11/10/2017. Building Resilience in Medicine. Objectives. Nothing to disclose

Transcription

1 Building Resilience in Medicine Cynthia M Stonnington, M.D. Associate Professor of Psychiatry Chair, Dept. Psychiatry & Psychology, Mayo Clinic in Arizona Wellness Director, Mayo Clinic College of Science and Medicine, Mayo Medical School-Arizona, Mayo Clinic Stonnington.cynthia@mayo.edu 2015 MFMER slide-1 Nothing to disclose 2015 MFMER slide-2 Objectives Define resilience and review the science behind the concept. Explain the role of early adverse events and attachment systems in regulation of stress and affect. Develop treatment strategies for chronic headache that focus on function over symptoms, increased self-efficacy, and empowerment MFMER slide-3 1

2 Flourishing Absence of mental/physical illness is not the presence of mental/physical health* Even among patients with same severity/frequency of headaches, great variability in functional outcomes Pain defines life Thriving despite pain. *Keyes, C.L.M, Promoting and Protecting Mental Health as Flourishing. American Psychologist, MFMER slide-4 Resilient pain responses Shaped by Individual qualities Social/environmental factors Many of these responses can be learned and hold promise as treatment targets for patients for the way we respond to our patients 2015 MFMER slide-5 Woke up with a headache. Acceptance + belief in one s ability to cope Ignore Catastrophize Paced breathing, judicious medication, mindfulness and selfcompassion, revised action plan guided by values I can t afford to have a headache so I will act as if I don t have one that is what strong people do What if doesn t work and I can t function? I have so much to do today! I may lose the promotion I have been working so hard for. Full life Ultimately crashes and then hates self for being weak and not being able to live life as desired Life becomes dictated and defined by headaches 2015 MFMER slide-6 2

3 Patient complains of persistent or refractory headaches Empower Dismiss Collude Validate suffering Get annoyed, symptoms must be psychological I am pressed for time; maybe this new medication you heard about on TV will do the trick Don t blame, do ask questions that facilitate jointly finding solutions to increase function and QOL Patient either goes elsewhere or does not adhere with recommendations while feeling misunderstood Order lots of tests and prescribe more medications; reinforce belief that eliminating pain is the answer to a good life 2015 MFMER slide-7 Resilience Adapt to, respond to, and recover from current and potential life stressors 2015 MFMER slide-8 Common Qualities Focused attention and calm state Sought out and expressed human connections. Imitated role models They valued and loved something or someone. Approached instead of avoided (confronted fears). Acted rather than reacted. Accepted responsibility for their own emotional well-being. Optimistic but realistic outlook. Adapted from: Resilience: The Science of Mastering Life's Greatest Challenges by Southwick and Charney 2015 MFMER slide-9 3

4 Broaden and Build Pay attention to RELEVANT negative information But focus on what is right within what is wrong Using core values as a compass 2015 MFMER slide-10 Early Adverse Events (traumatic experiences during childhood) Physical, sexual, or emotional abuse, as well as discordant relationships with primary caretaker, the loss of a parent, or excessively rigid/unforgiving or excessively chaotic caregivers Associated with a wide range of medical disorders later in life and poorer health-related quality of life Anda RF, et al. The enduring effects of abuse and related adverse experiences in childhood. European Archives of Psychiatry and Clinical Neuroscience, 256(3), , R.A. Lanius, E. Vermetten, & C. Pain (Eds.). The impact of early life trauma on health and disease: The hidden epidemic. Cambridge: Cambridge University Press MFMER slide-11 The Brain is a Threat Detector Glucocorticoids liposoluble and easily cross the blood-brain barrier to access the brain Hippocampus, amygdala, frontal lobes involved in learning, memory, emotion regulation Early prolonged stress affects neurobiological systems and neural circuits involved in fatigue, pain, emotional, and sensorimotor processing Cortisol reactivity, inflammatory cytokines, decreased CSF oxytocin levels Central sensitization Chronic somatic symptoms increase stress Feedback loop 2015 MFMER slide-12 4

5 Secure Attachment Co-regulation of stress in relation to attachment figures Oxytocin Activation of reward system Downregulation of HPA axis and sympathetic nervous system Activation of neural systems involved in (embodied) mentalization Fosters ability to regulate stress Luyten and Fonagy, MFMER slide-13 Physical symptoms threat to body integrity distress and fear helplessness activation of attachment invalidation threat response validation emotional regulation Luytenand Fonagy(p. 130) IN: J. Hunter, R. Maunder (eds.), Improving Patient Treatment with Attachment Theory: A Guide for Primary Care Practitioners and Specialists, MFMER slide-14 Self-efficacy Has been linked to initiation and maintenance of health behavior The belief in one s capabilities to organize and execute the courses of action required to manage prospective situations. (Albert Bandura, 1995) Past performance Modeled behavior Constructive feedback/persuasion from others Physiological responses, e.g., level of felt anxiety, energy 2015 MFMER slide-15 5

6 Buffering Stress and Building Capacity Tend-and-Befriend/oxytocin Exploration/reward/dopamine circuit Exercise/endorphins/BDNF Mindfulness meditation/ hippocampus, amygdala, prefrontal cortex, connectivity, immune response, inflammatory cytokines Paced breathing/adequate sleep/parasympathetic Nutrition 2015 MFMER slide-16 VALUES Creswell (2005) thinking about personal values and affirming them: Decreases perception of threat Decreases defensive response to threat Decreases rumination after failure Significantly reduces cortisol levels during stressful lab tests 2015 MFMER slide-17 Compassion is a practical antidote for difficult life experiences Selfcompassion Offering compassion Receiving compassion 2015 MFMER slide-18 6

7 COMPASSION Decreased Negative rumination Depression Anxiety Self critical thinking Anger Anxiety about what others think of you Heart rate Increased Emotional coping skills Ability to cope with negative emotions Life satisfaction Sense of well being Happiness Optimism Curiosity Positive mood Motivation Better interpersonal relationships 2015 MFMER slide-19 Shifting from Control to Acceptance Acceptance of pain accounted for greater variance in psychosocial and physical functioning than did pain intensity [McCracken 2010] Those who responded to pain with acceptance experienced better physical functioning [Gillanders 2013] Acceptance of pain and values-based action accounted for 10 % of unique variance in headache severity and up to 20 % in headache-related disability [Foote 2015] Those with higher levels of pain-related acceptance engaged in a higher level of activity and needed to use fewer coping strategies on a daily basis [Chiros 2011] MBCT for H/A: acceptance differentiated responders from non-responders [Day 2014] 2015 MFMER slide-20 Acceptance giving up Acknowledge pain as part of the life experience Describing vs judging/evaluating Making space for the experience: salt metaphor Goal-directed behavior/living a full life Social connections support with someone empathetic 2015 MFMER slide-21 7

8 PAIN AND SUFFERING Two arrows of human experience The event itself Our reaction to the event Suffering = Pain x Resistance 2015 MFMER slide MFMER slide-23 chaos Window of Tolerance rigidity 2015 MFMER slide-24 8

9 Resilient and Non-resilient responses affecting functional outcomes and chronic headache symptoms Stonnington CM, Kothari DJ, Davis MC. Curr Neurol Neurosci Rep 2016 Jan; 16 (1): MFMER slide-25 Take home point Interventions are geared toward activating and developing those emotions and behaviors that enable positive adaptation to the adversity of chronic pain. Focus is on optimal functional health rather than number of symptoms Invalidating responses can potentially reactivate the stress response associated with insecure attachment, which in turn can fuel somatic symptoms 2015 MFMER slide-26 Resilience Interventions Mindfulness Based Stress Reduction (MBSR) Mindfulness Based Cognitive Therapy (MBCT) Acceptance and Commitment Therapy (ACT) Cognitive Behavioral Therapy (CBT) Biofeedback training Self-hypnosis Family resilience/strength based model Values based action therapy Yoga based therapies 2015 MFMER slide-27 9

10 2015 MFMER slide MFMER slide-29 Acceptance and Commitment Therapy 2015 MFMER slide-30 10

11 Mindfulness 2015 MFMER slide-31 Mind-Body Therapies THE BLOG 07/29/2016 Childhood Trauma Leads To Lifelong Chronic Illness So Why Isn t The Medical Community Helping Patients? By Donna Jackson Nakazawa 2015 MFMER slide-32 Cognitive Behavioral Therapy Find a local therapist: Multidisciplinary pain rehabilitation programs Focus on ability (not disability), activities (not symptoms), recovery (not relief) Behavioral activation with proper pacing Relaxation strategies Distress management Exercise Psychotherapy before pharmacotherapy 2015 MFMER slide-33 11

12 CBT for insomnia MFMER slide-34 Exercise and Motivational Interviewing 2015 MFMER slide-35 Internet-based CBT J Med Internet Res Feb; 19(2): e32. Review of web- and computer-based therapies for stress icbt Rosso IM, et al., Depress Anxiety Mar;34(3): MoodGYM Guille, C., et al., JAMA Psychiatry December ; 72(12): wcbt for medical interns 2015 MFMER slide-36 12

13 Questions & Discussion 2015 MFMER slide-37 13