Disaster Stress, Mental Health, and Aging: How Mind-Body Therapies Can Build Resilience

Helen Lavretsky, MD, MSProfessor of Psychiatry

Director, Integrative PsychiatryUCLA 2020

Disclosures

Grant funding –NIMH, NCCIH, PCORI, NIAMS, Alzheimer’s Research & Prevention Foundation

Advisory Board – Alzheimer’s Research & Prevention Foundation

Royalties for books from the Oxford University Press and Hopkins University Press

Objectives

• Growing global distress, global aging, and Mental Health

• Stress during COVID-19 pandemic

• To review neurobiology of stress response

• To review the evidence of mind-body yoga therapies use for resilience and psychological wellbeing

• The use of daily yogic meditation to reduce stress and improve cognition in informal (family) dementia caregivers

THE STATE OF GLOBAL MENTAL UN-HEALTH(prior to 2020 pandemic)

• 450 million people suffer from a mental or behavioral disorder.

• Nearly 1 million people commit suicide every year.

• 4 of 6 leading causes of years lived with disability are due to neuropsychiatric disorders (depression, alcohol-use disorders, schizophrenia and bipolar disorder).

• 1 in 4 families has at least one member with a mental disorder.

• Global cost of mental illness at nearly $2.5T in 2010, with a projected increase to over $6T by 2030.

Population aging

Increasing Rates of Anxiety with COVID-19(APA poll -September 2020)

• 62% more report feeling anxious then in 2019

• Keeping family safe (80%)

• Racism (76%)

• COVID-19 (75%)

• Gun Violence (73%)

• Presidential Election (72%)- 57% are anxious about outcome

Symptoms of stress• Fear and worry about own health and the health

of loved ones, financial situation or job, or loss of support services

• Changes in sleep or eating patterns• Difficulty sleeping or concentrating• Worsening of chronic health problems• Worsening of mental health conditions• Increased use of tobacco, and/or alcohol and

other substances.• Irritability, anger, violence

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html

Model of Stress and Health:

Allostatic Load =price of adaptation to stress and aging

• ALLOSTASIS=maintaining stability through change (Sterling & Eiler 1988)

• Systolic BP (> = 148 mm Hg) • Diastolic BP (> = 83 mm Hg) • Waist-hip ratio (> = 0.94) • Ratio total cholesterol/HDL (> = 5.9) • Glycosylated hemoglobin (> = 7.1%) • Urinary CORTISOL (> = 25.7 ug/g creatinine) • Urinary NOREPINEPHRINE (> = 48 ug/g creatinine) • Urinary EPINEPHRINE (> = 5 ug/g creatinine) • High Density Lipoprotein cholesterol (< = 37 mg/dl) • Dihydroepiandrosterone sulfate (DHEA-S) (< = 350 ng/ml)

Seeman TE et al PNAS 2001 McEwen 2004 (McArthur Study of Successful Aging)

Time

Hea

lth

Fo

otp

rin

t o

f P

an

dem

ic

Phase 2*• Psychological trauma

• Mental illness

• Burnout

• Worsens w/ new outbreaks

• Steeper curve w/ pre-existing

anxiety/depression (dashed line)

Wave 1Immediate mortality and

morbidity of COVID- 19

Phase 3Impact of resource

restriction on urgent

non-COVID

conditions Phase 4Impact of interrupted

care on chronic

conditions

Post-ICU

recovery

Preexisting anxiety/depressionNo history of anxiety/depression

Adapted from Tseng, 2020

*Sources: McKinsey; WHO; KFF

Psychological response to disasters

Mass-Disaster Response• HEROIC- March 2020-altruism, rescue; open-access innovation

(meditation apps; yoga on line; free group meditations)• HONEYMOON - APRIL 2020- highly motivated, optimistic, energized,

heroism- “Pace yourself for a long overhaul” and celebrate your resilience developing ZOOM and virtual platforms

• DISSILUSIONMENT (late May 2020)-low energy; exhaustion; anxiety; depression; anger; (compounded by BLM protests; financial crisis) -LOOK FOR SILVER LININGS! GRATITUDE! TAKE CARE OF YOUR BODY! REST! SLEEP! CREATIVITY! EXERCISE! SPRITUALITY! LAUGHTER! SURRENDER CONTROL! TRUST! PURPOSE!

• RECONSTRUCTION- return to recovery and responsibility- when and for how long?

• FRONTIER INNOVATION (GOVERNMENT CAN’T HELP YOU!)- AI; apps; assistive technology will reshape workforce- simple living; vocational retraining; Heightened awareness of the process and potential

• RESILIENCE BUIDLING- prepare humanity to be more flexible; proactively deal with disasters, honor self-reliance and strength; take care of each other

• COOPERATIVE GLOBAL SOLUTIONS-UNITY CONSCIOUSNESS!

WHO DEFINITION OF MENTAL HEALTH

• “HEALTH is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

• MENTAL HEALTH=a state of well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence and recognition of the ability to realize one’s intellectual and emotional potential.

• INDIVIDUALS are able to cope with stresses of life, work productively and fruitfully, and make a contribution to their communities.

Investing in Mental Health WHO 2009

Dimensions of Wellness

“Happiness is the consequence of personal effort. You fight for it, strive for it, insist upon it, and sometimes even travel around the world looking for it. You have to participate relentlessly in the manifestations of your own blessings. And once you have achieved a state of happiness, you must never become lax about maintaining it. You must make a mighty effort to keep swimming upward into that happiness forever, to stay afloat on top of it.”

Elizabeth Gilbert “Eat, Pray, Love” (EPL)

“Happiness is a Choice and a Birthright” Gurmukh Khalsa

Our greatest glory is not in never falling, but in rising every time we fall. Confucius

Resilience is a precious skill. People who have ittend to also have three underlying advantages:

a believe that they can influence life events; a tendency to find meaningful purpose in life’s turmoil; and a conviction that they can learn from both positive and negative experiences.Amanda Ripley

Success is not final, failure is not fatal: it is the courage to continue that counts.Winston Churchill

Resilience• Resilience is a dynamic characteristic of the interaction

between individuals and their environments- Ability to recover from adversity / trauma / stress / depression

• Does it require a major traumatic experience to manifest?-What about surviving day-to-day?

• This construct can be fostered in both younger and older individuals- leading to:

• Effective and positive coping• Turning adversity into an opportunity for growth• Develop interventions that enhance resilience using

integrative medicine approaches

• Consequentially leads to better outcomes for medical and mental disorders of aging

Biomarkers of Resilience

• Neuroimaging studies demonstrate neural substrates including the prefrontal cortex, hippocampus, amygdala, anterior cingulate as forming a pathway for resilience.

• HPA axis and Inflammatory mediators may constitute a link between lifestyle factors, infection, and the physiological changes of aging on the one hand and risk factors for age-associated diseases on the other and could serve as targets or biomarkers for resilience-building interventions.

Vulnerability and Resilience Factors in Aging

Weisenbach, Kumar 2014

Resilience-Building interventions

• Resilience enhancing interventions include wellbeing therapy, learned optimism training, hardiness training, all of which focus on positive aspects of difficult experiences thereby promoting more positive perceptions of challenges.

• Lifestyle factors such as diet, exercise, spirituality can enhance resilience by creating physical and mental wellbeing.

• Complementary and integrative medicine (CIM) is a holistic approach to wellness which encompasses varied approaches to wellness and stress reduction, including yoga

• CULTIVATE JOY!

• CHANGE ATTITUDES toward death and dying as a natural part of life to combat “FEAR OF DEATH”

Mind-Body Medicine

• Yoga

• Guided imagery

• Meditation

• Hypnotherapy

• Spirituality

• Tai Chi/Qi Gong

• Art, dance, music therapies

• VIRTUAL REALITY- YOGA on ZOOM?

• YOGA for FEAR of DEATH?

Priorities for Mind-Body Research

SELF-REGULATION AND EMOTION REGULATION

Enhance physical & mental health

Manage pain, depressive and anxiety symptoms, insomnia, PTSD disabilities

Impact health

Prevent disease

Targeting therapies for the stress-disease

diathesis

Physiological basis for modulating brain-

autonomic-hormonal-immune pathways

2017 National Health Interview Survey (NHIS)

• Yoga was the most commonly used complementary health approach among U.S. adults in 2012 (9.5%) and 2017 (14.3%).

• The use of meditation increased more than threefold from 4.1% in 2012 to 14.2% in 2017. In 2012, chiropractic care was as popular as yoga, followed by meditation; however, the popularity of meditation surpassed that of chiropractic care to become the second most used approach among those surveyed in 2017.

• The use of chiropractors increased from 9.1% in 2012 to 10.3% in 2017.

• In 2017, women were more than twice as likely to use yoga compared with men (19.8% versus 8.6%). Women were also more likely than men to use meditation (16.3% versus 11.8%) and see a chiropractor (11.1% versus 9.4%).

• Non-Hispanic white adults were more likely to use yoga, meditation, and chiropractors compared with Hispanic and non-Hispanic black adults.

• The use of yoga was highest among adults aged 18 to 44 compared to older adults, while the use of meditation and chiropractic care was higher among adults aged 45 to 64 years compared with younger and older age groups.

MINDFUL PRACTICES

• Effects of mindful practices that can help in achieving mental and physical HEALTH :

• Stress reduction

• Treatment and prevention of depression in high risk populations (e.g., stressed caregivers, older adults with chronic medical illnesses, victims of psychological and physical violence)

• Direct neuroplastic effects in the brain across lifespan

• Shifts in conscious awareness of reality

• CULTIVATION OF WELLBEING, GRATITUDE

• Novel treatments• Novel diagnostic and prognostic systems

• Compression of morbidity• Improved side effect profiles

• Benefits to cardio-metabolic, bone and vascular health

Dietary Physical activity

Body-based Natural products

Complementary and integrative therapies for mental health and aging

Genomic instability

Chronic inflammation

Epigenetic alterations

Telomere attrition

Loss of proteostasis

Mitochondrial dysfunction

Cellular senescence

Mechanisms of aging

Mind-body

What is yoga?

- Systems of ancient philosophy, practices, lifestyle- Breath control (pranayama), specific bodily postures (asanasand mudras), and meditation - World-wide use for health and stress-reduction

Mindful Physical Exercise=Moving Meditation• Mindful physical exercise (e.g., yoga, Qigong, and Tai Chi) is

increasingly utilized for improving psychological well-being, hypertension, cardiovascular disease, insulin resistance, depression, and anxiety

• Physical exercise executed with a profound inwardly directed contemplative focus or awareness

• Key elements:

• A non-competitive, non-judgmental meditative component, • Mental focus on muscular movement and movement awareness

combined with a low to moderate level of muscular activity, • Centered breathing (conscious breath)• A focus on anatomic alignment (i.e., spine, trunk, and pelvis) and

proper physical form, • Energy centric awareness of individual flow of intrinsic body energy

(prana, sekhem, life force, qi, or Kundalini).

“Abbott, Lavretsky; Psychiatric Clinics 2013”

Prevalence of Yoga

• About 31 million U.S. adults have ever used yoga

• About 21 million practiced yoga in the past 12 months

Cramer et al, 2016, Am J Prev Med

Most Frequently Reported Reasons for Practicing Yoga

Most Frequently Reported Outcomes of Practicing Yoga

Cramer et al, 2016, Am J Prev Med

What are the key elements of YOGA?

-Musculoskeletal strength/ flexibility-Breath control-Concentration, attention, mindfulness, awareness-Imagery, visualization-Physical sensations, body awareness-Psychosocial interactions-Spirituality, beliefs, norms-Rituals-Iconic Teachers/Gurus-Shared environmental influences

PFC

ACCPCC

Amygdala

Striatum

Insula

• Prefrontal cortex -cognitive processing and executive control, attention• Anterior and posterior cingulate- mood regulation, memory• Insula -sensory awareness• Striatum-reward, learning, and motivation• Amygdala -Emotional processing (fear, anxiety)

Neural mechanisms of mindfulness meditation

Acevedo, Lavretsky 2016

Neural mechanism differences between mindfulness and mindful exercise

Unique to mindfulness- four regions

• Premotor area (PMA) • Mid-cingulate • Angular gyrus (AG) • Primary and secondary

somatosensory cortex (SSI and II)• =Areas of motor and emotional, and

somatosensory integration- greater awareness of Self=Consciousness

• Can be used for treatment of mood disorders, anxiety, ADHD, impulsivity, movement disorders, stress

Unique to yoga-based practices-seven regions

• Dorsolateral prefrontal cortex (DLPFC)• Medial frontal cortex• Superior temporal area• Paracentral lobe• Precentral and postcentral gyrus• Superior parietal lobule (SPL)• =Areas of judgment- discernment;

memory, language; visual-spatial and somatosensory integration =Social cognition/behavior

• Useful for enhancing judgement and self-control on deliberate actions

• Can be used-criminal system, at risk youth, substance abuse, mood disorders, neurological illness, dementia, cognitive decline, caregiver stress

Acevedo, Lavretsky 2016

Brief Breathing Practices

• Long deep breath- 3 seconds inhale, 3 seconds hold; 3 seconds exhale; 3 seconds hold (5 breath per minute for 3-5 minutes) – reduces blood pressure and heart rate, and anxiety/stress

• 4-4-6-2 breath with longer exhale- stimulates parasympathetic nervous system, deactivates Amygdala

• Alternating nostril breathing:• Left nostril slow breath- 3 minutes- Calming• Right nostril slow breath- 3 minute- Activating• Right and Left- 3 minute- rebalancing breath• O-breath- slow with open mouth inhale (=sipping through

a straw- and exhale on the count of 4) filling up and emptying out your lungs (2 gallons capacity)- detoxifying

What is Kirtan Kriya?

• Kirtan Kriya is a 11-minute chanting exercise in the Kundalini yoga tradition

that people have been practicing for thousands of years. This meditation

involves repetitive finger movements, or mudras, plus verbal chanting and

silent chanting of the mantra “Saa Taa Naa Maa.”

• What does Kirtan Kriya mean in English?

A kirtan is a song. These ancient primal sounds from Sanskrit mean “birth, life,

death, rebirth.” Kriya refers to a specific set of movements or chants.

• The physical benefits of the mantra are:

• Saa evokes a sense of expansiveness

• Taa creates a feeling of strength

• Naa stimulates a sense of the universal

• Maa provides the quality of communication.

• In the yogic tradition, kriyas are used to help bring the body, mind, and emotions into balance, thus creating healing.

•

•Focus of attention

Study of stressed dementia caregivers(funded by ARPF)

Variables Meditation(N=23)

Relaxation(N=16)

t; P

Age 60.5 (8.2) 60.6 (12.5) 0.03; 0.9

Education 16.1 (2.1) 15.1 (2.8) -1.2; 0.2

Month of depression

45.1 (35.4) 39 (21.2) -0.6; 0.5

Yrs of caregiving 4.7 (2.4) 4.2 (2.9) -0.6; 0.6

Hours per week 47.8 (35.8) 63.3 (36.2) -0.2; 0.2

CIRS 3.0 (2.3) 4.6 (3.1) 1.8; 0.08

CVRF 5.2 (3.7) 7.4 (6.4) 1.4; 0.2

HAMD baseline 11.8 (4.1) 11.4 (4.0) -0.3; 0.7

HAMD scores over time

0

2

4

6

8

10

12

14

HAMD0 HAMD2 HAMD4 HAMD6

Meditation

Relaxation

Resilience

64

66

68

70

72

74

76

78

Baseline Week 8

Meditaion

Relaxation

Cognition-MMSE

28

28.2

28.4

28.6

28.8

29

29.2

29.4

29.6

29.8

30

Baseline Week 8

Meditation

Relaxation

Telomerase activity

0

0.5

1

1.5

2

2.5

3

3.5

4

Base Week 8

Meditation

Relaxation

-2 -1.5 -1 -0.5 0 0.5 1 1.5

NF-kB

IRF1

Promoter-based bioinformatic analysis implicated reduced

NF-kappaB signaling and increased activity of Interferon

Response Factor 1 in structuring those effects (both p < .05).

Fold-difference in TFBM distribution(Log2 Meditation / Control)

p-value

.0401

.0279

FIGURE 1. Cross sectional view shown above displaysthe crosshair intersection within the right inferior frontal area.

This region was the most significant and largest cluster demonstrating a decrease in the meditation group compared to the control group over time (t=4.74 with p=0.001,160 conti voxels at p<0.01)

FIGURE 2. Cross sectional view shown above displays the crosshair intersection at (-44,-74,-16), within the left associative visual cortex. This region also decreased in the meditation group compared to the control group over time (t=4.15, p=0.002)

fMRI in meditators showed higher activity in a functional network including the anterior cingulate, fronto-orbital cortex and insula

(Light blue areas show the ACC-orbito-insular network, pink for group difference, z=1.7, p<.05)

Sponsors and collaborators

• Sponsored by the grants from NCCIH, NIMH, PCORI, and Alzheimer’s Research Prevention Foundation.

• Collaborators: • Katherine Narr and Brain Mapping- fMRI

• Linda Ercoli and Prabha Siddarth- cognitive analyses

• Michael Irwin, Steve Cole, David Black and the Cousins Center- inflammatory markers

• Steve Cole, Stan Nelson and Nelson Freimer- genetic analyses

• Elissa Epel and UCSF Blackburn lab- telomerase

• Postdoctoral students: Hongyu Yang, Bianco Acevedo, Amber Leaver, Beatrix Krause, Rosa Vlasova, and Harris Eyre

• Study coordinators: Yesenia Aguilar, Michaela Milillo, Raquel Hernandez Sotomayor