FRIDAYPRESENTATION N ORTH C AROLINA N EUROLOGICAL S OCIETY 2017 - - PDF document

This continuing medical education activity is jointly provided by the North Carolina Neurological Society and the Southern Regional Area Health Education Center

NORTH CAROLINA NEUROLOGICAL SOCIETY

2017 ANNUAL MEETING FRIDAY฀PRESENTATION

FEBRUARY 17-19, 2017 THE PINEHURST RESORT, VILLAGE OF PINEHURST

A Program for the North Carolina Neurological Society Meeting February 17, 2017

 Assistant Consulting Professor  Department of Psychiatry and Behavioral

Sciences

 Duke University Medical Center  brantley65@gmail.com

“I’m trying to create a really thriving environment,” he says. “That means making it as rich as

• possible. So there’s noise,

competition, activity, energy— like when we play. It’s better than a pristine vacuum-type environment, as far as I’m

• concerned. Because we never

play there. We don’t talk about mindfulness that much, but that’s how we operate. We focus on what’s right in front of us. We don’t care about the other team

• r the environment we’re playing
• in. We just take every game as if

it’s the most important in the world and focus right on that. That takes great mindfulness.” ̶ Pete Carroll, NFL champion coach of Seattle Seahawks

"Now that I’m in a ’meditation cycle,’ it feels good… Let’s listen to silence. The more you understand silence, that’s where the balance comes."

Ric ick R Rubi bin, C Co-Fo Founde der o r of Def J Jam Reco cords rds

“Simply put, mindfulness is moment-to- moment non-judgmental awareness. It is cultivated by purposefully paying attention to things we ordinarily never give a moment’s thought to.”

• -Jon Kabat-Zinn

Mindful Awareness Attitude

Component mponents o

• f Mindf

dfulnes ulness

“Paying attention.” “On purpose.” “In the present moment, non- judgmentally.”

Adapted from Shapiro et al. (2006). J Clin Psychol.

"If you just sit and observe, you will see how restless your mind is. If you try to calm it, it only makes it worse, but over time it does calm, and when it does, there's room to hear more subtle things- that's when your intuition starts to blossom and you start to see things more clearly and be in the present more. Your mind just slows down, and you see a tremendous expanse in the moment. You see so much more than you could see before.“ ̶ Steve Jobs, Co-Founder, CEO of Apple

 Acute vs. Chronic Stress  The Power of Thoughts to Create Stress, or “Why

Zebras Don’t Get Ulcers” (Robert Sapolsky, PhD)

 Mindfulness-Based Stress Reduction  Selected Research Findings

 freeze—flight—or fight  acute reaction in mind and body

prepares you to meet danger.

 When the elements of the acute

stress reaction become chronic, health and well-being are endanger.

“Man i an is not

• t di

distur urbed b d by event ents, but ut by by t the he view he he takes of

• f them

hem.”

• Ep

Epic ictet etus us Gr Greek ek Ph Philo iloso sophe pher

Fear and negative affects stimulate widespread sympathetic nervous system activation (Thayer & Brosschot, 2005) Fearful cognitions and interpretations can manifest in somatic symptoms, and the same physiological responses arise for either real or imagined threats (Brosschot, et. al.,2005;2006; Thayer and Brosschot 2005) Example of how “depressogenic thinking” can transform momentary emotional distress into longer-lasting mood disturbance (Segal, Williams, & Teasdale, 2002)

…who tends to blame themselves for anything that goes “wrong?” …who is never satisfied when things go “right?” …who has that “little voice inside” that is always criticizing (usually themselves even more than

• thers)?”

Your “Inner Narrative”—what you are telling yourself, moment-by-moment, about what is happening and why.

 Imagined scenarios of threat or failure  Self-criticism or judgment  Recall of disturbing events  Rumination about a negative event  Perceived stress  Hostility  Denial or avoidance  Comparison to an imagined ideal

 How we judge others affects empathic brain responses.  Lack of empathy-related brain activation in the anterior insula

when a person in pain was perceived as unfair in their social behavior

Singer, T., Seymore, B., O’Doherty, J.P., Stephan, K.E., Dolan, R.J., & Frith, C.D. (2006). Empathic neural responses are modulated by the perceived fairness of others. Nature, 439, 466-469.

• Jon Kabat-Zinn, Ph.D.

Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life

“I try to have at least 15 minutes of still time and just kind of sit in my thoughts in the morning and just kind of meditate. And normally what happens with me is my mind would always drift to the game. Always," he said. "And then I found myself sitting

• there. My mind wouldn't drift towards the game all the time anymore. And that's

when I started realizing, ‘You know what? It's getting close. It's getting close.’ Because now I'm not obsessively thinking about the game anymore. It's not wired into my subconscious the way it used to be.” ̶ Kobe Bryant, 5-time NBA champion

 Teaches mindfulness meditation and

application of mindfulness in daily life

 Emphasis on what a person can do to help

themselves—using innate capacity for relaxation, attention, and awareness

 Classroom-based training for anyone

regardless of religious orientation

Mindfulness-Based Stress Reduction (MBSR)

 Eight week class  2—2.5 hours each

week

 Participants have

diverse motivations that are health- based

 Variety of

mindfulness methods taught

 Daily home practice  Formal and

Informal meditation

 Day of Mindfulness

 Dis-attention leads to dis-connection  Dis-connection leads to dis-regulation  Dis-regulation leads to dis-order  Dis-order leads to dis-ease

• -from “Coming To Our Senses” by Jon

Kabat-Zinn, Ph.D. 2005. New York: Hyperion

 Attention leads to awareness  Awareness leads to insight and

understanding

 Insight and understanding lead to increased

choices

Mindf ndfulne ness Stud udies es i in MED EDLI LINE

N = 157 RCTs N = 10 meta-anal. N = 1,084 total

• -chr

hroni

• nic pai

pain n (Kabat abat-Zin Zinn, 1982 1982, , 1985 1985; ; Mor

• rone
• ne,

, et.

• t. al.,

l., 2008 2008)

• -canc

ancer (Spec peca, et.

• t. al,

l, 2000 2000; ; Carlso rlson, et.

• t. al.,

l., 2007 2007)

• -ins

nsom

• mnia

a (Kreitze zer, e et.

• t. a

al., l., 2005 2005)

• -pso

soria riasis is (Kabat abat-Zin Zinn, et.

• t. al.,

l., 1998 1998)

• -type

pe 2 2 di diabet abetes es (Ro Rosenzwe weig, e

• et. a

al., 2007 2007)

• -fib

fibromyalg lgia (Gro (Grossman, et.

• t. al.,

l., 2007 2007)

• -rheum

heumatoi

• id

d ar arthr hritis (Zaut Zautra, et.

• t. al.,

l., 2008 2008)

• -mixed

ed medi edical al di diagnos agnoses es (Rei eibel bel, e

• et. a

al., 2001 2001)

• -or
• rgan t

gan trans ansplan ant pat patient ents (Gros

• ss, et
• et. al

al., 2004 2004)

• -hear

heart di diseas ease e (Sul ullivan an, et

• et. al

al., 2009 2009) )

• -depr

depres ession

• n (Jai

ain, n, et

• et. al

al., 2007 2007)

• -rel

elaps apsing ng depr depres ession

• n (Teas

Teasdal dale, e, et

• et. al

al., 2000 2000)

• -depr

depres ession

• n in

n bi bipol polar ar pat patient ents (William ams, et

• et. al

al., 2008 2008)

• -anx

anxiet ety (Kabat abat-Zi Zinn, et.

• t. al.,

l., 1992 1992; W ; Weiss iss, e et.

• t. a

al., l., 2005 2005; ; Orsi Orsillo llo & Roem

• emer

er, 2005 2005)

• -subs

ubstanc ance e abus abuse e (Ma Marla rlatt & & Chaw hawla, , 2007 2007; B Bow

• wen,

en, et et. al., l., 2009 2009; ; Zgie iersk rska, et.al.,2009 2009)

• -eat

eating ng disor

• rder

ders (Baer aer, 2006 2006)

• -bi

binge ea nge eating ( ng (Krist steller, et.

• t. al.,

l., 1999 1999)

• -ADHD

ADHD (Zylowska ska, et.

• t. al.,

l., 2008 2008)

• -aggr

aggres essive e behav behavior

• r in

n dev devel elopm

• pment

ental al di disabi ability (S (Sin ingh, et.

• t. al.,

l., 2007 2007)

 DBT—Dialectical Behavior Therapy  MBCT—Mindfulness Based Cognitive Therapy  ACT—Acceptance and Commitment Therapy  Addiction and Relapse Prevention Therapies

• Donald Hebb, Ph.D.

• -Greater left prefrontal cortical activity is associated with

mindfulness practice (Davidson, Kabat-Zinn, et. al., 2003)

• -Reduced activity in areas of the brain associated with OCD found

in patients who practiced mindfulness (Schwartz & Begley, 2002)

• -Higher levels of trait mindfulness is associated with a greater

ability to engage the prefrontal cortex (PFC) to manage emotional reactions in the amygdala (Creswell, et. al., 2007)

• -Mindfulness training over 8 weeks associated with greater

neural activity in areas of the brain believed to subserve self- awareness (dorsolateral prefrontal cortex and medial prefrontal cortex) (Farb, et. al.,2007)

 An anatomically defined brain system active when individuals

are engaged in internally focused tasks, including autobiographical memory retrieval, envisioning the future, and conceiving the perspectives of others.

 Is active in mind-wandering and self-referential processing  Two primary nodes: Medial Prefrontal Cortex (MPC) and the

Posterior Cingulate Cortex (PCC)

• -Buckner, Andrews-Hanna, and Schacter

“The Brain’s Default Network: Anatomy, Function, and Relevance to Disease”

• Ann. N

. NY Y Acad. S . Sci.

• i. 1124:1-38 (2008)

 In real-time fMRI neurofeedback studies of individuals practicing

mindfulness meditation, increased PCC activity corresponded with the subjective experience of mind wandering, and decreased PCC activity corresponded to the subjective experience of focused attention to present moment experience.

 Mindfulness training can help individuals be free of feeling

“caught up” in experience, such as drug craving or attachment to a particular viewpoint (attached to “being right”), possibly by its deactivation impact on the PCC. “What about the “self” is processed in the posterior cingulate cortex?” Brewer, Garrison, and Whitfield-Gabrieli Fron

• ntiers in Huma

man N Neuros

• science, Oc

Octob tober er 2, , 2013

Ch Chan ange ges i in gray ay mat atter er f follow

• wing

ng Mindf ndfulne ness-Ba Base sed Stre Stress R ss Reduct ctio ion

From Hölzel et al. (2009, May). North Am Res Conf on Compl and Integr Med.

*

Regi egion of

• f int

nter erest st anal analyses: Inc ncreases i s in n gr gray y mat matter er c con

• nce

centration f from

• m pr

pre- to

• post

post- inter ervent ention

• n

(paired t-test, cluster level values corrected for search region)

y=-34 x= -40

Increase in gray matter concentration in the left hippocampus (p = 0.032) Increase in gray matter concen- tration in the left inferior temporal lobe (p = 0.039)

Chan hange i in per n perce ceive ved stress ess c cor

• rrelates w

s with h cha hanges i in gr n gray mat ay matter er c con

• nce

centration i in t n the he right ht a amygdal gdala a

Larger decreases in stress were associated with larger decreases in gray matter concentration in the right basolateral amygdala. (cluster: 10 voxels, N = 26)

“Mindfulness practice means that we commit fully in each moment to being present. There is no “performance.” There is just this moment.”

• -Jon Kabat-Zinn

Wherever You Go, There You Are, (p. 22)

 Commit to bringing mindfulness into your life through daily

practice as formal meditation and informally in any moment.

 Establish a time and place for formal meditation and stick to it.  Pause and take a mindful breath, a mindful step, or a mindful

bite from time to time in the flow of daily life. Likewise, pause to listen mindfully, or simply notice how your surroundings look, sound, and feel.

 Take the time to do longer periods of intensive practice,

including going on days of mindfulness or on longer retreats.

 Work with acknowledged teachers and utilize resources such as

readings, classes, and recordings, or Internet-based resources

 Associate with like-minded people, and discuss your interest in

meditation with them, offering and giving support to each other.

 Positive thinking. It is not thinking at all!  Just another relaxation technique. It is about increasing

awareness, which is much more powerful.

 Going into a trance or “blissing out”.  Blanking your mind. It is actually about recognizing and

disentangling from the usual ruminations and thought patterns that dominate your life.

 Just for monks, nuns, or priests, and it is not a religion.  Selfish or self-centered. It is actually “self-full” in that it helps

you become more in touch with your wholeness and potential as a human being.

 Practicing and training attention to focus on a

chosen object—like breath sensations, or the sensations of walking; or not selecting a particular focus, but mindfully including all experience—such as practicing “bare attention” to the constantly changing flow of sensory experience impinging on consciousness in each moment.

 The method can involve any object of attention,

and any degree of attentional focus, from narrow to totally open.

“Mindfulness is a quality that’s always there. It’s an illusion that there’s a meditation and and post-meditation period, which I always find amusing, because you’re either mindful or you’re not.”

• -Thich Nhat Hanh

Emotional Exhaustion Depersonalization (cynicism) Perceived lack of personal achievement (Ineffectiveness)

Capacity for self-care, greater self- awareness, better emotion regulation and cognitive processing, and more skillful actions and behaviors… Resulting in greater Resili Resilienc ence!

RESILIENCE

 …THE CAPACITY TO

RESPOND TO STRESS IN A HEALTHY WAY SUCH THAT GOALS ARE ACHIEVED AT MINIMAL PSYCHOLOGICAL AND PHYSICAL COST;

 RESILIENT INDIVIDUALS

“BOUNCE BACK” AFTER CHALLENGES WHILE ALSO GROWING STRONGER.

“Mind

Mindfu fuln lness ess is is st stro rong ngly ly rela related ed t to co comp mpassio ssion, and nd it it is co is comp mpassio ssion n tha hat serves serves as s a so source fo urce for a r all ll hea healing ling int intent entio ionali lity.”

• Stefan

efan Schmi hmidt, P Ph.D.

Mindfulness a and Hea ealing I g Inte tenti tion

• n:

Conce cepts ts, Practice, e, a and Resea earch Ev ch Evalua uati tion

Schmi hmidt dt ( (2004 2004). J Alt C Compl mplement nt Me Med, d, 10 10, , S7-S14 14.

http://www.faithinhumanityrestored.com/2012_02_01_archive.html

“Man i an is not

• t di

distur urbed b d by event ents, but ut by by t the he view he he takes of

• f them

hem.”

• Ep

Epic ictet etus us Gr Greek ek Ph Philo iloso sophe pher

“Compassion is not an entity “we” show

toward the “other.”….We need to lose the

• dichotomy. It is not something I have, and give

to you. It manifests in the relationship between beings…. If we are wholeheartedly engaged in each moment, responding to what is front of us, not judging or labeling ourselves or others, then I believe that compassion cannot fatigue.”

• -Lisa Marr, M.D., Journal of Palliative

Care, Vol. 12, Number 8, 2009.

 Developing self-awareness  Developing self-awareness to enhance self-care

(when self-awareness permits the clinician simultaneously to attend to and monitor the needs of the patient, the work environment, and his or her

• wn subjective experience).
• -Kearney, et al., JAMA, March 18, 2009,
• Vol. 301, No. 11.

• -8-weekly classes plus 1/month for 10 months,

included home mindfulness practice, discussion, and narrative medicine exercises

• -70 primary care physicians

Led to:

• -reductions in burnout
• -improvement in empathy
• -improvement in mood states
• -improvement in emotional stability

“Do not despise the world, for the world too is God.”

• -Muhammad

“Perhaps everything that frightens us is, in its deepest essence, something helpless that wants our love.”

• -Rainer Marie

Rilke

Kris Kristin in Neff, Ph Ph.D. Associate e Profes essor Hu Huma man n De Develop

• pment and

nd Cul Cultur ure Edu ducational Psycholog

• gy Dep

Department nt Un University of Te Texas at Austin self.com

• mpassion@yahoo.com
• m

By By Kris Kristin in Neff, Ph Ph.D. Re Releas ased by Wi William am Mor Morrow w Ap April ril 201 011

 Se

Self lf-com compass passion ion is is exten ending ding compass assion n to

• ne'
• ne's sel

self in n ins nstan ances of

• f perc

percei eived ed inadeq nadequa uacy, fai failur ure, or

• r genera

general suf suffering.

Se Self lf-kindne ness (treat yourself as nicely as you would a stranger) Co Commo mmon human manity (realizing that we are all “only human”, one can practice patience and forgiveness for self and others ) Mi Mind ndful ulne ness ( learn to access the awareness that notices, sees clearly, and does not judge what is present)

Source: http://www.self-compassion.org

“Meditation practice isn’t about trying to throw ourselves away and become something

• better. It’s about befriending who we already

are.”

• -Pema Chodron

Spend time reflecting on the good you have done Think of someone who has helped you, been kind to you Spend some time each day in self-care Repeat one phrase in times of difficulty

 May I offer my care and presence unconditionally, knowing it

may be met by gratitude, indifference, anger, or anguish.

 I care about your pain, and I cannot control it.  May I remain in peace, and let go of expectations.  I wish you happiness and peace, and I cannot make your

choices for you.

 May I find the inner resources to truly be able to give.  May I see my limits compassionately, just as I view the

suffering of others.

 May this experience help me to open to the true nature of

life.



• -from Roshi Joan Halifax and Sharon Salzberg

Practice one act of generosity a day Keep a gratitude journal Go out in nature

“Why is mindfulness so sought after in this moment, and so necessary?...We long for some degree of effective balance and wisdom that supports meaningful, embodied, and significant work—the work of making a difference in the world, of adding value and beauty, of individually and collectively waking up to the full range of human intelligences and capacities we share for wisdom, ease of being, and kindness.”

• -Jon Kabat-Zinn



Mindfulness For The Next Generation: Helping Emerging Adults Manage Stress and Lead Healthier Lives, by Holly Rogers and Margaret Maytan



The stress reduction workbook for teens: mindfulness skills to help you deal with stress, by Gina M. Biegel



Buddha’s Brain: the practical neuroscience of happiness, love & wisdom



by Rick Hanson



Search Inside Yourself: The Unexpected Path To Achieving Success, Happiness (And World Peace) by Chade-Meng Tan



The Art and Science of Mindfulness: Integrating Mindfulness Into Psychology and the Helping Professions, by Shauna Shapiro and Linda Carlson



Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness, by Jon Kabat-Zinn



Real Happiness at Work: Meditations for Accomplishment, Achievement, and Peace, by Sharon Salzberg

 Mindfulness and Psychotherapy, edited by Germer, Siegel,

and Fulton

 The Art and Science of Mindfulness: Integrating Mindfulness

Into Psychology and the Helping Professions, by Shapiro and Carlson

 Mindfulness Meditation in Psychotherapy: An Integrated

Model for Counselors & Clinicians, by Steven A. Alper (in press, New Harbinger Publications)

 Real Happiness at Work: Meditations for Accomplishment,

Achievement, and Peace, by Sharon Salzberg

 www.mindfulexperience.org

a comprehensive research guide compiled by David S. Black, MPH, PhD.

 www.scholar.google.com  www.marc.ucla.edu

the website of the UCLA Mindful Awareness Research Center

 www.mindfulschools.org

• ffers information and resources
• n mindfulness in schools

 www.mindful.org

• nline magazine offers interesting articles

about mindfulness in modern society

 www.MindandLifeInstitute.org

institution that promotes research in mindfulness and dialogue between His Holiness the Dalai Lama, mindfulness scholars and practitioners, and scientists