Stress Cardiomyopathy: “Broken Heart Syndrome” Science Of Emotion: From Neurotransmitters to Social Networks

The New Science of Emotion: From Neurotransmitters to Social Networks Michael E. Lara, MD Diplomate, American Board of Psychiatry and Neurology Private Practice Psychiatry and Psychopharmacology Belmont, CA www.MichaelLaraMD.com

We are what we think. All that we are arises with our thoughts. With our thoughts we make the world. Speak or act with an impure mind And trouble will follow you As the wheel follows the ox that draws the cart. Your worst enemy cannot harm you As much as your own thoughts, unguarded - Dhammapada

What is An Emotion? The Feeling of What Happens

Emotions Defined <ul><li>Root of the word emotion is motere , to move, plus the prefix e- to connote "move away", suggesting that a tendency to act is implicit in every emotion </li></ul><ul><li>Emotion refers to a feeling and its attendant thoughts, psychological and biological states, and a range of impulses to act </li></ul><ul><li>Emotion can be defined as "any agitation or disturbance of mind, feeling, passion; any vehement or excited emotional state" </li></ul>

Emotions, Moods, and Temperament Feelings Emotions Moods Temperament

Domains of Emotional Life Anger Fear Worry Stress Creativity Ambition Forgiveness Joy Boredom Discouragement Failure Depression Generosity Contentment Calm Relaxation Hot Negative Hot Positive Cool Positive Cool Negative Richmond L, Work as a Spiritual Practice, 2000.

Universal Emotions <ul><li>Anger </li></ul><ul><ul><li>fury, outrage, resentment, wrath, exasperation, indignation, vexation, acrimony, animosity, annoyance, irritability, hostility, pathological hatred and violence. </li></ul></ul><ul><li>Sadness </li></ul><ul><ul><li>grief, sorrow, cheerlessness, gloom, melancholy, self-pity, loneliness, dejection, despair, and when pathological, severe depression. </li></ul></ul>

Universal Emotions <ul><li>Fear </li></ul><ul><ul><li>Anxiety, apprehension, nervousness, concern, consternation, misgiving, wariness, qualm, edginess, dread, fright, terror; as a psychopathology, phobia and panic. </li></ul></ul><ul><li>Enjoyment </li></ul><ul><ul><li>Happiness, joy, relief, contentment, bliss, delight, amusement, pride, sensual pleasure, thrill, rapture, gratification, satisfaction, euphoria, whimsy, ecstasy, and at the far edge, mania. </li></ul></ul><ul><li>Love </li></ul><ul><ul><li>Acceptance, friendliness, trust, kindness, affinity, devotion, adoration, infatuation, agape. </li></ul></ul>

Universal Emotions <ul><li>Surprise </li></ul><ul><ul><li>Shock, astonishment, amazement, wonder </li></ul></ul><ul><li>Disgust </li></ul><ul><ul><li>Contempt, disdain, scorn, abhorrence, aversion, distaste, revulsion </li></ul></ul><ul><li>Shame </li></ul><ul><ul><li>Guilt, embarrassment, chagrin, remorse, humiliation, regret, mortification, and contrition </li></ul></ul>

Two Dimensions of Emotion Aroused Not Aroused Pleasant Unpleasant Anger Sadness Fear Enjoyment Love Surprise Disgust Shame

Four Domains of Temperament <ul><li>Harm avoidance </li></ul><ul><ul><li>high harm avoidance is observed as fear of uncertainty, social inhibition, shyness with strangers, rapid fatigability, and pessimistic worry in anticipation of problems, even in situations that do not worry other people </li></ul></ul><ul><li>Novelty seeking </li></ul><ul><ul><li>Exploratory activity in response to novelty, impulsiveness, extravagance in approach to cures of reward; quick tempered, curious, easily bored, impulsive, extravagant, and disorderly </li></ul></ul>

Four Domains of Temperament <ul><li>Reward dependence </li></ul><ul><ul><li>Observed as sentimentality, social sensitivity, attachment, and dependence on approval by others. Individuals high in reward dependence are tender hearted, sensitive, socially dependent, and sociable </li></ul></ul><ul><li>Persistence </li></ul><ul><ul><li>Observed as industriousness, determination, ambition, perfectionism. Highly persistent people are hard working, perseverant, and ambitious overachievers who to tend to intensify their effort in response to anticipated reward and perceive frustration and fatigue as a personal challenge. </li></ul></ul>

Temperament Configurations Explosive Adventurous Passionate Sensitive Methodical Cautious Reliable Independent Harm-Avoidance Reward Dependence Novelty Seeking

Emotional Intelligence <ul><li>Self-awareness: recognizing one's feelings as they occur </li></ul><ul><li>Managing Emotions: Having appropriate emotional reactions; ability to modulate negative affects </li></ul><ul><li>Motivating oneself: being able to focus on a goal; emotional self control, delaying gratification or controlling impulsivity </li></ul><ul><li>Recognizing emotions in others: Empathy </li></ul><ul><li>Handling relationships: skill in managing others' emotions </li></ul>

The Physiology of Emotion How We Feel What We Feel

Neurotransmitters: The Molecules of Emotion Anxiety Irritability Motivation Sex Appetite Aggression Emotion Impulsivity Serotonin Energy Interest Attention Norepinephrine Drive Dopamine

Temperament and Neurotransmitters Explosive Adventurous Passionate Sensitive Methodical Cautious Reliable Independent Harm-Avoidance GABA, Serotonin Reward Dependence Norepinephrine, Serotonin Novelty Seeking Dopamine

Serotonin <ul><li>High levels may be associated with serenity, optimism and possibly spiritual experiences </li></ul><ul><li>Dysregulation associated with depression, impulsivity, eating disorders and suicidality </li></ul><ul><li>Regulates sleep, pain, appetite, and mood </li></ul><ul><li>Neurotransmitter altered by some antidepressant drugs </li></ul><ul><li>Some hallucinogens (LSD) alter serotonin in regions of the brain associated with integrating sensory stimuli </li></ul>

Norepinephrine <ul><li>Excitatory neurotransmitter that induces physical and mental arousal and heightens mood </li></ul><ul><li>Neurotransmitter involved in the “fight or flight” response and induces alterations in heart rate, blood pressure, and other physiologic parameters </li></ul><ul><li>Target of medications that increase alertness and attention and medications that alter blood pressure </li></ul>

Dopamine <ul><li>Controls arousal levels in many parts of the brain and is vital for motivation, pleasure and reward </li></ul><ul><li>Low dopamine levels implicated in apathy, anhedonia, and disorders such as Parkinsonism </li></ul><ul><li>Dysregulation implicated in schizophrenia, mania; high levels may give rise to delusions and hallucinations </li></ul><ul><li>Target of antipsychotic and some mood stabilizing drugs </li></ul>

The Yin and the Yang of Neurotransmitters GABA Glutamate Glutamate is the major excitatory neurotransmitter in the CNS GABA is the major inhibitory neurotransmitter in the CNS

Neurosteroids <ul><li>Cortisol </li></ul><ul><ul><li>Plays a major role in the stress response; alters blood glucose levels, fat deposition, and mood </li></ul></ul><ul><li>Estrogen </li></ul><ul><ul><li>Major female sex hormone; may regulate mood and serve as a neurotrophic factor in the brain </li></ul></ul><ul><ul><li>Estrogen levels skyrocket during pregnancy and plummet immediately postpartum </li></ul></ul><ul><li>Progesterone </li></ul><ul><ul><li>Unopposed, as in middle of menstrual cycle, may lead to neuronal excitotoxicity and mood changes seen in PMS </li></ul></ul><ul><li>Testosterone </li></ul><ul><ul><li>Regulates aggression, type-A behaviors </li></ul></ul>

Males: Age of Onset and Relation to Testosterone Production The incidence of depression rises in puberty and remains constant 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 .025 – .02 – .015 – .01 – .005 – Age Specific Rate of Depression Stahl S. Essential Psychopharmacology, Second Edition, 2000 – 100 – 75 – 50 – 25 – 0 % of Testosterone Production

Females: Age of Onset and Relation to Estrogen Production Incidence of Depression Mirrors Changes in Estrogen Across Life Cycle 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 .025 – .02 – .015 – .01 – .005 – Age Specific Rate of Depression Stahl S. Essential Psychopharmacology, Second Edition, 2000 – 100 – 75 – 50 – 25 – 0 % of Estrogen Production

Opiates <ul><li>Endogenous opiates modulate pain, reduce stress and promote a sensation of bliss </li></ul><ul><ul><li>Opiate blocking agents reduce pleasure derived from alcohol, heroin, and listening to music </li></ul></ul><ul><li>Suppress physical functions such as breathing and are associated with physical dependence </li></ul><ul><li>Self-mutilation (cutting) increases endogenous opiates and is physiologically similar to “runner’s high” </li></ul>

Other Molecules of Emotion <ul><li>Phenylethylamine (PEA) </li></ul><ul><ul><li>Chemically related to amphetamine and is found in chocolate; sometimes referred to as the “love drug” </li></ul></ul><ul><li>Anandamide </li></ul><ul><ul><li>Binds and activates same receptors as marijuana </li></ul></ul><ul><ul><li>May regulate mood, appetite, memory and pain perception </li></ul></ul><ul><ul><li>Rimonabant (Accomplia) blocks marijuana receptors in brain and causes significant weight loss, decreased EtOH cravings </li></ul></ul><ul><li>Oxytocin </li></ul><ul><ul><li>Coordinates physical events around childbirth </li></ul></ul><ul><ul><li>Play major role in bonding, emotional attachment, and monogamy </li></ul></ul>

Pathways of Emotion The Feeling Mind and the Thinking Body

The Case of Phineas Cage <ul><li>Construction foreman who, in 1848, sustained damage to frontal cortex </li></ul><ul><li>Dramatic changes in temperament led to important insights on the role of the frontal lobes in regulating emotion </li></ul>

Basic Anatomy of The Human Brain

The Limbic System <ul><li>Amygdala mediates fear, anger and the startle reflex </li></ul><ul><li>Hypothalamus regulates hormonal balance, appetite, sleep and wakefulness </li></ul><ul><li>Thalamus serves as pacemaker for cortical activity </li></ul><ul><li>Hippocampus important in short term recall and context of emotional memory </li></ul>

The Neural Circuitry of Fear and Anxiety LeDoux J. The Emotional Brain, 1996. Emotional Stimulus Sensory Thalamus Amygdala Primary Sensory and Association Cortices High Road Low Road Emotional Response Hippocampus

The Amygdala, The Caudate, and Obsessive Compulsive Thinking The caudate nucleus is closely connected to the amygdala. The knock-on effect of caudate activity in OCD may partly explain why people with the disorder suffer from anxiety.

Urbach-Wiethe and The Amygdala Damasio, Antonio, The Feeling of What Happens: Body and Emotion in the Making of Consciousness, p. 63

Hemispheric Lateralization of Positive and Negative Emotions <ul><li>Numerous studies have confirmed that negative emotions occur predominately in the right frontal lobe </li></ul><ul><li>Similarly, positive emotions occur on the left frontal lobe </li></ul><ul><li>In one study, 62% of patients with left-sided strokes were depressed and fearful, as compared with only 10% of right-sided stroke victims </li></ul><ul><li>Proximity of stroke to left frontal lobe correlates with severity of depressive symptoms </li></ul>S.E. Starkstein, et al., Journal of Neuropsychiatry and Clinical Neuroscience 3:3 (1991):276-285

Transcranial Magnetic Stimulation <ul><li>Application of magnetic current to cortex shown to reduce depressive symptoms in as little as one week with no major side effects </li></ul><ul><li>High frequency pulses to left cortex or low frequency pulses to right cortex lead to reduction of depression </li></ul>Gershon A, et al, Transcranial Magnetic Stimulation in the Treatment of Depression, Am J Psychiatry 160:5, May 2003.

The Lama in the Lab <ul><li>Mental training induces various changes in brain function that are diametrically opposed to changes seen in major depression and anxiety disorders </li></ul><ul><li>Negative emotions are regulated by the right frontal lobes; positive emotions, by the left frontal lobes </li></ul><ul><li>Advanced meditators exhibit an increase in left-sided cortical activity demonstrated on EEG </li></ul><ul><li>Advanced meditators show lower levels of cortisol and decreased startle response </li></ul>

The Lama in The Lab: The Physiological Effects of Meditation N=175 G.D. at .41 Distribution of Ratio of Left-to-Right Prefrontal Activity Negative emotions activate the right prefrontal area, positive the left; the ratio of the two predicts The range of moods a person is likely to feel day to day. Goleman, Destructive Emotions: How We Can Overcome Them, p.340

Exercise: Soundscape

Self-Destructive Emotions

The Spectrum of Self-Destructive Emotions Aroused Not Aroused Pleasant Unpleasant Anger Sadness Fear Disgust Shame Annoyance Depression Hatred Guilt

Inside the Mind of a Sociopath The brain of this murderer shows significant lack of activity compared to a normal brain Raine et al. Selective reductions in prefrontal glucose metabolism in murderers. Biological Psychiatry Vol 36, Sept 1, 1994 Murderer Healthy Control

Does Chronic Stress Cause Brain Injury? Andreasen, Brave New Brain: Conquering Mental Illness in the Era of the Genome, 2001

Psychopathology and The DSM-IV <ul><li>Mood Disorders </li></ul><ul><li>Anxiety Disorder </li></ul><ul><li>Schizophrenia and Other Psychotic Disorders </li></ul><ul><li>Personality Disorders </li></ul><ul><li>Substance Use Disorders </li></ul><ul><li>Somatoform Disorders </li></ul><ul><li>Eating Disorders </li></ul>

The Major Disorders of Mood <ul><li>Major Depressive Disorder </li></ul><ul><li>Dysthymic Disorder </li></ul><ul><li>Bipolar Disorder </li></ul><ul><li>Cyclothymic Disorder </li></ul>

Prevalence of Major Depression Murray CJL, Lopez AD, eds. Summary: The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability From Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020 . Cambridge, Mass: Harvard School of Public Health, Harvard University Press; 1996; Regier DA, et al. Arch Gen Psychiatry. 1988;45:977-986; Blazer DG, et al. Am J Psychiatry . 1994;151:979-986; Regier DA, et al. Arch Gen Psychiatry. 1993;50:85-94; Kessler RC, et al. J Affect Disord. 1993;29:85-96; Greenberg PE, et al. J Clin Psychiatry . 1993;54:405-418. 0 5 10 15 20 Epidemiologic Catchment Area (ECA) National Comorbidity Survey (NCS) Patients (%) Point Prevalence Lifetime Prevalence

Anxiety Disorders <ul><li>Panic Disorder </li></ul><ul><li>Social Phobia </li></ul><ul><li>Obsessive-Compulsive Disorder </li></ul><ul><li>Posttraumatic Stress Disorder </li></ul><ul><li>Generalized Anxiety Disorder </li></ul>

Prevalence of Common Anxiety Disorders <ul><li>12 Months (%) Lifetime (%) </li></ul><ul><li>Social phobia (social anxiety disorder) (SAD) 7.4 13.3 </li></ul><ul><li>Posttraumatic stress disorder (PTSD) 2.0-3.2 8.0 </li></ul><ul><li>Agoraphobia w/o panic disorder (PD) 2.8 5.3 </li></ul><ul><li>Generalized anxiety disorder (GAD) 3.1 5.1 </li></ul><ul><li>Panic disorder 2.3 3.5 </li></ul><ul><li>Obsessive compulsive disorder (OCD) 0.6-1.3 2.5 </li></ul>Kessler RC, et al. Arch Gen Psychiatry . 1995;51:8-19; Kessler RC, et al. Arch Gen Psychiatry . 1995;52:1048-1060; Stein MB, et al. Am J Psychiatry . 1997;154:1114-1119; Stein MB, et al.. Am J Psychiatry . 1997;154:1120-1126. National Comorbidity Survey (NCS) (N = 8098)

Personality Disorders Borderline Antisocial Histrionic Narcissistic Obsessional Avoidant Staid Schizoid Harm-Avoidance Reward Dependence Novelty Seeking

The Mind/Body Connection in Mood and Anxiety Disorders <ul><li>The physical consequences of mood and anxiety disorders </li></ul><ul><ul><li>Muscle tension </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Appetite disturbance </li></ul></ul><ul><ul><li>Sleep disturbance </li></ul></ul><ul><ul><li>Weight changes </li></ul></ul><ul><ul><li>Physical pain </li></ul></ul><ul><ul><li>Cardiovascular dysfunction </li></ul></ul><ul><ul><li>Immune dysfunction </li></ul></ul>

Why Depression Hurts <ul><li>Serotonin and norepinephrine are found throughout the central and peripheral nervous systems </li></ul><ul><li>In descending columns of the spinal cord, serotonin and norepinephrine serve as “gate-keepers” that modulate pain comings coming into the spinal cord from the periphery </li></ul><ul><li>In serotonin and norepinephrine are dysregulated in the spinal cord, minor sensory stimuli from the body are perceived as painful </li></ul>

How Negative Emotions Impact the Body

Physical Symptoms Simon GE, et al. N Engl J Med . 1999;341:1329-1335. Primary Care Patients With Major Depression (N = 1146) symptoms

HPA Axis: Cortisol <ul><li>“ Stress hormone” (steroid) secreted by the adrenal glands </li></ul><ul><li>Regulates BP, CV function, secretion of insulin, and fat deposition </li></ul><ul><li>Normal diurnal variation with highest levels near 8-9am and lowest levels near midnight. </li></ul><ul><li>Often higher with depression, alcohol abuse, anxiety </li></ul><ul><li>Addison’s (decreased cortisol) and Cushing’s disease (increased cortisol) </li></ul>

Psychoneuroimmunology <ul><li>Acute stress temporarily improves general “frontline” immunity but suppresses slower specific immunity </li></ul><ul><li>Chronic stress impairs mot types of immunity </li></ul><ul><ul><li>Damages/destroys T cells </li></ul></ul><ul><ul><li>Induces premature migration of T cells from Thymus </li></ul></ul><ul><ul><li>Results in Thymus shrinkage </li></ul></ul>

Stress Cardiomyopathy: “Broken Heart Syndrome” <ul><li>Rapid and severe heart muscle weakness (cardiomyopathy) caused by intense emotional or physical stress </li></ul><ul><li>May occur with grief, fear, extreme anger, and surprise </li></ul><ul><li>Symptoms include chest pain, shortness of breath, congestive heart failure and low blood pressure and begin within minutes to hours after the stressor </li></ul><ul><li>Caused by excessive norepinephrine load and symptoms are usually temporary and reversible </li></ul>Pavin D, et al. Human Stress Cardiomyopathy mimicking acute myocardial syndrome. Heart, 1997;78:509-511.

Effects of Negative Emotions on The Heart

Exercise: Noting Positive and Negative Affects

Scrambled Sentence Test <ul><li>Him was worried she always </li></ul><ul><li>Clouds rain indicate firehouse dark </li></ul><ul><li>Should now withdraw forgetful we </li></ul><ul><li>Smoke psychiatric padlock patients cigarettes </li></ul><ul><li>Shaving cut towers himself he </li></ul><ul><li>Quietly Herman sleeping is fork </li></ul><ul><li>Should now withdraw forgetful we </li></ul><ul><li>Be will sweat lonely they </li></ul><ul><li>Paid he evening sales tax </li></ul>

Exercise: Noting Positive Affect

Biologic and Cognitive Therapies for Negative Emotions

Major Classes of Antidepressants <ul><li>Serotonin Specific Reuptake Inhibitors </li></ul><ul><ul><li>Zoloft, Paxil, Prozac, Lexapro </li></ul></ul><ul><li>Serotonin-Norepinephrine Reuptake Inhibitors </li></ul><ul><ul><li>EffexorXR, Cymbalta </li></ul></ul><ul><li>Norepinephrine Reuptake Inhibitors </li></ul><ul><ul><li>WellbutrinXR, Strattera </li></ul></ul><ul><li>Tricyclic Antidepressants </li></ul><ul><ul><li>Imipramine, Amitriptyline, Clomipramine, Desipramine </li></ul></ul><ul><li>Monoamine Oxidase Inhibitors </li></ul><ul><ul><li>Parnate, Nardil </li></ul></ul><ul><li>Others </li></ul><ul><ul><li>Remeron, Serzone, Desyrel </li></ul></ul>

Nature’s Antidepressant: The Role of Dietary Practices on Mood Tryptophan Tyrosine Serotonin Dopamine Norepinephrine

Serotonin Pathway Tryptophan 5-HTP Serotonin Melatonin Tryptophan Hydroxylase (rate-limiting enzyme)

5-HTP <ul><li>Elevate mood in cases of depression, anxiety, and panic attacks </li></ul><ul><li>Treat insomnia </li></ul><ul><li>Promote weight loss </li></ul><ul><li>Ease migrain pain </li></ul><ul><li>Increase pain tolerance in fibromyalgia </li></ul>

Dopamine and Norepinephrine Pathway Tyrosine L-Dopa Dopamine Norepinephrine Tyrosine Hydroxylase (rate-limiting enzyme) Dopamine ß hydroxylase Phenylalanine

L-Tyrosine <ul><li>Essential amino acid; precursor for dopamine </li></ul><ul><ul><li>Reported to also increase PEA, a mild stimulant found in high concentrations in chocolate </li></ul></ul><ul><li>Benefits include relief of fatigue, ADHD, mental concentration, athletic performance enhancement </li></ul><ul><li>Side effects include mild weight loss and GI upset </li></ul>

DLPA <ul><li>D,L-phenylalanine is an essential amino acid </li></ul><ul><ul><li>L-form: naturally occuring isomer; boosts NE, DA </li></ul></ul><ul><ul><li>D-form: synthetic isomer; believed to block pain </li></ul></ul><ul><li>Benefits include relief of chronic pain, mild depression, PMS, ADHD, and fibromyalgia </li></ul><ul><li>Side effects are minimal but may include heartburn, nausea or headaches </li></ul><ul><li>Should only be taken under the supervision of a physician when used with other pharmaceuticals </li></ul>

S-Adenosyl Methionine Tryptophan Tyrosine Serotonin Dopamine Norepinephrine SAMe

S-Adenosyl Methionine <ul><li>SAMe is a naturally occuring amino-acid deriviative found in body; synthesized from amino acid methionine </li></ul><ul><li>Works by donating methyl groups to form dopamine and serotonin </li></ul><ul><li>Reported benefits include relief of depression, chronic fatigue syndrome, fibromyalgia; arthritis </li></ul><ul><li>Should be taken with B-vitamin complex to reduce buildup of homocysteine, a sulfur containing amino acid linked to cardiovascular disease </li></ul>

Omega-3 Fatty Acids <ul><li>Nature’s anti-inflammatory agent </li></ul><ul><li>Omega-3 and Omega-6s are essential fatty acids (EFAs) </li></ul><ul><li>Different types of Omega-3s </li></ul><ul><ul><li>EPA and DHA: tuna, salmon, mackeral </li></ul></ul><ul><ul><li>ALA: dark, leafy green vegetables and flaxseed </li></ul></ul><ul><li>Benefits include relief of diseases associated with chronic inflammation: depression, ADHD, Alzheimer’s; cardiovascular disease </li></ul>

Major Depression and Omega-3 Fatty Acid Consumption J.R. Hibbeln, “Fish consumption and major depression,” The Lancet 1998;351:1213. Country Rate of Depression Annual Consumption of Fish, lbs. Per capita New Zealand 5.8% 42 West Germany 5.0% 22 United States 3.0% 49 Canada 5.2% 59 Korea 2.3% 105 Japan 0.12% 144

Key Elements of Cognitive Behavioral Therapies <ul><li>Goal: Identify and correct cognitive distortions and dysfunctional beliefs that maintain symptoms </li></ul><ul><li>Focus: Beliefs about oneself, the world, and the future </li></ul><ul><li>Duration: Time limited, usually 15 to 25 weeks </li></ul><ul><li>Techniques: Identification of irrational beliefs and automatic thoughts; identification of attitudes and assumptions underlying negatively biased thoughts </li></ul>Sadock, B, Kaplan & Saddock’s Comprehensive Textbook of Psychiatry, Seventh Edition, 2000

Cognition and Psychopathology Beliefs and Assumptions External Events Automatic Thoughts Emotional Responses Interpersonal Behavior Biased Perception And Recall Response of Others

Exercise: The Art of Therapeutic Listening

Therapeutic Attention: The Wisdom of Listening Speeth, Kathleen, “On Therapeutic Attention”, from The Wisdom of Listening, ed. Mark Brady, 2003 Client Therapist Ordinary attention is invested in one direction But attention can be divided between the inside and the outside Attention can be used to notice whether the attention is inside or outside

Relapse Rates With Cognitive Therapy Following Incomplete Remission Paykel ES, et al. Arch Gen Psychiatry . 1999;56:829-835. 0 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0.1 0.2 4 8 12 16 20 24 40 44 48 64 68 28 32 36 52 56 60 Control group Cognitive therapy group Proportion Not Relapsing Time (weeks)

Treatment of Chronic Depression: Antidepressant v. CBT Study Week CBASP = cognitive behavioral-analysis system of psychotherapy; observed cases, LS means; NFZ = nefazodone. * P <.05 NFZ compared with CBASP; † P <.01 NFZ + CBASP compared with CBASP; ‡ P <.01 NFZ + CBASP compared with NFZ. No statistical difference between NFZ compared with NFZ + CBASP through week 4. ‡ Mean change in HAM-D scores: CBASP = -10.4; NFZ+CBASP = -16.6; NFZ = -11. Keller MB, et al. N Engl J Med. 2000;342:1462-1470. HAM-D Change From Baseline ‡ -20 -15 -10 -5 0 Baseline 1 2 3 4 6 8 10 12 CBASP NFZ + CBASP NFZ (max 600 mg/day) † † † * † ‡ ‡ ‡ ‡ † * † * † * †

The Real Reason Why People Recover in Therapy Norcross JC, Goldfried MR, Handbook of Psychotherapy Integration, 1992.

Aerobic Exercise v. Zoloft for Major Depression Babyak, M (2000). Exercise Treatment for Major Depression: Maintenance of Therapeutic Benefit At 10 months. Psychosomatic Medicine , 62:633-638. N=29 N=29 N=25 Those exercising were more likely to be partially or fully recovered and less likely to have relapsed

Qigong and Tai Chi <ul><li>Combine movement, meditation, and breath to enhance flow of vital energy, improve blood circulation, and enhance immune function </li></ul><ul><li>Used in the treatment of balance disorder, chronic pain, and anxiety </li></ul><ul><li>Shares similarities to other energy-based systems of healing </li></ul>

Health Conditions Benefited by Yoga Goldberg B. Alternative Medicine, The Definitive Guide, 2 nd Edition, 469. Ailment Number of Cases % Claiming Benefit Back pain 1,142 98 Premenstrual 848 77 Anxiety 838 94 Migraine 464 80 Arthritis 589 90

Mindfulness-Based Stress Reduction (MBSR) <ul><li>Program of stress-reduction based on insight (vipassana) meditation techniques </li></ul><ul><li>Choiceless awareness of different dimensions of moment-to moment experience: </li></ul><ul><ul><li>Breathing </li></ul></ul><ul><ul><li>Sounds </li></ul></ul><ul><ul><li>Body Sensations </li></ul></ul><ul><ul><li>Thoughts </li></ul></ul><ul><li>Emphasis is on mode of being as opposed to mode of doing </li></ul><ul><li>Typical course is eight weeks and includes body scan, sitting meditation, and restorative yoga postures </li></ul>Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body And Mind to Face Stress, Pain, and Illness, 1990

Research on Mindfulness <ul><li>Participants in mindfulness meditation program experienced less pain, anxiety, and depression than patients treated with conventional medicines. 1 </li></ul><ul><li>Meditators utilize medical care services 30 to 87% less than a control group utilizing conventional practices. 2 </li></ul><ul><li>Chronic pain patients practicing meditation noted a 36% reduction in their use of clinics during the first year. 3 </li></ul><ul><li>Kabat-Zinn, J et al. (1987). Four-year follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance. Clin J Pain, 2:159-73. </li></ul><ul><li>Orme-Johnson, DW (1987). Medical care utilization and the Transcendental Meditation program. Psychosomatic Medicine, 49:493-507. </li></ul><ul><li>Caudill, M. et al. (1991). Decreased clinic use by chronic pain patients: response to behavioral medicine intervention. Journal of Chronic Pain, 7:305-10. </li></ul>

Impact of Meditative Practices Schwartz, J The Mind and The Brain: Neuroplasticity and the Power of Mental Force, 2002

Exercise: Mindfulness of the Body

Positive Emotions

The Spectrum of Positive Emotions Aroused Not Aroused Pleasant Unpleasant Enjoyment Love Surprise Euphoria Satisfaction Kindness Acceptance Friendliness

Acceptance <ul><li>“ God grant me the courage to change the things I can, the serenity to accept the things I cannot, and the wisdom to know the difference.” </li></ul><ul><li>Cultivating an attitude of non-judgment </li></ul><ul><li>Acceptance is not resignation. It is a realization and appreciation of the inherent imperfections of life. </li></ul>

Forgiveness <ul><li>Forgiveness is NOT forgetting. </li></ul><ul><li>Forgiveness is not surrender, resignation, or reconciliation with the offender. </li></ul><ul><li>Forgiveness is an active, ongoing process that may take years to evolve. </li></ul><ul><li>The primary beneficiary is the person doing the forgiving (not the perpetrator) </li></ul>

Stanford Forgiveness Project (Carl Thoresen, Fred Luskin) <ul><li>Six 90min group sessions </li></ul><ul><li>Start with stress reduction/relaxation, anger management </li></ul><ul><li>Learn to “de-personalize” – take less offense </li></ul><ul><li>Be aware of personal health consequences of holding a grudge and choose to direct your attention elsewhere </li></ul><ul><li>Build empathy skills, “grace” </li></ul><ul><li>Take small steps – do “easy forgiveness” first </li></ul>

How To Want What You Have <ul><li>Core Practices </li></ul><ul><ul><li>Compassion </li></ul></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Gratitude </li></ul></ul><ul><li>Cognitive Approach to Practicing Compassion, Attention, and Gratitude (CAG) </li></ul><ul><ul><li>Identify non-CAG thinking </li></ul></ul><ul><ul><li>Formulate CAG thoughts </li></ul></ul><ul><ul><li>Substitute CAG-thoughts for non-CAG thoughts </li></ul></ul><ul><ul><li>Act with Compassion, Attention, and Gratitude </li></ul></ul>Miller, T. How To Want What You Have: Discovering the Magic and Grandeur of Ordinary Existence, 1995.

Exercise: Journaling with CAG

Cardiac Coherence During Positive Emotion <ul><li>Heartmath research demonstrate that positive emotions (love, appreciation) increase coherence in heart’s beating patterns </li></ul><ul><li>During states of cardiac coherence, brain wave patterns entrain with heart rate variability </li></ul><ul><li>Parasympathetic nervous system activity is increased, cortisol levels are reduced, and immune function is enhanced </li></ul>Childre D. The Heartmath Solution, 1999.

Effects of Negative Emotions on The Heart

Resilience and Cognition <ul><li>Psychological resilience is flexibility in response to changing situational demands, and the ability to bounce back from negative emotional experiences </li></ul><ul><ul><li>Learned helplessness, by contrast, is seen in depression </li></ul></ul><ul><li>Optimists may overestimate their influence in situations where they have little or no control </li></ul><ul><ul><li>“ unrealistic optimism” </li></ul></ul><ul><li>Depressives more accurately assess their own influence in situations where they have little or no control </li></ul><ul><ul><li>“ depressive realism” </li></ul></ul><ul><li>Resilience Gene </li></ul><ul><ul><li>Two copies of the long form serotonin transporter gene may confer resistance to childhood trauma </li></ul></ul><ul><ul><li>Two copies of the short form of the serotonin transporter gene may confer susceptibility to trauma </li></ul></ul>Alloy, Abramson, 1979

The Resilience Gene Probability of Major Depressive Episode 0.70 0.60 0.50 0.40 0.30 0.20 0 Short/short Short/long Long/long No Maltreatment Probable Maltreatment Severe Maltreatment Caspi A, et al. Science . 2003;301:386-389.

Positive Psychology What Happy People Know

Positive Psychology <ul><li>Mental health is more than the absence of mental illness </li></ul><ul><li>The impact of positive emotions, spirituality, and belief systems can be quantified, studied, and cultivated </li></ul><ul><li>Mental health and physical health are deeply interconnected </li></ul><ul><li>New research confirms the power of thoughts on our emotional and physical well-being </li></ul>

Five Happiness Traps <ul><li>Trying to buy happiness </li></ul><ul><li>Trying to find happiness through pleasure </li></ul><ul><li>Trying to be happy by resolving the past </li></ul><ul><li>Trying to be happy by overcoming weaknesses </li></ul><ul><li>Trying to force happiness </li></ul>Baker D. What Happy People Know: How The New Science of Happiness Can Change Your Life For the Better, 2003.

Five Factors Affecting Happiness <ul><li>Family relationships </li></ul><ul><li>Financial situation </li></ul><ul><li>Work </li></ul><ul><li>Community and friends </li></ul><ul><li>Health </li></ul>Layard, Richard. Happiness: Lessons from a New Science, 2005.

Happiness in Different Activities Layard, Richard. Happiness: Lessons from a New Science, 2005. Activity Average Happiness Average Hours/Day Sex 4.7 0.2 Socializing 4.0 2.3 Relaxing 3.9 2.2 Meditating/Praying 3.8 0.4 Eating 3.8 2.2 Working 2.7 6.9

Happiness and Income in Economically Advanced Nations Deiner, E. Factors Predicting Subjective Wellbeing in Nations. Journal of Personality and Social Psychology, vol. 69, pp 851-864, 1995. Nation Happiness Ranking Income Index (Compared to US) Switzerland 1st 4th Denmark 2nd 19th Canada 3rd 16th Ireland 4th 48th Netherlands 5th 24th United States 6th 1st

Essential Spirituality: Lessons From the World’s Major Religions <ul><li>Reduce Craving </li></ul><ul><li>Cultivate Emotional Wisdom </li></ul><ul><li>Live Ethically </li></ul><ul><li>Concentrate and Calm Your Mind </li></ul><ul><li>Cultivate Awareness </li></ul><ul><li>Cultivate Wisdom </li></ul><ul><li>Embrace Generosity and the Joy of Service </li></ul>Walsh R. Essential Spirituality: Exercises From The World’s Religions to Cultivate Kindness, Love, Joy, Peace, Vision, Wisdom, and Generosity, 1999.

Research in Spirituality and Health Medical Compliance: Study of Heart Transplant Patients at University of Pittsburgh <ul><li>• Those who participated in religions activities and said their beliefs were important showed: </li></ul><ul><li>- better compliance with follow-up treatment </li></ul><ul><li>- improved physical functioning at the 12-month </li></ul><ul><li> follow-up </li></ul><ul><li>- higher levels of self-esteem </li></ul><ul><li>- less anxiety and fewer health worries </li></ul>Hams, RC et.al. Journal of Religion and Health . 1995: 34(1) 17-32

Research in Spirituality and Health Immune System Functioning: Study of 1,700 older adults <ul><li>• Increased levels of IL-6 associated with increased incidence of disease </li></ul><ul><li>Those attending church were half as likely to have elevated levels of IL-6 </li></ul><ul><li>• Hypothesis: religious commitment may improve stress control by: </li></ul><ul><li>- better coping mechanisms </li></ul><ul><li>- richer social support </li></ul><ul><li>- strength of personal values and world-view may be </li></ul><ul><li>mechanism for increased mortality observed in other studies </li></ul><ul><li>Koenig, HG et.al. International Journal of Psychiatry in Medicine. 1997 27(3) 233-250 </li></ul>

Intercessory Prayer <ul><li>RCT of 393 cardiac patients at UCSF; patients randomized into two groups </li></ul><ul><ul><li>One group was prayed for; the control group was not </li></ul></ul><ul><ul><li>Patients did not know whether they were being prayed for or not </li></ul></ul><ul><li>Over ten months, the prayed for group had fewer deaths, required less ventilatory assistance, antibiotics, and diuretics </li></ul><ul><li>Overall, the prayed for group required less CPR, had a lower incidence of pulmonary edema and required less time in the hospital </li></ul>Source: Byrd, R. (1988). Positive therapeutic effects of intercessory prayer in a coronary Care unit population. Southern Medical Journal , 81:826-29.

The Search for God in the Brain <ul><li>Higher probability of experiencing religious feelings in individuals with temporal lobe epilepsy </li></ul><ul><li>Application of magnetic field to temporal lobes resulted in “sensed presence” in 80% of individuals without TLE </li></ul><ul><li>Studies of Buddhist meditators reveal increased blood flow to temporal lobes but flow to parietal lobes, which regulate sense of space and time, slowed down </li></ul><ul><li>Individuals reporting frequent spiritual experiences have lower levels of serotonin receptors in the limbic brain </li></ul>Persinger, M. Religious and Mystical Experiences as Artifacts of Temporal Lobe Function: A General Hypothesis. Perceptual and Motor Skills, 1983. 57:1255-1262

Exercise: The Experience of Gratitude

The Gratitude Questionnaire (GQ-6) <ul><li>I have so much in life to be thankful for </li></ul><ul><li>If I had to list everything I felt grateful for, it would be a very long list </li></ul><ul><li>When I look at the world, I don’t see much to be grateful for </li></ul><ul><li>I am grateful to a wide variety of people </li></ul><ul><li>As I get older I find myself more able to appreciate the people, events, and situations that have been a part of my life history </li></ul><ul><li>Long amounts of time can go before I feel grateful to someone or something </li></ul>1=Strongly Disagree 2=Disagree 3=Slightly Disagree 4=Neutral 5=Slightly Agree 6=Agree 7=Strongly Agree Add up your scores for items 1, 2, 4, and 5:______ Reverse you scores for items 3 and 6: ________ Your GQ-6 Score:________________________

The Gratitude Questionnaire (GQ-6) Based on a sample of 1, 224 adults Seligman M. Authentic Happiness: Using the New Positive Psychology to Realize Your Potential For Lasting Fulfillment, 2002. 42 Top 1/8 of sample 39-41 Top 1/4 of sample 36-38 Bottom 1/2 of sample 35 or less Bottom 1/4 of sample

Summary and Conclusions

Summary and Conclusions <ul><li>Emotion Defined </li></ul><ul><li>The Physiology of Emotion </li></ul><ul><li>Self-Destructive Emotions </li></ul><ul><li>The Biological and Cognitive Treatment for Self-Destructive Emotions </li></ul><ul><li>Positive Psychology </li></ul>

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