Mind Over Misery: Stress, , Mood, and Pain

Presented by

John Arden, Ph.D.

Disclosure Dr. John Arden the presenting speaker, nor the activity planners of this program are aware of any actual, potential or perceived conflict of interest

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Institute for Brain Potential

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COURSE OBJECTIVES As a result of completing this program participants will be able to identify: 1. Calm the stress response through increasing predictability and control, 2. Reduce intrusive thoughts and impulses in OCD and phobic disorders through involving the habit brain, 3. Enhance social reasoning through the key interpersonal techniques, 4. Relieve anxiety, elevate mood, and deepen sleep through cognitive approaches, 5. Reduce pain in patients undergoing medical and dental treatment through mind-body therapies, and 6. Elevate positive through the practice of positive psychology. Policies and Procedures

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IBP is a nonprofit scientific and educational organization dedicated to promoting advances in behavioral medicine. IBP is entirely supported by the tuition it charges for its seminars and the sale of educational materials. Neither IBP, its planning committee, nor any of its instructors has a material or financial interest with any entity, product, or service mentioned in the seminar unless such relationship is disclosed at the beginning of the program. The information presented is of a general nature. For specific advice, please consult a specialist in your area. Mind Over Misery Today’s Agenda A Neuroscience Perspective • 9 AM: Practical Neuroscience 10 AM Healthy Brain Factors Institute for Brain Potential * Planting SEEDS 11 AM Memory Systems 1 PM Generalized Anxiety 1:45 PM Panic 2:30 PM PTSD 3:30 PM Pain John B. Arden, PhD 4 PM adjourn

The BASE of BBT Worth a Thousand Words

Brain Alliance changes the brain

Evidence-Based Systems Practice Goldapple, Segal, et al. (2004). Arch. Gen. Psych., 61, 34–41.

Psychotherapy and the Brain Brain-Based

Direct, observable links between successful CBT/IPT and brain changes • BBT changes how we think – Reduced amygdalar activity in treated about the relationship and phobics ( Straube, et al., 2006), panickers (Prasko et al., 2004), and social phobics (Furmark et.al, 2002) change: – Reduced frontal activity in treated –Need a “Safe emergency.” depressives (Goldapple et al., 2004) – Increased ACC activation in PTSD clients –Experience creates brain (Felmingham et al., 2007) biology – Increased hippocampal activity in depressives (Goldapple et al., 2004) –Brain biology effects

– Decreased caudate activity in OCD (Baxter, et al., experience (e.g. depression) 1992)

1 Maximizing the Placebo Effect Frontal Lobes: & Brain Evolution

• Good listening skills •Human evolution is • Empathetic Attention the story of growth & increased • Gaze Attunement complexity of the • Appropriate Touch cortex and PFC • Communication style (language and prosody) • Humans: 30% • Welcoming physical appearance • Chimps: 12% • Physical Proximity • Dogs 6% • Asymmetrical power dynamics between • Cats 3% therapist/client (Kradin, 2008)

Pre-Frontal Lobes

• The “Executive” brain –CEO-- control Dorsolateral center Prefrontal Cortex • Motor pre-frontal lobes are last to myelinate – e.g., teenagers – Identity – Insight Orbital – Sense of Self Prefrontal Cortex – OFC part of the “limbic system”

Pre-Frontal Cortex Practical Neuroscience

• Dorsolateral pre-frontal cortex (DLPFC)--- • Asymmetry –set points working memory: 7, plus or minus 2, ……….or 20-30 seconds of information • The —fast and slow tracks • Orbital frontal cortex (OFC) • Default Mode Network – Social brain • Neuroplasticity – Affect regulator • Neurogenesis – Empathy • Mirror neurons – Attachment, warmth, and love – Connections with limbic area, i.e., amygdala • Spindle Cells – Phineas Gage • Nutritional Neuroscience

2 Affect Asymmetry “Neurons that fire together, Set points wire together.”

LEFT FRONTAL LOBE RIGHT FRONTAL LOBE • Neuroplasticity is a general term that describes changes in the brain as you

• Positive emotions • Negative experience and learn (Buonomano & Merzenich, 1998) emotions • Approach behaviors • Neuroplasticity involves many changes to • Withdrawal the brain including: • Labeling thoughts behaviors and feelings and – New synaptic connections • Feeling – Strengthening of connections through LTP •Developing new overwhelmed narratives (helps to – The growth of new dendrites (dendritogenesis) Alexithymic pts. have – Neurogenesis (the growth of new neurons) alleviate anxiety and smaller right ACCs depression) larger right ACCs-- more fearfulness

and worry (Gandell, et al, 2004)

Neuroplasticity Yerkes Dodson arousal curve • Increases in: • synaptic efficacy • receptor density –Up-regulating their activity –Glial cell availability –Changes in the shape and structure of synapses

Examples of Neuroplasticity Examples of Neuroplasticity

• London cabdrivers - larger right posterior • Musicians using specific fingers to play their hippocampus. The longer they were on the instruments showed enlarged areas of their job, the larger the size of their hippocampus. somatosensory strips associated with those (Maguire, et al, 2000) fingers. (Pantev, et al, 2001) • Adults who juggled three balls for 3 months increased grey matter in the midtemporal • Blind Braille readers showed enlarged area and left posterior intraparietal sulcus. - cortical areas associated with their reading 3 months of little or no juggling, -- grey finger compared to blind non-Braille readers matter decreased and approached baseline and to sighted people. (Pascul-Leone & Torres, 1993) values. (Draginski, et al, 2003)

3 Task-induced activity in the Increasing Neuroplasticity default mode network

• Tasks are of sufficient difficulty • Increased difficulty as you master each level • Sufficient intensity • A few learning sessions each day • At least 3 learning sessions each week • Done for several weeks • Like body building • Lift more than you can easily • 3 reps of 10 • 3 xs per week • Several weeks Sheline Y I et al. (2009)

DMN Variations BBT Strives to: • Increases when DLPFC is not engaged: • Induce repeated states (weak – Stressed, bored, no novelty, or tired attractors) • Malfunctions in the DMN: • (i.e. positive moods) – Schizophrenia—defective mPFC— impaired self reflection—not sure • Repeat often enough so they where thoughts come from become traits – (or strong – Depression—obsessive ruminations over negative experiences attractors) • Need meta-awareness for creativity (notice that they are doing it)

A Mnemonic “Recipe” for Neuroplasticity Brain Derived Neurotropic Factor

• BDNF plays a crucial role in reinforcing • Focus neuroplasticity and neurogenesis. • BDNF is like Miracle Grow to help: • Effort – Consolidate the connections between neurons. – Turn on the nucleus basalis to focus • Effortlessness attention, deciding what’s important for neuroplasticity • Determination – Promotes the growth of myelin to make your neurons fire more efficiently – Acts on stem cells in the hippocampus to grow into new neurons

4 Factors that Decrease Factors that Increase Neurogenesis Neurogenesis • Aging • Exercise • Chronically high cortisol • Fasting – Chronic stress • Fewer calories consumed – Recurrent depression • Type of food content (Omega—3) • Radiation • New learning (neuroplasticity) • TBI

Brain Healthy Factors Regulatory Networks of the Social Brain

• Social • Bonding/Attachment • Exercise • Affiliation • Education • Regulation • Diet • Affect Regulation • Sleep • Safety

Loneliness The Effects of Social Medicine

• Cardiovascular reactivity (Lepore, et al, 1993) • In Portugal 1000 people • Blood pressure (Spitzer, et al, 1992) 65> assessed: • Cortisol levels (Kiecolt-Glaser, et al, 1984) – Loneliness was the single • Serum cholesterol (Thomes, et al, 1985) most important predictor of depression (Paul, et al, 2006) • Vulnerability to catching a cold (Cohen, et al, 2003)

• Depression (Russell & Cutrona, 1991) • In London 2600 people 65> • Anxiety (Cohen, 2004) • More than 15% were at risk • Natural killer cells (Kiecolt-Glaser, et al, 1984) for social isolation and depression (Illife et al., 2007) • Slows cognitive decline (Bassuk, et al 1999)

• Improves sleep (Cohen, 2004)

5 The Cost of Loneliness Cell Aging: Telomeres Length • In the long-run as detrimental as • “Psychobiomarker”: Linked to social status,

smoking to longevity (Cacippo & Hawley, 2009) perceived stress, depression, predictive of • The temporal-parietal junction (TPJ)— mortality (Epel, 2009, Current Directions) associated with cognitive empathy is • •Telomeres: non-coding sequences capping much less activated and can atrophy ends, serving as a

– Creates a downward spiral → less • “senescence clock” (Blackburn, 1978) successful → less successful • •Telomerase: enzyme that prevents • Less activity of the ventral tegmental telomere shortening, promotes cell area (VTA) and the nucleus accumbuns resilience. • Psychobiomarker”: Linked to social status, perceived stress, – Less of a sense of pleasure • depression, predictive of mortality (Epel, 2009, Current Directions)

Hungry Systems of the Social Brain Systems of the Social Brain

• Brain Structures • Neurotransmitter systems – Orbital Frontal Cortex (OFC) include: – Amygdala –Oxytocin – Insula –Dopamine – Cingulate – Mirror Neurons • Central Parasympathetic Nerve – Spindle Cells –“Smart” Vagus Nerve – Facial expression modules

The Vagus Nerve System Variations in Vagal Tone (Porges)

• Tenth Cranial Nerve • Higher vagal tone correlates with: --a complex of sensory and motor – Self-Soothing capacity nerve fibers. – Quality of caretaking and attachment – More reliable autonomic responses the Vagal tone- – The range and control of emotional states ability to modulate target organs without • Lower vagal tone correlates with: sympathetic arousal •--Anxiety – Impulse Control problems • allows attachment and sustained – Hyperactivity, Attention deficit and distractibility relationships. – Avoidant & Disorganized Attachment – Irritability

6 Mirror Neurons

Cingulate • Helps us respond sympathetically Cortex and empathically to others • Gives us the ability to anticipate Orbital others’ intentions Frontal • Mirror systems are found in: Cortex – Motor – Affect Fusiform Gyrus – Cognition Theory of Mind (ToM) – Social contagion (e.g., yawning)

Facial Expressions Facial Expressions

Left Hemisphere Right Hemisphere • Therapists can model and influence the patient’s facial expressions and mood Controls expression Controls via the mirror neuron system on the lower right expression on the • Feedback system: side of face lower left side of face – Contracting muscles on the right side • Is NOT adept at activates LH and positive emotions reading facial • Is adept at expression reading facial – Contracting muscles on the left side (e.g. alexithymics) emotion activates RH and negative bias--e.g., expression a “smirk” (Schiff, et al, 1992)

D Smiles Social Summary

• Guillaume Duchenne (1806-1875) • Social brain networks need activation identified the activity of the orbicularis • Health related costs without activation oculi muscle • Neurochemistry of social connection • Non-D smiles possibly masking negative states and more likely to be • Non conscious facial expressions asymmetrical • The emotional and cognitive costs of • D smiles -- L-PFC activation loneliness • Social medicine for stress reduction • Non-D smiles -- R-PFC activation (Ekman, et al,

1996)

7 The Equator Exercise Optimizes

Evolution • Mood 5 million years –↑ neurotransmitters Hunter‐gathers »Serotonin Activity level »Dopamine »norepinephrine Walking 10 miles –physical health a day

Exercise Optimizes Exercise Optimizes

•Cognition • Neurogenesis –alertness –new neurons in the hippocampus –attention • Neuroplasticity –motivation –↑ BDNF –cognitive flexibility

Effect on C-Reactive Protein Exercise and Depression

• The effect of exercise on C-Reactive Protein (inflammation chemical). Degree of physical activity by level of C-Reactive • Alameda County study of 8,023 tracked for 26 years Protein Based on study of 13,748 people (Ford, 2002) – Those that didn't exercise were 1.5 times more likely to be depressed • Finnish study of 3.403 – those that exercised 2 to 3 times per week were less depressed, angry, stressed and cynical • Dutch study of 19,288 twins and their families – – those that exercised were less anxious, depressed, neurotic and more socially outgoing • Columbia University study of 8,098 – same inverse relationship between exercise and

depression (Ratey, 2008)

8 Exercise and Depression Exercise and the Brain

• Ohio State study---45 minutes of walking per day/ 5 days per week (heart rate at 60% to 70% of their maximum) lowered BDI Mechanism Impact mean scores from 14.81 to 3.27 compared to no change for Gene Expression Neuroplasticity controls (depressed non-walkers) (Cottman & Blanchard, 2002) • Univ. of Wisconsin – exercise (jogging) as effective as Brain Derived psychotherapy for moderate depression Neuroplasticity Neurotrophic Factor (Adlard, et al, 2005) – After one year 90% of exercise group were no longer (BDNF) depressed. 50% of psychotherapy group • Duke Univ. – found that exercise was as effective as Zoloft Insulin-like Growth Factor Enhanced Neural (IGF-1) (Carro. et al 200) – At 6 month follow-up exercise was 50% more effective in preventing relapse Nerve Growth Factor Enhanced Neuroplasticity – Combining exercise and Zoloft added no benefit re: relapse (Neeper, et al, 1996) (Babyak, et. al. 2000) Vascular Endothelial Enhanced Neurogenesis • NIMH panel concluded that long-term exercise reduces Growth factor (VEGF) (Fabel, et al, 2003) moderate depression.

Exercise Summary •Evolutionary imperative •Not exercising is worst than SEEDS “Smokadiabesity” Education •Exercise boosts mood Memory Improvement •Exercise boost cognition •Miracle grow—neurogenesis

Working Memory 20-30 seconds

9 Two LT Memory Systems Implicit Explicit Non-declarative Declarative • Procedural • Episodic • Emotional • Autobiographical • Generalized • Semantic • Classical • Context Specific conditioning AMYGDALA Amygdala and BG- Hippocampus- driven driven HIPPOCAMPUS

Henry Molaison

AMYGDALA HIPPOCAMPUS Implicit Memory System Explicit Memory System

• Fear Conditioning • Many Cortisol • Emotional Valance Receptors • Generalized • Context Specific • Cortisol Heightened Sensitivity • Heightened Cortisol (Hypervigilence) leads to atrophy • Matures Early • Matures Later • “Little Albert” • Infantile Amnesia • “LSMFT” • “H.M.” Dr. Brenda Milner

Henry’s Brain Amygdala and Hippocampus • Amygdala contributes to emotional amplification of explicit memories • Explicit memories can be state-based (e.g., when we are depressed, we remember depressing events) • When working well together memories are more robust and durable – Make what you want to remember emotionally relevant

10 Threat Appraisal: The Fast Circuit to the Amygdala

Amygdala Level • Goes from the Thalamus directly to the Amygdala • Fight or Flight: HPA activation • Emotional Learning • Fear Conditioning • PTSD, panic, etc. • Flashbacks • “Bottom up”

Threat Appraisal The Slow Circuit to the Amygdala

Cortical Level • Goes from the Thalamus through the Cortex and Hippocampus to the Amygdala • Worries and GAD • and • Tames the Amygdala • With exposure, New Thinking (cortex) • “Top down”

The Dynamics of Fear The Amygdala and Traumatic Memories • Participants who were closer to the WTC showed decreased activation in the • Amygdala memories are hard posterior parahippocampal cortex and increased activation in the amygdala to forget (“Stone tablet”) bilaterally during retrieval of 9/11 memories relative to summer memories.

• Hippocampal circuits tell us what to fear and in what context (“Etch-a-Sketch”)

11 Flashbulb Memories Negative Memories • A particular type, not class • Fear and negative emotion narrows • During emotional peaks, NE attention to threat: dramatically sensitizes synapses – Increasing the ability of receptors to be –“weapons focus” recruited to synapses • Thus, less accuracy for peripheral – Primes neurons by increasing their memory of stimuli (i.e. color of the sensitivity car or person’s hair) more to the object of threat (gun, knife, etc.)

Positive Emotion and Recovered Memory Therapy? Memory Be Careful! • Positive emotion promotes wide frame • 183 claims of repressed memories of • During positive experience we may want childhood abuse: to “take it all in” • 100% report torture/mutilation (no evidence) • Recalling positive memories -- • 100% in therapy 3-5 years after first “memory” “reminiscence bump” • 83% employed before therapy—37% after therapy • with increased • 23% lost parental custody • 100% estranged from families • positive memories • (Bertsen & Rubin, 2002) • 10% SI before therapy—67% after therapy!

Are traumatic memories accurate? Memory and Brain Complexity • Generally accepted theory: • Memory is not an exact copy—Not in one neuron or byte on a hard drive. –Central facts remembered more accurately • Distributed network located in multiple locations –Peripheral details inaccurate and often fabricated in later stories –Not possible to distinguish repressed memory from fake memory without some form of corroborating evidence

12 Memory (summary) Break a Fast Skipping Breakfast contributes to: • Attention is critical to the coding of new ↓ problem solving memory ↓ working memory ↓ attention • The power of mnemonics ↓ concentration • The “Inverted U”: too little stimulation (e.g., boredom) or too much stimulation (e.g., ↑ Mood swings trauma) conflict with the coding of new ↑ depression memory ↓ energy • A moderate degree of anxiety works best to facilitate neuroplasticity and new memory ↑ stress reactivity ↑ anxiety

Hydration Amino Acids • Dehydration contributes to:

– Brain cells shrivel up Amino Acid Neurotransmitter Effects

L-Trytophan Serotonin Improves sleep and – Enlarging ventricles calmness and mood

– Brains work harder with poor L-Glutamine GABA Decreases tension and results irritability

– Impaired cognition L-Phenylalanine Dopamine Reduces and increases feelings of » Attention pleasure

L-Phenylalanine Noreprinephrine Increases energy, » Forgetfulness feelings of pleasure, and memory » Speech problems

Blood Sugar Glycation (excess glucose)

• When blood sugar drops below 50 • Blocks protein from moving freely milligrams per milliliter symptoms include: • The body’s membranes become – Free-floating anxiety “gunked up”--slowing down neural communication – Shakiness • Interferes with synaptic transmission – Lightheadedness • Causes structural damage to the – Irritability mitrochondria (the cells’ energy – Rapid heartbeat factories) – Difficulty concentrating • Lead to free radicals – Memory problems • Causes inflammation.

13 Glycemic load (GL) – a Advanced glycosylated end measure of rise in blood sugar products (AGEs). • The higher the GL of a food: • AGEs acts like a chemical glue –the greater the adverse insulin that attaches molecules to one effects another –Long-term consumption of foods with a high GL leads to a greater • AGE causes what has been risk of: referred to as a cross-link. (like • Obesity overcooked meat) • Diabetes • Inflammation.

trans-fatty acids trans-fatty acids

• Formed when an vegetable oil is heated for a long time in a metal container (i.e. • Cookies • Crackers deep frying). • Doughnuts •Cake • tends to be solid at body temperature • Potato chips • Deep-fried and acts like saturated fat foods • trans-fatty acids makes nerve cell • Candy membranes rigid and inflexible, • Mayonnaise • Cheese puffs interfering with their functioning. • Vegetable • Margarine shortening

trans-fatty acids can: trans-fatty acids

1. Be absorbed directly by the nerve 6. Increase plaque in the blood vessels membranes 7. Increase blood clots • 2. Block the body’s ability to make its 8. Increase triglycerides, which cause the own essential fatty acids blood to be sluggish and reduces the • 3. Alter the synthesis of amount of oxygen to the brain neurotransmitters such as dopamine 9. Cause excess body fat, which can have • 4. Negatively effect the brain’s blood a destructive effective on the brain supply i.e. cytokines • 5. Increase bad (LDL) cholesterol while decreasing good (HDL) cholesterol

14 Diet Summary

–The importance of breakfast SEEDS –The perils of simple carbohydrates Sleep –Essential fatty acids –Transfatty acids clogging –Alcohol and marijuana –3-4 balanced meals

Circadian Rhythm Normal Sleep Architecture

• Wake and asleep times • Body temperature • Release of specific hormones • Regulation of the immune system • Recalibrating the brain

Pathologic blunting of slow wave sleep (e.g. drugs, alcohol, caffeine)

89

15 The Importance of Sleep for the Brain

• Protein synthesis (Ding, et al, 2004) • Synthesis and transport of cholesterol (Cirelli, 2005) • Expression of molecules associated with synaptic plasticity (Taishi, et al, 2005)

• Increase LTP (Cirelli, 2005)

• Gene expression (Cirelli, 2005) • Memory consolidation

Medications and Insomnia Medical Conditions - Insomnia

• Decongestants • Fibromyalgia • Corticosteriods • Huntington’s disease • Diuretics • Kidney disease • Heart medications • Hyperthyroidism • Parkinson’s medications • Parkinson’s disease • Asthma medications • Appetite suppressants • Epilepsy • Kidney medications • Cancer • Hypertension

“Learned” Insomnia Defusing NSTs

• “I’m not going to get to sleep tonight.” • This isn’t great but at least I’ve got • Bed becomes an enemy—a negative cue. my core sleep. • Sleep later on the weekends to • If I don’t get a good night sleep compensate. tonight I will tomorrow night. • Next night you feel as you are losing sleep. • I may get back to sleep, I may not. • You try too hard to get to sleep. Either way it is not the end of the • Thoughts about sleep add to daytime world. stress.

16 Sleep Hygiene Sleep Hygiene

• Don’t “try too hard” to go to sleep. • Don’t do anything in your bed other – You’ll frustrate yourself, leading to a than sleep (except for sex). Do not paradoxical effect, and work yourself into an watch television, balance your anxious state of mind. checkbook, discuss finances with your spouse, or argue in bed. Make • Tell yourself “it’s okay if I get just a few your bed carry only one hours sleep tonight. I will catch up the —sleep. next night.” • If you can’t sleep and find yourself – This change in expectation will free you up to tossing and turning, get up and go to be able to relax. The harder you try to go to sleep the harder it will be to induce sleep. another room.

Sleep Hygiene Body Temp and Sleep

• Try eating a light snack with complex carbohydrates before bed.

– Foods rich with L-Tryptophan are advisable. Don’t eat anything with sugar or salt before bed.

• Avoid protein snacks at night because protein blocks the synthesis of serotonin and as a result promotes alertness.

Sleep Summary

• Under 6 hours impairment • Avoiding sleep depressors Allostasis • Negative sleep thoughts Vs. • Body temperature Allostatic Load • Diet • Exercise

17 Allostasis Amygdala- Hypothalamo-Pituitary-Adrenocortical (A- HPA) Axis: Cortisol Levels

• Allostatic adjustments are adaptive over the short term—cortisol helps orchestrate adjustments by: – enhancing or inhibiting gene transcription – regulation of BDNF – up regulates amygdala activity – targets prefrontal systems involved in stress and the emotion (Sullivan & Gratton, 2002).

– maintaining stability through a change (McEwen, 1998).

• Allostatic load --When demands exceed the balance of energy expenditure against the energy and regulatory gains from rest and recuperation. (McEwen and Wingfield, 2003).

Locus Coeruleus (LC) source of NE which has extensive projections throughout the brain and can trigger the HPA axis (Aston-Jones, et al., 1994).

Affect Regulation Excessive Cortisol

• Thinning of the lining of stomach---↑ gastric ulcers • Thinning of bones---osteoporosis and bone fractures • ↓ reproductive systems Shuts down • Cardiovascular systems the HPA axis – ↑ heart rate – Damage to inner surface of the heart – Constricting blood vessels – Heart beat can decrease in variability--↑ risk of heart attack (i.e. “Soldier's Heart)

• Bad Diet • Simple carbs Excessive Cortisol • Transfatty acids Di • Causes: Major Depression (60%) and extremely • Saturated severe stress, prolonged, inescapable fats • Food (perceived lack of control) allergies • Bad oils Hypercortisolemia • High dairy • High gluten •No exercise and damage to arteries •Chronic illnesses • Autoimmune disorders •Chronic pain • Chronic stress • Being overweight • Apple shape • Leaky gut

18 Get rid of the Belly fat The ACE Study

• Belly fat generates inflammation by • Examined the health and social effects of ACE’s throughout the lifespan among 17, releasing inflammatory cytokines 421 members of the Kaiser Health Plan in • Lowers BDNF San Diego county • What do we mean by Adverse Childhood • ↑ in dementia Experience? • The pear not – Childhood abuse and neglect the apple shape – Growing up with domestic violence, substance abuse or mental illness in the home, parental discord, crime

The ACE Score and the Prevalence of The ACE Score and the Prevalence of Severe Obesity (BMI>35) Attempted Suicide Percent attempted(%) Percent Percent obese (%) Percent

ACE Score ACE Score

The ACE Score and a History of The ACE Score and Drug Lifetime Depression Addiction Percent depressed (%) Percent

ACE Score

19 The ACE Score and the Risk of ACE’s Smoking and Lung Disease Coronary Heart Disease Increase in RiskinIncrease (%)

ACE Score

ACE Score and HIV Risks

Death

Early Death

Disease, Disability and Social Problems Adoption of Health-risk Behaviors

Social, Emotional, & Cognitive Impairment

Adverse Childhood Experiences

Auto-Stress Disorders: Anxiety OCD

25% lifetime prevalence: > Phobias > Social Anxiety > Obsessive-Compulsive Disorder > Panic disorder > Generalized Anxiety > PTSD: Post-traumatic > Anxious/agitated depression

20 Structures The Habit Brain and OCD with Roles in OCD Cues: e.g. an • Striatum-- gate is left open emotional state, – caudate part serves as a gate for stress, fatigue, thoughts and emotions addictive cue – putamen part serves as the gate movement Ignites a Behavioral • Amygdala-- activates the fear circuit routine: previously – hijacks the OFC associated with reward • Orbital frontal cortex-- gets flooded with or relief (e.g. counting, information food, grit teeth, bite finger nails, hair – generate error messages: “This is wrong!” Then you engage in compulsive pulling, tics…) behaviors to “make it right.”

Flooded OFC in OCD OCD: failure of top down control

• OFC flooded with nuisance info and tries to make sense of it Caudate • Given its inhibitory role pts try to use it to Thalamus “stop that thinking!” Orbital But that results in a Frontal paradox—“try not to think about pink elephants”

Strengthened Pathways and Exposure + Response Prevention Improved Gating • Exposure must be at least 20 minutes • Resist the urge …inhibit impulses Anterior • “Learning” to control Caudate Cingulate impulses • Actively re-directing PFC ones attention activates and “strengthens” the PFC and its neural network of inhibition

21 Pulling Out of the OCD Circuit Real OCD ORDER

• Prefrontal Cortex (DLPFC and OFC) • O—Observe-- Observing the OCD – DLPFC—Decides “time to do thoughts and behaviors for what they are: something new” obsessions and compulsions. – ACC—dealing with conflict –PFC (DLPFC the OFC) activation. – OFC can learn to inhibit the amygdala and the fear network –Attention key first step for neuroplasticity. • Hippocampus-- provides context and what is worthy of fear • R—Remind--By reminding yourself that –Remembers that you engaged in a you are obsessing you call it a symptom compulsive behavior that never of your brain's OCD habit and nothing seems to solve the problem. more to be concerned about. “This is just OCD. Nothing bad ever happens.”

Real OCD Order Real OCD Order

• D—Doing--By doing something different • R—Response Prevention--Refraining than the usual OCD compulsive behaviors from compulsive behaviors that establishes a new habit. The new contribute to momentarily “feeling behavior draws attention and interest. better.” This is the “R” and “P” in –L-PFC activation ERP of CBT. –Neuroplasticity –Strengthening all inhibitory • E—Exposure--To the situation or place circuits that is intolerable. Exposure allows habituation. This is the “E” of ERP. –Taming of the amygdala

Anxiety Physiology of GAD

• Less parasympathetic more sympathetic • Bed nucleus of the stria terminalis (BNST) is referred to as the “extended amygdala” – BNST associated with GAD – Free-floating anxiety • GAD—an intolerance for ambiguity – Anxious individuals select more threatening interpretations of ambiguous

stimuli (e.g., Mathews & Mackintosh, 2000) •

22 The Vagus and Parasympathetic Tempering Upward Arousal

• Tenth Cranial Nerve --a complex of sensory and motor nerve fibers.

Vagal tone- the ability to modulate target organs without sympathetic arousal

• allows attachment and sustained relationships. Sensory input Collateral axons

Breathing and Over-Breathing Activating the PNS Most people breathe 9 to 16 breaths per minute. Panic attacks - 27 breaths Kegel Over-breathing pulls in too much oxygen forces down the carbon dioxide Exercise level in the blood stream. Kegel response: Carbon dioxide helps maintain the critical acid base (pH) level in blood. impact on Lower pH level causes nerve cells vagus nerve: become more excitable and people associate the feelings with a panic pelvic floor… attack. (20‐30”)… The excessive dissipation of carbon rapid activation dioxide leads to hypocapnic alkalosis of PNS making blood more alkaline and less acidic.

Interrupting the Worry Loop GAD Exposure Fundamentals

–Accept uncertainties –Appreciate ambiguity –See the shades of grey –Thought diffusion • Face Fears – “Nothing to Fear But Fear Itself” • FDR

23 BBT and GAD REAL not GAD “R” is for relaxation, including deep breathing, stretching, self • Parasympathetic activation— , mediation, and prayer to activate their parasympathetic nervous system and increase vagal tone. somatic exercises “E” is for exposure such as in scheduling an hour of worry time, • Cognitive reframing and allowing focused exposure to all their worries, and giving their orbital frontal cortex a chance to work on developing the capability of dealing with the ambiguities inherent to life. • Flooding the Worry Circuit— “A” is for acceptance. Since there is no ultimate certainty with much of life, acceptance of uncertainties allows worries to scheduled worrying fade into the texture of normal living. “L” is for labeling. When they have an anxious thought they can • GAD— The Orbital Frontal Cortex label it as just “an anxious thought,” thereby detaching from (OFC) and exposure to ambiguity the feeling of anxiety.

Deborah’s Worry Loop Neurodynamics of Anxiety

B—OFC hijacked by amygdala • Two routes to the amygdala, the fast and slow A—Critical gambling father, worrying mother • Right frontal bias in general for anxiety disorders S—GAD, need for ambiguity • Under-activation of the left acceptance frontal lobes and in Broca’s area explains why some E—Exposure to ambiguity people feel “speechless”

especially to boring part of 1 when they’re scared (Rauch et al., 1997). hour worry time, until there is no energy anymore, REAL mnemonic

Avoidance: the Polarizer Interoceptive Exposure +

•Sensitizing the Amygdala • There are a variety of introceptive exercises including: –Forms of Avoidance –Running in place--- to increase heart »Escape behaviors rate and hyperventilation –Holding your breath--- to tighten the »Avoidant behaviors chest and create sensations of suffocation »Procrastinating –Spinning--- leading to dizziness »Safety behaviors –Hyperventilation or breathing through a straw---leading to light-headedness

24 Interoceptive Feedback Intoroceptive Exposure + –Swallowing quickly--- to cause a lump in the patient’s throat –Tensing the body--- leading to chest constriction –Standing up quickly from lying Insula on the floor---to cause dizziness. –Staring at one spot---to increase the feeling of being trapped

Exercise and Anxiety Leaning Left for Speeding the Slow Track

• Provides a distraction • Slow track errors—needing rewiring • Reduces muscle tension – automatic thoughts—fast track • Builds brain resources impulse (neuroplasticity and neurogenesis) – Assumptions—worry track • Increases GABA and serotonin • Introceptive exposure – core beliefs—state based assessment • Improves resilience – self-mastery • Global/Passive (R-PFC) vs. • Mobilized vs. immobilized feelings – taking action Detail/Action (L-PFC)

Speeding Up the Slow Track BBT and Panic Disorder

• Labeling thoughts—”That is an anxiety provoking thought” vs. “This makes me anxious!” • Desensitizing the Amygdala— Avoiding avoidance • Externalizing—”What would another person in this situation say and how is • Exposure—Habituation and Amygdala s/he right?” • Interceptive exposure exercises— • Distance—”How will I sensibly view this Embracing body sensation situation in six months?” • Speeding up the slow track—Getting • Humor—”What is funny about this?” the left pre-frontal cortex involved • Wisdom—”How can I grow from this?”

25 BEAT Panic Post Traumatic Stress Disorder “B” is for body, so that when they feel their heart race or breathe too fast they should just ride it out. “I can befriend my own body! “E” is for exposure through the interceptive exposure exercises to regain tolerance to body sensations and say, “this is not a heart attack but just body sensations that I have felt many times before. “A” is for the amygdala with its fast and slow tracks. “I can learn to slow down my fast track and speed up my slow track. “T” is for thinking speeding up their slow track and cortex. They can remind themselves that what they think is happening has a dramatic effect on what they feel is happening.

Chronic, severe, inescapable Long-Term or Traumatic Stress • War Zones Cortisol Cascade Hypothesis: • Stress causes production of cortisol • Child abuse • Excessive cortisol causes dendrites in the • Elder abuse hippocampus to shrivel up (Sapolsky, 1996) • This feedforward loop leads to heightened • Domestic reactivity of amygdala • The hippocampus is essential for turning off HPA violence axis, damage to it leads to even more cortisol release as time passes

• POWs and • PTSD patients with smaller hippocampi (Bremner, 1999) refuges

Long-Term or Traumatic Stress and hippocampal atrophy

26 PTSD Neurodynamics Window of Tolerance

• ↑ amygdala—general false positive for threat • ↓ mPFC especially the ACC (reduced neurointegration and cortical volumes (De Bellis, et. al., 2000) (inadequate top down inhibition of the amygdala) • ↓ hippocampus (cortisol, excitotoxity, blocking of neurogenesis)

Trauma Responses are Autonomically Driven Dual Processing Theory Hyperarousal-Related Symptoms: High activation resulting in impulsivity, risk-taking, poor judgment Chronic hypervigilance, post-traumatic paranoia, chronic dread Intrusive emotions and images, flashbacks, nightmares, racing thoughts • Limitations of the “fear network” – Obsessive thoughts and behavior, cognitive schemas focused on worthlessness and dread doesn’t account for implicit memory: Hyperarousal –Verbally accessible memories (VAMs) on the conscious memory level. VAMs can be accessed in “Window of Tolerance”* therapy through deliberate recall. Optimal Arousal Zone –Situationally accessible memories (SAMs) unconscious. SAMs are only accessible through cues that Hypoarousal Hypoarousal-Related Symptoms: Flat affect, activate the unconscious network numb, feels dead or empty, “not there” (Brewin, Dalgleish, and Joseph, 1996). Ogden and Minton (2000); Cognitively dissociated, slowed thinking process Fisher, 2006 Cognitive schemas focused on hopelessness *Siegel (1999) Disabled defensive responses, victim identity

Orienting Response, REM, and VAM and SAM integration Memory • Somatic stimulation of the orienting response (i.e. • The process needs to be repeated EMDR, EFT, acupressure etc.) involve: for: – Reorienting of attention -- triggered automatically when a sudden movement grabs attention or –Neuroplasticity—the inverted “U” intentionally when you chose to look at an object –To provide easier access to the – The reorienting of attention requires you to release your focus on one location so that it can shift to a SAM system new location –So that VAMs can compete with • The shift in attention involve: – The orienting response (Sokolov, 1990) SAMs – Induces REM like state

• The new VAM system puts the • Both facilitate cortical integration of memories (Stickgold, 2002) SAM system in perspective

27 BBT and PTSD SAFE from PTSD “S” is for stabilizing to establish a healthy • Phase 1: Psychological first aid— stabilizing and preventing PTSD foundation for recovery. • Phase 2: Integration of implicit and explicit “A” is for acceptance of what happened as memory systems an event(s) that occurred in the past, – Verbally accessible memories (VAMs) –the conscious memory level. VAMs can be accessed in therapy “F” is for future to visualize a hopeful through deliberate recall. posttraumatic growth. – Situationally accessible memories (SAMs) –the unconscious. SAMs are only accessible through cues “E” is for exposure to confront the feelings that activate the network. – Phase 3: Posttraumatic growth—developing and sensations that trigger flashbacks. meaning and direction (Constructivism)

Bret’s BASE Ascending Nerve Pathways

B--Increased amygdala and dampened Touch hippocampus—Substance abuse Vibration A--Buddy connection Temperature S--Numbing, re-experiencing Pain (barbecue) and avoidance (nociception) E--New Narratives—Exposure at McJack Jr’s—Posttraumatic Growth

Chronic Pain “The strain of the pain is mainly in the brain” Jason Satterfield, PhD • 100 million adults in US

• The most common forms of pain –45 million – back pain –9 million – head ache

28 Pain Pathways Chronic Pain • Transduction – Transformation of chemical, thermal, or mechanical stimuli at When nerve endings • Transmission Plasticity – Neural impulses of nociceptive info sent along ascending sensory nerves causes • Modulation – Descending info from the brain and problems PAG either inhibit or facilitate pain. • Perception – Influenced by emotional state and previous experience as well as beliefs

Neuro‐Plasticity, Chronic Pain Plasticity and Chronic Pain and Central Sensitization and Central Sensitization With time…remodeling of dorsal horn (spinal cord) BDNF • Gets wired into Touch: lemniscus 4 pain perception Pain (nociception): leminiscus 2 network Collateral fibers (dendrites) grow from 2 to 4: • Thus touch now rewires dorsal horn represents pain

Acute‐to‐Chronic Pain Mind/Body Interaction Barry Elliot Cole: Amer. Society of Pain Education, 2009 • Critical window: 30‐100 days Struggling against pain often increases suffering • Disuse may be a factor - Tibetan Buddhist Tradition • Treatment on many fronts “The best way out > Treat depression is through” > Physical therapy, - Robert Frost exercise…

29 Top‐Down Control via Mind Over Misery Descending Inhibition • Feelings of fear, anxiety, and anger • Placebos dampen pain transform to: • Despair perception • Frustration > Blocked by naloxone • Hopelessness • Maybe depression • Focus on pain: amplifies • Positive mood states activation * reduces pain • Depression increases pain • Distraction: dampens pain * perception – * Irene Tracy (Oxford)

Meditation, Yoga, Tai Chi Mindfulness: Brain Changes (Sara Lazar: Harvard, Davidson and Kabat-Zinn, 2003) • Shifting attention activates prefrontal circuits • Increase in size of L-PFC • Increase left PFC activation (better affect • PFC dampens anterior cingulate regulation) (a region of pain experience) • ↑ awareness of pain… • The perception of suffering ↓ Improved affective control

Mindfulness and the Brain

PFC: • Long-term meditators show increased thickness of the medial prefrontal cortex and also enlargement of the right insula (Lazar, et al, 2005).

• The process of verbal labeling of affective states reduces anxiety and negative affect Left PFC: (Leiberman, et al, 2004) • The middle prefrontal cortex has been Activating associated with self observation and

mindfulness meditation (Cahn and Polich, 2006). Positive • A shift to the left PFC which puts a Emotions positive spin on the experience (Davidson, et al., 2003).

30 7 Principles of Relaxation 7 Principles of Relaxation – 3) A quiet environment—This will give you Common to prayer, meditation, relaxation exercises, and hypnosis. an opportunity to learn how relax without distractions. – 1) Breathing Rhythmically—Deep, deliberate, and focused breathing allows – 4) An accepting and a nonjudgmental you to slow your heart beat. attitude—By shifting away from rigid expectations and to an accepting attitude – 2) Focused attention—By shifting attention you’ll appreciate reality as it is, rather than on the here and now you can transform what you fear it could be. each experience into a rich and calm experience in the present. This activates – 5) A relaxed posture—This can include your PFC to inhibit the over-reactivity of sitting in a relaxed posture or stretching your amygdala. (e.g. hybrid yoga)

Mindfulness and Anxiety 7 Principles of Relaxation Reduction

– 6) Observation—This allows you to detach 1) The process of labeling your from anxiety by not denying its existence. emotions reduces anxiety. • As you observe whatever experience 2) Strong relationship between high nonjudgmentally you can simply note mindfulness and L-PFC regions what is occurring at any one time. which tame the amygdala. – 7) Labeling what you experience accesses 3) These positive effects seem also to your left frontal lobe and its positive correlate with enhancements in emotions. these neural emotional regulation pathways.

Mindfulness and Open Focus Mindfulness for Various Groups

• Increases in Gama waves • Borderline via Dialectic Behavior with meditation Therapy-DBT (Linehan, 1993) • Neurofeedback • OCD (Baxter, et al., 1992) • Depression (Teasdale, Sigal) –Global coherence • General medical problems such as –Open focus—widened chronic pain (Kabit-Zinn, 1990). •

31 Sustaining Positive habits

• Positive habits that are associated with greater sustained levels of well being • But during stressful times: having fun, self-nurturing and humor are the first to go •

“Travel Light” Transcendence • Know what to ignore and choose • Pleasure…often fleeting your battles (Serenity Prayer) • Engagement • If you are riding a dead horse… dismount ! • Meaningfulness • Avoid Black Holes • Sacrifice • Forgiveness and making amends • Transcending suffering • Share secrets, confide, confess • And psychological • burdens (bigger picture) •

Positive Psych Research

• The habit of recapturing • The most potent way to improve positive memories mood: Once a day: an act of kindness –Photos, scrapbooking, • Every day: write: 3 things for digital photo frames… which you feel grateful reminiscing with old friends • Ongoing work toward a valued goal • Daily contact with nature

32 Positive Psych Research Smiling Kindles Positive Moods • Each day ask: “what three • Perceiving the smiles of others triggers the release of DA (Depue & Morrone- Strupinsky) things went well today?” • Presenting smiles for a fraction of a second followed by neutral stimulus • express: increases the positive reaction to

that stimulus (Dimburg & Ohman, 1996) –Gratitude • Bilateral smiles ↑L-PFC positive moods –Empathy • Smiling during periods of stress –Compassion ↓cardiovascular arousal back to baseline (Fredrickson & Levenson, 1998)

Kindling Laughter Circuits Laughter is Good Medicine

Breathing out with laughter triggers the • Improves cognitive function (Fry, 1992)

vagal nerve and the parasympathetic • Exercises and relaxes the muscles (Kuhn, 1994) nervous system • Increases heart rate and blood pressure (Pearce, 2004) ↓heart rate ↓blood pressure • Decreases cortisol levels (Berk, et al, 1988) ↑relaxation • Increases natural killer cell activity (Takahashi, et al, 2001) Laughter module • Altering gene expression (Hayashi, et al, 2006) Supplementary motor area (SMA)

From the SMA to the insula • Stimulates the dopamine reward system (Mobbs, et al, 2003) To the amygdala • Increased longevity (Yoder & Haude, 1995)

Through mirror neurons both experience mirth and shared understanding

Zen is not like chopping wood Psychological Boost of Humor it is chopping wood • Happy people take things in: • Less Anxiety (Yovetich, et al, 1990) moment-to-moment • Reduced Stress (Wooten, 1996) (spend time…take it in) • Lifts Depression (Deaner & McConatha, 1993) • Concrete reminders to savor the

• Boosts Self esteem (Martin, etal, 1993) moment

• Fuels Energy and hope (Bellert, 1989) • Deathbed Regrets: 9/10 regret what they • Adds a sense of empowerment (Wooten, 1996) didn’t do rather than what they did

33 [email protected] www.drjohnarden.com

.

Abbreviation Glossary

• AAI—Adult Attachment Inventory • ACTH—Adrenocorticotropin Hormone • ACC—Anterior Cingulate Cortex • BDNF—Brain Derived Neurotrophic Factor • CRH—Corticotropin Releasing Hormone • DA—dopamine • DLPFC—Dorsolateral Prefrontal Cortex • DMN—Default Mode Network • ISS—Infant Strange Situation • OFC—Orbital Frontal Cortex • NE—Norepinphrine • NMDA—n-methyl-D-asparate receptors • 5-HT—Serotonin

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Mind Over Misery Presented By: John Arden, PhD

1. How does Neuroscience change how we think about mental health and change? a. Experience changes brain biology. b. Brain chemistry must precede therapy. c. Change occurs immediately and permanently. d. Genetic influences are paramount.

2. The orbital frontal cortex is involved in: a. Memory for childhood events, visual imagery, and hopes for the future. b. Fear and details about safety. c. Language functions d. Affect regulation, attachment, and social perception

3. The new developments in neuroscience relevant to mental health are: a. New lines of medication, deep brain stimulation, and ECT. b. Computer games, the Internet, and the Iphone. c. Affect Asymmetry, Neuroplasticity, and Mirror neurons d. New techniques in neurosurgery.

4. Affect asymmetry shows that: a. The right hemisphere controls positive emotions. b. The right hemisphere is creative and always should be honored. c. The left hemisphere controls positive emotions. d. The left hemisphere is too linear to cultivate.

5. The amygdala and the hippocampus function to code which types of memory? a. The amygdala is involved in Implicit and the hippocampus with explicit memory. b. The amygdala is involved in explicit memory and the hippocampus implicit memory. c. The amygdala is involved short term memory and hippocampus long term memory. d. Memory coded from the amygdala should be analyzed and memory from the hippocampus should be ignored.

6. Neuroplasticity and therapeutic gain can be achieved through: a. Reducing all stress. b. Maximizing through a moderate degree a stress. c. Adding insightful analysis. d. Recovering repressed memories.

7. The Institute of Medicine (IOM) study on PTSD found that what therapeutic approaches are efficacious? a. Prolonged Exposure and IPT b. Long term analysis and c. EMDR and DBT d. and Mind Over Misery Presented By: John Arden, PhD

8. Immediately after a traumatic event it is best to: a. Help the hippocampus code in all the memories b. Medicate heavily c. Explore the symbolic significance of the trauma d. Provide supportive therapy, education about self-care so that the excessive traumatic memories do not get coded.

9. The three neural structures involved in the OCD loop includes: a. The hypothalamus, thalamus, and fusiform gyrus b. The striatum, the orbital frontal context, and the amygdala c. The parietal lobes, temporal lobes, and the occipital lobes d. The brain stem, cerebellum, and thalamus

10. A Brain-Based Therapy approach to OCD represented by the mnemonic ORDER emphasizes: a. Overcoming, Rehearsing, Describing, Erase, and Return b. Ongoing, Repeating, Dito, Erase, and Return c. Observation, Remind, Doing something different, Exposure, and Relapse Prevention. d. Doomed, Rocked, Done, Exhausted, Ridiculous