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Managing stress mindfully. Dr Craig Hassed Senior Lecturer Monash University Dept. of General Practice. 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

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managing stress mindfully

Managing stress mindfully

Dr Craig Hassed

Senior Lecturer

Monash University

Dept. of General Practice

the fight or flight response
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
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 load13
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
“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
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
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
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
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
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
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.
hebbe s hypothesis
Hebbe’s hypothesis
  • “Neurons that fire together, wire together.”
chronic pain and the brain
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 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

Plato’s 3 aspects of the psyche

Botticelli’s “Pallas and the Centaur”

plato the republic
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

Neuroscience and the brain
allostatic load32
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 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
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
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.

Attention and dementia
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

“Attentional blink”
exam stress and performance
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 curve
Stress-performance curve

Performance

High performance

Poor performance / burnout

Stress

Inertia

stress performance curve45
Stress-performance curve

Performance

Peak performance

“The zone”

Mindfulness

High performance

Poor performance / burnout

Stress

Inertia

what is mindfulness
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
slide48
“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

Mindfulness-based therapies

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

basic assumptions
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 2004;57:35-43.
slide53
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
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
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 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
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.
mindfulness brain and immunity
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
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
The ESSENCE of health
  • Education
  • Stress management
  • Spirituality
  • Exercise
  • Nutrition
  • Connectedness
  • Environment
health of medical students
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.

Mindfulness in medical education
and remember
And remember …
  • When you’re looking at the universe, the universe is also looking back at you!