Mindful breathing: Healing or hindrance for posttraumatic stress disorder survivors: A mental health professional’s standpoint

Dear Editor, Posttraumatic stress disorder (PTSD) is a mental health condition that can develop after exposure to a traumatic event like actual or threatened death, serious injury, or sexual violence.[1] Individuals who have experienced or witnessed a traumatic event may experience negative alterations in mood, cognition, and arousal; these could include persistent negative mood states, irritability, heightened anxiety, hypervigilance, detachment, and even dissociation. They also develop intrusive symptoms such as recurring memories, flashbacks, and nightmares and may exhibit avoidance symptoms to prevent distressing thoughts and feelings. Pharmacological, psychotherapeutic, and psychosocial interventions are currently used to treat PTSD. The latest evidence provides compelling evidence in favor of using trauma-focused therapies as the recommended course of treatment. These therapies include cognitive processing therapy, prolonged exposure therapy, eye movement desensitization and reprocessing, and others. In addition, the use of medications such as selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors has been most beneficial in reducing PTSD symptomology.[2] Mindfulness has its origins deeply rooted in Indian spiritual traditions such as Buddhism and Yoga. The Buddhist concept of Sati (mindfulness) serves as a cornerstone of practices such as Vipassana meditation, emphasizing present-moment awareness. Similarly, Patanjali’s Yoga Sutras outline techniques such as Pratyahara (withdrawal of senses) and Dharana (concentration), which are foundational to mindfulness. Mindfulness-based interventions (MBIs) are one of the most used positive psychology interventions drawn from Eastern cultures and have gained popularity today. Mindfulness is a technique that involves being aware of one’s thoughts, feelings, and bodily sensations without any judgment. It is a powerful tool for coping with stress and negative emotions and improving well-being. Different MBIs include meditation, yoga, breathing, body scanning, journaling, visualization, and various mindful movements. Mindful breathing (MB) is one of the core techniques for practicing mindfulness. It involves directing one’s attention to the natural rhythm or flow of breath, allowing them to cultivate a heightened sense of self and acknowledge and accept their thoughts, emotions, and bodily sensations. Practicing MB can lead to a greater sense of control, heightened self-awareness, increased calmness, inner peace, and happiness, as well as an improved ability to cope with stress.[3] While mindfulness has shown promising results in treating anxiety and promoting emotional regulation and well-being,[4] its effectiveness with people diagnosed with PTSD is still being explored due to the nature of the disorder. The association between PTSD and MB lies in the potential for MB techniques to alleviate some of the symptoms associated with PTSD. However, it is essential to acknowledge that MB may not be appropriate for all those with PTSD, as it has the potential to trigger traumatic memories or exacerbate distress, especially if done without proper guidance or in an unsafe environment. This editorial delves into the intricate relationship between MB and PTSD. By examining both the benefits and drawbacks, we aim to provide a nuanced understanding of the role of MB in the lives of individuals affected by PTSD. Mindfulness-based methods are believed to address various key aspects of PTSD, such as avoidance, heightened arousal, emotional detachment, negative emotions like shame and guilt, and dissociation. Lang et al. identified three elements of mindfulness that could support recovery from PTSD: attention, a mindful cognitive approach, and nonjudgmental acceptance. They explain how consciously shifting attention to the present moment can enhance attentional control and potentially reduce focus on trauma-related stimuli. A mindful cognitive approach can potentially reduce repetitive and intrusive thoughts, which may lead to lower levels of anxious arousal and loss of pleasure. A nonjudgmental perspective might encourage individuals to confront fear-inducing stimuli, thereby reducing avoidance.[5] MB involves focusing on the breath and engaging in slow, deliberate breathing patterns, allowing individuals to activate the body’s relaxation response, decreasing physiological arousal, and fostering a sense of calmness. Concentrating on the breath is especially beneficial as it acts as a point of reference-something you can redirect your focus whenever you feel overwhelmed or consumed by negative feelings. Furthermore, MB can improve coping mechanisms and emotional regulation, which can break the cycle of emotional reactivity and rumination. King et al. found that after undergoing mindfulness-based cognitive therapy, there was a notable decrease in self-blame thoughts and emotional numbness. This indicates that mindfulness may enhance the ability to accept and regulate emotions, as well as accept trauma-related thoughts, ultimately leading to reduced feelings of shame, self-blame, and emotional instability. These findings are especially significant, as recent models have highlighted the role of shame and guilt-based thoughts in the onset and persistence of PTSD.[6] Mindfulness-based methods can also be used to address dissociative symptoms. Corrigan suggests that mindfulness and dissociation exist on opposite ends of a spectrum, and research has shown that traits of mindfulness, such as awareness and nonjudgment, are associated with lower levels of dissociation.[7] The rhythmic nature of breathing can promote a sense of rhythm and stability, helping individuals feel more grounded and centered amidst the chaos of their symptoms. In addition, with consistent practice, individuals may be better equipped to manage these symptoms and regain control over their thoughts and emotions. Although research indicates that MBI is beneficial for most individuals, there have also been cases of individuals reporting unpleasant experiences and harm resulting from the practice. A systematic review of 83 studies published from 1975 to 2019 focused on adverse events associated with meditation practice. Out of these studies, 55 reported at least one type of meditation adverse event. The prevalence of MAEs was 8.3%, with experimental studies showing a prevalence of 3.7% and observational studies showing a higher prevalence of 33.2%. The adverse events reported included somatic, psychiatric, and neurological/cognitive symptoms, with common symptoms being anxiety, depression, cognitive anomalies, stress, and hallucinations. Most AEs occurred during or immediately after meditation practice or intervention. The review also emphasizes the importance of understanding participant vulnerabilities and how appraisals may moderate adverse events.[8] Unpleasant experiences refer to experiences during mindfulness practices that individuals find challenging, uncomfortable, or distressing. It includes difficult emotions such as anxiety, sadness, or anger that arise during the practice. In some cases, introspection and increased bodily awareness associated with MB may trigger unwanted memories or physical sensations that mirror a previous traumatic event, causing significant disruption and distress; this is known as vicarious trauma, secondary trauma, or re-traumatization. This leads to feelings of helplessness and being trapped and potentially gives rise to dissociative symptoms. Trauma survivors actively try to avoid or distract themselves from thoughts or feelings related to trauma, but when forced to relax, their defenses might relax, and the images, sensory associations, and bodily sensations return, causing increased distress. Racing thoughts, intrusive memories, and external distractions can easily divert attention, leading to frustration, self-criticism, and potentially worsening feelings of overwhelm. In a study conducted among university teachers and students, about two-thirds of participants reported experiencing unpleasant events associated with mindfulness practice during the course. The unpleasant experiences reported included difficult emotions, thoughts, sensations, and negative feelings about mindfulness practice. Some participants also described self-criticism regarding their mindfulness practice, such as not doing it correctly or not practicing enough, leading to feelings of guilt, frustration, and annoyance.[9] The Dharmatrata Meditation Scripture, one early collection of Buddhist meditation techniques, reports that if the meditation is not carried out properly, the mind can become unstable, restless, or even confused, and the meditator feels dull, confused, and hollow.[10] Another study suggests that meditation can act as a stressor in vulnerable patients and cause a brief psychotic episode with a variety of symptoms. In addition, it introduces the term “Qi-gong Psychotic Reaction,” which is used in Chinese medicine to describe a mental state that can result from specific kinds of meditation exercises[11] Therefore, for individuals with PTSD, traditional mindfulness practices might not be the best starting point. In India, a participant in a Vipassana retreat reported severe emotional distress, including flashbacks, due to unprocessed childhood trauma, which led to a state of dissociation rather than relaxation. Another example involved a patient reporting heightened anxiety after a body scan exercise, as it triggered somatic memories linked to past abuse. These experiences underscore the need for trauma-sensitive adaptations and professional oversight to ensure safety in vulnerable populations.[12] A trauma-informed approach that prioritizes safety and a sense of control. This approach acknowledges the unique psychosocial needs and sensitivities of trauma survivors, offering tailored techniques and personalized treatments. Trauma-informed meditation integrates elements of mindfulness with trauma-sensitive principles, emphasizing gentle exploration, grounding techniques, and self-compassion. Trained mental health professionals guide individuals through meditation exercises, providing support and validation while fostering a sense of agency and control by helping identify potential triggers and developing coping strategies to manage them. Techniques include grounding exercises (focusing on external stimuli such as sounds or textures) and modifications to traditional practices like body scans, allowing participants to skip steps if discomfort arises. This allows individuals to gradually explore their internal experiences, cultivate resilience, and navigate their trauma-related symptoms with greater ease. This approach honors the complexities of trauma recovery, offering a holistic framework that respects individuals’ boundaries and promotes healing at their own pace. In Indian mental health settings, NIMHANS integrates trauma-sensitive yoga practices such as pranayama (breathing exercises) and shavasana (relaxation techniques) to help survivors reconnect with their bodies safely. These culturally adapted techniques reduce re-traumatization and enhance accessibility.[13] PTSD manifests differently in everyone, what works for one person might not be suitable for another. While MB can help treat certain symptoms of PTSD, further research is crucial to solidify our understanding of MB’s role in PTSD treatment. This includes investigating the optimal frequency, duration, and specific techniques that may be most beneficial for different cases of PTSD. MBIs are particularly effective for individuals with mild to moderate symptoms of anxiety, depression, or PTSD. Gu et al. noted that individuals with high emotional awareness tend to benefit the most, while those with dissociative tendencies or active trauma may experience challenges.[14] In addition, mindfulness practices are most effective when introduced gradually and in structured environments, particularly for those new to the concept. A personalized approach is essential, tailoring practices to individual psychosocial needs and preferences. This may involve incorporating MB exercises into existing treatment plans, such as cognitive-behavioral therapy, or using it as a standalone practice for those who find it helpful. By continuing to explore and refine the use of mindfulness in trauma recovery, we can empower individuals with PTSD with a wider range of tools and techniques on their path toward healing and well-being. Author contribution KM (60%) Contributed to writing a manuscript draft, literature search. PS (40%) Contributed to the review and content of the manuscript.