Mindfulness in Medicine

Patricia M. Arenth, PhD

Definition

• "Mindfulness means paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.“

~Jon Kabat-Zinn

Mindfulness-Based Stress Reduction

• A specific program, designed by Jon-Kabat-Zinn.

• This program has been used with patients and individuals with all types of medical diagnoses, as well as other life stressors.

• Designed as an 8-week group program.• Participants are required to participate in

group and individual practice (“homework”)

Brief History of MBSR

• Stress Reduction Clinic was started in 1979 by Jon Kabat-Zinn at the University of Massachusetts Medical Center to care for patients.

• The Center for Mindfulness in Medicine, Healthcare and Society was formed in 1995.

• Aims of the Center: “…integration of mindfulness meditation and other mindfulness-based approaches in mainstream medicine and healthcare through patient care, research, academic medical and professional education, and into the broader society through diverse outreach and public service initiatives.”

Mindfulness as a Public Health Initiative

• Started as a program for patients– 8 week course has been offered to more than 19,000 patients at

UMass alone• Professional Education

– 8 week course and other Mindfulness-Based Inverventions now offered globally

• Annual Scientific Conference• Research• Mindful Leadership Programs• Mindfulness in Education• Programs adapted for many other populations (i.e., teens,

substance use, prisons, depression/anxiety)

MBSR vs. MBIs

• “Mindfulness-Based Stress Reduction” is a specific program, with specific training for teachers

• “Mindfulness-Based Interventions” are also valid and important tools, but are not MBSR.

• Why is the distinction important, especially right now?

Components of MBSR Course

• Breath Awareness• Body Scan• Sitting and Lying meditation• Mindful Movement (Walking, Yoga)• Mindful Awareness (eating, positive and negative

thoughts)• Didactics and discussion• PRACTICE• All day session as part of program

Why Focus on the Physical?

• “Bringing awareness to the breath in this focused way grounds us in physical reality. Entering the world of physical reality takes us out of our spinning mental world and provides a taste of experiencing”…

~Ezra Bayda

Mindfulness

MBSR Weekly Themes

• “There is more right with you than wrong with you”• Perception of and responding to situation• Triangle of awareness – body sensation, thought, and

emotion• Learning about the stress response/reactivity, stress

physiology• Distinguishing thoughts as events, with choices for

responding• Working through difficult situations• Cultivating kindness towards self and others

Being Absent vs. Being Present

• “It is a commonly held view that meditation is a way to shut off the pressures of the world or of your own mind, but this is not an accurate impression. Meditation is neither shutting things out nor off. It is seeing clearly and deliberately positioning yourself differently in relationship to them.”

~Jon Kabat-Zinn

Why Mindfulness for Rehab Populations?

Stress related to:-Chronic Disability-Chronic Pain-Cognitive difficulties-Emotional Adjustment, anxiety, depression-Changes in roles, work, finances, family-Changes in needs, priorities, way of living

Mindfulness and Rehab Patients

• Living in and finding meaning in the present life as it is, rather than continuing to focus on “the way things used to be”

• Focusing on the fact that a person is whole AS THEY ARE…

• Experiencing and examining the present to move towards future choices…

Mindfulness and Pain

• Experiencing the moment can help patients to learn to manage/work through pain

• Breathing through pain• Examining the thoughts that accompany the

experience of pain• Learning about the pain through observation• Changing the relationship to the pain

The Science Behind the Practice

• First scientific studies from Umass clinic were of chronic pain (Kabat-Zinn et al., 1985, 1986), psoriasis patients (Berhard, Kristeller and Kabat-Zinn, 1988), and anxiety (Kabat-Zinn et., al 1992).

• In recent years, research in this area has grown exponentially

• Some of the most exciting recent studies have been in the areas of neuroscience, immunology and genetics

Growth in the Literature

Physiological Changes with Mindfulness• Psychosom Med. 2003 Jul-Aug;65(4):564-70.• Alterations in brain and immune function produced by mindfulness meditation.• Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, Urbanowski F, Harrington A, Bonus K, Sheridan JF.• Source• Laboratory for Affective Neuroscience, Department of Psychology, University of Wisconsin, Madison, Wisconsin 53706, USA.

rjdavids@facstaff.wisc.edu• Abstract• OBJECTIVE: • The underlying changes in biological processes that are associated with reported changes in mental and physical health in response to

meditation have not been systematically explored. We performed a randomized, controlled study on the effects on brain and immune function of a well-known and widely used 8-week clinical training program in mindfulness meditation applied in a work environment with healthy employees.

• METHODS: • We measured brain electrical activity before and immediately after, and then 4 months after an 8-week training program in mindfulness

meditation. Twenty-five subjects were tested in the meditation group. A wait-list control group (N = 16) was tested at the same points in time as the meditators. At the end of the 8-week period, subjects in both groups were vaccinated with influenza vaccine.

• RESULTS: • We report for the first time significant increases in left-sided anterior activation, a pattern previously associated with positive affect, in the

meditators compared with the nonmeditators. We also found significant increases in antibody titers to influenza vaccine among subjects in the meditation compared with those in the wait-list control group. Finally, the magnitude of increase in left-sided activation predicted the magnitude of antibody titer rise to the vaccine.

• CONCLUSIONS: • These findings demonstrate that a short program in mindfulness meditation produces demonstrable effects on brain and immune function.

These findings suggest that meditation may change brain and immune function in positive ways and underscore the need for additional research.

Your Brain on Mindfulness• J Neurosci. 2009 Oct 21;29(42):13418-27.• Mental training enhances attentional stability: neural and behavioral evidence.• Lutz A, Slagter HA, Rawlings NB, Francis AD, Greischar LL, Davidson RJ.• Source• Waisman Laboratory for Brain Imaging and Behavior, University of Wisconsin-Madison, Madison, Wisconsin 53705,

USA.• Abstract• The capacity to stabilize the content of attention over time varies among individuals, and its impairment is a hallmark

of several mental illnesses. Impairments in sustained attention in patients with attention disorders have been associated with increased trial-to-trial variability in reaction time and event-related potential deficits during attention tasks. At present, it is unclear whether the ability to sustain attention and its underlying brain circuitry are transformable through training. Here, we show, with dichotic listening task performance and electroencephalography, that training attention, as cultivated by meditation, can improve the ability to sustain attention. Three months of intensive meditation training reduced variability in attentional processing of target tones, as indicated by both enhanced theta-band phase consistency of oscillatory neural responses over anterior brain areas and reduced reaction time variability. Furthermore, those individuals who showed the greatest increase in neural response consistency showed the largest decrease in behavioral response variability. Notably, we also observed reduced variability in neural processing, in particular in low-frequency bands, regardless of whether the deviant tone was attended or unattended. Focused attention meditation may thus affect both distracter and target processing, perhaps by enhancing entrainment of neuronal oscillations to sensory input rhythms, a mechanism important for controlling the content of attention. These novel findings highlight the mechanisms underlying focused attention meditation and support the notion that mental training can significantly affect attention and brain function.

Structural Changes in the Brain• Soc Cogn Affect Neurosci. 2010 March; 5(1): 11–17. • Published online 2009 September 23. doi: 10.1093/scan/nsp034• PMCID: PMC2840837• Stress reduction correlates with structural changes in the amygdala• Britta K. Hölzel,1,2 James Carmody,3 Karleyton C. Evans,1 Elizabeth A. Hoge,4 Jeffery A. Dusek,5,6 Lucas Morgan,1 Roger K. Pitman,1 and Sara W. Lazar1

• 1Massachusetts General Hospital, Charlestown, MA 02129, USA, 2Bender Institute of Neuroimaging, Justus-Liebig Universität Giessen, 35394 Giessen, Germany, 3University of Massachusetts Medical School, Worcester, MA 01605, 4Massachusetts General Hospital, Boston, MA 02114 and 5Abbott Northwestern Hospital, Penny George Institute for Health and Healing, Minneapolis, MN 55407, USA, 6Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, Boston, MA 02114, USA

• Corresponding author.• Correspondence should be addressed to Britta K. Hölzel, Massachusetts General Hospital, 149 13th Street, Charlestown, MA 02129, USA. E-mail:

britta@nmr.mgh.harvard.edu • Author information Article notes Copyright and License information ► ► ►• Received December 17, 2008; Accepted August 6, 2009.• Copyright © The Author (2009). Published by Oxford University Press. For Permissions, please email: journals.permissions@oxfordjournals.org• This article has been cited by other articles in PMC.• Go to:• Abstract• Stress has significant adverse effects on health and is a risk factor for many illnesses. Neurobiological studies have implicated the amygdala as a brain

structure crucial in stress responses. Whereas hyperactive amygdala function is often observed during stress conditions, cross-sectional reports of differences in gray matter structure have been less consistent. We conducted a longitudinal MRI study to investigate the relationship between changes in perceived stress with changes in amygdala gray matter density following a stress-reduction intervention. Stressed but otherwise healthy individuals (N = 26) participated in an 8-week mindfulness-based stress reduction intervention. Perceived stress was rated on the perceived stress scale (PSS) and anatomical MR images were acquired pre- and post-intervention. PSS change was used as the predictive regressor for changes in gray matter density within the bilateral amygdalae. Following the intervention, participants reported significantly reduced perceived stress. Reductions in perceived stress correlated positively with decreases in right basolateral amygdala gray matter density. Whereas prior studies found gray matter modifications resulting from acquisition of abstract information, motor and language skills, this study demonstrates that neuroplastic changes are associated with improvements in a psychological state variable.

• Keywords: stress, amygdala, gray matter, MRI, mindfulness

Your Brain on Mindfulness• Emotion. 2010 Feb;10(1):65-71.• Differential effects on pain intensity and unpleasantness of two meditation practices.• Perlman DM, Salomons TV, Davidson RJ, Lutz A.• Source• Department of Psychology, University of Wisconsin, Madison, WI 53705, USA.• Abstract• Pain is an unpleasant sensory and emotional experience that can be regulated by many different

cognitive mechanisms. We compared the regulatory qualities of two different meditation practices during noxious thermal stimuli: Focused Attention, directed at a fixation cross away from the stimulation, which could regulate negative affect through a sensory gating mechanism; and Open Monitoring, which could regulate negative affect through a mechanism of nonjudgmental, nonreactive awareness of sensory experience. Here, we report behavioral data from a comparison between novice and long-term meditation practitioners (long-term meditators, LTMs) using these techniques. LTMs, compared to novices, had a significant reduction of self-reported unpleasantness, but not intensity, of painful stimuli while practicing Open Monitoring. No significant effects were found for FA. This finding illuminates the possible regulatory mechanism of meditation-based clinical interventions like Mindfulness-Based Stress Reduction (MBSR). Implications are discussed in the broader context of training-induced changes in trait emotion regulation.

Structural Changes in the Brain• Psychiatry Res. 2011 Jan 30;191(1):36-43. Epub 2010 Nov 10.• Mindfulness practice leads to increases in regional brain gray matter density.• Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, Lazar SW.• Source• Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. britta@nmr.mgh.harvard.edu• Abstract• Therapeutic interventions that incorporate training in mindfulness meditation have become increasingly

popular, but to date little is known about neural mechanisms associated with these interventions. Mindfulness-Based Stress Reduction (MBSR), one of the most widely used mindfulness training programs, has been reported to produce positive effects on psychological well-being and to ameliorate symptoms of a number of disorders. Here, we report a controlled longitudinal study to investigate pre-post changes in brain gray matter concentration attributable to participation in an MBSR program. Anatomical magnetic resonance (MR) images from 16 healthy, meditation-naïve participants were obtained before and after they underwent the 8-week program. Changes in gray matter concentration were investigated using voxel-based morphometry, and compared with a waiting list control group of 17 individuals. Analyses in a priori regions of interest confirmed increases in gray matter concentration within the left hippocampus. Whole brain analyses identified increases in the posterior cingulate cortex, the temporo-parietal junction, and the cerebellum in the MBSR group compared with the controls. The results suggest that participation in MBSR is associated with changes in gray matter concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing, and perspective taking

Brain Connectivity• Neuroimage. 2011 May 1;56(1):290-8. Epub 2011 Feb 18.• Impact of Mindfulness-Based Stress Reduction training on intrinsic brain connectivity.• Kilpatrick LA, Suyenobu BY, Smith SR, Bueller JA, Goodman T, Creswell JD, Tillisch K, Mayer EA, Naliboff BD.• Source• David Geffen School of Medicine, University of California, Los Angeles, CA, USA. lakilpatrick@mednet.ucla.edu• Abstract• The beneficial effects of mindful awareness and mindfulness meditation training on physical and psychological health

are thought to be mediated in part through changes in underlying brain processes. Functional connectivity MRI (fcMRI) allows identification of functional networks in the brain. It has been used to examine state-dependent activity and is well suited for studying states such as meditation. We applied fcMRI to determine if Mindfulness-Based Stress Reduction (MBSR) training is effective in altering intrinsic connectivity networks (ICNs). Healthy women were randomly assigned to participate in an 8-week Mindfulness-Based Stress Reduction (MBSR) training course or an 8-week waiting period. After 8 weeks, fMRI data (1.5T) was acquired while subjects rested with eyes closed, with the instruction to pay attention to the sounds of the scanner environment. Group independent component analysis was performed to investigate training-related changes in functional connectivity. Significant MBSR-related differences in functional connectivity were found mainly in auditory/salience and medial visual networks. Relative to findings in the control group, MBSR subjects showed (1) increased functional connectivity within auditory and visual networks, (2) increased functional connectivity between auditory cortex and areas associated with attentional and self-referential processes, (3) stronger anticorrelation between auditory and visual cortex, and (4) stronger anticorrelation between visual cortex and areas associated with attentional and self-referential processes. These findings suggest that 8 weeks of mindfulness meditation training alters intrinsic functional connectivity in ways that may reflect a more consistent attentional focus, enhanced sensory processing, and reflective awareness of sensory experience

MBSR and Stress Reduction• J Clin Psychol. 2012 May 23. doi: 10.1002/jclp.21865. [Epub ahead of print]• Weekly Change in Mindfulness and Perceived Stress in a Mindfulness-Based Stress Reduction Program.• Baer RA, Carmody J, Hunsinger M.• Source• University of Kentucky.• Abstract• OBJECTIVE: • The purpose of the study was to examine weekly change in self-reported mindfulness and perceived stress in participants who

completed an 8-week course in mindfulness-based stress reduction (MBSR).• METHOD: • Participants were 87 adults with problematic levels of stress related to chronic illness, chronic pain, and other life

circumstances (mean age = 49 years, 67% female) participating in MBSR in an academic medical center. They completed weekly self-report assessments of mindfulness skills and perceived stress. It was hypothesized that significant improvement in mindfulness skills would precede significant change in stress.

• RESULTS: • Mindfulness skills and perceived stress both changed significantly from pretreatment to posttreatment. Significant increases in

mindfulness occurred by the second week of the program, whereas significant improvements in perceived stress did not occur until week 4. Extent of change in mindfulness skills during the first three weeks predicted change in perceived stress over the course of the intervention.

• CONCLUSIONS: • Evidence that changes in mindfulness precede changes in perceived stress in a standard MBSR course is consistent with

previous studies suggesting that improvements in mindfulness skills may mediate the effects of mindfulness training on mental health outcomes

MBSR and Chronic Illness• Aust J Prim Health. 2010;16(3):200-10.• Mindfulness-based stress reduction for people with chronic diseases.• Merkes M.• Source• Australian Institute for Primary Care, La Trobe University, Bundoora, Vic. 3086, Australia.

m.merkes@latrobe.edu.au• Abstract• Mindfulness-based stress reduction (MBSR) is a structured group program that uses mindfulness meditation to

improve well-being and alleviate suffering. This article reviews the impact of MBSR for people with chronic diseases. The review includes original research that was published in English and peer-reviewed and reported outcomes for adults with chronic diseases who had participated in an MBSR program. Fifteen studies were identified. Outcomes related to mental and physical health, well-being, and quality of life. The studies included different research designs, and used self-report and physiological outcome measures. Participants' clinical diagnoses included fibromyalgia, chronic pain, rheumatoid arthritis, type 2 diabetes, chronic fatigue syndrome, multiple chemical sensitivity, and cardiovascular diagnoses. All 15 studies found that participation in an MBSR program resulted in improvements. No negative change was reported between baseline and follow up. Outcomes in regard to specific variables were difficult to compare and equivocal. Overall, positive change predominated. Chronic diseases are associated with a range of unwelcome psychological and physical consequences. Participation in an MBSR program is likely to result in coping better with symptoms, improved overall well-being and quality of life, and enhanced health outcomes. As an adjunct to standard care, MBSR has potential for much wider application in Australian primary care settings.

Mindfulness and Cancer• Psychosom Med. 2003 Jul-Aug;65(4):571-81.• Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and

prostate cancer outpatients.• Carlson LE, Speca M, Patel KD, Goodey E.• Source• Department Psychosocial Resources, Tom Baker Cancer Centre, Calgary, Alberta, Canada. lcarlso@ucalgary.ca• Abstract• OBJECTIVES: • This study investigated the relationships between a mindfulness-based stress reduction meditation program for early stage breast and

prostate cancer patients and quality of life, mood states, stress symptoms, lymphocyte counts, and cytokine production.• METHODS: • Forty-nine patients with breast cancer and 10 with prostate cancer participated in an 8-week MBSR program that incorporated

relaxation, meditation, gentle yoga, and daily home practice. Demographic and health behavior variables, quality of life (EORTC QLQ C-30), mood (POMS), stress (SOSI), and counts of NK, NKT, B, T total, T helper, and T cytotoxic cells, as well as NK and T cell production of TNF, IFN-gamma, IL-4, and IL-10 were assessed pre- and postintervention.

• RESULTS: • Fifty-nine and 42 patients were assessed pre- and postintervention, respectively. Significant improvements were seen in overall

quality of life, symptoms of stress, and sleep quality. Although there were no significant changes in the overall number of lymphocytes or cell subsets, T cell production of IL-4 increased and IFN-gamma decreased, whereas NK cell production of IL-10 decreased. These results are consistent with a shift in immune profile from one associated with depressive symptoms to a more normal profile.

• CONCLUSIONS: • MBSR participation was associated with enhanced quality of life and decreased stress symptoms in breast and prostate cancer

patients. This study is also the first to show changes in cancer-related cytokine production associated with program participation.

Mindfulness and Cancer• Brain Behav Immun. 2007 Nov;21(8):1038-49. Epub 2007 May 22.• One year pre-post intervention follow-up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-based stress

reduction (MBSR) in breast and prostate cancer outpatients.• Carlson LE, Speca M, Faris P, Patel KD.• Source• Department of Psychosocial Resources, Tom Baker Cancer Centre Holy Cross Site, Alberta Cancer Board, 2202 Second St. S.W., Calgary, Alta.,

Canada T3B 0W7. lindacar@cancerboard.ab.ca• Abstract• OBJECTIVES: • This study investigated the ongoing effects of participation in a mindfulness-based stress reduction (MBSR) program on quality of life (QL),

symptoms of stress, mood and endocrine, immune and autonomic parameters in early stage breast and prostate cancer patients.• METHODS: • Forty-nine patients with breast cancer and 10 with prostate cancer enrolled in an eight-week MBSR program that incorporated relaxation,

meditation, gentle yoga and daily home practice. Demographic and health behaviors, QL, mood, stress symptoms, salivary cortisol levels, immune cell counts, intracellular cytokine production, blood pressure (BP) and heart rate (HR) were assessed pre- and post-intervention, and at 6- and 12-month follow-up.

• RESULTS: • Fifty-nine, 51, 47 and 41 patients were assessed pre- and post-intervention and at 6- and 12-month follow-up, respectively, although not all

participants provided data on all outcomes at each time point. Linear mixed modeling showed significant improvements in overall symptoms of stress which were maintained over the follow-up period. Cortisol levels decreased systematically over the course of the follow-up. Immune patterns over the year supported a continued reduction in Th1 (pro-inflammatory) cytokines. Systolic blood pressure (SBP) decreased from pre- to post-intervention and HR was positively associated with self-reported symptoms of stress.

• CONCLUSIONS: • MBSR program participation was associated with enhanced quality of life and decreased stress symptoms, altered cortisol and immune

patterns consistent with less stress and mood disturbance, and decreased blood pressure. These pilot data represent a preliminary investigation of the longer-term relationships between MBSR program participation and a range of potentially important biomarkers

“The Emotional Life of Your Brain”New Book by Richard Davidson

• “Outlook Style”– Resilience (Fast to recover – Slow to Recover)– Outlook (Negative – Positive)– Social Intuition (Puzzled – Socially Intuitive)– Self-Awareness (Self Opaque – Self Aware– Sensitivity to Context (Tuned Out – Tuned In)– Attention (Unfocused – Focused

• Neural Correlates for Each• Plasticity – we can choose to make changes

How can Mindfulness Impact Care?

• For patients• For clinicians• For clinical teams• For Health Systems• For Society

Contact Information:Patty Arenth

arenthpm@upmc.edu412-648-6186