Meditation, Cognitive Functioning, and Indian Army Veterans

Amendment Rules 2012, dated October 04, 2012, Government of India has defined veterans

as those persons who has served in any rank whether as a combatant or non combatant in the

Regular Army, Navy, and Air Force of the Indian Union, and who has been retired or relieved

or discharged from such service at his own request or being relieved by the employer after

earning his or her pension [1].

US Armed Forces has defined veteran as a person who has served in the active military naval,

or air service and who was discharged or released under conditions other than dishonourable

(Title 18 of the Code of Federal Regulations) [2].

Similarly, NHS England stakeholder engagement survey questionnaire defines veteran as a

person who has been a serving member of the British armed forces for a day or more.

According the question, the 'ex-service personnel' means the same thing when the word,

'veteran' or 'armed forces experiences', is used including the reservists and regulars [3].

Post-traumatic stress disorder (PTSD) is an anxiety disorder following very stressful,

frightening, or distressing events. The condition is caused by exposure to life threatening

situations which include clusters of re-experiencing, avoidance, and hyper-arousal [4]. It has

also been conceptualized as a disorder of memory centred on etiological traumatic events [5].

This condition is associated with high rates of morbidity and mortality and is the most

common sequelae in veterans returning from combat. Prevalence of PTSD has been found as

high as 12% even after 45 years of combat among older World War II and Korean War

veterans [10].

Several studies have found that veterans diagnosed with PTSD showed decline in sustained

attention, learning, memory, and executive functioning [6-9]. Available studies on

neuroimaging data suggested significant reductions in hippocampal volume making it as a

major risk factor for memory impairment in PTSD [11-13]. Similarly, the diminished activity

of rostral anterior cingulate cortex (rACC) has been found to be inversely correlated with

PTSD symptoms resulting into impairment of emotion, motivation, and attention [14-16].

Meditation is defined as a group of emotional and attentional regulatory practices wherein

mental and bodily related functions are affected by engaging a specific attentional set. Among

all types of meditation styles, attention regulation is a central feature [19]. Depending on how

the attentional resources are directed, meditation styles are classified into two categories -

Focussed Attention (FA) and Open Monitoring (OM) [20, 21]. While focussed attention (FA)

involves focusing of attention on an object in a sustained manner, open monitoring (OM)

involves non reactive monitoring of the content of ongoing experience, primarily as a means

to become reflectively aware of the nature of emotional and cognitive patterns [21].

In the study done by Lutz and colleagues [22], three months of Vipasana meditation, a form

of focussed attention (FA), has improved the ability to sustain attention among novice

meditation practitioners in the age range 22-64 years [22]. Similarly, studies evaluating the

efficacy of long term meditation practices have shown enhanced activity in fronto-parietal,

cerebellar, temporal, parahippocampal, and posterior occipital cortex during the meditation

among in long term meditation practitioners. And these areas have been implicated in a

variety of memory tasks utilizing fMRI [29].

Existing studies are majorly done on US, UK, and Korean veterans, to our knowledge, no

studies to date have documented the effect of meditation in improving the attention among

Indian Army Veterans.

With this background, the present study has been designed to longitudinally study the

subjects before and after a meditation training program to determine if there are long term
effects of such a program on sustained attention and memory among Indian Army Veterans

who have been exposed to combat during their services.

Since attentional network in the brain such as frontal lobe structure as well as anterior

cingulate cortex have been found to be activated during the meditation practices [17, 18]

along with the parahippocampal region [29], based on these findings, we hypothesize that

there would be improvement in sustained attention and memory after the meditation training

among the veterans.

Materials and Methods

Participants:

In the proposed study, 100 male veterans with PTSD in the age range 35 - 60 years who have

been relieved from their regular services in Indian Army will be recruited from the

Directorate of Indian Army Veterans, Delhi Cantonment, Delhi.

The veterans will be randomly allocated to two groups, experimental group consisting of 50

participants and the waitlisted control group with same sample size and comparable ages.

Veterans will not be included if they will have experienced head trauma (loss of

consciousness for more than 30 minutes), central nervous system disease, or systemic

medical illness. In addition, assessed by the Structured Clinical Interview for DSM-III-R

Diagnoses [23], veterans diagnosed with current (i.e. previous 3 months) alcohol or substance

disorders, lifetime history of bipolar or psychotic disorders, mood disorder with psychotic

symptoms, borderline or antisocial personality disorders, sub threshold manifestations of

PTSD, or PTSD preceding military service will be excluded from the study participants.

Further, in addition to above, those using beta-blocking medications will also be excluded
because of possible interference with psychological measure. And, only those sample will be

recruited who have no prior meditation experience. The meditation session will be taken by a

certified meditation teacher. The signed informed consent will be obtained from the study

participants.

Design

The proposed study will be longitudinal study of five months, lasting for 20 weeks,

implementing a focused attention meditation technique, Sahaj Samadhi Meditation, assessing

the sustained attention and memory among the veterans. The Sahaj Samadhi Meditation is a

concentrative form of meditation where attention is focused on breath and mantra [24].

Experimental group Control

Pre-Assessment 1. PTSD Checklist- 1. PTSD Checklist-

Military Version Military Version

2. Combat Exposure 2. Combat Exposure

Scale Scale
3. Continuous Visual 3. Continuous Visual

Memory Test Memory Task

4. Continuous 4. Continuous

Performance Task Performance Task

Conditions Meditation training 12 week Quiet sitting with comparable

time
Post-Assessment 1. Continuous Visual 1. Continuous Visual

Memory Task Memory Task

2. Continuous 2. Continuous

Performance Task Performance Task

Fig. 1. Diagram showing the Pre-Post Control design of the study.

Week 1-4 Week 5-16 Week 17-20

Pre assessments Meditation Training Post assessments

20 minute two times a day

for seven days a week

Fig. 2. Diagram showing the timeline of the proposed study.

Assessment

Assessments will be done post randomization, and one week before and after the training

session using the following measures:

1. Corner's Continuous Performance Test which is a test to measure sustained attention.

The test involves computerized administration including the scoring of commission

and omission errors. In the test, alphabets are displayed, and the respondent is asked

to press the space key when any letter except the letter X appears on the screen.

Pressing letter X is a commission error, and not pressing for any of the other letters is

an omission error. The administration procedure requires approximately 15 minutes

[25].
2. Continuous Visual Memory Test is a test, administered individually, to assess ability

to learn and remember visually presented information. The test consist of three task

conditions - acquisition, delayed recognition, and visual discrimination.

In acquisition task, 112 abstract drawings are there which are difficult to encode in a

verbal fashion. Each of the drawings are presented for 2 seconds. Among the 112

stimuli, each of the seven of the pictures are repeated six times at random intervals.

During the acquisition trial, the subject has to indicate for each picture whether it is
 new or whether it has been presented previously. The Total score is the number of

correct (“old”) responses to recurring items plus the number of correct (“new”)

responses to nonrecurring items. After a 30-minute delay, the subject is given a

recognition trial during which seven pages are presented consecutively, each

containing seven drawings from the acquisition trial, including six nonrecurring items

and one of the recurring items. The subject then has to indicate which of those seven

drawings is the previously recurring item, resulting in a Delayed Recognition score

(0–7). At the end of the test, participants are asked to match each of the seven

recurring items to visible targets, resulting in a Visual Discrimination score [26].

3. Combat Exposure Scale to assess the nature and severity of exposure to traumatic

combat experience [27].

4. PTSD will also be assessed with PTSD Checklist-Military version [28]. It comprises

of three sub scales - Re-experiencing, Avoidance, and Hyperarousal.

(The last two assessments will be done only at the baseline).

Intervention

Participants, in the experimental group, will be taught Sahaj Samadhi Meditation for 20

minutes, two times a day, and seven days a week for twelve weeks. The waitlisted control

group participants will be asked to sit quiet with their spine erect and eyes closed, and will be

allowed random thoughts to pass through their mind without modifying them. They will also

be told to avoid modifying their breath or being aware of their breathing. There will be no

other activity. They will be taught the meditation after the training session gets completed.

Data Analysis
2*2 Mixed ANOVA will be performed on the task response time and errors (commission and

omission errors) in Continuous Performance Test, and on the total and delayed recognition

scores in the Continuous Visual Memory Test.

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