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Mindfulness Based Stress Reduction: Non-doing for Well-being
By Nancy J. Selfridge, MD. Dr. Selfridge is Associate Professor, Department of Integrated Medical Education, Ross University School of Medicine, Commonwealth of Dominica, West Indies; she reports no financial relationship to this field of study.
Synopsis: Mindfulness Based Stress Reduction (MBSR) research over 30 years has explored its potential benefits for mood disorders, chronic medical illness, and pain as well as mental and physical health for non-medical populations. Newer data suggest additional applications. Though research is limited by methodological flaws, MBSR is a low-risk intervention that may be helpful for a wide variety of patient problems.
History and Background of MBSR
Mindfulness is a term used to define a state of fo-cused attention that can be described as awareness of experience without evaluation or judgment. It has its origin in Buddhist tradition, where the practice of several meditation exercises are endorsed as training to allow more adept access to this mental state. From the Buddhist perspective, proficiency in mindfulness is believed to foster clarity of thinking and compassion, as well as to alleviate suffering and to promote well-being. Other common monikers for this mental state in the meditation literature include "being in the present moment," "nonjudgment," "nonattachment," "nonstriving," and "nondoing."
Interest in mindfulness meditation as a therapeutic intervention for medical and psychiatric problems has increased over the last 30 years or so. In addition, as functional neuro-imaging tools have evolved, neuroscientists investigating neural correlates of consciousness and affect regulation have become curious about how meditation and mental training alter these same correlates.
In 1979, Jon Kabat-Zinn began offering a secular course of mindfulness training called Mindfulness Based Stress Reduction (MBSR), through the Stress Reduction Clinic at University of Massachusetts Medical Center. Within a few years, he began publishing descriptive data about the effects of mindfulness training in patients with chronic pain, mood disturbances, and stress symptoms.1 The MBSR program is currently offered worldwide in more than 200 medical centers, hospitals, and clinics. There are other ways to become trained in mindfulness, many of them with the guidance of well known Buddhist teachers, such as Thich Nhat Hanh and Pema Chodron. However, MBSR offers a standardized program that has been widely and frequently studied since its introduction and its training and practice require no religious or philosophical affiliation.
Description of Course
MBSR is an 8-week structured course of training in mindfulness. Participants go through a pre-course screening interview with a course instructor to review the requirements of the course and to discuss the participants' motivations and expectations for course attendance. Participants are required to attend eight weekly 2 1/2 hour sessions and participate in an all-day mindfulness retreat. Make-up sessions for any missed classes are encouraged. Formal mindfulness meditation techniques are taught, including sitting meditation, body scan, and gentle Hatha yoga postures. Mindfulness practices applied to daily life experiences, such as eating and walking, are explored. Written documentation of daily practice of the techniques learned in class is endorsed during the course period. Audiotapes or CDs often are provided to participants to help guide home practice. Instructors are formally trained in an MBSR instructor course and are experienced meditators, committed to their own meditation practice.
Mechanisms of Action
Though meditation practice can lead to a deep state of physiologic relaxation, this is not the primary focus of the training and practice. In fact, MBSR trainees are encouraged to abandon any striving for a release of body or mental tension, instead cultivating an increased awareness of all physical, mental, and emotional experiences during the practice exercises without associated value judgments or interpretation. The development of this metacognitive skill then allows a participant to observe how both positive and negative sensations, emotions, and thoughts come and go, moving one beyond reflexive thinking and behavior. The neural and physiologic correlates of this state of mind are a subject of great interest. Though not all of the following research is specifically relevant to the MBSR course, it is still helpful in formulating hypotheses about how mindfulness meditation interventions may exert their effects.
EEG studies show enhanced alpha and theta activity during meditation. Neuroimaging studies have shown that mindfulness meditation practice activates the prefrontal cortex and anterior cingulate cortex.2 Functional connectivity appears to be increased in areas of the brain associated with attentional focus, sensory processing, and reflective awareness of sensory experience.3 Gray matter density is increased in brain regions associated with learning, memory, emotional regulation, and self awareness.4
Multiple studies have shown measurable physiologic effects, including increased natural killer cell function, enhanced antibody response, reduction in inflammatory cytokine levels, increased heart rate variability, and reductions in serum cortisol levels. However, the precise mechanisms by which mindfulness meditation may result in improvement in various medical and psychiatric conditions remains unclear. In fact, this is true of all mind-body techniques including relaxation exercises, breath work, guided imagery, journaling, and self-hypnosis. Hypotheses include a reduction in severity of physical symptoms, increased levels of psychological acceptance of various physical and emotional experiences, increased ability to cope, and reductions in the stress response to disease and symptoms.
Richard Davidson, Director of the Center for Investigating Healthy Minds at the University of Wisconsin and board member of the Mind and Life Institute, has contributed substantial insight into the neurophysiology of the brain as well as the effects of mental training, with his highly publicized research on the exceptional mental abilities of advanced Tibetan monks. Perlman et al recently compared a focused attention meditation technique to a mindfulness technique in long-term meditators proficient in both approaches, while exposing the subjects to noxious stimuli. Responses were compared to a control group of novice meditators using each technique. The mindfulness meditation technique resulted in a reduction of self-reported unpleasantness, though not intensity, of the noxious stimuli in the long-term meditators compared to novices. The focused attention meditation technique resulted in no differences between novice and long-term meditators in reported unpleasantness or intensity of the noxious stimuli.5
Pain. Medical research into mindfulness training initially focused on pain, stress, coping, and quality of life. In 1982, Kabat-Zinn reported reduction in perceived pain of at least 50% in half of chronic pain patients who completed MBSR compared to a control group of patients receiving usual care in a pain clinic.6 In a small (n = 25) randomized controlled trial, Esmer et al found improvements in pain acceptance, pain intensity, quality of life, and a reduction in functional limitation in patients with failed back surgery syndrome.7 Grossman et al noted significant improvement in pain and quality of life in a quasi-randomized controlled study of 58 patients with fibromyalgia who completed MBSR training, and improvements were sustained in a subgroup of 26 participants at 3-year follow up. However, in a larger, similarly structured study by the same researchers that was carefully randomized and included an active treatment control group, these improvements were not confirmed.8,9
Anxiety and Depression. Kabat-Zinn published descriptive data from long-term (3-year) follow up on a small (n = 18) cohort of patients with anxiety that completed MBSR. He found that they reported significant and sustained reductions in depression and anxiety, and a reduction in number and severity of panic attacks compared to pretraining baseline levels. Ten out of these 18 subjects also reported that they continued to practice a formal mindfulness technique at 3 years.10 A more recent randomized study with a wait list control group showed small to moderate improvement in 30 people with anxiety disorders immediately after MBSR training and at 6-month follow-up.11 Schizophrenia, active psychosis, and suicidality have been considered contraindications to participation in MBSR. There has been a particular concern about exacerbation of psychotic symptoms during meditation practice. However, a recent small study of 15 schizophrenic patients taking mindfulness training for anxiety symptoms showed no evidence of psychotic symptoms emerging during meditation practice.12 MBSR was shown by Sephton et al to alleviate depressive symptoms in women with fibromyalgia compared to a wait list control group.13 A meta-analysis of research on the effects of MBSR on the mental health of patients with chronic medical disease concluded that MBSR has small positive effects on depression, anxiety, and psychological distress.14
Cancer. MBSR has been investigated as a way to address psychological comorbidities in cancer survivors. A 2009 meta-analysis of 10 randomized controlled trials and observational studies concluded that MBSR may improve cancer patients' psychological adjustment to their disease.15 A 2011 literature review of MBSR studies in breast cancer survivor cohorts found moderate to large effect sizes on anxiety, stress, and mood disturbance.16
Other Applications. In a variety of controlled and observational studies, MBSR has been shown to improve response to PUVA treatment in psoriasis patients;17 to reduce the degree of bother and distress in women due to hot flashes;18 to improve glycosylated hemoglobin and blood pressure in patients with type 2 diabetes;19 to buffer CD4+T lymphocyte declines in HIV infected patients;20 and to improve quality of life in patients with traumatic brain injury.21 Drawing conclusions and making recommendations based on these isolated studies with small to moderate apparent effect sizes is not prudent. However, the results continue to support hypotheses that MBSR may have wide therapeutic applications. A systematic review of research on mindfulness meditation for substance abuse disorders reported that the intervention might be useful but no firm conclusions about its effectiveness could be made.22 A Cochrane analysis of the limited research on the use of meditation therapies for treatment of ADHD concluded that there is presently insufficient evidence of efficacy.23
Mindfulness training has been shown repeatedly in non-medical populations to improve measures of perceived stress, positive mood and affect, quality of life, and mindfulness.24
These effects of MBSR would suggest that medical students and physicians would benefit from mindfulness training and practice as a way of mitigating the stress of professional training and work. Groopman suggests that medical error is often the result of faulty thinking and cognitive traps, such as anchoring (snap judgments and premature closure), and attribution errors (stereotyping). He further proposes that paying attention to the process of thinking, a clearly mindful metacognitive practice, would help a physician to avoid these kinds of errors.25 To date, few studies have been done on medical students and physicians to assess the effects of mindfulness training. Rosenzweig et al reported a significant effect of MBSR training on total mood disturbance in second-year medical students in a prospective, non-randomized study that had an active cohort control group.26 Recently, Zeidan et al found that brief mindfulness training improved visuo-spacial processing, working memory, and executive functioning, suggesting other ways that physicians and medical students might benefit from MBSR.27
Though the field of mindfulness research is presently quite prolific (more than 350 research publications in 2010 alone), most of the research to date on mindfulness training as a medical intervention has been limited by a variety of methodological flaws. Many studies involve small sample sizes. Interventions labeled as mindfulness meditation can vary widely in format. For the MBSR course per se, which is a fairly standardized and structured intervention, there still may be wide variations in group experience based on instructor protocol adherence and participant skill acquisition during the sessions. The MBSR pre-course interview that illuminates expectations and the commitment necessary to complete the program often results in a cohort of patients who, though initially interested, fail to enroll or fail to show up for the first and subsequent sessions. Adherence has been cited as a problem in literature reviews and meta-analyses. Intention-to-treat analysis is lacking in many studies. Though some studies have included wait list control groups, helping to control for regression toward the mean, few have had active control groups to help assess for non-specific group effects of treatment. Many studies fail to discern between participants in the course who are compliant and non-compliant with the daily home practice or those who continue to practice after the course is completed. Information on long-term maintenance of measured improvements is lacking. In some studies, patients have been enrolled after referral by their personal physician or after reading a program brochure, thus, introducing bias through significant positive endorsement of the program. Consensus about working definitions of mindfulness is lacking in research, hindering interpretation of results both in basic science and clinical studies. More high-quality neurobiological and clinical research is needed to address the limitations in current studies before firm conclusions can be drawn about MBSR as an effective clinical intervention. The National Institutes of Health is presently supporting research on the use of mindfulness training for the management of irritable bowel syndrome, inflammatory bowel disease, diabetes, HIV and AIDS, respiratory infection, and mental health disorders.
MBSR research has shown no adverse effects to date. However, there is often a cost for the program that may be prohibitive for some patients. The course requires a significant time commitment. It is possible that patients participating in MBSR might postpone other appropriate treatments for their problems and that MBSR might not provide them with any benefits upon course completion. Nonetheless, the evidence suggests that MBSR may be helpful in improving stress symptoms, increasing ability to cope with pain and chronic illness, improving quality of life, and improving mental health both in sick and well individuals. Despite the limitations of existing research, it is a low-risk intervention. The implied benefits from existing clinical studies and evolving neurobiological research on mindfulness inform us that MBSR can be safely recommended and endorsed for motivated and interested patients, both for self care and as an adjunct therapy for many physical and psychological problems.
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