Overview: Mind-Body Medicine

1. Overview: Mind-Body Medicine The biopsychosocial model

2. Overview: Mind-Body Medicine The biopsychosocial model Effects of stress on the immune and cardiovascular systems

3. Overview: Mind-Body Medicine The biopsychosocial model Effects of stress on the immune and cardiovascular systems Stress management techniques: Types and effectiveness in relieving stress and stress-related disorders

4. Overview: Mind-Body Medicine The biopsychosocial model Effects of stress on the immune and cardiovascular systems Stress management techniques: Types and effectiveness in relieving stress and stress-related disorders Application of stress management techniques to headache, hypertension, immune function, and chronic disease

5. The biopsychosocial model Biological and cellular processes Psychological processes Social processes and contexts

6. 3-year incidence of 10 common symptoms in primary care

7. Psychological processes Hypochondriasis DSM-IV: “Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms [sensations]” 4-9% prevalence in general medical practice “sensitivity” to body sensations varies across the population Psychophysiology Psychological phenomena affecting physiology Stress is one common phenomenon that can affect cardiac, respiratory, immune, neuroendocrine, muscular, nocioceptive systems Pathophysiology 10-20% prevalence in 10 most common reasons for consultation Biological and cellular processes

8. Stress and the immune system Medical school examinations associated with decreases in cellular immunity and increases in proinflammatory and humoral immunity – this pattern is associated with increases in vulnerability to infectious disease as well as allergy and other “autotoxic” processes. Life stress is associated with 2-fold increase in susceptibility to the common cold virus above and beyond medical risk factors. Severe life stress is associated with a 4-fold increase in risk of HIV progression and 2.6-fold increase in mortality above and beyond medical risk factors (viral load, initial CD4 count).

9. Stress and the cardiovascular system The incidence of major depression is ~20% after MI; cardiovascular mortality is tripled in this group (15%) compared to nondepressed patients (5%) in the next 6 months. Risk equals that of poor left ventricular function.

10. Is it magic? The “mind-body” connection

11. Is it magic? The “mind-body” connection Autonomic nervous system Sympathetic innervation (red) Parasympathetic (blue) Regulates physiology to prepare for short-term vs. long-term projects

12. Blood flow changes with sympathetic activation

13. CRH ACTH cortisol Is it magic? The “mind-body” connection Short-term effect of cortisol Glucose release from liver and muscles Long-term effects Immune changes Loss of muscle and bone mass Loss of insulin sensitivity Hippocampus neuronal death

14. Stress STRESS MANAGEMENT Sympathetic activation Cortisol release among others Hypertension Immunosuppression Insulin resistance among others BETA-BLOCKERS ACE INHIBITORS Clinical health

15. Relieving stress: Relaxation techniques Forms of relaxation practice include progressive muscle relaxation, autogenic relaxation, stretch-based relaxation, the relaxation response, meditation, some kinds of yoga and other exercises coming from Eastern traditions (e.g., t’ai chi) Relaxation is often used in treatments for anxiety as a way for patients to control sympathetic activation and to provide a coping strategy Biofeedback involves direct visual or aural feedback regarding physiological states and can target muscle tension, skin temperature, or vasoconstriction (e.g., of the temporal artery)

16. Relieving stress: Relaxation techniques Relaxation effectively treated generalized anxiety disorder in 45 patients. 44% achieved “recovery” levels of trait anxiety post-treatment, 50% at 4 weeks post-treatment, and 53% at 6 months post-treatment

17. Relieving stress: Exercise Typical prescriptionin most studies is 20-30 minutes of exercise, usually aerobic, 3-4 times weekly Physiological effects of exercise are diverse and include improvement in cardiac function and insulin sensitivity Psychological effects of exercise are potentially robust and include decreases in stress and depression (mean –7 points on the Beck Depression Inventory) Potential biological mechanisms for psychological effects include increased endorphins and NE in the brain (NE is also increased by tricyclic antidepressants such as amitryptaline); potential social effects include increased social contact in exercise groups

18. Relieving stress: Exercise Exercise was equally effective as SSRI medication (sertraline) in alleviating depression in 156 adults > 50 years old with major depressive disorder after 16 weeks of treatment, although medication had a somewhat larger response in the first 8 weeks

19. Relieving stress: Cognitive-behavioral therapy Stress management therapies usually have several targets of action within the biopsychosocial model Social: Provide social support from group therapies; maximize support from existing social networks; teach assertion as a coping skill to resolve conflict Psycho: Teach adaptive interpretation of stressful events – challenge rather than threat; encourage active engagement rather than passive avoidance Bio: Teach relaxation, self-hypnosis, healthy behavior

20. Relieving stress: Cognitive-behavioral therapy Stress management decreased depressive and anxious responses to positive HIV serostatus notification in 47 gay men who attended group sessions twice weekly for 5 weeks before blood draw, while waiting for notification, and 5 weeks afterward. Change is from 1 week before to 1 after notification.

21. Evidence: Benign headache Relaxation training (such as progressive muscle relaxation), EMG biofeedback from frontal or forehead sites, and thermal biofeedback “are now well accepted in the larger headache treatment community . . . They are a typical part of the armamentarium of comprehensive headache centers or clinics . . . These treatments are clearly superior to headache monitoring while on a waiting list”. Progressive muscle relaxation or EMG biofeedback are typically attempted first for tension headache because they focus on muscle tension, whereas autogenic relaxation or thermal biofeedback are typically attempted first for migraine headache because they focus on vasodilation.

22. Issues with the Evidence: Benign headache Combination treatments may be more effective than pure treatments. Relaxation, biofeedback, and cognitive therapy can be combined in any configuration. In trials that compared behavioral treatments with medications (propanolol, diazepam, amitryptaline), “behavioral treatments seem generally as effective as medications”. The placebo effect may be responsible for some of the effects; similarly, the gain in coping efficacy may be responsible.

23. Efficacy and headache relief from EMG biofeedback Succeeding very well? No Yes Significant relief Minimal relief + Forehead muscle tension - Minimal relief Significant relief But efficacy and expectancies do not account for all the effects of behavioral treatments: Several studies have shown such treatments to be more effective than placebo.

24. Evidence: Hypertension Blood pressure (SBP or DBP) biofeedback, thermal biofeedback, stress management, meditation, various forms of relaxation, and autogenic training have all been used in controlled trials to decrease blood pressure. Single component interventions show little effect, but combination therapies on average decrease SBP 13.5 mm Hg, and DBP 3.4 mm Hg. As with headache treatments, relaxation, biofeedback, and cognitive-behavioral approaches are combined. Other behavioral remedies include exercise, which is effective at reducing blood pressure mostly to the extent that it reduces weight. Weight loss of 15-20 pounds typically reduces SBP by 6-10 mm Hg and DBP by 3-7 mm Hg.

25. Issues with the Evidence: Hypertension Even small reductions in blood pressure may have large clinical effects. Reduction in DBP of 5-6 mm Hg resulted in 42% decrease in stroke, 14% decrease in heart disease, and 21% decrease in vascular mortality in drug trials; mean reduction of only 2 mm Hg lowers stroke risk by 15% and heart disease risk by 6%. Behavioral interventions may reduce or eliminate the need for drug therapy in some patients. There are few randomized, controlled trials in this area, and more methodologically rigorous research is needed.

26. Evidence and Issues: Immune function If stress suppresses immunity, can interventions improve it? Stress management in general has no effect, but very few studies actually enrolled stressed populations. Those studies found increases in immune cell functions and helper T cell counts. Relaxation has few effects on the immune system, but it does reliably increase salivary IgA. Again, very few studies actually enrolled stressed populations. Hypnotic suggestion to increase or decrease immune reactions is effective only for decreases and only for suggestible people.

27. Evidence: Chronic disease Several studies with HIV and cancer suggest that stress management interventions may benefit physiological functioning and prolong life: Cognitive-behavioral stress management Michael Antoni and colleagues, University of Miami HIV Breast cancer Cognitive-behavioral therapy Fawzy Fawzy and colleagues, UCLA Malignant melanoma

28. CBSM with HIV: Effects on immunity In addition to buffering the psychological impact of HIV notification, CBSM buffered negative immunological changes; these changes may be prognostic in HIV.

29. CBSM with Breast Cancer: Effects on cortisol CBSM reduced serum cortisol; this changes may be prognostic in cancer, as dysregulated cortisol predicts breast cancer survival. This effect was most pronounced in women who found some benefit in their cancer experience during the group.

30. CBT with Malignant Melanoma: Effects on recurrence and survival CBT reduced rates of cancer recurrence and death 5-6 years after participating in a 6-week structured intervention. This effect was most pronounced in people who increased the amount of active coping with cancer stresses.