Meditation in Veterans With PTSD and Mild TBI

Approximately 18-22% of Operation Enduring Freedom/Operation Iraqi Freedom/ Operation New
Dawn (OEF/OIF/OND) Veterans have been diagnosed with posttraumatic stress disorder (PTSD),
and 15-30% of Veterans report mild traumatic brain injury (mTBI). The effects of mTBI and
PTSD have been evident since military personnel first came home and continue to be difficult
to eradicate. At 3-4 months post-deployment, OIF Veterans with mild TBI were more likely to
endorse PTSD symptoms than those without mTBI. The co-morbidity may be long-lasting, or at
least recurrent, as TBI-related symptoms were strongly associated with traumatic stress five
years after injury. In an examination of factors associated with postconcussive symptoms,
PTSD was a strong factor. In active duty marines, mTBI during deployment predicted PTSD after
deployment, and in a study of OEF-OIF-OND Veterans, 57.3% of those with mTBI had PTSD.

The literature on how mTBI and co-morbid PTSD affect each other and the effects on Veterans
several years post-deployment is sparse. Treatment recommendations specific to Veterans with
both mTBI and PTSD are in flux, and while treatments address each disorder independently,
they may not be effective when the two disorders co-occur. Further impacting successful
treatment of Veterans is the fact that many Veterans do not seek treatment, in part due to
the distance they travel to obtain VA services and stigma.

Treatments that are accessible and improve symptoms in patients with mTBI and PTSD alone may
facilitate rehabilitation in Veterans with co-morbid mTBI and PTSD. Meditation has been
suggested to be effective in Veterans with PTSD and in civilians with TBI, improving quality
of life. The current study proposes a type of meditation targeted for Veterans, Inner
Resources for Veterans (IRV).

Inner Resources for Veterans (IRV) meditation intervention is based on Inner Resources for
Stress, an intervention which utilizes mindfulness, techniques that encourage non-judgmental
attention to oneself in the present moment. The Inner Resources protocol targets PTSD and has
been associated with reduced PTSD and anxiety symptoms, reduced number of depressive
symptoms, and depression remissions at a 9-month follow-up, as well as increased perceived
self-efficacy. Pilot results of older combat Veterans with PTSD indicated that Inner
Resources is a safe, feasible, and acceptable intervention. In a previous study with IRV in
veterans at the Michael E. DeBakey VA, the control condition provided education on the
symptoms and effects of PTSD. For example, subjects learned to recognize the circumstances
that triggered their symptoms, how to identify and participate in healthy activities, and how
to monitor their sleep.

In addition to the changes in functional and psychological symptoms and neural pathways, IRV
would offer Veterans a treatment they could utilize whenever challenging situations occur
regardless of location. Since the treatment would be relatively cost-free after initial
training, IRV could also dramatically reduce financial burden to both Veterans and VA. Few
treatment studies focusing on Veterans with co-morbid mTBI and PTSD support the innovation of
this study, as does generation of community integration data to relate to changes in
functional connectivity.

Inclusion Criteria:

- Mild traumatic brain injury (mTBI) as defined by the VA/DoD Clinical Practice
Guideline.

- PTSD as assessed by the Clinician Administered PTSD Scale (CAPS);

- Aged 18 - 49;

- Have not previously participated in meditation training.

Exclusion Criteria:

The investigators will exclude subjects who:

- Meet DSM-IV criteria for drug or alcohol abuse in past 30 days;

- Have a history of severe TBI based on any of following:

- Glasgow Coma Score < 8;

- alteration of consciousness greater than 24 hours; loss of consciousness greater
than 30 minutes;

- Have current neurological or general medical conditions known to impact cognitive
and/or emotional functioning, including but not limited to:

- epilepsy,

- Parkinson's disease,

- Huntington's disease,

- Alzheimer's disease,

- stroke,

- chemotherapy for cancer;

- Have acute psychological instability as assessed by MEDVAMC clinician or study staff
or concurrent diagnosis or schizophrenia, schizoaffective disorder, delusional
disorder, organic psychosis, and subjects taking antipsychotic medication, and

- Have already completed a course of meditation training.

- The investigators will also exclude participants with general contraindications for
MRI, including metal in or around the head (e.g., orthodontia, non-removable body
piercings, etc.), ferromagnetic material in the body (e.g., non-removable body
piercings), or non-MRI compatible medical devices.