Acceptance and Mindfulness-Based Exposure Therapy for PTSD After Cardiac Arrest: An Open Feasibility Trial

Maja Bergman, PhD; John C. Markowitz, MD; Ian M. Kronish, MD, MPH; Sachin Agarwal, MD, MPH; Chana T. Fisch, BA; Elizabeth Eder-Moreau, MA; Yuval Neria, PhD

J Clin Psychiatry 2024;85(1):23m14883

ABSTRACT

Background: Posttraumatic stress disorder (PTSD) is prevalent after surviving sudden cardiac arrest (SCA). SCA-induced PTSD is associated with increased mortality and cardiovascular risk, yet no psychotherapeutic treatment has been developed and tested for this population. Exposure therapy is standard treatment for PTSD, but its safety and efficacy remain unconfirmed for SCA survivors: current protocols do not address their specific disease course and have high attrition. Mindfulness-based interventions are typically well-tolerated and have shown promise in reducing PTSD symptoms from other traumas.

Objective: This study sought to determine feasibility, safety, and preliminary efficacy of acceptance and mindfulness-based exposure therapy (AMBET), a novel SCA-specific psychotherapy protocol combining mindfulness and exposure-based interventions with cardiac focused psychoeducation to reduce symptoms and improve health behaviors in patients with post-SCA PTSD.

Methods: We conducted an open feasibility pilot study from January 2021 to April 2022 with a small sample (N = 11) of SCA survivors meeting DSM-5 PTSD criteria. AMBET comprised eight 90-minute remotely delivered individual sessions. Clinical evaluators assessed PTSD symptoms using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) at baseline, midpoint, posttreatment, and 3-month follow-up.

Results: Ten (91%) of 11 enrolled patients completed treatment. Satisfaction was high and patients reported no adverse events. PTSD symptoms significantly improved statistically (P < .001) and clinically with large effect sizes (g = 1.34–2.21) and treatment gains sustained at 3-month follow-up. Posttreatment, 80% of completers (n = 8) showed significant treatment response, 70% (n = 7) with PTSD diagnostic remission. No patient reported symptom increases.

Conclusions: This initial trial found AMBET feasible, safe, and potentially efficacious in reducing PTSD following SCA. These encouraging pilot results warrant further research.

Trial Registration: ClinicalTrials.gov identifier: NCT04596891

J Clin Psychiatry 2024;85(1):23m14883

Author affiliations are listed at the end of this article.

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References (49)

Sawyer KN, Camp-Rogers TR, Kotini-Shah P, et al; American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; Council on Quality of Care and Outcomes Research; and Stroke Council. Sudden cardiac arrest survivorship: a scientific statement from the American Heart Association. Circulation. 2020;141(12):e654–e685. PubMed CrossRef
Druss RG, Kornfeld DS. The survivors of cardiac arrest: a psychiatric study. JAMA. 1967;201(5):291–296. PubMed CrossRef
Agarwal S, Birk JL, Abukhadra SL, et al. Psychological distress after sudden cardiac arrest and its impact on recovery. Curr Cardiol Rep. 2022;24(10):1351–1360. PubMed CrossRef
Michaelides MG. Saint Lazarus, the Friend of Christ and First Bishop of Kition: The History of the Church at Larnaca. Larnaca; 1984. https://books.google.com/books?id=4IzJzQEACAAJ
Agarwal S, Presciutti A, Cornelius T, et al. Cardiac arrest and the subsequent hospitalization induced posttraumatic stress is associated with 1-year risk of major adverse cardiovascular events and all-cause mortality. Crit Care Med. 2019;47(6):e502–e505. PubMed CrossRef
O’Donnell CJ, Schwartz Longacre L, Cohen BE, et al. Posttraumatic stress disorder and cardiovascular disease: state of the science, knowledge gaps, and research opportunities. JAMA Cardiol. 2021;6(10):1207–1216. PubMed CrossRef
Edmondson D. An enduring somatic threat model of posttraumatic stress disorder due to acute life-threatening medical events. Soc Personal Psychol Compass. 2014;8(3):118–134. PubMed CrossRef
Vilchinsky N, Ginzburg K, Fait K, et al. Cardiac-disease-induced PTSD (CDI-PTSD): a systematic review. Clin Psychol Rev. 2017;55:92–106. PubMed CrossRef
Watkins LE, Sprang KR, Rothbaum BO. Treating PTSD: a review of evidence-based psychotherapy interventions. Front Behav Neurosci. 2018;12:258. https://www.frontiersin.org/articles/10.3389/fnbeh.2018.00258. Accessed December 15, 2022. PubMed CrossRef
Crocker LD, Jurick SM, Thomas KR, et al. Worse baseline executive functioning is associated with dropout and poorer response to trauma-focused treatment for veterans with PTSD and comorbid traumatic brain injury. Behav Res Ther. 2018;108:68–77. PubMed CrossRef
Bryant RA, Moulds M, Guthrie R, et al. Treating acute stress disorder following mild traumatic brain injury. Am J Psychiatry. 2003;160(3):585–587. PubMed CrossRef
Cusack K, Jonas DE, Forneris CA, et al. Psychological treatments for adults with posttraumatic stress disorder: a systematic review and meta-analysis. Clin Psychol Rev. 2016;43:128–141. PubMed CrossRef
Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of randomized placebo-controlled trials. Depress Anxiety. 2018;35(6):502–514. PubMed CrossRef
Myers US, Haller M, Angkaw AC, et al. Evidence-based psychotherapy completion and symptom improvement among returning combat veterans with PTSD. Psychol Trauma. 2019;11(2):216–223. PubMed CrossRef
Steenkamp MM, Litz BT, Hoge CW, et al. Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA. 2015;314(5):489–500. PubMed CrossRef
Schnurr PP, Lunney CA. Residual symptoms following prolonged exposure and present-centered therapy for PTSD in female veterans and soldiers. Depress Anxiety. 2019;36(2):162–169. PubMed CrossRef
Bryant RA. Post-traumatic stress disorder: a state-of-the-art review of evidence and challenges. World Psychiatry. 2019;18(3):259–269. PubMed CrossRef
Markowitz JC, Petkova E, Neria Y, et al. Is exposure necessary? a randomized clinical trial of interpersonal psychotherapy for PTSD. Am J Psychiatry. 2015;172(5):430–440. PubMed CrossRef
Shea MT, Krupnick JL, Belsher BE, et al. Non-trauma-focused psychotherapies for the treatment of PTSD: a descriptive review. Curr Treat Options Psychiatry. 2020;7(3):242–257. CrossRef
Boyd JE, Lanius RA, McKinnon MC. Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence. J Psychiatry Neurosci. 2018;43(1):7–25. PubMed CrossRef
Treanor M. The potential impact of mindfulness on exposure and extinction learning in anxiety disorders. Clin Psychol Rev. 2011;31(4):617–625. PubMed CrossRef
Bergen-Cico D, Possemato K, Pigeon W. Reductions in cortisol associated with primary care brief mindfulness program for veterans with PTSD. Med Care. 2014;52(suppl 5):S25–S31. PubMed CrossRef
Gallegos AM, Lytle MC, Moynihan JA, et al. Mindfulness-based stress reduction to enhance psychological functioning and improve inflammatory biomarkers in trauma-exposed women: a pilot study. Psychol Trauma. 2015;7(6):525–532. PubMed CrossRef
Brake CA, Sauer-Zavala S, Boswell JF, et al. Mindfulness-based exposure strategies as a transdiagnostic mechanism of change: an exploratory alternating treatment design. Behav Ther. 2016;47(2):225–238. PubMed CrossRef
Mehling WE, Chesney MA, Metzler TJ, et al. A 12-week integrative exercise program improves self-reported mindfulness and interoceptive awareness in war veterans with posttraumatic stress symptoms. J Clin Psychol. 2018;74(4):554–565. PubMed CrossRef
Schnyder U, Ehlers A, Elbert T, et al. Psychotherapies for PTSD: what do they have in common? Eur J Psychotraumatol. 2015;6(1):28186. PubMed CrossRef
Craske MG, Treanor M, Conway CC, et al. Maximizing exposure therapy: an inhibitory learning approach. Behav Res Ther. 2014;58:10–23. PubMed CrossRef
Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198. PubMed CrossRef
Attkisson CC, Zwick R. The Client Satisfaction Questionnaire: psychometric properties and correlations with service utilization and psychotherapy outcome. Eval Program Plann. 1982;5(3):233–237. PubMed CrossRef
Weathers FW, Bovin MJ, Lee DJ, et al. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): development and initial psychometric evaluation in military veterans. Psychol Assess. 2018;30(3):383–395. PubMed CrossRef
Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol. 1967;6(4):278–296. PubMed CrossRef
Trajković G, Starčević V, Latas M, et al. Reliability of the Hamilton Rating Scale for Depression: a meta-analysis over a period of 49 years. Psychiatry Res. 2011;189(1):1–9. PubMed CrossRef
First MB. Structured Clinical Interview for the DSM (SCID). In: The Encyclopedia of Clinical Psychology. John Wiley & Sons, Ltd; 2015:1–6. 10.1002/9781118625392.wbecp351.
Blevins CA, Weathers FW, Davis MT, et al. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489–498. PubMed CrossRef
Beck AT, Steer RA, Brown G. Beck Depression Inventory–II. Psychol Assess. 1996.
Mehling WE, Acree M, Stewart A, et al. The Multidimensional Assessment of Interoceptive Awareness, version 2 (MAIA-2). PLoS One. 2018;13(12):e0208034. PubMed CrossRef
Taylor S, Zvolensky MJ, Cox BJ, et al. Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3. Psychol Assess. 2007;19(2):176–188. PubMed CrossRef
Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot studies in clinical research. J Psychiatr Res. 2011;45(5):626–629. PubMed CrossRef
Brady K, Pearlstein T, Asnis GM, et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. JAMA. 2000;283(14):1837–1844. PubMed CrossRef
Rubin M, Shvil E, Papini S, et al. Greater hippocampal volume is associated with PTSD treatment response. Psychiatry Res Neuroimaging. 2016;252:36–39. PubMed CrossRef
van Lutterveld R, Varkevisser T, Kouwer K, et al. Spontaneous brain activity, graph metrics, and head motion related to prospective post-traumatic stress disorder trauma-focused therapy response. Front Hum Neurosci. 2022;16:730745. https://www.frontiersin.org/articles/10.3389/fnhum.2022.730745. Accessed July 17, 2023. PubMed CrossRef
Zimmerman M, Martinez JH, Young D, et al. Severity classification on the Hamilton Depression Rating Scale. J Affect Disord. 2013;150(2):384–388. PubMed CrossRef
Marx BP, Lee DJ, Norman SB, et al. Reliable and clinically significant change in the Clinician-Administered PTSD Scale for DSM-5 and PTSD Checklist for DSM-5 among male veterans. Psychol Assess. 2022;34(2):197–203. PubMed CrossRef
Thom R, Silbersweig DA, Boland RJ. Major depressive disorder in medical illness: a review of assessment, prevalence, and treatment options. Psychosom Med. 2019;81(3):246–255. PubMed CrossRef
Tremblay MS, Aubert S, Barnes JD, et al; SBRN Terminology Consensus Project Participants. Sedentary Behavior Research Network (SBRN) - Terminology Consensus Project process and outcome. Int J Behav Nutr Phys Act. 2017;14(1):75. PubMed CrossRef
Paluch AE, Bajpai S, Bassett DR, et al; Steps for Health Collaborative. Daily steps and all-cause mortality: a meta-analysis of 15 international cohorts. Lancet Public Health. 2022;7(3):e219–e228. PubMed CrossRef
Boudreaux BD, Schenck JA, Chu Z, et al. Effectiveness of fitbit activity prompts in reducing sitting time and increasing physical activity in university employees: a randomized controlled trial. J Meas Phys Behav. 2022;5(3):178–184. CrossRef
Simpson HB, Maher MJ, Wang Y, et al. Patient adherence predicts outcome from cognitive behavioral therapy in obsessive-compulsive disorder. J Consult Clin Psychol. 2011;79(2):247–252. PubMed CrossRef
Freedland KE. Pilot trials in health-related behavioral intervention research: problems, solutions, and recommendations. Health Psychol. 2020;39(10):851–862. PubMed CrossRef