The Neuroscience of MBCT for Depression. Thorsten Barnhofer Freie Universitaet Berlin 11 th of April, 2014

Transcription

1 The Neuroscience of MBCT for Depression Thorsten Barnhofer Freie Universitaet Berlin 11 th of April, 2014

2 The Problem: Recurrent Depression Lifetime prevalence of MDD about 25% More than 80% of people with MDD have recurrent episodes Risk of relapse or recurrence increases with number of previous episodes

3 % Patients for Whom Major Life Event Preceded Episode Association between Life Events and Onset of Depression FIGURE 2.2: Studies of the Link Between Stressful Life Events and First Versus Subsequent Episodes of Depression (Post, 1992) Episodes 1st 2nd 3rd 4th 1st 3+ 1st 2nd 3rd 4+ 1st 2+ 1st 2+ Matusek et al. (1965) Angst (1966) Gutierrez et al. (1981) Dolan et al. (1985) Ghaziuddin et al. (1990)

4 Cognitive Vulnerability to Depression Early experience of adversity (Beck et al., 1979) Negative beliefs about self, world and future Over-demanding standards (e.g. perfectionism, need for approval, need for control)

5 Differential Activation Response Tendencies (Suicidality) Negative Automatic Thoughts Depressive Mood Intrusive Memories Self-Discrepancies Fatigue

6 Maintaining Factors Rumination Response Tendencies (Suicidality) Negative Automatic Thoughts Depressive Mood Intrusive Memories Avoidance Self-Discrepancies Fatigue Suppression

7 Mechanisms of MBCT No Recurrence Depressive Episode Depressive Thinking Remission Non-Depressive Thinking Potential Recurrence Depressive thinking patterns nipped in the bud Depressive thinking patterns reestablished Low Mood Reactivation of depressive mode of thinking Recurrence

8 Depressive Interlock (Teasdale, 1996) Sensory Loop Proprioceptive Sensory Data Bodily Effects Situation Depressogenic Schematic Models (Implicational) Depression Cognitive Loop Negative Specific Meanings (Propositional)

9 MBCT: Core Skill ability, at time of potential relapse, to recognize and disengage from mind states characterized by selfperpetuating patterns of ruminative, negative thought. (Segal et al., 2002)

10 The Intervention

11 Mindfulness the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment to moment (Jon Kabat-Zinn, 2003) Pali: sati, Sanskrit: smrti: open-hearted knowing, meanings include elements of remembrance, reminiscence, thinking of or upon, calling to mind, memory

12 The Format of MBCT Eight weekly classes (2 2 ½ h) plus all-day session Pre-class interview To explain, motivate, and point out the commitment that will be necessary Homework, up to one hour per day, 6 days a week

13 Central Aim Sessions 1-4 Stabilising attention, concentration, steadying the mind Learning to notice, acknowledge and consciously let go of thoughts Sessions 5-8 Wider awareness Using the capacity for focussed attention as a basis for investigating painful thoughts and emotions with interest and kindness

14 Key Practices Mindfulness of routine activities (e.g. eating) Body Scan Awareness of sensations in the body; learning to direct attention to different part of the body Mindfulness of the breath Mindfulness of Body Sounds Thoughts & Feelings

15 Mindful movement (Yoga) Three minute Breathing Space Scheduled regularly in working day, and additionally when under stress CBT components Thoughts/feelings exercises Psycho-education Behavioral activation Relapse prevention

16 Evidence: Clinical Trials

17 Initial Trial (Teasdale, et al., 2000)

18 Procedural Replication (Ma & Teasdale, 2004)

19 Efficacy in patients with 3 or more episodes (Piet & Hougard, 2012) Relative risk reduction for 3 plus patients: 43%

20 Staying Well Trial (Williams et al., in press)

21 Mechanisms of Action

22 Staying Well Trial: Effects on Suicidal Pre to post changes: Cognitions Reactivity (BDI SCS):

23 Staying Well Trial: Session by Session RSQ Rumination: Change GAD Anxiety:

24 Staying Well Trial: Effect of Mindfulness Cox Proportional Hazard regression: practice (3+ versus 2-) predicting time to relapse Practice

25 Neuroscience of Mindfulness Meditation

26 Research in Expert Meditators: Lutz et al. (2004)

27 Research in Expert Meditators: Lazar et al. (2005) Fig. 1 Cortical regions thicker in meditators than in controls. (a and b) Statistical map depicting betweengroup differences in thickness at each point on the cortical surface overlaid on the inflated average brain. All points meeting a P0.01 threshold (uncorrected) are displayed to better illustrate the anatomic extent of the areas and the relative specificity of the findings. Numbered regions: (1) insula, (2) Brodmann area (BA) 9/10, (3) somatosensory cortex, (4) auditory cortex. (c and d) Scatter plot of mean cortical thickness of each participant in the subregion above threshold within each circled region of (c) insula and (d) BA 9/10, plotted versus age. Meditation participants: blue circles; control participants: red squares.

28 Research in Expert Meditators: Pagnoni et al. (2008) Figure 3. Estimates of the BOLD response associated with semantic processing in the ROI set, obtained by fitting a spline basis set model for the hemodynamic function and subtracting the average response to nonwords ( nw ) from the average response to words ( wo ) in meditators and controls.

29 Why Neuroscience Assessment of expertise and automaticity: Cognitive psychology methods assess automaticity and habitual responding through interference assessment of brain structure and functioning offers another metric Assessment of signatures: Cognitive psychology methods assess single constructs assessment of brain activity offers insights into function and relation between functions

30 Focused Breathing Meditation

31 Attention Regulation: Anterior Cingulate Cortex

32 Anterior Cingulate Cortex Enables executive attention (van Veen & Carter, 2002) by detecting presence of conflicts emerging from incompatible streams of information processing Central station for processing top-down and bottom-up stimuli and assigning appropriate control to other areas in the brain; connected with prefrontal and parietal cortex Conflict monitoring; conflict-related activity of the ACC signals predicts greater prefrontal cortex activity and adjustments in behaviour (e.g. Kerns et al., 2004) Together with fronto-insular cortex, ACC constitutes a network that is involved in switching between activations of different brain networks, thereby facilitating cognitive control

33 ACC Activation in Meditators (Hoelzel et al., 2007) Stronger brain activation in the rostral anterior cigulate cortex and medial prefrontal cortex in meditators than controls for the contrast mindfulness > arithmetic (threshold: p = 0.01, extend threshold >5 voxels; MNI coordinates: x =...

34 Increased ACC Thickness in Zen Meditators (Grant et al., 2010)

35 Short-Term Meditation Induces White Matter Changes in ACC (Tang et al., 2010) Eleven hours of IBMT increases fiber integrity in the left anterior corona radiata (after versus before training, two sagittal sections, x = 17 and 18).

36 Mindfulness of the Body

37 Bodily Awareness: Anterior Insular Cortex

38 Anterior Insular Cortex Primary interoceptive representation of the physiological condition of the body in the posterior insular cortex Anterior insular cortex contains interoceptive rerepresentations that substantialize all subjective feelings from the body AIC has fundamental role in awareness AIC and ACC often jointly activated serving as complementary limbic sensory and motor regions

39 AIC Thickness in Expert Meditators (Lazar et al., 2005) Fig. 1 Cortical regions thicker in meditators than in controls. (a and b) Statistical map depicting betweengroup differences in thickness at each point on the cortical surface overlaid on the inflated average brain. All points meeting a P0.01 threshold (uncorrected) are displayed to better illustrate the anatomic extent of the areas and the relative specificity of the findings. Numbered regions: (1) insula, (2) Brodmann area (BA) 9/10, (3) somatosensory cortex, (4) auditory cortex. (c and d) Scatter plot of mean cortical thickness of each participant in the subregion above threshold within each circled region of (c) insula and (d) BA 9/10, plotted versus age. Meditation participants: blue circles; control participants: red squares.

40 Brain Activation during Experiential Focus (Farb et al., 2007)

41 Mindfulness of Thoughts

42 Default Mode Network Berger (1929): EEG shows that that brain is constantly busy Ingvar (1974) found high levels of frontal activity during rest (regional blood flow) Deactivation : some brain regions are more active in passive control condition than task condition Meta-analyses of deactivations began to define anatomy (Shulman et al., 1997) Raichle et al. (2001) argued that default mode network activity is associated with self-referential processing

43 Default Mode Network: Anatomy

44 Default Mode Network Activity and Mind Wandering

45 Functions of the Default Mode Network: Internal Mentation

46 Default Mode Network: Anticorrelations

47 DMN and Stages of Meditation (Hasenkamp et al., 2012)

48 DMN and Stages of Meditation (Hasenkamp et al., 2012)

49 Default Mode Network and Task Performance

50 The Role of Default Mode Network Suppression in Depression Increased DMN connectivity during rest (Berman et al., 2011; Greicius et al., 2007, Zhang et al., 2011) Evidence for DMN-persistence (Grimm et al., 2009) and TPdeficiency Increased level of anti-correlation during rest (Zhou et al., 2010) Altered pattern of DMN to TP switching (Hamilton et al., 2010)

51 DMN and Cognitive Risk for Depression

52 DMN and Mindfulness (Way et al., 2010) Figure 3 Correlations of depression and mindfulness with self-referential regions during rest (fixation vs. shape match). Positive correlations with Beck Depression Inventory score in the ventromedial prefrontal cortex (A: 4, 56, -14) and negative correlations with dispositional mindfulness in the medial prefrontal cortex (B: 16, 68, 12) and the posterior cingulate (C: 8, -34, 48).

53 DMN connectivity in expert meditators and beginners (Taylor et al., 2013)

54 Mindfulness of Body Sensations, Emotions and Thoughts: Labeling

55 A Cognitive-Neurobiological Model of Depression (Disner et al., 2011) Limbic hyperactivity and attenuated cognitive control Bottom-up pathway begins with limbic system (most notably the amygdala) and proceeds through the subenual cingulate cortex, ACC, caudate, putamen, nucleus acumbens and hippocampus, to the PFC and frontal cortex Depressed patients show increased amygdala reactivity and decreased inhibitory input from prefrontal cortex

56 Affect Labeling (Creswell et al., 2007)

57 Affect Labeling and Mindfulness (Creswell et al., 2007)

58 Affect Labeling and Mindfulness (Creswell et al., 2007)

59 Sitting with the Difficult

60 Emotion Regulation Following Mindfulness Training (Hoelzel et al., 2013)

61 Amygdala Activation Following Compassion Training (Desbordes et al., 2013)

62 Reconsolidation and Memory Updating: Rewriting Emotional Memories (Schiller et al., 2010)

63 Reconsolidation and Memory Updating: Rewriting Emotional Memories (Schiller et al., 2010)

64 Reconsolidation and Memory Updating: Rewriting Emotional Memories (Schiller et al., 2010)

65 Implications for Practice and Teaching

66 Thank you