Download Mind Body Medicine and Women`s Health

It’s Not All In Your Head – Mind Body Medicine and Women’s Health
Shawn A. Tassone, MD, FACOG
Saybrook University
La Dea Women’s Health
Institute of Women’s Health and Integrative Medicine
July 13, 2012
Portland, OR
What is Mind Body Medicine?
• Mind-body Medicine is a revolutionary 21st –century
approach to health care that includes a wide range of
behavioral and lifestyle interventions on a equal basis
with traditional medical interventions (Moss, 2003, p.3)
• Mind-Body Medicine focuses on the interactions
between mind and body and the powerful ways in which
emotional, mental, social and spiritual factors can
directly affect health. (Center for Mind-Body Medicine,
http://www.cmbm.org)
What is Mind-Body Medicine?
• Partnership (physicians, NPs, psychologists,
biofeedback specialists, chiropractors, nutritionists, yoga
instructors, spiritual counselors)
• Behavioral and psychosocial interventions are treated as
first-line interventions.
• Patient education and self-awareness (self-care)
• Active patient – passive practitioner
Challenges for Primary Care
• Somatization and emotional distress – emotions become
physical begins at early age and continues for decades
(Quill, 1985)
• 20% of visits to primary care have demonstrable organic
causes (Kroenke & Mangelsdorff, 1989)
• One drug prescribed in at least 66% of all PCP office
visits (Fletcher, 2010, Forbes Online)
• Response stereotypy
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Cardiovascular responders
Gastrointestinal responders
Musculoskeletal responders
Cognitive responders
Challenges for Primary Care
• 65% of patients with anxiety seek treatment for a
potential somatic illness (Danton et al, 1994)
• Comorbidities of anxiety and depression in patients with
chronic medical disease is essential in understanding the
cause of the illness an identifying appropriate treatment
(Wayne, Lin & Kronke, 2007)
• Patients with chronic illness account for between 46 and
75% of the costs in healthcare (Moss, 2003, p.7).
• Challenges for the PCP are lifestyle and familial
variables and finding a leverage point into the care of the
patient before emotions become somatic.
Evidence Based Mind Body Medicine
• Jonas et al (1999, p.73) – epistemology of EBM
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Patient preferences and meaning
Mechanisms of action
Safety and efficacy
Treatment effect probabilities in the open clinical setting and
from observational and outcomes research
– Precise estimations of effects through systematic summaries and
calculation of confidence intervals when possible
– Demonstration of utility and benefit under normal health service
conditions examining the impact of access, feasibility, and costs.
HOW DO WE MAKE IT WORK??
MBM and CAM Therapies
Acupuncture
Hypnotherapy
Aromatherapy
Manual Therapies
Biofeedback
Massage Therapy
Biofeedback
Massage
Bioenergetics
Nutritional Counseling
Chiropractic
Prayer
Exercise
Spiritual Healing
Feldenkrais
Tai Chi
Herbal Therapy
Yoga
What Makes The CAM MBM Paradigm
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Emphasis on holistic practices and unitary view of mind, body, spirit
Treating each patient as a unique individual
Emphasis on a more personal relationship
Attribute and active role to the patient in the healing process
Belief in the inherent healing power of the person
Prescriptions of lifestyle and habit changes
Emphasis on interventions that elicit healing
Distrust of invasive treatments that crush the disease but harm the patient
Belief in eclecticism and empiricism
Readiness to accept unconventional interventions
Openness to prayer, meditation and spiritual practices
Integration of physical, psychological, and spiritual practices
(Freeman & Lawlis, 2001).
MBM and Women’s Health
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Headache
Urinary Incontinence
Fibromyalgia and Chronic Fatigue
Mood disorders
Sleep and Sleep Disorders
Premenstrual Dysphoric Disorder (PMDD)
Temporomandibular and Facial Pain
Spirituality and Healing
Task Force and Levels of Efficacy
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Level 1: Not Empirically Supported
– Supported only by anecdotal reports and/or case studies in nonpeerreviewed venues. Not empirically supported.
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Level 2: Possibly Efficacious
– At least one study of sufficient statistical power with well-identified
outcome measures but lacking randomized assignment to a control
condition internal to the study.
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Level 3: Probably Efficacious
– Multiple observational studies, clinical studies, wait-list controlled
studies, and within-subject and intrasubject replication studies that
demonstrate efficacy.
Task Force and Levels of Efficacy
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Level 4: Efficacious
a. control utilizing randomized assignment, the investigational treatment is shown to be statistically
significantly superior to the control condition, or the investigational treatment is equivalent to a treatment
of established efficacy in a study with sufficient power to detect moderate differences,
and
b. The studies have been conducted with a population treated for a specific problem, for whom
inclusion criteria are delineated in a reliable, operationally defined manner, and
c. The study used valid and clearly specified outcome measures related to the problem being treated,
and
d. The data are subjected to appropriate data analysis, and
e. The diagnostic and treatment variables and procedures are clearly defined in a manner that
permits replication of the study by independent researchers, and
f. The superiority or equivalence of the investigational treatment has been shown in at least two
independent research settings.
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Level 5: Efficacious and Specific
Evidence for Level 5 efficacy meets all of the criteria for Level 4. In addition, the investigational
treatment has been shown to be statistically superior to credible sham therapy, pill, or alternative bona
fide treatment in at least two independent research settings.
Headache and Migraine
• Primary and secondary headache
– Primary headaches have no underlying or medical condition
associated with the pain: migraine and tension
• Biobehavioral approach
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Assessment
Treatments
Skills Acquisition
Combination therapies
Biobehavioral Approach to Headache
• Biological – the headache comes from food triggers or
medical problems and can be treated with medications
• Psychobiological - biology changes affect behavior and
conditions of chronic headache involve emotional,
cognitive, and behavioral factors. (Moss et al, 2003,
p.209)
• An example of this is the cause of headache may be
simply stress related causing a migraine but over time
the patient symptoms transform into a daily headache.
Biological and psychological coping change with
chronicity and as such changes must be made – a
reprogramming
Assessment of Headache
for the Mind-Body Medicine Practitioner
• In depth clinical interview
– Many patients may feel there is serious cause – r/o with medical
work-up. Some also fear they may be told “it’s all in their head”
– Attempt to avoid categorizing headaches into organic and or
psychogenic as patients may respond to your questions
differently based on your approach
– Medication lists are essential as many patients have been
prescribed opioids and NSAID’s
• 80% of of chronic daily headache patients present because of
analgesic rebound (Rapoport, 1988; Colas et al, 2004) mainly in
women in their 50’s.
– Important to determine the type of headache, triggers, and
treatments used
Assessment of Headaches
• Assess if the patient has avoidance behaviors or
secondary gain related to the headaches. Some
patients phobic of the headache may take meds
preemptively as a means to avoid the headache.
• Psychophysiological assessment
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Arousal
Electrodermal response
Heart rate and heart rate variability
Respiratory dynamics
Skeletal muscle response
Smooth muscle response
Assessment of Headache
Electrodermal Response
• Definition
– a change in the electrical properties of the skin in response to
stress or anxiety; can be measured either by recording the
electrical resistance of the skin or by recording weak currents
generated by the body (Merriman’s Dictionary)
• Clinical Uses
– Polygraph
– Biofeedback devices
– E-meter – Scientology
Assessment of Headache
Heart Rate Variability
• Definition
– a measure of the naturally occurring beat-to-beat changes in
heart rate/heart rhythms. It serves as a critical method for
gauging human health and resiliency. www.heartmath.org
Heart Rate Variability Devices
Heart Rate Variability Devices
Wild Divine
Assessment of a Headache
Respiratory Dynamics
• RESPeRATE as example
Assessment of a Headache
Skeletal and Smooth Muscle Response
• Guarding responses in the muscles of the head and
neck or back
• Tenderness in certain muscle groups
• Twitching
• Trigger points
• Patient history and story
• Combine the location and severity of the pain with the
narrative the patient gives you and look beyond the
obvious.
Treatment
• The best approach for headache is usually multidimensional (Moss 2003, p.213)
– Education of triggers
– Cognitive strategies and coping mechanisms (relaxation
response (Blanchard et al)
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MBSR
Progressive relaxation and body scans
EMG assisted relaxation
Thermal control (thermistor)
– Self-regulation with headache diary
– Dietary and behavior change
– Adherence to drug regimens
Temporomandibular Disorders
• TMJ disorders cause tenderness and pain in the
temporomandibular joint (TMJ) — the joint on each side
of your head in front of your ears, where your lower
jawbone meets your skull. This joint allows you to talk,
chew and yawn. TMJ disorders can be caused by many
different types of problems — including arthritis, jaw
injury, or muscle fatigue from clenching or grinding your
teeth. In most cases, the pain and discomfort associated
with TMJ disorders can be alleviated with self-managed
care or nonsurgical treatments. Severe TMJ disorders
may need to be treated with dental or surgical
interventions. (Mayo Clinic, 2012)
TMJ – Medical History
• Injury
• Dental Work
• Gender and Age
– Women three times more likely than men
• Biopsychosocial approach
– Psychological history
– Social history
– Behavioral issues
TMJ – Psych and Behavioral
• Patients more likely to suffer from depression due to
chronic pain (Goto, 2009), and may elicit more anxiety
• Patients may have changed social life to accommodate
the inability to open mouth – soft foods or not going out
to restaurants
• Increased sick days from wok
• TMJ patients reporting myofascial or muscular pain may
also have a concomitant psychological disorder that can
be diagnosed through investigative medical questioning
(Glaros, 2001).
TMJ – MBM Interventions
• EMG biofeedback to aid the patient in decrease
functioning where focus is on relaxation of the mouth
and not allowing the teeth to touch
• Ask patient to stop chewing ice, nails, or gum
• Studies have shown that teaching patients generalized
relaxation skills with instructions to help avoid tooth
contact was most successful in reducing pain
• EMG based nocturnal alarms for patients with significant
grinding during sleep
Urinary Incontinence
• Determine the type of incontinence
– Stress urinary incontinence
– Overflow Incontinence
– Detrusor instability or Urge Incontinence
– Mixed
– Intrinsic Sphincter Deficiency
Urinary Incontinence - Kegels
• Who knows exactly how to do it
• Mostly ineffective if simply described to patients and
more effective when combined with pelvic examination to
show levator ani and pelvic floor musculature.
• 5-10 second contractions followed by similar period of
relaxation
• Primarily effective for stress incontinence and could
worsen urge or detrusor instability
• More efficacious in women with mild symptoms
• Vaginal weights effective for SUI (Herbison, 2009)
Pelvic Floor Electrical Stimulation
• Patients treated with a self-help 8 week course and
Kegel-type exercises had improvement but not as
significant as patients enrolled in a similar program in an
incontinence clinic
– Quality of life was improved in both groups but more significantly
in those women undergoing a clinical program with a
biofeedback device
– Timed voiding and habit voiding
Fibromyalgia
• American College of Rheumatology diagnosis of 11 out
of 18 tender points
• Sleep disturbances, poor immediate recall
• Poor concentration
• Irritable bowel syndrome
• Headaches
• TMJ
• Predominantly female (80%) between 40-64 (White et al,
1999)
• Myofascial pain and fibromyalgia are comorbid in many
cases
Fibromyalgia and Myofascial Pain
Features
Fibromyalgia Syndrome
Myofascial Pain
Musculoskeletal Pain
Widespread
Mainly regional
Tender points
Multiple
Regional
Referred Pain
Minimal
Follows patterns
Fatigue
Dominates
Variable
Poor sleep
Dominates
Variable with pain
Headaches
Common
Common
Irritable Bowel
Common
Rare
Pain medications
Long term
Possible short term
Providers
Sometimes multiple
Depends
Treatments
• Be aware of patients using long term analgesics and
opiates and do not ask them to stop these medications
quickly
• Combination of medications and naturopathic treatments
significantly reduced symptoms (Teitelbaum, 1999)
• Donaldson (2001) explored the effects of long term pain
on the nervous system. The more it is stimulated the
easier it becomes stimulated (neuroplasticity)
• Difficult to treat as Donaldson believes the causes are
neuroplastic, cognitive, and come from childhood
learning processes. Treatments with multi-modalities
like SEMG progressive muscle relaxation are
recommended
Fibromyalgia – Other Therapies
• High intensity exercise has improved symptoms for
some and worsened for others
• Feldenkreis – gentle movement of the muscles while
over stimulating the nerves
• TENS units are not recommended
• Muller (2001) reported a combined therapy:
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sEMG and biofeedback
Massage
EEG and neurotherapy
10% had increased pain
25% had a complete resolution of pain
65% had reduction of pain in varying degrees
Fibromyalgia Thoughts
• Often a frustrating and debilitating process for patients.
• It appears that brain function and learned neroplastic
events contribute to the pain process which then make
other stimuli appear more painful.
• Multiple modalities such as medications, movement,
supplements, MBM, and cognitive therapies have helped
some and worsened others
• Let us remember that first and foremost we are to do no
harm
Chronic Fatigue Syndrome
• What patients are using (Neisenbaum 2001)
– Vitamins (79%)
– Exercise (64%)
– Dietary changes (54%)
– Herbal treatments (37%)
CFS – Mind Body Therapy
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Acupuncture
– Wang et al (2009) – meta-analysis of 28 studies showed the therapeutic effect of
acupuncture in CFS was superior to control
Guided Imagery and Hypnosis
– Bernardy (2011) meta-analysis failed to show significant reduction in symptoms
but studies have had poor methodology due to poor follow up
Biofeedback and progressive relaxation reported as Level 2 – probably efficacious
(EMG being the most common modality utilized)
Cognitive Behavioral Therapy – somatic symptoms are perpetuated by errant illness
beliefs and maladaptive coping (Moss, 2003, p.340).
– 70% of participants undergoing combination cognitive and behavioral therapies
reported a decrease in symptoms. Difficulties with CBT are finding a qualified
therapist and that treatment is better if one-on-one as group therapies have not
been shown to be effective.
Premenstrual Dysphoric Disorder
PMDD
• Biological causes
• Psychological components
• Daily log of symptoms
• Societal views
• Hysteria
PMDD
Nonpharmalogical Treatments
• Change the diet to reduce salt, caffeine and alcohol
– Add magnesium and calcium along with DHA and EPA
– Smaller frequent meals decreased carbohydrates
• Cognitive Therapy (Steiner, 2000)
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Problem-solving
Reframing or looking at problems from other vantage points
Stress management
Interpersonal Competency
Education about PMS
• Wise Guide Imagery
Mood and Sleep Disorders
• Depression
• Dysthymia
• Bipolar
• Depressive Symptoms
• Postpartum Blues and Depression
Mood and Sleep Disorders
Future Directions
• EEG Biofeedback or Neurofeedback
Brainwave Cat Ears
Sleep Problems in Women
• Hormonal imbalance lends a special issue with women’s
studies and as such most have been done on males
• Women with PMDD have a higher incidence of sleep
disorder (Lee et al, 1990)
• Patients with mood disorders also have a higher
incidence of sleep disorder
• Pregnancy can also be a lengthy time of sleep disorder
due to progesterone
• Menopause also a state of increased sleep disorder
Mind-Body Therapies and Sleep
• Yoga and sleep – Khalsa (2004) demonstrated that
individuals practicing yoga each day for eight weeks had
a significant reduction in insomnia
• Manjunath (2005) demonstrated that elderly patients
practicing yoga had a shorter time span falling asleep
and slept longer.
• Irwin (2008) in a small study of 112 individuals
discovered that 25 weeks of Tai Chi practice improved
sleep quality in individuals who had a moderate
complaint profile of falling asleep
Spirituality and Healing
• Incorporate ritual and ceremony into the process of
healing.
• Know the spiritual background of your patient
• The Spirit Catches You and You Fall Down – Anne
Fadiman
• Allopathic or Allopathetic?
• Is there a place for spirituality in medicine ?
• Roman Catholic church list spiritual crises and similar
symptoms in their book on exorcisms (Karpel, 1975)
Spirituality and Healing
• Applications of Spirituality in Healing (Koenig, 2001,
p.214-219)
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Meaning and purpose in life
Intrinsic values
Transcendent belief
Community relationships
• Individuals with internalized spiritual and religious
dimensions score higher on measures of mental health
(Moss, 2003, 195).
Spirituality and Religion
A Piece of the Mind-Body Paradigm
• Individuals who attend religious services once a week
live longer than those who do not compared to similar
controls
• High blood pressure and heart disease are less common
amongst religiously oriented people
• (Koenig, 2001, p.249) demonstrated a link between
spirituality and heart disease in terms of prevention and
decreased treatment procedures.
• If health care providers could participate in spiritual
awareness health care would more closely reflect the
wholeness and integrity of individuals
Biofeedback Devices
stress thermometer
$21.95 on Amazon – measure vasodilation (headaches and stress)
Biofeedback Devices
stress dots
$12.95 comes with instruction cards and dots www.stressdot.com
Biofeedback Devices
emWave2 by Heartmath
$229 on Amazon. Comes with computer program and readout
Great for personal and office use, teaches breathing and heart
Rate variability compliance www.heartmathstore.com
Biofeedback Devices
Oh No!
Questions?
References
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Blanchard, EB, Appelbaum, KA, Radnitz, CL, Morrill, B, Michultka, D., Kirsch, C., Guarnieri, P, Hillhouse, J, Evans, DD, Jaccard, J, & Barron, KD
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