Strategies to Gain Acceptance for Wellness/ Mind-Body Programs by Skeptical Residents and Clinical Faculty: Stress Physiology Michael D. Lumpkin, PhD Professor of Integrative Physiology and Biochemistry Georgetown University School of Medicine 2017 CENTILE INTERNATIONAL CONFERENCE Georgetown University Medical Center Washington, DC October 24, 2017
Disclosures I have no conflicts of interest to disclose
2 Main Types of Stress Acute Stress: Survive and thrive Chronic Stress: Can lead to dysfunction/disease Excess Chronic Stress can result in Burnout
Ac u t e Stress: The 1 st Ye a r Medical Student
The Burned Out Resident or Clinical Faculty
Hypothalamus: Integrative Center of the Brain Hypothalamus
Neural Connections: Cognitive-Emotional-Autonomic Hypothalamus/CRH=Master Stress Hormone
Hypothalamus/ CRH Stimulates
Hypothalamus/ CRH Inhibits
Stress Circadian rhythm (-) Hypothalamopituitary adrenal (HPA) axis Anterior Pituitary Gland Cortisol Kidney Adrenals ACTH Hypothalamus CRH Posterior Pituitary Gland Glucocorticoids, Catecholamines, etc.. Immune system: altered Muscle: Net loss of amino Acids (glucose) Liver: Deamination of proteins into amino acids, gluconeogenesis Fat (glucose) Cells: Free fatty acid mobilization Heart rate: Increased
Behavioral (Neurotransmitter) Effects of Corticotropin-Releasing Hormone (CRH) 1. CRH injected into brain ventricles increases locomotor activity 2. CRH facilitates the acoustic startle response 3. CRH produces increased responsiveness to stress in an open field test 4. CRH has an anxiogenic-like effect in the operant conflict test 5. CRH produces enhanced suppression of responding in conditioned emotional response test 6. CRH produces a dose-dependent facilitation of stress-induced fighting 7. CRH produces anxiogenic-like response in the plus maze 8. CRH produces a dose-dependent taste aversion and place aversion
CRH drives Major Depression in the Brain
Over-activation of CRH-ACTH-CORTISOL System in Clinically Depressed Patients
Chronic Stress with High Cortisol may lead to Appearance of Cushing s-like Features
CORTISOL high CORTISOL low
Physiology of the Stress Response STRESS HORMONE LEVEL Stressor Stressor Stressor Severe Loss of Resiliency Moderate Loss of Resiliency Optimal Pattern TIME
Excess cortisol causes many metabolic substrate derangements (hyperglycemia, proteolysis, fat deposition) Importance of the return to baseline..if not, then: Sustained high cortisol damages/destroys the neurons mediating cortisol negative feedback restraint on CRH Chronic stress impairs memory, learning due to damage to hippocampal neurons with hippocampal volume reduction
Inhibitory effects Effects of Glucocorticoids in the Immune System Decreases peripheral blood lymphocytes, eosinophils, basophils, monocytes, and neutrophils Inhibits production of IL-1, IL-2, IL-2 receptor, γ-interferon Inhibits F C receptor expression Inhibits in vitro and in vivo proliferation of T lym phocytes to antigens and mitogens Inhibits many monocyte functions, including antigen presentation, lym phokine production, differentiation, and phagocytosis Inhibits immunoglobulin production in vivo Inhibits T suppressor cell function in vivo and in vitro
Stress on the GI Tract Fullness Bloating Diarrhea Inflamed Bowel Disrupts Cell Barriers Antibodies to Food Antigens Food Sensitivities
Chronic stress increases sympathetic drive to arterial blood vessels like coronary arteries and arterioles Sympathetic nerves/ norepinephrine, frequent contraction Smooth muscle cells hypertrophy Resting vessel diameter reduced Resting blood pressure Increased Extreme or Chronic stress, major constriction, loss of blood flow, myocardial infarction?
What is the Relationship of Stress to Cancer? Metastasis Beta receptor antagonist Stress hormone blocker Potent beta receptor agonist
The Proinflam m atory Cytokines Chronic Stress Cascade to Other Hypothalamic Releasing Hormones Inhibited Pituitary Hormones Decreased Disease Major hormonal and organ system impairment/failure
The most commonly studied interventions have involved mindfulness, stress management, and small group discussions, and the results suggest that these strategies can be effective approaches to reduce burnout domain scores.
Mind-Body Medicine: Therapies Meditation Imagery Biofeedback Autogenic Training (self-hypnosis) Breathing Techniques Exercise Yoga, Tai Chi Group Support
Efficacy of Mind-Body Therapies Considerable Evidence Coronary Artery Disease (cardiac rehabilitation) Headaches Insomnia Incontinence Chronic low back pain Disease and treatment-related symptoms of cancer Improving post-surgical outcomes Astin et al Mind-Body Medicine: State of the Science, Implications for Practice. J Am Board Fa m Pract 16:131-147, 2003
Benefits of Biofeedback Increased awareness and confidence in relaxation skills Control over involuntary functions Examples: recurrent migraine headache treatment of Raynaud s disease urinary incontinence arthritis
Let s try an Experiment Using your Mind-Body Physiology to Manage Stress and Improve Resiliency: Autogenic Biofeedback with a Simple Monitor
Neural Connections: Cognitive-Emotional-Autonomic Mind-Body Medicine practices reduce stress signaling to the hypothalamus and decrease CRH, lower stress hormone levels & reduce sympathetic activity. Result: Vasodilation, more blood flow to skin, increased warming. Hypothalamus/CRH=Master Stress Hormone
Chronic stress increases sympathetic drive to arterial blood vessels like coronary arteries and arterioles Sympathetic nerves/ norepinephrine, frequent contraction Smooth muscle cells hypertrophy Resting vessel diameter reduced Resting blood pressure Increased Extreme or Chronic stress, major constriction, loss of blood flow, myocardial infarction?