Applied Psychology OPUS

The Effect of Mindfulness-Based Stress Reduction on Anxiety and Aggression

Prairna Sethi

Mindfulness Based Stress Reduction (MBSR) is a popular group therapy program in which participants are taught about practicing mindfulness (Kabat-Zinn, 2003; Kabat-Zinn, 1990). Mindfulness is a traditional Buddhist state of being that fosters the ability to pay attention to the present moment on purpose and without any judgment (Eberth & Sedelmeir, 2012; Baer, 2003; Kabat-Zinn, 1990). Key characteristics of a mindful state include the self-regulation of attention, which refers to the ability to sustain attention, and non-judgmentally accept the present experience, which often occurs through mindfulness practices such as meditation (Eberth & Sedelmeier, 2012; Kabat-Zinn, 1990). The use of mindfulness is a key component of MBSR and may be beneficial in reducing symptoms associated with anxiety (Eberth & Sedelmeir, 2012).
While mindfulness is the underlying mechanism that allows MBSR to work, the structure of the therapy program also plays a role. MBSR is an 8–10 week group program with 2.5 hour sessions per week, in groups varying between 10 and 40 participants. The group sessions are conducted by a leader who is trained in mindfulness, and cover exercises and topics that are examined within the context of mindfulness (Eberth & Sedelmeir, 2012; Grossman et al., 2004; Kabat-Zinn, 1990). These exercises and topics focus on the progressive acquisition of mindfulness through three primary modalities: (1) yoga, a posture based exercise that combines physical and mental practices; (2) meditation, an exploration of one’s own consciousness through focused attention;  (3) body scans, which involve meditation while focusing on specific body parts and experiencing the feeling and location of the body in relation to their thoughts, emphasizing the importance of present awareness and focused attention (Eberth & Sedelmeier, 2012; Grossman et al., 2004; Kabat-Zinn, 1990). The structured and comprehensive program teaches participants how to continue practicing mindfulness after the intervention is over, prolonging the potential benefits of the therapy, thus making it a popular choice for many individuals, including those suffering from anxiety (Kabat-Zinn, 2003; Kabat-Zinn, 1990).

Many individuals suffering from Generalized Anxiety Disorder (GAD) feel a persistent and excessive worry over everyday activities, even when there is no reason for concern (American Psychiatric Association, 2013). In several ways, GAD limits individuals from living their lives normally, often times through the presence of panic attacks which are characterized by a sudden extreme fear or worry of losing control even when there is no real danger (American Psychiatric Association, 2013). Panic attacks manifest in many ways and can cause an increase in heart rate, dizziness, sweating, and breathing problems (American Psychiatric Association, 2013). The disruptive and difficult nature of GAD and panic attacks makes it imperative to explore new methods reducing the prevalence of these anxiety symptoms, so that individuals suffering from anxiety may be able to live high quality lives.

MBSR is hypothesized to impact anxiety by changing individuals’ relationship to thoughts (Teasdale, Segal, & Williams, 1995). Teasdale et al. (1995) suggest that mindfulness allows adults to take a decentered approach to thoughts that elicit worry and panic, meaning anxious thoughts become temporary and are no longer viewed as reflections of reality. For example, thoughts can be seen at transient; they come and go, and are not a static part of one’s identity (Teasdale et al., 1995). In turn, this leads to reductions in rumination and increases in emotional regulation (Lykins & Baer, 2009; Ramel, Goldin, Carmona, & McQuaid, 2004; Teasdale, Segal, & Williams, 1995). As a result, mindfulness gives individuals the ability to learn to identify and manage their feelings of anxiety and learn how to react to them effectively (Hazlett-Stevens, 2012). These findings support the hypothesis for how MBSR can impact anxiety, however, there is limited research on the relation between the two variables.

There is a growing body of research examining the relation between MBSR and anxiety. While some studies suggest that MBSR does have a positive impact in reducing anxiety (Hofmann, Sawyer, Witt, & Oh, 2010; Grossman et al., 2004; Baer, 2003; Kabat-Zinn, 1990), others have found that while MBSR has some impacts, methodological flaws across studies lead to inconclusive evidence (Toneatto & Nguyen, 2007). Although the literature is inconclusive on the relation between MBSR and anxiety, the evidence thus far provides support for future research to study the impacts of MBSR on anxiety. Thus the present literature review will examine the relation between MBSR and anxiety.

MBSR and Anxiety

When MBSR was first developed by Jon Kabat-Zinn (1979), it was used to treat adults suffering from both mental and physical chronic pain that was a side effect of illnesses, such as cancer (Baer, 2003; Kabat-Zinn, 1990). Specifically, the literature examining the impacts of MBSR found that it reduces anxiety and overall distress in women suffering from breast cancer (Zainal, Booth & Huppert, 2013). From these findings, MBSR has transitioned from a medical framework to the clinical environment in the hopes of demonstrating the intervention’s efficaciousness in treating clinical disorders regardless of comorbid illnesses (Hazlett-Stevens, 2012; Zainal et al., 2013). To support this, Hazlett-Stevens (2012) found that MBSR has a strong impact in treating anxiety disorders, regardless of comorbid medical conditions. These findings suggest that MBSR may be an effective treatment for adults suffering from anxiety.

Specifically, it has been theorized that through mindfulness practice, the constant awareness of the present moment interrupts the thought processes that would otherwise elicit these feelings of fear that precipitate panic attacks (Toneatto & Nguyen, 2007; Kabat-Zinn, 1990). Thus mindfulness refocuses thoughts and helps anxious individuals focus on the present moment instead of their feelings of worry (Toneatto & Nguyen, 2007; Kabat-Zinn, 1990). This suggests that the mindfulness component of MBSR would help anxious individuals be aware of their present thoughts, thus preventing panic attacks and making it easier for them to live their day to day lives (Toneatto & Nguyen, 2007). Additionally, the application of mindfulness techniques for individuals suffering from anxiety causes the anxiety itself to become the focus of their present, nonjudgmental awareness and allows them to learn how to deal with it in a positive, appropriate way (Kabat-Zinn, 1990). For example, sustained nonjudgmental awareness associated with mindfulness may increase an individual’s ability to recognize and decrease rumination and worry, both of which maintain feelings of anxiety, and increases comfort in unfamiliar situations (Hazlett-Stevens, 2012; Lykin & Baer, 2009; Teasdale et al., 1995; Ramel et al., 2004). Furthermore, there is evidence to suggest that MBSR helps individuals regulate their emotions, which in turn helps decrease instances of rumination and worry that are associated with anxiety (Goldin & Gross, 2010). These findings lead researchers to believe that mindfulness practice through MBSR allows for individuals to engage in sustained, nonjudgmental attention to anxiety without attempts to avoid it and thus may lead to reductions in anxiety and panic attacks (Goldin & Gross, 2010; Hazlett-Stevens, 2012; Toneatto & Nguyen, 2007).

Although limited in scope, studies have found that MBSR is connected to a reduction of anxiety (Baer, 2003; Eberth & Sedelmeir, 2012; Goldin & Gross, 2010; Grossman et al., 2004; Hazlett-Stevens, 2012; Hofmann, et al., 2008; Kabat-Zinn, 1990; Vollestad, Sivertsen, & Nielsen, 2011;  Zainal et al., 2013). When examining the impact of MBSR on anxiety, Kabat-Zinn (2003; 1990) has consistently found a significant decrease in anxiety and in the frequency and intensity of panic attacks following an MBSR intervention, as well as increased left side activation in the brain which is associated with positive moods and decreased anxiety. Similarly, moderate decreases in anxiety have been recorded in many studies, especially when the subjects have preexisting anxiety disorders (Baer, 2003; Goldin & Gross, 2010; Hazlett-Stevens, 2012; Hofmann et al., 2010; Vollestad et al., 2011). However, the vast amount of methodological flaws across studies lead some researchers to claim that the impact of MBSR on anxiety need to be measured more systematically (Baer, 2003; Toneatto & Nguyen, 2007), warranting further investigation of the impacts of MBSR on reducing anxiety.  

While the majority of the literature suggests that MBSR does have a positive effect on decreasing anxiety (Baer, 2003; Hofmann et al., 2010; Kabat-Zinn, 1990), some studies examining the effects of MBSR on anxiety have found no significant change in anxiety from before the intervention to after the intervention was administered (Toneatto & Nguyen, 2007; Weiss, Nordlie, & Siegel, 2005). These inconclusive results across studies may be a result of methodological issues in the literature, such as a lack of experimental conditions, thus making it difficult to confirm a causal link between MBSR and anxiety reduction (Baer, 2003; Hofmann et al., 2010; Toneatto & Nguyen, 2007).  The conflicting evidence provides support for further research to be done concerning the relation between MBSR and anxiety in order to draw more concrete conclusions about the treatment.

Methodological Flaws

Due to methodological flaws, results across studies measuring the relation between MBSR and anxiety are inconclusive (Baer, 2003; Goldin & Gross, 2010; Hazlett-Stevens, 2012; Hofmann et al., 2010; Toneatto & Nguyen, 2007; Vollestad, Sivertsen, & Nielsen, 2011). Although studies show that MBSR can reduce anxiety, very few of these studies have an active control group, meaning that there is no comparison group that is receiving no treatment at the same time the experimental group is receiving MBSR (Goldin & Gross, 2010; Grossman et al., 2004; Hazlett-Stevens, 2012; Hofmann, et al., 2010; Kabat-Zinn, 1990; Vollestad et al., 2011).  Instead, these studies have used a waitlist control group or a treatment as usual control group, meaning that half of the subjects were assigned to an MBSR group while the other half were placed on a waitlist for the intervention, or continued their course of usual treatment while the experimental group received the MBSR intervention (Hofmann et al., 2010). This contributes to methodological issues because individuals assigned to a waitlist control group eventually receive the treatment, and may see reductions in their anxiety symptoms over time before the intervention, and thus confound the results of the study (Hofmann et al., 2010; Toneatto & Nguyen, 2007; Baer, 2003). For example, Vollestad et al. (2011) conducted a randomized controlled trial, however their use of a waitlist control group limits the validity of their findings that MBSR reduces anxiety. Furthermore, Hazlett-Stevens (2012) conducted a case study, eliminating the possibility for a control group and limiting the generalizability of the results. Due to lack of an active control group across studies, it is difficult to determine a causal relation between MBSR and anxiety, and thus generalize the results to other populations, as there is nothing to compare the results of the experimental group to (Hofmann et al., 2010; Toneatto & Nguyen, 2007; Baer, 2003).

Additionally, studies supporting MBSR as an effective way to reduce anxiety often acknowledge that there were various confounds that were not controlled for across studies (Toneatto & Nguyen, 2007; Baer, 2003). These confounds include the lack of control for variables such as demand characteristics, where participants alter their behavior to fit expectations of the study, and the placebo effect, in which participants’ symptoms begin to decrease because they are receiving any type of intervention, not necessarily MBSR (Baer, 2003; Hazlett-Stevens, 2012; Hofmann et al., 2010; Toneatto & Nguyen, 2007). Other confounds include interacting in a group setting, varying expectations of instructors, the passage of time, and the individual motivation of each participant (Baer, 2003; Hazlett-Stevens, 2012; Hofmann et al., 2010; Toneatto & Nguyen, 2007). Although these confounds result in the inability to isolate MBSR as the sole cause for reduction in anxiety, many studies still conclude that MBSR has an impact on anxiety reduction (Baer, 2003; Toneatto & Nguyen, 2007). Thus, further systematic research needs to be done in order to draw a concrete conclusion about the relation between MBSR and anxiety.

While it is acknowledged that there is a link between the mechanism of mindfulness and reduced anxiety, methodological flaws hinder the ability to indicate whether MBSR causes reductions in anxiety due to the lack of controlled conditions across studies (Baer, 2003; Eberth & Sedelmeir, 2012; Goldin & Gross, 2010; Grossman et al., 2004; Hazlett-Stevens, 2012; Hofmann, et al., 2008; Kabat-Zinn, 1990; Vollestad et al., 2011; Zainal et al., 2013). Thus, further empirical research and randomized controlled trials are needed to achieve a concrete conclusion regarding the relation between MBSR and anxiety.
   
Conclusion

Throughout the literature, many studies have found that there is a positive effect of MBSR in reducing anxiety (Baer, 2003; Eberth & Sedelmeir, 2012; Goldin & Gross, 2010; Grossman et al., 2004; Hazlett-Stevens, 2012; Hofmann, et al., 2008; Kabat-Zinn, 1990; Vollestad et al., 2011; Zainal et al., 2013). The mindfulness component of MBSR has been found to be beneficial in reducing symptoms of worry associated with anxiety by helping individuals focus their attention on more present thoughts, and control their emotions and tendency towards worry and rumination (Goldin & Gross, 2010; Hazlett-Stevens, 2012; Vollestad et al., 2011; Zainal et al., 2013).

While there is support for why the mindfulness component of MBSR would lead to reductions in anxiety, the methodological issues surrounding the literature make it difficult to isolate whether the intervention itself is having an effect, or whether confounding variables are influencing results (Baer, 2003; Toneattoe & Nguyen, 2007). Often times, these variables are not controlled for and may be responsible for the changes in anxiety instead of MBSR (Baer, 2003; Toneatto & Nguyen, 2007). This means that there are no studies demonstrating a clear causal link between MBSR and anxiety, or between what mechanism lead to the change in anxiety.

These findings highlight the need for further research to be done, especially randomized control trials. These experimental trials are needed in order to determine a causal relation between MBSR interventions and anxiety, preferably with an active control group instead of a waitlist control group design. The research thus far supports a strong correlation between MBSR interventions in reducing anxiety, however there is no support for a causal relationship, which emphasizes the need for experimental research to be conducted (Baer, 2003; Eberth & Sedelmeir, 2012; Goldin & Gross, 2010; Grossman et al., 2004; Hazlett-Stevens, 2012; Hofmann, et al., 2008; Kabat-Zinn, 1990; Vollestad et al., 2011; Zainal et al., 2013). While it is difficult to control for all confounds due to the complex, multimodal nature of MBSR, future studies should aim to isolate as many confounds as possible in order to see the outcomes of MBSR on anxiety. MBSR may be incredibly beneficial for adults struggling with anxiety because of the unique characteristics such as mindfulness, and thus has the potential to help adults cope with their anxiety and reduce the panic and worry they face in their everyday lives, and should therefore be studied experimentally to further understand the potential impacts.

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