Post on 27-Nov-2021
Disaster Stress, Mental Health, and Aging: How Mind-Body Therapies Can Build Resilience
Helen Lavretsky, MD, MSProfessor of Psychiatry
Director, Integrative PsychiatryUCLA 2020
Disclosures
Grant funding –NIMH, NCCIH, PCORI, NIAMS, Alzheimer’s Research & Prevention Foundation
Advisory Board – Alzheimer’s Research & Prevention Foundation
Royalties for books from the Oxford University Press and Hopkins University Press
Objectives
• Growing global distress, global aging, and Mental Health
• Stress during COVID-19 pandemic
• To review neurobiology of stress response
• To review the evidence of mind-body yoga therapies use for resilience and psychological wellbeing
• The use of daily yogic meditation to reduce stress and improve cognition in informal (family) dementia caregivers
THE STATE OF GLOBAL MENTAL UN-HEALTH(prior to 2020 pandemic)
• 450 million people suffer from a mental or behavioral disorder.
• Nearly 1 million people commit suicide every year.
• 4 of 6 leading causes of years lived with disability are due to neuropsychiatric disorders (depression, alcohol-use disorders, schizophrenia and bipolar disorder).
• 1 in 4 families has at least one member with a mental disorder.
• Global cost of mental illness at nearly $2.5T in 2010, with a projected increase to over $6T by 2030.
Increasing Rates of Anxiety with COVID-19(APA poll -September 2020)
• 62% more report feeling anxious then in 2019
• Keeping family safe (80%)
• Racism (76%)
• COVID-19 (75%)
• Gun Violence (73%)
• Presidential Election (72%)- 57% are anxious about outcome
Symptoms of stress• Fear and worry about own health and the health
of loved ones, financial situation or job, or loss of support services
• Changes in sleep or eating patterns• Difficulty sleeping or concentrating• Worsening of chronic health problems• Worsening of mental health conditions• Increased use of tobacco, and/or alcohol and
other substances.• Irritability, anger, violence
https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html
Allostatic Load =price of adaptation to stress and aging
• ALLOSTASIS=maintaining stability through change (Sterling & Eiler 1988)
• Systolic BP (> = 148 mm Hg) • Diastolic BP (> = 83 mm Hg) • Waist-hip ratio (> = 0.94) • Ratio total cholesterol/HDL (> = 5.9) • Glycosylated hemoglobin (> = 7.1%) • Urinary CORTISOL (> = 25.7 ug/g creatinine) • Urinary NOREPINEPHRINE (> = 48 ug/g creatinine) • Urinary EPINEPHRINE (> = 5 ug/g creatinine) • High Density Lipoprotein cholesterol (< = 37 mg/dl) • Dihydroepiandrosterone sulfate (DHEA-S) (< = 350 ng/ml)
Seeman TE et al PNAS 2001 McEwen 2004 (McArthur Study of Successful Aging)
Time
Hea
lth
Fo
otp
rin
t o
f P
an
dem
ic
Phase 2*• Psychological trauma
• Mental illness
• Burnout
• Worsens w/ new outbreaks
• Steeper curve w/ pre-existing
anxiety/depression (dashed line)
Wave 1Immediate mortality and
morbidity of COVID- 19
Phase 3Impact of resource
restriction on urgent
non-COVID
conditions Phase 4Impact of interrupted
care on chronic
conditions
Post-ICU
recovery
Preexisting anxiety/depressionNo history of anxiety/depression
Adapted from Tseng, 2020
*Sources: McKinsey; WHO; KFF
Psychological response to disasters
Mass-Disaster Response• HEROIC- March 2020-altruism, rescue; open-access innovation
(meditation apps; yoga on line; free group meditations)• HONEYMOON - APRIL 2020- highly motivated, optimistic, energized,
heroism- “Pace yourself for a long overhaul” and celebrate your resilience developing ZOOM and virtual platforms
• DISSILUSIONMENT (late May 2020)-low energy; exhaustion; anxiety; depression; anger; (compounded by BLM protests; financial crisis) -LOOK FOR SILVER LININGS! GRATITUDE! TAKE CARE OF YOUR BODY! REST! SLEEP! CREATIVITY! EXERCISE! SPRITUALITY! LAUGHTER! SURRENDER CONTROL! TRUST! PURPOSE!
• RECONSTRUCTION- return to recovery and responsibility- when and for how long?
• FRONTIER INNOVATION (GOVERNMENT CAN’T HELP YOU!)- AI; apps; assistive technology will reshape workforce- simple living; vocational retraining; Heightened awareness of the process and potential
• RESILIENCE BUIDLING- prepare humanity to be more flexible; proactively deal with disasters, honor self-reliance and strength; take care of each other
• COOPERATIVE GLOBAL SOLUTIONS-UNITY CONSCIOUSNESS!
WHO DEFINITION OF MENTAL HEALTH
• “HEALTH is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
• MENTAL HEALTH=a state of well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence and recognition of the ability to realize one’s intellectual and emotional potential.
• INDIVIDUALS are able to cope with stresses of life, work productively and fruitfully, and make a contribution to their communities.
Investing in Mental Health WHO 2009
“Happiness is the consequence of personal effort. You fight for it, strive for it, insist upon it, and sometimes even travel around the world looking for it. You have to participate relentlessly in the manifestations of your own blessings. And once you have achieved a state of happiness, you must never become lax about maintaining it. You must make a mighty effort to keep swimming upward into that happiness forever, to stay afloat on top of it.”
Elizabeth Gilbert “Eat, Pray, Love” (EPL)
“Happiness is a Choice and a Birthright” Gurmukh Khalsa
Our greatest glory is not in never falling, but in rising every time we fall. Confucius
Resilience is a precious skill. People who have ittend to also have three underlying advantages:
a believe that they can influence life events; a tendency to find meaningful purpose in life’s turmoil; and a conviction that they can learn from both positive and negative experiences.Amanda Ripley
Success is not final, failure is not fatal: it is the courage to continue that counts.Winston Churchill
Resilience• Resilience is a dynamic characteristic of the interaction
between individuals and their environments- Ability to recover from adversity / trauma / stress / depression
• Does it require a major traumatic experience to manifest?-What about surviving day-to-day?
• This construct can be fostered in both younger and older individuals- leading to:
• Effective and positive coping• Turning adversity into an opportunity for growth• Develop interventions that enhance resilience using
integrative medicine approaches
• Consequentially leads to better outcomes for medical and mental disorders of aging
Biomarkers of Resilience
• Neuroimaging studies demonstrate neural substrates including the prefrontal cortex, hippocampus, amygdala, anterior cingulate as forming a pathway for resilience.
• HPA axis and Inflammatory mediators may constitute a link between lifestyle factors, infection, and the physiological changes of aging on the one hand and risk factors for age-associated diseases on the other and could serve as targets or biomarkers for resilience-building interventions.
Resilience-Building interventions
• Resilience enhancing interventions include wellbeing therapy, learned optimism training, hardiness training, all of which focus on positive aspects of difficult experiences thereby promoting more positive perceptions of challenges.
• Lifestyle factors such as diet, exercise, spirituality can enhance resilience by creating physical and mental wellbeing.
• Complementary and integrative medicine (CIM) is a holistic approach to wellness which encompasses varied approaches to wellness and stress reduction, including yoga
• CULTIVATE JOY!
• CHANGE ATTITUDES toward death and dying as a natural part of life to combat “FEAR OF DEATH”
Mind-Body Medicine
• Yoga
• Guided imagery
• Meditation
• Hypnotherapy
• Spirituality
• Tai Chi/Qi Gong
• Art, dance, music therapies
• VIRTUAL REALITY- YOGA on ZOOM?
• YOGA for FEAR of DEATH?
Priorities for Mind-Body Research
SELF-REGULATION AND EMOTION REGULATION
Enhance physical & mental health
Manage pain, depressive and anxiety symptoms, insomnia, PTSD disabilities
Impact health
Prevent disease
Targeting therapies for the stress-disease
diathesis
Physiological basis for modulating brain-
autonomic-hormonal-immune pathways
2017 National Health Interview Survey (NHIS)
• Yoga was the most commonly used complementary health approach among U.S. adults in 2012 (9.5%) and 2017 (14.3%).
• The use of meditation increased more than threefold from 4.1% in 2012 to 14.2% in 2017. In 2012, chiropractic care was as popular as yoga, followed by meditation; however, the popularity of meditation surpassed that of chiropractic care to become the second most used approach among those surveyed in 2017.
• The use of chiropractors increased from 9.1% in 2012 to 10.3% in 2017.
• In 2017, women were more than twice as likely to use yoga compared with men (19.8% versus 8.6%). Women were also more likely than men to use meditation (16.3% versus 11.8%) and see a chiropractor (11.1% versus 9.4%).
• Non-Hispanic white adults were more likely to use yoga, meditation, and chiropractors compared with Hispanic and non-Hispanic black adults.
• The use of yoga was highest among adults aged 18 to 44 compared to older adults, while the use of meditation and chiropractic care was higher among adults aged 45 to 64 years compared with younger and older age groups.
MINDFUL PRACTICES
• Effects of mindful practices that can help in achieving mental and physical HEALTH :
• Stress reduction
• Treatment and prevention of depression in high risk populations (e.g., stressed caregivers, older adults with chronic medical illnesses, victims of psychological and physical violence)
• Direct neuroplastic effects in the brain across lifespan
• Shifts in conscious awareness of reality
• CULTIVATION OF WELLBEING, GRATITUDE
• Novel treatments• Novel diagnostic and prognostic systems
• Compression of morbidity• Improved side effect profiles
• Benefits to cardio-metabolic, bone and vascular health
Dietary Physical activity
Body-based Natural products
Complementary and integrative therapies for mental health and aging
Genomic instability
Chronic inflammation
Epigenetic alterations
Telomere attrition
Loss of proteostasis
Mitochondrial dysfunction
Cellular senescence
Mechanisms of aging
Mind-body
What is yoga?
- Systems of ancient philosophy, practices, lifestyle- Breath control (pranayama), specific bodily postures (asanasand mudras), and meditation - World-wide use for health and stress-reduction
Mindful Physical Exercise=Moving Meditation• Mindful physical exercise (e.g., yoga, Qigong, and Tai Chi) is
increasingly utilized for improving psychological well-being, hypertension, cardiovascular disease, insulin resistance, depression, and anxiety
• Physical exercise executed with a profound inwardly directed contemplative focus or awareness
• Key elements:
• A non-competitive, non-judgmental meditative component, • Mental focus on muscular movement and movement awareness
combined with a low to moderate level of muscular activity, • Centered breathing (conscious breath)• A focus on anatomic alignment (i.e., spine, trunk, and pelvis) and
proper physical form, • Energy centric awareness of individual flow of intrinsic body energy
(prana, sekhem, life force, qi, or Kundalini).
“Abbott, Lavretsky; Psychiatric Clinics 2013”
Prevalence of Yoga
• About 31 million U.S. adults have ever used yoga
• About 21 million practiced yoga in the past 12 months
Cramer et al, 2016, Am J Prev Med
Most Frequently Reported Reasons for Practicing Yoga
Most Frequently Reported Outcomes of Practicing Yoga
Cramer et al, 2016, Am J Prev Med
What are the key elements of YOGA?
-Musculoskeletal strength/ flexibility-Breath control-Concentration, attention, mindfulness, awareness-Imagery, visualization-Physical sensations, body awareness-Psychosocial interactions-Spirituality, beliefs, norms-Rituals-Iconic Teachers/Gurus-Shared environmental influences
PFC
ACCPCC
Amygdala
Striatum
Insula
• Prefrontal cortex -cognitive processing and executive control, attention• Anterior and posterior cingulate- mood regulation, memory• Insula -sensory awareness• Striatum-reward, learning, and motivation• Amygdala -Emotional processing (fear, anxiety)
Neural mechanisms of mindfulness meditation
Acevedo, Lavretsky 2016
Neural mechanism differences between mindfulness and mindful exercise
Unique to mindfulness- four regions
• Premotor area (PMA) • Mid-cingulate • Angular gyrus (AG) • Primary and secondary
somatosensory cortex (SSI and II)• =Areas of motor and emotional, and
somatosensory integration- greater awareness of Self=Consciousness
• Can be used for treatment of mood disorders, anxiety, ADHD, impulsivity, movement disorders, stress
Unique to yoga-based practices-seven regions
• Dorsolateral prefrontal cortex (DLPFC)• Medial frontal cortex• Superior temporal area• Paracentral lobe• Precentral and postcentral gyrus• Superior parietal lobule (SPL)• =Areas of judgment- discernment;
memory, language; visual-spatial and somatosensory integration =Social cognition/behavior
• Useful for enhancing judgement and self-control on deliberate actions
• Can be used-criminal system, at risk youth, substance abuse, mood disorders, neurological illness, dementia, cognitive decline, caregiver stress
Acevedo, Lavretsky 2016
Brief Breathing Practices
• Long deep breath- 3 seconds inhale, 3 seconds hold; 3 seconds exhale; 3 seconds hold (5 breath per minute for 3-5 minutes) – reduces blood pressure and heart rate, and anxiety/stress
• 4-4-6-2 breath with longer exhale- stimulates parasympathetic nervous system, deactivates Amygdala
• Alternating nostril breathing:• Left nostril slow breath- 3 minutes- Calming• Right nostril slow breath- 3 minute- Activating• Right and Left- 3 minute- rebalancing breath• O-breath- slow with open mouth inhale (=sipping through
a straw- and exhale on the count of 4) filling up and emptying out your lungs (2 gallons capacity)- detoxifying
What is Kirtan Kriya?
• Kirtan Kriya is a 11-minute chanting exercise in the Kundalini yoga tradition
that people have been practicing for thousands of years. This meditation
involves repetitive finger movements, or mudras, plus verbal chanting and
silent chanting of the mantra “Saa Taa Naa Maa.”
• What does Kirtan Kriya mean in English?
A kirtan is a song. These ancient primal sounds from Sanskrit mean “birth, life,
death, rebirth.” Kriya refers to a specific set of movements or chants.
• The physical benefits of the mantra are:
• Saa evokes a sense of expansiveness
• Taa creates a feeling of strength
• Naa stimulates a sense of the universal
• Maa provides the quality of communication.
• In the yogic tradition, kriyas are used to help bring the body, mind, and emotions into balance, thus creating healing.
•
•Focus of attention
Study of stressed dementia caregivers(funded by ARPF)
Variables Meditation(N=23)
Relaxation(N=16)
t; P
Age 60.5 (8.2) 60.6 (12.5) 0.03; 0.9
Education 16.1 (2.1) 15.1 (2.8) -1.2; 0.2
Month of depression
45.1 (35.4) 39 (21.2) -0.6; 0.5
Yrs of caregiving 4.7 (2.4) 4.2 (2.9) -0.6; 0.6
Hours per week 47.8 (35.8) 63.3 (36.2) -0.2; 0.2
CIRS 3.0 (2.3) 4.6 (3.1) 1.8; 0.08
CVRF 5.2 (3.7) 7.4 (6.4) 1.4; 0.2
HAMD baseline 11.8 (4.1) 11.4 (4.0) -0.3; 0.7
Cognition-MMSE
28
28.2
28.4
28.6
28.8
29
29.2
29.4
29.6
29.8
30
Baseline Week 8
Meditation
Relaxation
-2 -1.5 -1 -0.5 0 0.5 1 1.5
NF-kB
IRF1
Promoter-based bioinformatic analysis implicated reduced
NF-kappaB signaling and increased activity of Interferon
Response Factor 1 in structuring those effects (both p < .05).
Fold-difference in TFBM distribution(Log2 Meditation / Control)
p-value
.0401
.0279
FIGURE 1. Cross sectional view shown above displaysthe crosshair intersection within the right inferior frontal area.
This region was the most significant and largest cluster demonstrating a decrease in the meditation group compared to the control group over time (t=4.74 with p=0.001,160 conti voxels at p<0.01)
FIGURE 2. Cross sectional view shown above displays the crosshair intersection at (-44,-74,-16), within the left associative visual cortex. This region also decreased in the meditation group compared to the control group over time (t=4.15, p=0.002)
fMRI in meditators showed higher activity in a functional network including the anterior cingulate, fronto-orbital cortex and insula
(Light blue areas show the ACC-orbito-insular network, pink for group difference, z=1.7, p<.05)
Sponsors and collaborators
• Sponsored by the grants from NCCIH, NIMH, PCORI, and Alzheimer’s Research Prevention Foundation.
• Collaborators: • Katherine Narr and Brain Mapping- fMRI
• Linda Ercoli and Prabha Siddarth- cognitive analyses
• Michael Irwin, Steve Cole, David Black and the Cousins Center- inflammatory markers
• Steve Cole, Stan Nelson and Nelson Freimer- genetic analyses
• Elissa Epel and UCSF Blackburn lab- telomerase
• Postdoctoral students: Hongyu Yang, Bianco Acevedo, Amber Leaver, Beatrix Krause, Rosa Vlasova, and Harris Eyre
• Study coordinators: Yesenia Aguilar, Michaela Milillo, Raquel Hernandez Sotomayor