Jeff Young, MD

Chronic Stress, Health Consequences and the Opportunity

to Become More Resilient

Jeff Young, MD

Topics Resilience defined

Brief overview: Acute and chronic stress; consequences

The off switch, mind-body medicine strategies

The Healthy Mind Platter

Why Mindfulness?

Mindfulness meditation versus mindful awareness

Mindfulness exercises

Resources for further exploration

Resilience

“The ability to successfully adapt and function proficiently when faced with traumatic circumstances”

“An organism with the ability to adapt to challenging environments will be able to minimize physiologic damage”

“The ability to bounce back from adverse circumstances and go on”

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Acute

Stress Response:

Effect on the Hypothalamic-Pituitary-Adrenal Axis

“Fight-or-Flight” Response

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Chronic Stress:Cause:

Due to repeated severe stressors, OR related to daily life insecurities/fear, cognitive distortions, threats to ego, loss of sense of control, unpredictability

Consequences: Brain remodeling (“plasticity”: more on next slide) HTN, CVD, Increased blood glucose Ulcers Anxiety, depression, burnout, exhaustion, “Stressed

out”: insomnia, XS eating, smoking, drinking, social withdrawal, seeking of medication solutions

Immune dysfunction Epigenetic changes Accelerated aging: decreased telomerase and

telomere shortening, decreased anti-oxidant activity, increased oxidative stress1

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Consequences of Chronic Stress: Brain plasticity, “neurons that fire together wire

together, and survive together” (Dan Siegel) : Habits remodel the brain and strengthen

proclivity for that habit Synaptic and dendritic remodeling

demonstrated with PET and fMRI: Atrophy of hippocampus, PFC Hypertrophy of amygdala Result:

diminished ability to cognitively process and respond to stressors

over-active amygdala.

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The Off Switch: The Relaxation Response Opposite physiology of acute stress

response2 mediated by parasympathetic NS: Decreased metabolism, Oxygen consumption,

carbon dioxide elimination, BP and respiratory rate, increased production of healthful nitric oxide3

Decreased heart rate and increased heart rate variability4

Decreased brain activity/increased alpha waves, state of “well being”, reduced psychological distress

Increased brain activity (fMRI) in attention and decision making regions (pre-frontal cortex) of brain5

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Mind-Body Medicine: Strategies for Wellness and Healthy Aging The “relaxation response”:

Increased brain cortical thickness in prefrontal cortex and right anterior insula in those who intensively meditate. First evidence of experience-dependent cortical plasticity associated with meditation practice6

Is associated with changes in gene expression opposite of those associated with stress7

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Strategies for wellness and resiliency

Ancient and modern strategies for eliciting the relaxation response: Meditation Imagery Biofeedback Autogenic Training (self-hypnosis) Breathing Techniques Yoga, Tai Chi, Qi gong, Repetitive-prayer

Relationships; helping others Healthy life-style and self care: sleep,

nutrition, moderate exercise, avoid smoking, hobbies

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Additional wellness strategies Development of self awareness and clarification of

personal values/priorities8

Spirituality: developing this aspect of self

Work attitudes and management: finding meaning, choosing to limit/manage aspects of work life

Positivity: playfulness, gratitude, awe, love, interest, serenity, feeling connected to others

Cognitive reframing

Not relying solely on medications or procedures to correct health problems

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The Healthy Mind Platter

Sleep time, physical time, focus time, down time, play time, connecting time, TIME IN.9

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Mindfulness and neural networks “Narrative”/”default” network:

Medial PFC, hippocampus

Where we keep our story, strategizing, planning, keeping track of self vs other,

“Monkey mind”, dreaming, resting mind, autopilot mind

Feels captivating: rehashing, rehearsing, ruminating

Nothing wrong with it, just wouldn’t want to spend life here

Mindfulness and neural networks

Direct experience network:

Lateral PFC, right insula where we perceive sensations, anterior cingulate cortex which switches our attention

You experience information coming to your senses in real time

Activated with mindful attention

Compare and contrast the two

Why Mindfulness? Promotes self awareness, self-regulation, positive

relationships between self and other, and increases pro-social characteristics…self transcendence.

Improving one’s awareness of sensations/thoughts/feelings, and yet, reducing one’s reactivity to challenging situations and feelings even if unpleasant.

Promotes action with awareness and attention.

Enhances our openheartedness

With practice: facilitation of more conscious choices, emotional regulation--equanimity, improved performance

Mindful awareness Not religious or esoteric, more about understanding

ourselves, anybody can do it, with perseverance

Everyday life awareness and presence

Enhances ability to "place and hold attention"10, leave the commentary (“narrative”/default network) and return to the present (direct experience network), improve perception of your thoughts and feelings, make choices.

Practices

Picking a project, eg. Intending to watch for the expression of an issue in the course of the day

Pausing

Paying attention to the simple activities

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Mindfulness meditation Intentional self-regulation of attention conducted

without judgment and focused on observation of the present moment using a point of focus

There is no single posture

Still or moving

Generally involves an object of focus

Noticing when our mind has wandered and gentle coming back to the focus without judgment and beginning again, and again. This is the practice

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Mindfulness practices Leaning forward with intention: COAL

Reasonable expectations for mindfulness and meditation

Meditation examples:

Somatic centering/grounding

Focused attention while still; the breath

(with movement: walking meditation, yoga, Tai Chi)

Loving kindness meditation

Special place imagery

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Resources: Mindfulness meditation coaching:

The Healthy Mind Platter: David Rock, Dan Siegel http://www.davidrock.net/files/

02_The_Healthy_Mind_Platter_US.pdf

Mindfulness meditation: Mindfulness for Beginners, Kabat-Zinn (CD) Your Brain at Work, David Rock Walk Like a Buddha, Lodro Rinzler Healing the Healer, Saki Santorelli The Mindful Path to Self-compassion, Germer and Salzberg Loving Kindness Meditation, Sharon Salzberg Zen Living, Domyo Burk

Physician wellness programs example:

http://healthandwellness.vanderbilt.edu/work-life/faculty-physician-wellness/

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References:1. Epel et al. PNAS USA 101:17312-5, 2004

2. Benson et al. The relaxation response. Psychiatry 37(1) 37-46, 1974.

3. Benson. Relaxation Revolution, 2010.

4. Thayer et al. A meta-analysis of heart rate variability and neuroimaging studies; implications for HRV as a marker of stress and health. Neurosci Behav Revs 36, 747-756, 2012

5. Lazar et al. Functional brain mapping of the RR and meditation. ANS, Vol 11, no7. 1581-1585. 2000

6. Lazar, et al. Meditation experience is associated with increased cortical thickness. NIH Neuroreport; 16(17): 1893-1897. 2005

References:7. Dusek et al. Genomic counter-stress changes induced

by the relaxation response. PLoS ONE 3(7): e2576. doi:10.1371/jounrnal.pone.0002576. 2008.

8. Shanafelt, The well-being of physicians. A J of Med. 114:513-19, 2003

9. Rock and Siegel, The Healthy Mind Platter

10. Burk, The Zen Guide for Living, 2014