Grief, Stress, and the Body: Using Integrative Medicine to Cope with Loss

Grief, Stress, and the Body: Using Integrative Medicine

to Cope with LossLarry Bergstrom MD FACPLarry Bergstrom MD FACP

Integrative Medicine Integrative Medicine

Division of Consultative Medicine (CMED)Division of Consultative Medicine (CMED)

Mayo Clinic Scottsdale AZMayo Clinic Scottsdale AZ

[email protected]

Joanne Cacciatore, PhDJoanne Cacciatore, PhD

Arizona State UniversityArizona State University

School of Social WorkSchool of Social Work

Goals and DeclarationsGoals and Declarations

1) To define Integrative Medicine1) To define Integrative Medicine

2) To recognize the Medicine Wheel of 2) To recognize the Medicine Wheel of HealthHealth

3) To know the three basic elements of 3) To know the three basic elements of healthhealth

Declarations: NoneDeclarations: None

““Our greatest glory is not in never Our greatest glory is not in never falling, but in rising every time falling, but in rising every time we fall.we fall.””

ConfuciusConfucius

StressStress

A physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation

Stimulates Sympathetic Nervous System

•Adrenaline

•Cortisol

Increases blood pressure, heart rate, affects coagulation system, immune system, blood sugar, sleep

An Exercise:An Exercise:Rate Your StressRate Your Stress

• Scale: 1-10, 10 is worst stress



• Includes health, finances, family, neighbors, in-laws, work, global warming, politics, etc.



• Includes health, finances, family, neighbors, in-laws, work, global warming, politics, etc.

• How much of the day do you think about things on your stressor list?

Rate Your StressRate Your Stress

• 1/10- Perfect idyllic life

• 5/10- Saber-toothed tiger is in the neighborhood somewhere

• 10/10- He’s breathing in your face

Conventional Treatment of StressConventional Treatment of Stress

Potential Complications of Chronic Potential Complications of Chronic StressStress

• Heart disease • Sleep problems • Digestive problems • Depression • Obesity • Memory impairment • Worsening of skin conditions, eczema

Mortality and BereavementMortality and Bereavement

• Question: Does death of a child increase Question: Does death of a child increase mortality of the mother?mortality of the mother?

• 69,224 mothers age 20–50 from National 69,224 mothers age 20–50 from National Longitudinal Mortality Survey, 9 yr follow-up, Longitudinal Mortality Survey, 9 yr follow-up,

• Results: Death of a child increases risk of death Results: Death of a child increases risk of death of mother by 133% especially in first 2 years. of mother by 133% especially in first 2 years. Not related to motherNot related to mother’’s education or marital s education or marital status, family size, the childstatus, family size, the child’’s cause of death or s cause of death or the gender of the child. the gender of the child.

Espinosa, J. Econ. Hum. Biol. (2012), http://dx.doi.org/10.1016/j.ehb.2012.06.002

Conventional MedicineConventional Medicine

• Focuses on treatment of physical disease, defined by measureable parameters; physical exam, lab tests, imaging, pathology, etc.

• Successful treatment is eradication or amelioration of the physical disease

• Ideal for acute care

Definition- Integrative MedicineDefinition- Integrative Medicine

Comprehensive system that emphasizes wellness and healing of the whole person as major goals, above and beyond suppression of a specific somatic disease.

Views the patient as whole people with minds and spirits as well as bodies and includes these dimensions into diagnosis and treatment.

BMJ. 2001;322:119-120.BMJ. 2001;322:119-120.

Integrative/Integrated MedicineIntegrative/Integrated Medicine

Combines treatments from conventional medicine and CAM for which there is some high-quality scientific evidence of safety and effectiveness.

National Center for Complementary and Alternative Medicine website

Integrative Medicine ConsultationIntegrative Medicine ConsultationReview:

• Medical condition(s)

• Conventional Medical Therapies

• Patient’s past and current use of CAM therapies.

• Potential interactions of CAM therapies with Conventional medical therapies

Discern patient’s attitudes towards potential therapies; the patient’s value system.

Integrative Medicine ConsultationIntegrative Medicine Consultation

Develop an Integrated treatment plan incorporating:• Exercise• Nutrition • Stress reduction• Complementary and Alternative

treatments tailored to the patient’s value system.

How can we make the patient healthier?

The Medicine WheelThe Medicine Wheel-Physical Health-Physical Health

• This is Western, Conventional medicine, defined by measurement• Examination• X-rays• Blood tests

• Tests give us name of the disease which we then treat the disease; however, what about when all tests are normal?

DiseaseDisease

dis·ease

A disordered or incorrectly functioning

organ, part, structure, or system of the body

resulting from the effect of genetic or

developmental errors, infection, poisons,

nutritional deficiency or imbalance, toxicity,

or unfavorable environmental factors

Patients suffer illnesses which are

discrepancies between states of being

and perceived role performances.

Illness

The Medicine WheelThe Medicine Wheel-Emotional Health-Emotional Health

Emotional Health

• Interface of Stress and Health through the sympathetic nervous system.

• “Fight or Flight”

• Saber-tooth Tiger analogy

• Patient rates stress level from 1 to 10, low to high


Coping skills learned when younger are used to deal with stressful situations.

Many people are: • Perfectionist• People pleasers• Ultra responsible

• Theme- “need for control”, “lack of trust”• Very difficult to say “no” to anyone• Black and white thinking


Mind-Body Medicine: enhance the mind's capacity to affect bodily function and symptoms. ↓ physical effects of Stress.

• Prayer• Meditation• Yoga, Tai Qi, QiGong• Biofeedback• Breathing Techniques• Exercise

RuminationRumination

Inward: Ruminating about the past: • Regret• Anger

Ruminating about the future: • Fear • Anxiety

Outward Living in the present• In front of you• Focused on the moment

MindfulnessMindfulness

“Mindfulness means paying attention in a particular way; On purpose, in the present moment, and nonjudgmentally.”

Jon Kabat-Zinn

Mindfulness ExerciseMindfulness Exercise

• Take 5 minutes

• Pen and Paper

• Find a peaceful and relaxing picture

• Describe what you see in a non-judgmental manner

• Write it down

Therapeutic use of slow breathing

Many favorable effects on the cardiovascular system and respiratory function

• Decrease in vascular resistance: BP

• Increase in peripheral blood flow

• Improved exercise tolerance

• Induce a sense of calm

• Decrease anxiety

RESPeRATE

Proven in 10 clinical trials to lower blood pressure naturally.

No side effects except for relaxation.

Reduces stress

Heart Math

Combining MindfulnessCombining Mindfulnessandand

Paced BreathingPaced Breathing

Think “I Am”

Breath in

5 Seconds

Think “At Peace”

Breath out

5 Seconds

6 Breaths/Minute

The Medicine WheelThe Medicine WheelMental HealthMental Health

Neurochemistry- Psychiatry• Target symptoms

• sleep • appetite• concentration • energy • sex drive

• Anxiety may be separate biochemical disorder• Treatment- Antidepressants, correction of sleep disorder

Target symptoms of Acute Target symptoms of Acute Grief/DepressionGrief/Depression

• Sleep disturbance• Appetite disturbance• Concentration difficulties• Poor energy

• Stamina• initiative

• Loss of sex drive• Passive death thoughts• Hopelessness

The Medicine WheelThe Medicine WheelSpiritual HealthSpiritual Health

History question: • Do you have a spiritual

part of your life that is helpful to you?

• What gives your life meaning?

• Defined by the patient. • May be religious but not necessarily

Spiritual Effect of IllnessSpiritual Effect of IllnessMeaningMeaning

Practices developed during health• satisfying, fulfilling, enjoyable• “charge our batteries”

Illness, life changes may prevent engaging in them• Deprives of energy, enjoyment, sense of control

• Can’t live up to self-expectations

SpiritualitySpirituality

The question:

•“Do you have a spiritual part of your life?”

•“What gives your life meaning?”


• Activities developed during health

• Satisfying, fulfilling, enjoyable

• Charge up our batteries

• May all be lost through accident, illness other life changes and lead to a “spiritual crisis”

What gives our life meaning?


In Short: •“Why do you get out of bed each day?”

Spiritual Effect of IllnessSpiritual Effect of Illness

• The Reality of illness- State of health with illness/disability. When one is unable to do the things that give life meaning.

• The Ideal- State of health when one is able to do what is needed to feel fulfilled and give life meaning.

• Developed during period of health

“Spiritual Crisis”

Meaning and grief- Case 1Meaning and grief- Case 1

50 y/o women

• 6 years ago, adopted son, age 13, killed while riding his bicycle

• She grieves but remains positive

• “I miss him terribly but he was a gift that I would not have otherwise. I am grateful for the time he was here.”

Meaning and grief- Case 2Meaning and grief- Case 2

45 y/o man

•3 y/o daughter died 5 years ago

•He decided no God could allow such a thing to happen

•Deacon but abandoned his church

•Divorced

•Became a Hedonist- lives for pleasure only, because there is nothing beyond what we can see.

ResilienceResilience

A dynamic process (not a personality trait) A dynamic process (not a personality trait) encompassing positive adaptation within encompassing positive adaptation within the context of significant adversity.the context of significant adversity.

Resilience is the result of individuals being Resilience is the result of individuals being able to interact with their environments able to interact with their environments and the processes that either promote and the processes that either promote well-being or protect them against the well-being or protect them against the overwhelming influence of risk factorsoverwhelming influence of risk factors

ResilienceResilience

• The process by which we find new things to give our lives meaning when the prior ones are unavailable or no longer possible

Resilience and OutcomesResilience and Outcomes

• Better physical health

• Lower anxiety and depression

• Well being

• Higher meaning in life

• More adaptive neuroendocrine response to stress

• Greater problem focused coping

Kobasa S.C. et al. J Psychosom Res 1985; Maddi S.R. Am Psychol 2005; Hull J.G. et al. J Pers Soc Psychol 1987; Brosschot J.F. et al. Psychosom Med 1998; Maddi S.R. et al. Am J Drug Alcohol Abuse 1996

The Medicine WheelThe Medicine Wheel-Community-Community

Community

We do not live our lives in isolation; our community should be as supportive to our health as we are to theirs. Community is the background to the Medicine Wheel.

The Medicine WheelThe Medicine Wheel-Community-Community

Community

We do not live our lives in isolation; our community should be as supportive to our health as we are to theirs. Community is the background to the Medicine Wheel.

Integrative MedicineIntegrative Medicine

Shift question from:

•“How do we treat your disease?

to

•“ How can we help you become healthy?

Patient-centered Outcomes research- What is most meaningful to the patient?

Integrative Medicine Integrative Medicine GriefGrief

• Five fundamental needs• Exercise• Nutrition• Hydration• Rest• Social support: main variable in

determining high vs. low grief.

Cumulative Survival time based on ↑ or ↓ changes in exercise capacity after exercise training and ↑ vs ↓ baseline psychosocial stress

Milani 2009

Exercise for You

Integrative Nutritional PlanIntegrative Nutritional Plan

• Utilizing food as a source of health and energy

• Emphasis is on food first

• Supplements are supplements to food

• Supplements are used to fill in where diet cannot cover everything.

• Mediterranean/Anti-inflammatory diet

http://www.oldwayspt.org/images/pyramid_med.pdf

Nutrition- Mediterranean Diet Pyramid

Mediterranean DietMediterranean Diet

• Fish- (wild ocean) 3 x weekly

• Fish oil- EPA + DHA = 1000 mg daily

• Fiber- 35 gm/d

• Olive oil (Canola oil- high temp cooking)

• Whole grain products (less processed)

• Soy- Soy milk 8 oz, tofu 3 oz, soy nuts, edemame (isoflavones)

• Nuts- walnuts, pecan, almonds (Sterols)


• Fruit- dark skinned fruit (Flavinoids)

• blueberries, blackberries, purple grapes

• red wine, purple grape juice 2-4 oz/d

• grape seed extract

• Vegetables- ½ of diet, Not all greens!

• Green tea 3 c/d (EGCG)


• Lean meats- chicken (without skin)

• Red meat- (4 legs, hooves) eat once a month at most (source of omega 6)

• Probiotic- yogurt, kefir, probiotic supplement

• Avoid

• Partially hydrogenated oil (trans fat)• High fructose corn syrup

SupplementsSupplementsMood, Anxiety, SleepMood, Anxiety, Sleep

• Inositol- may help depression, panic, OCD. 6-8 gm 2x/d

• SAMe- may help depression, athritis. Dose 200-800 mg 2x/d. may take 2 months to work. Do not take with antidepressants or if have bipolar disorder

• 5-HTP- may help depression. 150-300 mg/d, may help sleep


• St. John's wort- may help mild to moderate depression. 300 mg 3x/d. interacts with many medicines

• Kava- may help anxiety. 100 mg 3x/d. May not be safe (liver failure)

• Passionflower- may help anxiety and sleep. 45 drops or tea or 90 mg tab.


• Skullcap- may help anxiety and sleep. Skullcap- may help anxiety and sleep. Tea or alcohol extract Tea or alcohol extract

• Theanine- may help anxiety. Theanine- may help anxiety. 200 mg/day

• Valerian- may help sleep. Valerian- may help sleep. extract 400-900 mg up to 2 hours before bedtime

• Lemon balm-may help sleep. tea from Lemon balm-may help sleep. tea from flowersflowers


• Chamomile tea- may help sleep Chamomile tea- may help sleep

• Hops- may help sleep. dose/?Hops- may help sleep. dose/?

• Lavender- may help sleep. Lavender- may help sleep. tincture (1:5 in 50% alcohol) 60 drops/d

• Melatonin- may help sleep. Take 1 hr Melatonin- may help sleep. Take 1 hr before bed, dose 1-20 mg, take biggest before bed, dose 1-20 mg, take biggest dose tolerated without side effect, take dose tolerated without side effect, take x 6 wks. Quit if no benefit. x 6 wks. Quit if no benefit.

Questions for youQuestions for you

• Are you eating regularly?

• Are you skipping meals?

• Are you losing weight?

• Are you putting on weight?

• Is your refrigerator well-stocked?

• Are you shopping for empty calories and avoiding food that your body needs?

Positive Thinking and GriefPositive Thinking and Grief

• positive thinking was inversely related to measures of depression, anxiety, and traumatic grief symptomatology

• Findings- Among bereaved individuals, low positive thinking is a cognitive feature of depression that is relatively independent of anxiety and traumatic grief symptomatology.

Intentionally interpret life with higher principles: Daily Themes

Monday Gratitude

Tuesday Compassion

Wednesday Acceptance

Thursday Higher Meaning

Friday Forgiveness

Saturday Celebration

Sunday Reflection / Prayer

Integrative MedicineIntegrative Medicine

Documents

Grief, Stress, and the Body: Using Integrative Medicine to Cope with Loss