We propose to examine the hypothesis that veterans with posttraumatic stress disorder (PTSD) who attend prolonged exposure therapy (PE) along with transcendental meditation (TM) training have lower recurrences of PTSD symptoms than veterans who attend PE or TM group alone. The sampling frame of OIF/OEF veterans was systematically obtained from VAPAHCS, and we anticipate a sample of 100 participants. Participants will be randomly assigned into one of four conditions: control, TM, PE or combined TM/PE. The PTSD Checklist (Military) or the (PCL-M) will be used as pretest/posttest. Our anticipated findings are that scores in the control will not differ, the TM and the PE groups will have some relief of symptoms, and that the TM/PE group will show the most relief of PTSD symptoms.
Effects of Meditation and Prolonged Exposure Therapy on PTSD in Veterans
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This study will be focusing on Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans. The study will be considering the positive effects of prolonged exposure therapy as well as transcendental meditation, in the alleviation of veteran’s posttraumatic stress disorder (PTSD) symptoms. This study will contribute knowledge to the effectiveness of treatment options for PTSD, the populations they serve, and perhaps even contribute ideas for further research.
According to the American Psychiatric Association (DSM-IV-TR), PTSD is defined through six general criteria: the person has been exposed to a traumatic event or a stressor, the traumatic event is persistently re-experienced or intrusively recollected, there is persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, there are persistent symptoms of increasing arousal, the duration of the disturbance lasts more than one month, and the disturbance causes significant distress or impairment in occupational, social or other significant areas of functioning (2006).
The most common treatments for PTSD in veterans are drug therapy, group therapy, and exposure therapies (Comer, 2008). Current drug therapies for PTSD include anti-anxiety medications, and antidepressant medications (Davidson, et al. 2005). Beta-blockers, another form of drug treatment, block the bodily effects of adrenalin (Shay, 1995). Rap groups, which are a form of group therapy where veterans meet with each other to share experiences, feelings, develop insights, and give mutual support (Comer, 2008). Exposure therapies allow the veteran to reexperience traumatic events and the emotional responses that are elicited. They learn techniques to alleviate these negative feelings through exposure and retelling (Comer, 2008). Another consideration for treatment in veterans are meditation techniques, which teach relaxation and breathing methods for veterans to utilize if they are facing a stressful or anxiety provoking situation (Brooks & Scarano, 1985).
Literature Review
Brief History of PTSD
Since the 1800s, military doctors have diagnosed soldiers with “exhaustion.” During WWI, the term became “shell shock.” During and after WWII, the symptoms were referred to as “combat fatigue” (Comer, 2008). This implies that, until the mid-20th century, PTSD was thought of as a type of exhaustion, and not yet recognized as a psychological disorder requiring specific recognition and treatment. A study found that in veterans with current PTSD, those who served in WWII were less symptomatic than those who served in Vietnam (Davidson et al., 2005). This may be partially due to the differing conditions of homecoming experiences by these two groups: with WWII, the returning veterans were welcomed as heroes, while with Vietnam, the returning war veterans faced criticism because of the political disagreements surrounding the war. In either case, the APA and the first two editions of the DSM (1952 & 1968) did little to help as the military all-but-ignored their growing mental-health crisis. The DSM-IV-TR states that, PTSD used to be considered a lack of mental strength or courage by veterans to confront their battlefield experiences. It was not until 1980, after the Vietnam War that PTSD was recognized as a disorder (DSM-IV-TR, 2000). It was only with the publication, in 1980; of the DSM-III that PTSD finally received recognition as a psychological disorder that requires psychological attention.
Prevalence of PTSD in Veterans
In a study by the National Vietnam Veterans Readjustment Survey it was found that 15.2 percent of all male veterans (479,000 out of 3,140,000 who served in Vietnam) and 8.1 percent of all female veterans (610 out of 7,200) were diagnosed with PTSD (Kulka et al, 1988). These are considerable statistics that merit attention as we consider the long-term costs and effects of our current wars in Afghanistan and Iraq.
One study found that nearly one-fifth, or 20 percent, of U.S. troops who have returned from the war in Iraq now suffer from PTSD, a marked increase over Vietnam war veterans. The prevalence of the disorder is more than four times higher among veterans who were directly involved in fire fights than those who were never under fire (Emery, 2004). Fewer then half of those eligible for the diagnosis have sought treatment. Interviews with those at risk showed that only 23 percent to 40 percent sought professional help, most typically because they feared it would hurt their military careers, said a study published in the New England Journal of Medicine (Hoge et al., 2004). This is an alarming statistic, indicating that psychologically wounded soldiers are returning to service and civilian life without proper treatment.
Research has shown that deployment stressors and exposure to combat result in a multitude of mental health problems, including major depression, substance abuse, impairment in social functioning, an inability to work, and PTSD (Hoge, 2006). Schwartz (1984).explains that some of the comorbid disorders and problems that exist simultaneously with PTSD include: feelings of hopelessness, shame, despair, hostility, guilt, social phobia, relationship problems including divorce and violence, anxiety, acute stress disorder, chronic pain, self harm, and feelings of suicide (Schwartz, 1984).
Treatment Available for Veterans With PTSD
Drug therapy.
Drug therapy among veterans with PTSD is common. Current drug therapies for PTSD include: anti-anxiety medications to help control tension, and antidepressant medications to reduce the occurrence of nightmares, flashbacks, panic attacks and symptoms of depression (Davidson, et al. 2005).
Another drug used in treatment is beta-blockers, which block the bodily effects of the adrenalin rush during the cycle of rage reactions (Shay, 1995). According to Shay, the mind-body-mind cycle of rage in persons with PTSD is one that starts with rage in the mind, immediately followed by a rush of adrenalin in the body, and finally during the adrenalin rush ones mind becomes cloudy and it is difficult to think clearly (1995). Even though drug treatment has proven effective our goal of this study is to not use medication, but discover more natural ways of alleviating symptoms of PTSD.
Group therapy.
The most common group therapy for veterans is rap groups. A rap group is a group where veterans meet with others like themselves to share experiences and feelings, develop insights, and give mutual support (Comer, 2008). Group therapy may have such success in reducing the isolation and stigma these veterans experience by allowing them to have the understanding that they are not alone in these feelings, thoughts, and experiences. Group therapy is an efficient and valuable way to overcome the stigma of PTSD, however our focus is on the ability of the individual person to reduce intrusive symptoms.
Exposure Therapies.
Some studies indicate that exposure treatment is the single most helpful intervention for people with PTSD (Comer, 2008). One type of exposure treatment technique is called flooding, which is commonly paired with relaxation training. Flooding encourages the veteran to imagine and re-create a traumatic or disturbing scene that they experienced in great detail, and encourages them to hold the image until their anxiety about the image decreases (Comer, 2008). Next, the veteran replaces the negative image with a positive one, and finally, the therapist leads the veteran through some relaxation exercises (Comer, 2008). This is done over and over with the concept that the repeated exposure to the memory and the immediate relaxation in association with the positive images will alleviate the anxiety brought by these combat memories (Comer, 2008).
Another form of exposure therapy is Eye Movement Desensitization and Reprocessing (EMDR). During EDMR treatment, the patient is asked to hold in mind a disturbing image, as well as any associated negative cognition or bodily sensations associated with the traumatic memory, while tracking the clinicians moving finger in front of his or her visual field (Hoge et al, 2004). The treatment is repeated until distracting aspects of the traumatic event are reduced and more adaptive cognitions emerge regarding the trauma (Hoge et al, 2004).
A more recent form of exposure therapy combines aspects of flooding and EMDR with modern technologies called virtual reality exposure. Virtual Reality Exposure (VRE) integrates computer graphics, visual displays, body tracking system, and other sensory input devices to submerge a participant in a virtual environment (Rothbaum et al., 2003). VRE confronts the veteran with their disturbing memories and force them to relive these memories until their anxiety is somewhat alleviated and until more accepting feelings of the events are formed (Rothbaum et al., 2003).
According to Foa et al (1991), prolonged exposure therapy consists of psychoeducation; real world exposure (in vivo exposure) which encourages the veteran to approach safe situations he or she has not since the trauma (for example, driving a car if they were driving a tank in combat); and lastly, talking through the trauma with trained professional (imaginal exposure), which assists the veteran in making sense of the trauma. This helps the trauma related distress and negative emotions lessen over time due to the repeated exposure to the event (Foa et al, 1991). In a study of ten veterans with confirmed PTSD Rauch et al. (2009), found significant reduction of reexperiencing, avoidance, numbing and hyperarousal symptoms after prolonged exposure therapy (Rauch et al, 2009).
Transcendental Meditation as Treatment for PTSD
An Indian yogi named Maharishi Mahesh developed transcendental meditation in 1955 (Mahesh, 1963). According to yogi Maharshi Mahesh the practice derives from a Vedic Hindu tradition (Mahesh, 1963). Transcendental meditation is a mantra- based practice, which emphasizes a clearing of the mind (Wallace, 1971). According to yogi Maharshi Mahesh the process of learning the transcendental meditation technique is standardized and consists of seven steps (Mahesh, 1963). These steps include: an overview of scientific research regarding the possible benefits of transcendental meditation, lecture regarding the origins and mechanics of the transcendental meditation technique, one on one personal interview to gather basic information, private meditation sessions with instructor, practicing alone, further instruction based on personal experiences, and finally, higher stages of human development are discussed with instructor (Mahesh, 1963).
A study by Brooks and Scarano (1985) found that transcendental meditation was more effective in alleviating PTSD in veterans than therapy. 18 male veterans were studied and nine variables were measured. While therapy showed no significant improvement on any of the measures, the transcendental meditation group improved significantly on eight of the nine measures (Brooks & Scarano, 1985). It was so beneficial in fact, that after three months of treatment seven out of ten participants in the group felt improved enough that they no longer required services from the VA (Brooks & Scarano, 1985). One veteran even stated, “I no longer have the same intensity of tension, rage, and guilt inside – it’s as if a huge burden has been lifted” (Brooks & Scarano, 1985, p. 214).
Rationale
The prevalence of PTSD in our returning veterans is obvious. The treatment of their PTSD, however, is a different matter. Through the literature review it is clear that there are many treatments available and exposure therapy is one of the most beneficial ways to treat PTSD in our returning veterans. Our goal is to bolster prolonged exposure therapy by adding transcendental meditation training in order to maximize the effects of treatment.
Hypothesis: Returning OIF/ OEF veterans who attend transcendental meditation training as well as prolonged exposure therapy sessions sessions have lower recurrences of PTSD symptoms than those in the control, transcendental mediation training, or prolonged exposure therapy groups.
Methods
Sample
The sampling frame was obtained and drawn from a database from VAPAHCS, which consists of OIF or OEF male combat veterans. Inclusion criteria for the study include: (a) participant must be an OEF or OIF male combat veteran. (b) Between the ages of 18-25. (c) diagnosis of PTSD by a clinical professional (d) willingness to provide informed consent and (e) willingness to participate in either prolonged exposure therapy or transcendental mediation training group. Exclusion criteria are as follows: (a) veteran is unwilling to participate in groups, (b) veteran is on medications that will alter his ability to participate in the study, and (c) veteran has comorbid problem such as alcohol or drug abuse which may alter effectiveness of participation.
We used a systematic sampling technique and selected every other veteran from the VAPAHCS database, (which was not in alphabetical or numerical order of any kind) who met our inclusion criteria. The mean age of participants will be 21.5 years and we estimate (from comparison studies) that about 40% will be Caucasian, 30% will be Hispanic, 25% will be African American, and 5% will be self-identified as another ethnic/racial background. Our anticipated sample size is about 200 participants we expect around 100 of them to participate in the study (see appendix 1:1).
Measures
The PTSD Checklist (Military) or the PCL-M (see appendix 1.2) will be used as a measurement for pre-test and posttest. This scale has ordinal categories regarding reexperiencing symptoms of PTSD and is written specifically for those with military experiences. Each question on the scale asks how often the veteran has been bothered by the PTSD symptom over the last month. The scale has five ordinal categories for each question ranging from none to extreme. The scale is scored by points which are in accordance to the ordinal categories and are as follows: Not at all = 1, A little bit = 2, Moderately = 3, Quite a bit = 4, Extremely = 5. The points are added up for all 17 questions (the cutoff score is 50). We will compare the total score of the PCL-M from the pre-test to post-test after treatment.
The PCL-M is a 17-item checklist that has participants rate to what extent each of the 17 symptoms of PTSD have bothered them in the past month. The PCL-M has excellent testaˆ‘retest reliability over a 2aˆ‘3 day period (.96), as well as very high internal consistency for the full 17 item scale (.97). Construct validity is shown by the PCL-M’s strong convergent validity and correlation with other measures of PTSD, such as the Mississippi Scale (.93), the PK scale of the MMPIaˆ‘2 (.77), and the Impact of Event Scale (.90), and also moderately correlates with level of combat exposure scale (.46) this shows the scales construct validity (Weathers et al., 1993).
After the pre-test PCL-M is completed, participants will be randomly assigned into one of four conditions: (a) control (b) transcendental meditation training (c) prolonged exposure therapy (d) transcendental meditation training and prolonged exposure therapy group.
Procedures
The sampling frame will be obtained from VAPAHCS database. If potential participants meet inclusion criteria they will be considered for the study. Each participant will be given 100 dollars each to complete the study. Before beginning the study each participating member will sign an informed consent, which has been approved by the VA Central Institutional Review Board, form indicating (a) purpose of the research, duration, and procedures, (b) that all of their data and personal information will be kept confidential, (c) that if they chose to participate they can withdraw from the study with no negative effects, and (d) the assurance that no harm will come to them by participating in the study. After informed consent forms are signed the project proposal will be submitted to the IRB for expedited review. The study will take place through the VA Palo Alto Health Care System (VAPAHCS) in the Palo Alto division hospital in an outpatient branch of the facility.
After submission is approved by the IRB the participants who have signed the consent form will complete the PCL-M . After the pre-test PCL-M is completed, participants will be randomly assigned into one of four conditions: (a) control (b) transcendental meditation training (c) prolonged exposure therapy (d) transcendental meditation and prolonged exposure therapy group.
Each group will run at the same time in different locations of the VA hospital. All four of the experimental groups will have sessions with their designated group twice a week for 18 weeks (36 total sessions) with the combined group doing one of each session (transcendental meditation training and prolonged exposure therapy) per week. The control group will only be participating the first and last week to assess with a pre and posttest. The study’s duration is approximately 20 weeks. The first week will be assessment for study, followed by 18 weeks of sessions, and then one last meeting to gather comparison data.
Professionals trained in the transcendental meditation technique will conduct the transcendental meditation group. The professionals will meet weekly to ensure they are uniformly adhering to the seven standardized steps (Roth, 1994). Male PhD level clinical psychologists who specialize and have had appropriate training in exposure therapy will conduct the prolonged exposure therapy group. Each psychologist will meet weekly for supervision to review protocol and discuss cases. Supervisors will also review progress notes to ensure therapy is being conducted according to the study.
The control group will have no treatment for 18 weeks. After the pre test is administered they will make an appointment to take the posttest in exactly 18 weeks, until that appointment they have no further obligations to the study.
The transcendental meditation group will be attending 90-minute training sessions with a professional twice a week for 18 weeks. The sessions will be structured according to the seven standardized steps according to Roth (1994). Step 1 (1 session) participants will attend a 90-minute lecture with a trained professional and be given an overview of scientific research regarding the possible benefits of transcendental meditation. Step 2 (1 session) a 90-minute lecture regarding the origins and the mechanics of the transcendental meditation technique. Step 3 (2 sessions) one on one personal interviews to gather basic information, answer any questions about the technique, and aid with personalizing the technique to the individual. Step 4 (5 sessions) 90-minute training sessions where the professional directly teaches the participant the transcendental mediation techniques. Step 5 (24 sessions over 8 weeks) participant practices at home twice a week for 90 minutes with a 90-minute check in with a professional at the clinic every third session in lieu of home practice. Step 6 (1 session) the instructor will give further instruction and adjustments will be made to the practice based on the individual’s personal experiences and growth. Step 7 (2 sessions) Lastly, participant will have two final meetings with the professional where higher stages of human development are explained in regards to the transcendental mediation system, and plans for continuing the practice will be discussed.
The prolonged exposure therapy group will be attending 90-minute therapy sessions twice a week for 18 weeks. (36 total sessions). The prolonged exposure therapy sessions will be structured according to the phases of treatment according to (Foa et al, 1991). Sessions will be as follows: Stage 1 (2 sessions) Psychoeducation about PTSD and treatment. In this repertoire building stage, an overview of PTSD and the foundation of exposure therapy will explained to the participant, as well as other treatment options for PTSD. There is also an interview for information gathering along with treatment planning. Stage 2 (17 sessions) Talking through the trauma (imaginal exposure) During this stage of treatment the veteran is asked to relive the traumatic event by imagining it as vividly as possible and describing it aloud using the present tense. The therapist will instruct the veteran to focus on the image, emotion, negative thought, and body sensations surrounding the traumatic memory. This will be done every session. Stage 3 (15 sessions) Real world exposure (in vivo exposure) exposing the veteran to feared and typically avoided situations (due to traumatic event) that have been judged safe by patient and therapist. This will be done once weekly by the veteran excluding the first week, and discussed the following session. Stage 4 (2 sessions) Closure and termination The last two sessions will be to review the progress the veteran has made and to provide instruction and support for ongoing self-reflection, and more acceptable ways processing of events should they arise.
The combined transcendental meditation / prolonged exposure therapy group will be attending 90 minute sessions once a week for each of the two groups (2 sessions a week). The prolonged exposure therapy group will be structured according to Foa et al.’s (1991) phases of treatment, however each of the stages will be reduced to 18 sessions for the therapy. The transcendental meditation portion of the group will run concurrently to the prolonged exposure therapy group according to the seven standardized steps according to Roth (1994) and the amount of sessions will also be reduced to 18 sessions.
Minorities will be included in this study. Our Planned Enrollment Form is based on the racial breakdown of participants seen at Palo Alto University and on review of the literature. The recruitment of minorities is approximately 25% in this study. However, we will continue to make efforts to increase the presence of minority subjects in our studies.
Discussion
Potential limitations to this study include a possible sampling bias, which may not be representative of the veteran population as a whole (all of the participants are in the same geographic region and there may be extenuating factors in this region). Another possible limitation is administering the PCL-M as the pre-test and posttest, and having it as a main source for comparison data. The participants are self-reporting data, which can always lead to bias and error, especially since the same 17-question scale will be used. Perhaps adding extra questions to the scale, or having family members do a pre-test and post-test of what they believe the severity of the veterans PTSD symptoms are would be helpful in eliminating this limitation. An additional limitation to the study includes the participants being in an outpatient facility vs. inpatient, since the circumstances and situations will differ with each participant between treatments. Lastly, there is limitations of external validity based on recruitment estimates, based on the ethnic and gender make up of past studies in this research area, it is expected that the majority of subjects will be Caucasian. Thus, the results from this study can be generalized to the Caucasian population, but caution will need to be taken for application to other ethnic groups.
The anticipated findings of the study are that after comparing the PCL-M scores for each treatment group; the control groups scores will not differ, the transcendental meditation and the prolonged exposure therapy groups will have some relief of intrusive PTSD symptoms, and that the transcendental meditation training in combination with the prolonged exposure therapy group will show the most dramatic change and relief of PTSD symptoms.
