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By On July 12th, 2018

Post-Traumatic Stress Disorder: A Review of Therapeutic Role of Meditation Interventions

The following article is offered to us by contributor Ruwan M. Jayatunge, MD, and offers us new insights into the future of PTSD treatment.

by Ruwan M. Jayatunge and Mieczyslaw Pokorski

Abstract: This review is an attempt to provide a comprehensive view of post-traumatic-stress disorder (PTSD) and its therapy, focusing on the use of meditation interventions. PTSD is a multimodal psycho-physiological-behavioral disorder, which calls for the potential usefulness of spiritual therapy. Recent times witness a substantial scientific interest in an alternative mind-to- body psycho behavioral therapy; the exemplary of which is meditation. Meditation is a form of mental exercise that has an extensive, albeit still mostly empiric, therapeutic value. Meditation steadily gains an increasing popularity as a psycho behavioral adjunct to therapy in many areas of medicine and psychology. While the review does not provide a final or conclusive answer on the use of meditation in PTSD treatment we believe the available empirical evidence demonstrates that meditation is associated with overall reduction in PTSD symptoms, and it improves mental and somatic quality of life of PTSD patients. Therefore, studies give a clear cue for a trial of meditation-associated techniques as an adjunct to pharmacotherapy or standalone treatment in otherwise resistant cases of the disease.

Cite this article as:

Jayatunge R.M., Pokorski M. (2018) Post-traumatic Stress Disorder: A Review of Therapeutic Role of Meditation Interventions. In: . Advances in Experimental Medicine and Biology. Springer, New York, NY.

1 Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a clinical syndrome that may develop following extreme traumatic stress. It is an important, albeit relatively uncommon, consequence of exposure to traumatic events, presumably the result of life threats and conditioned fear (Greenberg et al. 2015; Ramage et al. 2015). PTSD is recently defined by four categories of socio-psychological symptoms(DSM-V 2013): 1/ intrusion that encompasses re-experiencing the traumatic event through intrusive memories, flashbacks, nightmares, and physiological responses similar to those when the traumatic event occurred; 2) avoidance that encompasses mind-numbing occurrences, such as avoiding situations and people reminding of past trauma, amnesia for trauma-related information, loss of interest in activities, social and emotional detachment, emotional numbing especially for feelings associated with intimacy, and nihilistic feelings of the future; 3/changes in arousal manifested by angry outbursts, sleep problems, startle responses, and hypervigilance; and 4/mood and cognition disorders consisting of difficulty to cope by feeling down and hopeless, dysphoric mood, problems with judgment, reasoning, and emotion perception, as well as with focusing attention on a task completion.

PTSD is a global health issue (Jindani ‎2015; Ramchand et al. 2015). The disorder develops in approximately 20% of people exposed to a traumatic event (Freedman et al. 2015). It is more prevalent in females than males: typically about twice the rate (Jaycox et al. 2004;Kessler et al. 1995). It affects about 8% of the general US population at some point during their lifetime (Gates et al. 2012).Risk factors for PTSD in adults vary across studies. The three factors identified as having relatively uniform effects are the following: 1/ preexisting psychiatric disorders; 2/ family history of such disorders; and 3/ childhood trauma (Breslau 2002). The lifetime prevalence in the US female population is more than 10% (Kessler et al. 1995). The prevalence rate of lifetime PTSD in Canada is estimated at 9.2%, with a rate of current (one- month) PTSD of 2.4% (Van Ameringen et al. 2008). According to the 2013 Canadian Forces Mental Health Survey, 5.3% of soldiers report experiencing PTSD at some point of service (Zamorski et al. 2016). PTSD is alleged to be associated with high rates of concurrent psychiatric disorders, particularly including but not limited to substance and alcohol/nicotine use disorders and all kinds of depressive disorders (Williamson et al. 2017; Bollinger et al. 2000; Keane and Wolfe 1990). Further, traumatic events triple the risk of developing subsequent psychotic experiences later in life; the effect persist after adjustment for the possible presence of a mental disorder preceding the psychotic post-traumatic episode, which points to a direct and strong association between PTSD and psychosis (McGrath et al. 2017).

Aside from the socio-psychological or psychiatric consequences, PTSDmay also encompass, debilitating somatic disorders. In this context, comorbid metabolic and hormonal sequelae are notably underscored (Morris et al. 2012). PTSD increases two-fold the risk to develop insulin- resistant diabetes type 2, and also is conducive to the development of obesity, and other atherosclerosis-related pathological conditions (Roberts et al. 2015). Although molecular phenomena linking such comorbid conditions to PTSD remain mostly conjectural, interestingly the common denominator seems to be pro inflammatory propensity endowed by PTSD (von Känel et al. 2007). Since somatic complications of PTSD may come to light in a variably and unpredictably delayed time scale, patients with the pathologies above outlined ought to be assiduously scrutinized in the process of anamnesis taking for the past history of a traumatic imbroglio to identify biopsychosocial disease links.

PTSD has complex and multiple symptoms and is a highly impairing condition that imposes a significant economic and social burden(Hawkins et al. 2015; Kessler 2000). When coping with serious illness, choosing the right therapy is of key importance. However, treating patients suffering from PTSD poses a significant challenge and therapy still remains within the arcana of medical art. The existing guidelines for pharmacotherapy concern so broad and divergent groups of drugs, for instance, selective serotonin reuptake inhibitor (SSRI) like fluoxetine and related compounds, monoamine oxidase inhibitors like phenelzine,tetracyclic antidepressants like mitrazepin, antipsychotics like risperidone, and the list goes on (Cipriani et al. 2017). Pharmacotherapy should be individually tailored, taking into account the background history and current disease manifestations, with the placebo effect being sometimes the best therapeutic solution.

2 Meditation Interventions in Post-Traumatic Stress Disorder

Since the available evidence is not robust enough to suggest any pharmacotherapy of PTSD of finite efficacy, psychotherapeutic interventions have come to the fore as a prioritized option (Bisson and Andrew 2007; Schäfer and Najavits 2007). A variety of psychotherapy treatments have been developed for PTSD, such as trauma-focused cognitive behavioral therapy, stress management, or eye movement desensitization and reprocessing; the therapies that also include cognitive group treatment. Among the psychological interventions, meditation has been recognized as one of the notably effective modes. Meditation is an empirically-validated treatment for PTSD. A growing body of evidence suggests that meditation-based interventions have the potential to reduce symptoms and improve mood and general well-being (Mitchell et al. 2014; Seppälä et al. 2014). Further, meditation enhances openness to experience, one of the personality traits, which is associates with improvement in coping with stress by decreasing avoidance-oriented‎ attitude‎ to‎ stressful‎ situationsand‎ with‎ better‎ control‎ of‎ one‟s‎ emotions(Pokorski and Suchorzynska 2017).

Meditation is a mind-body‎ practice.‎ It‎ is‎ an‎ essential‎ element‎ in‎ all‎ of‎ the‎ world‟s‎ major‎ contemplative spiritual and philosophical traditions (Walsh 1999;Shapiro 2008). According to Manocha (2000) meditation is a discrete and well-defined ‎experience‎ of‎ a‎ state‎ of “thoughtless‎ awareness‟‎ or‎mental‎ silence, ‎in‎ which‎ the‎ activity‎ of‎ the‎ mind‎ is‎ minimized without reducing the level of alertness. Walsh and Shapiro (2006) described meditation as self-regulation practices that aim to bring mental processes under voluntary control through focusing attention and awareness. The effects of meditation on health are based on the principle of mind-body connection and there is a growing body of literature showing the efficacy of meditation on various health related problems (Hussain and Bhushan, 2010). Mind-body practices are increasingly used in the treatment of PTSDand are associated with a positive influence onstress- induced illnesses such as depression and PTSDin most existing studies (Kim et al. 2013). As described by Cloitre et al. (2011) meditation has been identified as an effective second-line approach for emotional, attentional, and behavioral (e.g., aggression) disturbances in PTSD. Lang et al. (2012) further suggest the meditation as a therapeutic intervention for PTSD.

Anapanasati‎ meditation,‎ which‎ i s‎a ‎concentrative‎ meditation‎ that‎ focuses‎ on‎ one’s‎ respiration and suppresses other thoughts, is a tool for exploring subtle awareness of mind and life. Mindfulness of breathing helps oxygenate the body, reduces stress and anxiety, and induces peace of mind(Deo et al. 2015).The meditator is able to focus attention and see the

impermanence of his experiences, which nullifies the feeling of being destroyed by them. Breathing interventions boost emotion regulatory processes in healthy populations (Arch and Craske2006). Sack et al. (2004) have indicated that breathing-based meditation practices may be beneficial for PTSD. Seppälä et al. (2014) have reported that breathing-based meditation decrease posttraumatic stress disorder symptoms in US military veterans.

Mindfulness meditation, which is a sensitive non-concentrative type of meditation that notices things and picks up the object of attention as it pleases, helps reduce the level of stress in PTSD patients by cultivating awareness and acceptance of dysfunctional mental behaviors and helping change emotional experiences‎ (Steinbergand‎Eisner‎ 2015).‎ The‎term‎ „mindfulness‟‎ has‎ been‎ used to refer to a psychological state of awareness, a practice that promotes this awareness, a mode of processing information, and a characterological trait. Germer et al. (2005) defines mindfulness as moment-by-moment awareness. The evidence concur that mindfulness helps develop effective emotion regulation in the brain (Davis and Hayes 2011; Siegel 2007). Mindfulness is associated with low levels of neuroticism, anxiety, and depressive symptoms, as well as high levels of self-esteem and satisfaction with life (Tanner et al. 2009; Brown and Ryan 2003).Mindfulness meditation is indicated in PTSD as it leads to positive outcomes in trauma survivors (Christelle et al 2014; Follett et al. 2006).

Likewise, vedananupassana meditation or awareness of sensations and feelings is a form of mindfulness meditation which is useful in the treatment of PTSD. Chronic pain and PTSD commonly co-occur in the aftermath of a traumatic event (Palyo and Beck 2005). In addition, both are mutually maintaining conditions, and pain sensations can trigger PTSD symptoms(Sharp and Harvey 2001). People with chronic pain and co-morbid PTSD report poorer quality of life (Morasco et al. 2013). Vedananupassana meditation is beneficial in alleviating pain in the individuals with PTSD.

Loving-kindness meditation is a practice designed to enhance feelings of kindness and compassion for self and others. Self-compassion is considered a promising change mode of behavioral approach in the treatment of PTSD (Hoffart et al. 2015).Kearney et al. (2014) have conducted a loving-kindness meditation study in 42 military veterans with active PTSD and found the effect of increased positive emotions. According to Kearney et al. (2013), this kind of meditation appears safe and acceptable, and is associated with reduced symptoms of PTSD and depression. Hinton et al. (2013) have demonstrated that loving-kindness meditation has a potential to increase emotional flexibility and to decrease rumination. It may regulate emotional stability and form a new adaptive processing mode centered on psychological flexibility.

Research has shown that transcendental meditation can also be an effective technique to treat PTSD. Transcendental meditation is derived from the ancient yoga teaching (Lansky and St. Louis 2006). It is a purely‎ mental‎ technique‎ that‎ falls‎ within‎ the‎ category‎ of‎ “automatic‎ self-transcending‟‎ because‎ the‎ practice‎ allows‎ the‎ mind‎ to‎ effortlessly‎ settle‎ inward,‎ beyond‎ thought,‎ to experience the source of thought, pure awareness (Rees 2011; Travis and Shear 2010).

Chhatre et al. (2013) have described transcendental meditation as a behavioral stress reduction program that incorporates mind-body approach, and demonstrated its effectiveness in improving outcomes through stress reduction. Rees et al. (2013) have shown a reduction in posttraumatic stress symptoms in Congolese refugees practicing transcendental meditation. Rosenthal et al. (2011) have highlighted the successful use of transcendental meditation on the veterans of Operation Enduring Freedom and Operation Iraqi Freedom suffering from PTSD. Furthermore- Johnson and Barnes (2014) have explored a reduction in anxiety in response to transcendental meditation.

Meditation may have added value concerning PTSD, which is a hypnotic-like effect. Zazen, “seated‎ meditation‟‎ in‎ which‎ the‎ body‎ and‎ mind‎ are‎ calmed,‎ has‎ an‎ apparent hypnotic influence as evidenced by blocking the cortical alpha wave EGG response to repeat click stimuli (Kasamatsu and Tomio 1966). Hypnogenic engagement of attention with imaginary resources prevents the perception of the sense of reality and hinders the passage of external painful remembrances (Tellegen and Atkinson 1974), with understandably beneficial effects in PTSD. Hypnotherapy alone has a beneficial effect on PTSD symptoms. The largest to-date meta- analysis on the subject, performed on the selected 6 studies covering 391 subjects, has demonstrated positive effects of hypnotherapeutic techniques specifically related to avoidance and‎ intrusion,‎ and‎ in‎ generally‎ to‎ overall‎ PTSD‎ symptomatology‎ (O‟Toole‎ et‎ al.‎ 2016).‎ Meditation-associated hypnosis, although seldom by far considered for PTSD treatment, appears to be of distinct efficacy (Lesmana et al. 2009).

3 Conclusions

PTSD is a psycho-physiological-behavioral disorder, which calls for psycho behavioral ways of treatment. Meditation is an important part of health and spiritual practice. It is a form of mental exercise that has an extensive therapeutic value. There are three major types of meditative practices: mindfulness of breathing, non-concentrative mindfulness, and transcendental meditation. Due to a multitude of meditative techniques and approaches, it is hard to average meditations together to define the underlying mechanisms and clinical benefits. The difficulty consists in the paucity of verifiable research, small sample sizes of patients, variable methods of meditation, setting different outcome measures, and other issues. Despite these shortcomings, empirical evidence accumulates to demonstrate that meditation is associated with overall reduction in PTSD symptoms, and it improves mental and somatic quality of life of PTSD patients. Meditation interventions seem justifiable as an adjunct to ill-defined polypharmacy arsenal in PTSD treatment or a standalone trial in otherwise failed treatment efforts of this multimodal disease.

Acknowledgements: Our thanks go to Rev.Harispaththuwe Ariyawansalankara Thero from Vipassana Meditation Center in Colombo, Sri Lanka; Dr. David R. Leffler, Executive Director of the Center for Advanced Military Science (CAMS) Institute of Science, Technology and Public Policy, Iowa; and Dr. Fred Travis, a post-doc fellow in basic sleep research at the University of California, Davis, CA.

Conflicts of interest: The authors declare no conflicts of interest in relation to this article.

About Mieczyslaw Pokorski, M.D., Ph.D., D.Sc.

Professor at the Polish Academy of Sciences Medical Research Center – Head of the Department of Respiratory Research. Affiliated with Medical Research Center, Polish Academy of Sciences in Warsaw, Poland; Department of Neuroscience‎and‎Imaging,‎“G.‎d‟Annunzio”‎University‎of‎ Chieti-Pescara, Italy; and the University of Opole, Poland.

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