Grief, Stress, and the Body: Using Integrative Medicine to Cope with Loss

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Grief, Stress, and the Body Using Integrative
Medicine to Cope with Loss

• Larry Bergstrom MD FACP
• Integrative Medicine
• Division of Consultative Medicine (CMED)
• Mayo Clinic Scottsdale AZ
• bergstrom.larry_at_mayo.edu
• Joanne Cacciatore, PhD
• Arizona State University
• School of Social Work

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Goals and Declarations

• 1) To define Integrative Medicine
• 2) To recognize the Medicine Wheel of Health
• 3) To know the three basic elements of health
• Declarations None

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• Our greatest glory is not in never falling, but
  in rising every time we fall.
• Confucius

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Stress

• A physical, chemical, or emotional factor that
  causes bodily or mental tension and may be a
  factor in disease causation
• Stimulates Sympathetic Nervous System
• Adrenaline
• Cortisol
• Increases blood pressure, heart rate, affects
  coagulation system, immune system, blood sugar,
  sleep

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An ExerciseRate Your Stress

• Scale 1-10, 10 is worst stress

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An ExerciseRate Your Stress

• Scale 1-10, 10 is worst stress
• Includes health, finances, family, neighbors,
  in-laws, work, global warming, politics, etc.

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An ExerciseRate Your Stress

• Scale 1-10, 10 is worst stress
• Includes health, finances, family, neighbors,
  in-laws, work, global warming, politics, etc.
• How much of the day do you think about things on
  your stressor list?

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Rate Your Stress

• 1/10- Perfect idyllic life
• 5/10- Saber-toothed tiger is in the neighborhood
  somewhere
• 10/10- Hes breathing in your face

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Conventional Treatment of Stress
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Potential Complications of Chronic Stress

• Heart disease
• Sleep problems
• Digestive problems
• Depression
• Obesity
• Memory impairment
• Worsening of skin conditions, eczema

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Mortality and Bereavement

• Question Does death of a child increase
  mortality of the mother?
• 69,224 mothers age 2050 from National
  Longitudinal Mortality Survey, 9 yr follow-up,
• Results Death of a child increases risk of death
  of mother by 133 especially in first 2 years.
  Not related to mothers education or marital
  status, family size, the childs cause of death
  or the gender of the child.

Espinosa, J. Econ. Hum. Biol. (2012),
http//dx.doi.org/10.1016/j.ehb.2012.06.002
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Conventional Medicine

• Focuses on treatment of physical disease, defined
  by measureable parameters physical exam, lab
  tests, imaging, pathology, etc.
• Successful treatment is eradication or
  amelioration of the physical disease
• Ideal for acute care

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Definition- Integrative Medicine

• Comprehensive system that emphasizes wellness and
  healing of the whole person as major goals, above
  and beyond suppression of a specific somatic
  disease.
• Views the patient as whole people with minds and
  spirits as well as bodies and includes these
  dimensions into diagnosis and treatment.

BMJ. 2001322119-120.
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Integrative/Integrated Medicine

• Combines treatments from conventional medicine
  and CAM for which there is some high-quality
  scientific evidence of safety and effectiveness.

National Center for Complementary and Alternative
Medicine website
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Integrative Medicine Consultation

• Review
• Medical condition(s)
• Conventional Medical Therapies
• Patients past and current use of CAM therapies.
• Potential interactions of CAM therapies with
  Conventional medical therapies
• Discern patients attitudes towards potential
  therapies the patients value system.

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Integrative Medicine Consultation

• Develop an Integrated treatment plan
  incorporating
• Exercise
• Nutrition
• Stress reduction
• Complementary and Alternative treatments tailored
  to the patients value system.
• How can we make the patient healthier?

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The Medicine Wheel-Physical Health

• This is Western, Conventional medicine, defined
  by measurement
• Examination
• X-rays
• Blood tests
• Tests give us name of
  the disease which we then
  treat the disease however, what about
  when all tests are normal?

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Disease

• disease
• A disordered or incorrectly functioning organ,
  part, structure, or system of the body resulting
  from the effect of genetic or developmental
  errors, infection, poisons, nutritional
  deficiency or imbalance, toxicity, or unfavorable
  environmental factors

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Illness

• Patients suffer illnesses which are discrepancies
  between states of being and perceived role
  performances.

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The Medicine Wheel-Emotional Health

• Emotional Health
• Interface of Stress and Health through the
  sympathetic nervous system.
• Fight or Flight
• Saber-tooth Tiger analogy
• Patient rates stress level from 1 to 10,
  low to high

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The Medicine Wheel-Emotional Health

• Coping skills learned when younger are used to
  deal with stressful situations.
• Many people are
• Perfectionist
• People pleasers
• Ultra responsible
• Theme- need for control, lack of trust
• Very difficult to say no to anyone
• Black and white thinking

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The Medicine Wheel-Emotional Health

• Mind-Body Medicine enhance the mind's capacity
  to affect bodily function and symptoms. ?
  physical effects of Stress.
• Prayer
• Meditation
• Yoga, Tai Qi, QiGong
• Biofeedback
• Breathing Techniques
• Exercise

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Rumination

• Inward Ruminating about the past
• Regret
• Anger
• Ruminating about the future
• Fear
• Anxiety
• Outward Living in the present
• In front of you
• Focused on the moment

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Mindfulness

• Mindfulness means paying attention in a
  particular way On purpose, in the present
  moment, and nonjudgmentally.
• Jon Kabat-Zinn

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Mindfulness Exercise

• Take 5 minutes
• Pen and Paper
• Find a peaceful and relaxing picture
• Describe what you see in a non-judgmental manner
• Write it down

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Therapeutic use of slow breathing

• Many favorable effects on the cardiovascular
  system and respiratory function
• Decrease in vascular resistance BP
• Increase in peripheral blood flow
• Improved exercise tolerance
• Induce a sense of calm
• Decrease anxiety

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RESPeRATE
Proven in 10 clinical trials to lower blood
pressure naturally. No side effects except
for relaxation. Reduces stress
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Heart Math
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Combining MindfulnessandPaced Breathing
Think I Am Breath in 5 Seconds
Think At Peace Breath out 5 Seconds
6 Breaths/Minute
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The Medicine WheelMental Health

• Neurochemistry- Psychiatry
• Target symptoms
• sleep
• appetite
• concentration
• energy
• sex drive
• Anxiety may be separate biochemical
  disorder
• Treatment- Antidepressants, correction of sleep
  disorder

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Target symptoms of Acute Grief/Depression

• Sleep disturbance
• Appetite disturbance
• Concentration difficulties
• Poor energy
• Stamina
• initiative
• Loss of sex drive
• Passive death thoughts
• Hopelessness

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The Medicine WheelSpiritual Health

• History question
• Do you have a spiritual
  part of your life that is
  helpful to you?
• What gives your life
  meaning?
• Defined by the patient.
• May be religious but not necessarily

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Spiritual Effect of IllnessMeaning

• Practices developed during health
• satisfying, fulfilling, enjoyable
• charge our batteries
• Illness, life changes may prevent engaging in
  them
• Deprives of energy, enjoyment, sense of control
• Cant live up to self-expectations

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Spirituality

• The question
• Do you have a spiritual part of your life?
• What gives your life meaning?

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Spirituality

• Activities developed during health
• Satisfying, fulfilling, enjoyable
• Charge up our batteries
• May all be lost through accident, illness other
  life changes and lead to a spiritual crisis

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What gives our life meaning?

• Work
• Faith
• Family
• Hobbies
• Volunteering
• Pets
• Art
• Sports
• To be a parent

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Spirituality

• In Short
• Why do you get out of bed each day?

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Spiritual Effect of Illness

• The Ideal- State of health when one is able to
  do what is needed to feel fulfilled and give life
  meaning.
• Developed during period of health

Spiritual Crisis

• The Reality of illness- State of health with
  illness/disability. When one is unable to do the
  things that give life meaning.

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Meaning and grief- Case 1

• 50 y/o women
• 6 years ago, adopted son, age 13, killed while
  riding his bicycle
• She grieves but remains positive
• I miss him terribly but he was a gift that I
  would not have otherwise. I am grateful for the
  time he was here.

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Meaning and grief- Case 2

• 45 y/o man
• 3 y/o daughter died 5 years ago
• He decided no God could allow such a thing to
  happen
• Deacon but abandoned his church
• Divorced
• Became a Hedonist- lives for pleasure only,
  because there is nothing beyond what we can see.

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Resilience
A dynamic process (not a personality trait)
encompassing positive adaptation within the
context of significant adversity. Resilience is
the result of individuals being able to interact
with their environments and the processes that
either promote well-being or protect them against
the overwhelming influence of risk factors
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Resilience

• The process by which we find new things to give
  our lives meaning when the prior ones are
  unavailable or no longer possible

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Resilience and Outcomes

• Higher meaning in life
• More adaptive neuroendocrine response to stress
• Greater problem focused coping

• Better physical health
• Lower anxiety and depression
• Well being

Kobasa S.C. et al. J Psychosom Res 1985 Maddi
S.R. Am Psychol 2005 Hull J.G. et al. J Pers
Soc Psychol 1987 Brosschot J.F. et al. Psychosom
Med 1998 Maddi S.R. et al. Am J Drug Alcohol
Abuse 1996
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The Medicine Wheel-Community

• Community
• We do not live our lives in isolation our
  community should be as supportive to our health
  as we are to theirs. Community is the background
  to the Medicine Wheel.

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The Medicine Wheel-Community

• Community
• We do not live our lives in isolation our
  community should be as supportive to our health
  as we are to theirs. Community is the background
  to the Medicine Wheel.

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Integrative Medicine

• Shift question from
• How do we treat your disease?
• to
• How can we help you become healthy?
• Patient-centered Outcomes research- What is most
  meaningful to the patient?

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Integrative Medicine Grief

• Five fundamental needs
• Exercise
• Nutrition
• Hydration
• Rest
• Social support main variable in determining high
  vs. low grief.

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Exercise for You
Cumulative Survival time based on ? or ? changes
in exercise capacity after exercise training and
? vs ? baseline psychosocial stress
Milani 2009
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Integrative Nutritional Plan

• Utilizing food as a source of health and energy
• Emphasis is on food first
• Supplements are supplements to food
• Supplements are used to fill in where diet cannot
  cover everything.
• Mediterranean/Anti-inflammatory diet

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Nutrition- Mediterranean Diet Pyramid
http//www.oldwayspt.org/images/pyramid_med.pdf
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Mediterranean Diet

• Fish- (wild ocean) 3 x weekly
• Fish oil- EPA DHA 1000 mg daily
• Fiber- 35 gm/d
• Olive oil (Canola oil- high temp cooking)
• Whole grain products (less processed)
• Soy- Soy milk 8 oz, tofu 3 oz, soy nuts, edemame
  (isoflavones)
• Nuts- walnuts, pecan, almonds (Sterols)

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Mediterranean Diet

• Fruit- dark skinned fruit (Flavinoids)
• blueberries, blackberries, purple grapes
• red wine, purple grape juice 2-4 oz/d
• grape seed extract
• Vegetables- ½ of diet, Not all greens!
• Green tea 3 c/d (EGCG)

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Mediterranean Diet

• Lean meats- chicken (without skin)
• Red meat- (4 legs, hooves) eat once a month at
  most (source of omega 6)
• Probiotic- yogurt, kefir, probiotic supplement
• Avoid
• Partially hydrogenated oil (trans fat)
• High fructose corn syrup

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SupplementsMood, Anxiety, Sleep

• Inositol- may help depression, panic, OCD. 6-8
  gm 2x/d
• SAMe- may help depression, athritis. Dose 200-800
  mg 2x/d. may take 2 months to work. Do not take
  with antidepressants or if have bipolar disorder
• 5-HTP- may help depression. 150-300 mg/d, may
  help sleep

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SupplementsMood, Anxiety, Sleep

• St. John's wort- may help mild to moderate
  depression. 300 mg 3x/d. interacts with many
  medicines
• Kava- may help anxiety. 100 mg 3x/d. May not be
  safe (liver failure)
• Passionflower- may help anxiety and sleep. 45
  drops or tea or 90 mg tab.

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SupplementsMood, Anxiety, Sleep

• Skullcap- may help anxiety and sleep. Tea or
  alcohol extract
• Theanine- may help anxiety. 200 mg/day
• Valerian- may help sleep. extract 400-900 mg up
  to 2 hours before bedtime
• Lemon balm-may help sleep. tea from flowers

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SupplementsMood, Anxiety, Sleep

• Chamomile tea- may help sleep
• Hops- may help sleep. dose/?
• Lavender- may help sleep. tincture (15 in 50
  alcohol) 60 drops/d
• Melatonin- may help sleep. Take 1 hr before bed,
  dose 1-20 mg, take biggest dose tolerated without
  side effect, take x 6 wks. Quit if no benefit.

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Questions for you

• Are you eating regularly?
• Are you skipping meals?
• Are you losing weight?
• Are you putting on weight?
• Is your refrigerator well-stocked?
• Are you shopping for empty calories and avoiding
  food that your body needs?

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Positive Thinking and Grief

• positive thinking was inversely related to
  measures of depression, anxiety, and traumatic
  grief symptomatology
• Findings- Among bereaved individuals, low
  positive thinking is a cognitive feature of
  depression that is relatively independent of
  anxiety and traumatic grief symptomatology.

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Intentionally interpret life with higher
principles Daily Themes
Monday Gratitude
Tuesday Compassion
Wednesday Acceptance
Thursday Higher Meaning
Friday Forgiveness
Saturday Celebration
Sunday Reflection / Prayer
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Integrative Medicine