Thinking clearly: What is mindfulness all about?

Do you ever just wish you could get someone who knows virtually everything that’s known about the brain and quiz them about mindfulness? Well, I do – a lot – and I just got my wish!

It is my pleasure to present this interview with John McBurney MD. A practicing physician with of over 35 years’ experience, he is board certified in Neurology, Clinical Neurophysiology and Sleep Medicine. Dr. McBurney maintains a daily mindfulness meditation practice as well as home yoga practice.

Could you describe the neurological response to mindfulness practice?

Mindfulness practice ultimately comes down to the concept of neuroplasticity.

In mindfulness, in cultivating awareness of the breath and voluntary moment by moment awareness of the brain, we are training the brain – just like when you are learning to play the violin or any other complex skill – we are training to break out of those self-referential ruminative recursive mental states and to achieve an orientation toward the outer world and in the present moment rather than anticipating the future or reliving the past.

contemplative neuroscience mechanisms behind mindfulness

 Could we be losing something by focusing more on the external realities rather than the self?

Occasionally, we do hear of adverse experiences arising from mindfulness. With any robust intervention there are always potential risks.

How long does it take for mindfulness to have a noticeable effect?

The results can happen almost immediately, however, they are also cumulative. We are still figuring out what the minimum effective dose is. 

What is the relevance of the changes in functional connectivity in the brain in someone who has devoted  a monumental amount of time to meditation, such as Tibetan monks, who may put in more than 10,000 hours in to their practice, compared to the likes of you and me?

A very neat study was published by David Cresswell in Biological Psychiatry in 2016. They invited individuals with high level of stress, unemployed adults, to a weekend retreat experience. They were randomised to in 2 groups:

  • a 3 day mindfulness retreat (the treatment group) and
  • a 3 day relaxation retreat where they read stories, told jokes and had a good time (the control group).

The study was conducted in one centre over one weekend, so it is well controlled. Initially, both groups rated the interventions as being equally helpful to them, subjectively.

The researchers looked at the functional connectivity between the dorsolateral prefrontal cortex and the cingulate gyrus. They also looked at Interleukin-6, a known marker of inflammation, that has been previously shown to be elevated in stressed out unemployed people.

Even with this brief weekend mindfulness intervention, the treatment group developed increased connectivity between the dorsolateral prefrontal cortex and the cyngulate gyrus. There was a neuroplastic response even after a 3 day mindfulness retreat. This was also associated with a decrease in the marker IL-6. Even after 4 months, IL-6 was decreased in the treatment group, but in the control group, IL-6 levels continued to rise, independent of whether they managed to get a job or not.

This is also relevant to doctors, who are at high risk for burnout. Because of their work commitments, the mindfulness retreat for doctors was condensed from the standard 8 week model developed by John Kabat-Zinn to a weekend intervention. The question was: does the weekend model work? The research at the University of Wisconsin where this was developed was reassuring: the residents are less stressed out, more effective and have a greater level of satisfaction.

We still don’t know the absolute minimum dose, but it seems that a weekend of mindfulness can be life-changing for the brain.

Another paper published in PLOS ONE from the Benson-Henry Institute for Mind Body Medicine in Harvard looked at the practices such as meditation, prayer, mindful yoga, Tai-Chi, Qi Gong, etc, i.e. ones that elicit a relaxation response (as opposed the stress response).

This study showed that in both novice and experienced practitioners of relaxation response modalities, there were changes in the epigenetic transcription of the genome. There was upregulation of pathways associated with mitochondrial integrity, downregulation of inflammatory pathways, improved insulin-related metabolism and improved nitric oxide signalling.

Long term potentiation, the standard mechanism for memory formation, strengthens existing neural connections. This happens immediately, as you read this. Over time, long term potentiation leads to formation of new connections,through synaptogenesis, dendritic arborisation and neurogenesis i.e. brain structure changes. In turn, this affects the most neuroplastic neurons located in the hippocampus.

mindfulness minimum effective dose response neurology

In reference to this fascinating recent study of the fight or flight response, it seems plausible that breathing regulates our stress levels much more than conscious thought. Could you explain the significance of this in terms of mindfulness?

The ancients believed that emotions reside in the body. This comes up a lot in serious yoga classes.

This highly innovative study shows that the control of the adrenal medulla – the main effector of the stress response – is not from the conscious ruminating thinking centres, but by the motor and sensory cortex.

This explains why breathing, as well as yoga and Tai-Chi, are an important part of meditative practice. In my experience, these kind of interventions do affect the stress response in a beneficial way.

Mindful exercise exists in many form. For example, weightlifters need to be very mindful to maintain perfect form. Cycling is another example: it is vital to concentrate on every pedal stroke and maintain an even cadence. Once you start to day dream, you notice straight away that your output is way worse. This overlaps with the concept of flow. It is about getting in the zone. There is a very inspiring TED talk by Judson Brewer MD, Ph.D. that explains the physiology behind flow and how it is augmented by mindfulness. Mindfulness is work, and it does require discipline. There is a paradox here of non-striving and non-doing while also being disciplined.

You are a sleep medicine expert. Could you comment on the relationship between mindfulness and sleep?

Insomnia is a complex problem with many causes. However, for most people with idiopathic insomnia, the cause is these self-referential recursive ruminations. They aren’t able to “turn their brain off”. Through mindfulness practice, they are generally able to tame the default mode network that’s responsible for ruminating and daydreaming. A simple strategy would be to lie in bed and concentrate on the breath. This would ease the transition between wakefulness and sleep.

mindfulness default mode network neurological basis for the self

Mindfulness is a mainstay treatment for many mental health disorders. What about use of mindfulness in the treatment for organic pathology of the brain usually treated by neurologists?

There is some preliminary data that mindfulness training has a beneficial effect of seizure frequency in patients with epilepsy. It is a medical condition associated with tremendous anxiety and stress, so mindfulness could have a significant benefit in more than one way. It may even have a benefit it terms of remembering to take medication on time, etc.

Some robust studies show that the frequency of relapse in multiple sclerosis decreases with mindfulness intervention. The effect from mindfulness is similar in magnitude to the effect from beta-interferon. 

John Kabat-Zinn used to take the patients who suffered from chronic pain or had diseases for which we had no answer, and those patients got better. Even beyond neurology, there is some evidence that mindfulness can have benefits in psoriasis. We are probably only at the bottom of this mountain.

Dr McBurney has given me so much to think about. I will follow up with part 2 of our discussion that focuses more on the philosophical and life experience aspects of mindfulness once I wrap my head around it.

neurological path mindfulness default mode network adrenal medulla

Buried Alive!

burried alive

Adapted from : Hysterical Paralysis and premature burial: A medieval Persian case, fear and fascination in the west, and modern practice. 

By Paul S Agutter et al Journal of Forensic and Legal Medicine April 2013

The fear of premature burial is ancient but reached its heights in 18th and 19th century Europe. The fear has a modern equivalent, the fear of organs being harvested from a living patient. The certainty of a diagnosis of death are of medical and public concern. The diagnosis of brain death remains controversial.  Although multimodality evoked potentials are considered the most accurate way of determining irreversible brain death, doubts remain as to whether any test of brain death can be infallible.

Public fascination remains widespread. Past cases occasionally surface, it is a fear that pervades literature and film, and various means of prevention have been mooted. Some cases involve hysterical paralysis and this article discusses a case of this which arose in Qajarid Persia.

A family  of tobacco farmers had a 14 year old girl. The mother went to waken her daughter to get her ready for a day of work on the farm. As she didn’t want to do this the girl refused but her mother forced her out of bed. Immediately, the girl fell back on the bed and remained motionless. Thinking that her daughter had stopped breathing, the mother started to shout and cry. Other household members came into the bedroom and were also convinced that the girl had no breath or pulse. Partly due to poverty and partly due to the difficulty in obtaining a doctor, the family considered the girl to be dead and arranged the burial.

The girl’s body was washed and anointed as was the custom. A wise old woman observed that there appeared to be some movement of the girls head and hand and urged the family to wait overnight to see if recovery would occur. She was overruled and the girl was buried.

The old woman did manage to convince the girl’s brother, so shortly after burial, he exhumed the body. He found her motionless and reburied her.

The next morning a neighbour came to the house saying that he had been disturbed by a dream that indicated that the girl was alive. After a lot of dispute, the grave was eventually opened up again in the afternoon.

This time, the girl was indeed dead, but she had changed her position, was now lying curled up on her front,  and had banged her head on the stone covering the grave when she had tried to untie her shoe ties.  A lot of blood had come from the head wound. A tragedy for the entire family.

cobra

Muslim burials are usually carried out within 24 hours of death and sometimes very soon after death.  This was no doubt a factor in this case.

Hysterical paralysis is not the only condition that can simulate death. Severe trauma, Guillain-Barre syndrome, acute polyneuropathies and the effects of a cobra bite can mimic death.

Cardiac arrythmias, typhoid fever, brain stem stroke, and infectious disease epidemics have led to premature burials in the past.

Even in the present day, natural disasters, occupational accidents and the effects of war can lead to entrapment.

Hysterical conversion disorders can cause apparent paralysis and somatosensory loss that are difficult to explain medically. Sufferers tend to have psychosocial and emotional difficulties. But genuine disorders such as poliomyelitis, relapsing tetanus, neurological diseases,  spinal injury, acute transverse myelitis and stiff-person syndrome can mimic hysterical conversion disorders.

Fortunately if you test a person who has a conversion disorder with multi-modality evoked potentials, they show up very much alive but with certain areas of the brain working differently from the usual pattern.

Why do some consultations go wrong and what can we do about it?

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One in seven consultations are described as difficult by the doctors doing them. Why this happens can be grouped into several categories: patient, doctor, disease and system. More than one factor may contribute in any consultation.

Patients can come across as uncooperative, hostile, demanding, disruptive and unpleasant. Of course the patient may think exactly the same thing about the doctor! Patients may have unrealistic expectations or be unwilling to take responsibility for their health.

Doctors may be in sub-optimal states even before the consultation has started. They can be hungry, angry, late or tired. Their personal lives may be a mess. Their personality may clash with the patients. They may have pre-conceived ideas about the patient which handicaps the consultation before the patient even opens their mouth.

Some conditions are particularly challenging to deal with. These include chronic pain, ill -defined diagnoses and those with little prospect of improvement. Straightforward conditions where there is a recognised pathway of management broadly understood by both doctor and patient are much easier to deal with.

Limited resources, finances, support, interruptions and particularly time pressures all contribute to the difficulties experienced by doctors.

Difficult interactions with patients can take up a disproportionate amount of the doctor’s time, resources and emotional energy. They can cause the doctor to feel stress, anxiety, anger and helplessness and can lead to a dislike of the patient and the use of avoidance strategies. All this compromises the doctor’s ability to provide good care and can lead to increased mistakes which are bad for both doctor and patient alike.

A difficult interaction makes both parties feel frustrated and dissatisfied and may result in a breakdown of trust. The patient is then likely to seek another doctor in the practice or at the hospital and this uses up more precious health care resources.

A doctor who stops listening to patients, argues, talks over them and interrupts them does nothing to get out of the downward spiral that occurs in these consultations. Instead, these other suggestions, which may be made by either doctor or patient can help set things right again.

The first thing to do is to recognise when these difficult consultations arise and instead of getting sucked into the “I’m right and you’re wrong” game, take a step back and try to say what the problem is.

A doctor may say, “ We both have very different view about how your symptoms should be investigated and that is causing some difficulty between us. Do you agree?”  A patient may say, “We both seem to have very different views about the optimal number of blood sugar tests that a diabetic needs to do. Do you agree?”

This approach names the elephant in the room and avoids casting blame, fun though that sometimes is. It externalises the problem from both the patient and the doctor and creates a sense of shared ownership. Verbalising the difficulty is the gateway to working towards a solution.

Sometimes a person who is coming across as angry and abusive may be highly anxious about for example a terminally ill partner.  A doctor can say,  “You seem to me to be very angry about this.  Tell me more about this.”  It is important to listen to what the patient says, because if the patient really feels that they have been heard they are likely to calm down.

Sometimes what the patient wants really is unreasonable. A doctor may have to be clear about what is and is not acceptable sometimes. It is useful for all members of the practice to have consistent rules regarding such things as prescribing or late appointments. The way to explain this could be, our practice has a policy about this matter and the policy is…..

Doctors and patients will often have different ideas on issues such as diagnosis, investigations, and management options. Sometimes there seems to be no common ground which is often the result of unrealistic expectations.  Dr Google and The Daily Mail may have something to do with this.  If both can strive to achieve some common ground difficulties usually diminish.

A solution focused process helps the patient feel included and that they are not being abandoned. Asking them to come up with different options can take some of the burden off of the doctor.

 

Adapted from article by Marika Davies, medico legal adviser, Medical Protection Society, London.

Published in BMJ 3 August 2013

Heri’s Health Points: Why a good sleep should be your priority

When improving wellness, better sleep should a priority vs nutrition, fitness programs or prescription

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Too often, the focus is on being more active, look into new diets or exotic holidays.

These would bring energy, improve strength or cure depression.

The cornerstone of a sustainable and healthy body is quality sleep.

Many brush off sleep. Society or human groups do not value or celebrate when you take a good night sleep. Nobody gets alarmed when you miss a night sleep. Even, all-nighters marathons are celebrated as a proof of motivation and dedication.

Yet, lack of sleep or sleep deprivation deregulates main body functions : impaired brain activity, cognitive dysfunction, weakened immune response, hormonal system dysfunction, poor muscle repair, risk of Type 2 diabetes, higher blood pressure, weight gain, heart disease and so on.

This means quality sleep must be a priority, above nutrition, leisure, physical activity and even work.

Here’s my sleeping plan, let me know if it is good for you:

  • If I do not feel well, I try to see first if I had quality sleep recently, before thinking of stress, nutrition or anything else.
  • I close negative emotions.
  • If I have not been sleeping well recently, I make sure not to overstrain. That means in order : not taking any caffeine (coffee or tea) 5 hours before sleep, no strenuous exercise, no blue light 3 hours before sleep, lower home temperature 2 hours before sleep, massage 1 hour before sleep, camomille tisane 1 hour before sleep.
  • Moderate exercise such as 30mn walking at a good pace at 5pm can improve sleep.
  • Move or change sleeping conditions if not optimal. That can include moving out or thinking about the sound environment.
  • Activity trackers and sleep apps can help measure good sleep and give insights. However, trackers do not improve sleep quality and impact is limited.

References:

  • D. J. Bartlett, N. S. Marshall, A. Williams, R. R. Grunstein. June 2007. Sleep health New South Wales: chronic sleep restriction and daytime sleepiness. Internal Medecine Journal
  • June J. Pilcher PhD & Elizabeth S. Ott BS. March 2010. Relationships Between Sleep and Measures of Health and Weil-Being in College Students: A Repeated Measures Approach. Journal of Behavioral Medecine.
  • Hideki Tanaka, Shuichiro Shirakawa. May 2004. Sleep health, lifestyle and mental health in the Japanese elderly. Journal of Psychomatic Research
  • Making sleep a priority – Daily Health Points

Want to feel better? Write down your thoughts and then decide what to do with them.

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In experiments with students it has been found that writing down your thoughts, in your own handwriting, can help you feel more positive, provided you fling away your negative ruminations and keep your positive ones close.

Professor Richard Petty of Ohio State University Psychology department collaborated with colleagues in Spain and tested 83 high school students.

Spending time looking at your negative thoughts make you feel bad about yourself. Throwing out negative and positive thoughts immediately has little impact on you, but putting your positive thoughts in your pocket or purse and referring to them later, has all round positive effects on your mood and future behaviour.

Computerised lists that were either retained or deleted had some effect too, but simply imagining that you had deleted them didn’t work.

(Reported in Human Givens Volume 1 2013 from Brinol P et al, Treating thoughts as material objects can increase or decrease their impact on evaluation. Psychological Science, 24, 1, 41-7)

My comments: this little tip could be very helpful. I know that people who keep journals tend to be more depressed than average. This could be partly due to the introspective nature of journal writing but also perhaps because negative thoughts or events can be reinforced by referring to them or even just carrying them around! 

For avid diary writers perhaps they should keep two journals,   one only keep the good events thoughts and another much smaller book that can be thrown in the trash every so often, preferably quite frequently.

It could also help when you want to achieve something.  Put all of the pros in one list, all the cons on the other, and simply toss out the cons!

 

Weight loss increases hunger: a major obstacle for maintenance

weight-lossWe  know about the issue of slowed metabolism after weight loss due to the lean muscle mass loss that goes along with fat loss. This is one reason why higher protein/low carb diets work better than low fat diets; because muscle mass is maintained better. Well, new information from Diabetes in Control backs up what some of us know intuitively or may have experienced personally….

Losing Weight Increases Hunger

The study showed that for every kg of weight they lost, patients consumed an extra 100 calories a day — more than three times what they would need to maintain the lower weight.

This out-of-proportion increase in appetite when patients lost a small amount of weight may explain why maintaining long-term reduced body weight is so difficult.

A validated mathematical method was used to calculate energy intake changes during a 52-week placebo-controlled trial in 153 patients treated with canagliflozin, a sodium glucose co-transporter inhibitor that increases urinary glucose excretion, thereby resulting in weight loss without patients being directly aware of the energy deficit. The relationship between the body weight time course and the calculated energy intake changes was analyzed using principles from engineering control theory.

Previous studies show that metabolism slows when patients lose weight; however, these results suggest that proportional increases in appetite likely play an even more important role in weight plateaus and weight regain.

Knowing that patients with type 2 diabetes who receive the sodium-glucose cotransporter 2 (SGLT-2) inhibitor canagliflozin (Invokana) as part of a glucose-lowering strategy excrete a fixed amount of glucose in the urine (which causes weight loss), they used a mathematical model to calculate energy-intake changes during a 52-week placebo-controlled trial of the drug, in which 153 patients received 300-mg/day canagliflozin and 89 patients received placebo.  Using this approach meant that the participants who received canagliflozin consistently excreted 90-g/day glucose but were not aware of the energy deficit.

Previously, the researchers had validated a mathematical model to calculate the expected changes in caloric intake corresponding to changes in body weight (Am J Clin Nutr. 2015;102:353-358). They input the current study data into this model.

At study end, the patients who had received placebo had lost less than 1 kg and those who had received canagliflozin had lost about 4 kg. The weight loss with canagliflozin was less than predicted, due to the patients’ increased appetite. On average, patients who received canagliflozin ate about 100 kcal/day more per kg of weight lost — an amount more than threefold larger than the corresponding energy-expenditure adaptations.

“Our results provide the first quantification of the energy-intake feedback-control system in free-living humans,” the researchers write.

They add that in the absence of “ongoing efforts to restrain food intake following weight loss, feedback control of energy intake will result in eating above baseline levels with an accompanying acceleration of weight regain.”

The findings suggest that “a relatively modest increased appetite might explain a lot of the difficulty that people are having in both losing the weight and maintaining that weight loss over time. From the results it was concluded that, while energy expenditure adaptations have often been considered the main reason for slowing of weight loss and subsequent regain, feedback control of energy intake plays an even larger role and helps explain why long-term maintenance of a reduced body weight is so difficult.

The findings suggest that an increased appetite is an even stronger driver of weight regain than slowed metabolism. “The message to clinicians is to not only push physical activity as a way to counter weight regain but also use medications that impact appetite.”

In summary, the researchers conclude the few individuals who successfully maintain weight loss over the long term do so by heroic and vigilant efforts to maintain behavior changes in the face of increased appetite along with persistent suppression of energy expenditure in an omnipresent obesogenic environment. Permanently subverting or countering this feedback control system poses a major challenge for the development of effective obesity therapies.

Practice Pearls:

  • Findings suggest that an increased appetite is an even stronger driver of weight regain than slowed metabolism.
  • Appetite increased by ∼100 kcal/day above baseline per kilogram of lost weight.
  • The message to clinicians is to not only push physical activity as a way to counter weight regain, but also use medications that impact appetite.

Obesity. 2016;24:2289-2295. Abstract

Anger and exercise CAN trigger heart attacks

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Can Anger and Exercise Trigger a Myocardial Infarction?

Diabetes in Control October 29th 2016

An International study explores the role of physical exertion, anger, and emotional upset in triggering acute myocardial infarction.

In the INTERHEART study, researchers explored the triggering association of acute physical activity and anger or emotional upset with a myocardial infarction (AMI) to quantify the importance of these potential triggers in a large, international population.

INTERHEART was a case-control study of first AMI completed in 262 centers across 52 countries. In this analysis, they included only cases of AMI and used a case-crossover approach to estimate odds ratios for AMI occurring within 1 hour of triggers.

Trained study staff performed a standardized physical examination on participants and administered a structured questionnaire. Participants with AMI (cases) were asked the questions, “Were you engaged in heavy physical exertion?” and “Were you angry or emotionally upset?” in the 1 hour before the onset of symptoms and during the same hour on the previous day.

Control participants were asked, “During the last 24 hours, were you engaged in heavy physical exertion?” and “During the last 24 hours, were you angry or emotionally upset?”

Data were also collected on age, ethnicity, diet, physical activity, tobacco use, education, employment, psychosocial factors, and cardiovascular risk factors. Anthropometric measurements (height, weight, waist, and hip circumference) were measured in a standardized manner.

Medical history (diabetes mellitus, hypertension, angina, stroke, other vascular disease, and depression) and baseline medications were self-reported. Smoking was categorized as never smoking, former smoking, or current smoking. Obesity was defined as body mass index of ≥30 kg/m2.

Countries were grouped into 10 geographical regions: Western Europe, Central and Eastern Europe, Middle East and Egypt, Africa, South Asia, China and Hong Kong, Southeast Asia and Japan, Australia and New Zealand, South America and Mexico, and North America.

Physical activity was categorized as mainly sedentary, mild exercise, or moderate/strenuous activity. Stress was categorized as none or some periods of stress versus several periods or permanent stress. Education was categorized as none, 1 to 8 years, 9 to 12 years, trade school, or college/university.

Of 12,461 cases of AMI, 13.6% (n=1650) engaged in physical activity and 14.4% (n=1752) were angry or emotionally upset in the case period (1 hour before symptom onset).

Physical activity in the case period was associated with increased odds of AMI (odds ratio, 2.31; 99% confidence interval [CI], 1.96–2.72) with a population-attributable risk of 7.7%.

Anger or emotional upset in the case period was associated with increased odds of AMI (odds ratio, 2.44; 99% CI, 2.06–2.89) with a population-attributable risk of 8.5% (99% CI, 7.0–9.6).

There was no effect on modification by geographical region, prior cardiovascular disease, cardiovascular risk factor burden, cardiovascular prevention medications, or time of day or day of onset of AMI. Both physical activity and anger or emotional upset in the case period were associated with a further increase in the odds of AMI.

From the results, it was reported that physical exertion and anger or emotional upset are common in the 1 hour before the onset of symptoms of AMI and that either exposure may act as an external trigger for AMI in all age groups. We report no differences by geographical region, previous cardiovascular disease, cardiovascular prevention medications, cardiovascular risk factors, and INTERHEART risk score.

 

Circulation. http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.116.023142/-/DC1 and http://dx.doi.org/10.1161/CIRCULATIONAHA.116.023142. 2016;134:1059-1067