Normand 178 - Anxiety and Depression Association of America, ADAA

 Patricia Normand, MD Director, Mindful Life Program Department of Preven8ve Medicine Rush University Medical Center Disclosures I do not have conflicts of interest to disclose What is mindfulness? to moment awareness Non judgmental moment •  Prac8ce •  ADtude Outside Sensa8ons Thoughts Emo8ons Inside Mindfulness
•  Inten&onal cul8va8on of a*en&on using medita8ve techniques
•  A,tude of openness, curiosity and acceptance
•  Acknowledging the reality of the present moment, without geDng caught up in thoughts about, or emo8onal reac8ons to it •  Creates an approach to stressful situa8ons which promotes response rather than automa8c reac8on Na8onal government survey 2002-­‐ 15 million Americans had used medita8on in the past year 2007-­‐ 20 million had used medita8on in the past year 2007-­‐ 1% of children National Center for Complementary and Alternative Medicine - NIH
Walter Cannon “Fight-­‐or-­‐Flight” response Acute physiologic reac8on: •  Sympathe8c nervous system ac8vity •  Central nervous system arousal •  Skeletal-­‐muscle ac8vity Hans Selye Stress response -­‐ nonspecific response of the body to any demand. Unchecked, the organism becomes suscep&ble to disease and death. Stress -­‐ major cause of disease because chronic stress causes long-­‐term chemical changes “Every stress leaves an indelible scar, and the
organism pays for its survival after a stressful
situation by becoming a little older.”
Richard Lazarus Stress: a transac8on between a person and the environment that is appraised as being taxing or exceeding resources and endangering one’s well-­‐ being The Link Between HPA Axis Ac8va8on and Chronic Medical illness 2. The adrenal gland: excessive catecholamines and cor&sol 3. Increased catecholamines: can lead to coronary artery disease or cardiac arrhythmias 1. Hypothalamus and pituitary gland: excessive ACTH 5. Cor&sol antagonizes insulin and contributes to dyslipidemia, type 2 diabetes, and obesity; increases in cor&sol also suppress the immune system 4. Increased catecholamines (through platelet ac&va&on) and increased cytokines contribute to atherosclerosis and/or hypertension Musselman DL et al 1998 Mindfulness: Stress An8dote •  Decrease the severity of the stress response •  Modify it’s effects Stress Response McEwen BS, Protec&ve and Damaging Effects of Stress Mediators, NEJM 1998;. Mindfulness B
ased S
tress R
educ8on (MBSR)
•  1979 Stress Reduc8on Clinic founded by Dr. Jon Kabat-­‐Zinn at University of Massachuseds Medical Center for chronic pain pa8ents •  1995 Center for Mindfulness in Medicine, Healthcare and Society in the Division of Preven8ve and Behavioral Medicine •  Tens of thousands of people have adended MBSR programs worldwide •  Numerous clinical research studies MBSR •  2 hour mandatory orienta8on •  8 weekly 2 ½ hour classes – 8-­‐30 par8cipants •  All day retreat •  Guided exercises in mindfulness medita8on prac8ces – siDng, walking, ea8ng, interpersonal mindfulness •  Gentle stretching and mindful movement •  Group discussions about the prac8ce and incorpora8ng mindfulness into everyday life •  Daily home prac8ce assignments using workbook and CDs •  Teachers on CFM website Benefits of MBSR
•  Reduc8on of stress and anxiety •  Useful for a variety of chronic medical condi8ons including chronic pain •  Improvement in sleep •  Increased concentra8on and mental focus •  Ability to respond vs react •  Increased ability for self care Contraindica8ons •  Psychosis •  Ac8ve suicidal idea8on •  Severe MDD not in remission •  Acute PTSD •  Severe aden8on disorders •  Demen8a Principles of Teaching MBSR
•  Derives from vipassana or insight form of Buddhist medita8on •  Actual experience more important than didac8c material •  Teaching from the moment and one’s own prac8ce •  Presented as a secular program, use of ordinary language, no Pali or Sankrit words •  Non formulaic -­‐ although specific curriculum, flexible approach •  Use of poetry and stories for illustra8on Orienta8on session •  No cost •  Mandatory •  2 hours – includes 1:1 brief interview •  Introduc8on to concept of mindfulness and medita8on Class 1 Theme: Introduc0on to mindfulness-­‐ defini0on, le7ng go of judgment, expecta0ons.. Why are you here? The workability of challenges... Guided medita8on – example Discussion of experience-­‐ dyads, group T S E Class guidelines Ea8ng medita8on (beginner’s mind) Body scan CD’s, prac8ce manual, home prac8ce assignment Class 2 Theme: Percep0on & responding.: how you see things or don’t will largely determine how you respond to them -­‐how one sees program, pain, any stressor etc. How percep0on may be narrowed by mindset. The need to have a flexible perspec0ve, open mind Body scan Discussion of class and home prac8ce-­‐ challenges, etc Mindstate Percep8on Behavior (including how stressful something is) Class 3 Theme: Learning to be present with whatever is .. Guided medita8on Discussion of prac8ce Mindful movement (gentle yoga) while no8cing S,T,E including body’s limits Mindful walking Mindfulness of everyday life Pleasant events – S,T,E Class 4 Theme: Recogni0on of stress -­‐ how do we know the unpleasant ? Effect of stress on the body. Use of mindfulness and to work with and recover from stress Guided medita8on Discussion of prac8ce Discussion of unpleasant event – S,T,E Where do we find stress-­‐ internal and external, stress physiology Defini8ons of stress Not the stressor but how one handles it that determines how stressful something is –by changing how you look at something you can change your experience of it Stressà React Stress àAwareness, pause à Choice and Response (Breathe)
The truth that many people never understand, un8l it is too late, is that the more you try to avoid suffering the more you suffer because smaller and more insignificant things begin to torture you in propor8on to your fear of suffering (being hurt). Thomas Merton
Class 5 Theme: Con0nued explora0on of no0cing and response to stress. Emphasis on capacity to respond rather than react. Resilience as capacity to bear stress Guided medita8on -­‐ with increased awareness Mindful movement Wriden reflec8on on halfway point of class Discussion of reflec8on and prac8ce Maladap8ve responses to stress Mindful response to stress T S
E Awareness Pause Choice Effec8ve Response Class 6 Theme: Stressful communica0on and interpersonal mindfulness SiDng, moving medita8ons Discussion of mid way reflec8on and prac8ce Discussion of upcoming all day retreat Reflec8on and discussion of a difficult communica8on Old habits and personal styles can effect Paying aden8on àPausing àOpenness and Flexibilityà Response (not react) new perspec8ve maybe awareness of not taking interac8on personally Exercise in mindful speaking and mindful listening (pausing) (ac&ve listening vs passive hearing) All Day Retreat
Theme: Moment to moment presence. Being with what is whether pleasant or unpleasant. No0cing . Guidelines Most of day in silence (types of silence) Medita8ons – siDng, walking, visual, food Loving kindness medita8on – compassion for self and others Breaking of silence and discussion Class 7 Theme: Mindfulness of daily life. Choices of daily living -­‐ what is nourishing and what is not. Changing seats exercise -­‐ changing perspec8ve. Pleasant or unpleasant, When faced with change in our lives, are we rigid or flexible? Can we be at home wherever we are? Discussion of retreat Discussion of what we take in – when is it nourishing and when is it maladap8ve? Same thing can be both, depending on inten8on and use Class 8 Theme: Keeping up the momentum of what’s been learned. Resources to support the prac0ce. The shared experience of past 8 weeks Period of prac8ce-­‐ body scan, movement, siDng medita8on Discussion of prac8ce and making it your own Reflec8on on course and evalua8on, leder to self Brief review Resources and reminders handout Discussion of experience Goodbye... Mindfulness Based Interven8ons Mindfulness Based Stress Reduc8on MBSR Mindfulness Based Cogni8ve Therapy MBCT Mindfulness Based Relapse Preven8on MBRP Mindfulness Based Ea8ng Awareness MB EAT Mindfulness Based Mental Fitness Training MMFT Mindfulness for ADHD MAP Interven8ons where mindfulness is a component DBT, ACT Mindfulness in Educa8on Network (MIEN)
hdp://www.mindfuled.org Research in MBSR MBSR and Healthcare U0liza0on Roth, B 2002
MBSR and Medical Symptoms Reibel, D et al 2001 MBSR and Chronic Medical Illness •  15 published studies (meta-­‐analysis) • Outcomes related to mental and physical health, well-­‐being, and quality of life. • Clinical diagnoses -­‐ fibromyalgia, chronic pain, rheumatoid arthri8s, type 2 diabetes, chronic fa8gue syndrome, mul8ple chemical sensi8vity, and cardiovascular diagnoses. •  All studies showed improvements aoer MBSR. No nega8ve change was reported. Merkes, M 2010
MBSR and Chronic Pain
Chronic pain diagnoses: chronic neck or back pain chronic headaches/migraines, arthri8s, fibromyalgia •  99 pa8ents •  39% with 2 or more comorbid pain condi8ons •  Mean dura8on of pain = 12.1 years Significant improvement on all measures of physical and mental func8on (SF 36 & SCL 90R) Largest improvement in pain severity and func8onal limita8ons: Chronic back/neck pain, arthri8s and two or more comorbid pain condi8ons Rosenzweig , S 2010
Medita8on and Blood Pressure
Goldstein,C et al 2012
Pbert, L et al 2012 Longer Term Effects of MBSR
Carlson, L et al 2007
MBSR and Immune Func0on Immune Func8on with MBSR Davidson, R et al 2003 Brain Func0on and MBSR Davidson, R et al 2003 Davidson, R et al 2003 MBSR a nd t he B rain
MBSR and Grey Ma[er Density Holzel, B et al 2010 M BSR a nd A mygdala V olume Holzel,B 2010
E ffect o f C hronic S tress o n C ell A ging Epel 2005 MBSR a nd T elomerase i n B reast C ancer
(p < .01)
Lengacher, CA et al 2014
Mindfulness Medita0on and Telomeres
Epel, E et al 2009
Çhange in Pro-­‐inflammatory Gene Expression With Medita8on
Kaliman,P et al 2013
MBSR Effects on Anxiety and Depression Toneatto, T & Nguyen,L 2007
MBT for Anxiety and Depression 39 studies totaling 1,140 par8cipants Psychiatric or medical diagnosis Overall: Anxiety (Hedges’ g = 0.63) Mood symptoms (Hedges’ g = 0.59) Anxiety and mood disorders: Anxiety (Hedges’ g = 0.97) Mood symptoms (Hedges’ g = 0.95) Hofmann , S et al 2010
MBSR and Anxiety Disorders Vøllestad , J et al 2011
MBSR and SAD Goldin, P et al 2009
MBSR vs AE for SAD
Goldin,P et al 2012
MBSR and CBT for SAD Koszycki , D et al 2007
MBSR for Veterans with PTSD Kearney , D et al 2012
MBSR and CBT in Anxiety Disorders Heterogeneous anxiety disorders MBSR & CBT-­‐ Effec8ve at reducing severity and symptoms CBT -­‐ high anxiety sensi8vity MBSR -­‐ average anxiety sensi8vity and with depressive symptoms
Arch, J et al 2013
MBSR and Stress Reac8vity in GAD Hoge, E et al 2013
Limita8ons •  Long-­‐term follow-­‐up •  Ac8ve controls •  Hard to blind medita8on Clinical use of MBSR Chronic medical disease Chronic pain Non clinical anxiety Anxiety disorders par8ally remided from CBT or pharmacotherapy Soma8c arousal is decreased Residual depressed mood ( MBCT not available) ? Dysthymia Not as primary treatment for acute MDD, PD, simple phobias MBSR and Therapists
Shapiro, S et al 2007
Effect of Therapist Mindfulness on Pa8ents Grepmair, L et al 2007
MBSR for Burnout 70 primary care physicians MBSR based CME course Improvements in mindfulness: •  Improvements in total mood disturbance (P .001) •  Physician empathy ( P .001), •  Burnout (emo8onal exhaus8on and personal accomplishment) ( P.001) Krasner,M 2009
MBSR Teacher Training-­‐ How and Why? Personal prac8ce Formal training -­‐ Center for M,M H at U Mass-­‐Oasis Ins8tute Phase O ne: Silent medita8on retreat, 5-­‐10 days Eight Week MBSR Course as a par8cipant Clarify inten8ons for pursuing this course of study and prac8ce Graduate degree or equivalent work experience T wo: Develop prac8ce and understanding-­‐ ongoing daily medita8on prac8ce; yoga and Phase other body-­‐centered awareness prac8ces Addi8onal silent medita8on retreat(s) MBSR in Mind -­‐Body Medicine , 7 day residen8al program Prac8cum in MBSR-­‐ either 8 week or 9 day residen8al program Begin teaching short sessions of MBSR-­‐based prac8ces Adend Teacher Development Intensive (TDI) – 8 day residen8al program The range of what we think and do is limited by what we fail to no8ce. And because we fail to no8ce that we fail to no8ce, there is lidle we can do to change un8l we no8ce how failing to no8ce shapes our thoughts and deeds. ˜R. D. Laing
Everything can be taken from a man but one thing: the last of human freedoms -­‐ to choose one's a,tude in any given set of circumstances, to choose one's own way. Between s&mulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom Victor Frankel