Over the past decade, there has been an increasing interest in meditation as a mind-body approach, given its potential to alleviate emotional distress and promote improved well being in a variety of populations. The overall purpose of this review is to provide the practicing rheumatologist with an overview of mindfulness and how it can be applied to Western medical treatment plans to enhance both the medical and psychological care of patients.
Meditation, with its origins rooted in ancient religious and spiritual practices dating back over centuries ago, has only in the past several decades begun to capture the attention of mainstream Western researchers and health care providers who are gradually beginning to value this mind-body practice as a tool to foster improved physiologic and psychological health. In the current medical environment, it is not uncommon for patients to report the use of mind-body therapies as an adjunct to Western medical treatment. Over the past decade, there has been an increasing interest in meditation as a mind-body approach, and in particular mindfulness meditation, given its potential to alleviate emotional distress and promote improved well being in a variety of populations. The overall purpose of this review is to provide the practicing rheumatologist with an overview of mindfulness and how it can be applied to Western medical treatment plans to enhance both the medical and psychological care of patients.
What is mindfulness?
The word mindfulness is derived from the Pali word sati , meaning “to remember,” with secondary meanings of “attention” and “awareness.” Remembering refers to reconnecting to the immediate moment of experience, not the recollection of a past event. A contemporary definition of mindfulness offered by Kabat-Zinn, states that mindfulness is the awareness that emerges through, “paying attention on purpose, in the present moment, and non-judgmentally, to the unfolding of experience moment to moment.” Similar descriptions are offered by other leaders in the field, including “mindfulness is the nonjudgmental observation of the ongoing stream of internal and external stimuli as they arise” and “a receptive attention to and awareness of present events and experience.” Notably, two concepts pervade these descriptions of mindfulness: (1) holding one’s attention in the present moment and (2) maintaining an attitude of acceptance, openness, and nonjudgment. The validity of this two-component model has been debated; however, it still remains a useful, widely accepted definition.
Mindfulness meditation (process) is a mental technique that is used to strengthen the capacity to establish and sustain mindful awareness (outcome). The practice of mindful meditation cultivates attentional focus and stability by directing the mind to remain connected to the present moment experience. Attention is usually sustained by concentrating on the breath. Participants are instructed to follow the flowing cycle of breathing with their full attention. Depending on the exercise, the focus of attention can vary and may include sensations in the body during rest or movement, a sound, or a visual focus, such as a candle flame or an image. Although the object of focus varies, in all instances, the goal of the practice is to train attention to remain fully engaged with the experience and remain in the present moment. Although this may seem simple, after attempting to keep attention focused for only a few moments, it is natural for novices to relate difficulty in maintaining focus on the present moment. Without training, attention drifts and becomes lost in memories of the past and thoughts of the future. With practice over time, remaining in the present becomes easier and is more likely to occur spontaneously. Meditation is simply a tool to assist in the acquisition of an awareness, which is broad, balanced, present focused, and behaviorally neutral.
Health benefits linked to mindfulness practice
A relatively wide collection of studies, of varying quality, in healthy people have linked mindfulness training to improvements in stress, anxiety, and depressed mood. Mindfulness is also effective at decreasing stress and promoting positive mood states in patients with a variety of chronic health conditions. Studies examining the effects of mindfulness training on traditional Western medicine outcomes, including morbidity and mortality, are beginning to emerge. Data from the field of psychiatry and mental health show that mindfulness interventions can be efficacious in the treatment of mood disorders. Furthermore, accumulating data support the notion that mindfulness meditation may ameliorate physiologic changes that accompany chronic mental and emotional stress, including improved cortisol secretion profiles and beneficial anatomic changes in the brain. Although these early findings are encouraging, additional work examining psychological and physiologic changes that occur during and after mindfulness meditation training are clearly necessary.
Health benefits linked to mindfulness practice
A relatively wide collection of studies, of varying quality, in healthy people have linked mindfulness training to improvements in stress, anxiety, and depressed mood. Mindfulness is also effective at decreasing stress and promoting positive mood states in patients with a variety of chronic health conditions. Studies examining the effects of mindfulness training on traditional Western medicine outcomes, including morbidity and mortality, are beginning to emerge. Data from the field of psychiatry and mental health show that mindfulness interventions can be efficacious in the treatment of mood disorders. Furthermore, accumulating data support the notion that mindfulness meditation may ameliorate physiologic changes that accompany chronic mental and emotional stress, including improved cortisol secretion profiles and beneficial anatomic changes in the brain. Although these early findings are encouraging, additional work examining psychological and physiologic changes that occur during and after mindfulness meditation training are clearly necessary.
Proposed mechanisms of action
Given the significant salutary effects of mindfulness training, the question remains, “what mechanisms are mediating these outcomes?” The mechanisms through which mindfulness decreases stress and increases well being are not well understood; however, a variety of proposed mechanisms of action abound in the literature. Several of the more prominent theories will be briefly reviewed. One popular hypothesis is that the cultivation of mindfulness facilitates a fundamental shift in perspective, termed reperceiving. Similar to decentering, reperceiving refers to observing one’s thoughts and feelings as temporary emotion-neutral events occurring in the mind, which do not require judgment. Shapiro theorized that reperceiving leads to greater clarity, objectivity, and equanimity and facilitates improved self-regulation, values clarification, and cognitive and emotional flexibility. However, empiric testing of this theory suggests that reperceiving and mindfulness are in fact overlapping constructs, and there is little support that reperceiving alone mediates improvements in psychological outcome variables. Others speculate that it is the development of mindful awareness that mediates improved psychological outcomes. In a group of novices, there was a positive relationship between the time spent practicing meditation and (1) the tendency to be mindful in daily life and (2) psychological improvements. Increased mindfulness in turn mediated the relationship between the time spent meditating and reductions in stress and improvements in psychological functioning. Additional work supporting this concept showed that long-term meditation practice is associated with being able to describe one’s internal experiences with words and being nonjudgemental and nonreactive toward them. Furthermore, these key constructs of mindfulness were found to mediate the relationship between meditation experience (measured in months) and well being in experienced meditators. These findings support the notion that mindfulness is cultivated through meditation and may mediate the relationship between meditation practice and improved mental health.
Experimentally, changes in the ability to direct and manage attention have been demonstrated only after 5 days of mindfulness meditation training as well as after longer periods of training. There are several proposed therapeutic benefits of maintaining a present-focused attention that is nonjudgemental and nonreactive. Self-focused attention, in the form of rumination, is linked to a variety of psychological maladies and poor outcomes. Rumination is the mental propensity to repetitively think about situations, thoughts, feelings, or emotions, which are typically of a negative nature. It has been theorized that the self-focused nature of the rumination is not harmful, rather it is how one processes these thoughts that predicts maladaptive outcomes. Sustaining a mindful self-focus that encourages a nonjudgmental nonreactive awareness of the present moment, even in people prone to rumination, promotes a mode of self-thought processing that is more adaptive. Additional benefits of self-focused attention have been theorized, including increased mental flexibility, improved self-regulation, decreased emotional reactivity, and reduced avoidance. For a more in-depth consideration of these issues, readers are directed to Baer’s thoughtful review.
Common methods used to teach mindfulness
In this section, the authors briefly reviews the most common mindfulness approaches used by patients. The intent is to enable the practicing rheumatologist to make more informed recommendations to patients interested in incorporating mindfulness into their treatment plans. The completely secular nature of these approaches accommodates a wide audience. These interventions follow in the footsteps of earlier psychological approaches, including behavioral therapy and cognitive behavioral therapy (CBT). In stark contrast to CBT, in which the emphasis is on the use of cognitive restructuring of beliefs that mediate negative effect, the so-called third wave therapies promote the creation of a constructive relationship with disturbing emotions, which ultimately promotes acceptance.
Mindfulness-Based Stress Reduction
Likely the most well-known and popular program designed to train participants in mindfulness, the Mindfulness-Based Stress Reduction (MBSR) program was developed in the 1970s by Jon Kabat-Zinn at the University of Massachusetts. Initially developed as a behavioral intervention for patients with chronic pain and stress-related conditions, the MBSR program has expanded globally and can now be found in a variety of health care and community settings, including more than 400 hospital and medical schools in the United States. MBSR is a standardized program conducted as an 8-week class with weekly sessions typically lasting for 2.5 to 3 hours. During the training, participants practice (1) sitting meditation using the breath as an anchor, (2) contemplative walking, (3) mindful movement through the use of gentle hatha-type yoga postures, and (4) the body scan in which attention control is practiced by systematically focusing on the sensations in various parts of the body. Near the end of the 8-week training program, application of mindful awareness to daily activities, often referred to as informal mindfulness practice, is encouraged. Mindfulness activities are practiced both in class and as homework. Audio recordings are provided to support home practice. Participants are expected to complete approximately 45 minutes of formal mindfulness practice at least 6 days per week during the 8-week period. During an all-day retreat near the end of the training, participants remain in silence and have the opportunity to practice their newly acquired mindfulness skills during a sustained and uninterrupted period of time. An essential component of the weekly classes includes discussion about the experiences that occur during the practice of mindfulness both in and out of the classroom. The effect of teacher experience, frequency of weekly session attendance, duration of home practice, and frequency of home practice likely affects the degree of symptomatic improvement reported by participants, but results have been mixed. Patients can be referred to the Center for Mindfulness in Medicine, Healthcare, and Society at the University of Massachusetts for a listing of teachers who have completed standardized MBSR training ( http://www.umassmed.edu/cfm/stress/index.aspx ).
Mindfulness-Based Cognitive Therapy
Largely based on the concepts of mindfulness derived from MBSR, the focus of mindfulness-based cognitive therapy (MBCT) is on the treatment of depression rather than stress. Specifically designed for use in the prevention of depression relapse, the theoretical foundation of MBCT rests on research showing that the individuals most vulnerable to depression relapse are those who have mood-related reactivation of negative thinking patterns and inappropriate responses to negative thoughts and emotions. A combination of mindfulness training and cognitive therapy are used to cultivate a decentered approach to internal experience. Unlike traditional CBT exercises that attempt to change thoughts, in MBCT, the focus is on acceptance rather than change. Because this is a relatively new intervention, at present, there is no network of qualified providers. Creators of the intervention recommend using their book The Mindful Way Through Depression and/or working with a teacher or therapist who incorporates MBSR or other mindfulness practices into their work for those interested in this approach.
Dialectical Behavior Therapy
Originally developed through insight gained while working with patients who had suicidal ideation and borderline personality disorder, dialectical behavior therapy (DBT) is a modified CBT program, drawing from principals in behavioral science, dialectical philosophy, and Zen meditation practice. Therapists and clients work to balance change with acceptance. Traditional CBT helps the participant change inappropriate behaviors, thoughts, and emotions, whereas mindfulness training helps to facilitate acceptance and change. Participants are asked to make a 1-year commitment to the therapy. There are several components to DBT, including individual psychotherapy, group skills training, and telephone consultations between sessions. Readers are referred to the DBT training manual for a more in-depth review.
Clinical applications of mindfulness specific to the practicing rheumatologist
Although there is a growing body of evidence supporting the use of mindfulness training as an adjunct to conventional therapy for a variety of medical and psychological conditions, studies specifically examining this intervention in patients with rheumatologic conditions are limited. The following discussion highlights several clinical concerns that are frequently encountered by the practicing rheumatologist for which mindfulness training may be beneficial.
Chronic Pain
Collectively, rheumatologic diseases have been classified to be the most prominent cause of chronic pain in the developed world. Chronic pain is often associated with a multitude of challenges not only for the patient but also for the cadre of family, friends, and health care providers caring for them. Uncontrolled chronic pain can lead to poorer quality of life, disability, and psychosocial problems in patients with rheumatologic conditions. Although most health care providers are aware of the role the mind-body connection has in partially mediating chronic pain symptoms, many feel underprepared and/or unqualified to make recommendations for therapeutic interventions intended to target this important symptom-modifying axis. Although a wide range of mind-body therapies have been shown to be effective for the treatment of chronic pain and the inclusion of these interventions into comprehensive treatment plans has been recommended by consensus panels, only 20% of patients with chronic pain report the use of such adjunctive therapies.
CBT is a widely used and accepted mind-body approach, which uses cognitive restructuring to modify maladaptive thoughts and behaviors related to pain; however, the overall reported effect sizes for CBT are generally small in patients with chronic pain. Eliminating maladaptive thoughts may not be a realistic strategy in patients with rheumatologic conditions who suffer from chronic pain because most face continual daily reminders of their chronic medical problems. A more realistic approach may be the promotion of acceptance. Mindfulness-based approaches to pain management encourage participants to alter their relationships and reflexive behavioral responses to these maladaptive thoughts through nonjudgmental acceptance. Pain acceptance has been described as “a willingness to experience continuing pain without needing to reduce, avoid, or otherwise change it.” Experienced mindfulness practitioners demonstrate reduced anticipation and negative appraisal of pain under experimental conditions. Higher degrees of mindfulness in patients with chronic pain are related to lower self-reported pain, emotional distress, disability, and use of pain medication. Lower degrees of mindfulness are related to greater distorted thinking about pain, specifically pain catastrophizing, characterized by rumination about pain, feelings of hopelessness, and exaggeration of pain-related symptoms.
Training in mindfulness, particularly through the use of MBSR, has been shown to be effective for the treatment of chronic pain originating from a variety of causes, although not all studies have shown positive results related to pain reduction. A recent uncontrolled observational study suggests that participants enrolled in a community-based MBSR training program who reported chronic pain exhibited improvements in pain scores after completion of the course. Participants with chronic neck/back pain and arthritis were most likely to have significant improvements in pain after the MBSR training, whereas those with fibromyalgia and chronic headache did not have significant improvement in self-reported pain, suggesting a potential role in certain patients with rheumatologic disease.
Some of the highest quality evaluations of mindfulness interventions in chronic pain have been in patients with rheumatoid arthritis (RA), osteoarthritis, and fibromyalgia. After 8 weeks of training, self-reported pain significantly improved in 144 participants with RA regardless of intervention (CBT vs mindfulness training vs disease education), although greater effects were seen with CBT and education compared with mindfulness training. Mindfulness training did not positively affect patients’ perceived control over their pain, whereas CBT and education showed beneficial effects. The relative value of the treatments in patients with RA varied based on depression history. Those with a history of two or more episodes of depression who completed mindfulness training were more likely to show improvements in pain-coping self-efficacy, pain catastrophizing, and physician-assessed joint tenderness and joint swelling. The data supporting the use of mindfulness in patients with pain due to osteoarthritis are less compelling. In two different heterogeneous groups of older adults with chronic low-back pain, in which a large proportion of the participants attributed the cause of their pain to osteoarthritis, the report of pain by those who had undergone MBSR training was not significantly different from those in the wait-list control or educational control conditions. Chronic pain self-efficacy and disability scores improved in both the mindfulness and educational control groups. In a randomized controlled trial of a mindfulness-based intervention for women with fibromyalgia, significant improvements in pain were noted for those in the mindfulness group compared with the wait-list control condition. Similar findings were noted in 58 women with fibromyalgia participating in a quasi-randomized trial. Self-reported pain scores, pain perception, and the ability to cope with pain improved after an 8-week MBSR training compared with the support control group immediately after the intervention. Improvements were maintained over a 3-year follow-up time period. In contrast, Astin and colleagues showed similar improvements in pain in patients with fibromyalgia completing a mindfulness-based movement class compared with those in an educational control group. Although no conclusive recommendations can be made regarding the use of mindfulness interventions as an adjunctive means to control pain in patients with rheumatologic conditions, these initial findings suggest that mindfulness training does not cause harm.
Mental Health
The benefits of mindfulness training, particularly on depression and anxiety, have been repeatedly shown in a variety of populations, including in those with chronic medical conditions. A more mindful awareness might buffer against the harmful influence of perceived stress on psychological well being, particularly in people who are susceptible to poor psychological functioning. Similar to other populations, improvements in mood have been shown to occur after mindfulness training in patients with rheumatologic conditions. In patients with RA, immediately after MBSR training, there were no notable improvements in psychological distress or depressive affect; however, 4 months after the intervention, improvements in psychological distress, but not depression, were noted. In a second study of patients with rheumatoid arthritis, positive affect improved for both those receiving CBT and mindfulness, but the greatest improvements in both negative and positive affect were seen in those with a history of two or more episodes of depression, suggesting that those with recurrent depression were most responsive to the mindfulness intervention. Modest improvements in psychological distress have been shown after completion of mindfulness training in patients with fibromyalgia compared with controls. In a group of 91 women with fibromyalgia, Sephton and colleagues showed specific improvements in depression in those who had mindfulness training compared to controls. Furthermore, mindfulness training in women with fibromyalgia has been shown to improve patients’ sense of optimism and control over their life, which was related to lower depressive symptoms. Mindfulness combined with a movement intervention was shown to be as efficacious as education and support in improving symptoms of depression in patients with fibromyalgia. Observational data evaluating changes in depression and anxiety before and after MBSR training suggest that patients with fibromyalgia had small nonsignificant changes in psychological distress, whereas patients with arthritis had the largest improvements in psychological distress when compared with patients with other types of chronic pain. Based on the data, a significant amount of work still needs to be done to evaluate the effect of mindfulness training on mental health in patients with rheumatologic conditions. MBCT, with its proven track record for depression relapse prevention, is a particularly appealing mindfulness approach for patients with rheumatologic disease given the high rates of clinically significant depression in these patients. MBCT has yet to be formally evaluated in a cohort with a specific rheumatologic disease. One word of caution to health care providers who may want to suggest mindfulness training as an adjunctive approach to a multidisciplinary care plan. Mindfulness interventions may not be appropriate for people who are actively suffering from acute clinical depression. It has been theorized that the intensity of negative thoughts, poor concentration, and restlessness, which often accompany an episode of acute depression, might make meaningful participation in mindfulness exercises difficult and uncomfortable. Developing the necessary attentional control skills may be challenging during a major depressive episode, although this long-held belief has recently been questioned.
Immune Function
Accumulating data suggest that training in mindfulness meditation may also support improved physiologic functioning. Although the exact mechanisms remain largely unknown, it is hypothesized that mindfulness meditation may exert its favorable effects through a variety of pathways, including decreased sympathetic activation and improved neuroendocrine function, two pathways intimately coupled to immune function. In a landmark study, Davidson and colleagues demonstrated that training in mindfulness meditation enhanced antibody production after influenza vaccination in healthy adults. Extending this work to conditions in which immune dysfunction plays an important role, including cancer and human immunodeficiency virus (HIV) infection, has also yielded promising results. In patients with breast and prostate cancer, a shift from a proinflammatory response, to a more antiinflammatory response, after MBSR participation has been observed. This shift from a proinflammatory state was maintained at the 1-year follow-up in this cohort of patients with breast and prostate cancer as evidenced by a continued decrease in Th1 cytokine production. In HIV-positive individuals, notable increases in natural killer cell activity from baseline were noted after MBSR training. In women with early-stage breast cancer not undergoing chemotherapy, those who underwent MBSR training displayed a restoration of natural killer cell activity and improvement in cytokine profiles, whereas those in the control group continued to show immune function abnormalities. The investigators speculate that this favorable shift in immune function may be related to lower cortisol secretion in the MBSR group compared with the non-MBSR group. The relationship between improved psychological well being and improved immune function is less clear, with some studies showing a positive relationship between the two and others showing no association. Although these findings are interesting, they are also preliminary and require confirmation in larger populations. To date, little work has been done on the impact of mindfulness training on immune function in patients with rheumatologic conditions. Two studies have evaluated the impact of mindfulness training on immune function in patients with RA and have shown no improvement in the Disease Activity Score (DAS), which includes a measure of the erythrocyte sedimentation rate, or IL-6 concentrations. While the apparent beneficial effects of mindfulness training on certain immune function parameters are interesting, they are also preliminary, and require confirmation in larger populations.
Related posts:
Perspectives About Complementary and Alternative Medicine in Rheumatology
Effectiveness of CAM Therapy: Understanding the Evidence
The State of Research on Complementary and Alternative Medicine in Pediatric Rheumatology
Fish Oil in Rheumatic Diseases
Herbal Medicine in the Treatment of Rheumatic Diseases
Glucosamine and Chondroitin Sulfate
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