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 psychobehavioral 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 psychobehavioral 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.
Keywords:Breathing - Meditation
- Mindfulness of breathing - Posttraumatic stress disorder - Psychobehavioral
therapy
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 encompassesre-experiencing the
traumatic event through intrusive memories, flashbacks, nightmares, and
physiological responses similar to those when the traumatic event occurred; 2)
avoidance that encompassesmind-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 suchdisorders; 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 andWolfe 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
proinflammatory 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 toidentify 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’ or mental 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 ofPTSDand
are associated with a positive influence onstress-induced
illnesses such as depression andPTSDin 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 meditationas a therapeutic intervention for PTSD.
Anapanasati meditation, which is a
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 impermanenceof 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 (Steinbergand Eisner 2015). The term ‘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 paininthe 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 thetreatmentof 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. Itmay 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 apurely 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 describedtranscendental 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. Further,Orme-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 psychobehavioral 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
improvesmental 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 toRev.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 fellowin 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 Neuroscience and Imaging, “G. d’Annunzio” University of Chieti-Pescara, Italy; and the University of Opole, Poland.
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