Mindfulness, depression and modes of mind: when East meets West

RANZCP Adelaide May 2009 Mindfulness, depression and modes of mind: when East meets West Mark Williams University of Oxford Department of Psychiatry Collaborators: Zindel Segal, John Teasdale, Jon Kabat-Zinn Oxford Team: Melanie Fennell, Thorsten Barnhofer, Catherine Crane, Danielle Duggan, Adhip Rawal, Emily Hargus, Wendy Swift www.mbct.co.uk

Outline What is mindfulness? Application to depression recurrence MBCT outcome evidence What is going on? Modes of self-focus Conceptual vs experiential Exploring modes of self-focus in eating pathology through neuroimaging MBCT in treatment-resistant depression

Mindfulness Translation of ancient Pali word sati - awareness direct, open-hearted knowing Traditionally cultivated by meditation practices Learning to pay attention Moment by moment Intentionally With curiosity and compassion

Relevance to Major Depression?

Age of onset of major depression (N = 4041; Zisook, 2007, Amer. J. Psychiat)

Depression recurrence n More than 50% who do recover will have at least one further episode n Those with history of 2 or more episodes have 70-80% chance of recurrence

When depression returns. What symptoms come back?

0.7 0.6 0.5 0.4 0.3 0.2 0.1 0-0.1 Patterns of Symptoms in Recurrence (Williams, et al., J Aff Dis. 2006) *** * Pearson r * p <.05 ** p <.01 *** p <.001 Sleep Disturbance Agitation/Retardation Fatigue Guilt Worthlessness Difficulty Concentrating Suicidality Appetite Change

Mindfulness-based Cognitive Therapy (MBCT) Designed for patients in remission to prevent relapse/recurrence Format Pre-class interview Eight weekly classes. Each 2 hours. Around 12 in each class Teaching meditation sustained attention on breath and body thoughts as mental events Home-based practice, up to one hour per day, 6 days a week - mostly CDs of mindfulness meditation practice

Teasdale, Segal & Williams, et al.,2000 Survival Curve (for patients with 3 or more previous episodes - 60 weeks) 1.00 MBCT: 37% 0.5 TAU: 66% 10 20 30 40 50 60

Procedural replication (Ma & Teasdale, 2004, J.Consult.Clin.Psychol.) Patients with 2 episodes (25% of sample; N = 18) - no significant effect

Those with 3 or more episodes had Early onset (longer histories) Autonomous onsets of new episodes (rather than reactions to life event) Difficult adolescent relationship with parents (Measure of Parental Style - indifference, over-control, abuse)

More about the mindfulness approach in :

Basic emotions Anger Sadness Disgust Happiness Fear Time-limited or lose signal function

Critical process.so what goes wrong? the inability to switch off something that evolved to be temporary

Two Modes of Self-focus: Conceptual and Experiential Environmental Input Experientia l / Direct Conceptual / Simulation Labeling Elaborating Analyzing Judging Goal-setting Planning Comparing Remembering Self-reflecting Seeing Tasting Touching Hearing Smelling Visceral sensations Proprioceptive sensing

Conceptual mode useful To complete meanings To complete tasks But when it becomes over-used Preoccupied by meaning Planning (even when not wanted)

Consequences of conceptual mode (from the Mindful Attention and Awareness Scale; Brown & Ryan, 2003) I find it difficult to stay focused on what s happening in the present. I tend to walk quickly to get where I m going without paying attention to what I experience along the way. It seems I am running on automatic without much awareness of what I m doing. I rush through activities without being really attentive to them. I get so focused on the goal I want to achieve that I lose touch with what I am doing right now to get there. I find myself preoccupied with the future or the past. Cf Cornell Campus experiment

in depression Key maintaining factor PERSISTENT OVER-USE OF CONCEPTUAL MODE adhesive pre-occupation (rumination) & Attempts to stop it (avoidance)» lack of interest in anything else

For example Focus on Feelings of tiredness

Mindfulness training: Shifting mode of self-focus - from conceptual to experiential Environmental Input Perceptual /Direct Conceptual/ Simulation A B

(Adhip Rawal s DPhil thesis) Choose a condition where self-focus most problematic Students with high eating concerns Anorexic in-patients

Induction of processing modes (Watkins & Teasdale, 2004) Sample item: the physical sensations in your body the way you feel inside how awake or tired you are Mode induction Conceptual: Think about the causes, meanings and consequences of Experiential: Focus your attention on the experience of 8 minutes

Stress test for Eating Concerns Imaginary meal procedure (Shafran et al.,1999) Participants asked to imagine eating a fattening food for a period of 2 minutes.

Outcome measures Estimate of actual weight How much do you think you weigh right now? Moral wrongdoing: How morally unacceptable/wrong do you feel (0-100%) it was to think about eating the food Urge to reduce/cancel effects: How strong do you feel is your urge (0-100%) to reduce or cancel the effects of thinking about the food? Neutralization imagining exercising imagining eating celery checking shape in a mirror

Analogue study: Pre and post stressor difference in weight estimate (in kg) for high ED group 0.3 Condition, p <.05 Mean Weight change 0.2 0.1 0-0.1-0.2-0.3 Conceptual Experiential

Mean ratings for moral wrongdoing/unacceptability post stressor for high and low ED groups Moral Wrongdoing 35 30 25 20 15 10 5 0 Analytical Experiential High ED Low ED

Proportion of neutralisers and non-neutralisers post stressor for the high ED group 18 Neutralisers Non-neutralisers 16 14 Frequency 12 10 8 6 4 2 0 Analytical Experiential

N = 13 in-patients BMI=17.2 Matched controls Anorexic patients?

Patient study: Pre vs post stressor difference in weight estimate (in kg) 1.4 1.2 1 0.8 0.6 Anorexic Controls 0.4 0.2 0 Conceptual Experiential Filler task

Patient study: Proportion neutralised after stressor in each condition 12 10 8 6 Neutralisers Non-neutralisers 4 2 0 Conceptual Experiential Filler

Effects of mindful movement class I think it makes you less preoccupied. I found that it s a slow process but in terms of getting you back to feel at one with your body and comfortable in your skin, I think that is something new for me. Particularly as you start to put a bit of weight on one can be extremely anxious and I find coming out of those sessions, you know that nothing has changed by itself, but you feel better, content and even slightly OK with your shape and as a whole.

Mindfulness training increases viscero-somatic processing and uncouples narrative-based processing (Farb et al, 07)

Content Negative thoughts Dysfunctional Attitudes Memories Negative interpretations Worries about future Hopelessness

Content Negative thoughts Habitual processing Analysing Dysfunctional Attitudes Memories Judging Comparing Negative interpretations Worries about future Hopelessness Elaborating Planning Goal-setting Recalling

Kenny & Williams (Beh. Res. Ther. 2007) All symptomatic, despite ADM (74%) and CBT (68%) N = 50 (49 completers) 25 20 43% in remission at end (<10 on BDI) 15 10 BDI 5 0 Pre Post

Eisendraeth, Delucci, Bitner, Fenimore, Smit & McLane (Psychoth. Psychosom., 2008) TRD - failure to remit with 2 adequate doses of ADMs N = 55 (51 completers) 29% in remission at end (BDI < 10) 25 20 15 10 5 BDI 0 Pre Post

MBCT for currently depressed & suicidal (Barnhofer, Crane et al, Behav Res Ther. 2009) Three or more prior episodes or chronic depression Currently depressed or residual symptoms Randomly allocated to MBCT + TAU TAU alone 35 30 25 20 15 10 5 MBCT TAU 0 Pre Post

Summary Mindfulness training can reduce depression recurrence Training in experiential mode of self-focus - can prevent over-use of conceptual mode Impact of mode of self-focus also seen in eating pathology can be explored through neuroimaging Encouraging evidence for MBCT in treatmentresistant depression

www.mbct.co.uk Thank you

Additional slides

Relapse signatures (Emily Hargus s data) Individual patterns of prodromal features that warn of onset of episode Very important for self-management (schizophrenia, bipolar disorder, suicidal behaviour) Not just whether noticed, but how we relate to them enmeshed I m not ever going to be able to sleep again with meta-awareness ( decentered ) I felt life was getting difficult, but it was my own inability to cope at that time

Meta-awareness of relapse signature 3 2.6 2.2 1.8 MBCT TAU 1.4 1 Pre Post

Effect of conceptual mode on autobiographical memory

Responses to Cue-words (Non-depressed) Happy When I went to see my daughter in her new house Sorry When I went to see my sister after her husband had had a heart attack

Responses to cue-words - suicidal patients (including following prompts) Safe Being in my flat Just when I'm sitting there Happy Being with John The night he told me he loved me Sorry Sorry if I've hurt anyone, any time Arguments This week-end, Friday

Effect of mode induction on over-general memories (Watkins and Teasdale, J.Abnorm. Psychol. 2001) 6 5 4 3 Pre Post 2 1 0 Conceptual Experiential

MBCT reduces Overgeneral Memories (Williams et al., 2000) 0.3 0.25 0.2 0.15 0.1 Pre Post 0.05 0 MBCT Treatment as usual