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…