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(overview of) Mindfulness in Medicine

mindfulness in medicine
by

Richard Roston

on 2 November 2013

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Transcript of (overview of) Mindfulness in Medicine

Decreased perception of pain severity
Increased ability to tolerate pain or disability
Reduced stress, anxiety, depression
diminished usage of and reduced adverse effects from analgesic, anxiolytic and antidepressant medications
enhansed ability to reflect on choices regarding medical treatments
improved adherence to medical treatments
increased motivation for lifestyle changes involving diet, physical activity, smoking cessation, or other behaviors
enriched interpersonal relationships and social connectedness
alterations in biological pathways affecting health, such as the autonomic nervous system, neuroendocrine function, immune system.
Mindfulness
What is Mindfulness?
How does mindfulness reduce stress?
An overview to understand its
role in medicine and your health

Mindfulness Based Stress Reduction
Sati
Pali word connoting:
Awareness
Attention
Remembering
Acceptance
the awareness that emerges through paying attention on purpose, in the present moment and nonjudgmentally to the unfolding of experience moment to moment
Jon Kabat-Zinn defines:
pointing to personal experience
(not) an activity, a 'state of being'
acceptance, curiosity, kindness
Informal practice:
"Life is what is happening while making other plans" - John Lennon
rehearsing and rehashing
Vs.
Autopilot and reactivity:
Mindfulness and spontenaity
Being fully aware of present activity
Between stimulus 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 E. Frankl
Formal practice:
sitting
or
lying down
or
slow movement
Intentional focus on:
Intentional behavior
Intentional attention
breath
body sensations
sounds
thoughts, emotions
"choiceless awareness"
Eating a vegetarian diet, exercising everyday, and meditating is considered radical. Allowing someone to slice your chest open and graft your leg veins in your heart is considered normal and conservative.

- Dean Ornish
“People don’t dislike change, they dislike being changed.”
― Dean Ornish
“… 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 (“master of themselves”) if he have it not. An education which should improve this faculty would be the education par excellence. But it is easier to define this ideal than to give practical directions for bringing it about.”
– William James 1890 (The principles of psychology).
"There are two ways to live: you can live as nothing is a miracle; you can live as everything is a miracle."
-- Albert Einstein
(yoga, walking, qi gong)
Growth in the mindfulness research literature across 32 years, 1980 - 2012
Results obtained from a search of the term "mindfulness" in the abstract and keywords of the ISI Web of Knowledge database (English Language only). From mindfulnessexperience.org
exposure
cognitive change
self-management
relaxation
acceptance
exposure to:
cognitions: "this is unbearable"
emotions: anxiety, anger
urges to move, shift position
desensitizes to:
negative emotional responses
negative cognitions
Leading to:
Reduction in distress around pain
With particular qualities:
curiosity
kindness
acceptance
from Meditation and Relaxation in Plain English by Bob Sharples
class structure
Eight 2.5 hour classes held weekly
one all day class (about 7 to 8 hours)
45mins to 1 hour practice daily
sometimes written 'assignments'
starts with body scan to moving meditations to sitting meditations.
class instructor
most are not 'certified'
not franchised, not overseen by Center for Mindfulness in Medicine, Healthcare and Society
have some training by John Kabat-Zinn and Saki Santorelli
have many years of meditation practice including retreats
have ongoing personal practice
MBSR teacher certification
one week JKZ and SS retreat (open)
MBSR practicum (apply - long history of meditation practice expected)
10+ full MBSR classes taught with supervision (apply for supervision)
Teacher development intensive
Final evaluation by senior practitioners at CMMHCS
"MBSR is a well-defined and systematic patient-centered educational approach which uses relatively intensive training in mindfulness meditation as the core of a program to teach people how to take better care of themselves and live healthier and adaptive lives" JKZ
History of class
Developed by John Kabat Zinn
First classes in 1979 at U Mass Medical Center
Small Stress Reduction Clinic has grown into large multipronged organization: Center for Mindfulness in Medicine, Health Care and Society run by Saki Santorelli
Research into MBSR efficacy central aspect from beginning
Featured in Bill Moyer's Healing and the Mind series in early 1990's contributed largely to interest and expansion
Over 230 MBSR classes in USA
731 practitioners listed in CMMHCS web site
key principles
class experience as challenge, not a chore; adventure in living rather than another thing one "has" to do for oneself to be healthy
emphasis on individual effort and motivation and regular disciplined practice (whether one "feels" like practicing on a particular day or not)
attention to immediate lifestyle changes to accomodate significant time commitment
importance of making each moment count by consciously bringing it into awareness
educational rather than therapeutic orientation; community of learning and practice; supporting each other in motivation and practice
medically heterogeneous environment; particulars of stress acknowledged but de-emphasized and commonalities of human embodiment emphasized, including capacity to access inner resources for learning, growing and healing
Aware
Connected
Balanced
(cc) image by nuonsolarteam on Flickr
Unaware
Unconnected
Unbalanced
Stress is "the nonspecific response of the organism to any pressure or demand"
- Hans Seyles
A wandering mind is an unhappy mind
2010 Science article by Harvard psychologists M.A. Killingsworth and DT Gilbert
iPhone app contacting 2,250 volunteers random intervals (ages 18 to 85)
what they were doing, were they thinking about something else, how happy?
"mind-wandering is an excellent predictor of people's happiness. In fact, how often our minds leave the present and where they tend to go is a better predictor of our happiness than the activies in which we are engaged"
time lag analysis suggested mind-wandering was the cause not result of unhappiness
160 depressed patients with at least 2 previous episodes entered study.
After >8 mo remission on antidepressant randomized to:
Continued antidepressant
Discontinued antidepressant and MBCT
Discontinued antidepressant and placebo
Antidepressant Monotherapy vs Sequential Pharmacotherapy and Mindfulness-Based Cognitive Therapy, or Placebo, for Relapse Prophylaxis in Recurrent Depression
Archives of General Psychiatry December 2010
Authors conclude: "Our data highlight the importance of maintaining at least one active long-term treatment in recurrently depressed patients whose remission is unstable… For those unwilling or unable to tolerate maintenance antidepressant treatment, mindfulness-based cognitive therapy offers equal protection from relapse during an 18-month period."
Study results more dramatic for patients who had "symptom flurries" or unstable remitters (still in remission but occasional, brief and mild depressive symptoms)
Relapse rates: AD maintenance 27%, MBCT 28%, Placebo 71%
MBCT reduced risk of relapse by 74%
Influence of a Mindfulness Meditation-Based Stress Reduction Intervention on Rates of Skin Clearing in Patients With Moderate to Severe Psoriasis Undergoing Photo Therapy (UVB) and Photochemotherapy (PUVA).
Psychosomatic medicine 1998. John Kabat Zinn and Dermatologists at U Mass
37 patients with psoriasis about to undergo ultraviolet phototherapy (UVB) or photochemotherapy (PUVA) were randomly assigned to one of two conditions: a mindfulness meditation-based stress reduction intervention guided by audiotaped instructions during light treatments, or a control condition consisting of the light treatments alone with no taped instructions.
For UVB, 50% cleared in 83 days for the tape group and 113 days for the no-tape group.
For PUVA, 50% cleared 48.5 days for the tape group and 85 days for the no-tape group respectively.
Long-term meditators self-induce high-amplitude gamma synchrony during mental practice
Proceedings of the National Academy of Sci 2004
Grad students with one week meditation experience vs. Tibetan monks 10k 50k hours meditation practice
EEG measurements of both groups before and then during meditative practice
Meditative practice variant of mindfulness called “nonreferential compassion”
High amplitude gamma synchrony is signature of neuronal activity that knits together far-flung brain circuits, it underlies higher mental activity such as consciousness.
The novice meditators "showed a slight increase in gamma activity, but most monks showed extremely large increases of a sort that has never been reported before in the neuroscience literature," says Prof. Davidson
Alterations in Brain and Immune Function Produced by Mindfulness Meditation
Biotechnology employees in MBSR course vs. wait listed controls
EEG measurements before and after course
Subjects given vaccine and antibody response measured in response to vaccine
significant increases in left-sided anterior activation, a pattern previously associated with positive affect, in the meditators compared with the nonmeditators.
significant increases in antibody titers to influenza vaccine among subjects in the meditation compared with those in the wait-list control group.
the magnitude of increase in left-sided activation predicted the magnitude of antibody titer rise to the vaccine.
Psychosomatic Medicine, 2007
When we scratch the wound and give into our addictions we do not allow the wound to heal. But when we instead experience the raw quality of the itch or pain of the wound and do not scratch it, we actually allow the wound to heal. So not giving into our addictions is about healing at a very basic level. It is about truly nourishing ourselves. --- Pema Chodron
What is Stress?
A selection of other "MB" interventions
mindfully based relapse prevention
mindfully based cognitive therapy
dialectical behavioral therapy
acceptance and commitment therapy
Psychological stress is, "a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well being"
- Dr. Richard Lazarus
three strategies to improving coping
physiology :
changing body responses
cognitive :
changing content of thought
MINDFULNESS
Changing relationship to body and thoughts
medicines
exercise
diet
"nutriceuticals"
Cognitive behavioral therapies
Traditional psychotherapy
Psychological defense mechanisms
Thoughts are not "facts"
I am not my thoughts
I am not my emotions
I am not my stories
I am not my bodily sensations
How being connected to experience may lead to balance
sustained non-judgemental observation of anxiety-related sensations, without attempts to escape or avoid them, may lead to reductions in the emotional reactivity typically elicited by anxiety symtoms
"just thoughts" leading to less rumination
making better decisions
more connected to body
that which you run from will follow you
that which you turn into will transform you
Causes of worsening stress
Mindfulness Based Relapse Prevention
SOBER
Stop
Observe
Breathe
Expand (evaluate options)
Respond
urge surfing
acknoledge cravings are not in one's control. They are going to happen.
Do not fight the urge. Letting go without giving in.
Using breath to ride wave
Bringing curiousity (non-judgemental attention) to craving experience
Sometimes wipeouts do occur (using), and each craving another opportunity to learn how to ride without falling off
Who is it for
Maintain treatment gains (>6mo sobriety)
Interested in broader healthy changes in patterns of daily living
May be adverse to 12-step and/or disease model
May have been through relapse prevention and interested in adding new skills
Who is it not for
actively using, or recently using (<6mo sobriety)
significant suicidal ideation
severe psychiatric symptoms (psychosis, depression)
unexplored sexual abuse and/or severe PTSD
hard of hearing
not fluent English
The marshmallow test:
1. Develop awareness of personal triggers and habitual reactions, and learn ways to create a pause in this seemingly automatic process.

2. Change our relationship to discomfort, learning to recognize challenging emotional and physical experiences and responding to them in skillful ways.

3. Foster a nonjudgmental, compassionate approach toward ourselves and our experiences.

4. Build a lifestyle that supports both mindfulness practice and recovery.
MBRP primary goals
alan Marlatt
Class structure
Similar 8 week structure as MBSR
More narrow selection of participants
Educational component most different with focus on relapse prevention
SOBER and urge surfing are two added practices
Depression, Craving, and Substance Use Following a Randomized Trial of Mindfulness-Based Relapse Prevention
Witkiewitz, Bowen (2010) Journal of Consulting and Clinical Psychology
168 substance users post intensive stabilization randomized to MBSR or TAU (treatment as usual)
TAU was mixture of 12 step, psychoeducation, process oriented groups all with some relapse prevention skills included.
Measured substance use, craving, depressive symptoms.

In TAU craving mediated the relation between depressive symptoms and substance use
In MBSR group significantly less association between depressive symptoms and cravings, leading to less substance use
Surfing the Urge: Mindfulness-Based Interventions for College Student Smokers
Bowen, Marlatt (2009) Addictive Behaviors
123 undergrads randomized to brief mindfulness-based instructions and no instruction
participated in cue exposure designed to elicit urges to smoke

Both groups had same amount of urges
Urge surfing group smokes significantly fewer cigarettes over 7 day follow up period
Intensive Meditation Training, Immune Cell Telomerase Activity, and Psychological Mediators
TL Jacobs, et al (2010) Psychoneuroendocrinology
Telomerase activity is a predictor of long-term cellular viability
30 retreat participants: 3 month every-day 6+ hour mindfulness meditation
30 wait-list control group: matched for age, weight, sex, prior meditation experience
Telomerase activity was significantly greater in retreat participants

Telomeres are protective DNA sequences at the ends of chromosomes that ensure genomic stability during cellular replication, but they shorten with each cell division and additionally shorten under conditions of oxidative stress unless counteracted by telomerase action.
Below a critical telomere length, cell division can no longer occur and a cell is at a higher risk for entering a state of senescence, which may underlie tissue aging.
During human aging, as cells divide, telomere length decreases on average and hence is one indicator of a cell’s biological age, predicting physical health and longevity.
what are Telomeres and Telomerase?
Effectiveness of a Meditation-Based Stress Reduction Program in the Treatment of Anxiety Disorders
J Kabat-Zinn, et al (1992) American Journal of Psychiatry
22
Distraction is the only thing that consoles us from our miseries and yet it is itself the greatest of our miseries. For it is this which principally hinders us from reflecting upon ourselves, and which makes us insensibly ruin ourselves.
-- Blaise Pascal 1669 (Thoughts, published posthumously)
Meditation is about making friends with yourself. This is the most eloquent expression of the simple and unaffected grace that can flow into our lives from the practice of meditation. Don't meditate to fix or redeem yourself; rather, do it as an act of love, of deep warm friendship towards yourself. In this view there is no longer any need for the subtle aggression of self-improvement, for self-criticism, for the endless guilt of not doing enough. In this spirit meditation is endlessly delightful and encouraging. How can this act of befriending oneself help us to heal; to feel more relaxed of body and mind; to become calmer; to deal with anger, panic and depression; to address our spiritual hunger? The answer to these questions is beguilingly simple: Everything is softened by this commitment to friendship; it is only when we can be a friend to ourselves that we can be a friend to the world. (not exact quote)
Mindfulness in Medicine
Growing interest in medical community
common goals
"Mederi"- root for meditation and medicine meaning "to heal" or "to cure"

For patient - encourages participation

For doctor - careful, compassionate engagement
Earlier Indo-European root meaning "to measure" (platonic ideal)
"all things have their own right inward measure"
Medicine - Means by which right inward measure restored when disturbed by disease or illness or injury
Meditation - Process of perceiving directly the right inward measure of one's own being through careful, non-judgemental self-observation
How mindfulness might benefit health
For Physicians, Nurses and therapists
see: Ludwig, D and Kabat-Zinn "Mindfulness in Medicine" JAMA sept 17, 2008 (vol 300, no. 11)
Reducing "burnout" (emotional exhaustion, depersonalization, low sense of accomplishment)
Decreasing medical errors
Increasing patient satisfaction
Decreasing risk of lawsuits
Increasing ability to express empathy
Improving patient care
A few notable studies of direct effects on biology
Promoting mindfulness in Psychotherapists in Training Influences the Treatment Results of Their Patients: A Randomized, Double-Blind, Controlled Study
Grepmair, L, et al (2007) Psychotherapy and Psychosomatics
124 inpatients treated 9 weeks by 18 therapists in training
9 therapists randomized to daily AM Zen meditation
63 patients treated by meditating therapists in training and 61 patients treated by non-meditating therapists in training
Patients scored on many different scales before & after 9 wks.
Patients, Zen master, and therapists in both groups blinded
Meditating therapists significantly higher evaluations and their patients reported significantly greater symptom improvments in many categories over non-meditating therapists.
<60 not significant
60+ slightly elevated
65 + significant
70 + strong
75 + strongly elevated
GSI - Global severity index (overall psychological stress)
I have no financial relationship(s) to any of the material presented in this talk
Association of an Educational Program in Mindfulful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians
Krasner, M (2009) JAMA
Before and after study (no control) of 70 PCP's in Rochester, NY area
8 week class modeled on MBSR, but with added material in narrative and appreciative inquiry exercises
Participants demonstrated improvements in mindfulness, decreased burnout, improved mood (correlating with changes in mindfulness), and empathy
Misdiagnoses mostly not from lack of knowledge, but from snap judgements, stereotyping, and other cognitive traps which mindfulness helps prevent
Lifetime of meditation
3 months intensive meditation
An 8 week MBSR class
The first few times meditating
PRI
Pain Rating Index
BPPA
Body Parts Problem Assessment Scale
MSCL
Medical Symptom Checklist
GSI
General severity Index
Four Year Follow-Up of a Meditation-Based Program for the Self-Regulation of Chronic Pain: Treatment Outcomes and Compliance
J Kabat-Zinn, et al
Clinical Journal of Pain 1987
225 patients with severe chronic pain
Questionnaires given over 4 years
No control group
Large and significant overall improvements were recorded post-intervention in physical and psychological status
Current pain level (at time of questionnaire) tended toward pre-intervention levels over time
Intervention greatly improved coping
Full transcript