The role of mindfulness as approach-based coping in the PTSD-substance abuse cycle

doi:10.1016/j.addbeh.2016.08.043

Addictive Behaviors

Volume 64, January 2017, Pages 212-216

https://doi.org/10.1016/j.addbeh.2016.08.043 Get rights and content

Highlights

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Mindfulness has shown an inverse relationship with avoidant coping styles, PTSD symptoms, and substance use disorders.
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Trait mindfulness and mindfulness training are associated with treatment efficacy in comorbid substance abuse and PTSD.
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The current study suggests mindfulness mediates the relationship between PTSD symptoms and substance dependence.
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A reverse mediation model suggests mindfulness mediates the relationship between substance dependence and PTSD symptoms.
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Results may point to the role of mindfulness in the bidirectional and cyclical nature of this comorbidity.
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Findings contribute to understanding underlying processes of comorbid PTSD and substance use, and may inform treatment.

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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Women with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) demonstrate the greatest psychiatric severity when entering mental health treatment, and poorest rates of treatment completion and relapse compared to those with either disorder alone. Mindfulness-based interventions (MBIs) for women with comorbid PTSD–SUD may be an effective treatment approach as it targets mechanisms underlying self-medication of trauma-related symptoms via substance use. Little is known, however, of the benefits of MBIs for this population. Thus, the purpose of this study was to qualitatively elucidate mechanisms of action in a pilot MBI adapted for women with comorbid SUD and PTSD, with the goal of identifying the most salient aspects of MBIs that target self-medication of PTSD symptoms via substance use. Following completion of a trauma-integrated MBI, women (N = 39) diagnosed with PTSD–SUD were invited to attend one of ten, 60-minute, audio-recorded focus groups. A semistructured interview protocol was utilized to investigate how participants perceived the utility of MBIs in mitigating PTSD and SUD symptoms over the course of the intervention. Conventional content analysis guided qualitative analysis and reporting. Participants described four mechanisms through which they experienced MBIs attenuating the relationship between PTSD and SUD: increased attention to trauma- and substance-related triggers occurring in the present moment; greater cultivation of nonjudgmental acceptance to aversive experiences; development of self-compassionate attitudes toward suffering; and increased tolerance to aversive experiences. Building upon these mechanisms of action, we propose a moderated mediation model, in which increased present-moment awareness, nonjudgmental attitudes toward distress, and self-compassion reduce impulsivity and negative affect, which then increases tolerance for aversive experiences, thereby attenuating the relationship between PTSD and SUD symptoms. Interventions targeting the four proposed mechanisms may be considered when treating women diagnosed with comorbid PTSD–SUD.
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University students (N = 304; M_age = 19; 52.3% female) completed a structured clinical interview to confirm trauma history and PTS. At an experimental session one week later, participants completed a series of three trauma cue exposures. Affect and drinking urge were measured at baseline, after each cue exposure, and at experiment's end.
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A recent study found that mindfulness mediates the relationship between PTSD symptoms and SUD severity such that those with more severe PTSD symptoms and substance use had low scores on measures of mindfulness. This suggests that altering one's relationship to these symptoms through nonjudgmental awareness and acceptance can improve PTSD symptoms and SUD [51]. Avoidant coping is a functional negative reinforcer that only perpetuates the PTSD symptom and substance use relapse cycle.
Comorbid post-traumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and is associated with a more complex clinical presentation with poorer clinical outcomes when compared with either disorder alone, and untreated PTSD can predict relapse to substance abuse. A number of integrated treatment approaches addressing symptoms of both PTSD and SUD concurrently demonstrate that both disorders can safely and effectively be treated concurrently. However, attrition and SUD relapse rates remain high and there is need to further develop new treatment approaches. Innovative approaches such as mindfulness meditation (MM) successfully used in the treatment of SUD may offer additional benefits for individuals with SUD complicated with PTSD. Specifically, Mindfulness-based Relapse Prevention (MBRP) integrates coping skills from cognitive-behavioral relapse prevention therapy with MM practices, raising awareness of substance use triggers and reactive behavioral patterns, and teaching skillful coping responses. Here we present the design and methods for the “Mindfulness Meditation for the Treatment of Women with comorbid PTSD and SUD” study, a Stage 1b behavioral development study that modifies MBRP treatment to address both PTSD and SUD in a community setting. This study is divided into three parts: revising the existing evidence-based manual, piloting the intervention, and testing the new manual in a randomized controlled pilot trial in women with comorbid PTSD and SUD enrolled in a community-based SUD treatment program.

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Short CommunicationThe role of mindfulness as approach-based coping in the PTSD-substance abuse cycle

Highlights

Introduction

Section snippets

Participants

Results

Discussion

Role of funding sources

Contributors

Conflict of interest

First page preview

Addictive Behaviors

Drug and Alcohol Dependence

Neuropharmacology

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Journal of Anxiety Disorders

Feasibility, acceptability, and preliminary outcomes of a mindfulness-based relapse prevention intervention for culturally-diverse, low-income women in substance use disorder treatment

Substance Use & Misuse

Substance use coping as a mediator of the relationship between trauma symptoms and substance use consequences among incarcerated females with childhood sexual abuse histories

Substance Use & Misuse

Using self-report assessment methods to explore facets of mindfulness

Assessment

Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples

Assessment

Posttraumatic stress symptom severity and marijuana use coping motives: A test of the mediating role of non-judgmental acceptance within a trauma-exposed community sample

Mindfulness

Mindfulness-based relapse prevention for addictive behaviors: a clinician's guide

Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders

Jama Psychiatry

Perils and promise in defining and measuring mindfulness: Observations from experience

Clinical Psychology: Science and Practice

Comorbid posttraumatic stress disorder and substance use disorders: treatment outcomes and the role of coping

The PTSD checklist—Civilian version: Reliability, validity, and factor structure in a nonclinical sample

Journal of Clinical Psychology

Exploring the relation between childhood trauma, temperamental traits and mindfulness in borderline personality disorder

BMC Psychiatry

The severity of dependence scale (SDS): Psychometric properties of the SDS in English and Australian samples of heroin, cocaine and amphetamine users

Addiction

A test of whether coping styles moderate the effect of PTSD symptoms on alcohol outcomes

Journal of Traumatic Stress

Short Communication
The role of mindfulness as approach-based coping in the PTSD-substance abuse cycle