Applying Mindfulness-Based Cognitive Therapy to Treatment

this program is a presentation of University of California television your support makes uv's programming possible contribute online at uv. tv/ support check out our YouTube original Channel uctv Prime at youtube.com/ uctv Prime subscribe today to get new programs every week [Music] I'd like to thank you all for coming out on a rainy night so you're all brave souls to make it here so congratulations I'm uh a professor here and director of the UCSF depression Center and also the principal investigator of uh several studies we're going to be talking a bit about but particularly the practicing alternatives to heal depression study we call for short the path the study and uh those are that and another study also involving uh depression and meditation and uh neuroimaging are both actively recruiting and uh as you learn more about it if you're interested we have some uh information packets and if you have questions uh feel free to call the numbers there and uh we have one of our research assistants Natalie who's here uh uh so uh you may grab pigeon hole her at the end as well so thanks again for coming uh I'm going to be discussing uh mindfulness in general terms and also how we apply it for uh in specific relationship to treating depression and uh there's been a sort of uh Resurgence of interest in using mindfulness meditation as an approach to help people with depression uh over the past uh five to 10 years and I think it's leading to some very uh interesting applications and potentially uh very helpful for a great number of people uh how many of of you have a mindfulness a practice of your own maybe if you could just show okay so a fair number uh mindfulness basically uh there's different definitions of it uh probably the most commonly used one is the one by John kabid Zin meaning paying attention in a particular way on purpose in the present moment and non-judgmentally so mindfulness means focusing the attention in this present moment and letting go of the future letting go of the past and just coming to be aware of whatever is present right now this is another definition of it it's nonevaluative awareness of one's inner and outer environment non-evaluative just like non-judgmental is oh I notice I have uh pain uh from my arm resting against uh the side of the chair or something like that it's noticing it and not saying this is good or bad but just being aware and observing it so mindfulness is bringing that non-judgmental attention to bear on something with intention mindfulness has been used for a a wide variety of different conditions uh John Kev Zen really brought it into public Consciousness with his uh stress reduction efforts mindfulness-based stress reduction at the University of Massachusetts about 25 to 30 years ago but it's been applied for other conditions pain psoriasis Eating Disorders fibromyalgia pain cancer uh the osher center here is using it for uh parenting teaching people how to be more mindful in their parenting or even as an alternative to coping with labor pains and then on the psychiatric side of things it's been used for treating anxiety depression people with borderline personality disorder who have difficulty regulating emotions for addictions and even for bipolar disorder some of these are more experimental they haven't been widely developed but they're all moving forward and uh the most uh developed area is the one I'm going to focus on tonight and I'm going to give you some examples of it and that is mindfulness-based cognitive therapy because that's the main intervention of our practicing alternatives to heal uh sorry about that I guess I'm free of viruses hopefully uh the uh the mindfulness based cognitive therapy is our our primary intervention for teaching people mindfulness approaches to depression over an eight-week course uh just to say a little bit about depression you know people used to sort of try to decide what what kind of depression a person had is it this is it this or maybe that or somewhere on the depression Highway what we know now is it uh it doesn't really matter uh so much how the person got there if they have depressive symptoms sympoms which are these if they have these they deserve to be treated so you it's inappropriate to say well of course this person is depressed because they got uh just received a cancer diagnosis or because they had a breakup or this or that if somebody has these symptoms lasting for two weeks or longer that's significant evidence of depression and they deserve to be treated otherwise it'd be like and somebody uh comes into the emergency room after being having a major artery severed by uh in a knife fight and saying well of course they're in choc but we're not going to treat them uh if they have depressive symptoms they need to be treated and these are the Hallmarks of what we call DSM 4 if you have five or more of these symptoms for two weeks or longer essentially you're talking about somebody having uh clinical depression or what we call major depression which is same uh same terminology so what do we do with our program mindfulness-based cognitive therapy is uh a mixture of some cognitive therapy aspects and many of you are probably familiar with in one way or another with cognitive behavior therapy or cognitive therapy and it mixes some elements from that with a very strong dose of mindfulness meditation and it's primarily mindfulness meditation that is the heart of the program and it's eight weekly sessions and they're two to two and a quarter hours in length and people on the other hand on the other six days of the week when they're not coming in for the class do a daily meditation practice at home the they're running groups of six to 14 people and it consists of different types of mindfulness exercises things like uh formal practice uh of like a sitting meditation paying attention to the breath a body scan paying attention to different Sensations in the body uh mindful stretching or ha Hatha Yoga and then a variety of other mindfulness uh approaches where you attend to different things and then there are informal practices where people become more familiar with say eating mindfully or doing everyday activities but in a more mindful way and we also teach very portable uh technique such as a three minute breathing space So at the end of this the person has gotten familiar with a variety of techniques and not everybody is going to be the same in what they walk away with some people may like the body scan and some people may hate it some people may like this element or this element and that's perfectly fine we know that uh it varies from person to person we're trying to expose them to a uh popere of different uh options so that by the time they finish they have a practice that they can walk away with and uh start applying for the rest of their life this is not a technique where you take the course and you're done with it what we're doing is offer the course and at the end of eight weeks the person is prepared to go on with their life incorporating a practice in their everyday life here I am on the beach doing doing a formal breath practice but here's another one this is a young fellow showing the portability of using mindfulness uh in a variety of settings so let's but let's to give you a little better flavor for this I thought uh we would do an exercise so we all at least have a little Common Ground here for for mindfulness uh so if if you're game for this if you'll uh sit in your seat and get in a comfortable uh position with your both feet planted on the floor and if you feel uh like it you can close your eyes if you rather you can just gaze softly at the seat in front of you and what I'd like you to do is just focus in on the breath moving in and out through your nostrils just paying attention to the breath focusing the attention on the breath moving in and out if the mind wanders as you're doing this gently and kindly bring the attention back to the breath now as you continue to focus on the breath I'd like you to add a second element to this and that is begin counting each inspiration and start counting it from zero and count up to 10 breaths if your mind wanders as Minds tend to do on the way up to 10 just go back down to zero and start counting again if you get up to 10 go back down to zero and start doing it again and whenever you're ready you can open your eyes and bring the attention back to the room okay would would anybody like to say uh what that experience was like for you what you observed you're breathing slowed okay thank you anybody else relaxing falling asleep heighten awareness so uh then did you go back to zero and start up again excellent very good anybody uh did anybody notice their mind wandering was that surprising have you noticed how your mind tends to wander sometimes until you get into a state of Stillness you you don't really pay attention to it and that's one of the things that uh we interested in in our work in applying mindfulness is that people uh often walk around on automatic pilot uh without paying attention to because they're so preoccupied by things that are popping into their mind uh Sylvia boury talks about our minds as being uh Popcorn Poppers of thoughts they just pop up and if somebody has trouble with anxiety or depression a lot of those thoughts that pop up are depressogenic or anxiogenic that they produce depression so that they the thoughts may be of a pending catastrophe or of a past catastrophe because anxiety tends to be in many ways future oriented and depression future oriented in the sense of there's some disaster that's going to happen whereas depression tends to be past oriented because the person feels as if it uh some disaster has already happened to them so with mindfulness you're helping the person focus on the present moment and give uh a release from future or past focusing and just focus on the present moment but I think as you could see from this exercise it's very common for these thoughts to be popping into our mind unbidden it's completely normal and no matter whether you're the most advanced meditator or not this is what happens many people are under the mistaken uh conception that that meditation means you focus the attention and you lack your attention onto something and then it doesn't change but actually that's incorrect what happens with meditation is you focus your attention and then your mind wanders and the meditation is noticing ah my mind just wandered I wonder what I'm going to have for dinner tonight or I had this interaction with this person before that irritated me or uh what do I have to do tomorrow or whatever the case may be and our minds do it all the time or I feel this sensation that's bothering me or I feel an itch uh so as those thoughts occur in depression what happens is these are often biased towards the negative so the person has thoughts like uh who uh this is going to be a disaster or in in this instance maybe everybody in the audience is going to fall asleep on me or uh something like that uh so uh what we're uh helping people to get the skill of becoming focused on their present moment and being able to let go of a thought and bring the attention back and that's uh uh the heart of what we're talking about with mindfulness now I'm going to say a bit about these studies uh the one the path D study is we're taking people who have treatment resistant depression and by that I people who have failed to recover fully with two or more anti-depressant trials and unfortunately this is not uncommon if somebody has uh major depression and you treat them with an anti-depressant at full doses only onethird of them will fully recover with that initial treatment you have to give a second anti-depressant trial to get 50% of them recovered fully so that means after two anti-depressant trials only 50% are recovered and our concern was trying to help get these other people fully recovered so we are studying individuals who have had two or more anti-depressant trials and want to try this approach to getting fully recovered and we're taking them splitting them into two groups one gets mindfulness-based cognitive therapy plus their medication management or a health enhancement program which consists of uh physical activity physical exercise music therapy and nutritional education by a dietitian so they both get eight weeks of classes but they're completely different one is mindfulness meditation focused and the other is Health enhancement focused and we're going to see if there's a difference in outcomes and what that difference looks like in seeing how if people can recover more effectively using uh one of these approaches these are people just uh this is from our current research uh we've actually enrolled about a hundred people so far but if you take a look at this the episode length of people is 91 months and they've suffered with depression for almost 30 years and this this is essentially similar uh division uh in both of these this is one one is getting they're blinded so we don't know one is getting mbct and one is getting the health enhancement that's why it's a condition b or a because they're blinded till the end of the trial but they're both as you see when people suffer from depression it tends to be a recurrent disease so it's very important to try to get them to fully recover that gives them the best chance of not having depression again in the future we're adding to this and I'm going to show you towards in the second half of today's talk some of the interesting I think quite exciting findings about the actual brain changes that take place with depression and with mindfulness meditation to some extent uh because we've added a second component to the study where we're getting fmri uh before and after mindfulness based cognitive therapy and after Health enhancement so we're looking at their brain function before and after and fmri is uh similar to an MRI but if you take an MRI of a person if you take an MRI and just look at it if I had one up here you couldn't tell whether it was on a living or dead individual it's a it's a structural image basically the fmri stands for functional that actually shows how the brain is functioning second to Second so it shows which areas of the brain are lighting up or not lighting up in response to stimuli so it's it's a much more uh Dynamic picture of how the brain is actually functioning we're we're doing a second study for individuals who are uh who are not on any medication or in any Psychotherapy this is the depression meditation and neuroimaging study and it's mbct the mindfulness based cognitive therapy as a standalone treatment and we're again looking at people before and after with fmri and comparing them to how much these people and I'll show you some of the uh images from this area how much these people return to look like healthy control rols so how much their brain abnormalities that are present before treatment change with mindfulness-based cognitive therapy uh let's talk a little bit how does mindfulness actually work in helping people with depression and I think i' I've alluded to some of the things already here uh one is the focus on the here and now in some ways depression and anxiety can be considered uh I think as uh time based diseases where the person is focused so much on the future and disasters or focused on the past that they're not in the present moment I mean it's kind of like uh I think we've all had the experience where you go to a a lecture perhaps or a concert or whatever the case may be and then you you forget about well did I you know uh do something I should have done uh did I mail that letter or did I do uh you know lock that door or something something that sort of stays on our mind keeping us out of the present moment and being able to enjoy the present activity that we're attending to so mindfulness helps teach individuals to be able to let go of those orientations and come to awareness about what's happening right in this moment in fact mindfulness-based cognitive therapy was originally called selective attention training because it trains people to focus very precisely and this has important ramifications both psychologically and also in terms of some of the brain effects that we'll take a look at in a little bit mindfulness also helps people to stop ruminating uh ruminating is uh a a condition where one continues to think about a situation and goes over and over in their mind you can actually ruminate about ruminating I mean when I started reading about ruminating I mean you know you could really go nuts I mean there's you know there's ruminating there's pondering there's brooding you know there's uh all kinds of things that you can get into uh brooding is the bad one but it turns out teaching people mindfulness skills in eight weeks decreases rumination rumination is a driver of depression so many people with depression ruminate for example uh a young woman who had a breakup in a relationship keeps on ruminating about what did I do wrong what should I have said what did you know why did why did this happen uh why did he leave me and keeps on going over and over again that's not problem solving problem solving leads to a solution ruminating leads to worse depression and that's one way of testing what it is you're doing if you ask somebody who's ruminating what do you think you're doing what what is happening when you're ruminating well they think I'm I'm trying to prevent it from happening again or I'm trying to figure out what went wrong well how do you feel afterwards you could just do a brief study ruminate for a short period of time and see how you feel usually they feel worse and so you're helping the person to disengage from rumination by saying okay what we do in mindfulness is is something like this okay focus on the breath and then notice ah I just had this thought about that breakup I just had that thought but I can let that thought go and bring the attention back so it's really radically different than other kinds of psychotherapy which get into uh trying to explore and and uh look at things in a in a more uh traditional psychotherapeutic way this doesn't do that this is focused more on attention as you'll see I'm going to show you the differences what mindfulness teaches is basically increased decentering we call it where the person starts to get some distance from thoughts and feelings so when they have uh something going on like I have the thought uh uh something bad is going happen the typically the person with a depressive kind of state or an anxious State tends to believe that thought they say oh this disaster is actually going to happen now if any of us believe that a disaster is going to happen why wouldn't you get anxious or depressed about it but the trick is that thought is not a fact it's just one of those popcorn thoughts that occurred in your mind and in depression for example you tend to latch onto it and believe it as if it's true and in mindfulness you learn to be able to say ah there's a thought but I can let it go I don't have to hang on to it and believe it and it also helps mindfulness also helps in helping the individual become uh more compassionate both to the others but very importantly to themselves so they become gentler with themselves how does this happen well some of it is that you c a little glimpse of it you know when we went through that exercise and I said if you if or when you notice your mind wandering you just notice that and you don't say gosh darn it what the heck is wrong with you you know you don't come down on yourself you say ah my mind wander and I bring the attention back so you're Kinder and gentler and can forgive yourself for things uh through this technique so it's basically teaching people how to see thoughts and feelings as mental events and not as facts here's another example of this let's let's do this as a group so if you're uh picture this you're walking down the street and you it's it's a nice day not a rainy one and you see somebody you know on the other side of the street and you wave to them and they don't wave back they just keep on walking what do you think or feel in that situation anybody hurt foolish foolish they're busy didn't they didn't have their glasses on they didn't see they didn't see me okay what's their what's their problem so any other feelings those are some good thoughts they suck okay good what was that shund yeah okay so there's a variety of things and we do this actually in the group and you see I mean we just had 10 people give different ideas or feelings about the situation nobody actually knows what the fact was right I didn't say whether this guy or this other person saw you or didn't see you or didn't have glasses or not we all come up with our own ideas about it we don't actually know but if you attach to a certain thing say well I know this person rejected me then it generates certain feelings but there when we did this in one group for example a fellow said yeah that happened to me I never spoke to that person again you know because I know he was shunning me you know and uh and so on by the end of eight weeks you saying boy that was ridiculous I didn't know anything about what was going on and it could have been any of these other possibilities so instead of hanging on to this thought like oh this is a a fact it's just a thought it's one of these popcorn thoughts that occur in our mind and one thing we I've seen repeatedly and this might be I don't know what your take is on this but uh our minds are not always our best friends you know does that seem odd to you you know in many ways uh our minds are are like bad friends uh you know you don't want to go there without a friend at your side it but our minds especially if you're prone towards depression or anxiety tends to have these popcorn thoughts coming up that are very negative so they come up and say yeah look uh you know this just happened uh you know this bad thing just happened and it's because of your weakness or failure or whatever it is and these uh uh these thoughts that come up from our mind are really as if it's a bad friend not not even necessarily a friend uh somebody I I was doing this this was driven home to me when I was uh actually meditating one time and I my mind got distracted and I was thinking about this interaction at work with somebody and I was kind of getting agitated about it and trying to bring my mind back and and this was going on and then I realized this these thoughts I were having it sounded like it was actually it was it sounded like somebody I knew and didn't like and I said what am I listening to this for you know it's like if somebody you didn't like says you're ugly uh you know or something else you you take it much differently than if a friend of yours did that we often don't think of our mind as not being our friend but in many instan is our mind isn't our friend and that I think deserves to be uh paid attention to in these uh states of anxiety and depression and this is sometimes we use the term decentering or what is called metacognition because it's beyond uh cognitive therapy in a sense we're not paying attention to the content of thoughts we're paying attention to the thought processes and that's really how this differs from other therapies and if if you can recognize this it's very liberating because you realize that these these thoughts are really not facts they're just something that's coming up and if you can let them go it's so much Freer for you it allows you to be in a position to respond skillfully and not just react as uh uh friend of mine Paul emman described it mindfulness tends to give you more of a gap between the spark and the flame so you have an opportunity instead of saying oh I'm angry at this guy for not waving back and this or that or I'm depressed about this saying well wait there's some other what are some other possibilities that might have gone on like the 10 we just heard that there's a whole variety of things so this is how mindfulness-based cognitive therapy differs from traditional CBT cognitive behavior therapy in cognitive behavior therapy the person might say something and incidentally like in depression uh the the main negative cognitions have all been cataloged we give people in our class a list of the top 30 it's like Letterman's top 30 and then ask people check off which ones apply to them because it it's different for each person but they're all really known like I'm a rotten person I feel like a failure I am a failure I'll never be successful blah blah blah blah blah and so the person says I'm a bad person well in mindfulness based well in let's go with this for a moment they say I'm a bad person so in cognitive therapy what happens is you attend to that and you try to help the person look at it a little bit differently you may have them challenge that you say well I'm a bad person well what's the evidence for that stew that you're a bad person uh well I you know stepped on an ant before I came in here uh and or I I didn't I I pushed clothes on the elevator when somebody was trying uh was running up uh you know well is there any evidence you're a good person well I did help this person cross the street or this that so so a more balanced thought would be I'm bad in many ways elevator wise but in some ways in some ways I'm an okay person so you're helping the person answer back and change the thought content that's what cognitive behavior therapy does in mindfulness when the person says I'm a bad person what you do is this say you're having the thought you're a bad person now we've decentered I'm having the thought I'm a bad person now what do you want to do with that we're not saying let's change that because one of the challenges in doing uh cognitive therapy and I did cognitive therapy for a long time and I ran cognitive therapy groups you get somebody who's been depressed for a long time and remember those figures from earlier people with depression can be depressed for a long time if you say what's the evidence that you're not a bad person or that you're a bad person that say you want evidence I got a book social basket full of evidence for you because they've been depressed for so many years that they've been raking in all this negative uh evidence so this doesn't get into that sometimes in those groups I would feel like I was an attorney you know like I was trying to prove a case or something with him and I was you know uh saying that they're not such a bad person or something because they were rigorously hanging on to it in this uh you don't do that you say okay I'm having the thought I'm a bad person and what do you want to do with that thought and you're focusing on the thought process and say well if you like you can let that go I'm not going to challenge the thought and try to prove it one way or another this is a different approach this is okay you have the thought but you now are in a position to say let that go just like you let go of other thoughts and brought your attention back to something it also identifies those thoughts as not a fact like I am I'm having the thought I'm a bad person that's not a fact that's a just a thought and allows the person to have a different way of being in the world whereas this CBT is more focused on looking at those negative things and trying to challenge those beliefs and come up with new ways and new thought content which is good for many people but sometimes it's quite challenging uh uh for people in doing cognitive therapy and this is a different approach so what do we do with mindfulness based cognitive therapy it was originally developed as a relapse prevention program to help people uh stay free of depression once they had fully recovered from an episode so the first study that was done in the year 2000 uh was looked at people half the people got mindfulness based cognitive therapy and half of them got treatment as usual and it showed that it basically many more people stayed free of depression if they had had the mindfulness training about twice as many so that was a very good sign particularly it was for people who had three or more episodes of depression for people who had just one or two episodes it wasn't there wasn't much difference but these are for people who had chronic recurrent depression another repeat of that study showed even somewhat better results in that more people stayed free of depression those were by The Originators of mindfulness-based cognitive therapy this was a study done uh and that was that that earlier study was in uh Canada and England this study was done in Belgium in 2ou 2010 and actually basically showed the same thing it was by people other than the originator so can other people get the same kind of results and this showed again the people with mindfulness training tended to stay in remission compared to people who relapsed down here this is a survival curb so many more people stayed free of depression now those were people getting treatment as usual so in some ways they were good preliminary studies but they weren't so powerful because the PE some people were getting uh mindfulness training and the eight weeks of group and the others weren't getting anything so you could say well it's not that surprising that that other the experimental group did so well this was a more uh demanding study this was done at uh exer university in England and it took people at high risk for depression they had multiple episodes of depression and uh as many of you may know one of sort of the gold standard is for people like that is to maintain them on anti-depressant medication if somebody's had three or more anti three or more depression episodes you would say well this person probably should be maintained on medicine rather than put on medicine and then taken off and put on taken off they probably should be uh stabilized on medication is a is the conventional uh wisdom uh and sort of like if somebody has high blood pressure you don't take them on and off you if they have it recurrently you would probably treat them on an ongoing basis so it took these people who were who had recovered from depression and then randomized them into two groups one got mindfulness-based cognitive therapy and were tapered off of their anti-depressant and the other one other group got maintained on a on an anti-depressant so it was a much more active comparison for mindfulness based cognitive therapy really essentially the gold standard treatment of yes yeah they were tapered off in the first three months it was a year-long study and they were tapered off in the first three months so if they were going to relapse there would be an uh opportunity for them to relapse during the study well I mean because if they taper them off at the end of the study you know it wouldn't would have been meaningless so uh they tried to get them off of it and there was a certain schedule that they used to do so and then they filed them up for one year how many people think mbct was better okay how many people think maintenance anti-depressants were better not many well you're both wrong they were equivalent they were equivalent so uh they were the same if you take people off the anti- depressant and taper them off essentially or if you kept them on maintenance they both showed the same uh rates of relapse the people who were uh however there was a significant difference in the people who had mindfulness training had less residual depression and improved quality of life so it was an interesting study the pharmaceutical makers didn't sponsor this one this is another study that's an interesting one it was a very unique powerful study which showed a basically uh that people who were were randomized to three groups after they achieved remission either they maintained uh anti-depressants or they got mbct training or they were given a placebo so it was a very unique and really exacting study and basically what it showed for people who were unstable remitters that means people who had ups and downs that mindfulness-based cognitive therapy or anti-depressant maintenance were much more effective than Placebo in preventing relapse but here's an interesting feature for people who are stable remitters and means people who got better with their initial treatment and didn't vary when we when they say stable remitters what they mean is this we use a a scale called The Hamilton most commonly in these studies so below this level is remission you want to have as few symptoms as possible so people who who remitted and were seven or lower that which is in remission and stayed there for the length of uh the treatment that they were receiving those people people were called stable versus the unstable remitters were people who were kind of bouncing up and down into remission the people who are stable remitters actually all three of the conditions had this equivalent effect in preventing relapse which was an interesting finding and again um goes against that conventional wisdom of saying that people had to be maintained on medication uh although uh this is the first study that had showed this effect and it was very unique finding uh let me say a little bit about treatment resistant depression that as we've said are the people who don't respond to don't remit with two or more anti-depressant trials and basically if you take people and follow them out over the course of the year you really end up with a very limited amount of people who have remitted 43% in this one study uh at the end of a year of treatment so it's a very challenging condition to treat and it's important for people to know this because that's why mindfulness based cognitive therapy was initially developed is we need to find better ways of preventing relapse it tends to be a relapsing illness and you have to give people tools for coping with the illness over the long term not just coping with it for an episode uh this is our study uh a pilot study we did here uh I won't say too much about it but again we had we compared 24 people who received mpct to 24 who received just medication and the actually the nbct group was somewhat more uh chronic and having had three or more episodes and this shows the results of the medication only people had only a mild decrease versus the decrease in depression and anxiety that the people receiving mindfulness-based cognitive therapy received and 30% remitted with mindfulness-based cognitive therapy whereas only 10% remitted with usual treatment again this is a severe population uh so there's been a number of studies actually around the world world uh this was uh in England and this was in Australia this is an interesting just sidelight uh This was done at the black dog clinic in Australia it's named after Winston Churchill because Churchill called his depression the black dog the black dog is back today uh say a little bit about self-compassion passion the it's basically accepting oneself again without the judgmental qualities so and uh it's it's different than self-esteem I mean it doesn't even a person who may not have so much self-esteem can still be compassionate towards them and doesn't have to be critical and judgmental and that's a big problem in depression uh you know you can call it by various terminology like harsh super ego or uh critical self or whatever but people with depression uh are very uh critical of themselves and mindfulness really teaches them a way to be uh Kinder towards themselves and less critical these are some comments taken from some uh patients who finish the group I'm gentler on myself I'm less critical I can talk talk back to myself more when those thoughts come up I can say Ah that's that person I didn't like now we'll talk some about the biological aspects of this um this was an intriguing study that was done with mindfulness-based stress reduction at the University of Wisconsin uh by Richie Davidson and John cabin Zin some years ago and basically it was an intervention where they took people uh and taught mindfulness based stress reduction is very similar to mindfulness-based cognitive therapy only it doesn't focus on anxiety and depression it focuses on stress reduction and coping with a whole variety of things from chronic pain to heart disease or cancer whatever the case may be it's kind of a a generic uh stress reduction approach and they took people at a corporation in uh mid Wisconsin and taught them mindfulness-based stress reduction and showed rather remarkably that at the end of eight weeks the people who had received the training compared to a weightless control had activation of this left frontal region which is associ iated with positive mood States detectable on EEG so eight weeks of training affected the brain and they also showed that there was an increased antibody response they gave them uh influenza vaccine and showed that the antibodies to influenza Rose significantly higher in the mindfulness group so suggesting there was some uh neuro humoral effects with uh from the mindfulness training so it was an intriguing study it was uh it it was sort of splashy in that it showed these dramatic effects after eight weeks however it was uh a little bit biased in the sense of they John caben if any of you have seen I it was kind of a charismatic figure flew in from Massachusetts each week to give the group the mindfulness-based training so one group got John cabat in flying in and the other group got nothing and they actually got a little worse you know because their friends were getting the good stuff but it was but it was an intriguing study and it highlighted uh something that I think is leads into probably one of the most important points to take away from tonight with and that is we now know there is significant abnormalities in the brain in people who are suffering depression from other psychiatric disorders as well but I'm going to focus on depression tonight because we now know a lot more specifically about the abnormalities that are taking place and in brief you can think of the brain as being reg the regulated by different systems of control there's a dorsal executive control system and dorsal means the top half of the brain and a vental or bottom half of the brain in yellow affective processing affect is another terminology for mood or appearance of mood uh so this is involved with decision making uh reason and so on a memory function and this is with processing of emotions and basically this system has a tendency to regulate what's going on down here to in in a loose sense you see how they're they I mean it's not completely it's not certainly isn't one way there's a lot of back and forth between these different parts of the system but in depression what you tend to see is this area for example I'm going to focus on this because you you'll see more of it in a little bit this is the dorsal lateral prefrontal cortex that's right in this area in the forehead and that's associated with executive functioning with making decisions with reason and uh and judgment memory whereas this area is with processing emotion and particularly the amydala is probably the most widely known although it's these other areas as well uh but take the amydala for example like it is very active in depression so the person is acting when you when you look at this and you'll see it in a little bit in depression this is has increased activation and this is decreased Activation so just breaking it down to simplify it a bit this is decreased or the emotional uh processing down here is hyperactive and this is hypoactive so the person is being driven by emotions and not thinking very clearly about uh processes and I don't think that's I think we could all relate to that when you're upset about something you're not thinking things through very clearly and if we took a snapshot of your brain wi with an fmri machine you we would see most likely some of these alterations in these systems uh this is and so we developed that study looking at the fmri hypothesizing we would see changes in treatment resistant depression that there would be decreased dorsal lateral prefrontal cortex but with mindfulness training we we see an increase we believe that mindfulness training energizes that area of the brain it restores attentional control to the dorsal lateral prefrontal cortex there's various studies that have shown that it just like Richie uh Davidson's study showed it with an EEG on uh fmri studies mindfulness is associated with enhancement of the dorsal lateral prefrontal cortex and just to we also see in depression The increased amydala activations and we are hoping that we will see decreased amydala activations along with an increase in dorsal lateral prefrontal cortex so in other words we're seeing this area re-exerting this is an example of of this that was done with mindfulness based stress reduction for eight weeks and the key finding here uh is to show that these are pre and post training to show if you can just see how this is active here and down here it's more lateral uh it's an example of how the uh mindfulness training shifts the brain function to be more focused on the present moment in this case on feeling Sensations in the body than existed before the training took place so we're using a couple of different tasks uh in the fmri machine to actually look at people's functioning while they're in the Mr fmri machine uh to see what happens in their brain and basically we have them look at a scrambled colored figure and then look at some objects and then some uh some more images and then show them uh objects and ask them to recall which of these which of these did you see and they press a uh they have a button on each on each hand they can press either right or left which one did you see before so you're checking how much they maintain things in their memory uh and you also give them different kinds of stimuli neutral stimuli or unpleasant stimuli emotionally evocative stimuli or Pleasant this is a baby and a baby seal uh so you show them different things to see how much they are affected and the idea with uh as you'll see is depression can affect this quite a bit so this is how much does the person maintain their uh working memory function and basically this top row are treatment resistant patients from our study and these are healthy controls from another study they're not perfectly matched but similar and what you see is that people with uh uh treatment resistant depression if you subtract this from that and this from that you this shows you how much the TRD patients are really different and you see that there's very great activation to both emotional distractors those things the emotionally evocative pictures as well as neutral distractors like the baby seal uh uh and or or The Scrambled picture rather uh and the amydala is very active in these patients so the amydala is firing both with neutral and emotionally evocative stimuli so it means that people with depression these are people coming into the study with depression are uh have very charged uh ventral affective processing system so they're responding to to stimuli neutral or emotionally evocative by getting very uh hyperactivation in the amydala which is sort of like the uh in some ways you know stimulates other areas of the brain to react here's here's another image that shows something quite similar uh the people with depression had here's the dorsal lateral prefrontal cortex and here's the vental lateral prefrontal cortex which is an area like the amydala which is deeper here but uh in this image it was focused on this it shows that these individuals have decre the depressed individuals have decreased activation it's cooler it's blue than the people down here in that in the ventral effective processing system and so these people are again have very charged emotion systems and they are decreased in their memory this relates to in ly why people with depression sometimes say I can't remember anything I mean it isn't just or uh or they sometimes they're mistaken for being demented so they they've called it you know pseudo depressive pseudo dementia it isn't really so pseudo in the sense of their brain function is actually decreased it's not Dementia in terms of it irreversible because if they get the depression treated appropriately it's completely reversible but they you can see how this area that that is tasked with maintaining memory and executive function is deactivated in a sense in this state uh and well this is another example to show that when you I think this one shows it probably well the best is with emotional probes you see in these individuals when they're trying to recall memory they have to light up much larger areas of the brain than the individual here because they they have trouble concentrating the person who has depression if any of you know uh folks like that you say I I don't remember anything or I can't decide anything I I don't know what to wear I don't know what I should do I don't know what I should do in this situation I can't problem solve well part of that is because they actually lack the ability in their work executive function areas of their brain to make those decisions and to remember as they would have if their brains were returned to normal this is shows in the the our population uh of people with treatment resistant depression what you see here is activation of the uh subgenual area in the rostal AC anterior singulate cortex this area broadman area 25 is uh a Hallmark of particularly difficult to treat depression and have have all of you heard about the deep brain stimulation for depression I I don't know if you yeah no this is it isn't the Vegas nerve what the deep brain stimulation is it's an experimental uh approach and actually it involves uh Neurosurgical procedure where they drill a hole in the brain in the skull and insert an electrode into the brain and and it's attached to a pacemaker and Helen mayberg uh who was at Emory now uh developed this and it's been done in probably about 60 people in the world so far so I mean it's not a widely uh you know it's still quite experimental but where it's placed is right here the electrode is placed in this region and when she turns on the stimulator before the stimulator the person says how do you feel terrible the weight of the world is on me they flip the switch the person doesn't know that it's blind this is while they're in the operating room incidentally so they are making sure they're in the right area I flip the switch how do you feel now light free just like that and the stimulation shuts this it isn't to stimulate it it's to turn it off this area has to be turned off and it's possible uh that we may start to see there are different ways of turning this area off Stanford is doing some research uh Ian golb on using fmri feedback to train people visually to turn this off and we are hopeful we'll see some changes with mindfulness training on this as well so we don't we don't have the results of that yet but uh let me let me save the questions for the end uh so it it but it's certainly intriguing and it' be a lot more palatable I think for people than having a a ho drilled in their head I think I don't know but it is dramatic shows videotapes of the people and these are people who have been very depressed uh they've had electr convulsive treatment they've had you know 20 different medications and nothing has helped them and they can respond instantly this is another condition that we use this is while the people are in the scanner we asked them to to look at these different images one is to label aect to label that mood state is this person angry or scared and then as a control for that we ask him what's this person's name Sylvia or Allen these are matched to be the same number of letters and the same uh length uh and and this is just observed the affec of face and this is a control to just see match this with this to do matching without any affect component to it so this is a way to see how people process emotions and our thought is that people with depression don't process them uh very well so here's an example of that this state just observing so look at this face they're in the scanner and then they uh we see what happens in their brain this is the amydala region now now watch what happens to that same region when we ask them to label it so they're seeing the face and say let's say angry let's say okay now label it watch this area so the Same by the process of labeling that's you can see in a sense drawing on that the executive functioning areas of the brain re dampens that amydala response so the person instead of having say oh it's an unpleasant face I'm exaggerating a little bit and they can't move their head in the scanner anyhow but uh they're uh you know instead of them having this reaction by saying ah angry face and this is essentially what we're doing in mindfulness training say so they're focusing on their breath and they start to feel oh I'm really angry about this interaction with my boss or this or I'm really uh depressed about this breakup or whatever say sadness what we teach people is to frame their emotions so say okay uh when your mind wanders notice what it is it's it's wandering to so uh okay I've got a planning thought what am I going to do tomorrow I've got uh anger anger and bring the attention back and you can start to see how some of these things are connected because they're not just uh you know sort of a uh blowing smoke it's actually affecting and enhancing the brain's ability to function in certain respects and restoring the dorsal executive control system uh to re-exerting component of the brain here you see it for treat uh the first 22 two patients that we've had you see how uh in healthy individuals you see the amydala tend to you see here how there's no emotional response to those shapes there was just those black dots there's very little reactivity here you see whether it's a neutral whether any of the other conditions just observing those faces labeling the gender or labeling the affect didn't really change much in normal people you would see this decrease significantly but in people who are depressed they're lacking that capacity to process emotions uh and this other area the VL ventrolateral pre prefrontal cortex was another part of that same vental system that I showed you on that slide like the amydala the same effect takes place here the vental prefrontal cortex is has increased activations across all these conditions except for just the matching shape control uh I'm going to uh I think thank various people who've uh uh helped you've already met Natalie here uh but Dan mathon is The neuroimaging Specialist who I collaborate with uh from the VA and I'm sure I'm leaving other people out but uh I've got a wonderful team that uh makes this uh research possible and uh oh I wanted to uh just highlight a couple other things this is uh the the book that really got it started is called mindfulness-based cognitive therapy uh oh I think it's about 2002 it's actually in revision he's making a new uh Edition but it isn't out yet uh but for this is focused on clinicians really to I would say for most people this would be the book to get and this is like 2007 or eight and the mindful way through depression this is a fabulous book it's written by uh all of The Originators of this approach and it has uh a CD at at the back cover uh with meditations by uh John cabitt Z in and so it's it it's very clear and very easy to read and very useful uh they they caution in there not to use it for people who are actively depressed which is different because these folks zindel seagull and Mark Williams have used it primarily for relapse prevention but but as you've heard we're using it to treat depression that is active and there's a broadening uh I think movement to do so around uh around the world so keep that in mind when you when you read that admonition in the book If you if you do get it but it's a wonder it's a beautifully written book and I think you all enjoy it this is the uh our our study uh there's a couple of these uh handouts up here if you're interested in participating or know somebody who might be either people who have failed to recover completely and are on two anti-depressants uh have had two anti-depressant trials rather or for people who aren't on any anti-depressants or aren't in any kind of therapy and want to do this both of them are free and actually we pay you to go through the assessments and you get your brain scanned before before and after so it's kind of neat they give you uh uh your brain scan on a on a in a dis and you can use it as a screen saver I should have brought mine I know I love mine they because they have this they do this 3D image of your head except they cut off your face it's rather eerie but kind of amazing because it's the perfect reconstruction of your brain and this is the website you can go to if you go to the UCSF Department of Psychiatry and search for me you'll get you can get it that way but this is in there as well and while at this point why don't we open up for questions yeah okay the question is what about obsessive compulsive disorder and the dorsal lateral prefrontal cortex or how are they related and can mindfulness uh training help with that I I think it it there haven't been much in the way of good studies about it but in uh obsessive compulsive disorder it's to a large extent uh deeper uh basil ganglia structures that are hyperfunctioning so you may see uh the cadate and paman and some of these other regions that are uh have increased activity along with some of these other areas of the brain uh that may be uh may be involved especially midline structure like the vental medial prefrontal cortex uh and the orbital frontal cortex where you you see some of those uh are also have increased activation what tends to occur in depressive disorders is those midline structures are that are focused and you see increased activation in depression and in rumination ruminative States tend to diminish as the person gets mindfulness training that's why I showed you that one slide where that shifted from the midline to be more laterally focused after mindfulness training but there haven't been really good randomized control Trials of OB of mindfulness training that I'm aware of for obsessive compulsive disorder you'd think it would be useful but I don't think it's been tested yet yes back there well the question is the depression can affect memory and is that a have some relationship to depression and Alzheimer uh that's a good question uh I uh I don't think the answer is completely clear uh depression is a risk factor for Alzheimer's that's definitely true why that is may not necessarily be related to what we were looking at here uh because that Alzheimer's is a more diffuse brain disease and this is really uh this is a talking about specific areas and about reversible changes so if you treat people uh successfully for depression you'll see that dorsal lateral prefrontal cortex that had decreased activation restored to normal it goes back to normal and that obviously isn't the case with Alzheimer's now on the other hand whatever may predispose say vascular changes that may pred disposed to depression or to alzheimer's may be a common link there so there's some connection but I don't think it's well worked out yet yes okay the the question is uh the yoga has some of the same features and and meditation and meditation Yes actually I think they might make the same claims it hasn't been as well studied but there are are studies particularly in India of using yoga as a treatment for major depression and one of our colleagues here at uh the osher center has been using Sky yoga as a treatment uh I can't pronounce the uh uh what it stands for but it involves breathing techniques and other elements of focusing the attention so there is a great deal of overlap you're quite right that there's a lot of overlap between some of the terminology and some of the features of yoga and we use yoga in uh in the mindfulness based cognitive therapy and some people that's the thing they come away with the most that they want to focus on so there is a lot of overlap in fact if somebody is practicing yoga twice a week or more they're ineligible for our study because they're already doing many of the same things okay well some of that's a good question a complicated one but there's uh what happens to people who've been traumatized uh it can be difficult to treat uh because it because it is so traumatic for them the there are efforts to apply this technique to uh trauma uh there's a study going on at the University of Michigan of using for uh using a mindfulness-based cognitive therapy for post-traumatic stress disorder in for example it has to be modified uh significantly from the approach I told you like for example you could see if you have somebody uh who's been uh molested or raped or something like that and you ask them to lie down in the class and do a body scan they may jump out of their skin uh it may not be an easy thing for them to do or for even to sit still for 45 minutes of breathing or something like that so there has to be significant modifications but on the other hand uh the mindfulness may help them gain some distance from the situation a lot of what happens in in a lot of different states I'd say a lot of psychiatric disorders is that people get upset about them and the upset about the disorder is is almost worse than the disorder so people with post-traumatic stress disorder get fearful about having a flashback and what as an example and there's a technique it's called metacognitive therapy for post-traumatic stress disorder which actually says okay you're going to have flashbacks but instead of saying oh that's terrible or that's abnormal or that's scary you say okay there's the flashback that's what happened I'm going to have it and and and accepting it as it were and paradoxic that tends to diminish it tending to resist it has a tendency to increase the prevalence of those things so it it's a specific technique uh that is that can be quite useful in helping people accept Okay this is what's going on and same thing is true of depression a lot of people get depressed about being depressed you know and I don't you know it's say oh because that part of what what we teach in mindfulness-based cognitive therapy is okay here's depression what does that feel like well it doesn't feel good or I feel tension or you know whatever it is or I got a headache with this or stomach ache or whatever but but it's only going to get worse this is going to be a disaster and the depressive thoughts start to occur about depression and if you can get the person to disengage and say okay here's the depression here's what it feels like but let go of those other thoughts like it's terrible I have depression I'm a weakling because I have depression it's morally bad that I have depression I must have sinned because I have depression all of that crap and just have the straight depression is actually diminishes the suffering it's like saying okay and we use this example in our course okay here's Winston Churchill's black dog came in the room here's the black dog now you could say I'm scared of black dogs you know they're terrible it's a big black dog this is terrible it's here you know this is what is it going to do what's the next thing that's going to happen it's going to bite me or this that you say okay here's the black dog but we Tre teach less resistance and say okay let's instead of panicking let's just take a look at this observe bring your mindful awareness to this what is the back black dog look like it may not be a good-look black dog but when you stop let go of the fear it changes the relationship and said actually it's not that bad looking you know or you know I may be able to learn something from it you know like one woman said when her depression came back she used to be terrified but after the course when the depression came up she says you know when the depression comes up now I I know it's a signal that I'm not asserting myself in a relationship and so she started to actually use the depressive awareness in a much different way than being terrified oh no here comes the depression again so that's I think the best answer I can give you about post-traumatic stress you up there okay is depression contagious uh there are also a lot of ways of dealing with depression too let's not forget that uh I hope I don't the other speakers have been addressing that as well um but uh I think gener certainly it's not contagious you know like an infectious disease exactly but I think you raise a good point you know there are these uh things called memes of ideas that can get transmitted to from one person to another or to whole groups of people and if you know if if if I say uh oh yes the world is a terrible place and everybody walks out of here believing that which I'm sure is not going to happen and I but uh but I mean if that was the case yes you you could have a contagion of ideas I think more resilient people are able to usually differentiate whether well this person is saying that because of you know their depressive state or or whatever so it normally is not contagious in that sense but it's not pleasant to be around some somebody who's depressed and if you're in that situation it it could be a a stressor in itself yes it could be but it's not exactly contagious per se and hopefully you'd be able to have the the enough distance from you know if I say you know the I don't even know why you're coming here because there's nothing to be done about any of this you know this is all garbage you know you know you would say well this guy's a lousy lecturer or something you know you wouldn't accept that and you'd have enough uh observation powers to to distance yourself so normally it does not directly lead to depression but it could it having a depressed loved one uh has the potential for being a significant stressor let's anybody hasn't yeah what the question is what what would qualify what professional training would qualify a person to do mbct training uh well I I think uh being in the mental health field of some type and there's you know a variety of different lures that one can have uh so they're very familiar with depression and the variations of it and then I think the other uh requirement is having your own personal mindfulness practice because you you can't read the book and say okay I'm gonna go do this and not have a mindfulness practice it doesn't work uh because like in order to be able to say well I can see these thoughts emerging you have to have seen your own thoughts emerging into Consciousness so you have to have a mindfulness practice so you know rather than being like I'm G to go teach swimming because I've read about it and you do one like this and one like this and it's easy as why you know unless you've swam you're not going to be able to teach it so that's probably the most important thing then I think you could be a variety of disciplines well the question is how does this relate to Buddhism and uh and I think uh some Buddhist practitioners uh I think a lot of them who get into the mental health Arena have uh degrees or lures in Psychology or uh counseling or something along that line I think you the difference I I would say to doing to teaching this the the structure and the terminology are are rooted in psychological Concepts built upon mindfulness meditation which is of course related to Buddhist Meditation in its early Roots uh so there is overlap but it's it's not it's it's rather secular and people have issues sometimes about that you know can you teach a meditation in a secular way and so on but uh our experience is yes you can and we don't use you know if you if you go to a Buddhist Retreat you get a completely different slant on these things than what we're teaching okay one more question oh the question is uh why couldn't this be taught in schools to prevent depression that's a great point and uh there's a movement to do exactly that there's a a growing uh tendency to have mindfulness meditation in schools uh and uh Stanford has a project teaching elementary school kids that and uh of trying to have it be part of uh the educational system there was a study that was done here of teaching teachers how to be more mindful uh called the cultivating emotional balance study that was partially funded by the do Lama actually and uh and show that you can by helping teachers become more mindful you passed it along to the Next Generation so I think there's a lot of effort occurring in trying to move it into preventive techniques in fact uh some of us were talking about trying to do it uh to giving mindfulness-based uh prevention to high school seniors going off to college as a way of preventing this but it's moving there but there's a lot of work to to show that it's effective and prove it and the challenges in developing a an an effort like that but it's definitely moving in that direction so thanks for that question all right thank you all for coming [Music] [Music]

Channel: University of California Television (UCTV)

Views: 234,504

Keywords: depression

Id: 5eQ3MWz4yrI

Length: 88min 14sec (5294 seconds)

Published: Thu May 31 2012