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Managing stress mindfully

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

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

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

  3. 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

  4. 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.

  5. 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.

  6. “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.

  7. 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.

  8. 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.

  9. 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.

  10. 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

  11. 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.

  12. 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.

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

  14. Hebbe’s hypothesis • “Neurons that fire together, wire together.”

  15. 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.

  16. 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.

  17. 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”

  18. 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.”

  19. 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

  20. 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.

  21. 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.

  22. 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.

  23. 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.

  24. 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

  25. 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”

  26. 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.

  27. Stress-performance curve Performance High performance Poor performance / burnout Stress Inertia

  28. Stress-performance curve Performance Peak performance “The zone” Mindfulness High performance Poor performance / burnout Stress Inertia

  29. 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

  30. “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

  31. 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.

  32. 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.

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