Mindfulness-Based Therapies: Exploring potential benefits of mindfulness in the post-stroke population Steven Selchen, MD, MSt, FRCPC Head, Mindfulness-Based Interventions (MBI), Department of Psychiatry, University of Toronto Head, Cognitive Behaviour Therapy & MBI, Sunnybrook Health Sciences Centre Director, Sunnybrook Psychiatry Institute for Continuing Education (SPICE) www.sunnybrook.ca/mindfulness
None. Disclosures
Mindfulness-Based Therapies Typically involve eastern meditative practice in a secular, clinical context Robust evidence supporting therapeutic value in depression, anxiety, stress, chronic pain, coping with physical illness, etc. (e.g. Teasdale et al., 2000; Ma & Teasdale, 2004; Segal et al., 2010; Hofmann, et al., 2010; Khoury et al., 2013)
Objectives Identify core principles of mindfulness Summarize the application of mindfulnessbased therapies to various clinical populations Discuss potential applications in the poststroke population
John was on his way to school. He was worried about the math lesson. He was not sure he could control the class again today. It was not part of a janitor s duty. We actively make meaning out of bare facts and are barely conscious that we are doing so (Segal et al, 2002)
John was on his way to school. He was worried about the math lesson. He was not sure he could control the class again today. It was not part of a janitor s duty. We actively make meaning out of bare facts and are barely conscious that we are doing so (Segal et al, 2002)
John was on his way to school. He was worried about the math lesson. He was not sure he could control the class again today. It was not part of a janitor s duty. We actively make meaning out of bare facts and are barely conscious that we are doing so (Segal et al, 2002)
John was on his way to school. He was worried about the math lesson. He was not sure he could control the class again today. It was not part of a janitor s duty. We actively make meaning out of bare facts and are barely conscious that we are doing so (Segal et al, 2002)
John was on his way to school. He was worried about the math lesson. He was not sure he could control the class again today. It was not part of a janitor s duty. We actively make meaning out of bare facts and are barely conscious that we are doing so (Segal et al, 2002)
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Two Arrows
What is Mindfulness? Mindfulness is the awareness that emerges from paying attention - on purpose - in the present moment - non-judgmentally to things as they are. Themes: interest; curiosity; receptivity; observation; openness; compassion
Thought/image emotion urge/impulse sensations
Cultivation Through mindfulness meditative practice, cultivate new relationships to thoughts, emotions, bodily sensations and behaviour Thoughts are thoughts; not facts Emotions are emotions; tolerable Urges are urges; need not be acted upon Bring interest, curiosity and compassion to our exploration of ourselves and our patterns of mind and experience
Metacognitive Awareness Instead of viewing thoughts as absolutely true or as descriptive of important selfattributes, patients learn to see negative thoughts and feelings as passing mental events that are not necessarily valid reflections of reality or central aspects of the self (Segal, et al.)
Learn to Unhook ourselves from automatic maladapitve patterns of mind and behaviour (e.g. rumination & avoidance) Increase freedom and choice Make more adaptive choices
Strategic Maintenance Processes Rumination Patients believe rumination will help uncover the causes of depression and its solutions However, the main effect of going over and over losses, past mistakes, judgments and comparisons is often to perpetuate and amplify negative affect
Strategic Maintenance Processes Avoidance Similarly, patients often believe avoidance will protect them from further harm However, avoidance and withdrawal can keep people stuck, and confirm (or at least fail to disconfirm) negative predictions
Approach vs. Withdrawal When difficult thoughts, emotions or urges arise, can learn to turn toward them ( approach ) and explore them experientially in the present moment, rather than engaging in the kind of rumination or avoidance that would exacerbate and perpetuate them These mental events are then able to dissipate as the transient phenomenon they were designed to be
Responding vs. Reacting Mindfulness does not eliminate cognitive reactivity, but it can restrain us from getting carried away by it and spiraling down Instead, we can learn to respond more wisely and adaptively to our experiences and situations
Engagement in Life Mindfulness training can shift negative filters; directs attention also to positive aspects of experience and encourages deeper engagement in life
Mindfulness-Based Interventions MBSR (Mindfulness-Based Stress Reduction) Secularized adaptation of Eastern meditative practices to a western medical context Developed by Kabat-Zinn at UMass MBCT (Mindfulness-Based Cognitive Therapy) integration of MBSR and CBT Developed by Segal, Williams & Teasdale
Mindfulness-Based Interventions Group-based Structured; e.g. 8 weekly classes Psychoeducational, experiential Focus: mental process > content Teach a variety of meditations MBCT also weaves in a variety of cognitivebehavioural exercises Up to an hour of daily home practice
MBCT Mindfulness of routine activities (e.g. eating) Body Scan awareness of sensations in the body; learning to direct attention to different parts of the body Mindfulness of the breath (concentration on a single focus), then moving to mindfulness of: sounds, the whole body, and thoughts Mindful movement Breathing Spaces scheduled regularly in working day, and additionally when under stress CBT components
Relapse Prevention in Depression (3 or more previous episodes) 1.00 Teasdale et al., 2000 in JCCP And replicated: Ma & Teasdale, 2004 in JCCP MBCT: 37% 0.5 TAU: 66% 10 20 30 40 50 60
Recurrence Across 18 Months Intention to Treat Analysis - Unstable Remitters 27% 28% 71% Log-rank test = 8.24, df =2, p = 0.016 Segal et al., 2010, Arch Gen Psychiatry
Hofmann et al., 2010 (JCCP): The Effect of MBT on Anxiety and Depression: A Meta-Analytic Review Effect size analysis of MBSR and MBCT for anxiety and mood symptoms in clinical samples 39 studies totaling 1,140 participants Range of conditions, incl. cancer, GAD, depression, chronic fatigue syndrome, panic disorder, fibromyalgia, chronic pain, social phobia, ADHD, arthritis, binge eating disorder, bipolar disorder, diabetes, heart disease, hypothyroidism, insomnia, organ transplant, stroke, and traumatic brain injury Updated and supported further in Khoury et al., 2013
The Effect of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review Results: MBI were moderately effective for improving anxiety (Hedges s g 0.63) and mood symptoms (Hedges s g 0.59) from pre- to post-treatment in the overall sample In patients with anxiety and mood disorders effect sizes (Hedges s g) of 0.97 and 0.95 for improving anxiety and mood symptoms, respectively Effect sizes were robust and were maintained over follow-up Conclusions: These results suggest that mindfulness-based therapy is a promising intervention for treating anxiety and mood problems in clinical populations.
Mindfulness training increases viscero-somatic processing and uncouples narrative-based processing (Farb et al, 2007, 2012) Farb, N., Segal, Z.V., Mayberg, H., Bean, J., McKeon, D., Fatima, Z., & Anderson, A. (2007). Attending to the present: Mindfulness meditation reveals distinct neural modes of self-reference. Soc Cog Aff Neurosci., 2, 313-322.
Kuyken et al., 2010
Kuyken et al., 2010
Possibilities Post-Stroke
Possibilities Post-Stroke Moustgaard, A. (2005). Mindfulness-based cognitive therapy (MBCT) for stroke survivors: An application of a novel intervention. Unpublished Dissertation. n=23; no comparison condition Statistically significant improvement in depressive (BDI-II) and anxious (BAI) symptoms
Possibilities Post-Stroke Johansson, B., Bjuhr, H., & Rönnbäck, L. (2012). Mindfulness-based stress reduction (MBSR) improves long-term mental fatigue after stroke or traumatic brain injury. Brain Injury, 26(13-14), 1621-1628. Primary endpoint: Mental Fatigue reduced capacity for work and participation in social activities n=18 (stroke); 11 (TBI); randomized Statistically significant improvement on selfassessment for mental fatigue; also: neuropsych tests (Digit Symbol-Coding and Trail Making Test)
Possibilities Post-Stroke H. Hofer, M. G. Holtforth, F. Luthy, E. Frischknecht, H. Znoj, and R. M. Muri (2012). The potential of a mindfulness-enhanced, integrative neuropsychotherapy program for treating fatigue following stroke: a preliminary study. Mindfulness. combination of neuropsychological interventions, psychoeducation, cognitive-behavioral therapy, and mindfulness techniques. n=8; significant improvement in mental fatigue (pre vs. post)
Possibilities Post-Stroke? Decreasing risk of recurrence E.g. diabetes management, blood pressure management, etc. Clinicians, caregivers
Summary Mindfulness-Based Interventions (MBIs) help cultivate new relationships with our experiences MBIs have led to improved coping with psychological distress and increased wellbeing across a number of populations Early studies show promise for positive impact of MBIs on the post-stroke population, but much more research is needed