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Strategies to Gain Acceptance for Wellness/Mind-Body Programs by Skeptical Residents
and Clinical Faculty: Stress PhysiologyMichael D. Lumpkin, PhD
Professor of Integrative Physiology and BiochemistryGeorgetown University School of Medicine
2017 CENTILE INTERNATIONAL CONFERENCEGeorgetown University Medical Center
Washington, DC October 24, 2017
Disclosures
I have no conflicts of interest to disclose
2 Main Types of Stress
Acute Stress: Survive and thrive
Chronic Stress: Can lead to dysfunction/disease
Excess Chronic Stress can result in Burnout
Acute Stres s :The 1 s t
Yea r Medica l Student
TheBurned Out Resident or
Clinical Faculty
Hypothalamus
Hypothalamus: Integrative Center of the Brain
Neural Connections:Cognitive-Emotional-Autonomic
Hypothalamus/CRH=Master StressHormone
Hypothalamus/CRH
Stimulates
Hypothalamus/CRH
Inhibits
Adrenals
Kidney
PosteriorPituitary Gland
Hypothalamus
AnteriorPituitary Gland
ACTH
StressCircadian
rhythm
CRH
(-)Glucocorticoids,
Catecholamines, etc..Glucocorticoids,
Catecholamines, etc..
Muscle:Net loss of aminoAcids (glucose)
Liver:Deamination of
proteins into amino acids,
gluconeogenesis (glucose)Fat Cells:
Free fatty acid
mobilizationHeart rate:Increased
Immune system:altered
Hypothalamopituitary adrenal (HPA) axis
Cortisol
1. CRH injected into brain ventricles increases locomotor activity
2. CRH facilitates the acoustic startle response
3. CRH produces increased responsiveness to “stress” in an open field test
4. CRH has an “anxiogenic-like” effect in the operant conflict test
5. CRH produces enhanced suppression of responding in conditioned emotional response test
6. CRH produces a dose-dependent facilitation of stress-induced fighting
7. CRH produces “anxiogenic-like” response in the plus maze
8. CRH produces a dose-dependent taste aversion and place aversion
Behavioral (Neurotransmitter) Effects of Corticotropin-Releasing Hormone (CRH)
CRH drives Major Depression in the Brain
Over-activation of CRH-ACTH-CORTISOL System inClinically Depressed Patients
Chronic Stress with High Cortisol may lead toAppearance of “Cushing’s-like” Features
CORTISOL high CORTISOL low
Moderate Loss of Resiliency
STRE
SS
HO
RMO
NE
LE
VEL
TIME
Optimal Pattern
Stressor
Severe Loss of Resiliency
Stressor
Stressor
Physiology of the Stress Response
Importance of the return to baseline…..if not, then:
Sustained high cortisol damages/destroys the neurons mediating cortisol negative feedback restraint on CRH
Chronic stress impairs memory, learning due to damage to hippocampal neurons with hippocampal volume reduction
Excess cortisol causes many metabolic substrate derangements (hyperglycemia, proteolysis, fat deposition)
Inhib itory e ffe cts
Decreases periphera l b lood lym phocytes , eos inophils , basophils , m onocytes , and neutrophils
Inhib its p roduction of IL-1 , IL-2 , IL-2 recep tor, γ-interferon Inhib its FC recep tor express ion Inhib its in vitro and in vivo prolifera t ion of T lym phocytes
to antigens and m itogens Inhib its m any m onocyte functions , includ ing antigen presenta t ion, lym phokine
production, d ifferentia t ion, and pha gocytos is Inhib its im m unoglobulin p roduction in vivo Inhib its T suppressor cell function in vivo and in vitro
Effects of Glucocorticoids in the Immune System
Stress on the GI Tract
Fullness Bloating
DiarrheaInflamed BowelDisrupts Cell BarriersAntibodies to Food
AntigensFood Sensitivities
Sympathetic nerves/norepinephrine,
frequent contraction
Chronic stress increases sympathetic drive to arterialblood vessels like coronary arteries and arterioles
Smooth muscle cellshypertrophy
Resting vesseldiameter reduced
Resting blood pressureIncreased
Extreme or Chronic stress, major constriction, loss of blood flow, myocardial infarction?
What is the Relationship of Stress to Cancer?
Beta receptor antagonistStress hormone blocker
Potent beta receptor agonist
Metastasis
The Chronic Stress
Cascade to Disease
Other HypothalamicReleasing Hormones Inhibited
Pituitary HormonesDecreased
Major hormonal and organ system impairment/failure
Proinflam m atory Cytokines
The most commonly studied interventions have involved mindfulness, stress
management, and small group discussions, and the results suggest that these strategies
can be effective approaches to reduce burnout domain scores.
Mind-Body Medicine: Therapies Meditation
Imagery
Biofeedback
Autogenic Training (self-hypnosis)
Breathing Techniques
Exercise
Yoga, Tai Chi
Group Support
Efficacy of Mind-Body Therapies Cons iderable Evidence
Coronary Artery Disease (cardiac rehabilitation) Headaches Insomnia Incontinence Chronic low back pain Disease and treatment-related symptoms of cancer Improving post-surgical outcomes
Astin et al Mind-Body Medicine: State of the Science, Implications for Practice. J Am Board Fam P ract16 :131 -147 , 2003
Benefits of Biofeedback Increased awareness and confidence in relaxation skills
Control over “involuntary” functions
Examples: recurrent migraine headache treatment of Raynaud’s disease urinary incontinence arthritis
Let’s try an Experiment Using your Mind-Body Physiology to Manage
Stress and Improve Resiliency:
Autogenic Biofeedback with aSimple Monitor
Neural Connections:Cognitive-Emotional-Autonomic
Hypothalamus/CRH=Master StressHormone
Mind-Body Medicine practices reduce stresssignaling to the hypothalamus and decrease CRH,lower stress hormone levels & reduce sympathetic activity.Result: Vasodilation, more blood flow to skin, increased warming.
Sympathetic nerves/norepinephrine,
frequent contraction
Chronic stress increases sympathetic drive to arterialblood vessels like coronary arteries and arterioles
Smooth muscle cellshypertrophy
Resting vesseldiameter reduced
Resting blood pressureIncreased
Extreme or Chronic stress, major constriction, loss of blood flow, myocardial infarction?