Short CommunicationThe role of mindfulness as approach-based coping in the PTSD-substance abuse cycle
Introduction
The association between trauma-related disorders, such as post-traumatic stress disorder (PTSD), and problematic substance use remains alarmingly high. In the National Epidemiologic Survey on Alcohol and Related Conditions (2011), almost half (46.6%) of individuals meeting criteria for lifetime PTSD had a comorbid substance use disorder (SUD). Additional studies have found that comorbidity rates for PTSD and SUD range between 25%–55% across various clinical populations (Brown and Ryan, 2004, Brown et al., 2003, Kessler et al., 1995, Pietrzak et al., 2011). Several studies have shown that experienced trauma is associated with multiple indices of substance abuse, including problematic use (Lisak & Miller, 2003), severity of substance-related negative consequences (Asberg & Renk, 2012), and heightened risk for relapse following treatment (Souza & Spates, 2008). While these maladaptive coping strategies may temporarily help alleviate or avoid discomfort, they often lead to longer-term negative consequences (Tiet et al., 2006).
Research suggests that there may be bidirectional effects that perpetuate this cycle, such that consequences of substance use exacerbate PTSD symptoms, and PTSD symptoms increase risk of problematic substance use and exposure to situations in which traumatic experiences and resulting PTSD are more likely to occur (Read et al., 2014, Stewart and Conrod, 2003). The presence of an SUD not only increases risk for and symptom expression of PTSD, it also predicts poorer treatment outcomes for those individuals who do seek treatment (Ouimette, Finney, & Moos, 1999).
Several studies indicate that a factor underlying both SUDs and PTSD is mindfulness, often described as an intentional, present-centered and nonjudgmental awareness (Kabat-Zinn et al., 1990). The Five-Facet Mindfulness Questionnaire (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006), commonly used in psychology literatures, describes mindfulness as comprised of 5 constituents factors: acting with awareness, observing, describing, nonjudgment, and nonreactivity. Levels of mindfulness may be negatively affected by trauma, as evidenced in a study by Elices et al. (2015) suggesting childhood abuse is negatively associated with mindfulness, particularly factors of acting with awareness and nonjudgment (Michal et al., 2007). Mindfulness has also been shown to be inversely related to addictive behaviors (Karyadi, VanderVeen, & Cyders, 2014) with lower levels of mindfulness negatively predicting the presence of a SUD (Levin, Dalrymple, & Zimmerman, 2014), as well as intensity of the disorder, and comorbid PTSD and depression (Shorey, Brasfield, Anderson, & Stuart, 2014).
Conversely, mindfulness has been shown to be positively associated with approach-based coping and improvement to treatment outcomes in individuals with trauma history (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011), and negatively related to severity of avoidance-related PTSD symptoms (Thompson & Waltz, 2010), with evidence that the non-reactivity element of mindfulness (Baer et al., 2006) may be uniquely associated with overall positive PTSD outcomes (Kalill, Treanor, & Roemer, 2014). The nonjudgmental acceptance of experience, a central aspect of mindfulness (Kabat-Zinn et al., 1990), appears to predict a reduction in PTSD symptomology and an increase in potential treatment efficacy (Vujanovic, Youngwirth, Johnson, & Zvolensky, 2009). These findings suggest that mindfulness training may foster more adaptive coping responses for individuals with comorbid PTSD and SUDs, as it is associated with the symptom sets independently (Karyadi et al., 2014, Shorey et al., 2014, Vujanovic et al., 2009), as well with mechanisms that may underlie PTSD-SUD comorbidity.
Other recent studies exploring this relationship have yielded similar results, indicating that global measures of dispositional mindfulness, including factors of observing, describing, acting with awareness, and non judgmental acceptance, have a inverse predictive influence on post traumatic stress symptoms and craving (Garland & Roberts-Lewis, 2013), and that nonjudgmental acceptance of experience exhibits a partial mediating role in the relationship between cannabis and alcohol use motives and PTSD symptom severity with nonjudgmental acceptance negatively predicting motives for substance use (Bonn-Miller, Vujanovic, Twohig, Medina, & Huggins, 2010).
Given the common processes and mechanisms underlying mindfulness and the development and maintenance of PTSD symptoms and SUDs, the potential benefits of mindfulness in this endemic comorbidity is worthy of further exploration. The current study aims to replicate and expand the foundation of literature assessing effects of mindfulness in the PTSD-addiction cycle by assessing whether mindfulness, and its constituent facets, have a mediating role in the relationship between PTSD symptoms and severity of substance dependence. The study assesses a broader index of substance abuse that includes psychological components of addictive behavior, such as feeling out of control and worry regarding use (Gossop et al., 1995), rather than solely amount of use of a specific substance, cravings, or motives for use. It was hypothesized that mindfulness would be a significant mediator in the relationship between PTSD symptoms and substance use, such that levels of mindfulness would partially explain the predictive relationship between PTSD symptoms and severity of substance dependence. Results of this study may provide valuable information on these interrelated processes, and potentially inform interventions for dually-diagnoses populations, specifically highlighting potential mindfulness-based mechanisms that may help substance abuse treatment for individuals with PTSD.
Section snippets
Participants
Data in the current study were drawn from a larger multi-site study of Mindfulness-Based Relapse Prevention, an outpatient aftercare program for adults (N = 286) with substance use disorders. Participants were recruited via flyers posted at the treatment facilities and informational sessions held by researchers (see Bowen et al., 2014 for full study description). This population has reported high rates of trauma exposure in previous studies (Brown and Ryan, 2004, Brown et al., 2003, Kessler et
Results
The primary goal of our analyses was to assess the association between PTSD symptoms, mindfulness, and severity of substance abuse using a cross-sectional model.
Data were examined for outliers and normality of distribution, and found to be within the acceptable ranges. Descriptive statistics and bivariate correlation coefficients for all variables in the analyses are shown in Table 1, Table 2, respectively.
In the following analyses, gender and age were included as a covariates, as it they were
Discussion
The current findings support the hypothesis that mindfulness is a significant mediating factor in the relationship between symptoms of PTSD and severity of substance dependence, such that higher levels of PTSD symptoms are associated with lower levels of mindfulness, and subsequently more severe substance dependence. Specifically, acting with awareness and nonjudging emerged as significant mediating facets.
The relationship between PTSD and SUDs has been established in numerous studies, and
Role of funding sources
Funding for this study was provided by NIDA Grant R01 DA025764-01A1. NIDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Contributors
All authors must have materially participated in the manuscript preparation. Authors De Boer and Bergman conducted literature searches and provided summaries of previous research studies. Author Bowen conducted the statistical analysis. All authors contributed to original drafts and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
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