Transcript Research Methods in Health Promotion

Managing stress mindfully
Dr Craig Hassed
Senior Lecturer
Monash University
Dept. of General Practice
COPD
Osteoarthritis
Lung cancer
Hearing loss
Cerebrovascular
disease
Diabetes
Alcohol abuse
Dementia
IHD
Leading
causes of
DALYs in high
income
countries (%)
Depression
10
9
8
7
6
5
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2
1
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Mathers CD, Loncar D. PLoS Med. 2006 Nov;3(11):e442.
The “fight or flight response”
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A natural, necessary and appropriate
physiological response to a threatening situation
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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)
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Changes clinically significant for people with high
SNS reactivity to (perceived) stressful events
Allostatic load
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Prolonged stress leads to wear-and-tear on the
body (allostatic load)
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Mediated through the Sympathetic Nervous System
Allostatic load leads to:
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Impaired immunity
Accelerated atherosclerosis
Metabolic syndrome (hypertension, high cholesterol,
type-2 diabetes, central obesity)
Bone demineralization (osteoporosis)
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McEwen BS. Ann N Y Acad Sci. 2004;1032:1-7.
Allostatic load
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Allostatic load also leads to:
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Atrophy of nerve cells in the brain
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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
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McEwen BS. Ann N Y Acad Sci. 2004;1032:1-7.
“I don’t like Mondays”
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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.
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The Relaxation Response & genomics
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“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.”
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Dusek JA, Otu HH, Wohlhueter AL, et al. Genomic counterstress changes induced by the relaxation response. PLoS
ONE. 2008 Jul 2;3(7):e2576.
Gender and the stress response
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Men and women respond to stress differently
Early stress research on men and not women
Men respond to stress through ‘fight or flight’
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Predominantly sympathetic arousal accentuated by
testosterone
Women experience ‘tend and befriend’ response
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Fight and flight moderated through oxytocin and other
hormones
Secreted at times of bonding, nurturing, breast feeding
and relationships
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Taylor SE et al. Psych Review 2000;107(3):411-29.
Football and heart attacks
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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
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Men incidence was 3.26 times
Women incidence was 1.82 times
Incidence higher in those with pre-existing heart
disease
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Wilbert-Lampen U, Leistner D, Greven S, et al. NEJM 2008;
358 (5):475-483.
Stress and perception
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“Man is not disturbed by events, but by the
view he takes of them.”
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Epictetus
“An optimist sees an opportunity in every
calamity; a pessimist sees a calamity in
every opportunity.”
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Winston Churchill
Antidepressants
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Data on all clinical trials
submitted to the US FDA
Virtually no effect greater than
placebo for mild to moderate
depression
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Relatively small difference for
very severe depression
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Kirsch I et al. PLoS Medicine
2008 Feb;5(2):e45
doi:10.1371/journal.pmed.0050
045
On brain scan, placebo
response biologically similar to
receiving active drug
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Mayberg HS, et al. Am J Psych.
2002;159(5):728-37.
Wine, marketing and enjoyment
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Brain scans used while subjects tasted wines that
they believed to be different and sold at different
prices
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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
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Higher price corresponded with increased activity in
the pleasure centres of the brain
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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
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“Neurons
that fire
together, wire
together.”
Chronic pain and the brain
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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
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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
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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
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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:
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statistically and clinically significant reductions in impairment
significant increases in daily arm function
new ability to perform important activities of daily living
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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
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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
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“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
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Corresponding areas in the
brain
Frontal lobes – reasoning
and emotional regulation
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Higher reasoning
Emotional regulation
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Left (positive) vs. right
(negative)
Appetite regulation
Directs immune system
Limbic system – emotion
and courage
Mesolimbic reward system
– appetites
Allostatic load
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Allostatic load also leads to:
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Atrophy of nerve cells in the brain
Hippocampal formation: learning and memory
 Prefrontal cortex: working memory, executive
function
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Growth of Amygdala mediates fear response
Many of these processes are seen in
chronic depression and anxiety
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McEwen BS. Ann N Y Acad Sci. 2004;1032:1-7.
Empathy and the brain
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Empathy, or experiencing another's pain,
has been shown to produce similar changes
in brain activity as the loved one actually
experiencing the pain
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Singer T, Seymour B, O'Doherty J, et al. Science.
2004 Feb 20;303(5661):1157-62.
Meditation and compassion
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Limbic brain regions (insula and anterior cingulate
cortices) implicated in empathic response to
another's pain
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The presentation of distressing sounds associated with
activation of limbic regions during meditation
Activation in insula greater in expert than novices
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Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson RJ. PLoS
ONE. 2008 Mar 26;3(3):e1897.
Default states and the brain
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Most default activity with rumination about
the “multifaceted self”
Attention-demanding tasks reduce this activity
and self-preoccupation
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Gusnard DA. Akbudak E. Shulman GL. Raichle ME. PNAS
USA 2001;98(7):4259-64.
Attention and dementia
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Brain regions active in
‘default states’ in young
adults also show amyloid
deposits in adults with AD
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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
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Buckner RL et al. J
Neurosci.
2005;25(34):7709-17.
Leisure associated with AD
risk
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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
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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”
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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
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3 months of mindfulness
training reduced the
attentional blink and
improved the ability to
sift out distractors
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Slagter HA, Lutz A,
Greischar L et al. PLOS
Biology
2007;5(6):e138. doi:10.
1371/journal.pbio.0050
138
Exam stress and performance
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High math anxiety led to smaller working
memory spans
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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.”
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Beilock SL, Carr TH. Psychol Sci. 2005;16(2):101-5.
Stress-performance curve
Performance
High performance
Poor performance /
burnout
Stress
Inertia
Stress-performance curve
Performance
Peak performance
“The zone”
Mindfulness
High performance
Poor performance /
burnout
Stress
Inertia
What is mindfulness
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Mindfulness is a way of being
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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.”
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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.”
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William James, Principles
of Psychology, 1890
Mindfulness-based therapies
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Stress
Anxiety
Depression
Eating disorders
Panic disorder
Symptom control
Coping
Chronic pain
Personality disorder
OCD
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Neural plasticity
Immune modulation
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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 assumptions
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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
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Grossman P et al. J Psychosomatic Research 2004;57:35-43.
MBCT
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Primary problem a lack of awareness
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Non-evaluative
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Develops power of discernment although does not seek to
analyse or judge thoughts as positive or negative
Meta-cognition
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Attention regulation
Explores the basic relationship of self to thoughts (i.e. no
particular relationship)
Autonomy through non-attachment
Only the present moment matters
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Present the product of past thoughts, feelings and actions
Future determined by present thoughts, feelings and actions
Mindfulness and depression
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CT and MBCT may reduce relapse by changing
relationships to negative thoughts rather than by
changing belief in thought content
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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)
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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
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Ma SH, Teasdale JD. J Consult Clin Psychol. 2004;72(1):3140.
Mindfulness and happiness
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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
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Depersonalization (DP), i.e., feelings of being
detached from one's own mental processes or
body, is a form of mental escape from reality
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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
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Michal M. Beutel ME. Jordan J. et al. J Nervous &
Mental Disease. 2007;195(8):693-6.
Emotional Intelligence
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Mindfulness related to
aspects of personality and
mental health
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Lower neuroticism,
psychological symptoms,
experiential avoidance,
dissociation
Higher emotional
intelligence and absorption
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Baer RA, et al.
Assessment.
2004;11(3):191-206.
Definition
Selfawareness
Ability to recognise and
understand emotions,
drives and effects
Selfregulation
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
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Effects on brain and
immune function of an 8week clinical training
program in mindfulness
At the end of course
subjects vaccinated with
influenza vaccine
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Significant increases in
left-sided anterior
(prefrontal) activation
(associated with positive
mood)
Increase in antibody levels
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Davidson RJ Psychosom
Med. 2003;65(4):564-70.
Mindfulness and the brain
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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”
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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.”
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Pagnoni G. Cekic M. Neurobiology
of Aging. 2007;28(10):1623-7.
The ESSENCE of health
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Education
Stress management
Spirituality
Exercise
Nutrition
Connectedness
Environment
Health of medical students
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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
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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 preexam period suggesting that the common decline in
wellbeing is avoidable.”
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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
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“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.”
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Rosenthal JM, Okie S.
New England Journal of
Medicine
2005;353;11:1085-8.
And remember …
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When you’re
looking at the
universe, the
universe is
also looking
back at you!