Reduced Symptoms of Post-Traumatic Stress Disorder and Irritable Bowel Syndrome Following Mindfulness-Based Stress Reduction Among Veterans

Mediating effect of coping dispositions on the association between trauma and gastrointestinal symptoms

Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) are two gastrointestinal (GI) conditions known to be exacerbated by traumatic life experiences. One way in which these experiences might influence individuals' susceptibility to GI pathology, is by reducing their ability to deal with adversities effectively and predisposing them to passive coping styles that leave them vulnerable to the somatic effects of trauma. To validate this hypothesis, the present cross-sectional study assessed the mediating effect of coping dispositions on the association between trauma and GI disease activity in an adult sample of 189 bowel patients (94 IBD, 95 IBS) and 92 controls. Results confirmed that GI patients exhibit significantly more cumulative trauma, pervasive feelings of uncontrollability and passive coping strategies than controls. Moreover, the use of passive coping styles was positively associated with the accumulation of trauma and the expression of GI symptoms. Using hierarchical regression and mediation analyses, we found support for the sequential model postulating passive coping styles as (partial) mediators of trauma-induced (GI) disease manifestations. Specifically, out of all coping styles associated with cumulative trauma, behavioural disengagement most powerfully mediated the effect of trauma on GI symptom severity, accounting for 12% (IBD) to 14% (IBS) of its total effect. A somewhat smaller mediating role was observed for social support coping, the reduced reliance on which explained 7% (IBS) to 10% (IBD) of trauma's total effect. Finally, neuroticism acted as a channel through which past traumatization affected subjects' proneness to behavioural disengagement and, consequently, their GI disease activity.

The impact of posttraumatic stress disorder on upper gastrointestinal investigations in Australian Defence Force veterans: a retrospective review

Veterans with posttraumatic stress disorder (PTSD) commonly exhibit associated gastrointestinal (GI) symptoms. We compared upper GI endoscopy and abdominal ultrasound rates in veterans with and without PTSD. Veterans with PTSD were 77-81% more likely to undergo these procedures than those without PTSD. PTSD symptomatology influences GI investigation rate and more emphasis on clinician and patient education is recommended regarding stress-related gut symptoms.

Self-reported gastrointestinal disorders among veterans with gulf war illness with and without posttraumatic stress disorder

BACKGROUND

Gulf War Illness (GWI) is a chronic, multi-symptom disorder affecting 25%-32% of Gulf War veterans. Veterans with GWI disproportionately suffer from gastrointestinal (GI) disorders. Given the increasing evidence supporting a gut-brain axis, we explore the relationship between post-traumatic stress disorder (PTSD), GWI, and self-reported GI disorders among GW veterans.

METHODS

Veterans from the Gulf War Era Cohort and Biorepository responded to a mail-based survey (N = 1058). They were stratified by GWI (Centers for Disease Control definition) and PTSD status. This yielded three groups: GWI-, GWI+/PTSD-, and GWI+/PTSD+. Multivariable logistic regression adjusting for demographic and military characteristics examined associations between GWI/PTSD groups and GI disorders. Results were expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).

KEY RESULTS

The most frequently reported GI disorders were irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and colon polyps (CP). The GWI+/PTSD+ group had a higher odds of these disorders than the GWI+/PTSD- group (aOR_IBS  = 3.12, 95% CI: 1.93-5.05; aOR_GERD  = 2.04, 95% CI: 1.44-2.90; aOR_CP  = 1.85, 95% CI: 1.23-2.80), which had a higher odds of these disorders than the GWI- group (aOR_IBS  = 4.38, 95% CI: 1.55-12.36; aOR_GERD  = 2.51 95% CI: 1.63-3.87; aOR_CP  = 2.57, 95% CI: 1.53-4.32).

CONCLUSIONS & INFERENCES

GW veterans with GWI and PTSD have significantly higher odds of specific self-reported GI disorders than the other groups. Given the known bidirectional influences of the gut and brain, these veterans may benefit from a holistic healthcare approach that considers biopsychosocial contributors to the assessment and management of disease.

Prevalence and incidence of post-traumatic stress disorder and symptoms in people with chronic somatic diseases: A systematic review and meta-analysis

INTRODUCTION

Comprehensive evidence on prevalence and incidence of post-traumatic stress disorder (PTSD) and symptoms (PTSS) in people with chronic somatic diseases (CD) is lacking.

OBJECTIVE

To systematically and meta-analytically examine prevalence and incidence of PTSD and PTSS in people with CD compared with people without CD.

METHODS

MEDLINE, Embase, and PsycINFO were searched from inception (1946) to June 2020. Studies reporting point, 12-month, lifetime prevalence, or 12-month incidence of PTSD and PTSS in people with CD were selected and reviewed in accordance with PRISMA guidelines by two independent reviewers. Risk of bias was assessed by a combination of the Newcastle-Ottawa Scale and recommendations of the Cochrane Collaboration for non-comparative studies. Pooled estimates were calculated using random effects meta-analyses. Between-study heterogeneity was assessed using the I2 statistic.

RESULTS

Data were extracted from studies reporting on point prevalence (k = 60; n = 21,213), 12-month prevalence (k = 3; n = 913), and lifetime prevalence (k = 6; n = 826). 12-month incidence estimates were not available. The pooled estimate for the point prevalence of PTSD (k = 41) across CD was 12.7% (95% CI, 8.6 to 18.4%) and 19.6% regarding PTSS (13.2 to 28.1%; k = 24). Individuals with cerebrovascular disorder (k = 4) showed the highest pooled point prevalence for PTSD (23.6%, 95% CI, 16.8 to 32.0%), those with cardiovascular diseases the lowest (6.6%, 1.9 to 20.9%; k = 5). The pooled 12-month prevalence of PTSD (k = 3) was 8.8% (95% CI, 5.5 to 13.5%) and the lifetime prevalence (k = 6) was 12.1% (7.6 to 18.5%). Pooled estimates of PTSD prevalence in people with compared to those without CD showed an odds ratio of 9.96 (95% CI, 2.55 to 38.94; k = 5).

CONCLUSION

Post-traumatic stress disorder and PTSS are common and substantially higher in people with compared to those without CD. Earlier detection and treatment of this comorbidity might improve mental and physical health, reduce the incidence of further diseases, and reduce mortality.

CLINICAL TRIAL REGISTRATION

https://osf.io/9xvgz, identifier 9xvgz.

The pathological involvement of spinal cord EphB2 in visceral sensitization in male rats

Patients with post-traumatic stress disorder (PTSD) are usually at an increased risk for chronic disorders, such as irritable bowel syndrome (IBS), characterized by hyperalgesia and allodynia, but its subsequent effect on visceral hyperalgesia and the mechanism remain unclear. The present study employed single prolonged stress (SPS), a model of PTSD-pain comorbidity, behavioral evaluation, intrathecal drug delivery, immunohistochemistry, Western blotting, and RT-PCR techniques. When detecting visceral sensitivity, the score of the abdominal withdrawal reflex (AWR) induced by graded colorectal distention (CRD) was used. The AWR score was reduced in the SPS day 1 group but increased in the SPS day 7 and SPS day 14 groups at 40 mmHg and 60 mmHg, and the score was increased significantly with EphrinB1-Fc administration. The EphB2+ cell density and EphB2 protein and mRNA levels were downregulated in the SPS day 1 group and then upregulated significantly in the SPS day 7 group; these changes were more noticeable with EphrinB1-Fc administration compared with the SPS-only group. The C-Fos-positive reaction induced by SPS was mainly localized in neurons of the spinal dorsal horn, in which the C-Fos-positive cell density and its protein and mRNA levels were upregulated on SPS days 7 and 14; these changes were statistically significant in the SPS + EphrinB1-Fc group compared with the SPS alone group. The present study confirmed the time window for the AWR value, EphB2 and C-Fos changes, and the effect of EphrinB1-Fc on these changes, which suggests that spinal cord EphB2 activation exacerbates visceral pain after SPS.

A Rome Working Team Report on Brain-Gut Behavior Therapies for Disorders of Gut-Brain Interaction

BACKGROUND AND AIMS

This Rome Foundation Working Team Report reflects the consensus of an international interdisciplinary team of experts regarding the use of behavioral interventions, specifically brain-gut behavior therapies (BGBTs), in patients with disorders of gut-brain interaction (DGBIs).

METHODS

The committee members reviewed the extant scientific literature and, when possible, addressed gaps in this literature through the lens of their clinical and scientific expertise. The Delphi method was used to create consensus on the goals, structure, and framework before writing the report. The report is broken into 5 parts: 1) definition and evidence for BGBT, 2) the gut-brain axis as the mechanistic basis for BGBT, 3) targets of BGBTs, 4) common and unique therapeutic techniques seen in BGBT, and 5) who and how to refer for BGBT.

RESULTS

We chose to not only review for the reader the 5 existing classes of BGBT and their evidence, but to connect DGBI-specific behavioral targets and techniques as they relate directly, or in some cases indirectly, to the gut-brain axis. In doing so, we expect to increase gastrointestinal providers' confidence in identifying and referring appropriate candidates for BGBT and to support clinical decision making for mental health professionals providing BGBT.

CONCLUSIONS

Both gastrointestinal medical providers and behavioral health providers have an opportunity to optimize care for DGBIs through a collaborative integrated approach that begins with an effective patient-provider relationship, thoughtful communication about the brain-gut axis and, when appropriate, a well communicated referral to BGBT.

Behavioral and Diet Therapies in Integrated Care for Patients With Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common, symptom-based condition that has negative effects on quality of life and costs health care systems billions of dollars each year. Until recently, management of IBS has focused on over-the-counter and prescription medications that reduce symptoms in fewer than one-half of patients. Patients have increasingly sought natural solutions for their IBS symptoms. However, behavioral techniques and dietary modifications can be effective in treatment of IBS. Behavioral interventions include gastrointestinal-focused cognitive behavioral therapy and gut-directed hypnotherapy to modify interactions between the gut and the brain. In this pathway, benign sensations from the gut induce maladaptive cognitive or affective processes that amplify symptom perception. Symptoms occur in response to cognitive and affective factors that trigger fear of symptoms or lack of acceptance of disease, or from stressors in the external environment. Among the many dietary interventions used to treat patients with IBS, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols is the most commonly recommended by health care providers and has the most evidence for efficacy. Patient with IBS who choose to follow a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols should be aware of its 3 phases: restriction, reintroduction, and personalization. Management of IBS should include an integrated care model in which behavioral interventions, dietary modification, and medications are considered as equal partners. This approach offers the greatest likelihood for success in management of patients with IBS.

Mindfulness Practice for Glycemic Control: Could it be a New Strategy for an Old Problem? A Systematic Review and Meta-Analysis

BACKGROUND

The management of type 2 diabetes mellitus (T2DM) requires a complex and organized care that includes patient's lifestyle change. Additionally, emotional well-being is an important part of self-management, and it may impair the individual's adherence. Therefore, equipping the patients with the necessary coping and self-care techniques may be an important step in managing diabetes.

OBJECTIVE

To evaluate the effect of interventions using established mindfulness-based protocols on glycemic control of individuals with T2DM.

METHODS

Data sources: Two electronic databases (PubMed and EMBASE) were searched from inception to December 2019. We limited our search to published studies in English, Spanish and Portuguese languages.

STUDY SELECTION

Randomized clinical trials that assessed the effects of mindfulness in individuals with T2DM were selected.

DATA EXTRACTION

Two authors independently assessed the risk of bias and extracted data from the included trials. Data were pooled using inverse-variance random-effects meta-analyses. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Four randomized trials were included. There were no differences in blood glucose change (mean difference between groups (MD) -0.73mg/dl; 95% CI, -10.49; 9.02; I2 =0%; very low quality of evidence) or glycated hemoglobin (MD 0.05%; 95%CI -0.22 to 0.32; I2 =29%; very low quality of evidence).

CONCLUSION

Although the quality of current evidence is very low, our findings suggest that established protocols involving mindfulness have no effect on blood glucose or glycated hemoglobin in individuals with T2DM. Indeed, large-scale trials are needed to evaluate the contribution of mindfulness to glycemic control in clinical practice. PROSPERO Registration ID: RD42020161940.

Mindfulness-based interventions for military veterans: A systematic review and analysis of the literature

BACKGROUND

In recent years, mindfulness-based interventions (MBIs) have experienced exponential growth in terms of development, application, and research. However, few studies have examined implementation and efficacy of these interventions in particular populations, such as military Veterans. Such studies are needed as one cannot assume that the literature on MBIs implemented with the general population or other specific populations apply equally well to Veterans. This population is unique regarding professional competencies, military ethos, high degrees of medical comorbidities and barriers to treatment. The aim of this work was to review and summarize the literature over the previous five years (2014-2020) assessing the use of MBIs among military Veterans to guide clinical care and future research.

METHODS

Systematic literature review.

RESULTS

A total of 88 articles were found. Screening titles and abstracts resulted in 49 articles being excluded. The remaining 39 articles were read in full, and of these, 12 were excluded due to not fully meeting the inclusion criteria. Thus, the present review included a total of 27 articles, 3 of which used qualitative methods and 24 of which used quantitative methods.

CONCLUSIONS

MBIs hold promise as complementary adjunctive interventions for Veterans with PTSD and possibly other psychiatric disorders. Currently there are significant gaps in the literature that must be addressed to move the field forward. The main deficiency is, with a few exceptions, the lack of rigorous RCTs. Another major concern is the lack of generalizability to female and non-white Veterans given that the subject samples across all studies reviewed were 85% male and 76% white. At this time, MBSR, PCBMT and MBCT can be recommended as adjunctive complementary interventions for the reduction of PTSD symptoms. Research recommendations to move the field forward are provided.

Mindfulness and yoga for psychological trauma: systematic review and meta-analysis

Mindfulness-based interventions (MBIs), with postures, breath, relaxation, and meditation, such as Mindfulness-based Stress Reduction (MBSR) and yoga, are complex interventions increasingly used for trauma-related psychiatric conditions. Prior reviews have adopted a disorder-specific focus. However, trauma is a risk factor for most psychiatric conditions. We adopted a transdiagnostic approach to evaluate the efficacy of MBIs for the consequences of trauma, agnostic to diagnosis. AMED, CINAHL, Central, Embase, Pubmed/Medline, PsycINFO, and Scopus were searched to 30 September 2018 for controlled and uncontrolled trials of mindfulness, yoga, tai chi, and qi gong in people specifically selected for trauma exposure. Of >12,000 results, 66 studies were included in the systematic review and 24 controlled studies were meta-analyzed. There was a significant, pooled effect of MBIs (g = 0.51, 95%CI 0.31 to 0.71, p < .001). Similar effects were observed for mindfulness (g = 0.45, 0.26 to 0.64, p < .001), yoga (g = 0.46, 0.26 to 0.66, p < .001), and integrative exercise (g = 0.94, 0.37 to 1.51, p = .001), with no difference between interventions. Outcome measure or trauma type did not influence the effectiveness, but interventions of 8 weeks or more were more effective than shorter interventions (Q = 8.39, df = 2, p = .02). Mindfulness-based interventions, adjunctive to treatment-as-usual of medication and/or psychotherapy, are effective in reducing trauma-related symptoms. Yoga and mindfulness have comparable effectiveness. Many psychiatric studies do not report trauma exposure, focusing on disorder-specific outcomes, but this review suggests a transdiagnostic approach could be adopted in the treatment of trauma sequelae with MBIs. More rigorous reporting of trauma exposure and MBI treatment protocols is recommended to enhance future research.

Veterans' interests, perceptions, and use of mindfulness

Objective:

Mindfulness-based interventions are an evidence-based approach utilized in health care. There is developing evidence for effective use with military Veterans. However, little is known about Veterans’ view of mindfulness. This study aims to understand their interests, perceptions, and use of mindfulness to enhance educational outreach and treatment engagement.

Methods:

A cross-sectional study was conducted across the Veterans Health Administration in Salt Lake City, UT by administering a questionnaire to military Veterans. The questionnaire included the following themes: (1) demographics and respondents’ mindfulness practice; (2) respondents’ perceptions and beliefs about mindfulness; and (3) respondents’ knowledge and interest in learning about mindfulness.

Results:

In all, 185 military Veterans were surveyed; 30% practiced mindfulness in the past year, mainly for stress, posttraumatic stress disorder, sleep, and depression. Over 75% who practiced reported perceived benefit. Veterans rarely reported negative beliefs about mindfulness; 56% perceived an understanding of mindfulness and 46% were aware of Veterans Health Administration mindfulness offerings. In all, 55% were interested in learning about mindfulness, 58% were interested in learning how it could help, and 43% were interested in combining mindfulness with a pleasurable activity.

Conclusion:

Educational engagement approaches should be directed toward the benefits of mindfulness practice with minimal need to address negative beliefs. Outreach including education, with an experiential component, about mindfulness classes, availability of evening and weekend classes, individual sessions, and virtual offerings into Veteran’s homes, may enhance engagement in mindfulness-based interventions. Mindfulness-based interventions that combine mindfulness training with an experiential pleasurable activity may be one mechanism to enhance treatment engagement.