Coping with Adversity, Suffering and Disease


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  • [Use Whiteboard here] Optimistic Explanatory Style: Unstable?/Local/External Pessimistic Explanatory Style: Stable/Global/Internal
  • I go on to explain the condition and Hector reluctantly agrees to a trial of an antidepressant. Within two weeks he feeling remarkably better: for the first time in a long time he’s sleeping through the night, and he’s no longer wracked with guilt about leaving his Mother and Father back in Mexico City. He is effusive in his praise of this white “happy pill” , but a little later he comes back to my clinic with a dilemma. He tells me that about the same time he started seeing me, his parents in Mexico went to visit a renowned curandero living along the slopes of the Volcano Popocateptl just outside Mexico City. They paid thousands of pesos to the curandero to cure their son Hector from a distance. So as soon as I started treating Hector and he got better, he told his parents. What did his parents think? Of course, they believed that the legendary curandero in Mexico had cured their son. The curandero, they told Hector, had a message for me: “ Tell that Yankee Witch Doctor in San Jose that he’s taking credit for my cures” But here was the Dilemma: The Curandero was now demanding weekly payments to continue the treatment; if they didn’t pay, the curse he had removed would likely return. Hector was not sure who to believe at this point, and in the days that followed, his depression returned with a vengeance. Nevertheless, he continued to work with me, and after a few adjustments of his medication, we successfully treated his depression. To this day, he continues to do well; he has a new girlfriend and mentions that he might get a promotion at work. At his last visit, I asked about the Curandero. He looked up at me, smiled and said, “My parents are no longer paying the curandero, but I’m still paying you”
  • In fact, all of the men involved in the accident in Salinas had very severe symptoms of PTSD including.... Diagnostic Criteria for PTSD: Diagnostic symptoms for PTSD include re-experiencing the original trauma(s) through flashbacks or nightmares , avoidanc e of stimuli associated with the trauma, and increased arousal – such as di fficult y falling or staying asleep, anger , and hypervigilance . RANA: Remembers Atrociious Nuc lear Events (Reexperiencing, Numbing Arousal) [Relate GAD to Anxious Coping]
  • .
  • Vitamin D: hormone implicated in many chronic inflammatory diseases. Began checking vitamin D levels in my depressed patients AT RISK FOR VITAMIN D deficiency and have found that in more than half of cases they are vitamin D deficient. So to summarize the strategies of healthy coping, we can remember the acronym NO MEDS MEDS
  •   R efer to Gottman analysis he re?
  • Coping with Adversity, Suffering and Disease

    1. 1. Coping with Adversity, Suffering, and Disease Michael E. Lara, MD Diplomate, American Board of Psychiatry and Neurology Private Practice Psychiatry and Psychopharmacology Belmont, CA San Jose, CA
    2. 2. We are what we think. All that we are arises with our thoughts. With our thoughts we make the world. Speak or act with an impure mind And trouble will follow you As the wheel follows the ox that draws the cart. Your worst enemy cannot harm you As much as your own thoughts, unguarded - Dhammapada
    3. 3. Program Overview 9:00-10:15 AM <ul><li>An Overview of Stress, Coping and the Stress-Reaction Cycle </li></ul><ul><li>Stress and Chronic Disease </li></ul><ul><li>Adaptive and Maladaptive Coping </li></ul>
    4. 4. Program Overview 10:30-11:30 am <ul><li>Unhealthy Forms of Coping </li></ul><ul><ul><ul><li>Explanatory Style and Cognitive Distortions </li></ul></ul></ul><ul><li>Psychopathology and DSM-IV </li></ul><ul><ul><ul><li>Pathways of Fear and Pleasure </li></ul></ul></ul><ul><li>Neurotransmitters and Maladaptive Coping </li></ul><ul><li>Questions and Answers </li></ul>
    5. 5. Program Overview 12:30-2:00 pm <ul><li>Healthy Forms of Coping </li></ul><ul><ul><ul><li>Lessons from Positive Psychology </li></ul></ul></ul><ul><ul><ul><li>Mindfulness-Based Stress Reduction </li></ul></ul></ul><ul><ul><ul><li>Exercise and the Brain </li></ul></ul></ul><ul><ul><ul><li>The Role of Diet </li></ul></ul></ul><ul><ul><ul><li>Supplements </li></ul></ul></ul>
    6. 6. Program Overview 2:15-3:45 pm <ul><li>Words Matter: What to Say When </li></ul><ul><ul><ul><li>Empathic Communication </li></ul></ul></ul><ul><ul><ul><li>Words to Facilitate Change: Motivational Interviewing </li></ul></ul></ul><ul><ul><ul><li>CBT in Action: Words to Alleviate Anxiety, Lift Sadness and Cultivate Optimism </li></ul></ul></ul><ul><ul><ul><li>Words to Reduce Anger </li></ul></ul></ul><ul><ul><ul><li>Resolving Conflicts in Close Relationships </li></ul></ul></ul><ul><ul><ul><li>Keeping Irritating People in Perspective </li></ul></ul></ul><ul><li>Summary and Conclusions </li></ul><ul><li>Final Questions and Answers </li></ul>
    7. 7. Overview of Stress, Coping and the Stress-Reaction Cycle
    8. 8. Coping Defined <ul><li>Cope v. [intrans.] (of a person) deal effectively with something difficult; < origin > Middle English (in the sense ‘meet in battle, come to blows’): from Old French coper, colper, from cop, colp ‘a blow’, via Latin from Greek Kolaphos ‘blow with the fist’ </li></ul><ul><li>“ Process of managing taxing circumstances, expending effort to solve personal and interpersonal problems, and seeking to master, minimize, reduce or tolerate stress or conflict” </li></ul><ul><li>“ Coping is what people do to alleviate the hurt, stress or suffering caused by a negative event or situation” </li></ul>
    9. 9. Stress Defined <ul><li>Failure of an organism to respond appropriately to emotional or physical threats, whether real or imagined </li></ul><ul><li>Stress has cognitive, behavioral, physical and emotional consequences </li></ul><ul><li>General Adaptation Syndrome characterizes stress in 3 stages: alarm, resistance, exhaustion </li></ul><ul><li>Eustress enhances functioning of an organism </li></ul><ul><li>Cognitive appraisal is key in determining whether a psychosocial situation is perceived as stressor </li></ul>
    10. 10. Adaptive Response to Stress McEwen, B. The Protective and Damaging Effects of Stress Mediators: Central Role of the Brain, Dialogues in Clinical Neuroscience - Vol 8 . No. 4 . 2006
    11. 11. Physiologic Response to Stress Over Time McEwen, B. The Protective and Damaging Effects of Stress Mediators: Central Role of the Brain, Dialogues in Clinical Neuroscience - Vol 8 . No. 4 . 2006
    12. 12. Behavioral and Physiological Response to Stressors McEwen, B. The Protective and Damaging Effects of Stress Mediators: Central Role of the Brain, Dialogues in Clinical Neuroscience - Vol 8 . No. 4 . 2006
    13. 13. Stress Response and Disease <ul><li>Adaptive </li></ul><ul><ul><li>Increased cognition </li></ul></ul><ul><ul><li>Improved cardiovascular tone </li></ul></ul><ul><ul><li>Mobilize energy </li></ul></ul><ul><ul><li>Decreased digestion </li></ul></ul><ul><ul><li>Decreased immune function </li></ul></ul><ul><li>Maladaptive </li></ul><ul><ul><li>Myopathy </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Decreased libido </li></ul></ul><ul><ul><li>Neuronal death </li></ul></ul><ul><ul><li>Increased cancer risk </li></ul></ul>
    14. 15. The Brain Under Stress: Structural Remodeling McEwen, B. The Protective and Damaging Effects of Stress Mediators: Central Role of the Brain, Dialogues in Clinical Neuroscience - Vol 8 . No. 4 . 2006
    15. 16. Does Chronic Stress Cause Brain Injury? Andreasen, Brave New Brain: Conquering Mental Illness in the Era of the Genome, 2001
    16. 17. Mature Defenses and Adaptive Coping <ul><li>Suppression </li></ul><ul><ul><li>Emotion remains conscious but is suppressed </li></ul></ul><ul><li>Altruism </li></ul><ul><ul><li>Suppressing the emotion by doing something nice for others </li></ul></ul><ul><li>Sublimation </li></ul><ul><ul><li>Transmuting the emotion into a productive and socially redeeming endeavor </li></ul></ul><ul><li>Humor </li></ul><ul><ul><li>Expressing the emotion in an indirect and humorous way </li></ul></ul>
    17. 18. Immature Defenses and Maladaptive Coping <ul><li>Passive Aggression </li></ul><ul><ul><ul><li>Expressing anger indirectly and passively </li></ul></ul></ul><ul><li>Acting Out </li></ul><ul><ul><ul><li>Expressing the emotion in actions rather than keeping it in awareness </li></ul></ul></ul><ul><li>Dissociation </li></ul><ul><ul><ul><li>Dissociating instead of feeling the pain </li></ul></ul></ul><ul><li>Projection </li></ul><ul><ul><ul><li>Disavowing the anger and ascribing it to the object of the anger </li></ul></ul></ul><ul><li>Splitting (Idealization/Devaluation) </li></ul><ul><ul><li>Defining the rejecting person as being all bad versus having seen him as all good before the rejection </li></ul></ul>
    18. 19. Assessment of Coping Styles <ul><li>Ways of Coping Questionnaire (WOC) </li></ul><ul><ul><ul><li>Confrontive Coping, Distancing, Self-Controlling, Seeking Social Support, Accepting Responsibility, Escape-Avoidance, Planful Problem Solving, and Positive Reappraisal </li></ul></ul></ul><ul><ul><li>Coping Scale for Adullts (CSA) </li></ul></ul><ul><ul><ul><li>Seeking social support, Focus on solving the problem, Work hard and achieve, Worry, Investing in close friends, Seek to belong, Wishful thinking, Not coping, Tension reduction,Social action, Ignore the problem, Self-blame, Keep to self, Seek spiritual support, Focus on the positive, Seek professional help, Seek relaxing diversions, Physical recreation </li></ul></ul></ul>
    19. 20. Millon Behavioral Medicine Diagnostic <ul><li>Assessment of psychosocial factors that may support or interfere with a chronically ill patient's course of medical treatment </li></ul><ul><ul><ul><li>Identify patients who may have significant psychiatric problems and recommend specific interventions </li></ul></ul></ul><ul><ul><ul><li>Pinpoint personal and social assets that may facilitate adjustment to physical limitations or lifestyle changes </li></ul></ul></ul><ul><li>Coping Styles </li></ul><ul><ul><ul><li>1 - Introversion 2A - Inhibited 2B - Dejected 3 - Cooperative 4 - Sociable 5 - Confident 6A - Nonconforming 6B - Forceful 7 - Respectful 8A - Oppositional 8B - Denigrated </li></ul></ul></ul>
    20. 21. Millon Behavioral Medicine Diagnostic
    21. 22. Physiologic Changes in Repressive and Defensive Coping Styles Jamner, LD, Schwartz, GE, Leigh, H. The relationship between repressive and defensive coping styles and monocyte, eosinophile, and serum glucose levels: support for the opioid peptide hypothesis of repressionPsychosom Med 1988 50: 567-575
    22. 23. Unhealthy Forms of Coping
    23. 24. Explanatory Style <ul><li>‘ Explanatory style’ or ‘attributional style’ refers to how people explain the events of their lives. </li></ul><ul><li>Stable vs. Unstable: Can time change things, or do things stay the same regardless of time? </li></ul><ul><li>Global vs. Local: Is a situation a reflection of just one part of your life, or your life as a whole? </li></ul><ul><li>Internal vs. External: Do you feel events are caused by you or by an outside force? </li></ul>Kamen, Leslie P.; M. E. P. Seligman (1987). &quot;Explanatory style and health&quot;. Current psychological research and reviews 6 (3): 207–218
    24. 25. Cognitive Distortions <ul><li>Catastrophizing </li></ul><ul><ul><ul><ul><li>Focusing on the worst possible outcome, however unlikely, or thinking that a situation is unbearable or impossible when it is really just uncomfortable. </li></ul></ul></ul></ul><ul><li>All-or-Nothing Thinking </li></ul><ul><ul><ul><ul><li>Thinking of things in absolute terms, like &quot;always&quot;, &quot;every&quot;, &quot;never&quot;, and &quot;there is no alternative&quot;. </li></ul></ul></ul></ul><ul><li>Fortune Telling </li></ul><ul><ul><ul><ul><li>Exaggerating how things will turn out before they happen </li></ul></ul></ul></ul><ul><li>Mind-Reading </li></ul><ul><ul><ul><ul><li>Assuming special knowledge of the intentions or thoughts of others. </li></ul></ul></ul></ul><ul><li>Emotional Reasoning </li></ul><ul><ul><ul><ul><li>Making decisions and arguments based on intuitions or personal feeling rather than an objective rationale and evidence. </li></ul></ul></ul></ul>Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975
    25. 26. Cognitive Distortions <ul><li>Overgeneralizing </li></ul><ul><ul><ul><ul><li>Taking isolated cases and using them to make wide generalizations </li></ul></ul></ul></ul><ul><li>Labelling </li></ul><ul><ul><ul><ul><li>Explaining behaviors or events, merely by naming them; related to overgeneralization. </li></ul></ul></ul></ul><ul><li>Making Demands </li></ul><ul><ul><ul><ul><li>Patterns of thought which imply the way things &quot;should&quot; or &quot;ought to be&quot; rather than the actual situation the patient is faced with, or having rigid rules which the patient believes will &quot;always apply&quot; no matter what the circumstances are. </li></ul></ul></ul></ul><ul><li>Mental Filtering </li></ul><ul><ul><ul><ul><li>Focusing almost exclusively on certain, usually negative or upsetting, aspects of an event while ignoring other positive aspects. For example, focusing on a tiny imperfection in a piece of otherwise useful clothing </li></ul></ul></ul></ul><ul><li>Disqualifying the Positive </li></ul><ul><ul><ul><ul><li>Continually reemphasizing or &quot;shooting down&quot; positive experiences for arbitrary, ad hoc reasons </li></ul></ul></ul></ul><ul><li>Personalizing </li></ul><ul><ul><ul><ul><li>Attribution of personal responsibility (or causal role) for events over which the patient has no control . </li></ul></ul></ul></ul>Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. International Universities Press Inc., 1975
    26. 27. Psychopathology and The DSM-IV <ul><li>Mood Disorders </li></ul><ul><li>Anxiety Disorder </li></ul><ul><li>Schizophrenia and Other Psychotic Disorders </li></ul><ul><li>Personality Disorders </li></ul><ul><li>Substance Use Disorders </li></ul><ul><li>Somatoform Disorders </li></ul><ul><li>Eating Disorders </li></ul>
    27. 28. Basic Anatomy of The Human Brain
    28. 29. The Limbic System <ul><li>Amygdala mediates fear, anger and the startle reflex </li></ul><ul><li>Hypothalamus regulates hormonal balance, appetite, sleep and wakefulness </li></ul><ul><li>Thalamus serves as pacemaker for cortical activity </li></ul><ul><li>Hippocampus important in short term recall and context of emotional memory </li></ul>
    29. 30. Major Depressive Disorder <ul><li>Sleep disturbance </li></ul><ul><li>Interest deficit (anhedonia) </li></ul><ul><li>Guilt (worthlessness, hopelessness, regret) </li></ul><ul><li>Energy deficit </li></ul><ul><li>Concentration deficit </li></ul><ul><li>Appetite disorder </li></ul><ul><li>Psychomotor retardation/agitation </li></ul><ul><li>Suicidality </li></ul>
    30. 31. Generalized Anxiety Disorder <ul><li>Muscle Tension </li></ul><ul><li>Fatigue </li></ul><ul><li>Concentration Difficulties </li></ul><ul><li>Restlessness </li></ul><ul><li>Irritability </li></ul><ul><li>Sleep disturbance </li></ul>
    31. 32. The Neural Circuitry of Fear and Anxiety Emotional Stimulus LeDoux J. The Emotional Brain, 1996. Sensory Thalamus Amygdala Primary Sensory and Association Cortices High Road Low Road Emotional Response Hippocampus
    32. 33. Neurotransmitters and Coping Behaviors Impulsivity Serotonin Norepinephrine Drive Dopamine Motivation Energy Interest Attention Sex Appetite Aggression Anxiety Irritability
    33. 34. Conditioned Hypereating as Maladaptive Coping Mechanism <ul><li>Mindless eating remains one of most pervasive forms of coping </li></ul><ul><li>Sugar, fat and salt trigger reward circuits in the brain and are extremely reinforcing </li></ul><ul><ul><ul><ul><li>Opioid reward circuits are activated by high-sugar, high-fat foods </li></ul></ul></ul></ul><ul><li>Rewarding foods rewire the brain </li></ul><ul><li>Conditioned hypereating </li></ul>Kessler, D. The End of Overeating: Taking Control of the Insatiable American Appetite, 2009
    34. 35. Serotonin and Obsessive-Compulsive Coping Styles <ul><li>High levels may be associated with serenity, optimism and possibly spiritual experiences </li></ul><ul><li>Dysregulation associated with depression, impulsivity, eating disorders and suicidality </li></ul><ul><li>Regulates sleep, pain, appetite, and mood </li></ul><ul><li>Neurotransmitter altered by some antidepressant drugs </li></ul><ul><li>Some hallucinogens (LSD) alter serotonin in regions of the brain associated with integrating sensory stimuli </li></ul>
    35. 36. The Amygdala, The Caudate, and Obsessive Compulsive Thinking The caudate nucleus is closely connected to the amygdala. The knock-on effect of caudate activity in OCD may partly explain why people with the disorder suffer from anxiety.
    36. 37. Healthy Forms of Coping
    37. 38. Healthy Forms of Coping <ul><li>Mindfulness/Cognitive Techniques </li></ul><ul><li>Exercise </li></ul><ul><li>Dietary Practices </li></ul><ul><li>Supplements </li></ul>
    38. 39. Lessons from Positive Psychology <ul><li>Happiness and well-being are desired outcomes of Positive Psychology </li></ul><ul><li>Positive emotions (past): satisfaction, contentment, pride, serenity </li></ul><ul><li>Positive emotions (future): optimism, hope, confidence, trust, faith </li></ul><ul><li>Positive emotions (present): pleasures and gratifications </li></ul><ul><ul><li>Pleasures include bodily pleasures and higher pleasures such as bliss, glee, and comfort </li></ul></ul><ul><ul><li>Gratifications: Activities we enjoy that engage us fully </li></ul></ul>Seligman, M. (2002) Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment.
    39. 40. Positive Psychology and The Good Life <ul><li>Good life: using signature strengths to obtain abundant gratification in the main realms of life </li></ul><ul><li>Meaningful life: using signature strengths and virtues in the service of something much larger than you are </li></ul><ul><li>Full Life: experiencing positive emotions about the past and future, savoring positive feelings from the pleasures, deriving abundant gratification from signature strengths, and using these strengths in the service of something large to obtain meaning </li></ul>Seligman, M. (2002) Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment.
    40. 41. The ABCs of Cognitive Behavioral Therapy <ul><li>A = Activating Event </li></ul><ul><ul><li>A real external event that has occurred, a future event that you anticipate occurring, or an internal event in your mind </li></ul></ul><ul><li>B = Beliefs about the Event </li></ul><ul><ul><li>Your thoughts, personal rules, the demands you make, and the meanings that you attache to external and internal events </li></ul></ul><ul><li>C = Consequences </li></ul><ul><ul><li>Emotions, behaviors, and physical sensations that accompany the different emotions. </li></ul></ul>Ellis, Albert (2001). Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Behavior Therapy
    41. 42. ABCs of CBT Ellis, Albert (2001). Overcoming Destructive Beliefs, Feelings, and Behaviors: New Directions for Rational Emotive Behavior Therapy
    42. 43. Mindfulness-Based Stress Reduction (MBSR) <ul><li>Program of stress-reduction based on insight (vipassana) meditation techniques </li></ul><ul><li>Choiceless awareness of different dimensions of moment-to moment experience: </li></ul><ul><ul><li>Breathing </li></ul></ul><ul><ul><li>Sounds </li></ul></ul><ul><ul><li>Body Sensations </li></ul></ul><ul><ul><li>Thoughts </li></ul></ul><ul><li>Emphasis is on mode of being as opposed to mode of doing </li></ul><ul><li>Typical course is eight weeks and includes body scan, sitting meditation, and restorative yoga postures </li></ul>Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body And Mind to Face Stress, Pain, and Illness, 1990
    43. 44. Research on Mindfulness <ul><li>Participants in mindfulness meditation program experienced less pain, anxiety, and depression than patients treated with conventional medicines. 1 </li></ul><ul><li>Meditators utilize medical care services 30 to 87% less than a control group utilizing conventional practices. 2 </li></ul><ul><li>Chronic pain patients practicing meditation noted a 36% reduction in their use of clinics during the first year. 3 </li></ul><ul><li>Kabat-Zinn, J et al. (1987). Four-year follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance. Clin J Pain, 2:159-73. </li></ul><ul><li>Orme-Johnson, DW (1987). Medical care utilization and the Transcendental Meditation program. Psychosomatic Medicine, 49:493-507. </li></ul><ul><li>Caudill, M. et al. (1991). Decreased clinic use by chronic pain patients: response to behavioral medicine intervention. Journal of Chronic Pain, 7:305-10. </li></ul>
    44. 45. How Mindfulness Changes Brain Function Schwartz, J The Mind and The Brain: Neuroplasticity and the Power of Mental Force, 2002
    45. 46. The Role of Exercise <ul><li>Intentional increase of physical activity resulting in heart rate elevation of approximately 60% MHR </li></ul><ul><li>30 minutes, 2-3 x week, for 12 weeks </li></ul><ul><li>High Intensity Interval Training elicits unique hormonal responses in cortisol and testosterone </li></ul><ul><li>Steady, state aerobic training elicits transient changes in levels of neurotransmitters </li></ul><ul><li>Cognitive flexibility improves after just one 35 min treadmill session at 60% of maximum heart rate </li></ul>Ratey, J. (2008). Spark: The Revolutionary New Science of Exercise and The Brain.
    46. 47. Exercise and The Brain <ul><li>Regular aerobic activity facilitates synaptic plasticity via brain-derived neurotrophic factor </li></ul><ul><li>BDNF facilitates learning, memory and maintenance of positive emotional states </li></ul><ul><li>Cognitive flexibility improves after just one 35 min treadmill session at 60% of maximum heart rate </li></ul>Ratey, J. (2008). Spark: The Revolutionary New Science of Exercise and The Brain.
    47. 48. Aerobic Exercise v. Zoloft for Major Depression Babyak, M (2000). Exercise Treatment for Major Depression: Maintenance of Therapeutic Benefit At 10 months. Psychosomatic Medicine , 62:633-638. N=29 N=29 N=25 Those exercising were more likely to be partially or fully recovered and less likely to have relapsed
    48. 49. Mindful Eating <ul><li>Conditioned Overeating can be overcome through the practice of mindful eating </li></ul><ul><li>Guiding awareness to domains of experience before, during and after eating: </li></ul><ul><ul><ul><li>Thoughts </li></ul></ul></ul><ul><ul><ul><li>Sensations </li></ul></ul></ul><ul><ul><ul><li>Emotions </li></ul></ul></ul><ul><li>Identify personal triggers for mindless eating, such as emotions, social pressures, or certain foods </li></ul><ul><li>Awareness of physical hunger and satiety cues to guide your decision to begin eating and to stop eating </li></ul>
    49. 50. Dietary Sources of Neurotransmitters Tryptophan Tyrosine Serotonin Dopamine Norepinephrine
    50. 51. Omega-3 Fatty Acids <ul><li>Nature’s anti-inflammatory agent </li></ul><ul><li>Omega-3 and Omega-6s are essential fatty acids (EFAs) </li></ul><ul><li>Different types of Omega-3s </li></ul><ul><ul><li>EPA and DHA: tuna, salmon, mackeral </li></ul></ul><ul><ul><li>ALA: dark, leafy green vegetables and flaxseed </li></ul></ul><ul><li>Benefits include relief of diseases associated with chronic inflammation: depression, ADHD, Alzheimer’s; cardiovascular disease </li></ul>
    51. 52. Major Depression and Omega-3 Fatty Acid Consumption J.R. Hibbeln, “Fish consumption and major depression,” The Lancet 1998;351:1213. Country Rate of Depression Annual Consumption of Fish, lbs. Per capita New Zealand 5.8% 42 West Germany 5.0% 22 United States 3.0% 49 Canada 5.2% 59 Korea 2.3% 105 Japan 0.12% 144
    52. 53. Supplements for Managing Stress <ul><li>SAMe </li></ul><ul><li>L-Glutamine </li></ul><ul><li>Folic Acid </li></ul><ul><li>L-Tyrosine </li></ul><ul><li>Alpha Lipoic Acid </li></ul><ul><li>Omega-3 Fatty Acids </li></ul><ul><li>GABA </li></ul><ul><li>DHEA </li></ul><ul><li>N-acetylcysteine </li></ul><ul><li>Vitamin D </li></ul>
    53. 54. Words Matter: What To Say When
    54. 55. Empathic Communication Models <ul><li>The Four Habits of Highly Effective Clinicians </li></ul><ul><ul><ul><li>Invest in the beginning, Elicit the patient’s perspective, Demonstrate empathy, Invest in the end </li></ul></ul></ul><ul><li>The Four E’s </li></ul><ul><ul><ul><li>Engage, Empathize, Educate, Enlist </li></ul></ul></ul><ul><li>PEARLS </li></ul><ul><ul><ul><li>Partnership, Empathy, Apology, Respect, Legitimize, Support </li></ul></ul></ul>Barrier PA, Li JT, Jensen NM. Two words to improve physician-patient communication: what else? Mayo Clin Proc 2003 Feb;78(2):211-4.Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001 Apr;76(4):390-3.Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA 1997 Feb 26;277(8):678-82.
    55. 56. Key Steps to Effective Empathy <ul><li>Recognizing presence of strong feeling in the clinical setting (i.e., fear, anger, grief, disappointment); </li></ul><ul><li>  Pausing to imagine how the patient might be feeling; </li></ul><ul><li>Stating our perception of the patient's feeling (i.e., &quot;I can imagine that must be ...&quot; or &quot;It sounds like you're upset about ...&quot;); </li></ul><ul><li>Legitimizing that feeling; </li></ul><ul><li>  Respecting the patient's effort to cope with the predicament; </li></ul><ul><li>Offering support and partnership (i.e., &quot;I'm committed to work with you to ...&quot; or &quot;Let's see what we can do together to ...&quot;) </li></ul>Platt FW, Keller VF. Empathic communication: a teachable and learnable skill. J Gen Intern Med 1994 Apr;9(4):222-6
    56. 57. Statements that Facilitate Empathy <ul><li>Queries &quot;Can you tell me more about that?&quot; &quot;What has this been like for you?&quot; &quot;How has all of this made you feel?&quot; </li></ul><ul><li>Clarifications &quot;Let me see if I've gotten this right ...&quot; &quot;Tell me more about ...&quot; &quot;I want to make sure I understand what you've said ...&quot; </li></ul><ul><li>Responses &quot;Sounds like you are ...&quot; &quot;I imagine that must be ...&quot; &quot;I can understand that must make you feel ...&quot; </li></ul>Coulehan JL, Platt FW, Enger B, et al. &quot;Let me see if I have this right ...&quot;: words that help build empathy. Ann Intern Med 2001 Aug 7;135(3):221-7
    57. 58. Therapeutic Attention: The Wisdom of Listening Ordinary attention is invested in one direction But attention can be divided between the inside and the outside Speeth, Kathleen, “On Therapeutic Attention”, from The Wisdom of Listening, ed. Mark Brady, 2003 Attention can be used to notice whether the attention is inside or outside Client Therapist
    58. 59. The ABCs of Cognitive Therapies Activating Event Beliefs Disputation Consequences Energization
    59. 60. Words that Heal: A Framework for Alleviating Negative Emotions <ul><li>Listen Actively and Identify Cognitive Distortions and Automatic Negative Thoughts (ANTs) </li></ul><ul><ul><ul><li>“ Why does this always happen to me?” </li></ul></ul></ul><ul><ul><ul><li>“ What if I make a fool of myself?” </li></ul></ul></ul><ul><ul><ul><li>“ This is the worst thing that could ever happen!” </li></ul></ul></ul><ul><li>Express Empathy by Reflecting </li></ul><ul><li>Propose Alternative Ways of Thinking; Dispute Negative Thinking; Reframing </li></ul><ul><li>Consider Consequences of Changing and Not Changing; Cost/Benefits Analysis </li></ul>
    60. 61. Motivational Interviewing <ul><li>Directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence </li></ul><ul><li>Motivation to change is elicited from the client, and not imposed from without </li></ul><ul><li>It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence </li></ul><ul><li>Direct persuasion is not an effective method for resolving ambivalence </li></ul><ul><li>The counseling style is generally a quiet and eliciting one </li></ul><ul><li>The counsellor is directive in helping the client to examine and resolve ambivalence </li></ul><ul><li>Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction </li></ul><ul><li>The therapeutic relationship is more like a partnership or companionship than expert/recipient roles </li></ul>Miller, W.R. and Rollnick, S. Motivational Interviewing: Preparing People to Change. NY: Guilford Press, 2002
    61. 62. Motivational Interviewing: General Principles <ul><li>General Principles behind Motivational Interviewing </li></ul><ul><ul><li>Express Empathy </li></ul></ul><ul><ul><ul><ul><li>Reflective listening devoid of judgment or criticism </li></ul></ul></ul></ul><ul><ul><li>Support Self-Efficacy </li></ul></ul><ul><ul><ul><ul><li>Person’s belief in the possibility of change is an important motivator </li></ul></ul></ul></ul><ul><ul><li>Roll with Resistance </li></ul></ul><ul><ul><ul><ul><li>Therapeutic aikido; reframe resistance to create change </li></ul></ul></ul></ul><ul><ul><li>Develop Discrepancy </li></ul></ul><ul><ul><ul><ul><ul><li>Create and amplify discrepancy between present behavior and broader goals and values; Create “cognitive dissonance” </li></ul></ul></ul></ul></ul>Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992).  Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence
    62. 63. Fundamental Approach to Motivational Interviewing <ul><li>Collaboration </li></ul><ul><ul><ul><ul><li>Partnership that honors the client’s expertise and perspectives </li></ul></ul></ul></ul><ul><li>Evocation </li></ul><ul><ul><ul><ul><li>Resources and motivation for change are presumed to reside within the client </li></ul></ul></ul></ul><ul><li>Autonomy </li></ul><ul><ul><ul><ul><li>Counselor affirms the client’s right and capacity for self-direction and facilitates informed choice </li></ul></ul></ul></ul>Miller, W.R. and Rollnick, S. Motivational Interviewing: Preparing People to Change. NY: Guilford Press, 2002
    63. 64. Decisional Matrix Making a Change Not Changing Benefits/Pros Costs/Cons
    64. 65. Setting S.M.A.R.T. Goals <ul><li>Specific </li></ul><ul><li>Measurable </li></ul><ul><li>Attainable </li></ul><ul><li>Realistic </li></ul><ul><li>Tangible with a target date </li></ul>
    65. 66. Cultivating Optimism <ul><li>Positive Emotions about Future </li></ul><ul><ul><ul><ul><li>Optimism, hope, faith and trust </li></ul></ul></ul></ul><ul><li>Positive Emotions about Present </li></ul><ul><ul><ul><ul><li>Joy, ecstasy, calm, pleasure, flow </li></ul></ul></ul></ul><ul><li>Positive Emotions about Past </li></ul><ul><ul><ul><ul><li>Satisfaction, contentment, fulfillment, pride, serenity </li></ul></ul></ul></ul>Seligman, M. (2002) Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment.
    66. 67. Cultivating Optimism <ul><li>Gratitude </li></ul><ul><ul><ul><ul><li>Optimism, hope, faith and trust </li></ul></ul></ul></ul><ul><li>Forgiving and Forgetting </li></ul><ul><ul><ul><ul><li>REACH </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Recall, Empathize, Altruism, Commit, Hold </li></ul></ul></ul></ul></ul><ul><li>Positive Emotions about Past </li></ul><ul><ul><ul><ul><li>Satisfaction, contentment, fulfillment, pride, serenity </li></ul></ul></ul></ul>Seligman, M. (2002) Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment.
    67. 68. Resolving Conflicts in Close Relationships <ul><li>Make sure that good relationships are the first priority: As far as possible, make sure that you treat the other calmly and that you try to build mutual respect. Do your best to be courteous to one-another and remain constructive under pressure. </li></ul><ul><li>Keep people and problems separate: Recognize that in many cases the other person is not just &quot;being difficult&quot; – real and valid differences can lie behind conflictive positions. By separating the problem from the person, real issues can be debated without damaging working relationships. </li></ul><ul><li>Pay attention to the interests that are being presented: By listening carefully you'll most-likely understand why the person is adopting his or her position. </li></ul>
    68. 69. Resolving Conflicts in Close Relationships <ul><li>Listen first; talk second: To solve a problem effectively you have to understand where the other person is coming from before defending your own position. </li></ul><ul><li>Set out the “Facts”: Agree and establish the objective, observable elements that will have an impact on the decision. </li></ul><ul><li>Explore options together: Be open to the idea that a third position may exist, and that you can get to this idea jointly </li></ul>
    69. 70. How To Handle Other People’s Anger <ul><li>Active Listening – Paralanguage skills, position, posture, eye contact, facilitative responses, silence </li></ul><ul><li>Framing – “Sounds like what you are telling me…” </li></ul><ul><li>“ Let’s see if I have this right…” </li></ul><ul><li>Reflecting Content – Factual as well as nature and intensity </li></ul><ul><li>Identifying and Calibrating the Anger – Sometimes content is evident, but nature of anger is unclear </li></ul><ul><li>“ That situation really got to you, didn’t it?” </li></ul><ul><ul><li>“ I can imagine how angry I’d feel if that happened to me” </li></ul></ul>
    70. 71. How To Handle Other People’s Anger <ul><li>Requesting and Accepting the Correction – “Did I get that right...?” </li></ul><ul><li>Empathy – Three implications </li></ul><ul><ul><ul><li>Cognitive – enter patients’ perspective but don’t loose your own </li></ul></ul></ul><ul><ul><ul><li>Affective – put yourself in patient’s place </li></ul></ul></ul><ul><ul><ul><li>Action – verify emotion so patient can correct and/or feel listened to. </li></ul></ul></ul>
    71. 72. How to Keep Irritating People in Perspective <ul><li>Tips for dealing with Aggressors: </li></ul><ul><li>Let them vent: Letting them vent satisfies their need to get it all out. Wait for them to calm down. Try not to prejudge. </li></ul><ul><li>Use active listening skills: Practice active listening skills by listening to understand, not to respond. Hold your thoughts, make eye contact and take notes. Remain objective and do not take what they say personally. They may actually have a valid point once you get beyond the aggressive and dominating behavior. </li></ul><ul><li>Keep your emotions under control: An emotional response will only add fuel to the fire. If you try to point-and-counterpoint with an Aggressor, you will lose and possibly say something you will regret later. </li></ul>
    72. 73. How to Keep Irritating People in Perspective <ul><li>Hold your ground: Do not change your position out of intimidation. If you allow an Aggressor to intimidate you into getting his or her way, you will have supported the unacceptable behavior, further convincing the Aggressor that bullying behavior gets results. </li></ul><ul><li>Address the key issue only: Clarify their point on the key issue. Do not get drawn into other issues. As the Aggressor gets going, they may bring up all of the things that ever bothered them! Calmly say things like, “For now, let’s focus on your key point.” </li></ul><ul><li>Do not embarrass them: Do not embarrass them in public. This creates an aggressive defensive reaction, escalating the angry behavior. </li></ul><ul><li>Give them a way out/seek a win-win: Aggressors need to feel respected, even if they cannot be right. Say, “You know, I hear what you are saying and you make some valid points, but in order for us to move forward, it has been determined that the best path is … and we are asking that you become part of the team, even if you think we are wrong.” </li></ul>
    73. 74. Summary and Conclusions
    74. 75. Summary and Conclusions: Stress, Coping, and the Stress-Reaction Cycle <ul><li>Stress is a multifactorial phenomenon, neither inherently good or bad, whose outcome depends on an individual’s cognitive reappraisal </li></ul><ul><li>Coping includes adapative and maladaptive cognitive, behavioral, and physiologic responses to stress </li></ul><ul><li>Coping styles have direct influence over physiologic processes and disease development </li></ul>
    75. 76. Summary and Conclusions: Unhealthy Coping <ul><li>Psychopathology can result from abnormal reactions to “normal” stressors </li></ul><ul><li>Mood and anxiety disorders result from dysregulation of specific pathways in the brain </li></ul><ul><li>Neurotransmitters regulate emotional and physical symptoms in mood and anxiety disorders </li></ul>
    76. 77. Summary and Conclusions: Healthy Coping <ul><li>Cognitive-behavioral therapies </li></ul><ul><li>Positive Psychology </li></ul><ul><li>Mindfulness Based Stress Reduction </li></ul><ul><li>Exercise and the Brain </li></ul><ul><li>Dietary practices and mindful v. mindless eating </li></ul>
    77. 78. Summary and Conclusions: Words Matter <ul><li>Elements of empathic communication </li></ul><ul><li>Eliciting behavioral change through Motivational Interviewing </li></ul><ul><li>ABCs of CBT </li></ul><ul><li>Reframing and resolving conflict </li></ul>