Embed Size (px)
Citation preview
4/13/2012
1
Mind/Body Strategies to Manage Stress & Optimize Wellness
after a diagnosis ofBone Marrow Failure Disease
Anne Coscarelli, Ph.D.
April 21, 2012p
Director, Simms/Mann – UCLA Center for Integrative OncologyUCLA Jonsson Comprehensive Cancer Center
Adjunct Professor of Medicine, Hematology OncologyDavid Geffen School of Medicine
Clinical Professor, Department of Psychology UCLA
Optimizing Wellness
Optimize • to make as perfect, effective or functional as possible • to make the most of
W llWellness• the quality or state of being in good health especially as
an actively sought goal• the condition of good physical and mental health
Mind/Body Medicine - Defining• Catch all phrase• What does it include?
– CAM approaches– Mainstream psychological approaches, e.g., groups, CBT– Relaxation mindfulness– Relaxation, mindfulness
4/13/2012
2
Definitions- Mind Body Medicine Focuses on …
• the interactions among the brain, mind, body, and behavior AND
• the powerful ways in which emotional, mental, social, spiritual and behavioral factors can directly affect healthspiritual, and behavioral factors can directly affect health
Assumptions • BMFD is not one entity • There are variations in presentation, treatments and
outcome• BMFD comes with a measure of uncertainty• BMFD changes life as an individual knows it
Physically– Physically– Mentally– Spiritually
• Everything presented today, will not apply to every person and will require evaluation, adaptation, acceptance or rejection
Assumptions about Illness
• Illnesses can be long-term, episodic, recurrent, or constant
• Illnesses can be short-lived or single episode• Illness creates a “new normal,” which involves a
diagnosis which may impact you for a long timediagnosis which may impact you for a long time
4/13/2012
3
Individual Difference
Challenge: The “New Normal”
• Regular monitoring of symptoms• Powerful treatments (such as stem cell transplant) are
on the horizon• Don’t know what treatments are ahead or how things will
changechange• Living day to day with the changes
The New Normal
• Changes in daily functioning and physical functioning• Diminished physical energy• Loss of independence• Changes in roles in families• Emotional/psychological• Increased contact with the health care system• Impact on employment/financial status• Heightened sense of vulnerability• Spiritual questions
4/13/2012
4
Coscarelli Law #1• For every physical effect, there is an equal reactive
psychological effect.
Psychological
• Feelings of shock/disbelief • Anger• Depression• Anxiety• Concern for the future• Concern for the future• Fear• Helplessness• Loss• Sadness
Additional Consequences
• Increased stress• Difficulties sleeping• Diminished cognitive functioning• Diminished enjoyment in life• Restriction in social activities• Frustration/irritability• Living in the future• Reduction/shifts in meaning
4/13/2012
5
Coscarelli Law # 2• Treatment of physical conditions, must also include
treatment of the psychological effects; the mind and body are inextricably linked.
Stress
• Not a “formal” psychiatric diagnosis• A real and valid experience• A normal response to life’s problems
Definition of Stress
• A physical, chemical, or emotional factor that causes bodily or mental tension
• A state resulting from a stress; especially: one of bodily or mental tension resultingone of bodily or mental tension resulting from factors that tend to alter an existent equilibrium
Merriam Webster online dictionary
4/13/2012
6
Stress
• An accurate way to describe your reaction to diagnosis, and your experience of illness
• A code word for anxiety or depression…
The Stress of Diagnosis
• Stress and anxiety become imprinted• Both in the mind and the body• An “extreme traumatic stressor”
– For patients and families
A ti ti f th “Fi ht Fli ht” R• Activation of the “Fight or Flight” Response
The Fight or Flight Response
• Instinctive response• Evolutionary instinct, responsible for keeping your
ancestors alive long enough for you to be here today• Whole systems response to immediate threat
S th ti N S t• Sympathetic Nervous System
4/13/2012
7
The Fight or Flight Response
• Sympathetic Nervous System– Heart races– Muscles tighten– Pupils dilate– Shallow breathing
Blood flow directed to the heart for action– Blood flow directed to the heart for action– Lots of hormones power up
• Great and necessary system• Body also can down regulate, create an automatic
relaxation response
The Fight or Flight Response
• Parasympathetic Nervous System– Heart slows– Muscles looses– Pupils constrict– Deep breathingp g– Blood flow re-directed back to other parts of the body– Reduction in adrenaline production
The Challenge with BMFD’s
• You may have a life threatening or life shortening illness and it may not go away
• Ongoing dangers• In addition to normal stresses of living
4/13/2012
8
The Challenge with BMFD
• How do you manage your sense of – Threat– Danger– Stress
• When the threat is – Not immediate– Not imminent– Does not pass– Becomes chronic
• When the automatic relaxation response does not come
Managing Stress is NOT Controlling Stress• Control is a word that gets people into trouble• Control is actually part of the problem, a goal we cannot
meet• Myth about controlling all kinds of things that are outside
of our controlof our control • More honest/useful to think of this process of managing
stress as adding to your sense of well being
Key is Managing Stress
• Many different ways to manage stress• Mind and body intimately connected• Thoughts influence the body, the body influences the
mind• Serve as feedback loopServe as feedback loop • Specific types of coping strategies
4/13/2012
9
“Coping can be defined as cognitive, behavioral, or social strategies that patients and families use to bring
about relief in relation to a perceived th t d d d t tthreat or a demand and to restore
equilibrium.”
– Singer, JE Some issues in the study of coping. Cancer, 53, 1984
Coping
• Three decades of research• A process of self-regulation• Patients use a variety of strategies• Intra individual and contextual• Intra-individual and contextual
What We Know about Coping
• Each person has their own coping strategies• Not every coping strategy is going to work for every
person • Some coping strategies are healthier than others
P t i t t i b h l f l t t• Past coping strategies may be helpful to you or not...– Strengthen healthiest of coping strategies– Add some new ones
4/13/2012
10
What are Less Healthy Coping• Deny or avoid crisis• All or none thinking• Avoid information• Repress negative emotion
R i i l d• Remain isolated• Remain passive• Focus on what is lost without balancing with gains
Schurermeyer & Scribner, 2009
Healthy Coping
• Taking one day at a time & focus on real issues• Realistic optimism• Keeping a sense of balance• Manage stress levels• Accepting your feelings• Using your support network and asking for help when
you need it• Working with your healthcare team
Schurermeyer & Scribner, 2009
Healthy Coping
• Multiple strategies• Flexible strategies• Problem oriented• Confrontation• Compliance with authority• Compliance with authority• Information seeking• Share concerns-Express emotion• Humor• Distraction—mood elevators• Family cohesion
4/13/2012
11
Resilience
“At the heart of human adaptation is resilience, the ability to create a positive world for ourselves, often in the face of stressful life experiences, and the ability to resist being overtaken by negativethe ability to resist being overtaken by negative experiences when they seem to be overwhelming”
– John Reich, social psychologist
Interventions to Enhance Copingp g
Breathing Techniques
• Four Square Breathing– 1Take a deep breath in for four seconds– 2 Hold your breath for four seconds– 3 Slowly exhale for four seconds– 4 Pause for four seconds, doing nothing, then repeat the , g g, p
process as many times as you need until you calm down
• Attention to Breath• Signal Breath• Diaphragmatic Breathing
4/13/2012
12
Autogenic Training• Allows the conscious mind to connect to the
unconscious control of the autonomic nervous system– A form of self-hypnosis
• Typical training– Heaviness– Hand-warming– Breathing– Warm belly– Slow heart beat– Cool forehead
• Progressive Muscle Relaxation
Guided Imagery
• A safe place• A place in nature that is relaxing• Using visualization to create that space
Mindfulness or Mindful Awareness • The process of the moment –to moment attention to
present experience with a stance of open curiosity• Distinction between doing and being• Focusing on
– Breath– Bodily sensations– Sound– Eating
• Can be applied in any situation or environment (example cell phone ringing)
4/13/2012
13
Attitudinal Foundations of Mindfulness• Non-judging: Impartial witness to your own experience• Patience: Sometimes things must emerge in their own
time• Beginner’s mind: Willing to see everything for the first time• Trust: Listening to your own inner self• Non-striving: Back off• Acceptance: Seeing things as they actually are in the
present• Letting go: Our minds like to hold on to thoughts, patterns,
judgments. (JKZ)
Mindfulness Meditation-Based Stress Reduction vs Wait List Control (N=90)• 7 week sessions (1.5 hrs)• Education• Visualization• Gentle yoga stretches• Relaxation response and physiological correlates• Mindfulness with attention to breath• Relationship between breath and emotional responses,
cognition and emotion
Speca M, Carlson L, Goodey E, Angen M,. A Randomized, Wait-list Controlled Clinical Trial: The Effect of a Mindfulness Meditation-Based Stress Reduction Program on Mood and
Symptoms of Stress in Cancer Outpatients, Psychosomatic Medicine 62:613-622 (2000).
Mindfulness Meditation-Based Stress Reduction vs Wait List Control (N=90)• Dropouts more mood disturbance• 65% Reduction in mood disturbance in TX group;
– Anxiety, Depression, Anger, Confusion, Increased vigor• 31% reduction of total stress symptoms in TX group
– Upper respiratory tract symptoms, habitual patterns, emotional pp p y y p , p ,irritability, & Total stress score
• Daily meditation in treatment group = 32 minutes suggesting behavior led to changes
Speca, M, Carlson, L, Goodey, E, Angen, M, A Randomized, Wait-list Controlled Clinical Trial: The Effect of a Mindfulness Meditation-Based Stress Reduction Program on Mood and Symptoms of Stress in
Cancer Outpatients, Psychosomatic Medicine 62:613-622 (2000)..
4/13/2012
14
Cognitive Reframing
• How you evaluate a situation• Can you change the way you view it• Is there a cognitive understanding that can help you to
feel less anxious, worried, overwhelmed“I t h t I d t b b t I till j ”• “I am not what I used to be, but I can still enjoy ….”
Recreation/Fun Quotient
• Hours of fun ÷ 168 hrs wk• 7 hours/wk = 4%• 3 hours/day-21hrs wk = 12%• What else is missing/or low?
Activity Hours spent per week
% time
Sleeping 56 33%Self- grooming 11 6%
Food preparation &
21 12%
– Family time/taking care of kids or parents
– Relationships– Religious spiritual activities
eatingWorking 40 24%Commuting to work
5 3%
Exercise 3 1%Maintenance (e.g. shopping for groceries)
14 8%
Total 150 87%
Fun Quotient
• BMFD takes a toll on a person’s fun quotient• Sum up the number of hours spent on
– Seeing a member of the medical team– Getting tests– Setting appointments– Setting appointments– Traveling to medical centers– Getting treatments– Taking medications– Calling insurance companies or billing centers at hospitals– Waiting– Not feeling well and managing symptoms
4/13/2012
15
Fun Quotient
• Be mindful of your fun quotient• Take “BMFD vacations”• Plan goals for fun and recreation and rebuild fun into
your life with intentionBMFD d t h t ll f• BMFD does not have to remove all fun
Social Network
• Connection to a social network can buffer people from the stress/distress of the illness
• Your perception of adequate social support is important• Linked to lower levels of anxiety/depression better social
adjustment and higher self-esteemj g• Improves quality of life• Improves coping• Enhances physical and mental well-being
Lewis JA, Manne SL, DuHamel KN, et al. Social Support, Intrusive Thoughts and Quality of Life In Breast Cancer Survivors, PJ of Behavioral Med, 24: 231-245 (2001).
Social Network
• Breast Cancer patients, age 30-81, M=59.2• M 6.7 years post
tx (1-15 yrs)
Lewis JA, Manne SL, DuHamel KN, et al. Social Support, Intrusive Thoughts and Quality of Life In Breast Cancer Survivors, PJ of Behavioral Med, 24: 231-245 (2001).
4/13/2012
16
Social Network
• “There is at least one person whose advice I really trust”• “I feel there is no one with whom I can share my most
private worries and fears”
Lewis JA, Manne SL, DuHamel KN, et al. Social Support, Intrusive Thoughts and Quality of Life In Breast Cancer Survivors, PJ of Behavioral Med, 24: 231-245 (2001).
Purpose and Meaning
• May be spiritual or religious• Having meaning helps to mitigate suffering• Being mindful of what is important to you• Post Traumatic Growth
Man is not destroyed by suffering; he is destroyed by suffering without meaning. – Vickor Frankl
4/13/2012
17
None of us will ever accomplish anything excellent or commanding except when he listens to this whisper which is heard by him alonewhich is heard by him alone.
– Ralph Waldo Emerson
Spirit implies energy and power. The word spirituality describes an awareness of relationships with all creation an appreciation of presencecreation, an appreciation of presence and purpose that includes a sense of meaning.
-Christine Pulchalski
Post Traumatic Growth
• PTG follows an initial period of turmoil and distress• Over time, many individual develop a growing sense of
enrichment and satisfaction that appears to exceed prior levels
4/13/2012
18
Post -Traumatic Growth
• “Growth”– Individual undergoes a stage in their personal development
that extends beyond their previous functioning
Post Traumatic Growth
• Relationships with friends and family are stronger• More emotionally connected• Greater feelings of closeness• Improvements in quality of marital relationships• Importance of awareness of one’s importance to others• Increased feelings of compassion for others/felt more
deeply• Renewed appreciation for life
Post Traumatic Growth
• New set of priorities or changes in goals• Shifts in life, school, family how they relate to themselves• Many feel they have grown stronger, giving new
resources and skills to tackle life’s problemsM f l t t• May feel more competent
• Empowerment to make changes
4/13/2012
19
Psychological Support/Therapy
• Patients and families benefit from psychological support and therapy from a knowledgeable health psychologist or medical social worker
Psychological Support/Therapy
• Individual– CBT based– Interactional– Integrative
• GroupsGroups– Professionally led– Talking– Didactic skills based
Palliative Care/Symptom Management
• Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life
• Palliative care should occur throughout treatment– Diagnosis, treatment, recurrence, remission, survivorship too
4/13/2012
20
Exercise and Nutrition
• Exercise and nutrition key in emotional well-being• Both can be helpful coping strategies• Nutrition and CAM can also be an indicator of distress• Source of empowerment and control• Exercise a stress reducer
Psychiatric Medications
• Referral to a psychiatrist for medication evaluation• Appropriate use of anti-depressants and anti-anxiety
agents• Large number of patients do not take or stop taking
these medsthese meds– They are started on high dosages– Side effects not explained adequately and monitored– Drugs are not tailored to the needs of the individual
When is Anxiety a Problem? • Worrying more often than not, even trivial things• Being unable to control your worries• Being unable to be reassured or distract yourself• Becoming preoccupied with rituals/habits/behaviors
( l i )(compulsions)• Associated physical symptoms such as palpitations,
sweating, shortness of breath…
4/13/2012
21
When is Depression a Problem?• Feeling depressed, prolonged sadness and/or not
enjoying things, more often than not for at least 2 weeks:– Sleep problems– Decreased interest in usual activities– Guilty feelingsy g– Fatigue/low energy– Concentration problems– Appetite changes– Feeling slower or quicker than usual (internally)– ANY SUICIDAL THOUGHTS, INTENTIONS, or PLANS
Treatments for Anxiety & Depression • Medication
– Antidepressants– Mood stabilizers
• Prefer psychiatrist to oncologist/primary care doc• Cognitive/Talk Therapyg py• Self-management/rehabilitation
– Physical activity (to the degree possible)– Pushing self over the wall toward social and pleasurable
activities– Reinforcement
• Techniques previously presented
Three Wishes
• BMFD could be prevented• BMFD could be cured for everyone• BMFD patients and their families receive optimal
integrated medical and psychosocial care throughout the continuum of carecontinuum of care
4/13/2012
22
Thanks to theSimms/Mann Family Foundation
for
their continued support and recognition oftheir continued support and recognition of the needs of patients with cancer and their
family members
