Mindfulness 2011 edit


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Mindfulness 2011 edit

  1. 1. Mindfulness: why attention matters Dr Craig Hassed Senior Lecturer Deputy Head of Department Monash University Department of General Practice
  2. 2. Mind wandering and happiness  “In conclusion, a human mind is a wandering mind, and a wandering mind is an unhappy mind. The ability to think about what is not happening is a cognitive achievement that comes at an emotional cost.”  Killingsworth MA, Gilbert DT. A Wandering Mind Is an Unhappy Mind. Science 12 November 2010: Vol. 330. no. 6006, p. 932 DOI: 10.1126/science.1192439
  3. 3. Attention Deficit Trait  Newly recognized neurological phenomenon: attention deficit trait (ADT)  Response to hyperkinetic environment  Trying to deal with too much input, results in:  Black-and-white thinking; perspective and shades of grey disappear  Difficulty staying organized, setting priorities, and managing time  Feel a constant low level of panic and guilt  Hallowell EM. Overloaded circuits: why smart people underperform. Harv Bus Rev. 2005 Jan;83(1):54-62, 116.
  4. 4. “The body is the shadow of the soul.” Marsilio Ficino (1433-99)
  5. 5. 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, atherosclerosis, metabolic syndrome, bone demineralization  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.
  6. 6. “Man is not disturbed by events, but by the view he takes of them.” Epictetus
  7. 7. Current trends in happiness  In developed countries depression is currently overtaking heart disease as the leading burden of disease
  8. 8. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006 Nov;3(11):e442.
  9. 9. Burnout and psychiatric morbidity in new medical graduates  8 months into internship: 75% interns had burnout  73% (of interns) met criteria for psychiatric morbidity on at least one occasion  Willcock SM et al. Burnout and psychiatric morbidity in new medical graduates. Med J Aust. 2004;181(7):357-60.
  10. 10. Antidepressants and placebo  Antidepressants no different to placebo for mild-moderate depression, and a relatively small difference for patients with severe depression  Kirsch I et al. PLoS Medicine 2008 Feb;5(2):e45 doi:10.1371/journal.pmed.0050045  Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010 Jan 6;303(1):47-53.
  11. 11. Albert Einstein  “Any man who can drive safely while kissing a pretty girl is simply not giving the kiss the attention it deserves.” 11
  12. 12. Mobile phone use and motor vehicle accidents  Passenger carriage increased the likelihood of a crash (odds ratio 1.6)  Carrying two or more passengers twice as likely to crash as unaccompanied drivers (OR 2.2)  Driver's use of a mobile phone within 5 min before a crash associated with fourfold increased likelihood of crashing (OR 4.1)  McEvoy SP, Stevenson MR, Woodward M.The contribution of passengers versus mobile phone use to motor vehicle crashes resulting in hospital attendance by the driver. Accid Anal Prev. 2007 Nov;39(6):1170-6. Epub 2007 Apr 9.
  13. 13. Multitasking or task-switching?  Multitasking is an illusion (misnomer)  Switching happens so fast that it appears we are performing multiple tasks simultaneously like the concurrent performance of several jobs by a computer  Reality is that we are switching back and forth between tasks  http://ucsdcfm.wordpress.com/2011/07/01/our-brains- are-evolving-to-multitask-not-the-ill-usion-of- multitasking/
  14. 14. Multi-tasking  On the performance levels of extreme multi- taskers: “These are kids who are doing 5, 6, or more things at once all the time. ... It turns out multi-taskers are terrible at every aspect of multitasking! They get distracted constantly. Their memory is very disorganized. Recent work we’ve done suggests that they’re worse at analytic reasoning. We worry that it may be we’re creating people who may not be able to think well, and clearly.”  Dr. Clifford Nass on his studies at Stanford University from Dretzin, Rachel. Rushkoff, Douglas. “digital_nation life on the virtual frontier.” pbs.org Frontline. Feb. 2010. Web. 14 Apr. 2011.
  15. 15. Multitasking  “In 2005, the BBC reported on a research study, funded by Hewlett-Packard, and conducted by the Institute of Psychiatry at the University of London, that found, workers distracted by e-mail and phone calls suffer a fall in IQ more than twice that found in marijuana smokers.”  Christine Rosen, “The Myth of Multitasking.” The New Atlantis thenewatlantis.com. Spring 2008. Web. 14 Apr. 2011.
  16. 16. Simple and Complex Multitasking (Continuous Partial Attention)  Simple multitasking: each task given the same priority (e.g. stirring pasta while talking to spouse)  Aim to be more productive  Complex multitasking: two activities which demand cognition (e.g. driving while speaking on phone)  Aim not to miss anything by maintaining CPA  Continuous overstimulation and lack of fullfilment  “When we do this, we may have the feeling that our brains process multiple activities in parallel. Researchers say that while we can rapidly shift between activities, our brains process serially.”  Stone, Linda. “Beyond Simple Multi-Tasking: Continuous Partial Attention.” Lindastone.net. Nov. 2009. Wen. 14 Apr. 2011.
  17. 17. Multitasking  “Heavy media multitaskers performed worse on a test of task-switching ability, likely due to reduced ability to filter out interference from the irrelevant task set.”  Ophir, Eyal. Nass, Clifford. Wagner, Anthony D. “Cognitive control in media multitaskers.” PNAS.org. Proceedings of the National Academy of Sciences of the United States of America, Jul. 2009. Web. 15 Apr. 2011.
  18. 18. Three regions of the brain  Corresponding areas in the brain  Frontal lobes – reasoning and emotional regulation  Higher reasoning (buddhi)  Emotional regulation  Left (positive) vs. right (negative)  Appetite regulation  Directs immune system  Limbic system – emotion and courage  Mesolimbic reward system – appetites
  19. 19. Stress Performance Inertia Poor performance / burnout Stress-performance curve High performance
  20. 20. Doctor health and medical errors  Study determined prevalence of depression and burnout among residents medical staff in 3 US hospitals  20% of residents met criteria for depression  74% met the criteria for burnout  Depressed residents made 6.2 times as many medication errors as residents who were not depressed  Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ, doi:10.1136/bmj.39469.763218.BE (published 7 February 2008)
  21. 21.  “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 What is mindfulness?
  22. 22. Mindfulness  Mindfulness is a mental discipline involving training attention  It is not a method of distracting ourselves or tuning out, it is about tuning in – hence people perform better when mindful (in the zone/flow)  The anxious, stressed or depressed state of mind is the distracted state  Hence the negative impact upon performance
  23. 23. Applications of mindfulness  Mental health  E.g. depression relapse prevention, anxiety, panic disorder, stress, emotional regulation, addiction, psychosis  Neuroscience  E.g. structural and functional changes in the brain, neurogenesis, dementia prevention, amygdala, executive function, working memory  Clinical  E.g. pain management, symptom control, cancer, metabolic, hormonal, genetic function and repair  Performance  E.g. sport, academic, leadership  Spiritual  E.g. deep peace, insight, oneness 23 Results suggest that MBSR may help a broad range of individuals to cope with their clinical and non-clinical problems. Grossman P. J Psychosomatic Research. 2004;57(1):35-43.
  24. 24. Meditation and cognition  Study on brief meditation training effects on cognition and mood  Four sessions of either meditation training  Participants were assessed with measures of mood, verbal fluency, visual coding, and working memory  Mindfulness training improved mindfulness, mood, and reduced fatigue, anxiety, and increased visuo-spatial processing, working memory, and executive functioning  Zeidan F, Johnson SK, Diamond BJ, David Z, Goolkasian P. Mindfulness meditation improves cognition: evidence of brief mental training. Conscious Cogn. 2010 Jun;19(2):597-605. Epub 2010 Apr 3.
  25. 25. Stress Performance Inertia Poor performance / burnout Stress-performance curve Peak performance “The zone” Restful alertness
  26. 26. Mindfulness and mental health  Meta-analysis on 39 studies totaling 1,140 participants receiving mindfulness-based therapy for conditions, including cancer, generalized anxiety disorder, depression, and other psychiatric or medical conditions  Effect size estimates show mindfulness-based therapy moderately effective for improving anxiety (Hedges's g = 0.63) and mood symptoms (Hedges's g = 0.59) in general population  In patients with anxiety and mood disorders mindfulness associated with effect sizes (Hedges's g) of 0.97 and 0.95  Effect sizes were robust, unrelated to publication year or number of treatment sessions, and maintained over follow-up.  Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol. 2010 Apr;78(2):169-83.
  27. 27. Mindfulness and depression  Patients with 3 or more previous episodes of depression  Mindfulness-Based Cognitive Therapy reduced relapse from 78% (what you would expect with usual treatment) to 36%  Ma SH, Teasdale JD. J Consult Clin Psychol. 2004;72(1):31-40.
  28. 28. Mindfulness, depression and the stress response  Mindfulness negatively correlates with depressive symptoms and reactivity of the amygdala  Way BM., Creswell JD., Eisenberger, NI., Lieberman MD. Dispositional mindfulness and depressive symptomatology: Correlations with limbic and self- referential neural activity during rest. Emotion. Vol 10(1), Feb 2010, 12-24.
  29. 29. Mindfulness and craving  Study on the effectiveness of suppression vs. mindfulness-based strategy for coping with cigarette cravings  Both groups reported significantly reduced amount of smoking and increased self-efficacy in coping with smoking urges  Only participants in the mindfulness group demonstrated reductions in negative affect (mood), depressive symptoms, and marginal reductions in their level of nicotine dependence  Rogojanski J, Vettese LC, Antony MM. Coping with Cigarette Cravings: Comparison of Suppression Versus Mindfulness-Based Strategies. Mindfulness 2011;2(1):14-26. DOI: 10.1007/s12671-010-0038-x
  30. 30. The ESSENCE of health  Education  Stress management  Spirituality  Exercise  Nutrition  Connectedness  Environment
  31. 31. HEP and student wellbeing  Study of 2006 cohort of medical students found that 90.5% of students personally applied strategies  Improved student wellbeing noted on all measures of wellbeing even in the pre-exam period  Reduced depression, hostility and anxiety subscale  Improved psychological and physical quality of life  Hassed C, de Lisle S, Sullivan G, Pier C. Adv Health Sci Educ Theory Pract. 2008 May 31. [Epub ahead of print]
  32. 32. Mindfulness and doctor wellbeing  An 8-week mindfulness program: improvements on all measures of wellbeing including:  Mindfulness  Burnout (emotional exhaustion; depersonalization; personal accomplishment)  Empathy and responsiveness to psychosocial aspects  Total mood disturbance  Personality (conscientiousness; emotional stability)  Improvements in mindfulness correlated with improvements on other scales  Krasner MS, Epstein RM, Beckman H, et al. JAMA. 2009;302(12):1338-40.
  33. 33. Mindfulness and the workplace  8 week mindfulness program for ANU staff  Key findings include:  Increased self-rated performance (ECDP)  Improved wellbeing (PANAS)  Improved eudaimonic wellbeing (meaningfulness) (PWB)  Increase in 2 subscales of work engagement (vigour and dedication) (UWES)  Increased authenticity (self-awareness, authentic behaviour, open relationships) (AI3)  Increased satisfaction with life (SWLS)  Improvements sustained at 6 month f/up  Atkins P, Hassed C. Unpublished data.
  34. 34. Mindful practice  Mindfulness is essential underpinning for self-monitoring  “Mindful practice is conscious and intentional attentiveness to the present situation – the raw sensations, thoughts, and emotions as well as the interpretations, judgments and heuristics that one applies to a particular situation.”  Avoids automatic pilot  Epstein R, Siegel D, Silberman J. Self-monitoring in clinical practice: a challenge for medical educators. J Cont Educ Health Prof 2008;28(1):5-13.  Epstein RM. Mindful practice in action (II): Cultivating habits of mind. Fam Syst Health . 2003;21: 11-17.
  35. 35. Roots of Diagnostic Errors  “Cognitive dispositions to respond that influence the diagnostic process are characterized by a lack of awareness and responsiveness by the individual to his or her own cognitive and affective processes.”  Confirmation bias: the pursuit of data that support a diagnosis over data that refute it  Anchoring bias: a resistance to adapting appropriately to subsequent data that suggest alternative diagnoses  Sibinga EM, Wu AW. Clinical Mindfulness and Patient Safety. JAMA 2010;304(22):2532-3.
  36. 36. Self-monitoring leads to; 1. Early recognition of cognitive biases 2. Avoidance of technical errors 3. Awareness of emotional reactions 4. Facilitation of self-correction 5. Development of therapeutic relationships  Epstein R et al, 2008
  37. 37. Mindfulness and the brain  Brain scans on long-term meditators  Regions associated with attention, self-awareness and sensory processing thicker in meditators (E.g. prefrontal cortex)  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.
  38. 38. Meditation and compassion  Limbic brain regions implicated in empathic response to another's pain  Meditators have more active empathic response  Activation in insula greater in expert than novices  Empathy w/o stress reduces carer fatigue  Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson RJ. PLoS ONE. 2008 Mar 26;3(3):e1897.
  39. 39. Emotional Intelligence & mindfulness  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. EI Definition Self- awareness Ability to recognise and understand emotions, drives and effects Self- regulation 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
  40. 40. Genetic ageing and pessimism  The combination of lower optimism and higher pessimism increases risk for disease and early mortality  Sample of healthy post-menopausal women  Pessimism is independently associated with over10 years accelerated ageing  Shorter Telomere length and higher Interleukin-6 concentrations  Lin J,Dhabhar FS, Wolkowitz O, Tillie JM, Blackburn E, Epel E.Pessimism correlates with leukocyte telomere shortness and elevated interleukin-6 in post-menopausal women. Brain Behav Immun. 2009 May;23(4):446-9.
  41. 41. Mindfulness and cellular ageing  Meditation may slow genetic ageing and enhance genetic repair  “...we propose that some forms of meditation may have salutary effects on telomere length by reducing cognitive stress and stress arousal and increasing positive states of mind and hormonal factors that may promote telomere maintenance.”  Epel E, Daubenmier J, Moskowitz JT, Folkman S, Blackburn E. Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres. Ann N Y Acad Sci. 2009 Aug;1172:34-53.