Overview: Mind-Body Medicine

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Overview Mind-Body Medicine
The biopsychosocial model
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Overview Mind-Body Medicine
The biopsychosocial model
Effects of stress on the immune and
cardiovascular systems
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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
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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
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The biopsychosocial model
Biological and cellular processes
Psychological processes
Social processes and contexts
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3-year incidence of 10 common symptoms in primary
care
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Psychological processes
Hypochondriasis
DSM-IV Preoccupation with fears of having, or
the idea that one has, a serious disease based on
the persons 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
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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).
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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.
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Is it magic? The mind-body connection
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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
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Blood flow changes with sympathetic activation
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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
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Stress
STRESS MANAGEMENT
Sympathetic activation Cortisol release among
others
Hypertension Immunosuppression Insulin
resistance among others
BETA-BLOCKERS
ACE INHIBITORS
Clinical health
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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., tai 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)
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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
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Relieving stress Exercise
Typical prescription in 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
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Relieving stress Exercise
Exercise was equally effective as SSRI medication
(sertraline) in alleviating depression in 156
adults gt 50 years old with major depressive
disorder after 16 weeks of treatment, although
medication had a somewhat larger response in the
first 8 weeks
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.