Managing stress mindfully

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Managing stress mindfully

• Dr Craig Hassed
• Senior Lecturer
• Monash University
• Dept. of General Practice

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Mathers CD, Loncar D. PLoS Med. 2006
Nov3(11)e442.
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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

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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. 200410321-7.

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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. 200410321-7.

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I dont 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
  199678(11)1198-201.
• Peters RW. et al. Circulation 199694(6)1346-9.
• Willich SN. et al. Circulation 199490(1)87-93.
• Manfredini R. et al. American Journal of Medicine
  2001111(5)401-3.

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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 23(7)e2576.

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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 2000107(3)411-29.

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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.

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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

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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 Feb5(2)e45
  doi10.1371/journal.pmed.0050045
• On brain scan, placebo response biologically
  similar to receiving active drug
• Mayberg HS, et al. Am J Psych. 2002159(5)728-37.

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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 2008105(3)1050-4.

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The body is the shadow of the soul. Marsilio
Ficino (1433-99)
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Hebbes hypothesis

• Neurons that fire together, wire together.

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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.
  200456(4)445-8.
• Ursin H, Eriksen HR. Ann N Y Acad Sci. 2001
  Mar933119-29.

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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
  Apr38(4)1293-7. Epub 2007 Mar 1.

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Platos 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

Botticellis Pallas and the Centaur
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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.

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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

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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. 200410321-7.

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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 20303(5661)1157-62.

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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 263(3)e1897.

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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 200198(7)4259-64.

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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. 200525(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 200157(12)2236-42.

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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 20075(6)e138. doi10.
  1371/journal.pbio.0050138

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Exam stress and performance

• High math anxiety led to smaller working memory
  spans
• Ashcraft MH, Kirk EP. J Exp Psychol Gen. 2001
  Jun130(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.
  200516(2)101-5.

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Stress-performance curve
     
Performance
High performance
Poor performance / burnout
Stress
Inertia
 
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Stress-performance curve
     
Performance
Peak performance The zone Mindfulness
High performance
Poor performance / burnout
Stress
Inertia
 
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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
  oer with the pale cast of thought.
• Shakespeare Hamlet

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• 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

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Mindfulness-based therapies

• Neural plasticity
• Immune modulation
• Anti-inflammatory
• Enhancing immune function
• Behaviour / lifestyle change
• Improvements in sleep
• Rumination
• General wellbeing

• Stress
• Anxiety
• Depression
• Eating disorders
• Panic disorder
• Symptom control
• Coping
• Chronic pain
• Personality disorder
• OCD

Ivanovski B, Malhi G. Acta Neuropsychiatrica
20071976-91.
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Basic assumptions

• We generally operate on automatic pilot and
  unaware of moment-to moment experience
• We are capable of developing sustained attention
• Development of this ability is gradual,
  progressive and requires practice
• Awareness makes life richer and more vivid and
  replaces unconscious reactiveness
• Gives rise to veridicality (truthfulness) of
  perceptions
• Awareness enhances perceptiveness, effective
  action and control
• Grossman P et al. J Psychosomatic Research
  20045735-43.

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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

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Mindfulness and depression

• CT and MBCT may reduce relapse by changing
  relationships to negative thoughts rather than by
  changing belief in thought content
• Dont have to control thoughts, but dont have to
  be controlled by them
• Dont have to reason about the thoughts (as
  compared to conventional CBT)
• Teasdale JD, Moore RG, Hayhurst H, et al. J
  Consult Clin Psychol. 200270(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.
  200472(1)31-40.

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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

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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. 2007195(8)693-6.

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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. 200411(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
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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. 200365(4)564-70.

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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. 200516(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.
  200728(10)1623-7.

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The ESSENCE of health

• Education
• Stress management
• Spirituality
• Exercise
• Nutrition
• Connectedness
• Environment

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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

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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 Australias Monash University.
• Rosenthal JM, Okie S. New England Journal of
  Medicine 2005353111085-8.

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And remember

• When youre looking at the universe, the universe
  is also looking back at you!