group therapy condition. While the improve-
ment in PTSD symptoms in the brief 8-week MBCT
intervention was moderate (averaging 16 points on
the total CAPS, effect size Hedge’s g 0.7), this level
of CAPS reduction has been interpreted as represent-
ing a clinically meaningful improvement in PTSD (e.g.
10 points or more),[33] and 73% of patients in MBCT
(compared to 33% in TAU groups) showed clinically
meaningful improvement. While the effects of MBCT
on PTSD symptoms were smaller than treatment effects
reported with individual, 12–15 week, prolonged expo-
sure therapy,[31, 32 ] group PTSD treatments have shown
smaller effects sizes; and the present data compare fa-
vorably to effects reported in other group therapies for
combat PTSD, including a 30-week trauma-focused ex-
posure based group therapy.[17] The outcomes seen in
MBCT (adapted for PTSD) on both self-reported and
clinician-rated PTSD symptoms found in this study were
similar to effects of MBSR on self-reported PTSD symp-
toms in recent studies.[20–22 ]
These findings are particularly noteworthy in light
of the short duration of MBCT-based intervention in
this trial on one hand, and the chronicity of PTSD
symptoms reported by our veterans (15–50 years) on
the other. Interestingly, the mindfulness group appeared
to reduce mainly the avoidant cluster symptoms, on
CAPS, suggesting potential specificity of action here,
which is consistent with the emphasis on reduced avoid-
ance of unwanted emotions, and experiences in mindful-
ness training.[6,8,11] Given that one might expect avoid-
ance symptoms to change first, a longer intervention or
follow-up assessments may show greater impact on in-
trusive and hyperarousal symptoms, although such spec-
ulation requires further study. Additionally, consonant
with an emphasis on mindful attention to positive expe-
riences and nonjudgmental acceptance, the intervention
led to a significant decrease in cognitions of self-blame
and a trend toward decreased perception of the world as
a dangerous place.
Several limitations of this pilot study should be noted.
Our patients were recruited based upon availability and
included veterans of a range of ages, conflicts, and de-
ployments (e.g. WWII, Korea, Vietnam, Desert Storm),
but were primarily older veterans with long-term PTSD.
While we are reporting results of a “treatment as usual”
group intervention for comparison, with a well-matched
long-term combat PTSD patient sample, it is important
to note that patients were not randomly assigned to dif-
ferent treatments. Thus, the reported results must be
considered as preliminary, and these finding have to be
replicated in random assignment design (currently un-
derway). Nevertheless, groups were recruited one at a
time with consecutive patients, and patients were not
selected based upon clinical characteristics or prefer-
ences. Furthermore, although the TAU groups were
both brief weekly group interventions for PTSD, they
had lower contact time than MBCT and did not match
amount of daily homework. It should be noted that the
lack of significant decrease in PTSD symptoms in the
IRT intervention was inconsistent with our initial ex-
pectations, but is consistent with subsequent findings of
only small improvements in PTSD symptoms in group
Depression and Anxiety
Research Article: Mindfulness-Based Cognitive Therapy for Combat PTSD
7
IRT in Vietnam veterans with PTSD.[28] The study
included a relatively small sample and several patients
did not complete posttreatment measures. MBCT and
IRT treatment fidelity was assessed by therapist check-
list, but not by independent assessment of recorded
sessions.
Nonetheless, despite the small sample, patients who
completed the MBCT group showed meaningful im-
provements in both PTSD symptoms and cognitions.
Future studies with larger samples and random assign-
ment will be needed to determine whether mindfulness-
based interventions also significantly reduce PTSD
symptoms beyond the avoidance cluster. Additionally,
the lack of follow-up assessment in this study limits abil-
ity to determine additional symptom changes subsequent
to treatment. Given the long-term protection from de-
pression relapse afforded by MBCT,[2–4] future studies of
this type of intervention should assess PTSD outcomes
at later follow-ups.
The purpose of the present pilot study was to provide
initial data on the feasibility and acceptability, as well as
estimates of effect sizes, of a mindfulness-based group
intervention (MBCT) targeted for treatment of com-
bat PTSD. The brief 8-week group-based intervention
appeared acceptable to veterans in a VA PTSD clinic,
who demonstrated high levels of engagement, and was
associated with a statistically significant and clinically
meaningful improvement in PTSD symptoms. Thus,
despite limitations, the preliminary results of this pilot
study are encouraging and support further investigation
of mindfulness-based interventions for combat-related
PTSD, particularly with larger samples and treatment
randomization. Mindfulness-based therapies provide a
strategy that encourages active engagement without ex-
plicit cognitive restructuring or exposure to trauma
memories, are relatively easy to learn, and can be ad-
ministered in an efficient group format. Increased abil-
ity to actively attend to, and generate nonjudgmental
acceptance of, traumatic memories and physiological re-
sponses may help prepare individuals for trauma-focused
therapies, such as prolonged exposure. Further research
is needed to determine whether mindfulness training is
more aptly considered an adjunct to the gold-standard
treatment of prolonged exposure, or whether PTSD in-
terventions including mindfulness can function as inter-
ventions for treating avoidant and other symptoms of
combat PTSD in their own right.
Acknowledgment. This research was sup-
ported by Department of Defense TATRC, grant
W81XWH0820208 to IL and AK, and Mind and Life
Institute Varela Award to AK.
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Depression and Anxiety
... Interestingly, self-kindness and common humanity correlated with more anxiety after the experiential induction, although positive affect was found to be increased, whereas positive outcomes were observed after the analytical induction and in the control condition. In agreement with King et al. (2013), the authors concluded that mindfulness exercises that involve attending to bodily states might increase anxiety by triggering traumatic memories of an assault. Valdez and Lilly (2019) further observed that higher scores in self-kindness and mindfulness at baseline were associated with a diminished increase in guilt after trauma processing. ...
... Almost all studies reported improvements in intrusions and re-experiencing symptoms. In most studies, the participants were veterans (Bremner et al., 2017;Felleman et al., 2016;Jasbi et al., 2018;Kearney et al., 2012;King et al., 2013King et al., , 2016Shipherd et al., 2016;Stephenson et al., 2017). Participants also included: incarcerated women with histories of childhood sexual and/or physical abuse (Bradley & Follingstad, 2003); refugees (Hinton et al., 2005); survivors of childhood sexual abuse (Earley et al., 2014;Kimbrough et al., 2010); patients treated for cancer (Bränström et al., 2012); nurses with subclinical PTSD (Kim et al., 2013); survivors of interpersonal violence (Müller-Engelmann et al., 2017; and psychology students that had been exposed to lifetime trauma, or had experienced life stress in the past year (Zhu et al., 2019). ...
... Eight studies used pure MBSR (Bränström et al., 2012;Bremner et al., 2017;Earley et al., 2014;Felleman et al., 2016;Kearney et al., 2012;Kimbrough et al., 2010;Müller-Engelmann et al., 2017;Stephenson et al., 2017) or MBSR in combination with lovingkindness meditation (Müller-Engelmann et al., 2019). Two of the studies used MBCT (Jasbi et al., 2018;King et al., 2013), and one MBCT in combination with PTSD psychoeducation, exposure therapy, and self-compassion (King et al. (2016). Other mindfulness-based exercises integrated with stretching and deep breathing techniques (Kim et al., 2013), or with acceptance-based training (Shipherd et al., 2016), were also investigated. ...
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Objectives Autobiographical memory (AM) is linked to the construct of self, which is influenced by mindfulness training. Furthermore, both self-reference and AM can be affected by psychopathological conditions, such as depression. This article offers a critical review with a systematic search of the studies using different paradigms to investigate the effects of mindfulness training on AM, as well as the relationships between trait mindfulness and AM. Methods The review includes studies with behavioral, self-report, and neuroimaging methods by considering both non-clinical and clinical investigations in an integrative perspective. Fifty articles were reviewed. The review addressed the following main fields: mindfulness and autobiographical memory specificity; mindfulness and emotional autobiographical recall; and self-inquiry into negative autobiographical narratives and mindfulness. An additional section analyzed 18 studies that addressed the effects of mindfulness training on memory flashbacks. Results In line with the hypotheses, grounded on theories of AM, self, conscious processing, memory reconsolidation, and Buddhist psychology, the review results suggest that the influences of mindfulness training and trait mindfulness on AM can be related to enhanced cognitive, emotional, and self-referential flexibility. This influence is also associated with improved meta-awareness, acceptance, and the flexibility to shift from a first- to a third-person self-perspective in AM recall. In particular, the review highlights increased self-referential flexibility related to mindfulness, which during AM recall would enable a more balanced retrieval of episodic, semantic, and emotional contents, as well as increased AM specificity and reduced emotional reactivity. A mindfulness-related reconsolidation of the links between AM traces and the self might play a crucial role. The mindfulness-related changes of the experiences during AM recall may be translated into long-term reconsolidation-related changes in the AM traces, with a potential interactive effect on the self, thus becoming more flexible. The review also highlights brain mechanisms underlying these influences, given by changes in activity and functional connectivity of core regions in the default mode network (medial prefrontal cortex and posterior cingulate cortex), salience network (anterior cingulate cortex and anterior insula), and central executive network (dorsolateral prefrontal cortex). Finally, we suggest new research developments from the review and the related theoretical perspective. Conclusion The review results, together with the proposed theoretical accounts, bridge a set of investigations on several autobiographical memory phenomena and mindfulness, and might usefully lead to further studies, also with relevant clinical and cognitive neuroscience implications.
... Maladaptive metacognitions were observed in several ADs, encompassing social anxiety disorder (social phobia) [33,55,71,99], panic disorder [4, 22,68], and generalized anxiety disorder [4, 49,99,105]. ...
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... Moreover, mindfulness appears to mitigate the negative effects of combat experience (Barr et al., 2019). This is true of both brief and primary care-based mindfulness training (Possemato et al., 2016), as well as more structured interventions such as Mindfulness Based Stress Reduction, which tend to show better results for depression and anxiety (Davis et al., 2019;Kearney et al., 2012;King et al., 2013;Polusny et al., 2015). ...
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Objectives Mindfulness is increasingly relevant to posttraumatic stress disorder (PTSD) in veterans as a treatment component. The Mindful Attention Awareness Scale (MAAS) and Five Facet Mindfulness Questionnaire (FFMQ) are measures commonly used to assess mindfulness, but it is unclear if these scales measure distinct constructs, and their applicability to veterans has not been studied. We compare the psychometric properties of the MAAS and FFMQ in data collected from clinical trials. Methods Across three trials involving veterans with PTSD (n = 487), analyses of factor structure, reliability, and validity were conducted for the MAAS and FFMQ. Validity analyses examined correlations between scales, demographic associations, treatment effects, and correlations with the PTSD Checklist 4 (PCL-4) and the World Health Organization Quality of Life scale (WHOQOL). Results The MAAS was consistent with a single-factor measurement model, and the FFMQ was consistent with a five-factor model. The FFMQ did not have a clear higher-order factor. Scores for both the MAAS and FFMQ demonstrated good reliability. Treatment had positive association with both MAAS and FFMQ Nonreactivity scores, and follow-up PCL-4 scores were strongly negatively associated with baseline MAAS scores and FFMQ Acting with Awareness and Nonreactivity scores. Also, WHOQOL scores were associated with MAAS and FFMQ baseline and change scores indicating good validity in this population. Conclusion The MAAS and FFMQ are reliable and valid measures of mindfulness in veterans with PTSD, though they measure different aspects of mindfulness, suggesting clinical trials should not use the MAAS or FFMQ as outcomes by themselves.
... Furthermore, there is no consensus on what can be considered an adverse effect in mindfulness trainings. The main challenges with extended sitting practice, body scan or breath awareness for patients with posttraumatic stress disorder (15) or histories of trauma including childhood maltreatment (16) are attributed to over-arousal, distress due to embodied traumatic memories, or feeling overwhelmed with relaxationinduced anxiety and loss of structure. In addition, early maltreated patients reported to feel unsafe lying down with eyes closed in a closed room with other unfamiliar participants (17). ...
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... These findings suggest that more frequent practice of repeating one's mantram is beneficial to psychological outcomes and wellbeing, lending support to the few studies which found clinical benefits from increased use of meditation practice (Lloyd et al., 2018). Particularly, the present findings are consistent with a pilot study of MBCT for Veterans with PTSD, which demonstrated that the average time per week spent on mindfulness practice using audio recordings was correlated with the reduction in PTSD intrusive symptoms (King et al., 2013). Correlations between practice and other outcome measures were not reported, hindering a full comparison. ...
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... The range of severity of clinical symptoms (mild to severe) was reflective of presentations in primary health care in Australia where a K10 score >20 is frequently used to initiate treatment referral. The rate of adherence to the MiCBT treatment is consistent with other studies [e.g., (66,67)] with 77% (47/61) of participants receiving four or more sessions. The mean practice hours was less than the recommended 7 h per week (64% of recommended). ...
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... There is also research on many complementary treatments for PTSD. There is particularly robust support for groupbased MBSR, which research suggests is associated with reductions in PTSD and depressive symptoms and increases in general quality of life (Felleman, Stewart, Simpson, Heppner & Kearney, 2016;Kearney, McDermott, Malte, Martinez & Simpson, 2012;Polusny et al., 2015;Possemato et al., 2016; see also King et al., 2013). Similarly, a number of studies suggest that group-based IPT is associated with reductions not only in PTSD symptoms, but also in symptoms of anxiety, depression, and other aspects of mental health, as well as increases in quality of life (Campanini et al., 2010;Krupnick et al., 2008;Ray & Webster, 2010). ...
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... One strength of mindfulness and self-compassion interventions lies in their high standardization and evidence base in several clinical fields, as depression, anxiety, bereavement Kabat-Zinn, 1990), and their role in reducing PTSD symptoms (Banks et al., 2015). In other application fields, mindfulness training has lessened avoidance symptoms, reduced shame-based trauma appraisals, increased acceptance, and significantly decreased numbing and self-blame (Goldsmith et al., 2014;King et al., 2013). It has also proven effective in patients with suicidal ideation (Chesin et al., 2016). ...
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Objectives People bereaved by suicide represent a vulnerable population, but postvention still lacks evidence-based resources to support them. Mindfulness and self-compassion–based interventions have proven effective in countering depression, PTSD symptoms, and traumatic bereavement, and may also be beneficial in suicide postvention. To assess the effectiveness of Panta Rhei, a short, intensive, mindful self-compassion-based intervention for people bereaved by suicide, we evaluated baseline and follow-up levels of psychological distress, mindfulness, and self-compassion in participants and a control group. Methods The intervention was a non-randomized trial conducted with 147 people bereaved by suicide of whom 97 participated in a short 16-h intensive experiential intervention. Each of them completed the Self-Compassion Scale (SCS), Five-Facet Mindfulness Questionnaire (FFMQ), and Profiles of Mood States (POMS) 4–6 days prior to and after the intervention. Results Psychological distress significantly decreased in all areas evaluated by POMS. Participants also showed a significant increase in the FFMQ subscales Observe, Describe, Non-judge, and Non-react, in the SCS Self-Kindness subscale, and in overall Self-Compassion as inferred from significant group*time interaction effects. Sociodemographic, grief-related variables, SCS, and FFMQ at baseline did not correlate with changes in participants’ psychological distress. Conclusions Despite being limited by the lack of randomization for ethical reasons and the high prevalence of highly educated females in the control and intervention groups, this study illustrates the effectiveness of a short, intensive, mindful self-compassion-based intervention for a self-selected group of people bereaved by suicide.
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Background: Comorbid post-traumatic stress disorder and substance use disorder (PTSD-SUD) among women receiving substance use treatment are common. Few evidence-based interventions target PTSD-SUD, however, fewer are gender responsive. Mindfulness-based relapse prevention (MBRP) has shown effectiveness for women with SUD, although it does not explicitly target PTSD. Integration of trauma-focused and gender-responsive treatments into MBRP may address the limited availability of PTSD-SUD interventions for women. This study assessed feasibility and acceptability of trauma-integrated MBRP (TI-MBRP). Methods: A single-blind computer-generated cluster-randomized design was employed in which women with PTSD-SUD (N = 83) received either TI-MBRP (k = 5) or MBRP (k = 5). Measures of PTSD symptom severity and craving were administered at pre-, post-, 1-, 3-, 6-, 9-, and 12-month follow-up and assessed at the individual level. Results: TI-MBRP demonstrated acceptability among participants; however, attrition was high (64%) at 12-month follow-up. Reductions in PTSD were greater in the MBRP than in the TI-MBRP group at postcourse and 1-month follow-up, and there were significant reductions in PTSD severity and craving over the 12-month period in both conditions. Conclusions: Integrating trauma- and gender-focused interventions into MBRP was feasible and acceptable. MBRP alone may be effective in reducing both PTSD and SUD symptoms in women with PTSD-SUD; however, confirmatory studies are warranted. Clinical Trial Registration number NCT03505749.
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