Craving To Quit - Mindfulness by Jud Brewer

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Craving to quit: insights from Craving to quit: insights from studies of mindfulness training studies of mindfulness training

for alcohol, cocaine and for alcohol, cocaine and nicotine dependencenicotine dependence

Judson Brewer MD PhDJudson Brewer MD PhDMedical DirectorMedical Director

Yale Therapeutic Neuroscience ClinicYale Therapeutic Neuroscience ClinicAssistant ProfessorAssistant Professor

Department of PsychiatryDepartment of PsychiatryYale University School of MedicineYale University School of Medicine

www.ytnc.yale.eduwww.ytnc.yale.edu

For our considerationFor our consideration•• What is stress and how do we cope?What is stress and how do we cope?•• What is mindfulness?What is mindfulness?•• Does mindfulness help us with our addictions?Does mindfulness help us with our addictions?•• What do we know about neural mechanisms of What do we know about neural mechanisms of

mindfulness?mindfulness?–– Mindlessness as a starting pointMindlessness as a starting point

•• Our ‘default mode’? Our ‘default mode’? •• How does the “average” meditator’s brain How does the “average” meditator’s brain

differ from anyone else’s?differ from anyone else’s?•• How can neuroscience improve treatment of How can neuroscience improve treatment of

stress and related disorders?stress and related disorders?

StressStress

•• Consequences of the failure to respond Consequences of the failure to respond appropriately to emotional or physical appropriately to emotional or physical threats to the organism, whether actual threats to the organism, whether actual or imagined. or imagined. ((SelyeSelye 1956)1956)

•• [Ven. [Ven. SariputtaSariputta:]:] "Now what, friends, is "Now what, friends, is the noble truth of stress? …not getting the noble truth of stress? …not getting what is wanted is stressful... what is wanted is stressful... (MN 141)(MN 141)

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Stress and AddictionStress and Addiction

•• Acute stress leads to increases in Acute stress leads to increases in selfself--administration of drugs such as amphetamines administration of drugs such as amphetamines (Bradley 1989)(Bradley 1989), cocaine , cocaine ((KalivasKalivas 1989)1989), and alcohol , and alcohol (Nash (Nash 1988)1988)

•• Stress induces drug craving Stress induces drug craving ((SinhaSinha 2005) 2005) and and consumption consumption (De wit 2003)(De wit 2003)

•• Stressful life events are associated with nicotine Stressful life events are associated with nicotine dependence dependence (Balk 2009)(Balk 2009)

•• Negative affect drives continuation of smoking Negative affect drives continuation of smoking ((MarkouMarkou 1998)1998)

Stress and RelapseStress and Relapse

•• Stressful events, negative emotions and Stressful events, negative emotions and psychological distress are frequently cited reasons psychological distress are frequently cited reasons for relapse to drug use among opiate and cocaine for relapse to drug use among opiate and cocaine addicts addicts (Grant 1994, Lowman 1996, Marlatt 1985)(Grant 1994, Lowman 1996, Marlatt 1985)..( )( )

•• Exposure to stressors increases relapse to Exposure to stressors increases relapse to smoking smoking (Swan 1998, Cohen 1990)(Swan 1998, Cohen 1990)

•• Lapses in smoking abstinence that are triggered by Lapses in smoking abstinence that are triggered by stress progress more quickly to relapse stress progress more quickly to relapse ((ShiffmanShiffman1996)1996)

Sensory Sensory InformationInformation

ChangesChangesChanges Changes how we see how we see the worldthe world

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ChChChanges Changes how we see how we see the worldthe world


“Craving, not having, is the mother of a “Craving, not having, is the mother of a reckless giving of oneself.”reckless giving of oneself.”

--Eric HofferEric Hoffer

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AutomatedAutomated

Neutral Cue(get in your car)Neutral Cue(get in your car)

Negative Cue(get yelled at by your

boss)


boss)

Positive Cue(have a good meal or

sex)


sex)

Negative Affect (stressed out)Negative Affect (stressed out)

Positive Affect (happy or relaxed)Positive Affect

(happy or relaxed)

AVOIDANCE OF CUES

AVOIDANCE OF CUES

SUBSTITUTE SUBSTITUTE

CRAVINGCRAVING

re

BEHAVIORSBEHAVIORS

in

ZinserZinser 1992, 1992, PiaseckiPiasecki 1997, Carter 1999, 1997, Carter 1999, LazevLazev 1999, Cox 2001, Robinson 2003, 1999, Cox 2001, Robinson 2003, BevinsBevins 2004, Baker 2004, Cook2004, Baker 2004, Cook2004, 2004, OlaussonOlausson 2004, Shiffman 2004, Carter 2008, Perkins 20102004, Shiffman 2004, Carter 2008, Perkins 2010

SMOKESMOKE

Reinforcement of Associative Memory/Habit (smoking makes you feel

better)


better)

Maintain or Increase Positive Affect/Decrease

Negative Affect


Negative Affect

“I can't get no satisfaction “I can't get no satisfaction I can't get no satisfaction I can't get no satisfaction

'Cause I try and I try and I try and I try 'Cause I try and I try and I try and I try I can't get no, I can't get I can't get no, I can't get no…” no…” g , gg , g

--Mick Mick JaggarJaggar

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SelfSelf--control: competing systemscontrol: competing systems•• Affective (selfAffective (self--referential?)/referential?)/hot processinghot processing

–– involves selfinvolves self--referential valuation, is automatic and referential valuation, is automatic and unplanned, and influences behavior through impulses unplanned, and influences behavior through impulses (Weber (Weber 2004, 2004, KableKable 2007). 2007).

–– frontofronto--striatalstriatal--limbic loop, including the orbitofrontal cortex, limbic loop, including the orbitofrontal cortex, ventromedial prefrontal cortex (vmPFC), posterior cingulate ventromedial prefrontal cortex (vmPFC), posterior cingulate cortex (PCC) and ventral striatumcortex (PCC) and ventral striatum (McClure 2004; Hare 2009; Kober(McClure 2004; Hare 2009; Kobercortex (PCC), and ventral striatum cortex (PCC), and ventral striatum (McClure 2004; Hare 2009; Kober (McClure 2004; Hare 2009; Kober 2010) 2010)

•• Deliberative/Deliberative/cold processingcold processing

–– effortful, influences behavior through rules of logic effortful, influences behavior through rules of logic and involved in inhibitory control and involved in inhibitory control (Weber 2004; McClure 2004; (Weber 2004; McClure 2004; OchsnerOchsner 2005, 2005, KnochKnoch 2007; Hare 2009) 2007; Hare 2009)

–– dorsolateral prefrontal cortex (dlPFC), and posterior dorsolateral prefrontal cortex (dlPFC), and posterior parietal cortex etc parietal cortex etc (McClure 2004; Hare 2009; Kober 2010; (McClure 2004; Hare 2009; Kober 2010; SteinbeisSteinbeis2012) 2012)

How to improve the balance How to improve the balance between cold and hot processing?between cold and hot processing?

HOTHOT COLDCOLD

“There “There is no end of craving. Hence is no end of craving. Hence contentment alone is the best way contentment alone is the best way

to to happiness.”happiness.”

--SivanandaSivananda SaraswatiSaraswati

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Overview of MindfulnessOverview of MindfulnessTwo Component Definition:Two Component Definition:1) 1) SelfSelf--regulation of regulation of attentionattention so that it is so that it is

maintained on immediate experience, thereby maintained on immediate experience, thereby ll i f i d i i f lll i f i d i i f lallowing for increased recognition of mental allowing for increased recognition of mental

events in the present moment. events in the present moment. 2) Adopting a particular orientation toward one2) Adopting a particular orientation toward one’’s s

experiences in the present moment, experiences in the present moment, characterized by curiosity, openness, and characterized by curiosity, openness, and acceptanceacceptance..

Bishop 2004


TriggerTrigger

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Applied mindfulness: RAINApplied mindfulness: RAIN

•• RRECOGNIZEECOGNIZE

––“Oh that’s a craving”“Oh that’s a craving”

•• AACCEPT/ALLOWCCEPT/ALLOW

––See if you are resisting the experienceSee if you are resisting the experienceSee if you are resisting the experienceSee if you are resisting the experience

•• IINVESTIGATENVESTIGATE

––“what’s happening in my body right now?”“what’s happening in my body right now?”

•• NNOTEOTE

––Label or mentally note the body Label or mentally note the body sensations from moment to momentsensations from moment to moment

Pilot Study of MT for AddictionsPilot Study of MT for Addictions

•• Mindfulness Based Relapse Prevention vs. CBT Mindfulness Based Relapse Prevention vs. CBT for alcohol and/or cocaine dependence for alcohol and/or cocaine dependence –– randomized controlled trialrandomized controlled trial–– No previous trials of MT as primary treatmentNo previous trials of MT as primary treatment–– No previous trials of MTNo previous trials of MT vs. active controlvs. active controlNo previous trials of MT No previous trials of MT vs. active control vs. active control

groupgroup•• Is it wellIs it well--tolerated? (yes)tolerated? (yes)•• Does it stack up to gold standard treatment (yes)Does it stack up to gold standard treatment (yes)•• Does it change psychological and physiological Does it change psychological and physiological

responses to stress? (yes)responses to stress? (yes)

Brewer et al 2009

Does mindfulness Does mindfulness training work for training work for

smoking cessation?smoking cessation?

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Nicotine dependence is Nicotine dependence is difficult to treatdifficult to treat

•• 70% of smokers report wanting 70% of smokers report wanting to quit to quit (CDC, 2002)(CDC, 2002)qq ( , )( , )

•• 5% of individuals achieve 5% of individuals achieve abstinence annually abstinence annually (CDC, 2002)(CDC, 2002)

•• High relapse rates (>70%High relapse rates (>70%))

Mindfulness Training for SmokingMindfulness Training for Smoking1 month outpatient training (twice weekly):1 month outpatient training (twice weekly):•• Emphasis on Emphasis on awareness, acceptance of and awareness, acceptance of and

working with craving/wantingworking with craving/wanting•• Setting aspirations:Setting aspirations: work toward a quit date at the work toward a quit date at the

end of week twoend of week two–– Learn relationship between craving and behaviorLearn relationship between craving and behavior–– Body scan, Body scan, lovingloving--kindness meditations (formal)kindness meditations (formal)–– RAIN (informal)RAIN (informal)

•• Reinforcing resolve:Reinforcing resolve: work skillfully with cravings for work skillfully with cravings for the remaining two weeksthe remaining two weeks–– Interaction of thoughts with body sensationsInteraction of thoughts with body sensations–– Breath awareness meditation (formal)Breath awareness meditation (formal)–– Noting craving, realigning with aspirations, Noting craving, realigning with aspirations,

moving forward using RAINmoving forward using RAIN etc. (informal)etc. (informal)

Randomized (n=88)Randomized (n=88)

*Attended 6 out of 8 sessions*Attended 6 out of 8 sessions

**Excluded from all analyses due to VA regulations**Excluded from all analyses due to VA regulations

***Mistakenly force randomized to MT***Mistakenly force randomized to MT

Screened by Phone (n=757)Screened by Phone (n=757)

Assessed for Eligibility (n=134)Assessed for Eligibility (n=134)

Did not meet inclusion/exclusion criteria (n=459)Did not meet inclusion/exclusion criteria (n=459)Eligible by phone screen but not interested Eligible by phone screen but not interested

or lost to followor lost to follow--up (n=212)up (n=212)

Dropped out before randomization (n=12) Dropped out before randomization (n=12) Did not meet inclusion/exclusion criteria (n=21)Did not meet inclusion/exclusion criteria (n=21)Force randomized to MT*** (n=3) Force randomized to MT*** (n=3)

Allocated to FFS (n=47)Allocated to FFS (n=47)Started Treatment (n=39)Started Treatment (n=39)Randomized but did not complete baseline Randomized but did not complete baseline assessments or start treatment (n=8)assessments or start treatment (n=8)

Completed Treatment (n=32)*Completed Treatment (n=32)*

Allocated to MT (n=41)Allocated to MT (n=41)Started Treatment (n=33)Started Treatment (n=33)Randomized but did not complete baseline Randomized but did not complete baseline assessments or start treatment (n=8)assessments or start treatment (n=8)

Completed Treatment (n=29)*Completed Treatment (n=29)*

Completed 6 week followCompleted 6 week follow--up interview (n=33) (87%)up interview (n=33) (87%)Completed 12 week followCompleted 12 week follow--up interview (n= 32) (84%)up interview (n= 32) (84%)Completed 17 week followCompleted 17 week follow--up interview (n= 33) (87%)up interview (n= 33) (87%)

Completed 6 week followCompleted 6 week follow--up interview (n= 27) (82%)up interview (n= 27) (82%)Completed 12 week followCompleted 12 week follow--up interview (n= 29) (88%)up interview (n= 29) (88%)Completed 17 week followCompleted 17 week follow--up interview (n= 29) (88%)up interview (n= 29) (88%)

Included in Analysis (n=41)Included in Analysis (n=41)Included in Analysis (n=46)Included in Analysis (n=46)Excluded from analysis (**incarcerated, n=1) Excluded from analysis (**incarcerated, n=1)

Brewer et al 2011

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99

12

14

16

18

20

FFS

MTS

aret

tes

/day

aret

tes

/day

Greater reduction in smoking with Greater reduction in smoking with MT vs. Freedom from SmokingMT vs. Freedom from Smoking

0

2

4

6

8

10

12

1 2 3 4 5

Ave

rag

e C

iga

Ave

rag

e C

iga

Treatment weekTreatment week0 1 2 3 4 0 1 2 3 4

Brewer et al 2011

Group*Time

F=11.11, p=.001

25

30

35

40

tin

en

ce

(%

)

MT FFS

Greater sGreater smoking moking aabstinence bstinence with with MT vs. MT vs. Freedom from SmokingFreedom from Smoking

******

0

5

10

15

20

25

End of Treatment 17 week follow-up

Po

int

Pre

va

len

ce

Ab

st

**pp = .= .063063****pp = .= .012012

Brewer et al 2011

What about craving?What about craving?•• Craving intensity predicts smoking relapse risk in both Craving intensity predicts smoking relapse risk in both

adults and adolescents adults and adolescents (Shiffman (Shiffman 1997, 1997, BagotBagot 1997)1997)

–– Every additional point on the Questionnaire on Smoking Every additional point on the Questionnaire on Smoking Urges (QSU) increased risk of lapse in adults by 10%Urges (QSU) increased risk of lapse in adults by 10%

–– relapse within 1 week of cessation relapse within 1 week of cessation (Killen & (Killen & FortmannFortmann 1997)1997)

•• > 32% of those with high craving scores> 32% of those with high craving scoresg gg g

•• < 15% of those with low craving scores< 15% of those with low craving scores

–– In a study of 324 treatmentIn a study of 324 treatment--seeking smokers: seeking smokers: (Ferguson (Ferguson 2006)2006)

•• For each 1 SD increase in craving score on target For each 1 SD increase in craving score on target quit date, daily risk of lapsing rose 43%quit date, daily risk of lapsing rose 43%

•• For each 1 SD increase in the average craving For each 1 SD increase in the average craving experienced during a given day, risk of lapsing the experienced during a given day, risk of lapsing the following day rose 65%following day rose 65%

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Working hypothesisWorking hypothesis

•• Hypothesis: MT works by decoupling Hypothesis: MT works by decoupling craving and behavior (e.g. smoking)craving and behavior (e.g. smoking)

•• Prediction: should see dissociation Prediction: should see dissociation between craving and smokingbetween craving and smokingbetween craving and smoking between craving and smoking BEFORE they both subsideBEFORE they both subside

––i.e. should still have some craving, i.e. should still have some craving, but it is not coupled to smokingbut it is not coupled to smoking

What about craving?What about craving?•• Craving intensity predicts smoking relapse risk in both Craving intensity predicts smoking relapse risk in both

adults and adolescents adults and adolescents (Shiffman (Shiffman 1997, 1997, BagotBagot 1997)1997)

–– Every additional point on the Questionnaire on Smoking Every additional point on the Questionnaire on Smoking Urges (QSU) increased risk of lapse in adults by 10%Urges (QSU) increased risk of lapse in adults by 10%

–– relapse within 1 week of cessation relapse within 1 week of cessation (Killen & (Killen & FortmannFortmann 1997)1997)

•• > 32% of those with high craving scores> 32% of those with high craving scoresg gg g

•• < 15% of those with low craving scores< 15% of those with low craving scores

–– In a study of 324 treatmentIn a study of 324 treatment--seeking smokers: seeking smokers: (Ferguson (Ferguson 2006)2006)

•• For each 1 SD increase in craving score on target For each 1 SD increase in craving score on target quit date, daily risk of lapsing rose 43%quit date, daily risk of lapsing rose 43%

•• For each 1 SD increase in the average craving For each 1 SD increase in the average craving experienced during a given day, risk of lapsing the experienced during a given day, risk of lapsing the following day rose 65%following day rose 65%

Working hypothesisWorking hypothesis

•• Hypothesis: MT works by decoupling Hypothesis: MT works by decoupling craving and behavior (e.g. smoking)craving and behavior (e.g. smoking)

•• Prediction: should see dissociation Prediction: should see dissociation between craving and smokingbetween craving and smokingbetween craving and smoking between craving and smoking BEFORE they both subsideBEFORE they both subside

––i.e. should still have some craving, i.e. should still have some craving, but it is not coupled to smokingbut it is not coupled to smoking

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Craving and cigarette use become Craving and cigarette use become dissociated during treatmentdissociated during treatment

Baseline(Week 0)

End of Treatment(Week 4)

6-WeekFollow-Up

3-Month Follow-Up

4-MonthFollow-Up

Craving (QSU)X

Cigarette Use

r = 0.582p < 0.001

N = 32

r = 0.126p = 0.491

N=32

r = 0.474p = 0.020

N = 25

r = 0.788p < 0.00001

N=28

r = 0.768p < 0.00001

N=29

p = .04p = .04p .04p .04

Predictor of Smoking r R2 β p Effect size

Overall ModelBaseline Craving

Baseline Cigarette UseEnd of Treatment CravingInformal practice (days/wk)Craving*Informal (days/wk)

0.735 0.5400.266-0.0530.208-1.5220.515

0.0010.5910.53

0.652<0.0001

0.026

1.17

Mindfulness practice moderates dissociationMindfulness practice moderates dissociation

Elwafi et al Drug and Alcohol Dependence (in press)

MT MT practicepractice modifies relationship modifies relationship between craving and smokingbetween craving and smoking

Variable r r2 p df bb

(standardized)

p

Baseline QSU 0.582 0.339 < 0.00011, 31

3.41 0.58 < 0.0001

Week 4 QSU 0.126 0.016 0.4912, 31

0.41 0.13 0.491

QSU+Formal

(days/week)0.561 0.315 0.004

2, 31

0.47,-1.33

0.14,-0.55

0.358,0.001

QSU+Informal

(days/week)0.484 0.234 0.021

2, 31

0.35, -0.99

0.11,-0.47

0.516,0.008

QSU+Formal

(total minutes)

0.482 0.232 0.0222, 31

0.33,-0.009

0.10,-0.47

0.533,0.008

QSU+Informal

(total times)0.566 0.320 0.004

2, 31

0.56,-0.03

0.17,-0.55

0.273,0.001

Moderation in a single slideModeration in a single slide(as taught by a psychiatrist)(as taught by a psychiatrist)

Independent Variable (X)Independent Variable (X)“psychotherapy”“psychotherapy”

A moderator (M) is a variable that alters the direction or strength of the relation between a predictor and

DDependent Variable (Y)ependent Variable (Y)“depression”“depression”

Moderator Variable (M)Moderator Variable (M)“gender”“gender”

or strength of the relation between a predictor and outcome (Frazier 2004)

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Does home practice moderate the Does home practice moderate the relationship between craving and relationship between craving and

smoking?smoking?Independent Variable (X)Independent Variable (X)

“Craving”“Craving”

DDependent Variable (Y)ependent Variable (Y)“Daily number “Daily number

oof cigarettes smoked”f cigarettes smoked”

Moderator Variable (M)Moderator Variable (M)“Mindfulness home “Mindfulness home

practice”practice”

Craving and cigarette use become Craving and cigarette use become dissociated during treatmentdissociated during treatment

Baseline(Week 0)

End of Treatment(Week 4)

6-WeekFollow-Up

3-Month Follow-Up

4-MonthFollow-Up

Craving (QSU)X

Cigarette Use

r = 0.582p < 0.001

N = 32

r = 0.126p = 0.491

N=32

r = 0.474p = 0.020

N = 25

r = 0.788p < 0.00001

N=28

r = 0.768p < 0.00001

N=29

p = .04p = .04pp

Predictor of Smoking r R2 β p Effect size

Overall ModelBaseline Craving

Baseline Cigarette UseEnd of Treatment CravingInformal practice (days/wk)Craving*Informal (days/wk)

0.735 0.5400.266-0.0530.208-1.5220.515

0.0010.5910.53

0.652<0.0001

0.026

1.17

Mindfulness practice moderates dissociationMindfulness practice moderates dissociation


Reduction of craving scores with MTReduction of craving scores with MT

2 5

3

3.5

4

4.5

core

(Q

SU

) Abstainers

Non-Abstainers

0

0.5

1

1.5

2

2.5

Baseline End of Trmt 6-Week f/u 3-Month f/u 4-Month f/u

Cra

vin

g S

c

**

pp = 0.03= 0.03


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Neutral Cue(get in your car)Neutral Cue(get in your car)


boss)


boss)


sex)


sex)

Negative Affect (stressed out)Negative Affect (stressed out)

Positive Affect (happy or relaxed)Positive Affect

(happy or relaxed)

AVOIDANCE OF CUES

AVOIDANCE OF CUES

SUBSTITUTE SUBSTITUTE

CRAVINGCRAVING

re

BEHAVIORSBEHAVIORS

in

ZinserZinser 1992, 1992, PiaseckiPiasecki 1997, Carter 1999, 1997, Carter 1999, LazevLazev 1999, Cox 2001, Robinson 2003, 1999, Cox 2001, Robinson 2003, BevinsBevins 2004, Baker 2004, Cook2004, Baker 2004, Cook2004, 2004, OlaussonOlausson 2004, Shiffman 2004, Carter 2008, Perkins 20102004, Shiffman 2004, Carter 2008, Perkins 2010


better)


better)

SMOKESMOKE


Negative Affect


Negative Affect

“The destruction of craving conquers all “The destruction of craving conquers all suffering.suffering.””

--DhammapadaDhammapada (354)(354)

Next steps in MT for addictionsNext steps in MT for addictions

•• Standardize evidenceStandardize evidence--based based approachesapproaches––WebWeb--based trainingsbased trainings

––Smart phone appsSmart phone apps

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Craving to QuitCraving to Quit(iPhone App)(iPhone App)

•• 21 day training for 21 day training for smoking cessationsmoking cessation

•• Daily modulesDaily modules

•• In vivo exercisesIn vivo exercises

•• Track progressTrack progress

•• Experience SamplingExperience Sampling–– Test efficacyTest efficacy

–– Improve treatmentImprove treatment

Mechanisms of Mindfulness?Mechanisms of Mindfulness?•• Improved Improved attentionalattentional focus focus ((JhaJha 2007; Lutz 2009)2007; Lutz 2009)

•• Improved cognitive flexibility Improved cognitive flexibility (Moore 2009) (Moore 2009)

•• Reduced affective reactivity Reduced affective reactivity ((FrewenFrewen 2008; 2008; FarbFarbyy2010; 2010; GoldinGoldin 2010)2010)

•• Modification or shifts away from Modification or shifts away from distorted or exaggerated selfdistorted or exaggerated self--view view (Teasdale 2002; (Teasdale 2002; RamelRamel 2004; 2004; FarbFarb 2007; 2007; GoldinGoldin 2009)2009)

•• What’s going on in the brain?What’s going on in the brain?

How common is Mindlessness?How common is Mindlessness?

•• Prevalence: ~50% of waking life is Prevalence: ~50% of waking life is spent mindspent mind--wandering.wandering.

•• No happier when mind is No happier when mind is wandering vs. on task.wandering vs. on task.

•• “A wandering mind is an unhappy “A wandering mind is an unhappy mind.”mind.”

KillingsworthKillingsworth 20102010

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Overlap between DMN and Overlap between DMN and SelfSelf--referential processingreferential processing

WhitfieldWhitfield--GabrieliGabrieli NeuroimageNeuroimage (2011)(2011)

Mindfulness meditation practicesMindfulness meditation practices

ConcentrationConcentration LovingLoving--kindnesskindness

Choiceless Choiceless AwarenessAwareness

In the next period, please pay attention to the physical sensation of the breath wherever you feel it most

Please think of a time when you genuinely wished someone well (pause). Using this feeling as a focus silently wish all beings

In the next period please pay attention to whatever comes into your awareness, whether it is a thought emotion or bodywherever you feel it most

strongly in the body. Follow the natural and spontaneous movement of the breath, not trying to change it in any way. Just pay attention to it. If you find that your attention has wandered to something else, gently but firmly bring it back to the physical sensation of the breath.

focus, silently wish all beings well, by repeating a few short phrases of your choosing over and over (for example: May all beings be happy, may all beings be healthy, may all beings be safe from harm.)

is a thought, emotion, or body sensation. Just follow it until something else comes into your awareness, not trying to hold onto it or change it in any way. When something else comes into your awareness, just pay attention to it until the next thing comes along.

Attention directed at Attention directed at single (physical) objectsingle (physical) object

Attention directed at Attention directed at physical and mental physical and mental objectsobjects

Attention focused, but not Attention focused, but not directed to specific objectdirected to specific object

Task of MT?Task of MT?

•• The “task” common to all of these The “task” common to all of these meditation techniques is the training meditation techniques is the training of attention away from selfof attention away from self--referencereferenceof attention away from selfof attention away from self reference reference and mindand mind--wandering and toward wandering and toward one’s immediate experience. one’s immediate experience.

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Mechanisms of Mindfulness Mechanisms of Mindfulness Meditation?Meditation?

•• DoesDoes meditation change meditation change brain brain activation patternsactivation patterns??

––In the moment (state)In the moment (state)

––Over time (trait)Over time (trait)

Experienced meditator study Experienced meditator study (n=12)(n=12)

Meditation hoursMindfulness 7748.3+4250.5Loving Kindness 1060.1+958.9gOther 1756.8+2476.6Total 10565.2+5148.9

Brewer et al 2011

baseline

Trial Time CourseTrial Time Course

Instructions2 min

30 sec

4.5 min

Choiceless Awareness Meditation

Concentration Meditation

Loving Kindness Meditation

2x Trial (randomized between conditions)

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Decreased DMN activity during Decreased DMN activity during meditation in experienced meditation in experienced

meditatorsmeditators(all meditations, Experienced > Novice)(all meditations, Experienced > Novice)

zz == 2121x = x = --66

Brewer et al 2011

z = 21z = 21x =x = --66

-0.5

-0.3

-0.1

0.1

0.3

BO

LD

sig

na

l ch

an

ge

(%

)

z 21z 21x x 66

Meditators ControlsMeditators Controls-0.5

-0.3

-0.1

0.1

0.3

Meditators ControlsMeditators Controls

“Science “Science is a way of trying not is a way of trying not to fool yourself. The first to fool yourself. The first

principle is that you must not principle is that you must not fool yourself, and you are the fool yourself, and you are the y , yy , y

easiest person to fooleasiest person to fool.” .”

--Richard FeynmanRichard Feynman

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baseline

RealReal--time meditation feedbacktime meditation feedback

1 min

3 min

meditate“active”

feedback“dummy” feedback

RealReal--time time NeurofeebackNeurofeeback(PCC ROI)(PCC ROI)

Run 1Run 1

ExpertExpertNoviceNovice

Decreased Decreased ff

Run 4Run 4

selfself--related related activationactivation

Increased Increased selfself--related related activationactivation

RealReal--time time NeurofeebackNeurofeeback(PCC ROI)(PCC ROI)

ExpertExpert

Run 1Run 1 Run 4Run 4

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"Practice does not make perfect. "Practice does not make perfect. Only perfect practice makes Only perfect practice makes

perfectperfect.”.”

--Vince Vince LombardiLombardi

What ingredients are needed What ingredients are needed for mindfulness practice?for mindfulness practice?

Pay attentionPay attention

“felt a lot more “felt a lot more relaxed, like it relaxed, like it was less of a was less of a struggle to struggle to

prevent my mind prevent my mind from wandering”from wandering”

NNOVICEOVICE MMEDITATOREDITATOR

RRUNUN 11 RRUNUN 22 RRUNUN 33 RRUNUN 44

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2020



relaxedrelaxed

NNOVICEOVICE MMEDITATOREDITATOR

Thinking Thinking about the about the

breathbreath

”focused more on ”focused more on the physical the physical

sensation instead sensation instead of thinking in and of thinking in and

out”out”

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RelaxRelax Drop the Drop the selfself

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Mindfulness may increase cold Mindfulness may increase cold while decreasing hot processingwhile decreasing hot processing

ACCACC

dlPFCdlPFCPCCPCC

HOTHOT COLDCOLD

SummarySummary•• Stress leads to craving and unhealthy coping Stress leads to craving and unhealthy coping

(e.g. addictions)(e.g. addictions)•• MT may be helpful with alcohol and cocaine MT may be helpful with alcohol and cocaine

dependencedependence–– Changes psychological and physiological Changes psychological and physiological

responses to stressresponses to stressresponses to stressresponses to stress•• MT may help people quit smokingMT may help people quit smoking

–– More practice = better outcomeMore practice = better outcome•• MT seems to decouple craving and smokingMT seems to decouple craving and smoking

–– Practice may moderate thisPractice may moderate this•• Neural mechanisms of MT may involve DMNNeural mechanisms of MT may involve DMN

–– Less selfishness = happier and healthier?Less selfishness = happier and healthier?

Thanks for listening!Thanks for listening!

•• For more information:For more information:

––www.cravingtoquit.comwww.cravingtoquit.com

H ffi t P t bl (J d B )H ffi t P t bl (J d B )––Huffington Post blog (Judson Brewer)Huffington Post blog (Judson Brewer)

––www.ytnc.yale.eduwww.ytnc.yale.edu

––[email protected]@yale.edu

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Many Thanks!Many Thanks!SubjectsSubjects

Theresa BabuscioTheresa BabuscioKeri BergquistKeri Bergquist

Sarah Bowen (UW)Sarah Bowen (UW)Kathy CarrollKathy Carroll

Neha Chawla (UW)Neha Chawla (UW)Justin ChenJustin Chen

Michael CohenMichael Cohen

Jeremy GrayJeremy GrayMichelle Hampson Michelle Hampson Hayley JohnsonHayley Johnson

Yoona KangYoona KangHedy KoberHedy Kober

Cheryl Cheryl LacadieLacadieDaniel LibbyDaniel Libby

Marc PotenzaMarc PotenzaMaolin QiuMaolin QiuDeidre ReisDeidre Reis

Bruce RounsavilleBruce RounsavilleDustin ScheinostDustin Scheinost

Rajita SinhaRajita SinhaTommyTommy ThornhillThornhill

www.ytnc.yale.eduwww.ytnc.yale.edu

FUNDINGFUNDING:: NIDANIDA (R(R0303 DADA029163029163--0101AA11,, KK1212 DADA0016700167,, PP5050 DADA0924109241),), MindMind andand LifeLife Institute,Institute,YaleYale CenterCenter forfor ClinicalClinical InvestigationInvestigation (UL(UL11 RRRR024139024139),Yale),Yale StressStress CenterCenter (UL(UL11 DEDE019586019586--0202),),VAMCVAMC MIRECCMIRECC

Michael CohenMichael CohenTodd ConstableTodd Constable

Cameron DeleoneCameron DeleoneColin DeYoungColin DeYoung

Hani Hani ElwafiElwafiReza Reza FarajianFarajian

Daniel LibbyDaniel LibbySarah MallikSarah Mallik

G. Alan Marlatt (UW)G. Alan Marlatt (UW)Candace MinnixCandace Minnix--CottonCotton

Charla NichCharla NichXenios PapademetrisXenios Papademetris

Tommy Tommy ThornhillThornhillAndrea Weinstein Andrea Weinstein

JochenJochen WeberWeberPatrick WorhunskyPatrick Worhunsky

Documents

Craving To Quit - Mindfulness by Jud Brewer