Transcript Mindfulness-Based Cognitive Therapy for PTSD

Advancing Treatment Outcomes for Post-Traumatic Stress Disorder through Alternative and Complementary Health Practices
Maryam Navaie, Dr.P.H.1, Karen Bibbins E.D.D.1, and COL (Ret.) Elspeth Cameron Ritchie, M.D., M.P.H.2
Advance Health
Solutions, LLC1
 The objectives of this presentation are to help interested professionals and
patients suffering from PTSD better understand the growing evidence-base for
CAM therapies for PTSD by:
1.
2.
Summarizing results related to the following promising CAM therapies: virtual
reality, medical acupuncture, animal-assisted therapy, mindfulness-based
cognitive therapy and meditation, and stellate ganglion block; and
Highlighting the practice, policy and research implications of CAM therapies for
PTSD.
 PTSD has an estimated lifetime prevalence of 7% in the U.S. population, 10–20%
among active duty service members and 35-45% among veterans.1-4
 Common co-morbidities include: Depressive disorders, substance abuse, panic
disorder, agoraphobia, generalized anxiety disorder, social phobia, bipolar
disorder, somatization, and chronic pain.5-12
 A strong association has been shown between PTSD and suicidal ideation,
attempts or completions.6,13
Department of Mental Health
Washington, DC2
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Mindfulness therapy attempts to increase awareness of thoughts and feelings, facilitate
emotional expression, discourage trying to control thoughts and engage in avoidance, and
target improvements in quality of life.44
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Attention training mindfulness programs have been shown to reduce anxiety symptoms and
alter cognitive processing.45-49
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Mindfulness meditative practices have been associated with reduced anxiety and negative
affects.50
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Mindfulness meditation may be of particular benefit for patients who have difficulty
focusing, avoidance symptoms and suppression of painful memories, and who are unable
to connect to bodily sensations such as tension.
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 It has been hypothesized that acupuncture may mediate its anti-pain, anti-anxiety, and other
therapeutic effects via this intrinsic neural circuit that plays a central role in the affective and
cognitive dimensions of pain as well as in the regulation and integration of emotion, memory
processing, autonomic, endocrine, immunological, and sensorimotor functions.37,38
SGB, a well-established pain management procedure, is the first promising biologic treatment
that is emerging in the literature for PTSD.51
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5 to 10-minute procedure that involves injecting a local anesthetic at the right-sided C6/C7
cervical vertebrae.
 Several types of acupuncture have shown promise for use in combat situations as well as in
clinical settings for PTSD.22,24
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Several pathways have been posed to explain SGB’s mechanism of action in PTSD:
1. SGB influences PTSD via connections that exist between the stellate ganglia and insular
cortex and other intracerebral structures.52
2. SGB may be altering melatonin rhythm and sleep.53
3. SGB results in an overall decrease in sympathetic tone as a mode of improving PTSD
symptoms.54
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A recently review of all published case reports and case series of SGB treatment for refractory
PTSD found clinically significant and rapid symptom reduction across multiple health care
settings treating active duty military service members (Navy and Army), veterans and civilian
populations.55
 Involves visualization, manipulation, and interaction with computers and complex data [a
form of exposure therapy].16
 A systematic review of Virtual Reality Exposure Therapy (VRET) studies in the treatment of
PTSD suggests potential efficacy for different types of trauma, most notably among veterans
and treatment-resistant PTSD patients.17,18
 VRET is effective for individuals who are averse to engaging in recall of feared memories. It
allows for careful observation and manipulation of virtual environments to suit the needs of
each patient and allows gradual exposure to feared situations.17,18
 Various acupuncture techniques have shown promise for reducing trauma spectrum response,
which includes some PTSD symptoms, but there is a lack of sufficient evidence for complex
PTSD (e.g., refractory PTSD or PTSD with comorbid conditions).19-23
 Acupuncture is well suited for patients with anxiety, insomnia, headaches, depression,
musculoskeletal pain, and fatigue , all common co-morbidities of PTSD.21-36
 Fewer than 10% of PTSD-affected patients seek treatment within 1 year following  Combat-specific “battlefield acupuncture”(BFA) involves needling 5 points that influence the
cingulate cortex and thalamic nuclei.23,24
trauma exposure, with a median 12-year delay in seeking treatment.1,14,15
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Current Evidence-based therapies include:
1.
Trauma-focused psychotherapies (e.g., prolonged exposure-therapy, cognitive
processing therapy, eye-movement desensitization and reprocessing)
Stress inoculation training approaches (e.g., cognitive behavior intervention)
Pharmacotherapies: first-line therapies include selective serotonin reuptake
inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)
2.
3.
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Many barriers exist to successful treatment for PTSD including:
 Access to care
 Patient preferences/acceptability
 Lengthy duration of treatment
 Contraindications due to co-morbidities
 Stigma
 Current evidence-based treatments for PTSD have an overall success rate of only
20–30%, leading doctors and researchers to explore the benefits of
complementary and alternative medicine (CAM) for PTSD.14
 Service dog training and equine-assisted therapy are being used as purpose-driven
interventions for managing PTSD by facilitating psychological and social improvement and
functional independence.39,40
 Studies suggest optimization of social support can improve PTSD symptoms by increasing
endogenous levels of oxytocin, an effect that may be achieved by using therapy animals.41
 Use of therapy animals may especially benefit PTSD patients who are withdrawn,
uncooperative and uncommunicative or those who lack a sense of support.42
 Evidence is mostly anecdotal but positive:41,43
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Increased patience, impulse control, and emotional regulation
Improved ability to display affect
Improved sleep
Decreased depression
Decreased startle response
Decreased pain medication use
Increased sense of belonging
Lowered stress levels & more calm
Presented at the Annual Convention of the National Alliance on Mental Illness (NAMI)
September 3–6, 2014 in Washington, D.C.
 Current limitations in existing research include:
 Inadequate number of rigorous studies – lack of RCTs
 Limited study designs
 Inconsistent methodologies
 Further research is needed to:
 Gather long-term follow-up data
 Evaluate potential placebo effects
 Determine the potential mechanism(s) of action for various CAM therapies
 Identify which patient characteristics are most likely to benefit from CAM
treatments to guide clinical decision-making
References may be obtained from
Advance Health Solutions by contacting
Dr. Maryam Navaie at
[email protected] or
Dr. Karen Bibbins at
[email protected].