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Building Resiliency in our patients
What I learned from the Benson-Henry Institute for Mind-Body Medicine and the
Institute of Lifestyle Medicine at Joslin Diabetes Center
60-90% of healthcare visits are related to
mind/body stress induced conditions We know these things about the relaxation
response:lower O2 consumptionlower CO2 eliminationlower RR, P, BP, limbic system arousalgreater slow brain wavesmany changes in genetic coding activity for
proteins
Mind-Body Medicine overview
The repetition of a word, sound, prayer,
thought, phrase or muscular activity The passive return to the repetition when
other thoughts intrude
2 basic steps necessary to elicit the relax. response
Progressive relaxation Numerous types of meditation Yoga Hypnosis Simple generic techniques
Possible Techniques
Changes in the amygdala, hippocampus, pons,
anterior cingulate and intraparietal sulcus. Some are more active, other have a delayed
onset of activity
fMRI shows us
From the mundane to the horrific There is no pill to reverse this. Medication can
help but it doesn’t solve anything. Ultimately, finding ways to increase resiliency
is necessary to withstand the stress of the world
Stress is all around us
“Mind-body medicine focuses on the
interactions among the brain, mind, body, and behavior, and on the powerful ways in which emotional, mental, social, spiritual, and behavioral factors can directly affect health. It regards as fundamental an approach that respects and enhances each person’s capacity for self-knowledge and self-care, and it emphasizes techniques that are grounded in this approach.”
-National Center for Complementary & Alternative Medicine
Mind-Body Medicine
Pilot project pub’d J. of Alt & Comp Med 2010:
-331 pts did pre & post intervention Medical Symptom Checklist (MSCL), Health Promoting Lifestyle Profile-II (HPLP-II) and Symptom Checklist 90R (SCL-90-R).-Intervention: taught and practiced relaxation response (RR) as well as training re: mind-body interactions, cognitive restructuring, nutrition and physical activity-Results: significant improvements in nearly every single symptom on these checklist, which include somatic, psychiatric, and self-care items.
~50 years of research
Maintaining stability through change Capacity to adapt or constantly change,
thereby modifying physiologic parameters in order to adjust to every-shifting environmental conditions
In the normal allostatic response, a stressor is presented, a physiologic response is initiated and sustained, and then there is a return to baseline
Allostasis
The physiologic consequences of chronic exposure to
fluctuating or heightened neural or neuroendocrine response that results from repeated or chronic stress
Wear and tear the body experiences due to repeated cycles of allostasis
Accumulated effects on body of allostatic stress response, as well as inefficient turning on and shutting off
Or…the price the body pays for being forced to adapt to adverse psychosocial or physical situations (limited resources get depleted over time)
Allostatic Load
Ability to maintain adaptation under significant adversity or challenging life conditions
Resiliency
Changes in gene expression studied in
-long-time meditators-novices before meditation training-novices after 8 weeks meditation training
There were hundreds of genetic expression profile differences between #1 & #2, and similar changes seen in #2 vs #3 though the magnitude was less.
316 genes up regulated279 genes down regulated
Genetics
This is like a master switch or hub in a large
network of neural pathways for the stress response (measured in B cells)
Macaque dominance study... Cognitive-Behavioral Stress Management
study (Antoni et al 2012)… MBSR study (Creswell et al 2012)… 2 days of Yoga, 2 hrs @ study (Qu et al 2013)
…
NF-KB
Modifiable behaviors are the major drivers of
mortality, disease, and health care costs WHO – by 2020 2/3 of all global disease will be
lifestyle related In 2011 health care spending in the US was
$2.92 trillion (78% consumed by managing chronic disease)
Estimate it’ll be $4.48 trillion in 2019. $3 trillion is 2/3
If we could change behaviors by 2% that’d perhaps save $60 billion/year
Behavior and $
Inactive people cost $1543 more per year than
active ones = >$12/hr of benefit for brisk walking
The 4 cornerstones of lifestyle counseling are: -not smoking-physical activity-good nutrition-stress resiliency
Behavior and $....
We are a potent source of advice, coaching,
and support. The more we try this with our patients the
better we get. The more we do it ourselves the better we get. The Institute of Lifestyle Medicine has the goal
to train physicians in this to ultimately transform primary care medicine.
Physician’s Role
First, we help ourselves. Better self-care -> joy in practice->more
compassion, awareness and personal knowledge of topic
HOW?
Relaxation response Minis (brief relaxation exercises to do throughout the
day) Mindfulness (beginner’s mind/presence/attentive
observtn) Cognitive skills Sleep Diet Exercise Humor Social support
Resiliency Toolbox
Becoming more aware of conditioned, self-defeating habits of thought known to perpetuate stress.
Cognitive Reappraisal:
Building Adaptive Beliefs
Metaphors and stories help illustrate
maladaptive and adaptive beliefs or responses to similar situations
Cognitive exercises can help with awareness re: automatic thoughts, their distortions & patterns (tend to be overly simplistic, inflexible, over-determined, negative habits of thinking re: oneself, others and the world). These block coping and compromise flexible responses and adaptive thinking. Once identified they can be challenged and restructured.
Cognitive Reappraisal…
All or nothing polarized thoughts Focusing on the negative to the exclusion of the positive Disqualifying positives Mind reading Fortune telling Shoulds Labeling Emotional reasoning Personalization Perfectionism Approval seeking Self-righteousness Comparison
Examples
We can practice alternative thoughts We can think flexibly about what might be
possible re: problem solving We can accept things we can’t change We can work on optimism (this leads to
greater well-being, active coping strategies, less mood disturbance, less physical sx’s, longer life span, supports + change)
Examples…