j young plenary chronic stress
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2014 Physician Well Being ConferenceTRANSCRIPT
Jeff Young, MD
Chronic Stress, Health Consequences and the Opportunity
to Become More Resilient
Jeff Young, MD
Topics Resilience defined
Brief overview: Acute and chronic stress; consequences
The off switch, mind-body medicine strategies
The Healthy Mind Platter
Why Mindfulness?
Mindfulness meditation versus mindful awareness
Mindfulness exercises
Resources for further exploration
Resilience
“The ability to successfully adapt and function proficiently when faced with traumatic circumstances”
“An organism with the ability to adapt to challenging environments will be able to minimize physiologic damage”
“The ability to bounce back from adverse circumstances and go on”
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Acute
Stress Response:
Effect on the Hypothalamic-Pituitary-Adrenal Axis
“Fight-or-Flight” Response
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Chronic Stress:Cause:
Due to repeated severe stressors, OR related to daily life insecurities/fear, cognitive distortions, threats to ego, loss of sense of control, unpredictability
Consequences: Brain remodeling (“plasticity”: more on next slide) HTN, CVD, Increased blood glucose Ulcers Anxiety, depression, burnout, exhaustion, “Stressed
out”: insomnia, XS eating, smoking, drinking, social withdrawal, seeking of medication solutions
Immune dysfunction Epigenetic changes Accelerated aging: decreased telomerase and
telomere shortening, decreased anti-oxidant activity, increased oxidative stress1
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Consequences of Chronic Stress: Brain plasticity, “neurons that fire together wire
together, and survive together” (Dan Siegel) : Habits remodel the brain and strengthen
proclivity for that habit Synaptic and dendritic remodeling
demonstrated with PET and fMRI: Atrophy of hippocampus, PFC Hypertrophy of amygdala Result:
diminished ability to cognitively process and respond to stressors
over-active amygdala.
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The Off Switch: The Relaxation Response Opposite physiology of acute stress
response2 mediated by parasympathetic NS: Decreased metabolism, Oxygen consumption,
carbon dioxide elimination, BP and respiratory rate, increased production of healthful nitric oxide3
Decreased heart rate and increased heart rate variability4
Decreased brain activity/increased alpha waves, state of “well being”, reduced psychological distress
Increased brain activity (fMRI) in attention and decision making regions (pre-frontal cortex) of brain5
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Mind-Body Medicine: Strategies for Wellness and Healthy Aging The “relaxation response”:
Increased brain cortical thickness in prefrontal cortex and right anterior insula in those who intensively meditate. First evidence of experience-dependent cortical plasticity associated with meditation practice6
Is associated with changes in gene expression opposite of those associated with stress7
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Strategies for wellness and resiliency
Ancient and modern strategies for eliciting the relaxation response: Meditation Imagery Biofeedback Autogenic Training (self-hypnosis) Breathing Techniques Yoga, Tai Chi, Qi gong, Repetitive-prayer
Relationships; helping others Healthy life-style and self care: sleep,
nutrition, moderate exercise, avoid smoking, hobbies
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Additional wellness strategies Development of self awareness and clarification of
personal values/priorities8
Spirituality: developing this aspect of self
Work attitudes and management: finding meaning, choosing to limit/manage aspects of work life
Positivity: playfulness, gratitude, awe, love, interest, serenity, feeling connected to others
Cognitive reframing
Not relying solely on medications or procedures to correct health problems
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The Healthy Mind Platter
Sleep time, physical time, focus time, down time, play time, connecting time, TIME IN.9
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Mindfulness and neural networks “Narrative”/”default” network:
Medial PFC, hippocampus
Where we keep our story, strategizing, planning, keeping track of self vs other,
“Monkey mind”, dreaming, resting mind, autopilot mind
Feels captivating: rehashing, rehearsing, ruminating
Nothing wrong with it, just wouldn’t want to spend life here
Mindfulness and neural networks
Direct experience network:
Lateral PFC, right insula where we perceive sensations, anterior cingulate cortex which switches our attention
You experience information coming to your senses in real time
Activated with mindful attention
Compare and contrast the two
Why Mindfulness? Promotes self awareness, self-regulation, positive
relationships between self and other, and increases pro-social characteristics…self transcendence.
Improving one’s awareness of sensations/thoughts/feelings, and yet, reducing one’s reactivity to challenging situations and feelings even if unpleasant.
Promotes action with awareness and attention.
Enhances our openheartedness
With practice: facilitation of more conscious choices, emotional regulation--equanimity, improved performance
Mindful awareness Not religious or esoteric, more about understanding
ourselves, anybody can do it, with perseverance
Everyday life awareness and presence
Enhances ability to "place and hold attention"10, leave the commentary (“narrative”/default network) and return to the present (direct experience network), improve perception of your thoughts and feelings, make choices.
Practices
Picking a project, eg. Intending to watch for the expression of an issue in the course of the day
Pausing
Paying attention to the simple activities
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Mindfulness meditation Intentional self-regulation of attention conducted
without judgment and focused on observation of the present moment using a point of focus
There is no single posture
Still or moving
Generally involves an object of focus
Noticing when our mind has wandered and gentle coming back to the focus without judgment and beginning again, and again. This is the practice
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Mindfulness practices Leaning forward with intention: COAL
Reasonable expectations for mindfulness and meditation
Meditation examples:
Somatic centering/grounding
Focused attention while still; the breath
(with movement: walking meditation, yoga, Tai Chi)
Loving kindness meditation
Special place imagery
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Resources: Mindfulness meditation coaching:
The Healthy Mind Platter: David Rock, Dan Siegel http://www.davidrock.net/files/
02_The_Healthy_Mind_Platter_US.pdf
Mindfulness meditation: Mindfulness for Beginners, Kabat-Zinn (CD) Your Brain at Work, David Rock Walk Like a Buddha, Lodro Rinzler Healing the Healer, Saki Santorelli The Mindful Path to Self-compassion, Germer and Salzberg Loving Kindness Meditation, Sharon Salzberg Zen Living, Domyo Burk
Physician wellness programs example:
http://healthandwellness.vanderbilt.edu/work-life/faculty-physician-wellness/
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References:1. Epel et al. PNAS USA 101:17312-5, 2004
2. Benson et al. The relaxation response. Psychiatry 37(1) 37-46, 1974.
3. Benson. Relaxation Revolution, 2010.
4. Thayer et al. A meta-analysis of heart rate variability and neuroimaging studies; implications for HRV as a marker of stress and health. Neurosci Behav Revs 36, 747-756, 2012
5. Lazar et al. Functional brain mapping of the RR and meditation. ANS, Vol 11, no7. 1581-1585. 2000
6. Lazar, et al. Meditation experience is associated with increased cortical thickness. NIH Neuroreport; 16(17): 1893-1897. 2005
References:7. Dusek et al. Genomic counter-stress changes induced
by the relaxation response. PLoS ONE 3(7): e2576. doi:10.1371/jounrnal.pone.0002576. 2008.
8. Shanafelt, The well-being of physicians. A J of Med. 114:513-19, 2003
9. Rock and Siegel, The Healthy Mind Platter
10. Burk, The Zen Guide for Living, 2014