2013 WJ Sieber

Buddha
To tame this mind of ours
We are what we think. All that we are
arises with our thoughts.
With our thoughts we make the world.
Speak or act with an impure mind and
trouble will follow you. Speak or act with a
pure mind and happiness will follow you.

2013 WJ Sieber
Calming an
Overactive Brain
William J. Sieber, Ph.D.
Inner Solutions for Success
Clinical Professor
Department of Family & Preventive Medicine
Department of Psychiatry
UC San Diego
2013 WJ Sieber
What to expect
Learn how stress and anxiety-related disorders
affect your brain
Understand how stress affects your sleep, your
eating habits, and your overall energy levels
Evidence-based strategies to manage anxiety-
related disorders
Meditation, contemplative practices and their
impact on our health
2013 WJ Sieber
Alphabet soup
HPA = hypothylamic pituitary adrenal
PNI = psychoneuroimmunology
CPAP = continuous positive airway pressure
CRF = corticotropin releasing factor
BNST= Bed Nucleus of the Stria Terminalis
OR = Odds Ratio
ACT = Acceptance and Commitment Therapy
MBSR = Mindfulness Based Stress Reduction
rCBF = regional cerebral blood flow
2013 WJ Sieber
Stress in America
22% of Americans report stress at 8 or higher on 10-point
scale
32% of adults say it is very important to talk with their
health care provider about stress; less than 18% do
92 % believe stress negatively impacts health; only 31%
believe stress negatively affects their health
Nearly half state theyre poor at preventing or managing
stress
Top symptoms of stress: irritability (42%), anxious (39%),
and fatigue (37%), feeling sad (37%), and low energy
(35%)
2013 WJ Sieber
32% of adults report not getting enough sleep
Importance to well-being? Good family/friend relationships
(76%), managing stress (61%), getting enough sleep (60%),
eating well & exercising (54%)
Westerners report using meditation & yoga more to manage
stress, while Easterners drink more alcohol.
Midwesterners are more likely to turn to family/friends than
other regions. Midwesterners are also more likely to state
willpower and lack of confidence as factors that prevent
healthy behaviors.
Stress in America
(StressinAmerica.org)
2013 WJ Sieber
How do you feel?
Dread
Fretful
Nervous
Panicked
Restless
Anxious
Apprehensive
Worried
Tense
Angst
Concerned
Uneasy
Fidgety
2013 WJ Sieber
What models do we use?
Symptoms as pathology DSM-IV criteria for over-
active brain disorders (GAD, OCD, PTSD, Social
Phobia)
Dualism or integration?
Psychological or physical
Holistic, multi-factorial model of inter-connectivity (e.g.,
allostatic load, childhood trauma, neuroplasticity)
Direct mind-body connection (HPA axis)
Behavioral response to stress/anxiety that perpetuates
over-activity of the brain (caffeine/ nutrition, social
isolation & rumination, physical inactivity)
2013 WJ Sieber
Self-assessment, self awareness,
and emotional intelligence
Avoidance (cognitive, affective, and
behavioral) leads to lowered tolerance
Many effective techniques are based on
reflection and awareness
Self-care, and balancing action with
acceptance are critical
2013 WJ Sieber
The mind-body connection
Maladaptive thought patterns & controlling the frontal
lobe (social/emotional intelligence) ! lowers anxiety
rCBF studies show "amygdala response when affect was
labeled (intellectualized) vs. when affect stayed
perceptual self-awareness/self-assessment IS executive
functioning (i.e., building descending inhibitory circuitry)
Hypothalamus ! CRF ! pituitary ! beta-endorphins &
adrenocorticotropin hormone (ACTH) ! adrenal !
cortisol, gluccocorticoids, and pro-inflammatory cytokines
! down regulate system elements upstream
+
+
Adrenal Glands
adrenaline
glucocorticoids
Hypothalamic Pituitary Adrenal (HPA)
Anterior Pituitary
Hypothalamus
2013 WJ Sieber
Corticotropin-releasing factor (CRF) in the
Hypothalamus, Medulla, and Amygdala
1. Hypothalamus
a. Activation of endocrine (hormonal) stress
response stimulates release of ACTH from pituitary
b. ACTH in turn stimulates release of
glucocorticoids from adrenal gland
c. Glucocorticoids increase blood sugar,
suppress immune function, and break down
fats
Neurobiology of Stress Response
2013 WJ Sieber
Neurobiology of Stress Response
Corticotropin-releasing factor (CRF) in the
Hypothalamus, Medulla, and Amygdala
2. Medulla
a. Activation of sympathetic nervous system-
release of norepinephrine (noradrenaline)
b. Stimulates nerves leading to adrenal
medulla- release of epinephrine (adrenaline)
c. Norepinephrine and epinephrine increase
heart rate, increase blood pressure, and
produce bronchial dilation
2013 WJ Sieber
Neurobiology of Stress Response
Corticotropin-releasing factor (CRF) in the
Hypothalamus, Medulla, and Amygdala
3. Amygdala
a. Coordination of behavioral responses to
stress
b. Associated with fear and survival/threat
response
2013 WJ Sieber
The amygdala
Decision-making in unpredictable and ambiguous situations.
Neuroimaging shows induced negative emotion leads to greater
amygdala activation than positive emotions.
Patients with bilateral amygdala damage judge unfamiliar
individuals to be more approachable and trustworthy suggesting
their fear-trigger is muted, as the amygdala is important in the
recognition of cues of threats or danger.
Amygdala is crucial for learning new stimulus-threat
contingencies and in the expression of cue-specific fear. The
amygdala and BNST are where memories are burned into
memory, because fear-associated events need to be remembered
for our survival.
2013 WJ Sieber
The amygdala
The amygdala is not necessary for the expression of already
acquired individual differences in temperament or affective
style. Generally the initial reactivity of amygdala is unrelated
to trait anxiety, though recovery time is.
The Bed Nucleus Stria Terminalis (BNST), the extended
anygdala, is more implicated in chronic anxiety per se.
PET / fMRI studies show amygdala activation when anxiety-
disordered patients are exposed to their specific anxiety-
provoking stimuli compared to control stimuli. However
there is rapid habituation of the amygdala response,
suggesting the time-limited function of the amygdala in the
stream of affective information processing.
2013 WJ Sieber
The mind-body connection
The prefrontal cortex is related to affective chronometry
Right-sided prefrontal and orbitofrontal cortex activation:
withdrawal-related negative emotions.
Left-sided prefrontal cortex activation: experience of positive
affect (damage results in depressed mood /anhedonia).
PET scan studies show that negative affect activates anterior
orbital, inferior frontal, middle and superior frontal gyri;
positive affect is associated with left-sided metabolic changes.
For example, when social phobics anticipate making a public
speech, they show a large increase in right-sided anterior
activation, including right-sided prefrontal cortex.
2013 WJ Sieber
The mind-body connection
Asymmetric activation of these brains
regions are associated with specific reactive
emotions when a person is confronted with
an environmental challenge, not in
differences in mood without such stressors
(i.e., temperament, personality).
2013 WJ Sieber
Overactive Brain: Fatigue and sleep
Prolonged HPA activation, often the result of
hyper-vigilance secondary to a traumatic event,
impairs sleep and reduces sleep quality.
Chronic stress can result in hormonal
imbalances and impact thyroid function. A low
thyroid level can cause fatigue, weakness,
lethargy, weight gain, and depression; high
thyroid levels can cause fatigue, and/or anxiety.
Poor sleep quality & fatigue leads to over-
reactive amygdala.
2013 WJ Sieber
Chronic fatigue syndrome
Definition / criteria (CDC); Women account for 65-80% of CFS.
A. Chronic fatigue for >6 months that doesnt resolve with bedrest &
impairs function by 50% or more
B. Exhaustion after completion of simple tasks.
C. 7 or more of the following: (main symptom having abrupt onset)
1. Mild fever and chills
2. Sore throat
3. Painful lymph nodes
4. Generalized muscle weakness
5. Myalgias
6. Post-exertional fatigue/malaise
7. Headaches
8. Joint aches
9. Neuropsych complaints
10. Sleep disturbances
11. Non-productive congestion
2013 WJ Sieber
CFS Stress syndrome
Metabolism of CFS patients is normal so symptoms are due to
psychological factors, with mental fatigue considered a lack of
motivation (brain is major consumer of resting cellular energy!)
Parental physical abuse, childhood GI symptoms, and parental
reports of many colds each had ORs > 1.6 for patients with CFS.
Outcomes are predicted by ! in perceived problems with activity and an "
in sense of control over fatigue. Patients with CFS tend to perceive
problems with activity independent of their own objective
performance and see CFS as uncontrollable, itself resulting in
chronic anxiety and fatigue.
When gluccocorticoids are released as part of short term stress they
destroy weaker/older lymphocytes; prolonged stress leads to
indiscriminate destruction of lymphocytes. Prolonged stress
elevations and compromised compensatory recovery systems can
result in autoimmunity.
2013 WJ Sieber
CFS Immune dysfunction
Findings have consistently shown adrenal insufficiency/
low cortisol especially during typical morning surge. CFS
also have been shown to have low heart rate variability.
Pro-inflammatory cytokines act on the brain to cause
sickness behavior. When inflammation continues
unabated, such as during systemic infections, cancer or
autoimmune disorders, the ensuing immune signaling to
the brain can lead to exacerbation of depression. This
may be why depressive symptoms such as fatigue, reduced
interest, and low mood is more prevalent with immune
dysfunction.
2013 WJ Sieber
CFS Immune dysfunction
As compared to non-CFS patients, CFS patients with post-
infective (mononucleosis) fatigue had gene expression
profiles of altered host response, with most of these
genes affecting mitochondrial functions. It remains
unclear whether this fatigue reflects chronic effects of
persistent Epstein Barr Virus (EBV) or if the EBV triggers
a chronically altered host response to various viruses.
When the digestive system is operating properly glucose
and lipids are fed into the blood stream, and with
erythrocytes (red blood cells) are transported to every cell
in blood. GI disturbance can thus lead to insufficient
energy production and fatigue.
2013 WJ Sieber
Chronic fatigue syndrome
While immune dysfunction is associated with CFS we do
not know if this plays an etiological role or is simply
confounded with low cortisol levels or sleep dysfunction,
both of which are common in CFS and both of which are
associated with immune activation. Cross sectional studies
that compare CFS to other medical conditions have shown
that the proportion of these patients with co-morbid
psychological disorders is too high to simply be a reaction to
having the illness but is compatible with the idea that this
co-morbidity might reflect a shared underlying CNS
dysfunction. Simon Wessely, CFS expert
2013 WJ Sieber
Chronic fatigue syndrome
CFS has multiple causes and to call it a single disease
greatly underestimates the complexity of the problem.
Thus to look for the cause of CFS is a self-defeating
exercise. There is accumulating evidence for a wide
variety of abnormalities in CFS, including altered
adaptive immunity, disordered pain perception,
endocrine abnormalities, sleep disorders, and
cardiovascular dysfunction. However, one is left with a
strong sense that post-viral events are a common trigger in
CFS, but how they lead to chronic disease remains
unresolved. Stephen Hilgate, CFS expert
2013 WJ Sieber
Chronic fatigue syndrome
Even when they sleep, their stress-responsive neural
systems are on high alert, signaling that it is not safe to
relax. I think this condition may be understood by
analogy to PTSD, just that in CFS the original trauma is
most likely a physiological, internal one, such as a severe
infection. Ute Vollmer-Conna, CFS expert
2013 WJ Sieber
Self-assessment - sleep
Sleep diary # Sleep efficiency
Sleep restriction, sleep hygiene, and
stimulus control
What will be different next week?
2013 WJ Sieber
Consensus Sleep Diary-Core
Thanks to Dr. Ancoli-Israel
Date 8/19/12 8/20/12 8/21/12 8/22/12
Time into bed 10:30 pm
Time tried to sleep 11:35 pm
Time to sleep onset 55 min.
# awakened 3
Total awakened time 75 min
Final awakening 6:40 am
Time out of bed 7:00 am
Sleep quality (1-5) 2 (poor)
Comments Wine w/dinner;
Olympics
Sleep efficiency for 8/19 = 58%
2013 WJ Sieber
Homeostasis Sleep Drive
!"#
2013 WJ Sieber
Effects of sleep deprivation
Two studies using fMRI showed sleep restriction
$amygdala activation (and subjective emotional
intensity) and lessens connectivity between amygdala
and medial-prefrontal cortex (controller of amygdala)
when exposed to 150 affective pictures. (van der Helm E, Yao J, et
al, (2011) Current Biology; Yoo SS, Gujar N, Hu P, Jolesz FA, Walker MP (2011) Current Biology)
Cross sectional survey in Japan showed < 6 hours
sleep had OR 1.42 for diabetes than those with 8+
hours average (Kobayashi, Takahashi et al, 2010, Internal Medicine)
Improved sleep for 3 months (via CPAP crossover
design) in patients with metabolic syndrome results in
lower blood pressure, cholesterol, and A1c (Sharma, Agrawal et
al 2011, NEJM)
2013 WJ Sieber
Sleep problems
Consequences of impaired sleep
Daytime sleepiness, depression, cognitive
impairment, anxiety, emotional reactivity
Inflammation: Cardiovascular & immunologic
effects
Cohen, 2009, < 6 hrs/night more susceptible to flu
Heffner, 2012 & Haack and Mullington, 2007, sleep deprived
$interleukin-6/pain sensitivity
Extending sleep $pain tolerance by 25%, more than 60 mg of
codeine (Sleep, 2012)
< 6 hours/night = higher breast cancer recurrence, post-
menopausal only
Prostate cancer (OR 1.6 2.0) for sleep problems in > 65 age
(Cancer Epi, 2013)
Mortality (OR 1.97)
2013 WJ Sieber
Sleep restriction
NIH Consensus Panel concluded sleep restriction,
sleep hygiene and stimulus control are most effective
treatment for Onset insomnia; terminal insomnia
(SSRIs)
Physical activity (vigorous, no closer than 3 hours)
Set wake time
No naps
Bed when sleepy; 30 minute maximum per attempt
2013 WJ Sieber
Sleep hygiene and stimulus control
All activity outside bedroom
darkness/no electronics 60 minutes prior to bedtime
cool temperature to mimic lowered body temp at night
no clock visible
list of concerns outside bedroom (60 min pre, night-stand)
pets in their place (53% of pet owners report disrupted
sleep every night)
Caffeine, alcohol, tryptophan
What will be different next week?
2013 WJ Sieber
Cathy H.
56 y.o. female, entertainment publisher, unknown
work hours
Adult son & family in transition
GAD-7 = 16, sleep diary, cognitive log (re: work)
Intervention: bed only for sleep, no alcohol past 7 pm,
sleep restriction, worry pad, 60 minute pre-bed
routine, mid-day walk, daily planner, assertiveness
training, plan for dedicated work space at home,
unifying principles to guide work decisions,
biofeedback (MyCalmBeat.com)
2013 WJ Sieber
Gut Brain - Ghrelin
Adiposity hormones, leptin and ghrelin, regulate short-term
food intake to achieve long-term energy balance.
Leptin signals satiety, down regulates food intake
Ghrelin increase appetite and peaks during first bites
Decreased sleep ! ghrelin levels and ! leptin levels
Ghrelin : circulating levels surge shortly before meals,
and secondary to stress.
Ghrelin is most quickly suppressed by ingestion of
carbohydrates. Proteins and then fats suppress ghrelin
to a lesser degree. Crude fiber also lowers ghrelin
production.
2013 WJ Sieber
The Gut Brain - caffeine
o
Most often used psychoactive substance on earth; improves
attention and concentration yet impairs short-term memory
when eliminated
o
Caffeine intensifies dopamine receptors, resulting in stimulation
of the cardiovascular system. May lower risk of Alzheimer disease.
o
Chronic use increases risk of dehydration, and poor sleep quality,
leading to fatigue and susceptibility to anxiety.
o
Long-term caffeine consumption has been linked to fibrocystic
breast disease &cardiovascular disease (DBP 3 pts.).
o
Now often combined with sweeteners which increases dopamine
(addictive substance?).
2013 WJ Sieber
Acquired dopamine deficiency
Repeated exposure to drugs of abuse or fatty
foods leads to down-regulation of dopamine
receptors
Dopamine-deficient animals show compulsive
drug or food seeking (i.e. will seek out junk
food or drugs despite punishment)
Mindful eating ?
2013 WJ Sieber
Managing cravings
with increased dopamine?
When dopamine is low in the limbic system then immediate
rewards (simple decision) wins out. When sufficient
dopamine is present, then prefrontal cortex (complexity,
delayed gratification) will win out.
Memory, based in hippocampus, tends to lower firing of
dopamine neurons with expectation of a familiar non-
gratifying activity, more firing of dopamine neurons with a
familiar pleasurable activity, whereas greater firing of
dopamine neurons occur when opportunity for pleasure is
novel (encouraging exploration).
Gratitude journal, self-care, massage, dance, play, novelty
2013 WJ Sieber
Generalized Anxiety Disorder
uncontrollable, excessive worry across variety of
issues, restlessness, fatigue, poor concentration,
muscle tension, and sleep disturbance.
Lifetime prevalence in U.S. of 8.3% with one-year
prevalence of 3.1%
Only 13% of patients with GAD present to their
PCP with a chief complaint of anxiety; common
presentations include vague somatic symptoms,
pain, sleep disturbance, and depression.
2013 WJ Sieber
Generalized Anxiety Disorder
The neurobiology of the disorder is thought
to involve a wide cortical and subcortical
network that includes but is not limited to
the amygdala and the bed nucleus of the
stria terminalis (BNST). These two regions
have been hypothesized to play different
roles in stress and anxiety; the amygdala
regulates responses to brief emotional
stimuli, while the BNST is involved in
regulation of sustained anxiety.
2013 WJ Sieber
Generalized Anxiety Disorder
Trait anxiety associated with decreased connectivity
between amygdala and anterior cingulate.
fMRI scans show that GAD patients have decreased
activity in the amygdala and increased activity in the
BNST, supporting advocates of SSRIs/SNRIs versus
short-acting benzodiazepines. GAD patients
disengage the amygdala and its response to acute
stress earlier than non-anxious controls, making way
for the BNST to maintain a more sustained state of
anxiety. (Bishop, 2009).
2013 WJ Sieber
PTSD
Lifetime Prevalence
8% of general population
15-30% of Vietnam veterans
21-48% of sexual abuse survivors
18-32% of firefighters
7-11% of inhabitants of NYC after 9/11
Females 2x as likely to develop PTSD post-
trauma
2013 WJ Sieber
Post Traumatic Stress Disorder
DSM-IV-R Criteria
Traumatic event
Symptoms
Re-experiencing
Persistent avoidance
Hyper-arousal
Impairment in functioning, one month or more duration
Neuropsychological mechanisms (e.g., hippocampus) that
are affected and the reciprocal loop of memory, arousal,
and avoidance (Ravindran, Stein, 2009). Consolidation of
memories is when reminders are associated with hyper-
arousal (intrusion, nightmares, startle response).
Low levels of cortisol increase risk for PTSS
2013 WJ Sieber
An intact hippocampus is necessary for the consolidation of
information from short-term memory to long-term memory (all
explicit memories).
Hippocampus is necessary for the consciously recalled details of
events associated with fear memories (again explicit memories)
An intact amygdala is necessary for the production of implicit
memory reflected in conditioned fear (reflexive, visceral
symptoms).
Peri-traumatic dissociation impairs consolidation (explicit
memories) yet fear and arousal (implicit memories) remain.
Role of the hippocampus and amygdala
in fear memory processing?
2013 WJ Sieber
Obsessive Compulsive Disorder
obsessions or compulsions : time-consuming &
unreasonable
obsessions: recurrent thoughts/images experienced as
intrusive and not worries about real-life problems
compulsions: repetitive behaviors or mental acts aimed
at preventing a dreaded event.
Actions associated (brain connected) with decreased anxiety
are going to be repeated (i.e., compulsions), yet always be
connected with anxiety
Thought-action fusion: Individuals assume that thoughts
imply the immorality of their character or increase the
likelihood of catastrophic events (superstition); this may not
be specific to OCD, but more general to anxiety.
2013 WJ Sieber
Panic Disorder
Unexpected Panic attacks (pounding heart,
sweating, choking, dizzy, depersonalization,
shaking, numbness, fear of dying),
experienced repeatedly or chronic fear of
having another
Lifetime Prevalence of 4.7%
Only 11% of patients receive SSRIs, similar
for CBT
Increased risk of Coronary Artery Disease
2013 WJ Sieber
Social Anxiety and Phobias
Social Anxiety Disorder: persistent fear of
scrutiny or humiliation in social situations ;
fear to display anxiety symptoms or act in way
(e.g., stuttering) that will be embarrassing or
potentially lower social status or acceptance.
Annual prevalence of up to 7% in U.S.
Hyperactivity of amygdala (also in specific
phobias and PTSD)
Specific phobia: excessive, persistent, and
unreasonable fear cued by object or situation
2013 WJ Sieber
Other resources
NCCAM.NIH.GOV
Googlescholar
2012 WJ Sieber
2013 WJ Sieber
There is nothing either good or bad,
but thinking makes it so.
- Hamlet
The mind is its own place, and in itself
Can make a Heaven of Hell, a Hell of
Heaven.
- Milton
2013 WJ Sieber
Common cognitive distortions in anxiety
Shoulds/ perfectionism
Catastrophizing
Mind reading
Forecasting
Feelings are Facts
CBT: Thought Record
Situation Mood Automatic Thoughts Impact on
What
happened?
The event.
How did you
feel in this
situation?
What are you telling yourself about the
event?
Mood
-5 to +5
Late for work Angry
Upset
Stupid
Anxious
1. I cant do anything right.
2. Im an idiot.
3. I should have left earlier.
4. Im going to get red.
Replacement thoughts
5. This is the rst time Ive been late this
year.
6. I will stay 20 minutes later to make up
the time.
-3
-4
-2
-4
+1
+2
2013 WJ Sieber
Attributional style
Personal? (internal ... external)
Pervasive? (global . specific)
Permanent? (stable ...... temporary)
2013 WJ Sieber
Essential concepts in mood management
Awareness: hard to change what youre not aware of.
Control:
Central to anger and depression
Illusion and perceived control
Eysencks Attentional Control Theory: Anxiety impairs
efficient functioning of the goal-directed attentional system
and increases the extent to which the processing is influenced
by the stimulus-driven attentional system.
Inhibition and Shifting
The AAA model.
2013 WJ Sieber
Control Over a Stressor
vPFC turns off the stress response
Control activates the ventral prefrontal cortex (vPFC) (trait
anxiety lowers top-down control over threat-related distractors)
Perceived control eliminates the effects of stress; after
experiencing control, extrapolate to other stressors
PTSD patients dont activate this region under stress
Top (dorsal) portion of anterior cingulate involved in cognitive
processing, whereas bottom/rear of anterior cingulate is
involved in emotional processing and is most associated with
anxiety.
2013 WJ Sieber
Interventions for anxiety
Coping skills training (Donald Meichenbaum) for
panic disorder: This evidence-based strategy teaches
skills for de-escalation for several of the patients
physiological and cognitive symptoms of panic.
Important to its success is brief cycling of skills with
refocus away from success.
A highly similar approach is described as
Interoceptive exposure by (Boswell and Barlow,
2013). A patient re-imagines the physiological
sensations during a panic episode in order to apply
learned relaxation skills.
2013 WJ Sieber
Interventions for PTSD
Emotional regulation and prolonged exposure (Foa)
Eye Movement Desensitization Reprocessing (Shapiro):
Using a 3-pronged approach: past (trauma), present
(symptom and recent experiences), and the future (prepare
a template for the future). Identify negative cognitions
about the traumatic event and install positive cognitions
via bilateral sets.
Recent neuro-imaging studies show outcome of EMDR is
increased thalamic activity (involved in integration of
perceptual, somatosensory, memorial, and cognitive
processes). Proposed mechanism of benefits of EMDR are
that bilateral stimulation increase thalamic activation,
during which time there is repair/integration. (Bergmann,
2008).
2013 WJ Sieber
Behavioral interventions - exposure
Flooding therapy:
Studies have shown little evidence that cortisol
increases during naturally occurring panic
attacks.
Cortisol levels are higher in those with Panic
Disorder than controls.
Lower cortisol release during exposure predicted
poorer response to exposure-based therapies
including virtual reality studies.
2013 WJ Sieber
Behavioral interventions - Journaling
Emotional disclosure /diary-keeping (J. Pennebaker):
When 3 elements are present in describing previous
traumatic events experienced personally, most studies
show emotional and immunological benefit, though only
after a given period of time (usually 3 - 6 months). The 3
elements are: initial disclosure, heartfelt, and new
meaning achieved from processing.
Story-telling increases integration between hemispheres as
stories are both linear and emotive
Increased somatic illnesses if right hemisphere activation
is inadequately transferred to left hemisphere for verbal
expression
2013 WJ Sieber
.
Action trumps anxiety
W. J. Sieber
2013 WJ Sieber
Unified Protocol for the Transdiagnostic Treatment of
Emotional Disorders (Barlow et al, 2011)
An emotion-focused CBT treatment that distills and
incorporates common evidence-based treatment
strategies (identifying &modifying maladaptive
appraisals, changing maladaptive action tendencies/
experiential prevention of avoidance/exposure), and is
designed to be applied to anxiety and unipolar mood
disorders.
These modules are preceded by motivation
enhancement and psycho-education on the nature of
emotions.
Final sessions focus on relapse prevention techniques.
2013 WJ Sieber
Acceptance & Commitment Therapy
(Hayes, 1999)
A contextually focused therapy that uses mindfulness and behavioral
activation to increase psychological flexibility, engagement in values-based
positive behaviors while experiencing difficult thoughts and emotions
Experiential Avoidance
The tendency to avoid making direct contact with distressing
thoughts or images, unpleasant emotions, painful memories,
distressing physical sensations, and the situations that trigger
them
Cognitive Fusion
Tendency of human beings to get caught up in the content of
what they are thinking so that it dominates over other useful
sources of behavioral regulation.
2013 WJ Sieber
Acceptance & Commitment Therapy
F.E.A.R.:
Fusion with your thoughts
Evaluation of experience
Avoidance of your experience
Reason giving for your behavior
D.A.R.E.:
Disengagement from unhelpful thinking
Acceptance that at times you will feel discomfort
Realistic goals
Embracing values
2013 WJ Sieber
A C T
Accept your reactions and be present
Choose a valued direction
Take action
Describe clients change agenda and how it hasnt worked
Undermine attachment to change agenda
Maybe the solutions make things worse because the whole
thing is a setup
Maybe these so-called solutions are actually part of the
problem
The point isnt to get to a relaxed state, the
point is to be aware of whatever is going on for
you without avoidance or fusion
2013 WJ Sieber
Now what?
2013 WJ Sieber
Final ideas on overactive brain
& emotional management
20 minutes in 20 seconds
Framing CBT (tolerance and reduction, full tool
box)
He who fears he shall suffer already suffers what he
fears. Michel de Montaigne
Thought-stopping/attention grabbing
tasks
Worry box/compartmentalizing
2013 WJ Sieber
Average effect size estimates (Hedges g) and corresponding 95% confidence intervals of the acute
treatment efficacy of CBT as compared to placebo on the various anxiety disorders for the primary
continuous anxiety measures (red bars) and depression measures (green bars)
2013 WJ Sieber
Foundational concepts
Intolerance for Uncertainty (Alan Watts)
Sense of coherence
Hedonic pleasure (e.g., good meal, plasma TV)
Eudaimonic (i.e., meaning, noble purpose) is
associated with significant decrease in stress-related
gene expression profile
2013 WJ Sieber
Control over oneself
Anxiety = aberrant ANS cardiac control.
A range of HRV indices converge to implicate low
vagal and elevated sympathetic activity in anxiety.
These findings fit a theoretical model that views
anxiety as a systemic inflexibility grounded in poor
inhibition.
This is compatible with systems models of
biological stability that stress the importance of a
wide range of responsiveness for maximal
adaptation and resiliency.
2013 WJ Sieber
2013 WJ Sieber
Factors in effective treatment
Exposure to trauma scripts produces:
Increased activity (as measured by blood flow) in:
Right medial orbital frontal cortex, insula, and amygdala
Decreased activity in:
Left anterior prefrontal cortex- especially Brocas area (expressive
speech)
Increased HR and decreased HRV occurs in Panic
Disorder patients; CBT treatment increases HRV by
correcting dysregulated breathing.
Adding HRV biofeedback may enhance treatment effects
for panic.
2013 WJ Sieber
Mindfulness
Meditation is not a means to an end. It is both means
and the end. - J. Krishnamurti
What lies behind us and before us are tiny matters
compared to what lies within us. - Oliver W. Holmes
All of mans difficulties are caused by his inability
to sit, quietly, in a room by himself. Pascal
Our intent is not to feel better, but to get better at
feeling. Michael Brown
Live vertically, not horizontally. W. Sieber
Cognitive flexibility & non-judgmental focus on the
present.
2013 WJ Sieber
Mindfulness
(Fraser et al, Healing Power of Meditation)
Mistakenly we identify with thoughts and emotions and take
them to be all that we are. So if we have a positive thought
we conclude that we are good; if we have a mean thought we
condemn ourselves as terrible and unworthy.
Where are all the thoughts you had this morning they
dont exist. They were fleeting and impermanent and
constantly changing. And does anyone see these thoughts of
yours? Do you? They just come and they go. But we attach
such huge importance to them.
Thoughts settle on their own, quite naturally just like the
waves that arise and then settle back into the ocean.
2013 WJ Sieber
Mindfulness
Thoughts and emotions are not really our mind. They just go
drifting by like the clouds. Its all a question of our perspective.
Whether we view the thoughts and emotions the way the sky
views the clouds, or we view them like someone down on the
ground looking up and unable even to believe there is a sky
up there beyond the clouds.
Were plagued by restlessness, speed & aggression. We dont
know how to settle in ourselves, come in touch with
ourselves, and find our ground.
2013 WJ Sieber
Mindfulness
We also have the capacity to hear and articulate sounds, yet
the habit of hearing sounds may create in us a stubborn
attitude of always blaming sounds as external.
good sounds and bad sounds?
If there were no notion of good sounds or bad sounds, we
would not have feelings of aversion or attachment toward the
things we hear (e.g., neurolinguistic programming).
2013 WJ Sieber
Mindfulness
It is the same with our senses of taste, touch, and smell. Most
importantly this attachment and aversion applies to our mind which
comes up with all kinds of different thoughts. Its a wonderful
potential that we are all naturally gifted with, yet that gift becomes
intertwined with two things: stubbornness and impatience. Since we
are always impatient and we are going to be stubborn we have to
find quick answers to everything. The quickest answer seems to be to
segregate everything into things we like and things we dont like. So
we have developed a habit of always saying this is what I like, and
this is what I dont like. What you do not like is blamed for a
number of negative emotional experiences that we go through in life.
What you do like you can never get enough of. Half of your life is
spent chasing after that, and the other half is spent running away
from what you do not want to encounter.
2013 WJ Sieber
Mindfulness
Allow yourself to be still for at least 15 minutes.
Be patient as you are actually reversing the current (e.g.,
52 years of action-engaged body versus 15 minutes of
stillness). Which one is going to win? which one will I be
more familiar with? You need to know what your habit is
and what you are reversing.
Each day try to find stillness. Sit still.
2013 WJ Sieber
Meditation
o
Meditation is not the same as relaxation
o
All meditation is not the same
o
Major subtypes:
o
Focused attention (concentrative ) meditation
o
Open awareness (receptive/mindfulness) meditation
o
Meditative techniques that focus on a specific feeling
tone or relational stance (compassion, loving
kindness)
2013 WJ Sieber
Meditation
o
Focused attention
o
Directing and sustaining attention on a selected object (e.g.,
breath sensation)
o
Detecting mind wandering and distractors (e.g., thoughts)
o
Disengagement of attention from distractors and shifting
attention back to the selected object
o
Cognitive reappraisal of distractor (e.g., just a thought, it is
OK to be distracted)
o
Open monitoring
o
No explicit focus on objects
o
Non-reactive meta-cognitive monitoring
o
Non-reactive awareness of automatic cognitive & emotional
interpretations of sensory and perceptual stimuli
2013 WJ Sieber
Vipassana
o
Open Monitoring practice leads one to a more acute, but less emotionally
reactive, awareness of autobiographical sense of identity
o
Open Monitoring involves cultivation of awareness and its emotional tone
without judgment; it engages processes involved in interoception/somatic
awareness
o
Apprehend how our feelings and attitudes change. For example, pain is pain,
but as you focus on your bodily sensations you begin to realize that what you
thought was pain is just a concept, and if you can peer beyond the concept
you perceive a cluster of sensations tingling in your feet, pressure in your
knees, burning in your calf muscles.
o
The whole gestalt adds up to pain, but if you focus on its constituents, it is no
longer painful the sensations are still there, but the way we attend to them
has changed. The strategy of labeling aspects of your experience (e.g., this is
distressing) is central to MBSR.
o
The new process is : That is my feet tingling (or knees burning), but the
mind learns not to conceptualize this set of sensations as the aversive,
unpleasant thing labeled pain.
2013 WJ Sieber
Meditation
o
So the discipline is to keep bringing your mind back to the breath. If
you are distracted, then the instant you remember, you simply bring
your mind back to the breath. Nothing less is necessary. Even asking
yourself How on earth did I get so distracted? is only another
distraction. Im not doing this right; Im not good enough.
o
Mind is the same as a restless child being put to bed. At first it may
be very jumpy. But however agitated it gets, keep bringing it back,
time and time again, to the simplicity of breathing. Gradually mind
will settle, in the mind.
o
Water, if you dont stir it, will become clear
o
Calm Abiding is not to fixate. It is recommended that only 25 % of
your attention should be on your breath, another 25% to watchful
awareness ( of your thoughts/attention), and the remaining 50% of
your attention is left abiding, spaciously.
2013 WJ Sieber
Meditation
o
Neuroplasticity: creating new connections and
associations
o
The brain is not static, it is constantly changing,
regenerating and rewiring
o
Thousands of new neurons are generated daily in the
hippocampus and ventricles
o
For example, scanning studies show with vipassana there is
enhanced frontal brain activity and enhanced gamma activation
of the posterior cortex
o
The brain changes function and structure based on
what is attended to
2013 WJ Sieber
Meditation & neuroplasticity
o
Focused attention activates (results in higher CBF) the
prefrontal cortex, anterior cingulate, and other executive
function areas of brain, whereasopen monitoring
decreases activation (Manna, Raffone, 2010).
o
Neurofeedback/neurotherapy helps patients change brain
waves in ways that activate some regions while lower in
activation in others (e.g., ADHD)
o
Mindful meditation > relaxation training for anterior
cingulate (Tang, Lu, Fan Yang, Posner, 2012, Proc Natl Acad Sci; Xue, Tang,
Posner, 2011, Neuroreprot)
o
Compassion changes the anterior cingulate (Richard
Davidson: www.investigatinghealthyminds.org)
2013 WJ Sieber
Meditation reduces activity and size of the amygdala.
Meditators increase size of their hippocampus, the posterior
cingulate, and the temporal-parietal junction (playing a central
role in empathy and compassion)
Meditation boosts telomerase.
Studies by Sara Lazar and others, using imaging techniques
show that certain zones of the cortex thicken with meditation.
Because our cerebral cortex thins as we get older, thickening of
the cortex can have anti-aging effects.
Meditation & neuroplasticity
2013 WJ Sieber
Meditation increases activity in the paralimbic cortex.
The limbic system is the emotional center of the brain, whereas
the cortical regions are engaged during thinking and problem-
solving.
The paralimbic cortex connects these regions, and so can be
seen as the mind-body connection. The paralimbic cortex has
been implicated in numerous psychological phenomena
including anxiety, depression, and bipolar disorders.
Meditators had expansion of their paralimbic regions, an area
involved in the integration of senses, emotions, and thoughts.
Meditation & neuroplasticity
2013 WJ Sieber
Resilience (too fast or slow to recover?): To speed up recovery from
stress change your environment, change your cognitions, practice
mindful meditation; to slow down recovery spend more time focusing
on negative emotional experiences, develop greater empathy.
Outlook (pessimistic or optimistic): To be more optimistic write down
3 positive characteristics of you and 3 of another each day, express
gratitude regularly, compliment others regularly. Depressive realism is
achieved by sitting with negative life events.
Social Intuition (other focused): To increase social intuition focus on
strangers and detect subtle social cues, predict their feelings. To
Richard Davidsons
Six Emotional styles
2013 WJ Sieber
Self-Awareness: To boost self-awareness practice mindful meditation,
decrease distractions and chose quiet environments; to decrease self-
awareness multitask more or have more external stimuli present.
Sensitivity to Context (myopic or big picture): To become more
sensitive to context try exposure therapy with a focus on
discriminating important from unimportant details. To become less
sensitive, engage in more self-reflection and complete activities that
increase self-awareness.
Attention (focused concentration): To improve focus try mindful
meditation and/or body scan. To reduce over-focused attention
scatter books, photos and objects to distract you.
Richard Davidsons
Six Emotional styles
2013 WJ Sieber
Wheres your motivation?
Often people attempt to live their lives backwards: they try
to have more things or more money, in order to do more of
what they want, so they will be happier. The way it actually
works is the reverse. You must first be who you really are,
then do what you need to do, in order to have what you want
Margaret Young
What is your goal, what would change if your brain were less
over-active? What is the benefit?
List 3 behaviors that you can place on next weeks calendar.

What will be different next week?