Journal of Cognitive Psychotherapy: An International Quarterly

Volume 25, Number 2 • 2011

Concurrent Relations Between

Mindful Attention and Awareness
and Psychopathology Among
Trauma-Exposed Adults: Preliminary
Evidence of Transdiagnostic Resilience
Amit Bernstein, PhD
Galia Tanay, MA
University of Haifa

Anka A. Vujanovic, PhD

Boston University School of Medicine

This study evaluated the concurrent associations between mindful attention and awareness
and psychopathology symptoms among adults exposed to trauma. Participants included
76 adults (35 women; Mage 5 30.0 years, SD 5 12.5) who reported experiencing one or more
traumatic events. As hypothesized, levels of mindful attention and awareness were significantly
negatively associated with levels of posttraumatic stress symptom severity, psychiatric multi-
morbidity, anxious arousal, and anhedonic depression symptoms, beyond the large, positive
effect of number of traumatic event types. In addition, statistical evaluation of the phenome-
nological pattern of these associations showed that high levels of mindfulness exclusively co-
occurred with low levels of psychopathology symptoms or high rates of mental health; whereas
low levels of mindfulness did not similarly exclusively co-occur with either low or high levels
of psychopathology symptoms but rather co-occurred with a broad range of symptom levels.
Findings are conceptualized in terms of transdiagnostic resilience and discussed in regard to
extant empirical and theoretical work.

Keywords: mindfulness; mindful attention; traumatic stress; psychopathology; transdiagnostic

T
here is an ongoing, field-wide effort to study malleable risk and protective factors re-
lated to posttraumatic stress disorder (PTSD; e.g., Elwood, Hahn, Olatunji, & Williams,
2009). Exposure to traumatic life events is also related to other various forms of psycho-
pathology, including a high prevalence of comorbid disorders among both trauma-exposed indi-
viduals and those with PTSD (e.g., Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). A growing
body of transdiagnostic scholarship has thus called for study of the common risk and protective
processes underlying trauma-related psychopathology (Harvey, Watkins, Mansell, & Shafran,
2004). Although we know much about risk markers associated with PTSD and other forms of

© 2011 Springer Publishing Company 99

DOI: 10.1891/0889-8391.25.2.99
100 Bernstein et al.

t­ rauma-related psychopathology (e.g., King, Vogt, & King, 2004), there is a relative dearth of em-
pirical knowledge regarding malleable risk and resilience factors and processes underlying the
development of psychopathology and recovery following trauma exposure (Elwood et al., 2009;
Feldner, Monson, & Friedman, 2007). However, this clinical knowledge is essential to advancing
more specialized trauma-related prevention and early intervention efforts (Litz, 2004; McNally,
Bryant, & Ehlers, 2003; Zvolensky, Schmidt, Bernstein, & Keough, 2006).
In recent years, various constructs have received increased study with respect to their po-
tential role(s) in the development and maintenance of trauma-related psychopathology (e.g.,
Elwood et al., 2009; Litz, 2004). One such theoretically and clinically promising variable is mind-
fulness (e.g., Batten, Orsillo, & Walser, 2005). There are various related conceptual or theoret-
ical perspectives on mindfulness and related operational definitions and measures (Baer, Smith,
Hopkins, Krietemeyer, & Toney, 2006; Bishop et al., 2004; Brown & Ryan, 2003; Demick, 2000;
Roemer & Orsillo, 2002; Zvolensky, Feldner, Leen-Feldner, & Yartz, 2005). One promising, con-
temporary conceptual model of mindfulness is focused on mindful attention and awareness (e.g.,
Follette, Palm, & Pearson, 2006). From this perspective, mindfulness may be conceptualized be-
haviorally as conscious attention to and awareness of the present moment and our experience of
that moment (Brown & Ryan). For the purposes of this article, hereafter we refer to this particular
conceptual definition and operationalization of mindfulness as mindful attention and awareness
to distinguish it from alternative conceptual perspectives on mindfulness (e.g., self-regulation of
attention and nonjudgmental acceptance; Baer, Smith, & Allen, 2004; Bishop et al.).
A growing body of research has documented clinically relevant associations between mind-
ful attention and awareness, specifically, as well as other conceptual and operational definitions
of mindfulness, more generally (e.g., present-oriented attention and nonjudgmental acceptance;
Baer et al., 2004), and various forms of psychopathology (e.g., Orsillo & Roemer, 2005). For ex-
ample, across cross-sectional and treatment studies, higher levels of mindfulness or greater mind-
fulness skills have been associated with lower levels of anxiety, depressive symptoms, substance
abuse, chronic pain, and borderline personality disorder (BPD) symptoms (Bond & Bunce, 2000;
Breslin, Zack, & McMain, 2002; Brown & Ryan, 2003; Hayes, Strosahl, & Wilson, 1999; Lynch,
Trost, Salsman, & Linehan, 2007; Ma & Teasdale, 2004; McBee, 2003; Parks, Anderson, & Marlatt,
2001; Teasdale et al., 2002; Vujanovic, Zvolensky, Bernstein, Feldner, & McLeish, 2007; Weissbecker
et al., 2002; Zvolensky, Solomon, et al., 2006). In addition to psychopathology, mindfulness has
also been linked to various indices of well-being (e.g., Brown & Ryan; Davidson et al., 2003;
Erisman & Roemer, 2010; Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008). Thus, one theoretically
and clinically promising element of the importance of mindfulness regarding psychopathology is
that mindfulness may be conceptualized as a transdiagnostic factor or process relevant to various
forms of psychopathology and well-being (e.g., Harvey et al., 2004; Hayes et al., 1999).
Furthermore, in more recent years, theoretical work and promising treatment models have
emerged implicating mindfulness (and acceptance) in trauma-related psychopathology, most no-
tably PTSD and its treatment (Batten et al., 2005; Follette et al., 2006; Walser & Westrup, 2007).
This work is rooted in the premise that mindfulness may promote resilience to and recovery from
traumatic stress exposure by several possible mechanisms. For example, mindfulness may coun-
teract processes theorized to potentiate and maintain posttraumatic stress symptoms, namely
chronic avoidance (e.g., avoidant-oriented coping, cognitive and affective suppression, affective
numbing) related to trauma-related thoughts, memories, affective states, and related physiolog-
ical cues. However, because of the novel, largely theoretical nature of the extant literature, our em-
pirical knowledge regarding relations between mindfulness and trauma-related psychopathology
symptoms, specifically, is lacking. Indeed, only two empirical studies have been published to date
that explicitly focused on delineating the relations between mindfulness and trauma-related symp-
toms. Vujanovic, Youngwirth, Johnson, and Zvolensky (2009) found, among 239 trauma-exposed
adults without current Axis I psychopathology, that the Accepting Without Judgment subscale of
 Mindfulness and Trauma 101

the Kentucky Inventory of Mindfulness Skills (KIMS; Baer et al., 2004) was significantly incre-
mentally (negatively) associated with posttraumatic stress symptoms; effects were observed be-
yond the variance accounted for by negative affectivity and number of trauma types experienced.
Vujanovic et al. (2009) also found that the KIMS Acting With Awareness subscale was incremen-
tally (negatively) associated with only posttraumatic stress–relevant reexperiencing symptoms;
no other KIMS subscale (e.g., Observing, Describing) was related to the PTSD-dependent mea-
sures. In a second study, Michal et al. (2007) evaluated the cross-sectional associations between
retrospectively reported childhood traumatic stress, depersonalization symptoms, and mindful
attention and awareness (as indexed by the Mindful Attention Awareness Scale [MAAS]; Brown
& Ryan, 2003). Michal et al. found large, significant (partial) correlations between levels of de-
personalization and mindful attention and awareness, after accounting for variance explained
by general psychological distress and age among a sample of medical students and a sample of
treatment-seeking nonmalignant pain patients in Germany.
Taken together, three interrelated gaps in our extant body of knowledge may justify initial
evaluation. First, despite strong theoretical advances and growing clinical application of mindful-
ness in the context of traumatic stress and related psychopathology, the empirical study of mindful
attention and awareness and levels of posttraumatic stress symptoms are strikingly lacking in our
extant literature (Vujanovic et al., 2009). Second, research to date indicates that (a) lower levels of
mindfulness are related to various forms of psychopathology (e.g., Vujanovic et al., 2007; Zvolensky,
Solomon, et al., 2006); (b) traumatic stress is associated with various forms of psychopathology
in addition to PTSD (Jacobsen, Southwick, & Kosten, 2001; Johnson, Cohen, Brown, Smailes, &
Bernstein, 1999; Shalev et al., 1998; Thompson et al., 2003); and (c) the co-occurrence of various
forms of psychopathology with PTSD is the modal phenomenology relative to unimorbid PTSD in
clinical and epidemiological research (e.g., Brown, Campbell, Lehman, Grisham, & Mancill, 2001;
Kessler et al., 1995). Nevertheless, there has been no study, to the best of our knowledge, focused
on the associations between mindful attention and awareness and various (transdiagnostic) forms
of psychopathology among trauma-exposed individuals beyond PTSD (e.g., anxiety, mood, psy-
chiatric multimorbidity). Third, we lack not only empirical data regarding an association between
mindful attention and awareness and psychopathology among those exposed to trauma stress, but
also basic phenomenological data regarding the nature of this putative association. Specifically,
mindful attention and awareness and psychopathology among individuals exposed to traumatic
stress may be related because elevated levels of mindfulness are protective and may result in develop-
ment of less psychopathology among trauma-exposed adults and/or in greater recovery or reduced
maintenance of psychopathology symptoms over time among trauma-exposed adults. In addition,
low levels of mindfulness may be associated with greater vulnerability to the development and/
or maintenance of psychopathology symptomatology among trauma-exposed individuals. These
forms of relations are not mutually exclusive per se (i.e., a variable may function as both risk and
protective factor), although evidence of one does not necessarily imply the other (Luthar, Cicchetti,
& Becker, 2000). Thus, mindfulness and psychopathology among trauma-exposed individuals may
be associated with vulnerability and/or resilience to psychopathology among trauma-exposed indi-
viduals. However, this core phenomenological characteristic of the putative association between
mindfulness and trauma-related psychopathology has not been tested empirically to date. Extant
theoretical work (Orsillo & Roemer, 2005) and initial empirical findings applying linear statistical
analyses (e.g., Vujanovic et al., 2009) may be interpreted to suggest that low levels of mindful-
ness may systematically covary with greater levels of vulnerability (i.e., greater levels of symptom-
atology); and in a similar fashion, elevated levels of mindfulness may systematically covary with
greater levels of resilience (i.e., lower levels of symptomatology) among trauma-exposed individu-
als. This knowledge is essential not only to understanding the basic nature of mindfulness and
trauma relations, but also to guiding clinical work integrating mindfulness within the context of
prevention and treatment of trauma-related psychopathology.
102 Bernstein et al.

The purpose of this study was thus to evaluate the concurrent associations between mindful
attention and awareness and psychopathology among adults exposed to trauma, as an initial test
to begin to address the aforementioned gaps in extant research. Prior to exploring the associations
between mindfulness and psychopathology symptoms among trauma-exposed adults, it was first
important to test the associations between traumatic stress and various forms of psychopathology
among trauma-exposed persons. This initial test is important to help justify conceptualizing the
identified forms of psychopathology as related to trauma. Thus, we first hypothesized that among
trauma-exposed adults, traumatic stress exposure severity (i.e., number of types of traumatic stress
events) will be associated with greater levels of posttraumatic stress symptom severity, positive cat-
egorical diagnostic status (i.e., presence of a psychiatric disorder[s]), greater levels of psychopa-
thology multimorbidity (i.e., number of psychiatric diagnoses), and higher levels of anxious arousal
and anhedonic depression symptoms. The aforementioned hypothesis is grounded in extant re-
search documenting the role of traumatic stress history and severity concerning psychopathology
and theorizing regarding the common role of traumatic stress for transdiagnostic forms of psycho-
pathology (Jacobsen et al., 2001; Johnson et al., 1999; Shalev et al., 1998; Thompson et al., 2003).
Second, we hypothesized that after accounting for variance explained by traumatic stress
exposure severity, mindful attention and awareness, as indexed by the MAAS, will be incremen-
tally associated with lower levels of posttraumatic stress symptom severity, negative categorical
diagnostic status, lower levels of psychopathology multimorbidity, and lower levels of anxious
arousal and anhedonic depression symptoms. The latter hypothesis is grounded in extant theo-
rizing indicating that levels of mindfulness ought to be negatively associated with the develop-
ment and maintenance of psychopathology symptoms among trauma-exposed persons (Follette
et al., 2006), and theorizing regarding the putative association between mindfulness and various
forms of psychopathology among at-risk individuals (e.g., Orsillo & Roemer, 2005).
Finally, we hypothesized that lower levels of mindfulness will co-occur with greater levels
of symptoms, and that greater levels of mindfulness will similarly co-occur with lesser levels of
symptoms. The latter hypothesis is grounded in initial theorizing that mindfulness may be asso-
ciated with vulnerability and resilience to the development and maintenance of symptomatology
following traumatic stress exposure.

Method
The sample consisted of 116 adults recruited for a larger study focused on smoking and emotion
(Vujanovic & Zvolensky, 2009). For this study, we examined the subsample of participants who
reported experiencing at least one traumatic life event. Approximately 66% of participants (n 5 76;
35 women; Mage 5 30.0, SD 5 12.5, range 5 18–60 years) self-reported experiencing one or more
traumatic events as indexed by the Posttraumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, &
Perry, 1997), consistent with prevalence of trauma in the general population (e.g., Kessler et al., 1995;
Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). In light of the very elevated rates of smoking
among trauma-exposed adults (Feldner, Babson, & Zvolensky, 2007), the fact that the sample was
composed of smokers may only minimally limit generalizability to the larger population of trauma-
exposed young adults. Furthermore, in light of evidence that smoking co-occurs with psychopa-
thology, study of trauma-exposed smokers serves to usefully increase the range of variability in levels
of psychopathology symptoms in the sample (Ziedonis et al., 2008). Such increased variability is
needed to meaningfully test the hypothesized associations (e.g., Tabachnick & Fidell, 2007). In light
of the fact that extant work evaluating associations between mindfulness and symptoms has been
conducted predominantly among healthy samples screened for psychopathology characterized by
limited variability, the present sampling approach is important and underrepresented in the mindful-
ness-psychopathology literature (e.g., Vujanovic et al., 2009; Zvolensky, Solomon, et al., 2006).
 Mindfulness and Trauma 103

The racial/ethnic composition of the sample was consistent with that of the state of Vermont
population (State of Vermont, Department of Health, 2007): Approximately 93.4% of the sample
identified as White, 2.6% identified as African American, 1.3% identified as Hispanic/Latino, and
2.6% identified as “other.” Participants were all cigarette smokers, and reported smoking an average
of 15.67 (SD 5 8.22) cigarettes per day and smoking for an average of 11.16 (SD 5 10.88) years.
In terms of traumatic stress exposure (lifetime) history, the mean number of traumatic events
reported by participants was 3.1 (SD 5 2.2, range 5 1–11). Specifically, in terms of number of
traumatic events reported, 25% (n 5 19) reported 1, 26.3% (n 5 20) reported 2, 18.4% (n 5 14)
reported 3, 9.2% (n 5 7) reported 4, 9.2% (n 5 14) reported 5, and the remaining 11.2% (n 5 9)
reported exposure from 6 to 11 traumatic event types. Traumatic events most frequently reported
included serious accident, fire, or explosion (n 5 38, 50%); natural disaster (n 5 25, 33%); non-
sexual assault by a family member or someone known (n 5 26, 34%); nonsexual assault by a
stranger (n 5 24, 32%); sexual assault by a family member or someone known (n 5 23, 30%);
sexual assault by a stranger (n 5 6, 8%); sexual contact by someone more than 5 years older when
the participant was younger than 18 years old (n 5 23, 30%); military combat (n 5 5, 7%); im-
prisonment (n 5 17, 22%); torture (n 5 6, 8%); life-threatening illness (n 5 11, 15%); and other
(n 5 29, 38%).
In terms of psychiatric diagnoses, excluding substance use disorders and Axis II disorders,
which were not assessed, 35.5% of participants met criteria for one or more current (past month)
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV; American Psychiatric
Association [APA], 1994) Axis I disorders, as indexed by the Structured Clinical Interview for
DSM-IV Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1995). Specifically, 64.5%
of cases did not meet diagnostic criteria (current [past month]) for any Axis I diagnosis (i.e., zero
diagnoses), 14.5% met criteria for one diagnosis, 11.8% met criteria for two diagnoses, and 9.2%
met criteria for three or more diagnoses. Specifically, the following disorders were observed: major
depression (n 5 13), generalized anxiety disorder (n 5 12), social phobia (n 5 6), panic disorder
with/without agoraphobia (n 5 5), specific phobia (n 5 6), PTSD (n 5 3), obsessive-compulsive
disorder (n 5 1), agoraphobia with no panic disorder (n 5 1), dysthymia (n 5 1), mania/cyclo-
thymia (n 5 1), and bipolar II (n 5 1). Observed rates of psychopathology among trauma-exposed
participants are consistent with those reported in previous research (Kessler et al., 1995).

Measures
Structured Clinical Interview for DSM-IV Axis I Disorders. Diagnostic assessments were con-
ducted using the SCID-I/NP (nonpatient version; First et al., 1995), administered by trained doc-
toral student raters. Interviews were audiotaped and the reliability of a random selection of 20.6%
of interviews (n 5 24/116) was determined and checked for accuracy by a doctoral-level indepen-
dent rater; no cases of diagnostic coding disagreement were noted.
Mindful Attention Awareness Scale. The MAAS is a 15-item questionnaire in which respon-
dents indicate, on a 6-point Likert-type scale (1 5 almost always to 6 5 almost never), their level
of attention and awareness to present events and experiences (Brown & Ryan, 2003). Sample
MAAS items include “I rush through activities without being really attentive to them” and “I find
it difficult to stay focused on what’s happening in the present.” A mean rating score is calculated,
with higher scores indicating greater mindfulness. The MAAS shows good internal consistency
across a wide range of samples (a 5 .80–.87; Brown & Ryan). Test–retest reliability data over a
1-month period suggest mindful attention and awareness, as indexed by the MAAS, are stable
(i.e., no significant differences in MAAS scores between time 1 and time 2; Brown & Ryan).
Posttraumatic Diagnostic Scale. The PDS (Foa et al., 1997) is a 49-item self-report instru-
ment designed to assess the presence of posttraumatic stress symptoms based on criteria outlined
in the DSM-IV (APA, 1994). The PDS is a well-established measure of trauma-related responding
104 Bernstein et al.

that has demonstrated criterion-related validity in relation to other measures of PTSD and anx-
iety (Foa et al., 1997). Respondents report if they have experienced any of 12 traumatic events
including an “other” category (which are totaled to derive a total traumatic event exposure index),
and then indicate which event was most disturbing. Respondents also rate the frequency (0 5  not
at all or only one time to 3 5 five or more times a week/almost always) of 17 PTSD symptoms
experienced in the past month in relation to the most disturbing event endorsed (total score
range of 0–51). The PDS also yields a continuous measure of posttraumatic stress symptom se-
verity. Consistent with research on the effects of trauma type exposure on posttraumatic stress
symptoms (e.g., Krause, Shaw, & Cairney, 2004; Schnurr, Friedman, & Bernardy, 2002; Zatzick
et al., 2002), a sum of the number of traumatic event types endorsed was used to index number
of trauma type exposures. Also consistent with recommendations (Foa et al., 1997), a sum of
frequency ratings of each symptom was calculated to index total posttraumatic stress symptom
severity. The PDS has demonstrated sound internal consistency (alpha coefficients: .97) and test–
retest reliability (e.g., r 5 .74 over 1 week; Foa, Riggs, Dancu, & Rothbaum, 1993).
Mood and Anxiety Symptom Questionnaire (MASQ). The MASQ is a comprehensive
measure of affective symptoms with well-established psychometric properties (see Watson et al.,
1995, for details). Participants indicate how much they have experienced each symptom from 1
(not at all) to 5 (extremely). The Anxious Arousal scale (MASQ-AA) measures the symptoms of
somatic tension and arousal (e.g., “felt dizzy”). The Anhedonic Depression scale (MASQ-AD)
measures a loss of interest in life (e.g., “felt nothing was enjoyable”) and reverse-keyed items
measuring positive affect. As in past work (Zvolensky, Kotov, Antipova, & Schmidt, 2005), the
MASQ-AA and MASQ-AD subscales were used in this investigation because they provide empir-
ically sound and specific composites for “pure” anxiety and “pure” depression symptoms, respec-
tively (Watson et al.). In this investigation, these subscales, specifically, allow for tests of specificity
between mindful attention and awareness and the unique symptoms of anxiety and depressive
states posttrauma. In this way, the MASQ can provide a degree of precision not permissible by
other measures of anxiety and depressive symptoms.

Procedure
Participants were recruited through newspaper advertisements and flyers posted in local busi-
nesses and on community bulletin boards. The original data collection recruited adults for a
study related to smoking and emotion (Vujanovic & Zvolensky, 2009). A subsample of partici-
pants was selected for this investigation based on self-reported exposure to traumatic event(s).
The original study consisted of two appointment sessions. Only data from the first session are
used in this investigation. Participants received $10 at the completion of the first session and
$25 at the conclusion of the second session. At the first session, participants completed informed
verbal and written consent, were administered a diagnostic interview, and completed various
self-report measures.

Results
Data Analytic Approach
Five dependent variables were tested indexing various facets of psychopathology: (a) posttraumatic
stress symptom severity (as indexed by the PDS), (b) categorical psychiatric diagnostic status (as
indexed by the SCID-I), (c) psychiatric multimorbidity (as indexed by number of SCID-I diag-
noses), (d) anxious arousal symptoms (as indexed by the MASQ-AA subscale), and (e) anhedonic
depression symptoms (as indexed by the MASQ-AD subscale). Four hierarchical multiple linear
regression analyses and one hierarchical logistic regression were performed, one for each of the
 Mindfulness and Trauma 105

dependent measures. The dependent variable in the logistic regression was categorical psychiatric
diagnostic status (negative or positive status). At Step 1 in each model, the number of traumatic
event exposure types (as indexed by the PDS) was included as a covariate. At Step 2 in each model,
MAAS total score was entered. This data analytic approach ensures that any observed effects for
mindful attention and awareness at Step 2 in the model are unique and cannot be attributed to
variance shared with number of traumatic event types in Step 1 (Cohen & Cohen, 1983).
In addition, to examine whether the association between mindful attention and awareness
and psychopathology among trauma-exposed adults is consistent with one of vulnerability and/
or resilience, we evaluated the variance in each dependent variable as a function of level of MAAS
total score. Specifically, we first assigned cases to lower (MAAS total score , 54; n 5 22), middle
(MAAS total score 54–69; n 5 26), and upper (MAAS total score . 69; n 5 23) thirds of the
MAAS total score distribution. Then we computed the mean and variance of each continuous
dependent variable (cf. categorical psychiatric status)—posttraumatic stress symptom severity,
psychiatric multimorbidity, MASQ-AA, and MASQ-AD. We then tested whether the variance in
the low MAAS subgroup was significantly different from that observed in the high MAAS sub-
group. The described test was intended to elucidate whether high levels of mindful attention and
awareness are concurrently associated with resilience to psychopathology, and/or whether low
levels of mindful attention and awareness are concurrently associated with vulnerability to psy-
chopathology, among trauma-exposed adults.
Descriptive Data for and Relations Among Independent and Dependent Variables. See
Table 1 for a summary of zero-order correlations and descriptive statistics of studied variables.
Number of traumatic event types experienced was not significantly related to mindful attention
and awareness (r 5 .13, p . .05). As expected, mindful attention and awareness was significantly
associated, at the zero-order level, with all trauma-related psychopathology dependent variables

TABLE 1.  Zero-Order Correlation and Descriptive Statistics of Independent and

Dependent Variables
Mean(SD) Observed
Variable Name 2 3 4 5 6 7 or % Range

1. M AAS total 2.47** 2.26* 2.30** 2.56** 2.44** .13 60 (16.4) 16–90
scores
2. Posttraumatic — .38** .54** .58** .44** .44** 11.6 (12.2) 0–42
stress severity
3. Categorical — — .88** .28** .30** .45** 35.5% 0 or 1
psychiatric [Positive
status Dx]
4. Psychiatric — — — .35** .25* .43** 0.7 (1.0) 0–3
multimorbidity
5. MASQ-anxious — — — — .48** .28* 26.9 (10.0) 17–59
arousal
6. MASQ-anhedonic — — — — — .28* 57.6 (17.0) 16–104
depression
7. Traumatic — — — — — — 3.1 (2.2) 0–11
event types

Note. MAAS 5 Mindful Attention Awareness Scale; MASQ 5 Mood and Anxiety Symptom
Questionnaire.
*p , .05. **p , .01.
106 Bernstein et al.

including: posttraumatic stress symptom severity (r 5 2.47, p , .01), psychiatric multimorbid-

ity (r 5 2.30, p , .01), categorical psychiatric diagnostic status (r 5 2.26, p , .05), anxious
arousal symptoms (r 5 2.56, p , .01), and anhedonic depression symptoms (r 5 2.44, p , .01).
Correlations between number of traumatic event types experienced and the dependent variables
are not reported here because they are described in Step 1 of the hierarchical multiple linear anal-
yses, which is discussed later in this article (see Table 2).
See Table 2 for a summary of regression results. First, as hypothesized, in Step 1 of the model,
number of traumatic event types accounted for 17% of variance in posttraumatic stress symptom
severity (F 5 12.2, p , .01). As hypothesized, in Step 2 of the model, MAAS total scores accounted
for an additional 17% of variance (F 5 15.5, p , .01); levels of MAAS total score were negatively
related to levels of posttraumatic stress symptom severity (t 5 24.0, p , .01).
Second, as hypothesized, in Step 1 of the hierarchical logistic regression model, greater
number of traumatic event types was associated with significantly increased risk for positive
categorical psychiatric diagnostic status (OR 5 1.6, 95% CI: 1.19–2.20, p , .01). In Step 2 of
the model, greater MAAS total scores demonstrated a strong trend toward a unique, significant
association with greater odds of negative categorical psychiatric diagnostic status (OR 5 .97, 95%
CI: .94–1.0, p 5 .057).
Third, as hypothesized, in Step 1 of the model, number of traumatic event types accounted
for 18% of variance in levels of psychiatric multimorbidity (F 5 15.6, p , .01). As hypothesized,
in Step 2 of the model, MAAS total scores accounted for an additional 6% of variance (F 5 5.6, p
, .05); levels of MAAS total score were negatively related to levels of psychiatric multimorbidity
(t 5 22.4, p , .05).
Fourth, as hypothesized, in Step 1 of the model, number of traumatic event types accounted
for 7% of variance in anxious arousal symptoms (F 5 4.8, p , .05). In Step 2 of the model, MAAS
total scores accounted for an additional 28% of variance (F 5 27.5, p , .01); levels of MAAS total
score were negatively related to levels of anxious arousal symptoms (t 5 25.2, p , .01).
Fifth, as hypothesized, in Step 1 of the model, number of traumatic event types accounted for
7% of variance in anhedonic depression symptoms (F 5 5.1, p , .05). As hypothesized, in Step 2
of the model, MAAS total scores accounted for an additional 17% of variance (F 5 14.9, p , .01);
levels of MAAS total scores were negatively related to levels of anhedonic depression symptoms
(t 5 23.9, p , .01).
Finally, see Table 3 for a summary of the mean, variance, and F statistics of each continuous
dependent variable by MAAS total score subgroup. The variance in each continuous dependent
variable—posttraumatic stress symptom severity, psychiatric multimorbidity, anxious arousal,
and anhedonic depression—differed significantly between the low- and high-MAAS subgroups.
Specifically, inconsistent with hypothesis that mindfulness and psychopathology among trauma-
exposed adults would reflect a pattern of covariation consistent with vulnerability and resilience,
variance of each dependent variable was significantly smaller among the high-MAAS subgroup
than among the low-MAAS subgroup.

Discussion
Research to date has documented the relevance of mindfulness concerning various forms of psy-
chopathology (e.g., Orsillo & Roemer, 2005). Furthermore, theory and novel clinical applications
have focused on the potential role of mindfulness in trauma-related psychopathology, specifically
PTSD (e.g., Batten et al., 2005). Despite theoretical promise and emerging clinical applications
(e.g., Walser & Westrup, 2007), empirical study of the degree and nature of putative association(s)
between mindfulness and psychopathology among trauma-exposed persons is greatly lacking
(Vujanovic et al., 2009). This investigation thus had two primary purposes: First, to evaluate the
 Mindfulness and Trauma 107

TABLE 2.  Concurrent Relations Between Mindfulness and Posttraumatic Stress Symptom
Severity, Psychiatric Multimorbidity, Anxious Arousal, Anhedonic Depression, and
Categorical Psychiatric Diagnostic Status
PTS Symptom Severity F DR2 T b sr2 p
Level 1 12.2 .17 — — — ,.01
  No. of traumatic events — — 3.5 .41 .17 ,.01
Level 2 15.5 .17 — — — ,.01
  No. of traumatic events — — 3.3 .35 .12 ,.01
  No. of MAAS total — — 24.0 2.42 .17 ,.01

Psychiatric Multimorbidity (No. of SCID Dxs)

Level 1 15.6 .18 — — — ,.01
  No. of traumatic events — — 3.9 .43 .18 ,.01
Level 2 5.6 .06 — — — ,.05
  No. of traumatic events — — 3.7 .40 .15 ,.01
  No. of MAAS total — — 22.4 2.25 .06 ,.05

MASQ Anxious Arousal

Level 1 4.8 .07 — — — ,.05
  No. of traumatic events — — 2.2 .26 .07 ,.05
Level 2 27.5 .28 — — — ,.01
  No. of traumatic events — — 1.9 .20 .04 ns (5 .056)
  No. of MAAS total — — 25.2 2.53 .28 ,.01

MASQ Anhedonic Depression

Level 1 5.1 .07 — — — ,.05
  No. of traumatic events — — 2.3 .26 .07 ,.05
Level 2 14.9 .17 — — — ,.05
  No. of traumatic events — — 2.0 .21 .04 ns(5 .055)
  No. of MAAS total — — 23.9 2.41 .17 ,.01

Categorical Psychiatric
  Diagnostic Status x2 Wald OR 95% CI p
Level 1 13.5 — — — ,.01
  No. of traumatic events — 9.6 1.6 1.19–2.20 ,.01
Level 2 3.8 — — — ns (5 .053)
  No. of traumatic events — 8.9 1.6 1.18–2.23 ,.01
  No. of MAAS total — 3.6 .97 .94–1.000 ns (5 .057)

Note. PTS 5 posttraumatic syndrome; MAAS 5 Mindful Attention Awareness Scale;

SCID 5 Structured Clinical Interview for DSM-IV Axis I Disorders; MASQ 5 Mood and
Anxiety Symptom Questionnaire.
108 Bernstein et al.

TABLE 3.  Mean and Variance in Dependent Variables as a Function of Low, Medium, and
High Mindfulness Subgoupings
Mean (Variance)
MAAS Subgroups (Thirds)
Low Moderate High
n 5 22 n 5 26 n 5 23 F (p)
Posttraumatic stress 19.3 (139.8) 11.7 (117.7) 2.4 (11.9) 11.7 (p , .01)
symptom severity
Psychiatric multimorbidity 1.13 (1.5) 0.62 (0.97) 0.22 (0.27) 5.6 (p , .01)
MASQ-anxious arousal 33.3 (119.7) 26.5 (66.8) 20.0 (24.6) 4.9 (p , .01)
MASQ-anhedonic depression 67.3 (323.2) 58.7 (255.6) 47.8 (113.6) 2.85 (p , .01)

MAAS 5 Mindful Attention Awareness Scale, MASQ 5 Mood and Anxiety Symptom
Questionnaire. MAAS low subgroup 5 MAAS total score , 54; MAAS moderate subgroup 5
MAAS total score 54–69; MAAS high subgroup 5 MAAS total score . 69. F statistic reflects
statistical ratio in variance of each continuous dependent variable between the low-MAAS
subgroup relative to the high-MAAS subgroup; critical F 5 2.81 at p , .01 or critical F 5 2.06
at p , .05.

degree of concurrent associations between mindful attention and awareness and indices of psy-
chopathology among a trauma-exposed population of adults; and second, to evaluate the phe-
nomenological nature of these associations in order to begin to elucidate whether their theorized
pattern of association(s) may be consistent with one of resilience and/or vulnerability.
First, prior to testing the incremental associations between mindful attention and aware-
ness and each of the dependent variables, it was important to evaluate the degree of association
between severity of traumatic stress event exposure and each dependent variable. Number of
traumatic event exposure types was significantly, and strongly, associated with each of the de-
pendent variables—posttraumatic stress symptom severity, positive categorical diagnostic status,
psychiatric multimorbidity, anxious arousal, and anhedonic depression. Because this investiga-
tion applied a cross-sectional correlational design, these trauma–psychopathology associations
provide only the initial empirical basis for conceptualizing these indices of psychopathology as
related to trauma—without implying directionality, causality, or temporal precedence. All depen-
dent variables were measured as current (cf. lifetime); the studied psychopathology symptoms
were present posttrauma and concurrent with (current) reported states of mindfulness; and we
observed that all studied dependent variables demonstrated significant associations with number
of traumatic event types experienced. Thus, the observed concurrent associations are theoreti-
cally and clinically important in the early stages of the development of this empirical literature,
prior to exploring prospective and/or controlled research (e.g., Zvolensky, Schmidt, et al., 2006).
Second, we observed that levels of mindful attention and awareness were significantly, and
strongly, concurrently predictive of levels of posttraumatic stress symptom severity, psychiatric
multimorbidity, anxious arousal, and anhedonic depression. These effects were observed be-
yond the large, significant effects of number of traumatic stress event exposure types. In addi-
tion, mindful attention and awareness demonstrated a strong trend regarding an incremental
association (p 5 .057) with (positive) categorical psychiatric status, as hypothesized; the latter
hierarchical logistic regression analysis, however, was statistically underpowered relative to the
other multiple linear regression analyses, and therefore ought to be interpreted accordingly in
 Mindfulness and Trauma 109

light of the greater relative possibility of a Type II error (Tabachnick & Fidell, 2007). In summary,
these findings broadly support the hypothesis that mindful attention and awareness may be con-
currently relevant to posttraumatic stress symptom severity (Vujanovic et al., 2009), as well as
transdiagnostically, to various forms of psychopathology (e.g., mood and anxiety symptoms) also
associated with traumatic stress.
Third, we observed that the dispersion or variance in levels of psychopathology (dependent)
variables differed as a function of the levels of MAAS scores. Specifically, inconsistent with the
hypothesis that mindful attention and awareness and psychopathology among trauma-exposed
adults may reflect a pattern of concurrent covariation consistent with vulnerability and resil-
ience, variance of each continuous psychopathology dependent variable was significantly smaller
among the high-MAAS subgroup than among the low-MAAS subgroup. Thus, in light of the
regression findings linking MAAS total scores to transdiagnostic forms of symptoms among
trauma-exposed adults (see Table 2), and the observed mean values of psychopathology (depen-
dent) variables among cases with low and high levels of mindfulness (see Table 3), observed data
suggest that low levels of mindful attention and awareness may not be associated with concurrent
risk or vulnerability to trauma-related psychopathology; in contrast, high levels of mindful atten-
tion and awareness are associated with resilience or mental health (i.e., absence of psychiatric
symptomatology among trauma-exposed individuals). We do not, however, imply directionality
or temporal precedence at this early stage in the literature and present concurrent test; rather,
tested vulnerability and resilience in the context of this study are intended to reflect the pattern of
concurrent co-occurrence between levels of psychopathology as a function of levels of mindfulness.
Such concurrent study must precede, and thereby justify, more costly and resource-demanding
controlled, prospective investigations (Zvolensky, Schmidt, et al., 2006). In addition, future study
could explore the possibility that certain forms of psychopathology may demonstrate a different
pattern of association with traumatic stress—for example, consistent with vulnerability not only
with resilience. Prospective, experimental, or intervention studies may be particularly helpful to
explore this issue more comprehensively and in a more controlled manner.
One conceptually alternative way to interpret these findings may be informed by recent research
linking mindfulness to health and wellness (cf. psychopathology; e.g., Brown & Ryan, 2003; Davidson
et al., 2003; Ekman, Davidson, Ricard, & Wallace, 2005; Erisman & Roemer, 2010; Fredrickson et al.,
2008). In this investigation, we did not measure mental health or well-being directly, but only in-
directly via (absence or low) levels of psychopathology variables. It may in part be, however, that
mindful attention and awareness and psychopathology, among trauma-exposed adults, are distally
associated by means of putatively more proximal or direct association(s) between mindfulness and
health (Brown & Ryan). Future study may directly measure mental health and wellness factors in
addition to psychopathology, and test possible mediating mechanisms involving such proximal and
distal processes in the context of traumatic stress. Such future research may help explicate these find-
ings as well as larger questions regarding the mechanisms by which mindfulness engenders change
from a psychological science perspective (e.g., Erison & Roemer; Zvolensky, Feldner, et al., 2005).
This study has several limitations that warrant mention and may be relevant to future study.
First, the study methodology involved a cross-sectional correlation design. We thus cannot infer
temporal order of the studied independent and dependent variables with one another, temporal
order with respect to the variables and traumatic stress exposure(s), or infer directionality or
causality. Future prospective and experimental study may help address these extant questions.
Second, the studied sample was demographically homogenous as well as composed of regular
cigarette smokers. More representative sampling of adults exposed to traumatic stress—racially
and ethnically diverse as well as composed of smokers and nonsmokers—is important to ad-
vance the external validity of future research. Third, our measurement of mindful attention and
awareness was conducted using only self-report measurement. Although the large proportion
of mindfulness-psychopathology study to date has similarly relied on such self-reported tools,
110 Bernstein et al.

Bishop et al. (2004) have made important recommendations for development and integration of
multimethod measures of mindfulness or closely related variables. Fourth, although (self-report
and interview-based) measurement of psychopathology was a strength of this study, we did not
similarly evaluate substance use disorders or Axis II disorders (e.g., BPD). In light of the docu-
mented association between traumatic stress and substance use problems (e.g., Jacobsen et al.,
2001) as well as personality disorders (e.g., Johnson et al., 1999), future research could fruitfully
also evaluate relations between mindfulness and these disorders in the context of traumatic stress.
Finally, in light of the very early stage of research on this topic, this study did not evaluate the in-
cremental validity of mindful attention and awareness in relation to psychopathology symptoms
among trauma-exposed adults beyond other factors that of theoretical and empirical relevance.
Future research may therefore fruitfully test the incremental validity of mindful attention and
awareness beyond factors that may be related both to mindfulness and psychopathology among
trauma-exposed persons, such as coping.
In summary, the present findings provide evidence of the concurrent associations between
mindful attention and awareness and trauma-related psychopathology. The study of transdi-
agnostic risk and resilience factors related to psychopathology outcomes is consistent with the
real-world phenomenology of psychiatric multimorbidity and common processes underlying
(co-occurring) putatively discrete disorders (e.g., Barlow, Allen, & Choate, 2004; Harvey et al.,
2004) and particularly relevant to traumatic stress—and is therefore theoretically and clinically
promising. The present findings make an initial contribution to the important emerging body of
theorizing, empirical study, and clinical application of mindfulness in the context of psychopa-
thology broadly and trauma-related problems specifically.

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Acknowledgments. This work was supported by a National Research Service Award (1 F31 DA021006-02)
granted to Anka Vujanovic. Dr. Bernstein recognizes the funding support from the Israeli Council for Higher
Education Yigal Alon Fellowship and the European Union FP-7 Marie Curie Fellowship International
Reintegration Grant.

Correspondence regarding this article should be directed to Amit Bernstein, PhD, The International Research
Collaborative on Anxiety. E-mail: abernstein@psy.haifa.ac.il
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