Robert B Ellis, DO, PhD FACP, CS Medical Oncology and Integrative Medicine Northwest Permanente Medical Group Clinical Assistant Professor of Medicine College of Osteopathic Medicine of the Pacific

OPSO Fall CME September 2015

I have no conflict of interest to report in terms of the material that I will discuss

I will not discuss any off label uses of pharmaceutical drugs or agents.

My opinions are my own and do not necessarily reflect those of Northwest Permanente, Kaiser Permanente or the College of Osteopathic Medicine of the Pacific.

44% of Americans feel more stressed than they did 5 years ago

1 in 5 Americans report “Extreme Stress” – Shaking, Heart Palpitations, Depression

56.3% of employees report stress has caused difficulty focusing on tasks

Over 14% report missing days at work or being late due to stress

21% report stress has caused them to make errors or miss deadlines

Stress-related ailments costs the nation $300 billion every year in medical bills

and lost productivity

75 -90% of all doctor’s office visits are for stress-related illness/disease

Stress is the basic cause of 60% of all human illness/disease

40% of stressed people overeat or eat unhealthy foods

44% of stressed people lose sleep every night

Stress is linked to the six leading causes of death – heart disease, cancer, lung

ailments, accidents, cirrhosis of the liver and suicide

Sources: http://www.compsych.com/press-room/press-releases-2010/353-nov-22-2010;

http://pyschcentral.com/lib/2007/how-does-stress-affect-us/

; http://apa.org/news/press/releases/phwa-survey-summary.pdf; "http://www.mastersdegreeonline.org/master-your-stress/

American College of

Physician Executives Survey

(2006)

1200 practicing physicians

6 in 10 have considered leaving

the profession

67% experience burnout

33% reported depression

Marital/family discord 34.2%

Emotional burnout 66.7%

Depression 32.2%

32% showed “high” levels of

emotional exhaustion

13% had “high” levels of

depersonalization

4% reported a low sense of

personal accomplishment

A person experiences stress when a demand exceeds a person’s coping abilities. resulting in reactions such as disturbances of cognition, emotion, and behavior that can adversely affect well-being Hans Selye, considered by many as the father of the study of stress, developed the idea that a direct relationship exists between chronic stress and excessive wear and tear throughout the body.

General Adaptation Syndrome (GAS)-response to stressors Three stages

▪ Alarm stage Arousal of body defenses

▪ Stage of resistance or adaptation Mobilization contributes to fight or flight

▪ Stage of exhaustion Progressive breakdown of compensatory mechanisms

Psychophysiology is a term to describe the body’s physiological reaction to perceived stressors suggesting that the stress response is a mind-body phenomenon.

Central Nervous System

Perception - Narrowed Memory - Coarse, Imprecise Learning - Blocked Conditioning - Defense Tendency - Regress or Perseverate Tone – Fight or Flight

Muscular System Tension Ready for Action Jaws Clench Body Braces for Action

Autonomic Nervous System Heart rate increases Blood pressure increases Oxygen need increases Breathing rate increases Palms, face sweat Blood sugar increases Adrenalin flows Digestive tract shuts down blood to muscles Blood vessels constrict in hands, face

Normal homeostasis (body temperature, etc) is

maintained within relatively narrow limits.

By contrast, the stress response maintains

homeostasis over a far wider range of adaptive

circumstances, and in responding to challenges.

This is 'allostasis': achieving stability through

change.

It occurs via the 'stress response'.

Limbic system: Adds emotional dimensions to stress perception: fear,

anger, anxiety

Especially centered in the hypothalamus

Worsened blood sugar control/increased

insulin resistance

Increased visceral fat deposition (apple-shaped

weight gain)

Increased inflammation

Decreased immunity

Hippocampal atrophy

CHD and stroke Gastrointestinal problems such as ulcers Impaired immune system Insomnia, headache and Backache Drug & alcohol use Cancer:

Increased relapse rates and

shortened survival

Maintaining stress

and adaptive

responses over

the long term

implies high levels

of activation of the

homeostatic

processes

This causes wear

and tear, called

'allostatic load'.

Resting response level

Allostasis

Perf

orm

an

ce

Stress (arousal)

–

–

+

+

Rust out

Comfort zone

Peak performance

Wear

out

Burn

out

16

“To understand the stress response, we must process a fundamental knowledge not only of psychology but of physiology as well.”

—George Everly

Relaxation Response

The biology of the relaxation response

Meditate on this, I will."

Mental- emotional

Physical

Mindfulness

Relaxation response

Herbert Benson, MD

founding President of the Mind/Body Medical Institute

Associate Professor of Medicine, Harvard Medical School

Counterbalancing mechanism to the Fight-or-Flight Response

Metabolism decreases

Heart rate decreases

Blood Pressure decreases

Breathing Rate decreases

Muscle Tension decreases

May be consciously elicited Generally needs to be practiced

Diaphragmatic

Breathing

Meditation

Body Scan

Mindfulness

Repetitive exercise

Repetitive prayer

Progressive muscle

relaxation

Yoga Stretching

Imagery

(Music)

“Mindfulness means paying attention in a particular way; On purpose, in the present

moment, and nonjudgmentally.”

-Jon Kabat-Zinn Founder of Mindfulness-Based Stress Reduction (MBSR)

Deliberate, sustained non-judgmental way of paying attention to one’s experience

Enhance self awareness

Change maladaptive thinking

Increase capacity skillful response to challenges

Reduce suffering

“Clear” Nonconceptual, nondiscriminatory Flexibility Empirical Oriented to the present moment Stability

In 1979, Jon Kabat-Zinn created Mindfulness-Based Stress Reduction (MBSR) at the University of Massachusetts Medical School to treat chronically ill patients.

Angina

Arrhythmias

Allergic skin reactions

Anxiety

Depression

Asthma

Herpes simplex

Cough

Constipation

Diabetes

Ulcers

Dizziness

Fatigue

Hypertension

Infertility

Nausea & vomiting

Nervousness

Pain

Postoperative swelling

Premenstrual syndrome

Rheumatoid arthritis

Side effect of cancer

Side effects of HIV/AIDS

Any condition caused by or

complicated by stress

Insomnia

With 7 weeks of meditation, cancer patients decreased their degree of depression, anxiety, anger, confusion, and chest and stomach symptoms by 50% - and felt more vigor.

With 10 weeks of meditation, 2/3’s of chronic pain patients had a 30% reduction in pain, and half had more than a 50% reduction.

With 10 weeks of meditation, chronic pain patients had less pain, less mood disturbances, used less pain medication, and could be more active. The benefits were still present one year later.

Three years after an 8-week meditation instruction, patients with anxiety and panic disorders still showed a benefit.

All patients with fibromyalgia who meditated for 10 weeks improved, and over half showed moderate to marked improvement in pain, fatigue and quality of sleep.

Medical benefits of meditation

Patients who meditated during ultraviolet light treatment for

psoriasis had quicker clearing of their skin disease.

With 6 months of meditating for 20 minutes twice a day,

hypertensive African Americans had a decrease in the carotid

artery wall thickness.

With 4 years of daily meditation, coronary artery narrowing

showed regression rather than progression.

Over a 5 year period, people who meditated had over 50% less

doctor’s office visits, and an average of 50% less hospital admissions (including a reduction all 17 major treatment

categories such as benign and malignant tumors, heart disease,

infectious disease, and nervous system disorders). Only childbirth rates were the unchanged.

Medical benefits of meditation

Meditation has been found to be quite useful in most of the including asthma, rheumatism, gut problems, blood pressure, diabetes etc.

With 6 weeks of meditation irritable bowel syndrome patients had less flatulance, belching, bloating and diarrhea.

Even though daily fluctuations in cortisol are unchanged, people who meditate don’ t have the daily fluctuations in the cortisol-stimulating hormone (ACTH), or beta-endorphins, suggesting a change in feedback sensitivity.

People trained in and performing an imagery-based relaxation prior to injection, had less inflammatory reaction to chili pepper “extract” (capsaicin) injected under the skin.

With 6 months of meditation, athletes had less increase in the CD8+ suppressor T cell response to strenuous physical stress, improving the immune system’s helper to suppressor cell ratio. It also reduces post-traumatic stress.

Medical benefits of meditation

Genomic Counter-Stress Changes Induced by the Relaxation Response

Jeffery A. Dusek et al Published: July 2, 2008 DOI: 10.1371/journal.pone.0002576

Manoj K. Bhasin et al

Published: May 1, 2013 DOI: 10.1371/journal.pone.0062817

Our results for the first time indicate that RR elicitation, particularly after long-term practice, may evoke its downstream health benefits by improving mitochondrial energy production and utilization and thus promoting mitochondrial resiliency through upregulation of ATPase and insulin function. Mitochondrial resiliency might also be promoted by RR-induced downregulation of NF-κB-associated upstream and downstream targets that mitigates stress.

Expert meditators (those with ten thousand or more hours of meditation training) were subjected to negative sounds (for example, a woman screaming), they showed lesser activation in the part of the emotional brain called the amygdala compared to novice meditators.14 Furthermore, the more hours of meditation training the expert had, the lower the activation in the amygdala. This is fascinating because the amygdala has a privileged position in the brain—it is our brain’s sentinel, constantly scanning everything we see for threats to our survival. The amygdala is a hair trigger, which would rather be safe than sorry. When your amygdala detects what looks like a threat to your survival, such as a saber-toothed tiger charging at you or your boss slighting you, it puts you in a fight-flight-freeze mode and impairs your rational thinking. simply with attention training, you can become good at regulating a part of the brain as

primitive and important as the amygdala

Based on the premise that the mind and body are intimately interconnected. Utilizes techniques to optimize this relationship for improved health and wellbeing.

Teach mindfulness-based skills that can be integrated into daily life to reduce stress, manage pain, enhance sleep, strengthen positive qualities, and improve overall quality of life.

Offers a low-cost, self-directed, complement to traditional medical care.

Broadly encompassing field

Addresses core questions of human nature

▪ Faculties mind and consciousness

▪ How the mind and body interact

▪ Nature of healing

Supports the principle of interconnectedness of mind, brain, body.

Psychoneuroimmunology

Psychoneuroendocrinology

Mindfulness Attention training to cultivate qualities of concentration, clarity, and

equanimity. The common thread connecting all other skills.

Relaxation Techniques to elicit the relaxation response in mind and body

Yoga Movement and breathing strategies to synchronize mind and body

and release tension.

Positive Psychology Practices to cultivate and strengthen positive mind/emotional states.

Resiliency Training Techniques for balancing the nervous system, processing trauma, and

strengthening the ‘resilient zone’.

Grounded in systems theory

Complex system viewed as a nonlinear dynamic “whole”

Capacity to self-regulate via feedback loops

Maintains stability while allowing for adaptability

Conscious self-regulation amplifies feedback

Pathway model: attention > connection > regulation > order > health/ease disattention > disconnection > disregulation > disorder

>disease

“the key to fostering self-regulation lies in the nature of the intention to direct attention”

Intention as an initiating antecedent: intention>attention>connection>regulation>order> health

Intention toward mindfulness qualities and systemic perspectives

“Implementation” or process intention

“Reductionistic” self-regulation techniques focus on symptoms or isolated goals and ignore the system

Concentration: The ability to focus and stabilize one’s attention.

Sensory Clarity: The ability to keep track of the components of sensory experience as they arise in various combinations, moment-by-moment.

Equanimity: The ability to ‘be with’ experience with an attitude of gentle matter-of-factness.

Regular Practice Cultivates 3 Core Skills

Let us now take three slow, deep breaths to inject both energy and relaxation into our practice. Now, let us breathe naturally and bring a very gentle attention to your breath. You can either bring attention to the nostrils, the abdomen, or the entire body of breath, whatever that means to you. Become aware of in breath, out breath, and space in between. If you like, you can think of this exercise as resting the mind on the breath. You can visualize the breath to be a resting place, or a cushion, or a mattress, and let the mind rest on it, very gently. Just be. If you like you can count the breaths or just watch them. If at any time you feel distracted by a sensation, thought, or sound, just acknowledge it, experience it, and very gently let it go. Bring your attention very gently back to the breathing. If you like, let us end this meditation by inviting joyful inner peace to arise. Breathing in, I am calm. Breathing out, I smile.

1. They work! For commonly seen acute and chronic conditions

2. They promote greater self-awareness and reflection for patients and providers

3. It encourages self care for providers

Old Brain Vs.

New Brain

What do you do?

What are the barriers?

How do you identify candidates?

How can you find enough time?

People are more open to this than you think.

But it takes so long!

It can – but you can always begin with a short version and expand later or give the patient handouts or websites

Just plant the seed….

• Formal practice – meditation • e.g. bodyscan, mindful movement, sitting practice,

breathing space

• Informal Practice – awareness of body sensations, thoughts, emotions and sensory input during daily life. • Practiced in ordinary activities like eating, washing

brushing teeth

Hinduism in India between 3000 and 4000 BC

Buddhism 600 BC

Judaism & Christianity & Hinduism

Progressive Muscle Relaxation - 1929

Autogenic Training - 1932

Biofeedback - 1968

Transcendental Meditation (TM) - 1972

Relaxation Response - 1975

Applied Relaxation - 1976

Mindfulness - 1979

One important similarity between exercise and meditation is that, in both cases, growth comes from overcoming resistance.

Every time your attention wanders away from your breath and you bring it back, it is like flexing your biceps—your “muscle” of attention grows a bit stronger.

Mindfulness of the body breath, contact, movements, technical skills

bodily sensations as a clue to state of mind

Mindfulness of feelings and emotions unpleasant and pleasant sensations (the “sinking

feeling”)

sadness, anxiety, heaviness, acceptance (dx of mental disorders)

Mindfulness of thoughts, attitudes, beliefs state of alertness/attentiveness/distractedness

“holding on”/“letting go”

cognitive processes (decision-making, “reflection”)

©Mindful Practice Programs, University of Rochester, 2010

1) Diaphragmatic breathing 2) Now add counting 3) Now add words. The hardest part may be “selling” it to the patient

Emphasize that this does NOT mean symptoms are “all in your head”

Explain how slow, deep breathing turns off the body’s “alarm system” which decreases adrenaline to all body parts (esp helpful re: pain, spasm)

Discuss how people have different set-points of arousal and this is a way to reset a taxed system

Note that it is free and no one needs to be aware of the practice if it’s needed in social situations.

Just get them to try it!

“Place hand on your stomach under the belly button. Breathe in and out. Notice if your hand moved. Now breathe in again and allow your stomach to fill with air; allow it to flatten as you breathe out.”

This may take practice for some patients

Sometimes they can feel it better if they

▪ Lie down

▪ Loosen tight clothing

▪ Let you hold their shoulders

Once they can breathe from the diaphragm “Now I will count for you as you breathe. Try breathing in for a count of 4, hold it for 4, then exhale for 4.”

As the patient relaxes you may be able to slow your counting. If he or she is too anxious to be able to do this,

just focus on the rhythm of “In, hold, out.” Some may want to try 4,7,8 breathing.

Examples from patients:

“Breathing in hope, breathing out fear” “Breathe air in, hold it in, breathe it out” Light comes in, cleaning house, dark goes out”

Remind patients that practicing when NOT overly stressed helps to teach their body how to relax better when needed.

Can link it to a smell and use the smell later to trigger relaxation.

Phase One 1. Pick a focus word, phrase, image or short prayer Or focus n

breathing 2. Find a quiet place and sit calmly in a comfortable position 3. Close your eyes 4. Progressively relax all your muscles 5. Breathe slowly and naturally. As you exhale repeat or picture

your image. 6. Assume a passive attitude When thoughts intrude, think oh

well and return to focus 7. Continue with this exercise for an average of 12-15 minutes. 8. Practice at least once per day.

Phase 2

Use mental imagery such as a picture of a scene in which you are free of medical condition or engage healing intention, belief.

Practice 8-10 minutes

Figure 4.14. Benson’s relaxation response. The relaxation procedure advocated by Herbert Benson is a

simple one that should be practiced daily.

From Benson, H., & Klipper, M.Z. (1975, 1988). The relaxation response. New York: Morrow.

Copyright © 1975 by William Morrow & Co. Reprinted by permission of HarperCollins Publishers.

Kabat-Zinn body scan is 45 minutes long Wonderful but can be hard to do in the office or ask

patients to do at home Shorter versions are great introductions The goal is to bring nonjudgmental attention to

each part of the body Just notice what is there

May be helpful to just think of colors rather than adjectives like “tight” or “hot”

Can add intention to relax or release or just notice what is there

This can be really helpful for those who have disconnected from their physical body

Can decrease some of the anxiety, generalizations when in pain: “Oh, it’s just that part of me– not my whole self”. “Look how much is not affected.”

Can help track changes over time Can give you and the patient information Helpful for those who do better with pictures

and color than with words.

Stop, breathe, be.

For the next week, each time you begin a new activity, or see a patient, stop momentarily before beginning, take a breath, and then begin.

Formal practice

Two minutes each morning

Two minutes each evening

Increase as tolerated

©Mindful Practice Programs, University of Rochester, 2010

Every day, find 2 brief opportunities during the

work day to stop briefly, take a breath and pay

attention to the moment

Notice the things in your environment you are reacting to

Notice any bodily sensations, thoughts and emotions

Take 2 minutes each morning and 2 minutes each

evening to breathe. Perhaps do 20 breaths – 10 in

the morning, 10 in the evening. Increase as

tolerated.

©Mindful Practice Programs, University of Rochester, 2010

Stop

Take a breath

Observe (What’s happening now?)

Proceed (What’s called for now?)

Patients with mental illness, especially with a history of psychosis or diffuse dissociative disorders may be at risk for being overwhelmed by emotional content, especially if explorative techniques are used.

Approximately 10–15% of patients have relaxation-induced anxiety and will become more anxious when asked to close their eyes, or as they begin to relax and do imagery work.

Patients can help themselves by using mind–body approaches, it does not mean that they caused their disease by mind–body error or neglect. Mind–body approaches should offer patients an opportunity to

participate in their efforts toward recovery or acceptance, and not be construed as “blaming the victim.”

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.

- Viktor Frankl

•Attentive observation

•Critical curiosity

•Beginners mind

•Presence

•Quality of care •Noticing

•Clinical reasoning

•Technical skills

•Quality of caring •Compassion

•Empathy

•Ethics

•Well-being •Adaptability

•Self-care

•Self-monitoring ©Mindful Practice Programs, University of Rochester, 2010

Mindful practitioners attend in a nonjudgmental way to

their own physical and mental processes during ordinary,

everyday tasks. This critical self-reflection enables physicians

to listen attentively to patients’ distress, recognize their own

errors, refine their technical skills, make evidence-based

decisions, and clarify their values so they can act with

compassion, technical competence, presence, and insight.

Epstein, RM. JAMA. 1999; 282:833-839.

Participants demonstrated improvements in:

Mindfulness

Burnout

Total mood disturbance

Emotional stability

Empathy

Stanford University’s School of Medicine The Center for Compassion and Altruism Research and Education (CCARE)

Which one are we?