3-Stonnington-Cynthia Building-Resilience-in-Medicine · Attachment Theory: A Guide for Primary Care Practitioners and Specialists , 2016. Physical symptoms threat to body integrity

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©2015 MFMER | slide-1

Building Resilience in Medicine

Cynthia M Stonnington, M.D.Associate Professor of PsychiatryChair, Dept. Psychiatry & Psychology, Mayo Clinic in ArizonaWellness Director, Mayo Clinic College of Science and Medicine, Mayo Medical School-Arizona, Mayo [email protected]


Nothing to disclose


Objectives

• Define resilience and review the science behind the concept.

• Explain the role of early adverse events and attachment systems in regulation of stress and affect.

• Develop treatment strategies for chronic headache that focus on function over symptoms, increased self-efficacy, and empowerment.

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Flourishing

• Absence of mental/physical illness is not the presence of mental/physical health*

• Even among patients with same severity/frequency of headaches, great variability in functional outcomes

Pain defines life Thriving despite pain

.*Keyes, C.L.M, Promoting and Protecting Mental Health as Flourishing. American Psychologist, 2007


Resilient pain responses

• Shaped by

• Individual qualities

• Social/environmental factors

• Many of these responses can be learned and hold promise as treatment targets

• for patients

• for the way we respond to our patients


Woke up with a headache….

Acceptance + belief in one’s ability to cope

Paced breathing, judicious medication, mindfulness and self-compassion, revised action plan guided by

values

Full life

Ignore

I can’t afford to have a headache so I will act

as if I don’t have one—that is what “strong”

people do

Ultimately crashes and then hates self for

being “weak” and not being able to live life

as desired

Catastrophize

What if doesn’t work and I can’t function? I have so much to do

today! I may lose the promotion I have been

working so hard for.

Life becomes dictated and defined by

headaches

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Patient complains of persistent or refractory headaches

Empower

Validate suffering

Don’t blame, do ask questions that facilitate jointly finding solutions

to increase function and QOL

Dismiss

Get annoyed, symptoms must be

psychological

Patient either goes elsewhere or does not

adhere with recommendations

while feeling misunderstood

Collude

I am pressed for time; maybe this new

medication you heard about on TV will do the

trick

Order lots of tests and prescribe more

medications; reinforce belief that eliminating

pain is the answer to a good life


ResilienceAdapt to, respond to, and recover from

current and potential life stressors


Common Qualities

• Focused attention and calm state

• Sought out and expressed human connections.

• Imitated role models

• They valued and loved something or someone.

• Approached instead of avoided (confronted fears). Acted rather than reacted.

• Accepted responsibility for their own emotional well-being.

• Optimistic but realistic outlook.

Adapted from: “Resilience: The Science of Mastering Life's Greatest Challenges” by Southwick and Charney

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Broaden and Build

•Pay attention to RELEVANT negative information

•But focus on what is right within what is wrong

•Using core values as a compass


Early Adverse Events(traumatic experiences during childhood)

• Physical, sexual, or emotional abuse, as well as discordant relationships with primary caretaker, the loss of a parent, or excessively rigid/unforgiving or excessively chaotic caregivers

• Associated with a wide range of medical disorders later in life and poorer health-related quality of life

Anda RF, et al. The enduring effects of abuse and related adverse experiences in childhood. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174–186, 2006.

R.A. Lanius, E. Vermetten, & C. Pain (Eds.). The impact of early life trauma on health and

disease: The hidden epidemic. Cambridge: Cambridge University Press. 2010.


The Brain is a Threat Detector

• Glucocorticoids liposoluble and easily cross the blood-brain barrier to access the brain

• Hippocampus, amygdala, frontal lobes involved in learning, memory, emotion regulation

• Early prolonged stress affects neurobiological systems and neural circuits involved in fatigue, pain, emotional, and sensorimotor processing

• Cortisol reactivity, inflammatory cytokines, decreased CSF oxytocin levels

• Central sensitization

• Chronic somatic symptoms increase stress

• Feedback loop

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Secure Attachment

• Co-regulation of stress in relation to attachment figures

• Oxytocin

• Activation of reward system

• Downregulation of HPA axis and sympathetic nervous system

• Activation of neural systems involved in (embodied) mentalization

• Fosters ability to regulate stress

Luyten and Fonagy, 2016


Luyten and Fonagy (p. 130) IN: J. Hunter, R. Maunder (eds.), Improving Patient Treatment with Attachment Theory: A Guide for Primary Care Practitioners and Specialists, 2016.

Physical symptoms

threat to body integritydistress and fear

helplessness→activation of attachment

invalidation→↑threat responsevalidation→↑emotional regulation


Self-efficacy

• Has been linked to initiation and maintenance of health behavior

• “The belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations.” (Albert Bandura, 1995)

• Past performance

• Modeled behavior

• Constructive feedback/persuasion from others

• Physiological responses, e.g., level of felt anxiety, energy

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Buffering Stress and Building Capacity

• Tend-and-Befriend/oxytocin

• Exploration/reward/dopamine circuit

• Exercise/endorphins/BDNF

• Mindfulness meditation/↑hippocampus, ↓amygdala,↑prefrontal cortex, ↑connectivity, immune response, ↓inflammatory cytokines

• Paced breathing/adequate sleep/parasympathetic

• Nutrition


VALUES

• Creswell (2005) – thinking about personal values and affirming them:

• Decreases perception of threat

• Decreases defensive response to threat

• Decreases rumination after “failure”

• Significantly reduces cortisol levels during stressful lab tests


Self-compassion

Receiving compassion

Offering compassion

Compassion is a practical antidote for difficult life experiences

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COMPASSION

• Decreased

• Negative rumination

• Depression

• Anxiety

• Self critical thinking

• Anger

• Anxiety about what others think of you

• Heart rate

• Increased

• Emotional coping skills

• Ability to cope with negative emotions

• Life satisfaction

• Sense of well being

• Happiness

• Optimism

• Curiosity

• Positive mood

• Motivation

• Better interpersonal relationships


Shifting from Control to Acceptance

• Acceptance of pain accounted for greater variance in psychosocial and physical functioning than did pain intensity [McCracken 2010]

• Those who responded to pain with acceptance experienced better physical functioning [Gillanders 2013]

• Acceptance of pain and values-based action accounted for 10 % of unique variance in headache severity and up to 20 % in headache-related disability [Foote 2015]

• Those with higher levels of pain-related acceptance engaged in a higher level of activity and needed to use fewer coping strategies on a daily basis [Chiros 2011]

• MBCT for H/A: acceptance differentiated responders from non-responders [Day 2014]


Acceptance ≠ giving up

Acknowledge pain as part of

the life experience

Goal-directed behavior/living

a full life

Social connections

support with someone

empathetic

• Describing vs judging/evaluating

• Making space for the experience: salt metaphor

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PAIN AND SUFFERING

• Two arrows of human experience

• The event itself

• Our reaction to the event

• Suffering = Pain x Resistance



Window of Tolerance

chaos rigidity

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Resilient and Non-resilient responses affecting functional outcomes and chronic headache symptoms

Stonnington CM, Kothari DJ, Davis MC. Curr Neurol Neurosci Rep 2016 Jan; 16 (1):6.


Take home point

• Interventions are geared toward activating and developing those emotions and behaviors that enable positive adaptation to the adversity of chronic pain.

• Focus is on optimal functional health rather than number of symptoms

• Invalidating responses can potentially reactivate the stress response associated with insecure attachment, which in turn can fuel somatic symptoms


Resilience Interventions

• Mindfulness Based Stress Reduction (MBSR)

• Mindfulness Based Cognitive Therapy (MBCT)

• Acceptance and Commitment Therapy (ACT)

• Cognitive Behavioral Therapy (CBT)

• Biofeedback training

• Self-hypnosis

• Family resilience/strength based model

• Values based action therapy

• Yoga based therapies

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Acceptance and Commitment Therapy

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Mindfulness


Mind-Body Therapies

THE BLOG 07/29/2016Childhood Trauma Leads To

Lifelong Chronic Illness — So Why Isn’t The Medical

Community Helping Patients?By Donna Jackson Nakazawa


Cognitive Behavioral Therapy

• Find a local therapist:

• https://www.adaa.org/

• http://www.abct.org/

• Multidisciplinary pain rehabilitation programs

• Focus on ability (not disability), activities (not symptoms), recovery (not relief)

• Behavioral activation—with proper pacing

• Relaxation strategies

• Distress management

• Exercise

• Psychotherapy before pharmacotherapy

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CBT for insomnia

• http://www.myshuti.com/

https://mobile.va.gov/app/cbt-i-coach


Exercise and Motivational Interviewing


Internet-based CBT

• J Med Internet Res. 2017 Feb; 19(2): e32.

• Review of web- and computer-based therapies for stress

• iCBT

• Rosso IM, et al., Depress Anxiety. 2017 Mar;34(3):236-245.

• MoodGYM

• Guille, C., et al., JAMA Psychiatry. 2015 December ; 72(12): 1192–1198. wCBT for medical interns

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Questions & Discussion

Documents

3-Stonnington-Cynthia Building-Resilience-in-Medicine · Attachment Theory: A Guide for Primary Care Practitioners and Specialists , 2016. Physical symptoms threat to body integrity