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Presentation2
1. Mind/Body Approaches to Stress
and Anxiety
Jennifer Phelps, MD
Phelps MD Integrative Medicine
2. Peace:
It does not mean to be in a place where there is no
noise, trouble or hard work, it means to be in the
midst of those things and still be calm in your
heart.
Author unknown
3. • Economic burden in 1998 $63.1 Billion
– Missed work, inc medical morbidity
– Treatment of panic disorder decreases healthcare
utilization and costs by 94%
(Langlieb, 2005)
– Anxiety has lifetime prevalence 25.1% 13-18 yr
olds
– 18% adults in any given year( NIMH,n.d.)
4. Mind-Body Modalities
• Biofeedback
• Autogenic training
• Guided imagery
• Hypnosis
• Yoga
• Tai Chi
• Meditation-Mindfulness, PMR, breathwork
6. Clinical Hypnosis
• Inner absorption, concentration and focused
attention
• Like a magnifying glass to focus the rays of the
sun and make them more powerful
7. Biofeedback
• Trains people to improve their health by
controlling certain bodily processes that
normally happen involuntarily such as heart
rate, blood pressure, muscle tension and skin
temperature
• Heart rate variability, EMG, thermal
biofeedback, and EEG
• Benefits-
BP, headaches, anxiety, depression, pain
8. Mindfulness
From a mind-body perspective, mindfulness
appears to "institute" a left-sided shift in
frontal electrical activity to support an
approach state as opposed to a withdrawal
state.
9. Mindfulness Meditation
• Shift to left frontal dominance
• Increased thickness of middle prefrontal
region
• Activation of middle prefrontal areas
• Activation of the Anterior cingulate cortex
10. Mind body practices
• Increased coordination of firing
• Activation of the superior temporal region
• Emotion regulation
• Capacity to disengage from top down brain
processes—caused by enhanced function of
the middle prefrontal areas of the brain that
arises from mindfulness practices
11. Mind
• The human mind is a relational and embodied
process that regulates the flow of energy and
information
• Knowing that our minds regulate this flow
enables us to feel the reality of these two forms
of mental experience and to act on them instead
of get lost in them
• We can learn to become more skilled at altering
our mind and brain by mind body practices.
14. Brain Plasticity
• Emerging research in neuroendocrinology
links stress and anxiety effects on neuronal
replacement, synapse turnover and dendritic
remodeling and the detrimental effects of
untreated anxiety (McEwen, 2012)
• This highlights the importance of effective
treatment approaches
15. • As Woody Allen said in the movie
Manhattan,"You know I can't express
emotions. I internalize, I grow a tumor."
17. neurogenesis
• 5-10K neurons each day average adult done in
animal models
• Impacts neurogenesis—stress inhibits growth
• Physical exercise enhances growth
18. Mental exercise
• Short amounts of practice can help
• If stop practicing after 2 weeks affects
19. Emotion Regulation
• Can be taught and aquired
• Important to manage everyday life
• Resilience maintenance of high levels of well
being in the face of adversity
• Positive emotions is associated with better
health
• Brain heart synchronicity in certain kind of
meditation-compassion meditation a fairly
dramatic synchronicity not in novices
23. 5 Major Diagnostic Groups
• Generalized anxiety
• Panic attacks
• Phobias
• Obsessive compulsive disorder
• Post traumatic stress disorder
24. Conventional treatment
• Psychopharmacology
-complete list of FDA approved found at NIH
website
• Antidepressants
-SSRI/SNRI, tricyclics, MAO, Benzos, B Blockers
• Psychotherapy
-talk therapy, cognitive behavioral therapy
-caution with internet based therapy
25. Integrative Care for Anxiety
• Important to screen for any medical
conditions that could mimic anxiety
• Examine meds and supplements
• Lifestyle changes
• Mind body or psychotherapy approaches
• Discuss risks and benefits of any therapy
26. Disease States assoc w anxiety
• Hypo/hyperthyroidism
• Vestibular dysfunction
• CHF/COPD/PE
• Cardiac arrhythmia
• Pheochromocytoma
• Pneumonia
• Hyperventilation
• Vit B12 Deficiency
• Porphyria
• Neoplasm
• Encephalitis
• Hyperadrenalism
• Substance OD
• Munchausen's
• Lead or pesticide toxicity
28. Lifestyle Factors
• Physical Activity
• Herring MP, Jacob ML, Suveg C, Dishman RK, O'Connor PJ. Feasibility of Exercise Training for the Short-Term Treatment of Generalized Anxiety Disorder: A
Randomized Controlled Trial. Psychother Psychosom. 81(1):21-28. Nov 22, 2011
• Ströaut;hle A, Stoy M, Graetz B, Scheel M, Wittmann A, Gallinat J, Lang UE, Dimeo F, Hellweg R. Acute exercise ameliorates reduced brain-derived neurotrophic factor
in patients with panic disorder. Psychoneuroendocrinology 35(3):364-8 Apr, 2010Nutrition
Nutrition
Cheatham RA, Roberts SB, Das SK, Gilhooly CH, Golden JK, Hyatt R, Lerner D, Saltzman E, Lieberman HR. Long-term effects of provided low
and high glycemic load low energy diets on mood and cognition. Physiology & behavior 98(3):374-9 Sep, 2009
• Bercik P, Denou E, Collins J, Jackson W, Lu J, Jury J, Deng Y, Blennerhassett P, Macri J, McCoy KD, Verdu EF, Collins SM. The intestinal
microbiota affect central levels of brain-derived neurotropic factor and behavior in mice. Gastroenterology.141(2):599-609 2011 Aug
• Sleep
• van der Helm E, Yao J, Dutt S, Rao V, Saletin JM, Walker MP REM Sleep Depotentiates Amygdala Activity to Previous Emotional Experiences.
Curr Biol. Nov 22, 2011
• Gujar N, McDonald SA, Nishida M, Walker MP. A role for REM sleep in recalibrating the sensitivity of the human brain to specific
emotions. Cereb Cortex. 21(1):115-23. Jan, 2011
29. Mind-Body Techniques for Anxiety
• Mindfulness and meditation
• Yoga
• Prayer/Spirituality
• Biofeedback
• Hypnotherapy
• Massage
• Music Therapy
• Energy Medicine
• Aromatherapy
Editor's Notes
Langlieb AM, Kahn JP. How much does quality mental health care profit employers? J Occup Environ Med. 2005 Nov;47(11):1099-109. National Institute of Mental Health (NIMH). Any Anxiety Disorder Among Children. [Web page]. NIMH Web site. Accessed December 5, 2011.
Subsequent surveys began showing that guided imagery was one of the more frequently used CAM therapies in oncology. Henry Bennett, a behavioral anesthesiologist, published a gold standard, randomized, placebo-controlled, double-blind study with 335 surgery patients and four different audio interventions, showing that the guided imagery alone significantly reduced blood loss, pre- and post-op anxiety and length of hospital stay.study by Blue Shield of California showed that this same guided imagery reduced cost per hysterectomy by an average of $2003.07 per procedure. Hospital-based guided imagery programs for surgery patients became commonplace. Along with the Health Journeys programs, the imagery protocols of Peggy Huddleston and Leslie Davenport became widely used.With MRI's of stroke and rehab patients demonstrating how imagining movement results in the same neurons firing as with actual movement; blood assays showing increased immune activity generated by imagining NK and T-cell proliferation;
(Nakao, 2003), showed that only relaxation-assisted biofeedback significantly decreased both SBP and DBP compared with sham Heartmath, NeurofeedbackCoherence Iswhen HRV waveform oscillates at a frequency of 0.1 Hz, synchronous with respriation Rate. Vagal activity, is increased, baroreceptors are stimulatedLehrer PM, Vaschillo E, Vaschillo B, Lu SE, Eckberg DL, Edelberg R, Shih WJ, Lin Y, Kuusela TA, Tahvanainen KU, Hamer RM. Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow. Psychosomatic medicine 65(5):796-805 Sept-Oct, 2003
225 chronic pain (Back pain, HA, neck pain)patients- mean duration of pain 8 yrs. 60-72% moderately to greatly improved. 86% felt they had gotten something of lasting importance from the experience.Kabat-Zinn J, Lipworth L, Burney R, et al. Clin J Pain 2,159-73. 1987Anxiety- 24 patients w panic or generlized anxiety20/22 showed significant improvement on Beck and Hamilton anxiety and depression scale; significant decrease with panic attacks. Gains maintained after 3 years.In another setting, two randomized controlled experimental studies on students (medical, premedical, and behavioral science) with no known medical or psychiatric diagnoses showed improvement in a variety of psychologic parameters (decreased anxiety and depression, increased empathy, sense of control, and measure of spiritual experiences) (Astin, 1997; Shapiro, 1998Similarly a randomized wait-list controlled study of 90 cancer patients showed improvement in depression, anxiety, anger, and confusion and fewer physical symptoms (Speca, 2000
Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, Urbanowski F, Harrington A, Bonus K, Sheridan JF. Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic medicine 65(4):564-70 Jul-Aug, 2003Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, McGarvey M, Quinn BT, Dusek JA, Benson H, Rauch SL, Moore CI, Fischl B. Meditation experience is associated with increased cortical thickness. Neuroreport 16(17):1893-7 Nov, 2005Cahn BR, Polich J. Meditation states and traits: EEG, ERP, and neuroimaging studies. Psychological bulletin 132(2):180-211 Mar, 2006
“[A]t this point, we do not have definitive data to suggest how focusing attention in the present moment may harness neural circuits in a particular way, nor why these potential attentional mechanisms would result in such improvements in physiological, psychological, and interpersonal well-being” Dan Seigel
Further, the exertion of willful effort generates a physical force that has the power to change how the brain works and even its physical structure. Dr Schwartz calls this “directed mental force.” In 1986, Sir John Eccles, a Nobel prize-winning Australian physiologist proposed that the probability of NT release depended on quantum mechanical processes, which can be influenced by the intervention of the mind.
Tang YY, Lu Q, Geng X, Stein EA, Yang Y, Posner MI. Short-term meditation induces white matter changes in the anterior cingulate. Proceedings of the National Academy of Sciences of the United States of America 107(35):15649-52 Aug, 2010
McEwen BS, Eiland L, Hunter RG, Miller MM. Stress and anxiety: structural plasticity and epigenetic regulation as a consequence of stress. Neuropharmacology.62(1):3-12. Jan, 2012We can use the power of the mind to change the firing patterns of the brain and thereby alter our feelings, perceptions, and responses.
When Freud listened to his hysterical patients, the patients themselves revealed the deeper layer of their suffering and the underlying currents of their physical symptoms and resultantly, meaningful symbolic connections began to emerge. When patient's minds were encouraged to speak aloud about previously resisted or denied truths about their situation, their bodies no longer had to speak those truths through physical symptoms.Returning to the impact of mind on body, the “body that speaks” narrative explores the impact of the mind on the body and more specifically, the impact of the subconscious mind, and we shall see, mind-body approaches/modalities can have the impact of shifting the interface between the subconscious and the conscious mind. The end result to this shift is that awareness is augmented so that more is in the field of awareness, and one is more aware of choices that are possible in the moment that are supportive to health, balance, and vitality.
Positive emotion assoc with Cortisol diurnalHigher in morning than eveningThose who fail to recover to lower level at night have more health issuesStanford paper mets breast ca cortisol not down at end of day died sooner
Dr. Schwartz had his OCD patients engage in intensive self-directed neuroplasticity through what he called Relabeling, Re-attributing, Refocusing, and Revaluing (the 4 Rs). Patients who undertook this therapy experienced considerable relief from OCD symptoms and their brain scans indicated a lasting realignment of brain-activity patterns. They were able to reorganize their brains by intentionally modifying their thoughts and behaviors. The important point for Schwartz is not simply that modified thoughts and behaviors permanently altered patterns of brain activity, but that such modifications resulted from, as he calls it, “mindful attention”—conscious and purposeful thoughts or actions in which the person adopts the stance of a detached observer (Schwartz, 2002)
Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, Urbanowski F, Harrington A, Bonus K, Sheridan JF. Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic medicine 65(4):564-70 Jul-Aug, 2003Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, McGarvey M, Quinn BT, Dusek JA, Benson H, Rauch SL, Moore CI, Fischl B. Meditation experience is associated with increased cortical thickness. Neuroreport 16(17):1893-7 Nov, 2005Cahn BR, Polich J. Meditation states and traits: EEG, ERP, and neuroimaging studies. Psychological bulletin 132(2):180-211 Mar, 2006
6 wk study 30 women 2x weekly, controls waitlisted: worry symptoms signif reduced in exercise group 60%resistance, 40%aerobicBrain Derived neurotrophic factor BDNF protects neurons and encourages growth and maturation. Low levels implicated in anxiety depression Signig improvement after 30 min exercise.Chronic stressinduces hypothalamus=pituitary-adrenal axis Increased cortisol and exercise improves thisCaffeine/glycemic load46 adults at Tufts showed worsening mood on HG load diet as opposed to LG load dietGut flora studies in mice demonstrate a complex interaction b/t gut flora and BDNF-flora can influence behavior independent of factors ANS, Gastrointestinal neurotransmitters, inflammationStrong association of insomnia with anxiety and mood disorders.Absence of REM is common with anxiety and studies show decreased
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. 78(2):169-83. Apr, 2010Vollestad J, Sivertsen B, Nielsen GH. Mindfulness-based stress reduction for patients with anxiety disorders: evaluation in a randomized controlled trial. Behaviour research and therapy 49(4):281-8 Apr, 2011Ospina MB, Bond K, Karkhaneh M, Buscemi N, Dryden DM, Barnes V, Carlson LE, Dusek JA, Shannahoff-Khalsa D. Clinical trials of meditation practices in health care: characteristics and quality. J Altern Complement Med. 14(10):1199-213. Dec, 2008Patients rating higher Gastrointestinal specific anxiety correlate with higher anxiety, inc GI symptoms and inc depression Jerndal P, Ringström G, Agerforz P, Karpefors M, Akkermans LM, Bayati A, Simrén M Gastrointestinal-specific anxiety: an important factor for severity of GI symptoms and quality of life in IBS. Neurogastroenterol Motil. 22(6):646-e179. Jun, 2010
