Mindfulness and PTSD

Review Paper
Mindfulness-based treatments for posttraumatic stress

disorder: a review of the treatment literature and
neurobiological evidence
Jenna E. Boyd, MSc; Ruth A. Lanius, MD, PhD; Margaret C. McKinnon, PhD, CPsych
Mindfulness-based treatments for posttraumatic stress disorder (PTSD) have emerged as promising adjunctive or alternative intervention
approaches. A scoping review of the literature on PTSD treatment studies, including approaches such as mindfulness-based stress re-
duction, mindfulness-based cognitive therapy and metta mindfulness, reveals low attrition with medium to large effect sizes. We review
the convergence between neurobiological models of PTSD and neuroimaging findings in the mindfulness literature, where mindfulness
interventions may target emotional under- and overmodulation, both of which are critical features of PTSD symptomatology. Recent
emerging work indicates that mindfulness-based treatments may also be effective in restoring connectivity between large-scale brain
networks among individuals with PTSD, including connectivity between the default mode network and the central executive and salience
networks. Future directions, including further identification of the neurobiological mechanisms of mindfulness interventions in patients
with PTSD and direct comparison of these interventions to first-line treatments for PTSD are discussed.
Introduction First-line treatments for PTSD, including prolonged ex-

posure therapy (PE) and cognitive processing therapy
About 60%–75% of individuals in North America experience (CPT), target symptoms of avoidance, ineffective process-
a traumatic event at some point in their lifetime.1,2 The ing of trauma memories and negative appraisals of trau-
12-month prevalence of posttraumatic stress disorder (PTSD) matic events.11 Although CPT and PE are associated with
is estimated to be 2.5%–3.5% in North America, making this large effect sizes and clinically important symptom reduc-
condition an important public health issue.2,3 Commonly ex- tion,11,12 a substantial proportion of patients retain their
perienced traumatic events include sexual assault or rape; re- diagnosis of PTSD following treatment (60%–72%)12 or con-
peated childhood emotional, physical or sexual abuse or ne- tinue to experience considerable residual symptoms. 13
glect; involvement in a serious accident (e.g., motor vehicle Moreover, attrition rates for leading treatment interven-
collision); and exposure to war or the combat theatre. Post- tions were reported to fall between 35% and 40% in recent
traumatic stress disorder is associated with a myriad of studies.14–16 In addition, resistance to use interventions in-
symptoms, including intrusions (e.g., unwanted memories or corporating exposure for PTSD has been noted among
flashbacks), avoidance of trauma reminders (e.g., objects in some clinicians because of, for example, concerns about po-
the environment that symbolize the trauma), negative altera- tential symptom exacerbation. 17 Thus, although trauma-
tions in cognitions and mood (e.g., altered view of the self, focused treatments, including CPT and PE, are considered
world, and others) and alterations in arousal (e.g., hypervigi- effective treatments for PTSD, the need for potential ad-
lance).4 In addition, a substantial subset of individuals with junctive or alternative treatments is evident.
PTSD (15%–30%) experience symptoms of dissociation, in- A personalized treatment approach would incorporate
cluding depersonalization (feeling outside of or as if you do identification of treatments most appropriate for each indi-
not belong to your own body) and derealization (feeling as vidual at a given time, taking into consideration factors such
though things around you are not real).5–10 Individuals with as symptom severity, safety and acceptability of the treat-
PTSD who experience depersonalization and/or derealiza- ment to the individual. The need for alternative treatment
tion symptoms are recognized in the DSM-5 as having a dis- approaches is also evident among those with PTSD+DS, in
sociative subtype of PTSD (PTSD+DS).4 whom dissociative symptoms have been associated with
Correspondence to: M.C. McKinnon, Department of Psychiatry and Behavioural Neurosciences, McMaster University, 100 West 5th Street,
Hamilton, ON, Canada; mmckinno@stjoes.ca
Submitted Jan. 23, 2017; Revised May 15, 2017; Accepted July 3, 2017; Online first Oct. 3, 2017
DOI: 10.1503/jpn.170021
© 2018 Joule Inc. or its licensors
J Psychiatry Neurosci 2018;43(1) 7

Boyd et al.
poorer treatment outcomes18,19 (but see the studies by Wolf Theoretical basis of mindfulness-based
and colleagues,20 Cloitre and colleagues21 and Resick and treatment approaches for PTSD
colleagues22). Further, depersonalization and derealization
symptoms have been associated with increased disease Mindfulness-based approaches, including MBSR and MBCT,
severity (e.g., suicidality), enhanced chronicity of illness and are thought to target several core features of PTSD, including
worse functional outcomes23 among individuals with PTSD. avoidance, hyperarousal, emotional numbing, negative emo-
Mindfulness-based treatments may represent an alterna- tions such as shame and guilt, and dissociation.26–28,37,38 Lang
tive to trauma-focused treatments, including CPT and PE, and colleagues27 discuss 3 components of mindfulness that
where such treatment approaches are considered to be may promote recovery from PTSD, including attention, a
“present-centred,” in that they encourage nonjudgment mindful cognitive style, and nonjudgment. Specifically, the
and acceptance of thoughts and emotions as they occur in authors explain how mindful, intentional shifting of attention
the present moment. Of note, a recent review identified to the present moment fosters a capacity for attentional con-
that present-centred therapies for PTSD were equally effi- trol and may lead to reductions in attentional bias to trauma-
cacious when compared with evidence-based trauma-focused related stimuli (see Fig. 1 for a summary of hypothesized
therapies and had significantly lower drop-out rates. 24 mechanisms by which mindfulness-based approaches target
Mindfulness, defined as “the awareness that emerges symptoms of PTSD). Furthermore, a mindful cognitive style
through paying attention on purpose, in the present mo- may reduce ruminative tendencies, leading to reductions in
ment, and nonjudgmentally to the unfolding of experience anxious arousal and anhedonia, and a nonjudgmental out-
moment by moment,”25 has emerged over the past decade look may promote a willingness to approach fear-provoking
as an alternative technique for targeting symptoms of stimuli, leading to reduced avoidance.27 Similarly, Follette
avoidance and negative cognitions, including self-blame, and colleagues28 describe patterns of emotional numbing,
shame and guilt among individuals with PTSD.26–28 With its suppression of intrusive thoughts and avoidance behaviours
roots in ancient Eastern traditions, the use of mindfulness- among individuals with PTSD as the antithesis of mindful
based treatments in psychiatric populations has grown ex- behaviour, suggesting that nonjudgmental acceptance of
ponentially following its introduction to Western psychology thoughts, experiences and emotions as taught through mind-
in the 1980s and 1990s.29 fulness may reduce these symptoms.
Mindfulness-based stress reduction (MBSR) is among the Another avenue through which mindfulness has been ex-
most commonly cited mindfulness-based treatment ap- plored as an intervention for trauma-related disorders is
proaches. Treatment consists of 8 weeks of 2- to 2.5-hour metta mindfulness, or loving-kindness meditation. In metta
group sessions with a full-day silent meditation retreat meditation, users practise the intentional development of
around week 6. These sessions cover a breadth of ap- kindness and compassion toward themselves and others
proaches, including mindfulness meditation, yoga, discus- through verbal and visual exercises (e.g., imagining the ex
sion about stress and coping, weekly homework assign- perience of a particular emotional state with mindful aware-
ments and daily mindfulness practice.30,31 Mindfulness-based ness and attention).37,39,40 Metta meditation is hypothesized to
cognitive therapy (MBCT) is another widely adopted promote emotional flexibility, or the ability to shift from neg-
mindfulness-based approach incorporating components of ative to positive emotional states, and psychological flex
cognitive behavioural therapy (CBT) and MBSR and was in ibility, or the ability to distance oneself from one’s current
itially developed to prevent relapse among individuals with mindset (affect, actions or responses, attentional bias) and
major depressive disorder (MDD).32 Mindfulness-based cog- contemplate other possible mindsets.39,40 These skills may be
nitive therapy focuses on changing awareness of and rela- crucial to recovery from trauma-related disorders, where
tionships with thoughts, promoting a “decentred” perspec- emotions such as shame, guilt, anger, inability to experience
tive (i.e., “thoughts are not facts”).32 This approach targets in positive emotions (anhedonia) and lack of self-compassion,
particular a reduction of residual symptoms and aims to pre- predominate.41–45 Specifically, by promoting the ability to ex-
vent relapse.33,34 Both MBSR and MBCT have shown efficacy perience positive emotions toward the self and others, one
across a wide range of psychiatric disorders, including MDD could expect reductions in anhedonia and negative emotions
and anxiety disorders, with medium effect sizes observed in of shame, guilt and anger while fostering an increase in com-
both populations. passion for self and others.
In this review we investigate the theoretical basis for the In addition to being explored as an intervention, mindful-
utility of mindfulness-based approaches in the treatment of ness has been shown to be a protective factor against the de-
PTSD. In addition, we assess the overlap between neurobio- velopment of trauma-related psychopathology.46–52 Indeed, it
logical models of PTSD and the nascent literature outlining has been suggested that pretraumatic mindful tendencies
the neurobiology of mindfulness, along with emerging work promote acceptance and awareness of posttraumatic re-
identifying neurobiological changes in individuals with sponses, thereby reducing avoidance, re-experiencing and
PTSD following mindfulness-based interventions.35,36 Finally, hyperarousal reactions to trauma-related stimuli and pre-
a growing number of studies suggest that mindfulness-based venting the onset of PTSD.38 In particular, facets of mindful-
interventions may be effective treatments for PTSD; these ness, including describing (the ability to label or note
studies are also reviewed. We then discuss limitations and observed phenomena, such as emotions), acting with aware-
future directions. ness and nonjudgment, mediate the association between
8 J Psychiatry Neurosci 2018;43(1)

Mindfulness-based treatments for PTSD
childhood and lifetime trauma exposure and the risk for Through these mechanisms, mindfulness may confer in-
posttraumatic symptoms.46 Similarly, mindfulness has been creased openness to experience and a sense of connection to
reported to be predictive of reduced negative affect, rumina- the self. Indeed, Frewen and Lanius58 suggest that mindful-
tion, depressive symptoms and posttraumatic stress symp- ness exercises may be particularly integral in facilitating re
toms via its association with cognitive fusion (the tendency integration of the self as a whole and increasing somatosensory
to identify strongly with one’s thoughts and emotions) fol- and emotional awareness among individuals with prominent
lowing trauma exposure.50 Further, a recent report indicated dissociative symptoms. Thus, mindfulness-based approaches
that mindfulness was negatively associated with disability may be efficacious in targeting both PTSD and PTSD+DS, a
among veterans, even after accounting for PTSD symptom- critical avenue for treatment development given that dissocia-
atology, suggesting that mindfulness may influence func- tive symptoms have been predictive of worse treatment re-
tional outcomes.48 sponse18,19 (but see the studies by Dahm and colleagues48 and
Dissociative symptoms may also be targeted by mindfulness- Glück and colleagues49) and chronicity of illness.23
based approaches, where mindfulness is thought to foster Figure 1 provides a summary of proposed mechanisms by
skills in staying present and cultivating a connection to the which mindfulness-based approaches may reduce symptoms
self and others, thus reducing dissociative symptoms that are of PTSD. Intrusive and hyperarousal symptoms are hypothe-
connected by the core feature of disconnection (e.g., from the sized to improve via increased attentional control or the abil-
present moment, others, or the self;53 Fig. 1). Here, C
orrigan54 ity to shift attention away from trauma-related stimuli and to
describes dissociation as existing on a continuum with mind- remain in the present moment. Mindfulness-based ap-
fulness, with each concept occupying opposite poles on the proaches are also hypothesized to target symptoms of avoid-
continuum. Consistent with this, constructs of trait mindful- ance by promoting openness to experiences and reducing
ness, including describing, acting with awareness, nonjudg- negative mood states and alterations in cognition (e.g., nega-
ment and nonreactivity, have been found to correlate negative beliefs about the self, the world, and others) by promot-
tively with dissociation.55–57 With respect to treatment, ing nonjudgmental acceptance of current and past experi-
Zerubavel and Messman-Moore53 suggest that mindfulness ences. Finally, dissociative symptoms may also be targeted
may be successful in reducing detachment by encouraging via increased connection to the self and greater awareness of
patients to endure aversive internal experiences and to re- internal and external experiences.
duce absorption (e.g., total immersion of attention to “noth- Despite the promise of mindfulness-based approaches as ad-
ing”; going blank) by increasing attentional control and re- ditional or adjunctive therapies, it is nonetheless critical to con-
ducing compartmentalization (e.g., fragmentation of the self). sider each patient’s symptom presentation and characteristics
PTSD symptom Hypothesized

Empirical evidence
cluster mechanism
Shifting attention to present

Intrusion
moment, reduced attentional Further research required
symptoms
bias to trauma stimuli
Reduced avoidance
Increased openness to
behaviour following
Avoidance experience, willingness to
mindfulness based
approach fearful stimuli
interventions134,142
Increase in self-compassion
Alterations in
Nonjudgemental acceptance drives change in PTSD
mood and
of trauma-related cognitions symptoms133, reduced self-
cognition
blame folowing MBCT142
Non-reactivity and acting

Alterations in Reduced attentional bias to
with awareness associated
arousal and trauma stimuli, greater ability
with reduced hyerarousal
reactivity to remain in the present moment
symptoms141
Connection and awareness of

Dissociative
somatic sensations, enduring Futher research required
symptoms
aversive internal experiences
Fig. 1: Hypothesized mechanisms by which mindfulness-based approaches may target posttraumatic stress disorder (PTSD) symptom clus-
ters along with current evidence and indication of where further research is required. MBCT = mindfulness-based cognitive therapy.

Boyd et al.
to determine if a mindfulness-based approach would be ap- the amygdala and anterior insula.7,63–65 Notably, emotional
propriate.58,59 Specifically, mindfulness-based approaches over- and undermodulation may exist simultaneously among
may increase distress or destabilize clients who are particu- individuals with PTSD+DS.66 However, the predominant re-
larly prone to flashbacks, rumination, or easily triggered sponse in those with PTSD+DS is overmodulation, leading to
trauma memories, given that they reduce avoidance of prominent emotional detachment. Thus, PTSD and PTSD+DS
trauma-related thoughts and emotions and may increase ex- are marked by impaired ability of cortical midline structures
posure to traumatic memories and emotional states.59 Simi- to accurately modulate the activity of limbic regions, leading
larly, mindfulness-based approaches may also be difficult for to both emotional over- and undermodulation
patients who have not developed appropriate emotion regu-
lation or distress tolerance skills.59 Frewen and Lanius58 em- Prefrontal modulation of limbic structures and mindfulness
phasize that although trauma-informed mindfulness inter-
ventions can be integral in the treatment of patients with Several studies have highlighted associations between
PTSD, particularly those experiencing symptoms of deper- mindfulness and changes in patterns of brain activation in
sonalization and derealization, they can be triggering for sur- regions impacted in patients with PTSD. Specifically,
vivors of physical or sexual abuse, as exercises such as the increased activation of the prefrontal cortex (including the
body scan ask patients to become aware of different regions dorsomedial PFC [dmPFC]) during expectation of negative
of the body. Thus, a paced and cautious approach involving pictures and reduced activation in the amygdala and
the patient’s fully informed consent is necessary. A personal- parahippocampal gyrus following perception of negative
ized medicine approach, whereby the individual characteris- stimuli has been observed following brief mindfulness
tics of each patient are considered and integrated with re- training among healthy controls. 67 Similarly, a study
search findings of the appropriateness of certain treatments investigating MBCT in the treatment of bipolar disorder
for individuals with specific symptom presentations may reported increased activity in the mPFC during a mindfulness
help to identify those who would benefit most from augmen- task following treatment as well as correlations between
tative mindfulness-based approaches to trauma treatment. signal changes in the mPFC and mindfulness, as measured by
the Five Factor Mindfulness Questionnaire (FFMQ).68 Further
Convergence between neurobiological studies have identified reduced amygdala reactivity in
mechanisms of PTSD and mindfulness response to emotionally valenced images in healthy controls
following a mindful attention group69 and during an emo
Emotional over- and undermodulation in patients with PTSD tional processing task among novice meditators.70
Critically, a recent study among individuals with general-
Early neurobiological models of PTSD emphasize a loss of ized anxiety disorder reported increased functional connec-
top–down inhibition over limbic regions (e.g., amygdala), tivity between the ventrolateral PFC (vlPFC) and amygdala
leading to exaggerated emotional reactivity and contributing with associated reductions in anxiety symptoms following an
to many of the hallmark symptoms of this disorder (e.g., 8-week MBSR intervention.71 Tang and colleagues72 suggest
hypervigilance, exaggerated startle response).60 Specifically, that positive coupling between these regions may be indica-
hypoactivation of the medial prefrontal cortex (mPFC; in- tive of improved arousal monitoring rather than a down
cluding the anterior cingulate cortex [ACC], ventromedial regulation of emotional response. Such improved monitoring
prefrontal cortex [vmPFC], subcallosal cortex and orbitofron- may be beneficial for individuals with PTSD and with
tal cortex [OFC]) is associated with hyperreactivity of limbic PTSD+DS, who show patterns of emotional under- and over-
regions (e.g., amygdala, anterior insula) to emotional stimuli.60 modulation. In addition, greater insular thickness has been
Moreover, abnormal functioning of the hippocampus is pos- noted among meditators,73 and a course of MBSR was associ-
ited to lead to a reduced capacity to extinguish fear re- ated with increased insular thickness and reduced alexithymia
sponses.60 These findings have largely been confirmed by re- in meditation-naive individuals.74 Thus, via restoration of insu-
cent meta-analyses of neuroimaging studies in patients with lar functioning, mindfulness-based approaches may be benefi-
PTSD, where consistent hyperactivation of the amygdala and cial in improving body awareness and awareness of emotions,
hypoactivation of cortical midline structures, including the abilities that are often compromised in those with PTSD75–77
mPFC, rostral ACC and OFC, have been reported.61,62 and are associated with emotional overmodulation.7,63
It is important to note that among individuals with Emerging work has also noted neurobiological changes
PTSD+DS a contrasting pattern of activation is present, where following a course of mindfulness-based exposure therapy
emotional overmodulation of limbic structures (as opposed to (MBET) among individuals with PTSD. Here, MBET treat-
undermodulation) is associated with symptoms of dissocia- ment consisted of 16 weeks of nontrauma-focused interven-
tion (e.g., depersonalization, derealization) and emotional tion, including elements of mindfulness training as in MBCT;
numbing (inability to effectively experience emotions).7,63 Spe- psychoeducation; and exposure to avoided situations (ex-
cifically, among this patient group, abnormally high activa- cluding imaginal exposure or processing of trauma mem
tion in prefrontal regions involved in emotion modulation, in- ories).36 Neural responses in an emotional face-viewing para-
cluding the dorsal ACC (dACC) and mPFC, has been noted digm (fearful, angry and neutral faces) were compared
during emotional script-driven imagery. In contrast, hypoacti- between individuals who had completed MBET and individ-
vation during such tasks is seen in limbic structures, including uals who had completed present-centred group therapy

(PCGT; control condition focusing on current life stressors All 3 networks have been implicated in the neuropathol-
contributing to PTSD). Greater posttreatment activation of ogy of PTSD. Figure 2 shows alterations in the DMN, CEN
the left mPFC in response to fearful faces following MBET and SN in PTSD as they are currently understood. Two re-
compared with PCGT was reported, suggesting increased cent meta-analyses have highlighted reduced activation in
modulation of limbic regions following MBET. areas of the brain associated with the DMN, including the
Taken together, these results suggest that mindfulness- mPFC, the PCC and posterior inferior parietal lobule, and the
based therapies may be effective in restoring top–down parahippocampal gyrus.61,92 Reduced functional connectivity
modulation of limbic regions with associated increases in between DMN nodes, including the PCC, posterior hippo-
modulation of emotional reactivity among individuals with campus and vmPFC, has also been reported92 and has been
PTSD. It is hypothesized that mindful emotion regulation is associated with PTSD symptom severity93,94 (Fig. 2). Reduced
mediated by enhanced prefrontal cognitive control and con- DMN functional connectivity is thought to underlie impair-
comitant downregulation of activity in limbic structures, ments in self-referential processes, autobiographical memory
including the amygdala.72,78 It is possible that increased and altered sense of self seen in patients with PTSD.75,92 By
modulation of limbic structures via mindfulness-based ap- contrast, increased resting-state functional connectivity
proaches36 could lead to further emotional overmodulation in among nodes of the SN, such as the amygdala and AI,92,94–96
individuals with PTSD+DS; however, it is also possible that as well as increased activation in SN regions at rest, including
mindfulness-based approaches may be associated with en- the AI, dACC and amygdala,61,92 have been reported consis-
hanced ability to accurately modulate limbic reactivity (e.g., tently among individuals with PTSD. Such changes in SN
via reducing or increasing top–down inhibition limbic re- nodes are posited to underlie hyperarousal symptoms in pa-
gions, depending on the circumstances), as has been sug- tients with PTSD and overall dominance of the threat sensi-
gested by Tang and colleagues.72 Thus, future work will be tivity circuit.92 In addition, altered functional connectivity has
necessary to elucidate the relative effectiveness of mindful- been consistently noted between nodes of the DMN and SN,
ness in improving both emotional under- and overmodula- where increased connectivity has been reported between the
tion in individuals with PTSD and with PTSD+DS. ventral ACC (vACC; generally considered to be part of the
mPFC) and PCC with the insula94,97 (Fig. 2). Furthermore,
The triple network model of psychopathology and PTSD increased connectivity of the amygdala with the PCC/
precuneus93,98 and the anterior insula94 has been noted, where
The triple network model of psychopathology, introduced by connectivity between the amygdala and PCC/precuneus
Menon,79 details 3 key neural intrinsic connectivity networks 6 weeks posttrauma predicted severity of PTSD symptoms at
(ICNs; brain regions that are temporally and functionally 12 weeks.93 Overall, patterns of increased connectivity be-
connected) that are implicated in psychiatric disorders and tween nodes of the SN and DMN are posited to reflect in-
are integral to higher-order cognitive functioning. These increased threat processing and hypervigilance at the expense
clude the default mode network (DMN), the salience net- of appropriate self-referential processing.92
work (SN) and the central executive network (CEN). The Activity and connectivity of the CEN is also disrupted in
DMN is made up of cortical midline structures and the lateral individuals with PTSD, with meta-analytic findings pointing
parietal lobes, with key nodes in the mPFC, posterior cingu- to reduced activity in the dlPFC.61 Interestingly, one study
late cortex (PCC) and precuneus and connections to the para- reported inappropriate activation of the DMN during a
hippocampal gyri and thalamus. The DMN is thought to be working memory task among patients with PTSD that con-
involved in internal mentation, including self-referential pro- trasted with appropriate activation of the CEN among con-
cessing, autobiographical memory and social cognition.80–82 trols, suggesting an inability to recruit task-positive net-
The SN comprises key nodes in the anterior insula (AI) and works in individuals with PTSD.99 In addition, reduced
dorsal anterior cingulate cortex (dACC), with connections to resting state functional connectivity among frontoparietal re-
various subcortical regions, including the amygdala and thal- gions of the CEN have been associated with PTSD symp-
amus.79,83,84 It is implicated in the detection, integration and toms and trauma history100 (Fig. 2). Notably, increased con-
filtering of salient internal and external stimuli as well as au- nectivity between DMN nodes and the dlPFC has been
tonomic and emotion regulation and conflict monitoring.84–86 associated with dissociative symptoms in patients with
Finally, the CEN is anchored in the dorsolateral prefrontal PTSD.98 In addition, increased connectivity within the CEN
cortex (dlPFC) and the posterior parietal cortex (PPC), and is during supra- and subliminal threat processing was noted
heavily involved in processes such as working memory and among women with PTSD+DS (Fig. 2), suggesting hyper-
executive functioning.87–89 Critically, whereas the DMN is connectivity of the CEN and potentially increased top–down
thought to be active during rest while individuals engage in inhibition of limbic regions.101
self-referential thought processes, including self-reflective
thought, envisioning future events, and mind-wandering,90,91 Mindfulness and the triple network model of
it remains inactive during cognitively demanding tasks. Con- psychopathology
versely, the CEN is generally inactive at rest and engaged
during cognitively demanding tasks. Finally, the SN (particu- Figure 3 depicts hypothesized mechanisms through which
larly the AI) is thought to play a crucial role in regulating the mindfulness-based approaches may improve functioning of
dynamic interplay between CEN and DMN activation.79,83 the DMN, SN and CEN, and therefore target symptoms of

Boyd et al.
PTSD. Mindfulness has been consistently linked with activity detachment of identification with the contents of conscious
and connectivity within and between the DMN, SN and CEN, thoughts, known as “reperceiving” or “decentering.”103,104 Acti-
with each network responsible for different stages of mindful- vation of the DMN during mindful states is decreased in ex
ness meditation among experienced meditators.102 Specif perienced meditators105,106 and following MBSR training in
ically, mind wandering has been associated with activity in meditation-naive participants,107 and greater activation of the
the DMN, and awareness of mind wandering has been associ- mPFC and functional connectivity of the mPFC with the DMN
ated with activity in the SN, while shifting of attention back to during rest (e.g., during self-referential processing) has been
focus on the present and subsequent focus on present experi- shown among meditators compared with controls108 (Fig. 3).
ence has most strongly been associated with activity in the Taken together, these findings suggest that mindfulness-based
CEN.102 Default mode network activity and connectivity has interventions may be associated with increased ability to ap-
been suggested as a potential biomarker for monitoring the propriately bring online the DMN when necessary (e.g., dur-
therapeutic effects of meditation.103 Specifically, whereas self- ing self-referential processing at rest) and in conferring
referential processing and activity within the DMN is associ- greater cognitive control over the DMN when its activation is
ated with mind wandering, the antithesis of mindful aware- not desired (e.g., during mindful awareness of the present).
ness of the present moment, mindfulness promotes These findings may translate to individuals with PTSD who
Fig. 2: Summary of the current literature implicating alterations in functional connectivity within and between the salience network (SN; shown
in orange), the central executive network (CEN; shown in red) and the default mode network (DMN; shown in blue) in individuals with posttraumatic
stress disorder (PTSD). Reduced connectivity within networks is depicted by red dashed lines, increased connectivity within networks is
depicted by solid green lines, reduced connectivity between networks is depicted by pink dashed lines, and increased connectivity between
networks is depicted by solid yellow lines. Consistent findings indicate reduced functional connectivity within the DMN among those with
PTSD, posited to underlie disruptions in self-referential processes, autobiographical memory and altered sense of self. Conversely, increased
connectivity is reported within the SN, thought to underlie hyperarousal and increased threat sensitivity. Similarly, increased connectivity
between the DMN and SN is thought to reflect hypersensitivity to threat at the expense of self-referential processing. Individuals with PTSD
also show impaired ability to appropriately recruit relevant networks (e.g., activation of DMN rather than CEN during a working memory task),
suggesting impaired switching between the DMN and CEN via the SN. Distinct patterns of connectivity within the CEN have emerged among
those with PTSD and PTSD with dissociative symptoms (PTSD+DS); those with PTSD+DS showed increased connectivity within the CEN and
those with PTSD showed decreased connectivity within the CEN. dACC = dorsal anterior cingulate cortex; dlPFC = dorsolateral prefrontal
cortex; mPFC = medial prefrontal cortex; PCC = posterior cingulate cortex.

typically show reduced resting-state activation and connec- thus leading to greater emotional regulation abilities.35 Nota-
tivity of this critical network for self-referential processing. bly, the authors also reported increased DMN–SN (dACC)
Emerging work among veterans with PTSD who partici- connectivity in the MBET group following treatment (Fig. 3).
pated in an MBET group (as described earlier) has identified The authors note that this finding may seem contradictory
potential neural markers of symptom change within the given previous work showing increased SN–DMN connec-
ICNs.35 Here, MBET was associated with increased DMN tivity among individuals with PTSD (as described earlier),
connectivity with the dlPFC, a main node of the CEN; no which is thought to underlie increased sensitivity to
such changes were reported in a PCGT comparison condition threat.93,94,97,98 However, King and colleagues35 suggested that
(Fig. 3). Furthermore, the authors noted that increased DMN– given the role of the dACC in attentional and executive con-
CEN connectivity was associated with reduced avoidant and trol, increased DMN–SN (dACC) connectivity may reflect an
hyperarousal symptoms, which the authors suggested may increased capacity for attentional shifting from internal self-
reflect an increased capacity for voluntary control of attention referential states to external stimuli, as is suggested in the
and the ability to shift attention from internal self-referential case of increased DMN–CEN connectivity.
processing via the DMN (e.g., rumination) to other forms of An additional key alteration in ICNs among individuals
internal experiences, including interoception via the CEN, with PTSD is increased functional connectivity and activity in
Fig. 3: Summary of findings suggesting that mindfulness may lead to restoration of functioning of the salience network (SN; shown in
orange), central executive network (CEN; shown in red) and defult mode network (DMN; shown in blue). Increased connectivity within net-
works is depicted by solid green lines, increased connectivity between networks is depicted by solid yellow lines, and reduced connectivity
between networks is depicted by dashed pink lines. Emerging work has indicated greater functional connectivity within the DMN during rest
among meditators when compared with controls and among veterans with posttraumatic stress disorder (PTSD) following mindfulness inter-
vention, suggesting that it may restore DMN connectivity and appropriate self-referential processing in those with PTSD.35 Increased CEN–
DMN connectivity was also reported and may reflect increased ability to shift between internal and external loci of attention. Mixed findings of
both increased and decreased DMN–SN connectivity following mindfulness intervention have been reported, depending on the region of the
SN. Increased dorsal anterior cingulate cortex (dACC)–DMN connectivity was reported following mindfulness intervention for PTSD,35 which
may suggest increased capacity for attentional shifting from internal to external stimuli (dACC implicated in executive control). In contrast, re-
duced SN (insula)–DMN connectivity was reported among controls, which may result in reduced hyperarousal symptoms and increased self-
referential processing if findings were replicated in individuals with PTSD. dlPFC = dorsolateral prefrontal cortex; mPFC = medial prefrontal
cortex; PCC = posterior cingulate cortex.

Boyd et al.
nodes of the SN at rest. As yet, few studies have examined internal stimuli) and the restoration of self-referential process-
the impact of mindfulness-based interventions on resting ing,92 reduced resting state connectivity between the DMN and
state functional activity of the SN. However, emerging work CEN may reduce symptoms of dissociation.98
has suggested that the SN is activated during certain aspects Of note, the cognitive control domain (the ability to flexibly
of mindfulness (e.g., awareness of mind wandering), but not and adaptively use cognitive resources) of the Research Do-
during others (e.g., mind wandering or attention to present main Criteria (RDoC) has been closely linked to the function-
moment) among experienced meditators compared with in- ing of both the CEN and SN and has been highlighted as an
experienced meditators.102 These findings suggest that mind- important transdiagnostic impairment across psychiatric ill-
fulness may lead to selected use of ICNs during specific nesses.113,114 Thus, the potential for mindfulness-based ap-
stages of the mindfulness process and overall greater control proaches to increase the functional integrity of the CEN and
over the use of these networks. This is particularly pertinent, SN, and hence the ability to accurately bring online pertinent
given that heightened resting state functional connectivity of ICNs, should be further studied with respect to the ability to
the SN may indicate inappropriate use of the network in the increase cognitive control.
absence of salient internal or external stimuli among individ-
uals with PTSD. Conversely, several sources have indicated Mindfulness and connectivity of subcortical brain structures
increased activity of the AI (a main node of the SN) during
mindful states,78,109,110 which may be construed as counterpro- The thalamus has been identified as a key node whose func-
ductive given heightened resting-state activation of SN re- tional connectivity with the DMN may underlie mindfulness.
gions in patients with PTSD. Notably, in these studies it is Specifically, Wang and colleagues115 found that the thalamus
not clear what aspect of mindfulness is used while the AI is was the only node within the DMN that was consistently
active (e.g., attention to external stimuli v. awareness of mind linked with trait mindfulness, where reduced connectivity of
wandering). Furthermore, studies investigating trait mindful- the thalamus with the DMN was related to higher trait mind-
ness have reported that individuals with greater trait mindfulness. The authors postulate that excessive connectivity of
fulness exhibit lower AI activation during expectation of and the thalamus with the DMN may promote mind wandering
exposure to negative stimuli. These results point toward re- and reduce the ability of the thalamus to effectively contrib-
duced automatic emotional responding,67,111 which could be ute to other networks with which it is involved. Specifically,
expected to lead to reduced hyperarousal in individuals with the thalamus is a key contributor to the ascending reticular
PTSD if these results were replicated in this population. activating system (ARAS; a network critical for the regulation
Finally, altered internetwork connectivity has been noted of wakefulness and vigilance), and may act as a switch be-
among individuals with PTSD. Specifically, hyperconnectivity tween the DMN and ARAS system.115 Similarly, the pulvinar
between DMN and SN nodes among individuals with PTSD nucleus of the thalamus is a key node of the innate alarm sys-
has been cited as a potential cause of increased hyperreactiv- tem (IAS), a network of interconnected brain regions in-
ity and threat processing at the expense of effective self- volved in subconscious detection of threat,116–119 allowing
referential processing.92 Similarly, increased connectivity be- rapid activation of defensive responses conferring an evolu-
tween the DMN and CEN has been associated with tionary advantage by rapidly facilitating response to
dissociative symptoms.98 Critically, a recent study reported threat.120,121 The IAS has recently been described as a brain-
that increased scores on measures of mindfulness following network that shows aberrant functional connectivity among
2 weeks of self-guided attention to breath training among individuals with PTSD during subconscious and conscious
healthy controls was associated with reduced resting state threat processing,122–126 including heightened activity of the
connectivity between the SN (anterior insula) and the thalamus, amygdala and parahippocampal gyrus during
DMN.112 Similar findings of decreased connectivity between subconscious threat processing in individuals with PTSD+DS
hubs of the DMN and SN have been reported among experi- in response to fearful faces, suggesting exaggerated IAS re-
enced meditators102 (Fig. 3). Doll and colleagues112 posit that sponding to subconscious threat.64 Given the emerging role of
this reduced interconnectivity between the DMN and SN may thalamus connectivity to the DMN in mindfulness, it will also
represent a clearer distinction between networks, and thus be important to determine the potential utility of mindfulness-
better effective connectivity of individual networks. Doll and based interventions in targeting dissociative symptoms asso-
colleagues112 also describe trend-level data suggesting re- ciated with PTSD. Here, according to the defence cascade
duced connectivity between the CEN and DMN among more model of dissociation, when an organism deems the level of
mindful individuals that could indicate a greater ability to threat in a given situation to be insurmountable, they may
switch between networks when attending to pertinent sen- engage in tonic or collapsed immobility (states of reduced
sory experiences. However, other groups have noted increased arousal that may promote survival by mimicking death),
connectivity of DMN regions (PCC) with CEN (dlPFC) and SN whereby “functional sensory de-afferentation” mediated by
(dACC) regions during meditation among experienced medita- the thalamus leads to reduced sensory integration and input
tors105 (Fig. 3). Notably, a critical difference between these to the cortex, a process thought to be mirrored by dissocia-
studies is engagement in meditation105 versus rest112 during tion in traumatized individuals.127,128 Thus, restoration of tha-
scanning. Accordingly, among individuals with PTSD, whereas lamic connectivity with the ARAS as a consequence of de-
reduced resting state connectivity between the SN and DMN creased thalamic connectivity with the DMN may promote
may lead to reduced hyperreactivity responses (particularly to decreased dissociation among patients with PTSD+DS.

Indeed, mindfulness-based skills have been suggested as modified to emphasize safety and positive growth experi-
strategies to shift out of dissociative states by improving ences found particularly large reductions on self-reported
awareness of mind–body states (possibly via the thalamus) PTSD avoidance/numbing symptoms and re-experiencing,
through focus on interoceptive, proprioceptive and touch hyperarousal, depression and anxiety symptoms among
sensations (e.g., during a body scan). women with PTSD as a result of childhood sexual abuse.134
These gains were maintained 2.5 years later,130 showing the
Evaluation of the evidence for mindfulness- potential long-term utility of MBSR. Moreover, these studies
based t reatments of PTSD reported low drop-out rates (10%–16%), suggesting high
treatment acceptability.131,132,134
A growing number of studies have investigated the efficacy A handful of RCTs investigating the efficacy of MBSR have
of mindfulness-based treatments, including MBSR and been completed among trauma-exposed populations.133,136–138
MBCT, among trauma-exposed populations with PTSD and The largest of these was a recent study in which 116 veterans
other primary diagnoses. Most of these studies have been with full or subthreshold PTSD were randomly assigned to
completed in veteran samples, with a handful of studies in receive MBSR (augmented to include psychoeducation about
other trauma-exposed populations (e.g., developmental trauma) or present-centred therapy (PCT; focused on current
trauma, interpersonal trauma, natural disasters). Table 1 problems as manifestations of PTSD).138 Significantly greater
summarizes the studies reviewed here and their main find- reductions in self-report and clinician-rated (Clinician Ad-
ings. Figure 1 links hypothesized mechanisms by which ministered PTSD Scale [CAPS]140) PTSD symptoms and im-
mindfulness-based approaches target symptoms of PTSD provements in quality of life were noted in the MBSR group
and current empirical evidence. (medium effect sizes) with adequate retention rates (78%).
Importantly, group differences emerged at the 2-month
Mindfulness-based stress reduction for PTSD follow-up, but were not present posttreatment (equivalent
symptom reduction was seen in both groups), suggesting
Standard and trauma-adapted MBSR are the most frequently that MBSR may be more effective than PCT at maintaining
assessed mindfulness-based therapies among trauma- symptom reduction. Similarly, Niles and colleagues137 re-
exposed populations, with 2 pilot studies, 3 larger uncon- ported high treatment acceptability (18% dropout rate) and
trolled studies and 5 randomized controlled trials (RCTs) significantly greater improvements on self-report and
reviewed here.129–139 In a recent pilot study Cole and col- clinician-rated (CAPS) PTSD symptoms (large effect size)
leagues129 investigated standard MBSR as a treatment for among veterans who participated in a telephone MBSR pro-
both PTSD symptoms and attention difficulties among veter- gram compared with those who participated in a telephone
ans with PTSD and a history of mild traumatic brain injury psychoeducation program; however, these results were not
(mTBI), reporting low drop-out rates (10%), significant reduc- maintained at follow-up.
tions in self-reported PTSD symptoms and significant im- In contrast to those studies, Possemato and colleages136 did
provements on attention measures posttreatment. In that not find significant differences on PTSD symptom severity
study, PTSD symptom reduction was maintained at 3-month (using intention to treat [ITT] analysis) among veterans who
follow-up, although attention improvements were not. 129 participated in a brief mindfulness program (4 wk) based on
Similarly, Gallegos and colleagues139 reported significant re- MBSR compared with those who received treatment as usual
ductions in self-reported depressive and PTSD symptoms (TAU). However, completer analysis (including participants
and improvements in emotion regulation immediately fol- who attended all classes) showed significantly greater improve-
lowing standard MBSR treatment and at 1-month follow-up ments on PTSD severity (CAPS) and depressive symptoms
among women with a history of interpersonal violence and among the mindfulness group compared with the TAU group,
high perceived stress. However, the authors noted lower re- with medium to large effect sizes.136 The authors posited that a
tention, with 43% of participants classified as noncompleters. minimum of 4 treatment sessions was needed to attain signifi-
A number of larger uncontrolled studies have also re- cant symptom reduction.136 Similarly, Kearney and col-
ported favourable outcomes following standard and trauma- leagues133 reported significant within-group improvements on
adapted MBSR treatment among individuals with measures of PTSD and depressive symptoms posttreatment
PTSD.130–132,134 Goldsmith and colleagues131 reported signifi- among veterans taking part in a standard MBSR program (not
cant improvements following a course of standard MBSR at maintained at follow-up). However, this study did not show
midtreatment and posttreatment on self-report measures of significant differences between veterans receiving MBSR in ad-
PTSD, depressive symptoms and shame-based trauma ap- dition to TAU and those receiving only TAU on any clinical
praisals among individuals with PTSD of mixed etiology. measure except for an assessment of mental HRQOL.
Similarly, Kearney and colleagues132 reported significant im- In summary, MBSR has emerged as a promising treatment
provements immediately posttreatment and at follow-up fol- approach for PTSD, with recent studies reporting significant
lowing standard MBSR on PTSD re-experiencing, avoidance, reductions in PTSD symptomatology following standard
emotional numbing and hyperarousal symptoms and on MBSR compared with PCT,138 brief MBSR compared with
measures of depression, experiential avoidance and mental TAU when a minimum number of treatment sessions was
health–related quality of life (HRQOL) among a sample of met136 (but see the study by Kearney and colleagues133), and
veterans. Another study investigating treatment with MBSR telephone MBSR compared with psychoeducation. 137 In

Table 1: Overview of included treatment studies and their main findings (part 1 of 3)
16
Study Sample Assigned therapy Assessments Study type Attrition Main findings
Bergen-Cico 40 veterans BMP based on MBSR Salivary cortisol RCT, pre/post 20% drop-out BMP completers showed significant reduction in CAR (0.2 μg/dL)
Boyd et al.
et al.135 (90% male) with (4 weekly 90-min sessions) PCL, PHQ-9 measures rate TAU and noncompleters did not show a significant decrease in CAR
PTSD plus TAU or to TAU alone (measure of Significant correlation between changes in cortisol levels and PTSD
(typical primary care for depression) and depression scores
veterans)
Bormann 146 veterans MRP (6 weekly 90-min CAPS, PCL-C, BSI- RCT, pre/post 95% of Significantly greater reduction in PCL-C, CAPS hyperarousal and
et al.146 (142 male) with classes) or TAU alone (case 18 (depressive measures MRP+TAU numbing symptoms, depression, and mental HRQOL in MRP+TAU
PTSD management and symptom completed group
consultation as needed) subscale), SF-12 treatment Significantly greater improvement on MAAS in MRP+TAU group
(mental health Mindful attention mediated effect of MRP on PTSD, depression and
component), MAAS psychological well-being measures
Daily mantrum practice mediated effect of MRP on mindful attention
Catani 31 children (17 Meditation–relaxation UPID (5 items to RCT, pre/post 100% No significant difference between groups on PTSD symptoms
et al.145 male) exposed to (individual psychoeducation assess problems in measures; 6-mo completed full Significant reduction in PTSD scores within meditation–relaxation
tsunami with and meditation relaxation functioning, follow-up treatment group immediately posttreatment (d = 1.83) and at follow-up (d = 2.20)
working strategies) or KIDNET 5 items to assess 71% of meditation–relaxation children did not meet criteria for PTSD at
diagnosis of (individual narrative presence of 6-mo follow-up and 81% did not meet criteria in KIDNET group (no
PTSD exposure therapy adapted somatic complaints) significant difference)
for children) Significant improvement on functional scores in both treatment groups
(no significant difference)
Cole et al.129 10 veterans with MBSR (1 introductory 2-hr PCL-C, Cogstate Single arm, 90% Significant reductions in PCL-C scores immediately posttreatment (d =
history of mTBI class, 8 weekly 2.5-hr computerized uncontrolled completed 1.56) and at follow-up (d = 0.93)
and PTSD sessions, 1 7-hr retreat) assessment to study, pre/post treatment Significant improvement on attention measures immediately
measure attention measures; 3-mo posttreatment (d = 0.57), not maintained at follow-up
follow-up
Earley 19 women MBSR (8 weekly 2.5–4 hr BDI-II, PCL, BSI- Single arm, NA Improvements at 1 mo posttreatment maintained at 2.5-yr follow-up for
et al.130 survivors of CSA classes and 1 5-hr retreat 18, MAAS uncontrolled depression (d = 1.10), anxiety (d = 0.90), and PTSD symptoms (d =
with general (augmented for CSA) with study; 0.80)
severity index concurrent psychotherapy 2.5-yr follow-up of PCL subscales significantly lower from baseline at 2.5-yr follow-up:
BSI score > 0.50 previous study133 avoidance/numbing (d = 0.70), re-experiencing (d = 0.50),
hyperarousal (d = 0.90)
Gallegos 42 women with MBSR (8 weekly 2.5-hr TLEQ, STAI, Single arm, 57% Significant reductions in depressive symptoms at all time points
J Psychiatry Neurosci 2018;43(1)

et al.139 history of sessions, 1 day-long DERS, CDES, uncontrolled completed Significant reductions in PTSD symptoms, state and trait anxiety
interpersonal retreat) MPSS, FFMQ, study, more than immediately posttreatment and at follow-up
violence and IL-6, TNF-α, CRP pre/mid/post 50% of classes Significant improvement in DERS scores immediately posttreatment
high perceived measures; 1-mo and at follow-up
stress follow-up Significant effect of attendance on IL-6 levels (reduced IL-6 with
increased attendance)
Goldsmith 10 individuals MBSR (8 weekly 2.5-hr PHQ-9, BDI-II, Single arm, 90% retention Significant reduction at mid-treatment and post-treatment in PTSD
et al.131 with exposure to sessions with 1 day-long PCL, CTQ, LEC, uncontrolled symptoms (d = 0.70, d = 0.73), depression (d = 0.30, d = 0.54) and
lifetime trauma or retreat) AAQ-II (measure of study, TAQ shame-based appraisals (d = 0.30, d = 0.70)
childhood abuse experiential pre/mid/post Significant improvement in AAQ scores mid-treatment and post-
(9 female) with avoidance),TAQ measures treatment (d = 0.77, d = 1.11)
primary diagnosis
of PTSD or MDD

Kearney 92 veterans with MBSR (8 weekly 2.5-hr PCL-C, PHQ-9, Single arm 74% met Significant improvement at baseline and follow-up on PCL total (d =
et al.132 PTSD sessions and 1 7-hr retreat) BADS, uncontrolled minimum 0.55; d = 0.65), PCL re-experiencing (d = 0.40; d = 0.56), avoidance
SF-8 (mental and study, compliance (d = 0.36; d = 0.35), emotional numbing (d = 0.46; d = 0.54), and
physical HRQOL), pre/post (4 of 8 classes) hyperarousal (d = 0.64; d = 0.67)
AAQ-II, FFMQ measures; 4-mo Significant improvement at baseline and follow-up on depression
follow-up score (PHQ-9; d = 0.53; d = 0.70), BADS (d = 0.47; d = 0.62), mental
HRQOL (d = 0.62, d = 0.73), and AAQ (d = 0.65; d = 0.68)
Clinically significant reductions in PCL scores in 47.7% of participants
Changes in FFMQ scores from baseline to post-treatment significantly
predicted PCL, PHQ-9, mental HRQOL immediately post-treatment
and at follow-up
Kearney 47 veterans MBSR (8 weekly 2.5-hr PCL-C, LEC, PHQ- RCT, pre/post 84% met No significant difference between MBSR and TAU groups on PTSD,
et al.133 (37 men) with sessions and 1 7-hr retreat) 9, SF-8, FFMQ, measures; 4-mo minimum depression or behavioural activation immediately post-intervention or
chronic PTSD plus TAU or TAU (usual BADS follow-up compliance in at follow-up
care for PTSD within MBSR group Significantly greater improvement in mental HRQOL in MBSR group
veterans health adminis- (4 of 8 post-treatment (d = 0.69), but this was not maintained at follow-up
tration clinics) sessions) Significant within-group improvement in the MBSR group on PTSD
(d = 0.64), depression (d = 0.65), and mental HRQOL (d = 0.77) post-
treatment (maintained only for mental HRQOL at follow-up)
Significant improvement in mindfulness scores immediately post-
treatment (d = 0.65) and at follow-up (d = 0.67) in the MBSR group
King et al.142 37 veterans with MBCT adapted for PTSD CAPS (all groups), Nonrandomized Dropout 25% Significant reduction in CAPS score (d = 2.20) within MBCT group (ITT)
long-term (8 weekly 8-hr group PDS (MBSR group controlled study, in MBCT and Significantly greater improvement on CAPS score in MBCT than in TAU
(> 10 yr) PTSD sessions) or TAU only), PTCI (MBSR pre/post 23.4% in TAU group (d = 1.14; ITT)
or PTSD in (psychoeducation and skills group only) measures groups Improvements on CAPS score in MBCT group explained by significant
partial remission training, 8 weekly 1-hr reduction in avoidant subscale (d = 2.11; ITT)
sessions) or imagery Significant reductions in CAPS intrusive (d = 0.64) and hyperarousal (d =
research therapy 0.78) symptoms also seen in MBCT group (ITT)
(6 weekly 1.5-hr sessions) 73% in MBCT group attained clinically significant reductions in CAPS
score (33% in TAU group; completer analysis)
Significant reduction in PDS numbing subscale (d = 0.57) and PTCI self-
blame cognitions (d = 1.80) in MBCT group (completer analysis)
King et al.35 43 veterans with MBET (16-wk nontrauma CAPS RCT, pre/post Not reported MBET participants attended an average of 13.5 of 16 sessions; PCGT

PTSD focused intervention; measures group attended an average of 7.5 of 16 sessions
mindfulness, No significant differences between groups on PTSD symptom severity
psychoeducation, self- differences between pre- and post-treatment assessments
compassion training; in-vivo MBET group showed significant reduction in total CAPS (d = 0.96),
exposure to avoided CAPS intrusion (d = 0.72) and CAPS avoidance (d = 0.97) symptoms
situations [no trauma PCGT group showed significant reduction in CAPS hyperarousal
exposure]) or PCGT (16-wk symptoms only (d = 0.79)
intervention identifying
current stressors
contributing to PTSD)
Kim et al.143 22 nurses with MBX (16 semi-weekly 60- PCL-C, serum RCT, pre/post Not reported Significantly greater decrease in PTSD symptoms and cortisol levels
PTSD, 7 healthy min sessions) or control cortisol, plasma measures; 2-mo in MBX group than in controls
control nurses condition ACTH, DHEAS follow-up No significant differences between groups in ACTH and DHEAS levels
MBX group showed significant reductions in PTSD symptoms (including
re-experiencing, avoidance, and hyperarousal) at 2-mo follow-up
Significant association between cortisol levels and PTSD symptoms
17
18
Kimbrough 27 survivors of MBSR (8 weekly 2.5–4 hr BDI-II, PCL, BSI, Single arm 85% retention Significant reduction immediately post-treatment and at follow-up on
Boyd et al.
et al.134 CSA (24 women) classes and 1 5-hr retreat MAAS, practice uncontrolled depression scores (d = 1.8; d = 1.0), anxiety (BSI; d = 1.1; d = 0.90),
with general augmented for CSA) with logs and study, PTSD symptoms (d = 1.2; d = 1.0)
severity index concurrent psychotherapy attendance pre/mid/post Significant reductions immediately post-treatment and at follow-up on
BSI score > 0.50 monitoring measures; 4-mo PTSD avoidance/numbing (d = 1.4; d = 0.90), re-experiencing (d = 0.70
follow-up both time points), and hyperarousal (d = 1.2; d = 0.60)
Significant reduction in individuals meeting criteria for PTSD post-
treatment but not at follow-up
Niles et al.137 33 veterans with MBSR-based telehealth CAPS, PCL-M, RCT, pre/post 76% completed MBSR group showed significant decrease in PCL score (d = 0.84) and
current PTSD group (2 45-min in-person PSQ measures; 6-wk MBSR decrease in CAPS score (d = 0.70)
sessions and 6 20-min follow-up treatment At 6-wk follow-up, changes in PTSD in MBSR group were not
weekly phone calls with sustained (d = 0.16)
weekly individual practice) or Significantly greater improvement in MBSR group at posttreatment on
telehealth psychoeducation PCL (d = 1.95) and CAPS scores (d = 1.27)
with same contact
Polusny 116 veterans MBSR (8 weekly 2.5-hr PCL, CAPS, RCT, pre/post Dropout 22.4% Significantly greater reductions in PCL (d = 0.40), CAPS (d = 0.41),
et al.138 with PTSD or sessions and 1 day-long PHQ-9, FFMQ, measures; 2-mo in MBSR and WHOQOL (d = 0.41) scores in MBSR group between baseline and
subthreshold retreat) or PCT (9 weekly WHOQOL follow-up 6.9% in PCT 2-mo follow-up
PTSD 1.5-hr sessions) Nonsignificant differences between groups on depressive scores
(similar improvement in both groups)
Improvements of FFMQ scores significantly correlated with PTSD
(PCL), depression and WHOQOL scores
Possemato 62 veterans with BMP (based on MBSR, CAPS, PCL, RCT, pre/post 20% dropout No significant difference between BMP+TAU and TAU groups using
et al.136 PTSD or 4 weekly 90-min sessions) PHQ-9, FFMQ, measures; 1-mo rate ITT analysis for CAPS and PCL scores
subthreshold plus TAU or TAU alone MAAS follow-up Significantly greater improvement in BMP+TAU group on depression
PTSD (typical primary care for scores (d = 0.86)
veterans) BMP+TAU completers showed significantly larger decreases in PTSD
severity (CAPS; d = 0.72) and depression scores (PHQ-9; d = 0.99)
FFMQ describing, nonjudgment and acting with awareness and MAAS
scores accounted for 30% of total effect of BMP completion on PTSD
severity
Rosenthal 7 veterans with TM (taught in 2 information CAPS, PCL-M, Single arm 71% Significant improvement on CAPS, Q-LES-Q, PCL-M, CGI-I at week 8
et al.144 PTSD (all men) lectures, brief personal Q-LES-Q, BDI, uncontrolled trial, completed

interview, individual CGI-S, CGI-I, CES pre-treatment
instruction and 3 follow-up measures; 8-wk
sessions on 3 consecutive follow-up
days; participants asked to
meditate at home for 20 min
twice daily for 12 wk)
AAQ-II = Acceptance and Action Questionnaire-II; ACTH = adrenocorticotropic hormone; BADS = Behavioural Activation for Depression Scale; BDI-II = Beck Depression Inventory-II; BMP = Brief Mindfulness Program; BSI-18 = 18-item Brief
Symptom Inventory; CAPS = Clinician-Administered PTSD scale; CAR = cortisol-awakening response; CDES = Center for Epidemiological Studies Depression Scale; CES = Combat Exposure Scale; CGI-I = Clinical Global Impression
Improvement; CGI-S = Clinical Global Impression Severity; CRP = C-reactive protein; CSA = childhood sexual abuse; CTQ = Childhood Trauma Questionnaire; DERS = Difficulties in Emotion Regulation Scale; DHEAS =
dehydroepiandrosterone sulfate; FFMQ = Five Factor Mindfulness Questionnaire; HRQOL = health-related quality of life; IL-6 = interleukin-6; ITT = intention to treat; MAAS = Meditation Attention and Awareness Scale; MBSR = mindfulness-
based stress reduction; MBX = mindfulness-based stretching and deep breathing exercises; MDD = major depressive disorder; MPSS = Modified PTSD Symptom Scale; LEC = Life Events Checklist; MBET = mindfulness-based exposure
therapy: MRP = mantram repetition practice; mTBI = mild traumatic brain injury; NA = not applicable; PCGT = present-centred group therapy; PCL = PTSD Check List; PCL-C = PTSD Check List–Civilian; PCL-M = PTSD Check List–Military;
PDS = PTSD Diagnostic Scale; PHQ-9 = Patient Health Questionnaire-9; PSQ = Patient Satisfaction Questionnaire; PTCI = Post-traumatic cognitions inventory; PTSD = posttraumatic stress disorder; Q-LES-Q = quality of life enjoyment and
satisfaction questionnaire; RCT = randomized controlled trial; SF-8/SF-12 = 8-item/12-item Short-Form Health Survey; STAI = Spielberger State-Trait Anxiety Inventory; TAQ = Trauma Appraisals Questionnaire; TAU = treatment as usual;
TLEQ = Traumatic Life Events Questionnaire; TM = transcendental meditation; TNF-α; tumour-necrosis factor-α; UPID = University of California, Los Angeles PTSD index for DSM-IV; WHOQOL = World Health Organization Quality of Life.
a ddition, MBSR appears to have a high level of acceptability completing treatment.146 Similarly, Rosenthal and colleagues144
among patients, with most studies reporting low drop-out studied the effectiveness of a transcendental meditation (a form
rates of 10%–22% 129,131,132,134,137,138 (but see the study by of mantra meditation) program in a sample of 7 veterans with
Gallegos and colleagues139). With respect to mechanisms of PTSD (5 completed treatment) and reported significant
change, aggregate data from 2 studies by Kearney and col- improvements on CAPS scores as well as a quality of life mea-
leagues132,133 and 2 unpublished studies reported changes in sure. Another recent study compared the effectiveness of a
nonreactivity and acting with awareness on the FFMQ to be meditation–relaxation program (including mantra repetition
most strongly associated with improvements in PTSD symp- and breathing exercises) to a validated narrative exposure ther-
toms, particularly hyperarousal symptoms.141 apy for children (KIDNET)149 among children with probable
PTSD (all criteria except duration met) following exposure to a
Mindfulness-based cognitive therapy for PTSD tsunami.145 The authors reported 100% participant retention and
equivalent reductions in PTSD symptoms immediately post-
In addition to investigations of the utility of MBSR among indi- treatment and at 6-month follow-up, with large effect sizes for
viduals with PTSD, one study has investigated the efficacy of both treatment modalities as well as improvements in functional
MBCT augmented for treatment of PTSD. In that study, King outcomes (e.g., self-reported school performance). At the
and colleagues142 assigned (nonrandomized) 37 veterans with 6-month follow-up 71% of children in the meditation–relaxation
chronic PTSD (> 10 yr) to receive either MBCT for PTSD or to treatment (81% in KIDNET) no longer met criteria for PTSD,
1 of 2 control conditions, psychoeducation with skills training or and there were no significant differences between groups on re-
imagery rehearsal therapy (focuses on reframing nightmare con- mission rates. A similar intervention using mindfulness-based
tent). The authors found significantly greater improvements on stretching and deep breathing exercises (MBX) compared with a
PTSD symptoms (CAPS) in the MBCT group than in the control control group among intensive care unit (ICU) nurses led to sig-
groups using ITT analysis (large effect size), which was largely nificantly greater reductions in PTSD re-experiencing, hyper-
explained by reductions in scores on the CAPS avoidance sub- arousal and avoidance symptoms.143
scale. In addition, the authors found that a significantly greater Thus, mantra repetition and meditation–relaxation treat-
number of veterans in the MBCT group than in the control ments are also emerging as efficacious approaches to the
groups achieved clinically significant reductions in PTSD symp- treatment of PTSD compared with TAU146 and control condi-
toms (73% v. 33%). Moreover, among those who completed tions.143 Moreover, a recent study reported equivalent symp-
treatment (75% of the MBCT group), significant reductions in tom improvement when compared with an exposure-based
numbing symptoms and self-blame cognitions were noted. therapy for children.145 Loving-kindness meditation has also
Thus, MBCT shows promise as an additional mindfulness-based emerged as a promising approach, with increases in self-
approach to treating PTSD, with reductions in avoidance symp- compassion as a putative driver of symptom improvement.147
toms emerging as a key mechanism of change.
Mindfulness-based exposure therapy for PTSD
Additional mindfulness-based approaches for PTSD
King and colleagues35,36 recently presented a novel approach to
Alternative mindfulness-based approaches for the treatment of mindfulness-based treatment for PTSD. Specifically, they de-
PTSD, including metta mindfulness approaches,143–148 have veloped a 16-week MBET that incorporates mindfulness train-
also been studied. A recent pilot study of a 12-week loving- ing as in MBCT and nontrauma in vivo exposures to avoided
kindness meditation intervention for veterans with PTSD re- situations. The approach consists of 4 modules — including
ported increased self-compassion and mindfulness skills and PTSD psychoeducation, mindfulness of the body and in vivo
reductions in PTSD symptoms (large effect size) and depres- exposure, mindfulness of emotions and in vivo exposure —
sive symptoms (medium effect size) at the 3-month follow-up, and self-compassion training. The authors compared MBET
with 74% attending at least 9 of 12 classes.147 Further, media- with PCGT focused on current life stressors contributing to
tion analyses identified changes in self-compassion as a driver PTSD. They reported results from a subsample of patients who
of changes in PTSD and depressive symptoms,147 while addi- also participated in an fMRI study,35 and found that although
tional analysis revealed increased feelings of mastery, personal both treatments led to reductions in PTSD symptom severity,
growth, life purpose, self-acceptance and decentring.148 only the MBET led to statistically significant reductions.
Mantrum repetition practice (MRP), the silent repeating of a Despite promising initial findings, future work will be neces-
sacred word or phrase, which is thought to reduce stress, anx sary to confirm the efficacy of this approach.
iety and anger and to increase mindful attention, was recently
studied in a large sample of veterans with PTSD assigned to re- Impact of mindfulness approaches on endocrine function
ceive TAU or MRP+TAU.146 The authors reported significantly
greater reductions in self-reported and clinician-rated (CAPS) Two studies have investigated the impact of mindfulness-
PTSD symptomatology and hyperarousal and numbing symp- based treatments on endocrine function.135,143 Bergen-Cico and
toms as well as decreased self-reported depression symptoms colleagues135 reported significant reductions in cortisol awaken
and improved mental HRQOL in the MRP+TAU compared ing response (CAR) among veterans who completed a brief
with the TAU group. Critically, the authors found this approach mindfulness intervention as compared with those receiving
to be highly acceptable among veterans, with 95% of the sample TAU. Importantly, CAR reduction was associated with

Boyd et al.
changes in PTSD and depression symptom severity. Con- ally, several single-arm uncontrolled trials reported significant
versely, Kim and colleagues143 reported a significant increase improvements in PTSD and related symptomatology following
in basal cortisol levels among ICU nurses with PTSD taking MBSR treatment among veterans129,132 and victims of interper-
part in MBX treatment as compared with the control condition. sonal or developmental trauma.131,134,139 Importantly, across these
Further, higher cortisol levels were associated with reduced studies, treatment gains were largely maintained at follow-up
PTSD symptoms in the combined MBX and control samples.143 ranging from 1 month to 2.5 years129,130,132,134,138,139 (but see the
Critically, these 2 studies used different methodology to meas studies by Kearney and colleagues133 and Niles and col-
ure cortisol, with Kim and colleagues143 measuring cortisol in leagues137). Critically, the study by Niles and colleagues,137
the early morning a few hours after wakening via phlebotomy which did not report maintained improvement at follow-up,
and Bergen-Cico and colleagues135 measuring salivary cortisol used a telehealth approach, suggesting that more intensive, in-
after participants first awoke to determine the CAR. In addi- person treatment may be necessary to maintain treatment gains.
tion, although it is well established that PTSD impacts nega- Additional mindfulness-based treatments have been assessed,
tively on the regulation of the hypothalamic–pituitary–adrenal including a recent investigation of MBCT modified for PTSD142
(HPA) axis,150,151 there has been substantial variability in re- and MBET36 in comparison to standard treatment protocols,
ports of the directionality of this association, with many showing promising results indicating greater efficacy of these
studies reporting lower basal cortisol levels among individuals approaches over control treatments.36,142 In addition, MRP and
with PTSD, some reporting high levels of basal cortisol in indi- meditation–relaxation techniques have been studied among in-
viduals with PTSD and others concluding that there may be a dividuals with PTSD.143–146 In those studies, initial evidence
loss of the normal circadian rhythm of cortisol release among shows enhanced efficacy of MRP over TAU146 and comparable
those with PTSD.151 Although the directionality of the associa- efficacy of a meditation–relaxation approach to first-line narra-
tion between cortisol levels and PTSD symptomatology is not tive exposure therapy among children.145 Moreover, emerging
clear, the studies reviewed here suggest that mindfulness- evidence indicates that mindfulness-based approaches may
based approaches may be effective in normalizing cortisol target neuroendocrine dysfunction that is characteristic of PTSD
response in individuals with PTSD.135,143 Furthermore, Gallegos by normalizing cortisol levels135,143 and reducing circulating
and colleagues 139 observed reductions in circulating inflammatory cytokines.139
interleukin-6 (IL-6; an inflammatory biomarker) as a function Of the studies reviewed here, most did not report on
of increased attendance at MBSR treatment sessions among changes in specific PTSD symptom domains (e.g., intrusions,
women with a history of interpersonal trauma. These findings avoidance, alterations in cognitions and mood, and arousal
are important in light of consistent reports of increased inflam- and reactivity). However, among those that did, significant
matory biomarkers among individuals with PTSD and given reductions were noted across symptoms of re-experiencing,
that proinflammatory cytokines, such as IL-6, have been avoidance, numbing, and hyperarousal.132,134,142,143 Further
shown to increase depressive and anxiety symptoms.152 work will be necessary to elucidate the mechanisms of action
by which mindfulness-based approaches lead to changes in
Discussion PTSD symptomatology. However, preliminary research has
begun to explore this question (Fig. 1). For example,
Mindfulness-based approaches in the treatment of PTSD Kimbrough and colleagues134 noted particularly strong re-
ductions in the CAPS avoidance/numbing subscale, whereas
On balance, an emerging and rapidly growing literature on King and colleagues142 posited that improvements on the
mindfulness-based treatment for PTSD shows considerable CAPS following MBCT were driven by reductions in the
promise. The studies reviewed here suggest that mindfulness- avoidance subscale. These findings support hypotheses that
based treatments are effective in reducing symptoms of PTSD, suggest a reduction in avoidance as a mechanism by which
with medium to large within-group effect s izes.129,131–134,136– mindfulness may reduce PTSD symptom severity through
138,142,145
Critically, most of these studies reported low dropout promotion of nonjudgmental acceptance of traumatic mem
rates (0%–29% attrition),129,131–134,137,138,142,144–146 although higher ories, thoughts and stimuli in the external and internal en
rates were reported by Gallegos and colleagues,139 (43% drop- vironment.27,28 Similarly, significant increases in acceptance,
out) who cited reasons such as difficulty with childcare and reductions in shame-based cognitions131 and improvements
transportation among a sample of mostly women of low socio- in emotion regulation139 have been reported following MBSR
economic status. Such low drop-out rates suggest high accept- treatment for PTSD. King and colleagues142 reported signifi-
ability of mindfulness-based treatments among individuals with cant reduction in self-blame cognitions and emotional numb-
PTSD and are important given that recent studies highlight ing following MBCT, suggesting that mindfulness may im-
35%–40% dropout rates among individuals receiving evidence- prove acceptance (i.e., nonavoidance) and regulation of
based treatments for PTSD (e.g., CPT, PE),14–16 with PE having emotions and acceptance of trauma-related cognitions, lead-
significantly higher dropout rates.16 At present, MBSR is the ing in turn to decreased shame, self-blame and emotional dys-
most evidence-supported approach, with 2 RCTs reporting sig- regulation.131,139,142 These findings are of particular importance
nificantly greater improvements in PTSD and related symptom- given recent models emphasizing the importance of shame
atology with MBSR than with active comparison therapies and guilt-based cognitions in the development and mainte-
among veteran populations137,138 (but see the studies by Kearney nance of PTSD.41,153 Finally, improvements in facets of mind-
and colleagues133 and Possemato and colleagues136). Addition- fulness, namely nonreactivity and acting with awareness,

have been associated with reduction in hyperarousal symp- mindfulness-based approaches as a first-line, evidence-based
toms, suggesting that a greater ability to remain in the pres- treatment for PTSD,145 and no studies have compared these
ent moment and be nonreactive to environmental stimuli is a approaches to CPT or PE; however, as reviewed, mindfulness-
mechanism of change for this symptom cluster. based treatments appear to have similar effect sizes (medium
to large), suggesting similar efficacy. Moreover, initial findings
Neurobiological evidence for mindfulness-based approaches are promising, with Catani and colleagues145 reporting equiva-
in the treatment of PTSD lent symptom reductions following either a meditation–
relaxation intervention or narrative exposure therapy among
There is considerable overlap between neurobiological models children with symptoms of PTSD.
of PTSD and neurobiological findings in the mindfulness litera- A further avenue for future research is the use of
ture. Recent research shows that mindfulness-based treatments mindfulness-based treatments as a means of preventing re-
have the potential to target emotional undermodulation (associ- lapse and reducing residual symptoms among those who
ated with hyperarousal and intrusion symptoms) and emotional have completed CPT, PE, or other first-line treatments for
overmodulation (associated with dissociative symptoms).7,60,61,63 PTSD, as has been shown with MBCT in the depression
Specifically, evidence suggests that mindfulness-based therapies l iterature. 32,154,155 This emerging avenue for the use of
may be effective in increasing activity in prefrontal regions (e.g., mindfulness-based treatments may be crucial given that a
mPFC) and reducing activity in limbic regions (e.g., amygdala), substantial proportion of individuals with PTSD retains their
and thus may effectively target intrusion and hyperarousal diagnosis following first-line psychotherapy12 or has substan-
symptoms.72,78 Moreover, increased connectivity between the tial residual symptoms.13 Additional work should also inves-
vlPFC and amygdala has been associated with reduced anxiety tigate the general utility of MBCT adapted for PTSD, as only
symptoms following MBSR treatment71 and may indicate im- 1 study to date has done so.142 Critically, as mentioned earlier,
provements in arousal monitoring that lead to reductions in personalized approaches to treatment are emerging as a
both hyperarousal and intrusion symptoms as well as dissocia- gold-standard approach where clinicians take into account
tive responses to traumatic stimuli.72 the specific characteristics of each patient to determine what
Furthermore, evidence indicates that mindfulness fosters treatment approaches may best fit their specific constellation
appropriate use and integrity of the DMN, SN and CEN, of symptoms and needs. Further work will be critical to gain-
given that different phases of mindfulness practice are associ- ing a better understanding of exactly what participant char-
ated with distinct use of different networks. 102 Indeed, acteristics predict response to different treatment modalities
mindfulness-based interventions show promise in restoring (e.g., primarily hyperarousal or dissociative symptoms), so
activity and functional connectivity within and between the that patients can be guided to the treatment approach that
CEN, DMN and SN in individuals with PTSD. Recent work would be most effective for them.
indicates that mindfulness may be effective in increasing rest- Importantly, no work to date has investigated whether dis-
ing state functional connectivity and activity within the sociative symptoms associated with PTSD can be ameliorated
DMN.108 These findings are particularly important given re- through mindfulness-based interventions despite theoretical
duced resting state activation and connectivity of the DMN models suggesting that mindfulness is opposed to dissocia-
in individuals with PTSD that is thought to lead to disrup- tive states and may improve pathological dissociative symp-
tions in self-referential processing.61,92 Additionally, mindful- toms (e.g., by improved connectedness to the self and present
ness may be effective in targeting the hyperactivity in the SN moment awareness).53,54 This is a crucial avenue to explore, as
and hyperconnectivity between the DMN and SN seen alternative treatment approaches may be particularly indi-
among individuals with PTSD61,92 by fostering reduced neural cated among individuals with PTSD+DS in light of poten-
responding to emotional cues (i.e., reduced AI activation in tially reduced treatment response18,19 and increased disease
response to negative stimuli)67,111 and decreased internetwork severity.23
connectivity between the DMN and SN.112 These alterations Another crucial area for future research is the use of metta
may lead, in turn, to reduced hyperarousal symptoms and mindfulness or loving-kindness approaches, which have gar-
restoration of self-referential processing among individuals nered recent interest because of their potential to assist pa-
with PTSD. Critically, future work will need to confirm these tients with PTSD in emotional and psychological flexibility
hypotheses regarding both the neurocircuitry and triple net- and to foster compassion and empathy for oneself and
work models among individuals with PTSD who are receiv- others.37,39,40 Preliminary work indicates that this form of
ing treatment via mindfulness-based approaches. meditation is effective in improving symptoms of PTSD and
promotes increased self-acceptance, life purpose and decen-
Limitations and future directions tring among veterans.133,148 Furthermore, research suggests
that changes in self-compassion mediated changes in symp-
Although the studies reviewed here provide promising initial toms of PTSD among those who participated in a loving-
evidence for the utility of mindfulness-based approaches in re- kindness mediation intervention.147,148 These results are crit
ducing symptoms of PTSD among military and other trauma- ical given recent conceptualizations of PTSD as a disorder
exposed populations, additional work is needed before these driven by shame, guilt and lack of self-compassion41,42 and
treatments can be considered as potential first-line interven- findings that reduced self-compassion is associated with
tions. Indeed, just 1 study has compared the usefulness of worse symptom severity among those with PTSD.156

Boyd et al.
In addition, future work should be aimed at gaining a bet- References

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Mindfulness and PTSD

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Review Paper

Mindfulness-based treatments for posttraumatic stress

Introduction First-line treatments for PTSD, including prolonged ex-

© 2018 Joule Inc. or its licensors

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PTSD symptom Hypothesized

Shifting attention to present

Non-reactivity and acting

Connection and awareness of

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In addition, future work should be aimed at gaining a bet- References

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