Download Use of Meditation in Combat-Related Posttraumatic Stress Disorder

Running head: USE OF MEDITATION IN PTSD
Use of Meditation in Combat-Related Posttraumatic Stress Disorder (PTSD)
Rachel Krogstie
Methodist University
11/16/2015
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USE OF MEDITATION IN PTSD
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Use of Meditation in Combat-Related Posttraumatic Stress Disorder (PTSD)
As conflicts continue to exist around the world, veterans are increasingly coming home
with significant symptoms of posttraumatic stress disorder (PTSD) (Bormann, Hurst, & Kelly,
2013b). Because of the occurrence of multiple deployments, the chance of acquiring PTSD is
twice as high as in previous eras (Bormann, Hurst, & Kelly, 2013b). Veterans with chronic
PTSD also have “higher rates of mortality and co-morbidities that result in using nearly twice the
amount of medical healthcare services” (Bormann, Hurst, & Kelly, 2013b). However, these
veterans are not seeking treatment for PTSD. In fact, almost 50% of veterans do not seek
treatment for various reasons including the stigma surrounding mental illness and side effects
from medication (Seppälä, et al., 2014; Bormann, Thorp, Wetherall, Golsham, & Lang, 2013a).
This is a serious problem that needs to be addressed. Veterans need to be able to be comfortable
being treated for such a serious health risk.
One way that veterans could reduce the number and/or severity of the symptoms of PTSD
is by using a meditative practice. There have been many studies done in the past 5 years showing
the efficacy of different meditative practices in veterans with combat related PTSD. While the
current clinical guidelines still strongly recommend exposure-based interventions, some veterans
may not be ready to face the experience again (Seppälä, et al., 2014; King, et al., 2013). These
meditative practices may help move the veteran towards these interventions (Bormann, Hurst, &
Kelly, 2013b). The propose of this paper is to present evidence that the Mantram Repetition
Program (MRP) and Mindfulness-Based Cognitive Therapy (MBCT) are valid complementary
therapies in be used in conjunction with other treatments for the reduction of symptoms of
combat-related PTSD in veterans.
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Definition of Terms
Complementary medicine is defined as “a group of therapeutic and diagnostic disciplines
that exist largely outside the institutions where conventional health care is taught and provided”
(Zollman & Vickers, 1999). In this paper, the term is used to mean “A group of therapeutic
disciplines that are used in conjunction with conventional medicine”.
The dictionary defines mantram, or mantra, as “a sound, word, or phase that is repeated
by someone who is praying or meditating; a word or phrase that is repeated often” (MerriamWebster, Inc., 2015). These terms will be used interchangeably in this paper using the above
definition. Mantram repetition will be used to mean “repeating a mantram, or sacred word,
during a meditative practice”.
Veteran is defined as “a person who has served in a military force, especially one who
has fought in a war”: ("veteran", 2015) or “someone who fought in a war as a soldier, sailor,
etc.” (Merriam-Webster, Inc., 2015). In this paper, veteran is used to mean “a person who has
served in a military service and has been in combat or other combat-related experience”.
The Greater Good Science Center at the University of California, Berkley defines
mindfulness as “maintaining a moment-by-moment awareness of our thoughts, feelings, bodily
sensations, and surrounding environment” (Weiss & Hickman, 2015). This is the definition being
utilized in this paper.
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5) defines
posttraumatic stress disorder (PTSD) as “clinically significant distress or impairment in the
individual’s social interactions, capacity to work or other important areas of functioning resulting
from exposure to actual or threatened death, serious injury, or sexual violation” (DSM-5, 2013).
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The author will use the DSM-5 definition of the term posttraumatic stress disorder (PTSD),
adding to the definition “exposure to combat-related atrocities”. This paper does not address
sexual based trauma.
PICO Question
In veterans treated for PTSD (P) at a VA clinic, how does the use of meditative practices
(I) used concurrently with treatment as usual (C) reduce symptoms of severity and increase
psychological well-being (O)?
Literature Review
According to the clinical practice guidelines released by the Veteran’s Health
Administration, management of PTSD should start early to prevent prolonging and worsening of
symptoms (2010). Recommendations are that evidence-based psychotherapy and/or evidencebased pharmacotherapy be used as first-line treatment. There is “insufficient evidence to
recommend” (Veteran's Health Administration, 2010) Complementary and Alternative Medicine
(CAM) as first line treatment. CAM includes relaxation exercises such as mindfulness
meditation and mantra repetition. The guidelines state no significant evidence that these
exercises are more effective than stress inoculation techniques. However, the CAM treatments
may be considered as initial therapy for patients refusing stress inoculation.
Bormann et al. (2013a) explored the efficacy of the Mantram Repetition Program (MRP)
on the reduction of PTSD symptoms on veterans from the Vietnam and Gulf War period. A
randomized clinical trial showed a statistically significant decrease of PTSD symptoms in a
group of veterans using MRP in addition to their treatment as usual (TAU) as compared to a
group that receive only TAU. The MRP+TAU group scored 5.42 points lower on a PTSD
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checklist as opposed to 2.47 points lower in the TAU group, and 16.9 points lower on a
Clinician-Administered PTSD Scale (CAPS) compared to 10.2 points lower in the TAU group.
In continuation, Bormann et al. (2013b) conducted a sub-study on the MRP+TAU group
above. The qualitative study was conducted 3 months after the initial intervention. The study
used subjective interviews to capture the perceptions, reactions to, and pattern of use of MRP in
the veterans. Of the 71 participants, 99% reported incidences where the intervention enhanced
their coping. The study further revealed that there was a wide range and variety of situations
where MRP was successfully implemented; however, it was the most effective on symptoms
from hyperarousal, such as anger, irritability, sleep disturbances, and inability to relax (Bormann,
Hurst, & Kelly, 2013b).
King et al. (2013) conducted a pilot study of Mindful-Based Cognitive Therapy (MBCT)
on a group of veterans with combat-related PTSD. These veterans were from the World War II,
Korea, Vietnam, and Desert Strom eras. The participants were separated into four MBCT groups
compared to the treatment as usual (TAU) groups (one psychoeducation group and two Imagery
Rehearsal Therapy groups). The study showed that veterans enrolled in MBCT showed a
significant (average of 16 points) decrease in CAPS scores, while the TAU groups experienced
no significant decrease. Similarly, self-reported symptoms were significantly reduced after
MBCT.
Action Plan
The first step in implementing a meditation intervention is timely assessment of the
severity of the symptoms. These include type of exposure, danger to self and others, and level of
daily function (Veteran's Health Administration, 2010). A trained clinician administers this
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assessment and several modalities can be included. A PTSD checklist is a self-administered
review of symptoms and should be used routinely in patients with a history, or potential history,
of PTSD (Veteran's Health Administration, 2010). This checklist can lead to a more thorough
clinical evaluation conducted by a highly trained practitioner. The CAPS assessment should be
considered for a more structured and diagnostic tool (Veteran's Health Administration, 2010).
Once the assessment for PTSD is complete, the clinician and/or practitioner should start
the treatment process. The first steps in this process are education and treatment of comorbidities. Common co-morbidities that may impede treatment are substance abuse, other
mental health disorders, medical disorders or symptoms, and psychosocial problems (Veteran's
Health Administration, 2010). Once these problems are addressed, then the clinician and patient
can discuss treatment options.
The current “gold standard” of treatment is “evidence-based trauma-focused
psychotherapeutic interventions that include components of exposure and/or cognitive
restructuring” (Veteran's Health Administration, 2010). However, a significant number of
veterans drop out, or outright refuse, this treatment because of the emotional impact (King, et al.,
2013). MBCT or MRP could prepare these individuals for exposure to the trauma-focused
interventions, or even stand alone to lessen the impact of triggers (King, et al., 2013; Bormann,
Oman, Walter, & Johnson, 2014; Bormann, Hurst, & Kelly, 2013b).
Both MBCT and MRP interventions are presented as weekly classes to train the patient
on the implementation of the technique. MRP consists of six weekly 90-minute sessions training
the participant how to choose and use a mantram, slowing one’s thinking, and developing onepointed attention to manage stress (Bormann, Thorp, Wetherall, Golsham, & Lang, 2013a).
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Assignments are given to continue the practice at home and change behaviors that exacerbate
symptoms (Bormann, Hurst, & Kelly, 2013b; Bormann, Thorp, Wetherall, Golsham, & Lang,
2013a). MBCT consists of eight eight-hour group sessions that include in-class practice and
skills training (King, et al., 2013). MBCT also includes assignments of home practice, but
included mindfulness and breathing exercises (King, et al., 2013).
Follow-Up and Evaluation Plan
After the intervention has been taught and followed, a reassessment should be performed
to evaluate the effectiveness of the treatment. The assessment should be done every 90 days, or
at the very least every treatment visit, to ensure continued efficacy (Veteran's Health
Administration, 2010). The assessment should include the PTSD checklist and assessment tools
for co-morbidities (Veteran's Health Administration, 2010). Follow-up should be conducted to
ensure compliance and effectiveness of the treatment. The patient should keep practicing the
meditation technique during non-stressful occasions and whenever the PTSD symptoms are
triggered in order to maintain a therapeutic effect (Veteran's Health Administration, 2010;
Bormann, Thorp, Wetherall, Golsham, & Lang, 2013a; Bormann, Hurst, & Kelly, 2013b).
Further research is needed in order to determine if these interventions could stand alone
as a treatment for combat-related PTSD in veterans. Current clinical guidelines state that there is
not enough significant evidence to recommend or not recommend relaxation techniques as
treatment of PTSD (Veteran's Health Administration, 2010). However, these guidelines have not
been updated recently and a significant amount of research has been published showing the
effectiveness of meditation in the treatment of combat-based PTSD.
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References
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