mind-body interventions: is there power in positive thinking?

Mind-body Interventions: Is there Power in Positive Thinking?

SPARCPortland, Oregon

April 16, 2011

Making the Case

• There are pathways by which positive emotions influence health and well-being

• Positive emotions are not the inverse of negative emotions

• Can positive emotional states be increased and maintained?

• Tools you can use

Making the Case


Let’s start with something more familiar

Early Medicine

• Evolved as a search to eliminate disease in the individual

• Early attempts to repel spirits by shamans with rituals …

Hippocrates’ Four Humors

• Many diseases were thought to result from negative emotions

• That produced imbalance in bodily fluids or “humors”

Early Mind-body Research Focused on Negative Emotions

and Stress

Negative Emotions

Disease Outcomes

Anger Depression

Anger & Disease

Religious Orders Study N = 851 clergy (average age = 75)

Suppressed anger and depression – both associated with increased death rates over 4-years, independent of age, sex, education, smoking, and obesity (Wilson, et al, 2003)

Hostility & Mortality Women’s Health Initiative

Cohort of 107,356 Womenfollowed 8 years

Cynical, hostile women hadan increased risk of death Most hostile - 63 deaths per 10,000

Least hostile - 47 per 10,000 Later – news on the “optimists” (Tindle, et al., 2009, APS)

Three pathways: • physiological responses• maladaptive behaviors• aversive environments

How do Negative Emotional states lead to Physical Health Outcomes?

Negative Affect

Disease Outcomes

Physiological Responses

It Affects all Systems

1 Nervous system:fight, flight, freeze

2 Musculoskeletal systemheadaches, muscle pain

3 Respiratory systemasthma, inhibited breathing

4 Cardiovascular systemcoronary heart disease

5 Endocrine system cortisol, epinephrine, glucose

6 Gastrointestinal systemacid reflux, nausea

7 Reproductive systemhormonal irregularities

Negative Affect --Brain Activity & Immune Function

• Negative and positive states are associated electrophysiological measures of prefrontal brain activity

• Negative states, particularly depression, associated with right-sided activation

(Tomarken et al, 1992: Henriques et al, 1991)

Negative Affect –

Brain Activity & Immune Function

People with right-sided activation -- • Lower basal levels of NK cell activity• Greater decreases in NK function during

natural stress of exam• Less rise in NK function to positive film clip• Lower antibody titres to an influenza vaccine

Davidson, et al

Negative Affect

Disease Outcomes


What specific Pathways link negative affect and immune function - ?Evidence suggests: Hypothalamic-pituitary- adrenal (HPA) axis Cortisol - “stress hormone”

Negative Affect

Disease Outcomes


MaladaptiveBehaviors

Depression & Health Behaviors

• Depression has been associated with poor health behaviors such as heavy alcohol use, sedentary behavior, and lower adherence to care

• In turn, these behaviors potentiate adverse health outcomes such as CHD

Negative Affect

Disease Outcomes


MaladaptiveBehaviors

SocialIsolation

Social Isolation and Mortality

• N = 1123 male, 245 female CAD patients

• 5 year survival rates Married or confidant 0.82 Unmarried, no confidant 0.50

Unmarried, without confidant - Threefold increase in risk of death

Cox adjusted hazard ratio = 3.34 (1.84-6.20)

( R. Williams, et al, JAMA, 1992)

Social Isolation and Cardiovascular Risk

• N = 188 healthy men and 110 women from White Hall II (45-59 yrs)

• Social isolation measured with the Close Person Questionnaire

• Socially isolated men and women had higher waking cortisol levels and greater cortisol output over the day

( Grant, Hamer & Steptoe, 2009)

This Afternoon – Focus on Positive Emotions

Impact on health

Approaches to Intervention

Positive Affect

Longevity ??

Findings from the Nuns Study

• 180 Catholic nuns• Handwritten autobiographies • Composed when nuns were 22 yrs of age• Scored for emotional content • Related to survival during ages 75-95

(Danner et al, 2001)

Nun with High Positive Emotion

“God started my life off well by bestowing upon me a grace of inestimable value….The past year which I have spent as a candidate studying at Notre Dame College has been a very happy one. Now I look forward with eager joy to receiving the Holy Habit of Our Lady and to a life of union with Love Divine.”

(Danner, Snowdon, & Friesen, 2001)

Results

• Emotion Cox proportional hazard Positive - 1.4 (-2.3, -0.6) *** Negative - 0.7 (-1.5, 0.2) None - 0.1 (-0.9,0.7)

Positive emotional content predicted survival (later mortality) six decades

later


Conclusion

“Finding such a strong association of written positive emotional expression to longevity indicates a need for research that sheds light on the underlying mechanisms and mediators responsible for and associated with this relationship.”


Optimism & Mortality

• Women’s Health InitiativeCohort of 107,356 Womenfollowed 8 years

• Optimistic women hadan decreased risk of death

Optimists - 46 deaths per 10,000 Pessimists - 64 per 10,000

(Tindle, et al., 2009, APS)

Psychological Well-being and Survival: Meta-Analysis

Population Hazard Ratio p Healthy .82

p< .001 population (.76 - .89)(35 Studies)

Disease .98 p< .030population (.95 – 1.0)(35 Studies)

(Chida & Steptoe, 2008)

Positive Affect


Longevity

Positive Affect & Immune Function

• Cohort of 1,149 faculty, high scores on positive affect were associated with fewer colds (Takkouche, et al., 2001)

• Positive emotional style was associated, in dose response pattern, to lower risk of developing cold following viral challenge

(Cohen, et al., 2003)

Positive Affect

Longevity


HealthBehavior

Positive Affect & Health Behaviors

• People with higher life satisfaction engage in health-promoting behaviors

(Castro, 2002; Scheier & Carver, 1992)

Physical activity Reduced levels of smoking Reduced alcohol intake Healthier diet

Positive Affect

Longevity


HealthBehavior

SocialSupport

Positive Affect & Social Support

• People who report positive emotions receive more social support (Fredrickson, 1998)

• Positive affect is associated with the number of people who provided help over a 12-month period

(Eckenrode, et.al., 1988)

Making the Case


Positive emotions are not the inverse of negative emotions

• Can positive emotional states be increased and maintained?


Positive & Negative Affect Can Co-exist

• Under chronic stressExpected: many individuals report high levels of negative affect

Unexpected: some report high levels of both positive and negative affect

(Folkman, et al, 2001; Diener, et al, 1985; Wortman, et al 1987)

Positive & Negative Affect Co-exist

• The chronic stress of care-giving for a dying partner,

• Positive affect and finding positive meaning, during care-giving, was associated with more rapid recovery during bereavement

(Folkman, et al, 2001)

Positive & Negative Affect Co-exist

• Survey of 150,046 adults, 140 countries• Affect & perceptions of physical health

Negative affect & health = -.29, p <.001

Positive affect & health = .25, p <.001

(Pressman, et al, APS, March, 2009

“Positive and negative affect are independently related to health, not opposite ends of a continuum”

Making the Case


• Positive emotions are not the inverse of negative emotions

Can positive emotional states be increased and maintained?


MBSR IncreasesPositive States

• Mindfulness-based Stress Reduction (MBSR) interventions focus on reducing distress and enhancing well-being

• N = 60, depressed individuals

• Randomized to MBSR vs. waiting list

• MBSR resulted in significant decreases in perceived stress and increases in positive affect

(Nyklicek & Kuijpers, 2008)

Other Positive Affect, Coping,Stress Management Interventions

• Combined Positive Affect and Self-Affirmation Intervention

(Mary Charlson et al.)

• Cognitive Behavioral Stress Management (CBSM)

(Antoni et al)

Coping Effectiveness Training – Combines

aspects of mindfulness & problem-solving (Chesney, Folkman, et al)

General Stressor

Specific Stressor

Changeable Aspects

UnchangeableAspects

Problem-FocusedStrategies

Problem-solvingNegotiation skills

Communication skills

Emotion-FocusedStrategies

Guided Imagery, Physical Activity, Humor

PLUS Strategies to Enhance Wellbeing

Coping EffectivenessTraining (CET)

Strategies to Enhance Well-being “BREATHE”

Breathe: Take a deep breath, be present with yourself in the moment - Be aware in the current moment - Accept what is, not what “ought to be” - Suspend judgment

Realistic Goals: Set realistic goals for this moment, hour and day, celebrate meeting them


Everyday events: Notice the positive moments in everyday life,

- sunset, flowers

recognize when things go rightshare these events with others


B - R - E -Acts of Kindness: Create positive events for

othersTurn it around: Reframe negative events, find

the silver liningHonor strengths: Acknowledge your personal

strengths


B - R - E - A - T - HEnd each day with gratitude: Note

positive steps and all you are thankful for

- Do positive accounting at the end of the day

Personal Growth Scale Items I learned to be myself and not try to be

what others want me to be I learned to communicate more honestly

with others I learned to be open to new information

and ideas I learned to find more meaning in life

0 = Not at all 1 = Somewhat 2 = A Great Deal* * * * * *

Parks, 2000

CHANGES ProjectHIV+ Men

(N=199)

CET-E(N=68)

Coping Effectiveness

Training(3 mo – 12 sessions)

EnhancedMaintenance

(9 mo – 18 sessions)

CET-S(N=66)

Coping Effectiveness

Training(3 mo – 12 sessions)

StandardMaintenance

(9 mo – 6 sessions)

MCC(N=65)

MinimalContactControl

(12 months)

Day-Long CET Workshop(in month 13)

Intervention Groups Control Group

Coping Self-EfficacyPercent Change from Baseline to Post (3 months)

Changes Project

14%

6%

CET Groups (N=112) MCC (N=61)0%

5%

10%

15%

20%

CET vs. MCC (p=.02)

Positive States of MindPercent Change from Baseline to Post (3 months)

Changes Project

8%

-1%

CET Groups (N=112) MCC (N=61)

0%

5%

10%

-5%

CET vs. MCC (p=.02)

Personal GrowthPercent Change from Baseline to Post (3 months)

Changes Project

15%

-1%

CET Groups (N=112) MCC (N=61)

0%

5%

10%

15%

20%

-5%

CET vs. MCC (p=.003)

Coping Self-Efficacy

Changes Project

0 3 6 9 12

Month in Study

0

0.25

0.5

0.75

-0.25

Standardized Mean Change from Baseline

CET Groups MCC

Positive States of Mind

Changes Project

0 3 6 9 12

Month in Study

0

0.25

0.5

0.75

-0.25


CET Groups MCC

Personal Growth

Changes Project

0 3 6 9 12

Month in Study

0

0.25

0.5

-0.25


CET Groups MCC

Making the Case

There are pathways by which positive emotions influence health and well-being

Positive emotions are not the inverse of negative emotions

Can positive emotional states be increased and maintained – YES!

Tools you can use - BREATHE

Suggest: Add Positive Affect to Mind-Body Medicine

• Research is demonstrating health- enhancing effects of positive mind-body approaches

• HIV• Metabolic syndrome• Cancer

Positive Affect:One of many CAM approaches

Set a goal beyond returning patients to a disease-free state

Strive to encourage personal growth enhanced well-being

CAM Approaches

That encourage people to actively participate in choices to enhance their resilience, prevent illness and Improve the quality of their lives

In AppreciationMichael Antoni Trish MagyariJill Bormann Judith MoskowitzBrian Berman Crystal ParkCharles Carver Sarah PressmanSheldon Cohen Carol RyffSheldon Cohen Saki SantorelliRichard Davidson Andrew SteptoeSusan Folkman Catherine StoneyBarbara Fredrickson Esther Sternberg

Frederick Hecht Joey TaylorGail Ironson Carl ThoresenLaura Lee Johnson Redford WilliamsJon Kabat-Zinn Eileen ZieglerElizabeth Kimbrough David Anderson

Please visit us!

www.osher.ucsf.edu

mind-body interventions: is there power in positive thinking?

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