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Mindfulness Meditation and Combat-Related Post- Traumatic Stress Disorder: A Psychological, Philosophical, and Neuroscientific Perspective Melissa T. Greene Lehigh University Cognitive Science Program Senior Thesis: Spring 2012


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Emotion and affective regulation strategies are core principles in cognitive science, clinical psychology, neuroscience, and a range of other fields that seek to understand the complex relationship between mind and brain. While the rich emotional lives we lead as human beings are certainly invaluable, they also lend themselves to an ever-expanding host of questions that attempt to identify the roots, purposes, and nuances involved in and pertaining to such a uniquely complicated experience. The experience of emotion is inextricably linked to both neurological/physiological and psychological processes, and the act of affective regulation has similar foundations in both neuroscience and psychology. Additionally, there exists a variety of exceptional philosophical and cultural tenets that influence the methods different individuals choose in attempting to moderate emotion, and these factors combined produce a very dense and very involved topic of study. While emotion and affective control are in and of themselves profoundly interesting topics, perhaps more intriguing still is the unique circumstance of emotion and emotional regulation within the context of psychiatric illness and mental disorders. Due to disruptions in both neurological and psychological functioningwhich emotion and emotion regulation strategies depend upon emotion regulation presents a new and unusual challenge to disordered patients. Effectively controlling affect is difficult for anyone; therefore, the additional impedances experienced by psychiatric patients certainly prove to further complicate the task. Of particular relevance today (although significantly underrepresented in the current literature) is this issue as it pertains to combat veterans suffering from post-traumatic stress disorder: the ongoing conflicts in the Middle East have resulted in unprecedented numbers of individuals experiencing intense psychological

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trauma, yet relatively little attention has been devoted to devising a thorough and effective solution to this pervasive issue. Returning war veterans often experience intense and debilitating psychological injuries that are extremely difficult to treat comprehensively. Many veterans grapple with transitioning back from combat modethe adaptations the mind makes to handle to kill or be killed reality of war zonesback to civilian life, and severe conflict results as the demands on the psyche worsen. In such instances, the experience of affect is overwhelmingly negative, neurological damage hinders high-level cognitive processing involved in executive control, and psychological coping strategies are often exhausted, rendering emotion regulation an extraordinarily difficult and daunting task. The best way to manage such psychological injuries then is understandably yet to be determined as treatment for post-traumatic stress disorder is broad; because the disorder presents such a challenge to both patients and clinicians, various intervention options are still being explored. Further complicating the issue are the philosophical and cultural ideologies present within the structure of the military itself. Psychological resilience is highly valued, admission of mental illness (PTSD in particular) is highly stigmatized, and outsiders (including psychologists, psychiatrists, and other medical professionals) are met with significant suspicion and hostility. This means that many individuals experiencing PTSD symptoms may refuse to seek treatment (Gould, 2007), adding yet another layer to an already compounded problem. In addition to attempting to regulate seriously powerful negative affect directly associated with the trauma they have experienced, veterans are also

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limited in which coping strategies and treatment options they may implement based upon the values and beliefs of the larger system of which they are a part. This purpose of this paper is then fourfold. First, an overview of the psychological experience of affect and cognitive regulation techniques will be provided; then the neurological and physiological experience of emotion and stress will be described along with their related interventions; next, these topics will be described in terms of their relationship to combat-related post-traumatic stress disorder; and finally, the current research and hypothesis regarding effective emotion regulation techniques for use in the treatment of combat-related PTSD will be described. II. THE PSYCHOLOGICAL EXPERIENCE OF AFFECT AND COGNITIVE MANAGEMENT TECHNIQUES While the term emotion has been generally applied up to this point, it is important to now specify that negative affectand stress in particularwill be the more narrow and appropriate terms in which regulatory strategies are described. While the human stress response is similar in both cases of good stress and bad stress, it is rarely the case that emotional regulation strategies are required in the experience of good stress. Likewise, post-traumatic stress disorder (as its name implies) involves extremely negative affect; therefore, stress will be used to comprehensively describe negative affect from this point forward, and emotional regulation will be described as it pertains to coping strategies implemented to reduce the effects of stress. Psychologically speaking, stress exists in two distinct forms acute and chronic. Acute and chronic stress differ in the domains of physical and physiological symptoms as well as psychological symptoms, and as a result are managed via different coping

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strategies, although there are overlaps in each of these areas as well. Before continuing, it is necessary to emphasize the previous point that overlaps between acute stress and chronic stress are very common. For this reason, types of stress exist more as different components of the stress process rather than distinct categories. There are no hard and fast lines that determine what counts as or causes acute versus chronic stress; sympathetic nervous system activation can attend chronic role strain, for example, and daily hassles typically considered acute stressorscan in some cases become chronic (Aldwin, 2009). For the purpose of this paper, working definitions of the terms acute stress and chronic stress will be established and the variances in symptoms and coping strategies will be understood through these lenses. The first type of stressacute stress seems to be the more common of the two, as it includes daily hassles that oftentimes do not lead to persisting psychological or physical symptoms (again, this is not to say that this never occurs). Acute stress is perhaps best differentiated from chronic stress based on temporal characteristics; that is, while acute and chronic stress typically share many features (neuroendocrine responses, immune responses, the experience of negative affect, etc.), acute stress generally occurs as rapid- onset and is intense for a short period of time, whereas the opposite is true for chronic stress (Aldwin, 2009). Similarly, because intensity is moderate and duration is short, lasting physical and psychological consequences are not usually observed in acute stress situations. To provide an example, students examinations (and particularly important examinations, such as the LSAT or bar exam) are often described as the prototypical acute stressor. They are associated with anticipatory stress, although for the most part, stress peaks a few days before the exam and drops off rapidly in the days following the exam.

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extended period of time (weeks, months, or years). Chronic stress does not follow the normal cyclical pattern of arousal and return to baseline observed with acute stress, and is instead represented by a flattening of normal diurnal patterns of hormone secretion, which results in persistent psychological and physical symptoms. Post-traumatic stress disorder qualifies as chronic stress: this stress is severe, unwavering, and pervasive, and lasts long after the initial trauma has passed. Negative affect is associated with both acute and chronic stress, although again, symptoms associated with acute stress do not persist for any significant length of time. Negative affect as it pertains to chronic stress is markedly different: psychological symptoms not only persist, but lead to conditions such as chronic mood and anxiety disorders, including PTSD (McEwen, 2005). Acute stress is also more commonly associated with symptoms such as situation-specific anxiety (as opposed to general), negative mood, or panic, whereas chronic stress is linked to generalized anxiety disorders and depression. Again, it is apparent that many differences between acute and chronic stress pertain to temporal factors, particularly within the realm of psychological symptoms: a bad mood will subside eventually, but depression may endure indefinitely. Because of these temporal differences, different coping strategies are employed accordingly. Lazarus and Folkman (1980) define coping strategies as cognitions (thoughts) and behaviors that a person uses to reduce stress and moderate its emotional impact, which suggests that we can and do consciously implement psychological techniques to combat our own psychological experience of stress. As Lazarus and Folkman

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explain, this occurs at two levelscognitive and behavioraland the choice of strategy depends largely on ones appraisal of the type of stress they are experiencing. Ultimately, this results in the choice between problem-focused and emotion-focused coping. However, some chronic stress situationsand PTSD is a particularly poignant examplenon- coping may be employed instead, resulting in exacerbated stress experiences that may require professional or medical intervention. Problem-focused coping is a cognitive coping strategy also known as active coping, and is typically implemented when the source of the stress is easily identifiable and appraised as manageable. Problem-focused coping typically involves acquiring resources that will aid in the direct management of the stress; in other words, problem-focused coping is the act of directly solving or managing the problem that is deemed the source of the stress (Kilburn & Whitlock, 2011). This type of coping is done by gathering information, making decisions, making plans, and resolving conflicts, and it includes situation-specific, instrumental, and task-oriented behaviors (Kilburn & Whitlock, 2011). This type of coping is typically implemented in acute stress situations. Emotion-focused coping focuses on the management of emotion related to stress and is typically employed in chronic stress situations in which the stressor is not directly manageable. Cognitive strategies are primarily relied upon in emotion-focused coping (as opposed to the behavioral strategies described in problem-focused coping), and include positive reappraisal, seeking emotional support, and meaning-focused coping in which an individual looks for positive meaning within the stress. Additionally, there are a few

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behavioral techniques that fall under the umbrella of emotion-focused coping, such as regulated breathing for example (Kilburn & Whitlock, 2011). To briefly elaborate upon behavioral methods, techniques such as regulated breathing and cognitive reappraisal are helpful in the short-term where stressors can be reevaluated in context, assuming that understanding the context will help relieve the stress. In other words, if a student taking the bar exam in two hours can relax, breathe deeply, and cognitively reappraise their stress such that they see it as having a foreseeable end, they may be better equipped to handle it and may observe a reduction in stress experienced. This does not work in chronic stress situations, as the stress typically has no foreseeable end. In the context of PTSD, the present stress actually results from situations that have occurred in the past, presenting a rather complicated problem. The future does not provide an escape from the present stress as it might in the acute stress example because it involves an indeterminate period of re-experiencing the trauma, which introduces a completely new (and arguably much worse) stress experience; in the acute stress situation, the future is relatively stress-free and provides something to look forward to. Because of this, stronger interventions than cognitive problem- or emotion-focused coping (specifically professional or medical interventions) are often necessary in chronic stress situations, and it similarly explains why normal emotion regulation strategies fail within the context of psychiatric disorders such as PTSD. Avoidance coping, or non-coping, is a maladaptive coping strategy in which the individual attempts to escape from a stressor without directly or indirectly dealing with it. Unfortunately, avoidance coping is sadly very common in cases of post-traumatic stress

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disorder, particularly within the context of the military, and PTSD symptoms have actually been described as the precursor to avoidance coping (Zeidner, 2005). Avoidance coping is marked by strategies such as avoidance (the act of deliberately avoiding addressing the trauma), numbing (refusal to acknowledge any sort of physical or affective response), repression of details about the stressor, and the use of drugs or alcohol as a means of escape from the stressor (Vijanovic, 2011). III. THE NEUROLOGICAL/PHYSIOLOGICAL FOUNDATIONS OF AFFECT: EXPERIENCE AND REGULATION There exists a significant neurological and physiological component to stress in addition to the emotional and cognitive elements previously described, which presents a unique interaction and a compounded challenge within the domain of stress and coping. It is undeniable that the interconnectivity between mind and body plays a significant role in the experience of emotion and the process of emotion regulation. Obviously, the two are closely linked; our thoughts and conscious experiences are not only at home in a material brain, but are also engaged in a unique causal relationship with the material world in which we operate. Therefore, when examining the psychological causes and implications of the experience of emotion and stress, it is critical to also explore the neurological and physiological experiences simultaneously. Because stress itself is a subjective mental state with roots in a material brain, it is often the case that stress manifests itself as physiological changes, disruptions, or malfunctions. Stress may be both psychological and physiological in nature, and thus, the relationship is such that psychological processes affect physiological ones and vice versa.

Greene 10 Before delving into the specifics of the bidirectional relationship of psychological

and physiological processes, it is important to understand why this connection is particularly strong within the context of stress and coping. As touched upon previously, psychological stress (which includes the experience of negative affect) is one of the few mental phenomena that may ultimately lead to physical consequences or repercussions over time; similarly, physical or physiological changes can also lead to psychological stress. This is consistent with the concept of transactionism; it is difficult to determine whether psychological or physiological changes initiate this complex feedback loop because once it begins, each component continues to influence the other (Aldwin, 2009). Now that this relationship has been explored in context and it is understood how

psychological processes affect physiological ones, it is useful to investigate the specific ways in which physiology affects psychology. Perhaps the best place to start in this discussion is the general adaptation response itself, which is explored in depth by Selye in his 1956 paper. The general adaptation syndrome consists of three distinct phases in which the body responds to stress; the firstthe alarm stageincludes the activation of the hypothalamus-pituitary-adrenal axis (HPA) and provides a very good demonstration of the mutual influence of psychological and physiological processes. This model posits that the complicated feedback loop between psychological processes and physiological processes begins with threat detection. Further emphasizing the transactionist model that Aldwin describes in the first chapter of her book, the notion of threat detection is a perfect place to begin when attempting to unravel the connection between psychology and physiology; interestingly, it highlights the fact that the one cannot

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be parsed in terms of the other. Threat detection is associated with heightened activity in the amygdala, which leads to activation of the hypothalamus in the HPA axisa physiological response yet it is also associated with the experience of fear and other negative affect. It is unclear whether the physiological activation of the HPA axis leads to the experience of fear or whether the experience of fear leads to the activation of the HPA axis, which is further evidence of the intricate relationship between psychological and physiological responses in the context of stress and coping. As Aldwin points out in her book, the brain and mind mutually affect one another, and it is inadequate to attempt to reduce one to an epiphenomenal property of the other, or speak of the two in terms of causal relationships (Aldwin, 2009, p. 6). It is crucial to have this concept firmly established before continuing: while there are distinct ways in which psychology affects physiology and vice versa, it is imperative to understand that which causes the other is difficult (if not impossible) to determine. Following the activation of the hypothalamus is the activation of the pituitary gland, which causes a number of endocrine responses (Aldwin, 2009). Once the pituitary gland is activated, vasopressin, oxytocin, and adrenocorticotropic hormones (ACTH) are released, again producing simultaneous psychological and physiological changes. Vasopressin is a vasoconstrictor and an antidiurectic; these are important physiological responses to stress as they prepare the body for fight or flight. However, vasopressin is also closely structurally related to oxytocin, which produces increased feelings of contentment and a decrease in anxiety and other negative affects, and prepares the mind to tend and befriend (a psychological process). Oxytocin serves as an antagonist to vasopressin, essentially by using psychological processes to regulate physiological ones.

The third stage in the HPA activation is the release of epinephrine and

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norepinephrine, catecholamines that increase heart rate and blood pressure, release stored energy, and initiate an immune response. Because catecholamines are toxic to the body, the stress hormone cortisol is simultaneously released in order to counteract these potentially harmful effects; here with the release of cortisol do we again see concurrent psychological effects. Following a normal diurnal pattern, cortisol peaks in the morning and decreases throughout the day. In individuals who experience chronic stress, however, cortisol peaks earlier and fails to drop. Heightened levels of cortisol (and thus lower levels of norepinephrine) interfere with serotonin production and thus may lead to depression. This concept is referred to as the catecholamine hypothesis of affective disorders and is described by Joseph Schildkraut in a 1995 paper (Schildkraut, 1995). Cortisol may also interrupt the sleep cycle, leading to rumination, impaired memory, and negative mood, which in turn erodes social support and exacerbates stress. The link to PTSD is clear in this case, and as one could easily predict, individuals suffering from PTSD show high levels of secretion of catecholamines and low levels of cortisol (which explains their inability to counteract the damaging effects of the catecholamines), as well as the subsequent psychological symptoms of depression. Individuals with PTSD typically experience heightened physiological arousal and an exaggerated adrenaline response, which over time results in deep neurological patterns that indicate a marked abnormality in the HPA axis (Geracioti, 2001). The second and third phases of the general adaptation syndrome involve resistance and exhaustion, and focus on various methods of coping and the psychological and physical consequences of a failure to cope. On page 96, Aldwin describes coping as cognitions and

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behaviors that are directed at managing a problem and its attendant negative emotional consequences (Aldwin, 2009, pg.96). The body produces the stress responses described above which themselves lead to physical ailments such as ulcers and other gastrointestinal problems, headaches, cardiovascular problems, and general pain (Selye, 1956). By implementing cognitive coping methods, one hopes to delay or prevent the onset of these physical maladies using preventative psychological measures such as reappraisal, support seeking, active coping, problem-focused/emotion focused coping, etc. In the case of PTSD, however, individuals experience allostatic overload and an inability to cope. Thus, these physical symptoms often manifest as a result of PTSD. There also exists an amygdalocentric model of PTSD, which suggests that post- traumatic stress disorder results from hyperarousal of the amygdala and insufficient top- down control from the medial prefrontal cortex and the hippocampus (Milad 2009). It is clear in cases of PTSD that the functioning of a variety of brain regions is seriously impaired, which is likely a result of (and, interestingly, a cause of) the prolonged stress response and hyperarousal of the HPA as previously described. Areas affected include the amygdala, hippocampus, and subregions of the medial prefrontal cortex (including ventromedial prefrontal cortex and dorsal anterior cingulate cortex), and the implications and consequences of the damage are quite extensive (Milad 2009). These areas (the amygdala specifically) are largely responsible for the fear response, and are also involved in a variety of memory processes (including learning, localized within the hippocampus). Thus, hyper- or hypoactivity in these areas ultimately results in an inability to diminish the fear response and also causes serious impairment in

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fear extinction learning and its recall (Milad 2009). Fear extinction learning refers to the gradual reduction of the conditioned fear response, and extinction recall refers to the retrieval and expression of the learned extinction response. This is important within the context of PTSD because the disorder is marked by heightened, exaggerated, and persistent fear responses to memories and reminders of the traumatic event with an inability to regulate or otherwise manage such an effect. Thus, disruption of extinction abilities results in repeated and exacerbated arousal in response to fear memories, which are pervasive in sufferers of PTSD. The amgydalocentric model explains this in terms of neurobiology, which speaks to the complexity of the issue; PTSD can be considered not only a mental disorder but also a neurobiological malfunction, meaning that treating it is particularly challenging. Current neurological solutions include transcranial magnetic stimulation, which stimulates the dorsolateral prefrontal cortex (responsible for affective regulation), and adult neurogenesis, which involves the creation of neurons in the hippocampus from neural stem and progenetor cells. Neurogenesis aids in the regulation of stress both by augmenting the role of the hippocampus in the negative feedback mechanism of the HPA axis (which again is extremely hyperactive in cases of PTSD) and may also inhibit the amygdala (responsible for fear), although this theory is yet to be explored in any extensive detail (Santarelli 2003). IV. AFFECTIVE EXPERIENCE AND REGULATION WITHIN THE CONTEXT OF COMBAT-RELATED POST- TRAUMATIC STRESS DISORDER Post-traumatic stress disorder (PTSD) presents a very grave challenge to the United States military. Estimated to affect about 33% of troops returning from operations

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overseas, PTSD is a tragic psychological injury that is difficult to treat and virtually impossible to eradicate; oftentimes, conventional solutions such as medication or traditional psychotherapy are seen as incomplete and insufficient and do little to resolve underlying issues with complex psychological and neurological roots. Because of this, various avenues for intervention have been explored recently, with the most common being cognitive behavioral therapy (specifically, cognitive processing therapy), social and family based interpersonal therapies, and meditation therapies. These treatments are all implemented with the goal of effectively regulating affect without the use of antidepressants, antipsychotics, or other psychopharmacological solutions, which have been linked to a rise in drug dependency, suicide, and fatal accidents within the armed forces (Dao, 2011). Before exploring the various interventions available in the management of post- traumatic stress disorder, it is first necessary to reiterate both the psychological and neurological symptoms of combat-related PTSD as well as the maladaptive coping strategies commonly implemented by combat veterans. As previously described, veterans experience traditional symptoms of PTSD (which include avoidance, numbing, and repressed memory) and typically engage in avoidance non-coping. Also, there has been a marked increase in drug abuse and dependency among combat soldiers and veterans due to the particularly troubling and persistent quality of the illness. The social stigma attached to other forms of treatment (including psychotherapy) may contribute to rampant drug abuse as well (Dao, 2011). For those who do seek traditional and clinical psychotherapy, many options are available, each with varying degrees of effectiveness.

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trauma victims feelings and actions by changing patterns in the victims thinking and behavior. It works by identifying the dysfunctional cognitive-affective-behavioral process and focusing on correcting such processes so that the victim may have more accurate beliefs about the causes and repercussions of the trauma. Of particular importance is understanding and contextualizing the trauma; oftentimes, avoidance (the act of deliberately avoiding addressing the trauma) prevents victims from realistically understanding it and dealing with the subsequent feelings. Cognitive behavioral therapy, and cognitive processing therapy in particular, is used to conquer the defense mechanism of avoidance and treat PTSD by formally processing the trauma such that the feelings associated with it and the meaning attributed to it are no longer overly negative or personal. Cognitive processing therapy, a subdivision of cognitive behavioral therapy, has been used specifically for the treatment of PTSD. Because it addresses the many symptoms of PTSD (including anxiety, depression, anger, etc.), cognitive processing therapy is empirically proven to be highly effective, clinically improving about 80% of patients with PTSD (Eftekhari, 2006). Cognitive processing therapy typically consists of two components: the traditional cognitive-behavioral components discussed previously, which include identifying and changing detrimental thought patterns and beliefs, and a prolonged exposure component, which allows for direct engagement with and an ultimate desensitization to traumatic stimuli.

Greene 17 The initial sessions of cognitive processing therapy, which may be conducted in

either a group or private session, involve first explaining PTSD, its symptoms, how it is addressed, and how therapy will proceed and ultimately succeed. The goal here is to begin the therapy by rationalizing the disorder in much the same was as the patient will ultimately be able to rationalize the thoughts, feelings, and behaviors associated with the disorder in subsequent sessions; by demonstrating the techniques and skills that will be taught later, the therapist develops rapport with the patient and also asks the patient to think logically and rationally very early on. As the patient begins to view the disorder and its symptoms and treatment from a calm and objective perspective, the foundation is set for viewing and considering more personal and emotionally loaded stuck points at a later time (Monson, 2006). The next step focuses primarily on directly confronting and formally processing the trauma by breaking avoidance patterns common in many sufferers of PTSD. At this point, exposure therapy is implemented, and patients are asked to first write about their traumatic experiences (their impact statements) and later read them aloud. As avoidance patterns are broken, strong emotions are dispelled; as a result, the patient is better able to address the trauma from a rational and objective perspective later on (Monson, 2006). As its name implies, prolonged exposure relies on various methods of exposing the patient to traumatic memories and triggers they would otherwise avoid. As PTSD is typified by the constant recurrence of intrusive thoughts, memories, nightmares, and external triggers associated with the trauma, it is not unusual that patients with PTSD seek to avoid such triggers at all costs; the problem here lies with the fact that these triggers might not be

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inherently harmful and may be encountered frequently in everyday life. In order to restore a patients ability to lead a normal, productive life, it is imperative to first desensitize them to common triggers; this is done via an intensive two-part intervention that includes imaginative and in-vivo exposure (Williams, 2010). Imaginative exposure occurs first and involves the impact statements described previously: trauma victims confront their most traumatic experiences directly by writing and speaking about them both in therapy sessions and as homework. The goal here is to address natural emotions that have been previously repressed; similarly, as the exposure is repeated, patients are asked to write specifically about thoughts and feelings associated with the trauma, thoughts about those thoughts and feelings, and, as the therapy concludes, ways in which they may challenge those maladaptive beliefs (Monson, 2006). The therapy proceeds by ultimately unraveling the disorder: first by addressing the feelings experienced, then by addressing the thoughts about those feelings, and then by questioning the validity of such beliefs. It is at this point that the traditional elements of cognitive therapies can be seen as the therapist uses a Socratic style of questioning to to ask [patients] questions regarding their assumptions and self- statements in order to begin challenging them (Monson, 2006). The benefits of a cognitive processing approach are readily apparent; not only does the patient learn to confront thoughts and triggers that have previously been avoided, but the patient also simultaneously learns to manage such feelings and develop skills that lead to feelings of empowerment. Cognitive processing therapy is considered to be the most effective treatment for PTSD to date, addressing many of the more complex symptoms such

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as depression and general anxiety, affect functioning, guilt distress, and social adjustment, which many traditional psychotherapies neglect (Monson, 2006). It is important to note that cognitive processing therapy is significantly more effective than prolonged exposure therapy alone; while cognitive processing therapy and prolonged exposure therapy are equally effective in treating depression in PTSD sufferers, cognitive processing therapy has been proven to more adequately treat trauma-related guilt (Monson, 2006). Such statistics again serve to highlight the complexity of PTSD; clinicians are dealing with a dangerously multifaceted issue and need to explore treatment options that successfully manage all symptoms. A second approach to the treatment of post-traumatic stress disorder involves interpersonal psychotherapy, or IPT. Because PTSD has long been associated with difficulties in marriage, families, and friendships, interpersonal psychotherapy may be implemented with the goal of fixing the individual by fixing his relationships with his loved ones. In other words, the underlying belief is that improving social functioning should lead to an overall improvement in other symptoms (Cukor, 2009). IPT treatments typically focus on the development of trust and interpersonal difficulties that arise as a result of the trauma experienced. Because of this, social relationships are typically improved, leading to reduced depression and social anxiety and a better general sense of well being; however, other, more intricate negative emotions remain unchanged (Cukor, 2009). IPT proceeds in stages, with the initial stages resembling those of CPT. The patient is assessed, diagnosed, and the major problem areas are identified (the stuck points of CPT),

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and a statement is drawn up in which the patient expresses his hopes and goals in therapy. The next stages work through the main problem areas via the four common themes of IP: grief, role dispute, role transition, and interpersonal deficits (Frank, 2010). The first theme, grief, addresses the repressed or misrepresented feelings of grief associated with PTSD. Similar to CPT, the patient is encouraged to overcome avoidance defenses by accepting their personal grief and other strong emotions; the therapist aids in the facilitation of this process by focusing on the present and talking through current understandings of the trauma. Once the grieving process has been completed, patients move on to address the second theme of role dispute, which is where the interpersonal aspect of IPT is first observed. Role dispute occurs when a patient has expectations about relationships that are not reciprocated. In the case of PTSD, patients may expect that their friends and family understand their unwillingness to talk or engage in other previously enjoyable activities; naturally, this is not the inclination of most loved ones and the discrepancy in relationship expectations needs to be addressed. IPT addresses role dispute by focusing first on understanding the nature of the dispute and the nature of the communication difficulties (here again we note similarities to CPT as accurate and rational perceptions are imperative in treatment). Once the situation is understood, the therapist works with the client to improve their ability to communicate while still catering to the patients personal needs. Once communication has been improved, role transition can be addressed. Because traumatic experiences tend to change the individuals who experience them, it can be assumed that their role in loved ones lives change as well. As a result, patients who suffer

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from PTSD must accept such a transition and learn to cope with both the loss of the old role as well as the adoption of a new one. Therapy at this stage focuses on emotions experienced as a result of both of these steps and developing the skills necessary to fulfill the new role. The final step in IPT is acknowledging, accepting, and overcoming interpersonal deficits. Through role-playing and other activities, clients adopt the perspective of other individuals in their life and attempt to identify their own interpersonal shortcomings. In other words, patients look at themselves from the perspective of a loved one and through that lens identify patterns of isolation, failures in communication, and other similar interpersonal deficits that they may have (Frank, 2010). A primary critique of interpersonal psychotherapy is that it focuses predominantly on treating depressive symptoms and for that reason cannot be considered comprehensive, especially in the case of PTSD. While PTSD patients showed improvement in response to IPT when compared to PTSD patients who received no treatment at all, merely treating the social aspects of PTSD may fail to address other symptoms such as re-experiencing and hyperarousal (Cukor, 2009). Similarly, post-traumatic stress disorder has been known to have a very high remission rate when treated without any type of exposure; because interpersonal psychotherapy focuses on relationships with others rather than the individuals relationship with his own maladaptive beliefs, the use of exposure is limited or non- existent and patients often continue to experience symptoms. While interpersonal psychotherapy is effective in aiding patients in improving relationships with their friends

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and families (a serious consequence of PTSD), it may not be effective in allowing the individual to overcome his own personal struggles. For this reason, IPT may not be the best stand-alone treatment for PTSD; however, when coupled with other therapies, it may prove to be effective. It is important to note that psychotherapy, while surely useful, fails to correct the neurological abnormalities present in sufferers of PTSD. Few (if any) of these strategies result in physiological or neurobiological changes or improvement, which is imperative in eradicating PTSD. Thus, it is clear that other, more comprehensive avenues need to be explored; specifically, a synthesis of neurological and psychological approaches to emotion regulation are crucial in the comprehensive treatment of PTSD. V. MEDITATION AS AN AFFECTIVE AND ATTENTIONAL REGULATION STRATEGY While it may seem that the only strategies that address the neurological and physiological roots of stress are those that directly intervene with the wetware (such as TMS and neurogenesis), there are cognitive coping strategies that have been shown to result in direct physiological changes. Fascinatingly, meditation as a stress-management technique is one such example. Meditation has roots in fundamental Buddhist teachings, and is best understood in the clinical sense as a complex, connected group of emotional and attentional regulatory training methods developed and practiced for a variety of purposes. Among these, the creation of a sense of overall well-being and emotional balance are often the primary goals in meditative practices, and these states are achieved via two distinct forms of practice (Lutz, 2008). The first, focused attention meditation (FA), requires that the practitioner

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direct and sustain attention on a single selected process (such as breath sensation) while disengaging from all other distractors. The practitioner typically tries to become fully cognizant of mind wandering and, when such deviations from practice are detected, the practitioner cognitively reappraises the distractor and directs attention back to the selected process. The second method of meditation is known as open monitoring (OM) and is rather different from FA; it involves nonreactive meta-cognitive monitoring and awareness of mental and emotional experience from moment to moment. There is no specific task or process that attention is focused on, and, on the contrary, fluidity of sensory, perceptual, and endogenous stimuli is embraced without judgment (Lutz, 2008). Both of these methods act as emotional and attentional regulatory strategies, and, similarly, both of these methods have long-term impacts on the brain and behavior (Lutz, 2008). Because each method differs fundamentally, it follows that they would invoke different neurological and psychological processes and result in different changes and effects. However, it is important to note that although the two practices are different, they are often used in conjunction with one another. Whether the two are used within one training session or over the longer course of the practitioners training, FA and OM meditation practices are integrated in order to maximize neurological and psychological benefits. In fact, it is often the case that a practitioner begins with FA meditation in order to calm the mind and reduce distractions, and later transitions into OM meditation (Lutz, 2008). The neurological and psychological benefits, as previously described, include both attentional and emotional regulation via the strengthening of skills necessary in higher- order functioning.

Greene 24 Attention is critical in successfully completing goal-directed behaviors, and

interestingly, there are a number of parallels between the processes involved in FA meditation and the processes described within recent cognitive neuroscience frameworks of attention. Both Buddhist scholars and Western clinicians and scientists recognize that focusing on a desired object, goal, or intention requires a strong ability to direct attention, recognize and block out distractors, and redirect focus to the desired object when concentration is broken. These processes have all been linked to clear and distinct parts of the brain; therefore, the current assumption is that the neural systems invoked in conflict monitoring, selective attention, and sustaining attention are all similarly involved in the induction and maintenance of FA meditation (Lutz, 2008). These systems include the dorsal antetior singular cortex, dorsolateral prefrontal cortex, ventro-lateral prefrontal cortex, temporal-parietal junction, and the thalamus, among others. It is crucial at this point to point out the link between these brain areas and the areas affected by PTSD according to the amygdalocentric model: many of the brain regions affected by PTSD are also involved in and strengthened by FA meditation, suggesting that FA meditation may serve to correct the deficiencies in top-down processing evident in patients with post-traumatic stress disorder. As Lutz and colleagues suggest, the neurophysiological changes induced by FA meditation should cause similar improvements in behavioral measures of sustained attention, which has been identified as a serious challenge in patients with combat-related PTSD (Lutz, 2008 & Vujanovic, 2011). Likewise, long-term changes in cognitive and brain function may be observed as a result of FA meditation, providing a promising future for treating PTSD neurologically through cognitive practice. Buddhist teachings describe FA meditation as voluntary sustain and control of attention, although they also indicate that

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this practice becomes involuntary and automatic over time. Therefore, it can be assumed that as the processes involved in directing and sustaining attention strengthen, the activation of and within neural systems will be reduced, optimizing performance in other attentional tasks (Lutz, 2008). While this may seem to be largely theoretical, studies involving expert practitioners have provided preliminary evidence for these hypotheses. Work by Carter et al. (2005) has demonstrated that Tibetan Buddhist monks exhibit changes in not only attentional processing, but also in brain structures: brain regions involved in monitoring, engaging attention, and attention orienting showed less activation in expert meditators than in novices. Similarly, expert meditators showed less activation in the amygdala during FA meditation. Again, it is critical to highlight the link to PTSD in such an instance; because PTSD is marked by hypersensitivity and heightened arousal of the amygdala, meditative practice that reduces activity in the region seems to clearly address the neurological root of the issue. Additionally, training in FA is associated with a substantial decrease in emotionally reactive behaviors, indicating that the psychological root of the problem is simultaneously addressed (Lutz, 2008). While much of the discussion has thus far focused on FA meditation and attention, OM meditation is valuable for its implications on emotional regulation as well as attentional regulation in some instances. OM differs from FA in that it does not involve brain regions responsible for directing and sustaining attention on a specific object; instead, OM meditation involves monitoring and disengaging attention from stimuli which distract attention from the stream of consciousness (Lutz, 2008). An interesting study

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revealed support for this conceptualization. Work by Valentine and colleagues (1999) showed that OM meditators performed better than FA meditators in a sustained attention task where the stimulus was unexpected, indicating a more distributed focus of attention in OM meditators. Similarly, another study by Tang and colleagues (2007) indicated that after just five days of OM meditation, the experimental group showed a greater improvement in conflict monitoring than did a control group assigned to a relaxation-based meditation program. Perhaps the more interesting aspect of OM meditation is its relationship with affect and affective regulation. OM meditation relies heavily upon the idea of awareness of the features of any given moment, and includes aspects such as that moments emotional tone. Thus, processes invoked in OM meditation are more directly related to internal bodily sensations, termed interoception, as opposed to attentional processes, and rely on mental representations of physical states (Lutz, 2008). Because these processes rely on mental representations, it also stands to reason that OM meditation may be useful in regulating limbic responses by invoking the prefrontal cortex in processing and cognitively reappraising these mental representations. This is done in OM through the act of labeling emotions, which is a central tenet of the practice and also a key component of many clinical interventions based on OM (Lutz, 2008). The prominent brain region involved in OM meditation is the insula, which is not only responsible for emotional processing but is also specifically involved in processing sights of mutilation, norm violation, and empathy. The connection with combat-related PTSD is very obvious in such an example. Fascinatingly, the insulas of individuals who

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meditate are significantly larger than those of individuals do not, further suggesting that meditation therapies such as OM may be clinically useful in the management of combat- related PTSD (Lutz, 2008). While the neuroscientific basis of meditation is still in its infancy, the preliminary findings and hypotheses are promising, and further research is necessary to confirm the benefits of such effects. VI. MINDFULNESS MEDITATION AND MINDFULNESS-BASED STRESS REDUCTION (MBSR) AS INTERVENTIONS FOR POST-TRAUMATIC STRESS DISORDER Meditation and relaxation therapies are perhaps the newest interventions in PTSD management and are largely empirically underexplored. Believed to have great potential to treat PTSD and comorbid disorders, meditation therapies primarily focus on mindfulness, an OM practice in which an individual is highly cognizant of sensations and being. Contrary to the conventional (and seemingly mechanical) process of desensitization to traumatic stimuli, mindfulness stresses acceptance without judgment and acting with awareness as imperative in overcoming symptoms associated with PTSD (Cukor, 2009). The draw of meditation therapies is that they focus primarily on teaching coping skills; because many veterans do not report symptoms of PTSD, do not seek treatment, or drop out of treatment (treatment referring to conventional options such as CPT), meditation therapy is a means of teaching similar coping strategies without raising the typically associated stigma of therapya major concern for veterans (Vujanovic, 2011). Similarly, veterans may experience other difficulties with exposure-based therapies: they often lack communication skills in the first place, inhibiting them from successfully participating in therapy, or do not feel able or ready to participate in intensely emotional

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exposure theories. Thus, mindfulness meditation training can be used to equip veterans with the skills they need in order to successfully begin other treatments (Vujanovic, 2011). The latest empirical evidence fails to address if, how, and which mindfulness-based approaches are best in treatment of PTSD, although there are two distinct goals of mindfulness. The first goal is intentional redirection of attention to the present moment, and the second is to approach traumatic experiences and their subsequent emotions, actions, thoughts, and feelings with nonjudgmental acceptance (Vujanovic, 2011). Currently, mindfulness therapy has been used in conjecture with other therapies and seems to be successful when utilized in such a way. Used independently, mindfulness therapy may cause problems in certain individuals with acute PTSD symptoms, which is currently its biggest criticism. Mindfulness is considered ill advised for veterans who have significant trouble regulating emotion, for example; clients who tend to experience very painful re-experiencing symptoms are typically not able to focus on the present, a central tenet of mindfulness meditation therapies. Similarly, patients with an inability to tolerate painful memories when subjected to long periods of silence (common in meditation practices) may also not be fit for such treatment options. While such individuals may not be prepared for long mindfulness meditation therapy sessions, they can participate in shorter sessions and build up to longer ones; thus, despite its apparent lack of general suitability, mindfulness training can be scaled to fit the needs of most individuals (Vujanovic, 2011). Another criticism, mentioned earlier in regards to IPT, is that remission rates of PTSD tend to be high without exposure; while mindfulness therapies emphasize

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acceptance, it is unclear whether or not acceptance is equivalent to exposure and thus PTSD treated with mindfulness training may have similarly high recurrence rates. VII. HYPOTHESIS Because mindfulness has been shown to have an inverse relationship with many of the symptoms of PTSD, including anxiety, depressive symptoms, substance abuse, and chronic pain, it stands to reason that mindfulness may be successful in treating PTSD, although current research is limited (Vujanovic, 2011). Nonetheless, empirical evidence suggests that mindfulness training is clinically useful in four different ways: (1) it fosters nonjudgmental acceptance of previously troubling internal states (including trauma- related triggers); (2) it enables individuals to successfully engage in other treatments; (3) it decreases physiological arousal and stress activity; and (4) it fosters psychological flexibility (Vujanovic, 2011). Psychological flexibility is akin to the concept of psychological resilience, which has been linked to adaptive responding to stress and trauma in a wide variety of situations (Bonanno, Westphal, & Mancini, 2011). Similarly, preliminary studies reveal that mindfulness training is very successful in reducing many associated PTSD symptoms, particularly avoidance/numbing (Vujanovic, 2011). For these reasons, we hypothesize that preemptive mindfulness meditation training may be useful in preventing or delaying the onset of post-traumatic stress disorder following traumatic experiences. If mindfulness skills are taught and perfected before trauma is experienced, it is possible that attention, focus, and emotion may be regulated and redirected from the traumatic stimuli and to the task at hand. The benefits could be twofold, reducing the incidence of PTSD, and improving task-related performance (thereby reducing costly errors).

VIII. METHODS Participants

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Participants were 70 Lehigh University undergraduates recruited from the PSYC1 Participant Pool. The male-to-female ratio was approximately 1:1. Participants completed the experiment for one full participation credit for the class, and each participant received a copy of the mindfulness training materials upon completion of the study regardless of their assigned condition. Design The goal of this study was to determine whether preemptive mindfulness meditation training is successful in preventing or delaying the onset of post-traumatic stress disorder following traumatic experiences; the current study sought to provide a first test of this basic hypothesis in a sample of normally functioning young adults. We examined performance and emotional reactivity during an emotionally evocative task at two points in time (separated by approximately 8-10 weeks). Between these two assessments, half of the participants completed eight weeks of training in mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990), a mindfulness training program developed by clinicians and supported by a host of empirical studies and clinical trials (e.g., Kabat-Zinn, Massion, Kristeller, Peterson, Fletcher, Pbert, Linderking, & Santorelli, 1992). The training was a combination of CD-guided training and self-guided training based in the technique of open monitoring (non-reactive monitoring of the content of experience from moment to moment), averaging approximately 20 minutes per day. The other half of the participants were asked to engage in a control task that required the same daily time investment; they

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completed a reflective writing task in which they were asked to keep a journal of their stressful experiences day-to-day. The emotionally evocative task was adapted from a paradigm developed by Correll and colleagues (2002) to assess racial bias. The original task, designed to mimic a video game, presented participants with a series of photographs of urban settings. Occasionally, a photograph of a black or white male would appear in a scene, holding either a gun or a neutral object. Participants' objective was to correctly identify whether the individual was threatening (if he was holding a gun) or benign (if he was holding a neutral object). Our adaptation removes the racial component and creates a scenario closer to that faced by modern combat soldiers. In our task, the background images were photographs of Middle Eastern and Central Asian settings, and the target individuals were young men from the same regions. These men were holding military weapons or neutral objects, and the participants' task was to correctly classify the men as threatening or not. Before each target appears, the participant was primed with a stimulus from the International Affective Pictures System (IAPS) with the intention of eliciting an emotional response and distracting the participant from completing the task successfully. The IAPS contains a wide range of emotionally evocative stimuli, which have been extensively studied and normed (Bradley & Lang, 2007). For our purposes, the emotionally evocative stimuli were ones that depicted graphic violence or injuries to people, such as victims of beatings, car accidents, or homicide, that are normatively described as high in arousal and negativity. The neutral stimuli also depicted people, but were chosen for normative ratings of low arousal and neutral valence.

Greene 32 The progression of each trial was as follows (consistent with Correll et al., 2002):

Participants viewed between 1 and 4 background images on a given trial (each presented for a random time between 500 and 1000 ms). Just prior to the presentation of the final background of the trial (in which the target individual appears), a neutral or emotional prime from the IAPS appeared for 275 ms. After the final background and target appeared, participants had 650 ms in which to respond. If this time elapsed without a response, participants were given a message encouraging them to respond more quickly on subsequent trials. The primary outcomes of interest were participants' ability to correctly and quickly classify the targets as threatening or not as a function of prime type, and their physiological reactivity as a function of prime and target type. Physiological responses to the stimuli (including heart rate, respiration, and skin conductance) were monitored using the BioPac MP150 system. Heart rate was measured via electrodes attached to the chest (just below the collarbone on either side), skin conductance was measured via electrodes attached to the tips of adjacent fingers on the non-dominant hand, and respiration was measured by a strain gauge belt around the chest. Before beginning the emotionally evocative task at each session, participants were also asked to complete the Perceived Stress Scale (PSS; Cohen, 1983), the Life Orientation Test-Revised optimism questionnaire (LOT-R; Scheier, Carver, & Bridges, 1994), the Berkeley Expressivity Questionnaire (BEQ; Gross & John, 1997), and the Emotion Regulation Questionnaire (ERQ; Gross & John, 2003). While we did not have specific predictions for these individual difference values, these measures were included so that their effects on compliance may be observed.


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The analyses performed on the data collected examined a variety of variables including prime type, target type, effects of condition, accuracy of response, reaction time on correct trials, percentage of gun response, skin conductance response heart rate, and individual difference variables, among others. We also examined these effects as they changed across sessions. We asked a variety of questions about these variables; we were interested specifically in which variables (both behavioral and physiological) were affected by the task (prime and target type), which variables were affected by the intervention, which individual difference variables were related to task performance, which factors predict accuracy, which factors predict faster reaction times on correct trials, and which factors predicted the probability of a gun response. We had a few general predictions about these questions. We expected that emotional reactivity, reaction time, and error rates would all be higher on emotional prime and target trials than neutral prime and target trials, but that these effects would be reduced in the mindfulness groups post-training point. Essentially (on a conceptual level), we believed that mindfulness training would improve performance and emotional reactivity on a laboratory-based stress task. We did not have any specific predictions for the individual difference variables, although we did run statistical analyses on these variables to gain a better understanding of what characteristics may affect compliance rates and task performance. The results indicated a wide range of interactions and main effects. It is perhaps best to begin with the most basic main effects observed; in looking at reactions at Session 1

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only, we found that accuracy, reaction time on correct trials, gun response, and GSR showed variance as a function of prime and target type (the heart rate measure did not show any significant effects and was thus left out of the subsequent analyses). In the accuracy analysis, we found a significant main effect of target type but not prime, indicating that participants were more accurate in gun trials regardless of prime type. While we did not see a significant interaction between prime and target type, we did see a trend: participants seemed to get more correct answers on emotional prime/gun trials than other trials. This is illustrated in Figure 1, Appendix A. At Session 1, we also noticed two significant main effects and a significant interaction between prime type and target type for reaction time on correct response trials. This indicates that participants were responding more quickly on gun trials regardless of prime and emotional trials regardless of target, and that they were responding particularly quickly on trials that paired an emotional prime with a gun target. This is depicted in Figure 2, Appendix A. There were also significant main effects of prime and target type on gun responses at Session 1, although there was no interaction. Participants were more likely to respond gun on gun trials, but were also more likely to respond gun on emotionally primed trials regardless of target type. See Figure 3, Appendix A. It is important now to point out that these results indicate a certain response bias in our participants. People were biased towards responding gun as a result of emotional primes, which has significant implications for our results.

Greene 35 The skin conductance responses demonstrated a similar pattern (and a similar

response bias) of two significant main effects of prime and target type, but no interaction. Skin conductance was higher in emotionally primed trials regardless of target type, and was also higher in gun trials regardless of prime. This pattern can be seen in Figure 4, Appendix A. The variable of greatest interest in this study was condition, and the changes in our measures as a function of condition proved to be interesting despite low compliance rates for the intervention. To account for this issue, we limited our analyses to only include participants above the median total time spent on the intervention. The first change we examined was change in accuracy as a function of condition (observable in Figure 5, Appendix A). Here, we noted an improvement in performance on neutral prime gun trials as a function of the mindfulness intervention, but it is likely that this is significant only because this group performed poorly in this area in Session 1. It is important to note that was a degree of inconsistency between the mindfulness group and the control at Session 1, which may account for some of the following significant results. Nevertheless, we did see a marginal interaction between prime type, target type, condition, and session for the accuracy measure. The second change we observed yields perhaps the best result: there was a significant main effect of session on response times for correct trials (see Figure 6, Appendix A). Participants were faster at responding in Session 2 than Session 1, but fascinatingly, the speed-up in the control group is consistent with the response bias demonstrated in the Session 1 results (these participants showed the greatest increase in

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speed on emotional primed gun trials). We observed a significant four-way interaction between prime type, target type, condition, and session for this measure. The gun response measure did not yield any significant main effects or interactions (see Figure 7, Appendix A). Everybody improved regardless of condition: gun responses increased on gun trials and decreased on neutral target trials. It is not clear that there is anything worth noting going on here, or that the two conditions differed in response to emotional prime or gun trials. Similarly, there were no significant changes in skin conductance as a function of condition. This can be seen in Figure 8, Appendix A. We next examined individual difference variables and observed some interesting effects: first, all six-way interactions were significant (emotional prime * gun * session * condition * total time * individual difference variables), and second, we noted that each individual difference variable had implications for the measures of accuracy, response time, gun response percentage, and skin conductance response. To reiterate, we examined individual difference variables in four areas: perceived stress, emotional expressivity, optimism, and emotion regulation ability. There was a significant interaction between the perceived stress measure and accuracy on gun trials: individuals who reported higher measures in perceived stress were less likely to be correct on gun trials. This effect was also observed in emotional suppression: individuals higher in emotional suppression were also less accurate on gun trials.

Greene 37 For emotional expressivity, we noticed that individuals with a higher composite

score were less accurate on emotional trials. We also noted a marginal interaction between emotional expressivity, emotional primes, and gun targets, indicating that people higher in emotional expressivity are exhibiting the response bias particularly strongly as compared to others. There were also effects of cognitive reappraisal, which is a subscale in the emotional regulation questionnaire. Individuals who reported higher scores in cognitive reappraisal were slower to respond on gun trials. There was a marginal tendency in the same direction with emotional suppression, another ERQ subscale. As we can see, the individual difference variables yielded complex results. Further analysis is necessary to determine the implications of these results. X. DISCUSSION It is important to understand that while our main effects and interactions were significant, at least some of this significance can be attributed to the induction of a response bias. To clarify, we found that participants were significantly quicker and more accurate at responding to gun trials primed with emotional stimuli; however the emotional prime may itself cause participants to answer gun simply due to its nature. There is a clear association between emotionally upsetting depictions of violence and guns, and thus, the emotional primes may invoke mental associations with guns and lead to such a response bias.

Greene 38 While we might take this as a reason to downplay the significance of our results, its

implications for real-world situations should not be ignored. The existence of a response bias in a combat situation could be a potentially grave consequence of war: if the results of the study carry and this effect is observed in combat, this suggests an innate mechanism by which terrible mistakes can happen. If violence makes people misperceive threat or pull the trigger in spite of their perceptions for defense purposes, costly errors may be made. Thus, it is crucial that this mechanism is understood and steps are taken to counteract its effects. In reflecting upon the narrower scope of this study, the most readily identifiable difficulty encountered in design and implementation was compliance among participants, which can be contributed largely to the method of recruitment. Because the participants were gathered from the PSYC1 participant pool, their commitment to the study was seriously lacking; participants received course credit as long as they showed up at the laboratory for both sessions, regardless of whether or not they completed the intervention between sessions as directed or not. Due to the ease, accessibility, and speed of recruiting from the participant pool, this source was ultimately determined to be the best place to find participants. Unfortunately, this had implications for the quality of participation: no participants completed the training for the entire eight weeks as instructed, few completed some training, and others completed no training at all. According to the work done by Kabat-Zinn (1982), the program requires significant dedication, with observable effects emerging after eight weeks of training for 45 minutes per day, six or seven days per week. None of our

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participants completed this amount of training and therefore our findings were not robust. Based on the results of Kabat-Zinns study, it is likely that our results would have been better had the participants completed the training as instructed. While this could be remedied by carrying out the study in a preexisting meditation clinic, the results would then lack generalizabiltiy: it is likely that we would see different results, but it would be difficult to apply them to soldiers, who are regular people rather than expert or particularly willing meditators. Continuing with the concept of generalizability, it is also important to note that the results of the current studyeven if they had been significantwould have been difficult to apply within the broad conceptual framework described. While emotional regulation may have improved and physiological arousal may have decreased within the context of the IAPS photographs, it is likely that the extent of the trauma experienced in a war invokes a far more complicated emotional and physiological response. Likewise, the duration of exposure to traumatic stimuli in a war is far greater than the 325ms presentation of the photographs in the experiment; such long exposure to such severely disturbing stimuli seems in many ways impossible to counteract. Nevertheless, the effectiveness of mindfulness meditation as a treatment for post-traumatic stress disorder (and combat- related PTSD in particular) still has merit, and additional research should seek to explore this relationship and tailor the practice such that it better fits the needs of soldiers. In summation, thoroughly assessing the overarching hypotheses was difficult given the available resources. Nonetheless, this study was a good first step. If more research can be completed to better understand mindfulness and its clinical benefits, perhaps more

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individuals can be convinced to comply with the training and experience such effects. As mindfulness becomes more mainstream, it is likely that more people will subscribe to the practice, making studies like this one easier and the results more robust. Hopefully, the use of such a therapeutic practice will become more common, and the significant advantages gained from it can be put to use in a variety of contexts to better ensure the safety and psychological well being of a multitude of populations.


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Aldwin, C. M. (2007). Stress, coping, and development (2nd ed.). New York: Guilford Press. Bonanno, G.A., Westphal, M., & Mancini, A.D. (2011). Resilience to loss and potential trauma. Annual Review of Clinical Psychology, 7, 511-535. Bradley, M.M, Lang, P.J., & Cuthbert, M.M. (2007). International Affective Picture System (IAPS): Affective ratings of pictures and instruction manual. Technical Report no. A- 6. University of Florida, Gainesville, Fl. Carter, O.L. et al. (2005) Meditation alters perceptual rivalry in Tibetan Buddhist monks. Current Biology, 15, R412-R413 Coan, J. A., & Allen, J. B. (2008). Handbook of emotion elicitation and assessment. Oxford University Press, USA. Cohen, S; Kamarck T, Mermelstein R (1983). A global measure of perceived stress. Journal of Health and Social Behavior 24 (4): 385396. Correll, J., Park, B., Judd, C., & Wittenbrink, B. (2002). The influence of stereotypes on decisions to shoot. European Journal of Social Psychology, 37, 1102-1117. Cukor, J., Spitalnik, J., Difede, J., Rizzo, A., Rothbaum, B. (2009). Emerging treatments for PTSD. Clinical Psychology Review, 29, 715-726. Dao, J. (2011). For some troops, powerful drug cocktails have deadly results. The New York Times. Retrieved from Eftekhari, A., Stines, L.R. and Zoellner, L.A. (2006). Do you need to talk about it? Prolonged exposure for the treatment of chronic PTSD. The Behavior Analyst Today, 7(1), 70-83 Frank, E, & C., J. (2010). Interpersonal psychotherapy. Amer Psychological Assn.

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Geracioti T.D. Jr, Baker, D.G, Ekhator, N.N, West, S.A, Hill, K.K, Bruce, A.B, Schmidt, D., Rounds-Kugler, B., Yehuda, R., Keck, P.E. Jr, Kasckow, J.W. (2001). CSF norepinephrine concentrations in posttraumatic stress disorder. American Journal of Psychiatry, 158 (8): 12271230. Gross, J.J., & John, O.P. (1997). Revealing feelings: Facets of emotional expressivity in self reports, peer ratings, and behavior. Journal of Personality and Social Psychology, 72, 435-448. Gross, J.J., & John, O.P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85, 348-362. Kabat-Zinn J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33-47. Kabat-Zinn, Jon. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York, NY: Pub. by Dell Pub., a Division of Bantam Doubleday Dell Pub. Group, 1991. Print. Kilburn, E. & Whitlock, J. (2011). Coping: A literature review. Cornell Research Program on Self-Injurious Behavior in Young Adults. 1-3. Lazarus, R. S., & Folkman, S. (1984). The stress concept in the life sciences. Stress, appraisal, and coping (pp. 1-21). New York: Springer. Lutz, A., Slagter, H.A., Dunne, J.D., & Davidson, R.J. (2008). Attention regulation and monitoring in meditation. Trends in Cognitive Sciences, 12(4), 163-169. McEwen, B. S. (2005). Stressed or stressed out: Whats the difference? Journal of Psychiatry and Neuroscience, 30, 315-318.

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Milad, M.R., Pitman, R.K., Ellis, C.B., Gold, A.L., Shin, L.M., Lasko, N.B., Zeidan, M.A., Handwerger, K., & Orr, S.P. (2009). Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder. Biological Psychiatry, 66(12): 107582. Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., & Young-Xu, Y. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74 (5), 898-907. Santarelli L., Saxe, M., Gross, C. (2003). Requirement of hippocampal neurogenesis for the behavioral effects of antidepressants. Science, 301: 8059. Scheier, M. F., Carver, C. S., & Bridges, M. W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A re-evaluation of the Life Orientation Test. Journal of Personality and Social Psychology, 67, 1063- 1078. Schildkrat, J. (1995). The catecholamine hypothesis of affective disorders: A review of supporting evidence. The Journal of Neuropsychiatry and Clinical Neurosciences. 7, 524-533. Selye, H. (1956). Selections from The stress of life (pp. 17-35). New York: McGraw-Hill. Tang, Y.Y. (2007) Short-term meditation training improves attention and self-regulation. Proceedings of the National Academy of Sciences, USA, 104, 1715217156 Valentine, E.R. and Sweet, P.L.G. (1999) Meditation and attention: a comparison of the effects of concentrative and mindfulness meditation on sustained attention. Mental Health, Religion, and Culture, 2, 5970 Vujanovic, A. A. (2011). Mindfulness in the treatment of posttraumatic stress disorder among military veterans. Professional Psychology: Research and Practice, 42 (1), 24-31.

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Williams, M., Cahill, S., Foa, E. Psychotherapy for Post-Traumatic Stress Disorder. In Textbook of Anxiety Disorders, Second Edition, ed. D. Stein, E. Hollander, B. Rothbaum, American Psychiatric Publishing, 2010. Zeidner, M., & Endler, N.S. (1995). Handbook of coping: theory, research, applications. Wiley. pp. 514.


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