Mindfulness meditation is a practice to achieve open, acceptant, nonjudgmental awareness (i.e., mindfulness) of the present moment by focusing the person’s attention on their breathing. Jon Kabat-Zinn is the pioneer of clinical applications of mindfulness in the West. He describes mindfulness as “the ability to maintain moment by moment, open, acceptant, non-judgmental awareness” [11]. Segal further describes four characteristics of this type of attention to present experience as curiosity, openness, acceptance, and love (COAL) [12]. He suggests that curiosity and ability to simply observe our feelings, thoughts, and reactions with openness lie at the heart of mindfulness and help generate self-acceptance and self-love .

To explore neural underpinnings of mindfulness, Farb used functional magnetic resonance imaging(fMRI) to trace two distinct forms of awareness [13]. The first type, awareness of the self across time, engages mPFC and results in cognitive attempts to control negative emotions. The second type is what we refer to as mindful awareness, directed to the self in the present moment, which focuses on somatosensory experience of the present by recruiting right lateralized network [13]. Voluntary regulation of prefrontal cortex and directing attention toward the transitory nature of a present somatosensory experience provides an alternative to cognitive efforts to control negative emotion and cultivates conscious, open, and receptive attitude rooted in the now [14, 15].

Since neural mechanisms show that mindful awareness activates the somatosensory cortex, it is not surprising that most meditation techniques (Fig. 10.1) involve focus on a particular somato-visceral sensation (e.g., breathing, vibration, muscle relaxation/heaviness) or rely on a sensory organ perception (e.g., vision in mandala meditation and hearing in chanting meditation). Based on this observation and the neural mechanism of mindful awareness described by Farb, it is fair to assume that although mindfulness meditation was specifically developed to cultivate mindfulness, other meditation traditions are likely to do the same to a certain degree. When Buddhist mindfulness meditation sees the development of mindful attitude toward life as a final goal, other meditation traditions may pursue additional aims. Loving–kindness meditation, for example, seeks to cultivate compassion, and transcendental meditations aim to free the mind of thought and achieve a more peaceful level of consciousness [16].

There are several types of mindfulness meditation that originated from different Buddhist monastic traditions, for example , Zen, Vipassana, and Shambhala meditations [17]. All universally involve the person sitting still and observing the breath, but may differ slightly in posture, eyes being open or closed, or hand and leg position. When thoughts inevitably arise, a meditator is instructed to nonjudgmentally acknowledge and accept them, and then bring her attention back to the simple sensation of air going in through her nostrils, into the chest and out again, in a natural and relaxed way. This process of repeatedly returning one’s attention back to the essential process of respiration, gradually trains the brain the mindful art of staying in the present, and offers significant benefits of controlling one’s otherwise automatic stress response to thoughts, negative emotions, and memories of PTSD [16, 18].

Several modern group-based meditation protocols have been developed in an attempt to standardize care delivery, target unique mechanisms of a specific condition, and help replicate research findings. These modern 6–8 weeks meditation programs are mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), mindfulness-based relapse prevention (MBRP), and mind–body bridging (MBB). Although most research studies use one of these structured programs, it is important to recognize that they were created to make it easier to standardize clinical programs, and replicate research protocols. The common active ingredient to all of these mindfulness-based group interventions is mindfulness meditation (Table 10.3). Therefore, if MBSR or MBCT is cost- or time-prohibitive or not available locally, a patient can start by following simple instructions for mindfulness meditation home practice. The following provides an example of such instructions adapted from Richard J. Davidson, one of the most prominent researchers of neurobiological basis of meditation [19].

MBSR was originally developed at the University of Massachusetts Medical School [20]. Below is the description of the 8-week MBSR program Kearney et al. used in the randomized controlled pilot in veterans with PTSD [21]. The MBSR groups usually meet for 2 h once per week for 8 weeks, in addition to a daylong retreat. MBSR instruction emphasizes bringing a curious, kind, and nonjudging attitude to the present moment, including any difficult or unpleasant experiences.

During each class, participants receive instructions on mindfulness meditation and have an opportunity to ask questions and practice newly learned skills. Homework assignments include daily meditation or yoga for 45 min per day, and bringing mindful attention to experiences in daily life. Attention training includes developing the ability to place and sustain attention on the breath, as well as maintaining flexibility of attention (e.g., the ability to let go of ruminative cycles of thought and return attention to the breath). The “body scan” and gentle yoga are two additional mindfulness exercises taught. The body scan exercise is a 45-min exercise in which attention is systematically directed to each part of the body. During the daylong mostly silent retreat, participants practice mindfulness exercises more intensively.

MBCT is a group program integrating cognitive behavioral therapy (CBT) and mindfulness meditation . It was initially developed by Teasdale, Segal, and Williams to prevent relapses of depression currently in remission [22]. The program teaches individuals to become more aware of thoughts and to view thoughts as “mental events” rather than as aspects of the self or accurate reflections of reality. Adopting this “mindful” mode of neutral nonjudgmental observation empowers patients to recognize and disengage from their dysfunctional ruminative negative thought patterns and prevent habitual reactive emotional responses that would otherwise fuel the relapse process. Unlike CBT, there is little explicit emphasis on changing the content or specific meanings of negative automatic thoughts. Teasdale states that the MBCT program “involves facilitation of an aware mode of being, characterized by freedom and choice of response, in contrast to a mode dominated by habitual, overwhelmed, automatic patterns of cognitive-affective processing” [22].

An MBCT program is usually delivered by an instructor in 8-week 2-h group training sessions with daily homework exercises. Homework consists of some form of awareness exercises, directed at increasing moment-by-moment nonjudgmental awareness of bodily sensations, thoughts, feelings, and integrating application of awareness skills into daily life. Specific relapse/recurrence prevention strategies are also explored. Most programs offer up to four, monthly follow-up meetings upon completion of the initial 8-week program, thus extending guided support of this therapeutic intervention for up to 6 months.

To better understand the neural mechanisms responsible for the therapeutic effect of mindfulness meditation in PTSD, it is important to recognize the abnormalities in the prefrontal cortex (PFC)—amygdala neurocircuit that are associated with PTSD. Amygdala, the brain structure responsible for memory and emotion processing, is overactivated in PTSD resulting in persistent negative emotions that are difficult to control. In healthy individuals, activation in the PFC inhibits the amygdala. In individuals with PTSD, the PFC is under-responsive, and therefore generates insufficient negative feedback on the hyperactive amygdala. Symptomatically, this manifests as persistent fear, phobic avoidance, hyperarousal, impulsivity, reexperiencing of painful memories, and depressive rumination. Coincidently, this very same neural mechanism is a shared neuropathology of PTSD, depression , poor impulse control in addictions, and aggressive outbursts.

Creswell, in his 2007 fMRI study, was able to show that mindfulness training is associated with greater PFC activation and reduced amygdala activity [23], the exact effect desired to normalize neural circuitry implicated in PTSD and comorbid disorders. A systematic review by Chiesa in 2010 confirmed that MM practice activates the PFC and the anterior cingulate cortex (ACC) [15]. Through PFC inhibition of the amygdala, mindfulness redirects attention from cognitive control of negative emotions to the transitory nature of momentary experience. This redirection of awareness helps people with PTSD to increase tolerance for negative emotions, such as fear, shame, guilt, and pain, to reduce automatic negative self-evaluation, and to engage in self-compassion [24]. Figure 10.2 illustrates the effect of mindfulness meditation on PFC-amygdala neurocircuit.

In another landmark study, anatomical MRI was done pre and post an 8-week MBSR program (N = 26) and illustrated that reported reduction in perceived stress positively correlated with decrease in right basolateral amygdala gray matter density. By decreasing amygdala activity these MBSR-mediated neuroplastic changes could help decrease the negative consequence of chronic stress [25]. MBSR also increased gray matter volume in areas of learning, attention and memory process, emotion regulation, and self-referential processing [26] .

Mindfulness meditation exhibits positive effect on emotional symptomatology of PTSD. It has been shown to increase positive mood, reduce distractive ruminative thoughts and behaviors [27], reduce emotional reactivity [28, 29], and improve impulse control [30]. One study showed that MBSR may influence the hypothalalmic-pituitary-adrenocortical (HPA) axis, resulting in adjustment of cortisol levels [23]. Higher plasma melatonin levels were also shown in advanced meditators and may be helpful in mitigating PTSD-related sleep difficulties [31]. These multifaceted neural, endocrine, and psychological effects of mindfulness and mindfulness meditation suggest its versatile clinical utilization for a variety of mental health conditions and warrants further investigation.

Limited number of randomized controlled trials on mindfulness meditation for PTSD exists to date. Several nonrandomized studies have assessed the efficacy of mindfulness meditation in the setting of PTSD with the evidence of improved PTSD symptoms, depression, mental health-related quality of life, as well as acceptance and mindfulness skills [32, 33]. These improvements were largely maintained at 6 months follow-up, with most pronounced reduction in avoidance, depression, and emotional numbing.

In two consequent randomized controlled trials in cancer patients (N = 71), an 8-week MBSR training course significantly decreased perceived stress and posttraumatic avoidance symptoms and increased positive affect and mindfulness compared to a wait-list control group, immediately post-intervention and at 6-month follow-up [3, 34]. The investigators suggest that improvements in psychological well-being are likely explained by increased levels of mindfulness as measured with the five-facet mindfulness questionnaire. In 2013 Kearney et al. conducted a randomized controlled pilot study to assess outcomes associated with an 8-week MBSR program for veterans with PTSD. They randomized participants to treatment as usual (TAU, N = 22), or MBSR plus TAU (N = 25) [21]. More veterans randomized to MBSR reported enhanced levels of mindfulness and had clinically significant improvement in health-related quality of life, but not PTSD symptoms. These changes were noted immediately post-intervention and at 4-month follow-up .

The largest and most rigorous RCT was completed by Polusny et al. It compared adjunctive MBSR and present-centered group psychotherapy in veterans with PTSD diagnosis (n = 116). Study participants did not use any other psychotherapeutic treatment during the study, but some were on psychoactive medications used at stable doses for at least 2 months prior to entering the study. MBSR resulted in a greater decrease of PTSD symptoms, and showed improvement of depressive symptoms, mindfulness, and quality of life. This therapeutic improvement was sustained during the 9-week intervention administration, and at 2-months follow-up.

Although, there were no neuroimaging studies done on meditation effects for PTSD, two fMRI studies confirmed that MBSR diminishes negative emotions, avoidance behaviors, automatic emotional reactivity, and engages attention regulation of distorted habitual self-views in patients with anxiety [35, 36]. It is thought to reduce negative emotions by enhancing emotional regulation and reducing reactivity through suppressing amygdala activity [36, 37]. Negative self-beliefs are also monitored through attention regulation in the parietal cortex neural networks [37]. Thus, MBSR employs both emotion and attention regulation to control anxiety -related symptoms.

In 2013, a nonrandomized pilot study investigated the feasibility, acceptability, and clinical outcomes of an 8-week MBCT group program (N = 20) in comparison to TAU (N = 17). Pre- and post-therapy assessments through clinician-administered and self-report PTSD measures suggest that group MBCT is an effective adjunctive therapy for combat-related PTSD , well accepted by patients, with good treatment compliance, and the potential for a reduction in the avoidance and numbing symptom cluster, and PTSD cognitions, such as self-blame [38]. No randomized controlled studies on use of MBCT for PTSD were done.

Several quasi experimental studies examined more traditional mindfulness meditation techniques. A mindfulness meditation intervention was used in a pilot study of mental health workers with PTSD who, 10 weeks after Hurricane Katrina, received 4 h of mindfulness training, followed by an 8-week home study. Participants reported good treatment adherence, significant improvements in well-being, and a decrease in PTSD and anxiety symptoms; the improved results were correlative with the total number of minutes of daily meditation practice [39]. A small Vipassana meditation study among incarcerated individuals showed no significant difference in PTSD symptom severity between Vipassana and treatment as usual groups; however, participation in the Vipassana course was associated with significantly greater reductions in comorbid substance use [40].

Further randomized controlled studies of sufficient sample size are needed to establish efficacy of mindfulness meditation as adjunct for PTSD. Preliminary findings suggest that mindfulness meditation is safe, well accepted by patients, effective adjunctive therapy with good treatment adherence, and meditation practice compliance at up to 6 months follow-up . Research findings are consistent in showing increased levels of mindfulness, improved health-related quality of life and well-being, and reduced avoidance, depression, and numbing symptoms (Table 10.4) [41].

Mantram repetition belongs to a group of mantra meditations. The other two well-known practices in this group are transcendental meditation (TM) and relaxation response training, and both use a similar technique of repeating a word, phrase or sound, silently or aloud to create a sense of peace and relaxation [68]. Mantra means “to cross the mind” in Sanskrit and has a purpose of bringing mental clarity, calmness, and inner peace. It is present in all major spiritual traditions with a sacred phrase handed down for generations. The term mantram, rather than mantra, is used to differentiate the mantram repetition program from TM and to acknowledge its originator, Eknath Easwaran [69].