[HD 202] E01-T11-Interface of Physical and Mental Health

• Non-communicable diseases (NCDs), or lifestyle diseases, are on the rise, influenced by diet, activities, and other lifestyle factors like cardiovascular, autoimmune and endocrine diseases
• Stress-related components are seen in up to 8 in 10 patients in primary healthcare, necessitating attention to physical, psychological, socioeconomic, and spiritual aspects of illnesses

Mind-Body Medicine Definition

• Encompasses the interactions among the brain, body, mind, and behavior
• Emotional, mental, social, spiritual, & behavioral factors affect health
• Uses evidence-based effects of thoughts, beliefs, emotions, and behaviors to positively influence physical health

Three-Legged Stool Model

• The model serves as a basis for medicine
• It involves Procedures, medications and self-care
• Mind-body medicine uses heterogeneous, researched techniques as mind-body therapies.
• Relaxation exercises include: Meditation, biofeedback,guided imagery, hypnosis, Yoga, Tai chi, Qi gong and Autogenic training,

Relaxation Response (RR)

• The main goal of mind-body medicine is to achieve a physiological state of decreased stress
• Biological parameters of RR include:
• Decreased heart rate
• Decreased blood pressure
• Decreased respiratory rate
• Decreased O2 consumption
• Peripheral vasodilation
• Two main features of eliciting the RR:
• Focus on a repetitive activity: e.g., breathing/phrase, word, or prayer
• Disruption of train of everyday thoughts & concerns: Common in people with depression and anxiety like "Boom boom brain"
• Relaxation exercises/techniques induce a psychophysiological state of relaxation or hypoarousal via reduced muscular tension
• Hypo-metabolic state is achieved via reduced sympathetic arousal e.g., deep breathing
• Example: Inhale for 4 seconds, exhale for 6 seconds (longer exhalation), but it cause frustration and is ineffective for severely anxious people at the beginning
• Mindfulness guru Jon Kabat-Zinn that being grounded to the present is vital
• Focusing too much on the past and future results in forgetting the present

Meditation

• Involves intentional self-regulation of attention
• Systematic mental focus on particular aspects of inner or outer experience
• Developed within a religious/spiritual context, ultimately aiming for spiritual growth, personal transformation, or transcendental experience
• Based on Buddhist practice being used as a healthcare intervention
• Two extensively researched forms:
• Transcendental meditation repeats a mantra silently to transcend the ordinary stream of internal mental dialogue
• Mindfulness meditation involves non-judgmental observing of/attending to thoughts, emotions, sensations, perceptions, etc., as they arise moment by moment in the field of awareness
• Judging thoughts and feelings as unacceptable, unwanted, and wrong causes overthinking
• Thoughts are transient, like clouds which we acknowledge and respect for what they are
• Focus returns towards breath, music, or chant, and rewires the brain through neuroplasticity

Guided Imagery

• Generates different mental images via visualization or imagination
• Done independently or with a practitioner while lying by the seashore, or hearing the palm trees swaying and the birds chirping inducing psychophysiological state of relaxation
• Specific outcome is kept in mind: e.g., visualizing one's immune system attacking cancer cells, etc. when they feel less anxious

Hypnosis

• A "Natural state of aroused, attentive focal concentration coupled with a relative suspension of peripheral awareness"
• Primary components:
• Absorption: Intense involvement of a central object of concentration
• Dissociation: Experiences that would ordinarily be experienced consciously occur outside of normal conscious awareness
• Suggestibility: Accepting outside input without cognitive censor or criticism

Biofeedback

• Uses devices that amplify physiological processes e.g., blood pressure, muscle activity
• Participants guided through relaxation & imagery exercises and instructed to alter their physiological processes using the provided biofeedback typically visual or auditory as a guide
• Common forms:
• Electromyographic EMG biofeedback for tension headaches provides feedback regarding tension.
• Temperature biofeedback (for migraine headaches) instructs to warm hands using tones for feedback cue sounds

Efficacy of Mind-Body Therapies (MBTs)

• Coronary artery disease (e.g., cardiac rehabilitation)
• Headaches and insomnia
• Incontinence and chronic low back pain
• Disease & treatment-related symptoms of cancer like side effects of chemotherapy
• Hypertension and arthritis

Allostasis

• Is the ability to achieve stability through change
• It involves biological mechanisms that protect the body from internal and external stress, and maintain homeostasis

General Adaptation Syndrome

• Hans Selye developed the syndrome in the 1930s
• It describes the short-term and long-term reactions of the body to stress based on three stages
• Acute stress response is activated in alarm stage
• Body makes an effort to return to a state of homeostasis in the resistance stage
• Stress continues for a long time resulting in the body being unable to function normally causing organ systems to fail during exhaustion stage

Allostatic Loading

• Long-term effect of the physiologic response to stress
• Metabolic wear and tear on the individual at the cellular level
• Price for maintaining allostasis of physiological systems
• Chronic stress overactivates allostatic systems, leading to diseases
• Burdens on allostatic load overactivate systems to compensate for deficit

Allostasis vs. Allostatic Loading

• Stress Response - Allostasis is an adaptive response to stress and the ability of the body to maintain stability through change
• Adjusts internal systems in response to external challenges without exhausting itself Example:

When a person on the seesaw experiences a stressor but maintains balance through conscious action and adaptation

• Stress Reaction - Allostatic Load happens when body suffers wear and tear on the body from chronic overactivation of stress responses where there is some kind of malfunction effect of chronic stress. Example:

A person is burdened by heavy stressors and appears fatigued or overwhelmed, even though they are still trying to maintain balance

Mechanisms of Allostatic Loading

• Frequent stress or multiple stressors
• Prolonged exposure to stress & lack of adaptation
• Inability to shut off allostatic responses or delayed shutdown once a stressor is terminated
• Inadequate (insufficient) response
• This all leads to dysregulations across systems in the body that maintain balance or homeostasis

Chronic Diseases and Allostatic Loading

• Allostatic loading plays a role in the development of chronic diseases such as elevated levels of depression & anxiety (allostatic load disorders), coronary artery disease, diabetes mellitus, and end stage renal disease

Oxidative Stress

• Phenomenon at the cellular level which is an effect of the translation of chronic psychosocial stress to metabolic activation stress: like Hippocampus neuronal cell
• Since, the hippocampus is important for emotional regulation and conversion of short-term to long-term memory during REM sleep, these functions are impaired under chronic stress

Proinflammatory Transcription Factor NF-kB

• Is the culprit behind oxidative stress produced under high levels of uncontrolled stress
• Usually downregulates within 60 minutes (1 hr) when stress is removed
• Both psychosocial and physiological stressors: like hypertension, obesity, diabetes mellitus and hyperlipidemia can activate transcription factor NF-KB and leads to endothelial dysfunction.

Resiliency

• Ability to rebound or bounce back from a stressor or adversity that reflects good adjustment across different domains in the face of significant adversity

5 Major Components of Resiliency:

• Experience reward and motivation nested in dispositional optimism and high positive emotionality
• Circumscribe fear responsiveness so that one can continue to be effective through active coping strategies despite fear
• Use adaptive social behaviors to secure support through bonding and teamwork and to provide support through altruism
• Use cognitive skills to reinterpret meaning of negative stimuli
• Integrate a sense of purpose in life along with a moral compass, meaning, & spiritual connectedness

Biological Underpinnings of Resiliency

• Resiliency is not just but a whimsical concept it is backed up by scientific knowledge that shows:
• High resilience is marked by indicators like high ratio of dehydroepiandrosterone (↑DHEA:S/cortisol) & low ratio of NPY/norepinephrine (↓NPY:norepinephrine
• Low resilience is showed by high CRH (↑ CRH) & low NPY (↓NPY)

Genetics of Resiliency

• Single Nucleotide Polymorphisms (SNPs) of the CRH type 1 receptor gene may moderate the effects of child maltreatment on susceptibility to depression in adulthood and offers protection
• SNPs of the FKBP5 gene modulate association of child abuse with the risk of PTSD in adulthood lessens the chances of PTSD during adulthood
• Catechol-O-methyltransferase polymorphism (Val158Met) is indicator of lower resilience to anxiety & negative mood states

Epigenetic Mechanisms of Resiliency

• Tackles the influence of the environment on gene expression which affects protein formation
• Maternal nurturance increases levels of nerve growth factor-inducible protein A (NGFI-A)

Conscious Positive Expectation (Optimism) & the Placebo Response

• Conscious positive expectation: Technical term for optimism: Part of resiliency
• Conscious positive expectation aids in the healing process

Anterior Cingulate Cortex (ACC)

• Plays a role in processing pain
• Activated when pain is detected during stress tests
• Activated in pain test but deactivated with placebo administration of pain during stress tests

Dorsolateral prefrontal Cortex (DLPFC)

• Responsible for higher-order functions, decision-making, memory, and abstract thinking
• Typically deactivated during pain

Holmes & Rahe (1967) Stress Scale

• Measures stress level and if there is a risk of becoming sick or having a health breakdown
• Interpretation:
• 150 or less suggests low susceptibility to stress-induced health breakdown
• 150-300 is 50% chance of a major health breakdown in the next 2 years
• 300 or more is 80% chance of a major health breakdown in the next 2 years

Health Index

• Determines inclination for good health by reciprocally using the illness index

Enviromimetics

• A new field of medicine that aims to develop therapeutic interventions that mimic or enhance the beneficial effects of environmental stimulation, due to it being based on Epigenetics
• Highly nurtured rat pups → hypomethylation at the 5-HT7 gene increased production of Glucocorticoid Receptor-promoter gene resistance to stress as adult rats
• Environmental enrichment may reverse effects of being a rat pup who has had a poorly nurturant upbringing epigenetic changes that elevates oxytocin functioning → increased attachment behavior in adulthood