Managing stress mindfully

Dr Craig HassedSenior LecturerMonash UniversityDept. of General Practice

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Leadingcauses ofDALYs in highincomecountries (%)

Mathers CD, Loncar D. PLoS Med. 2006 Nov;3(11):e442.

The “fight or flight response” A natural, necessary and appropriate physiological

response to a threatening situation This response, based on a clearly perceived threat, is

encoded into our physiology (through the brain and Sympathetic Nervous System) to preserve life Elevation of blood-pressure, heart rate Increased respiration and metabolic rate Diversion of blood-flow to muscles Platelet adhesiveness Effects on immunity and inflammatory hormones (e.g.

cortisol, cytokines, interleukins etc) Changes clinically significant for people with high SNS

reactivity to (perceived) stressful events

Allostatic load Prolonged stress leads to wear-and-tear on the

body (allostatic load) Mediated through the Sympathetic Nervous System

Allostatic load leads to: Impaired immunity Accelerated atherosclerosis Metabolic syndrome (hypertension, high cholesterol,

type-2 diabetes, central obesity) Bone demineralization (osteoporosis)

McEwen BS. Ann N Y Acad Sci. 2004;1032:1-7.

Allostatic load Allostatic load also leads to:

Atrophy of nerve cells in the brain Hippocampal formation: learning and memory Prefrontal cortex: working memory, executive function

Growth of Amygdala mediates fear response

Many of these processes are seen in chronic depression and anxiety

Chronic stress can sensitise the brain for the later development of depression

McEwen BS. Ann N Y Acad Sci. 2004;1032:1-7.

“I don’t like Mondays” Consistently found that Monday mornings are peak

period for heart attacks only among the working population.

Mondays are also the peak time for strokes. Weekends are associated with a reduced incidence of

AMI. Peters RW. et al. American Journal of Cardiology

1996;78(11):1198-201. Peters RW. et al. Circulation 1996;94(6):1346-9. Willich SN. et al. Circulation 1994;90(1):87-93. Manfredini R. et al. American Journal of Medicine

2001;111(5):401-3.

The Relaxation Response & genomics “This study provides the first compelling

evidence that the RR elicits specific gene expression changes in short-term and long-term practitioners. Our results suggest consistent and constitutive changes in gene expression resulting from RR may relate to long term physiological effects.”

Dusek JA, Otu HH, Wohlhueter AL, et al. Genomic counter-stress changes induced by the relaxation response. PLoS ONE. 2008 Jul 2;3(7):e2576.

Gender and the stress response Men and women respond to stress differently Early stress research on men and not women Men respond to stress through ‘fight or flight’

Predominantly sympathetic arousal accentuated by testosterone

Women experience ‘tend and befriend’ response Fight and flight moderated through oxytocin and other

hormones Secreted at times of bonding, nurturing, breast feeding and

relationships Taylor SE et al. Psych Review 2000;107(3):411-29.

Football and heart attacks FIFA World Cup (Germany 2006) study on relation

b/w emotional stress and cardiac emergencies Matches involving the German team incidence of

cardiac emergencies 2.66 times higher than usual Men incidence was 3.26 times Women incidence was 1.82 times Incidence higher in those with pre-existing heart

disease Wilbert-Lampen U, Leistner D, Greven S, et al. NEJM 2008;

358 (5):475-483.

Stress and perception “Man is not disturbed by events, but by the

view he takes of them.” Epictetus

“An optimist sees an opportunity in every calamity; a pessimist sees a calamity in every opportunity.” Winston Churchill

Antidepressants Data on all clinical trials

submitted to the US FDA Virtually no effect greater than

placebo for mild to moderate depression Relatively small difference for

very severe depression Kirsch I et al. PLoS Medicine

2008 Feb;5(2):e45 doi:10.1371/journal.pmed.0050045

On brain scan, placebo response biologically similar to receiving active drug

Mayberg HS, et al. Am J Psych. 2002;159(5):728-37.

Wine, marketing and enjoyment Brain scans used while subjects tasted wines that

they believed to be different and sold at different prices 5 tastings / 3 wines, 2 sampled twice (one expensive

and one cheap) with high and low price-tags (once with real price once with false price)

Increasing the price of a wine increases subjective reports of flavor pleasantness Higher price corresponded with increased activity in

the pleasure centres of the brain Plassman H et al. PNAS 2008;105(3):1050-4.

“The body is the shadow of the soul.”Marsilio Ficino (1433-99)

Hebbe’s hypothesis

“Neurons that fire together, wire together.”

Chronic pain and the brain Chronic pain syndromes are common Often difficult to demonstrate somatic disease Brain pain pathways become sensitized and

maintained by “sustained attention and arousal” A high level of reactivity sensitises the brain to

pain This may be why reducing reactivity through

mindfulness reduces pain Eriksen HR, Ursin H. J Psychosom Res. 2004;56(4):445-8. Ursin H, Eriksen HR. Ann N Y Acad Sci. 2001

Mar;933:119-29.

Mental Practice and stroke Mental practice (MP) of a motor skill activates the same

musculature and neural pathways as physical practice of the same skill

RCT on stroke patients compared the efficacy of a rehab +/- MP vs. a placebo intervention Experimental group received 30-minute MP sessions

twice/week for 6 weeks as well as usual rehab Patients had moderate motor deficits No pre-existing group differences

Subjects receiving MP showed: statistically and clinically significant reductions in impairment significant increases in daily arm function new ability to perform important activities of daily living

Page SJ, Levine P, Leonard A. Mental practice in chronic stroke: results of a randomized, placebo-controlled trial. Stroke. 2007 Apr;38(4):1293-7. Epub 2007 Mar 1.

Plato’s 3 aspects of the psyche 3 aspects of the psyche (soul)

Reason (intelligence) Emotion (passion,

courage) Appetite (instincts,

pleasure) Reason governs emotions and

appetites Health of body and mind are

based upon the right alignment of these elements

Botticelli’s “Pallas and the Centaur”

Plato: The Republic “Temperance is the ordering or controlling

of certain pleasures and desires; this is curiously enough implied in the saying of ‘a man being his own master’. In the human soul there is a better and a worse principle; and when the better has the worse under control, then a man is said to be master of himself; and this is a term of praise.”

Neuroscience and the brain Corresponding areas in the

brain Frontal lobes – reasoning

and emotional regulation Higher reasoning Emotional regulation

Left (positive) vs. right (negative)

Appetite regulation Directs immune system

Limbic system – emotion and courage

Mesolimbic reward system – appetites

Allostatic load Allostatic load also leads to:

Atrophy of nerve cells in the brain Hippocampal formation: learning and memory Prefrontal cortex: working memory, executive

function Growth of Amygdala mediates fear response

Many of these processes are seen in chronic depression and anxiety

McEwen BS. Ann N Y Acad Sci. 2004;1032:1-7.

Empathy and the brain Empathy, or experiencing another's pain,

has been shown to produce similar changes in brain activity as the loved one actually experiencing the pain

Singer T, Seymour B, O'Doherty J, et al. Science. 2004 Feb 20;303(5661):1157-62.

Meditation and compassion Limbic brain regions (insula and anterior cingulate

cortices) implicated in empathic response to another's pain The presentation of distressing sounds associated with

activation of limbic regions during meditation Activation in insula greater in expert than novices

Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson RJ. PLoS ONE. 2008 Mar 26;3(3):e1897.

Default states and the brain Most default activity with rumination about

the “multifaceted self” Attention-demanding tasks reduce this activity

and self-preoccupation Gusnard DA. Akbudak E. Shulman GL. Raichle ME. PNAS

USA 2001;98(7):4259-64.

Attention and dementia Brain regions active in

‘default states’ in young adults also show amyloid deposits in adults with AD Active tasks: tasks

associated with paying attention

Default states: when mind is inattentive, idle, recalling past

Early stages of AD prominent atrophy and metabolic abnormalities in these regions Buckner RL et al. J

Neurosci. 2005;25(34):7709-17.

Leisure associated with AD risk Lack of diversity Less time on leisure activities Passive leisure activities

(principally TV) Nearly four times as likely to

develop dementia over 40-year f/up

Friedland RP et al. Proc Nat Acad Sci USA, 10.1073/pnas.061002998

Scarmeas N et al. Neurology 2001;57(12):2236-42.

“Attentional blink” Information processing Time gap in being able to

identify and consolidate a stimulus in memory

Can take more than half a second before mind is free for a second stimulus

Person vulnerable to distractor interference

3 months of mindfulness training reduced the attentional blink and improved the ability to sift out distractors

Slagter HA, Lutz A, Greischar L et al. PLOS Biology 2007;5(6):e138. doi:10. 1371/journal.pbio.0050138

Exam stress and performance High math anxiety led to smaller working

memory spans Ashcraft MH, Kirk EP. J Exp Psychol Gen. 2001

Jun;130(2):224-37.

“Performance pressure harms individuals most qualified to succeed by consuming the working memory capacity that they rely on for their superior performance.”

Beilock SL, Carr TH. Psychol Sci. 2005;16(2):101-5.

Stress

Performance

Inertia

Poor performance / burnout

   

 

High performance

Stress-performance curve

Stress

Performance

Inertia

Poor performance / burnout

   

 

High performance

Peak performance“The zone”Mindfulness

Stress-performance curve

What is mindfulness Mindfulness is a way of being

Jon Kabat-Zinn “To be or not to be; that is the question. …

And thus the native hue of resolution is sicklied o’er with the pale cast of thought.” Shakespeare: Hamlet

“The faculty of voluntarily bringing back a wandering attention over and over again, is the very root of judgment, character, and will. No one is compos sui if he have it not. An education which should improve this faculty would be the education par excellence.” William James, Principles of

Psychology, 1890

Mindfulness-based therapies Stress Anxiety Depression Eating disorders Panic disorder Symptom control Coping Chronic pain Personality disorder OCD

Neural plasticity Immune modulation

Anti-inflammatory Enhancing immune

function Behaviour / lifestyle

change Improvements in sleep Rumination General wellbeing

Ivanovski B, Malhi G. Acta Neuropsychiatrica 2007;19:76-91.

Basic assumptions1. We generally operate on automatic pilot and unaware of

moment-to moment experience2. We are capable of developing sustained attention3. Development of this ability is gradual, progressive and

requires practice4. Awareness makes life richer and more vivid and

replaces unconscious reactiveness5. Gives rise to veridicality (truthfulness) of perceptions6. Awareness enhances perceptiveness, effective action

and control Grossman P et al. J Psychosomatic Research 2004;57:35-43.

MBCT Primary problem a lack of awareness

Attention regulation Non-evaluative

Develops power of discernment although does not seek to analyse or judge thoughts as positive or negative

Meta-cognition Explores the basic relationship of self to thoughts (i.e. no

particular relationship) Autonomy through non-attachment Only the present moment matters

Present the product of past thoughts, feelings and actions Future determined by present thoughts, feelings and actions

Mindfulness and depression CT and MBCT may reduce relapse by changing

relationships to negative thoughts rather than by changing belief in thought content Don’t have to control thoughts, but don’t have to be

controlled by them Don’t have to reason about the thoughts (as

compared to conventional CBT) Teasdale JD, Moore RG, Hayhurst H, et al. J Consult Clin

Psychol. 2002;70(2):275-87.

MBCT reduced relapse from 78% to 36% in 55 patients with 3 or more previous episodes

Ma SH, Teasdale JD. J Consult Clin Psychol. 2004;72(1):31-40.

Mindfulness and happiness Pleasure and happiness are not the same thing Happiness is natural and restores itself given the

right conditions We all meditate on something or other for better or

for worse Consciousness gives life to thoughts and feelings We are almost constantly thinking our way out of

happiness Mindfulness can gently refocuss the attention from

what is not useful to what is useful It is important to learn to be accepting of, and not

reactive to, the thoughts and feelings of which we wish to be free

Depersonalization and mindfulness

Depersonalization (DP), i.e., feelings of being detached from one's own mental processes or body, is a form of mental escape from reality Often linked with maltreatment during childhood

DP contrasts with mindfulness (being in touch with the present moment)

Study found a strong inverse correlation between DP and mindfulness

Michal M. Beutel ME. Jordan J. et al. J Nervous & Mental Disease. 2007;195(8):693-6.

Emotional Intelligence Mindfulness related to

aspects of personality and mental health Lower neuroticism,

psychological symptoms, experiential avoidance, dissociation

Higher emotional intelligence and absorption Baer RA, et al.

Assessment. 2004;11(3):191-206.

Definition

Self-awareness

Ability to recognise and understand emotions, drives and effects

Self-regulation

Can control or redirect disruptive impulses, can think before acting

Motivation Passion for work that goes beyond money or status, energy and persistence

Empathy Ability to understand emotions of others, skill in interacting with others

Social skill Can manage relationships and build networks, can find common ground, rapport

Mindfulness, brain and immunity Effects on brain and

immune function of an 8-week clinical training program in mindfulness

At the end of course subjects vaccinated with influenza vaccine Significant increases in

left-sided anterior (prefrontal) activation (associated with positive mood)

Increase in antibody levels Davidson RJ Psychosom

Med. 2003;65(4):564-70.

Mindfulness and the brain Brain scans on long-term

meditators Regions associated with attention,

self-awareness and sensory processing thicker in meditators

Offset age-related cortical thinning: “evidence for … cortical plasticity”

Lazar SW, Kerr CE, Wasserman RH, et al. Neuroreport. 2005;16(17):1893-1897.

“The regular practice of meditation may have neuroprotective effects and reduce the cognitive decline associated with normal aging.”

Pagnoni G. Cekic M. Neurobiology of Aging. 2007;28(10):1623-7.

The ESSENCE of health

Education Stress management Spirituality Exercise Nutrition Connectedness Environment

Health of medical students Health Enhancement Program (HEP) at Monash

comprises mindfulness and ESSENCE lifestyle programs 90.5% of students personally applying mindfulness Improved student wellbeing noted on all measures

Reduced depression, hostility and anxiety subscale Improved psychological and physical quality of life

“This study is the first to demonstrate an overall improvement in medical student wellbeing during the pre-exam period suggesting that the common decline in wellbeing is avoidable.”

Hassed C, de Lisle S, Sullivan G, Pier C. Adv Health Sci Educ Theory Pract. 2008 May 31. [Epub ahead of print]

Mindfulness in medical education

“At Harvard, a group of faculty members and students are developing workshops for first and second year students to teach “mindfulness” and self-renewal skills, based on a program pioneered by … Australia’s Monash University.”

Rosenthal JM, Okie S. New England Journal of Medicine 2005;353;11:1085-8.

And remember …

When you’re looking at the universe, the universe is also looking back at you!