Mind-body
Interventions:
Is there Power in
Positive Thinking?
SPARC
Portland, Oregon
April 16, 2011
Making the Case
•
There are pathways by which positive
emotions influence health and well-being
•
Positive emotions are not the inverse of
negative emotions
•
Can positive emotional states be
increased and maintained?
•
Tools you can use
Making the Case
•

There are pathways by which positive
emotions influence health and well-being
Let’s start with something more familiar
Early Medicine
•
Evolved as a search
to eliminate disease
in the individual
•
Early attempts to
repel spirits by
shamans with
rituals …
Hippocrates’ Four Humors
•
Many diseases were
thought to result
from negative
emotions
•
That produced
imbalance in bodily
fluids or “humors”
Early Mind-body Research
Focused on Negative Emotions
and Stress
Negative Emotions
Anger
Depression
Disease Outcomes
Anger &
Disease

Religious Orders
Study

N = 851 clergy
(average age = 75)

Suppressed anger and depression – both
associated with increased death rates over
4-years, independent of age, sex, education,
smoking, and obesity
(Wilson, et al, 2003)
Hostility & Mortality

Women’s Health Initiative
Cohort of 107,356 Women
followed 8 years

Cynical, hostile women had
an increased risk of death
Most hostile - 63 deaths per 10,000
Least hostile - 47 per 10,000

Later – news on the “optimists”
(Tindle, et al., 2009, APS)
How do Negative Emotional states
lead to Physical Health Outcomes?
Three pathways:
• physiological responses
•
•
maladaptive behaviors
aversive environments
Negative Affect
Physiological
Responses
It Affects all Systems
Disease Outcomes
1 Nervous system:
fight, flight, freeze
2 Musculoskeletal system
headaches, muscle pain
3 Respiratory system
asthma, inhibited breathing
4 Cardiovascular system
coronary heart disease
5 Endocrine system
 cortisol, epinephrine, glucose
6 Gastrointestinal system
acid reflux, nausea
7 Reproductive system
hormonal irregularities
Negative Affect -Brain Activity &
Immune Function
•
Negative and positive states are associated
electrophysiological measures of prefrontal
brain activity
•
Negative states, particularly depression,
associated with right-sided activation
(Tomarken et al, 1992: Henriques et al, 1991)
Negative Affect –
Brain Activity & Immune Function
People with right-sided activation --
•
•
Lower basal levels of NK cell activity
Greater decreases in NK function during
natural stress of exam
•
•
Less rise in NK function to positive film clip
Lower antibody titres to an influenza vaccine
Davidson, et al
Negative Affect
What specific Pathways
link negative affect and
immune function - ?
Physiological
Responses
Evidence suggests:
Hypothalamic-pituitaryadrenal (HPA) axis
Cortisol - “stress hormone”
Disease Outcomes
Negative Affect
Physiological
Responses
Maladaptive
Behaviors
Disease Outcomes
Depression & Health Behaviors
• Depression has been associated with
poor health behaviors such as heavy
alcohol use, sedentary behavior, and
lower adherence to care
• In turn, these behaviors
potentiate adverse health
outcomes such as CHD
Negative Affect
Physiological
Responses
Maladaptive
Behaviors
Disease Outcomes
Social
Isolation
Social Isolation and Mortality
•
N = 1123 male, 245 female CAD patients
•
5 year survival rates
Married or confidant
Unmarried, no confidant
0.82
0.50
 Unmarried, without confidant Threefold increase in risk of death
Cox adjusted hazard ratio = 3.34 (1.84-6.20)
( R. Williams, et al, JAMA, 1992)
Social Isolation and
Cardiovascular Risk
•
•
•
N = 188 healthy men and 110
women from White Hall II (45-59 yrs)
Social isolation measured with the
Close Person Questionnaire
Socially isolated men and women had higher
waking cortisol levels and greater cortisol
output over the day
( Grant, Hamer & Steptoe, 2009)
This Afternoon – Focus on
Positive Emotions
Impact on health
Approaches to
Intervention
Positive Affect
Longevity ??
Findings from
the Nuns Study
•
•
•
•
•
180 Catholic nuns
Handwritten autobiographies
Composed when nuns were 22 yrs of age
Scored for emotional content
Related to survival during ages 75-95
(Danner et al, 2001)
Nun with High Positive Emotion
“God started my life off well by bestowing
upon me a grace of inestimable
value….The past year which I have spent
as a candidate studying at Notre Dame
College has been a very happy one. Now I
look forward with eager joy to receiving
the Holy Habit of Our Lady and to a life of
union with Love Divine.”
(Danner, Snowdon, & Friesen, 2001)
Results
• Emotion
Positive
Negative
None
Cox proportional hazard
- 1.4
- 0.7
- 0.1
(-2.3, -0.6) ***
(-1.5, 0.2)
(-0.9,0.7)
 Positive emotional content predicted
survival (later mortality) six decades
later
(Danner et al, 2001)
Conclusion
“Finding such a strong association of written
positive emotional expression to longevity
indicates a need for research that sheds light
on the underlying mechanisms and
mediators responsible for and associated
with this relationship.”
(Danner et al, 2001)
Optimism & Mortality
•
Women’s Health Initiative
Cohort of 107,356 Women
followed 8 years
•
Optimistic women had
an decreased risk of death
Optimists - 46 deaths per 10,000
Pessimists - 64 per 10,000
(Tindle, et al., 2009, APS)
Psychological Well-being
and Survival: Meta-Analysis
Population
Healthy
population
Hazard Ratio
.82
p
p< .001
(.76 - .89)
(35 Studies)
Disease
population
.98
p< .030
(.95 – 1.0)
(35 Studies)
(Chida & Steptoe, 2008)
Positive Affect
Physiological
Responses
Longevity
Positive Affect &
Immune Function
•
Cohort of 1,149 faculty, high scores on
positive affect were associated with fewer
colds
(Takkouche, et al., 2001)
•
Positive emotional style was associated,
in dose response pattern, to lower risk of
developing cold following viral challenge
(Cohen, et al., 2003)
Positive Affect
Physiological
Responses
Health
Behavior
Longevity
Positive Affect &
Health Behaviors
•
People with higher life satisfaction engage
in health-promoting behaviors

Physical activity
Reduced levels of smoking
Reduced alcohol intake

Healthier diet


(Castro, 2002; Scheier & Carver, 1992)
Positive Affect
Physiological
Responses
Health
Behavior
Longevity
Social
Support
Positive Affect &
Social Support
•
People who report positive
emotions receive more social
support (Fredrickson, 1998)
•
Positive affect is associated
with the number of people
who provided help over a
12-month period
(Eckenrode, et.al., 1988)
Making the Case
•
There are pathways by which positive
emotions influence health and well-being
 Positive emotions are not the
inverse of negative emotions
•
Can positive emotional states be
increased and maintained?
•
Tools you can use
Positive & Negative Affect
Can Co-exist
•
Under chronic stress
Expected: many individuals report high
levels of negative affect
Unexpected: some report high levels of
both positive and negative affect
(Folkman, et al, 2001; Diener, et al, 1985; Wortman, et al 1987)
Positive & Negative
Affect Co-exist
•
•
The chronic stress of
care-giving for a dying partner,
Positive affect and finding positive
meaning, during care-giving, was
associated with more rapid recovery
during bereavement
(Folkman, et al, 2001)
Positive & Negative
Affect Co-exist
•
Survey of 150,046 adults, 140 countries
•
Affect & perceptions of physical health

Negative affect & health = -.29, p <.001

Positive affect & health = .25, p <.001
(Pressman, et al, APS, March, 2009
 “Positive and negative affect are independently
related to health, not opposite ends of a continuum”
Making the Case
•
There are pathways by which positive
emotions influence health and well-being
•
Positive emotions are not the inverse of
negative emotions
 Can positive emotional states
be increased and maintained?
•
Tools you can use
MBSR Increases
Positive States
•
Mindfulness-based Stress Reduction (MBSR)
interventions focus on reducing distress and
enhancing well-being
•
N = 60, depressed individuals
•
Randomized to MBSR vs. waiting list
• MBSR resulted in significant decreases in perceived
stress and increases in positive affect
(Nyklicek & Kuijpers, 2008)
Other Positive Affect, Coping,
Stress Management Interventions
•
Combined Positive Affect and SelfAffirmation Intervention
(Mary Charlson et al.)
•
Cognitive Behavioral Stress Management
(CBSM)
(Antoni et al)
 Coping Effectiveness Training – Combines
aspects of mindfulness & problem-solving
(Chesney, Folkman, et al)
Coping
Effectiveness
Training (CET)
General Stressor
Specific Stressor
Changeable
Aspects
Unchangeable
Aspects
Problem-Focused
Strategies
Emotion-Focused
Strategies
Problem-solving
Negotiation skills
Communication skills
Guided Imagery, Physical
Activity, Humor
PLUS Strategies to
Enhance Wellbeing
Strategies to
Enhance Well-being
“BREATHE”
Breathe:
Take a deep breath, be present
with yourself in the moment
- Be aware in the current moment
- Accept what is, not what “ought to be”
- Suspend judgment
Realistic Goals: Set realistic goals for this
moment, hour and day, celebrate meeting
them
Strategies to
Enhance Well-being
“BREATHE”
Everyday events: Notice the positive moments
in everyday life,
- sunset, flowers
recognize when things go right
share these events with others
Strategies to
Enhance Well-being
“BREATHE”
B-R-EActs of Kindness: Create positive events for
others
Turn it around: Reframe negative events, find
the silver lining
Honor strengths: Acknowledge your personal
strengths
Strategies to
Enhance Well-being
“BREATHE”
B-R-E-A-T-H
End each day with gratitude: Note
positive steps and all you are thankful
for
- Do positive accounting at the
end of the day
Personal Growth Scale Items
 I learned to be myself and not try to be



what others want me to be
I learned to communicate more honestly
with others
I learned to be open to new information
and ideas
I learned to find more meaning in life
*
0 = Not at all
*
*
*
*
*
1 = Somewhat 2 = A Great Deal
Parks, 2000
CHANGES Project
HIV+ Men
(N=199)
CET-E
CET-S
MCC
(N=68)
(N=66)
(N=65)
Coping
Effectiveness
Training
Coping
Effectiveness
Training
Minimal
Contact
Control
(3 mo – 12 sessions)
(3 mo – 12 sessions)
(12 months)
Enhanced
Maintenance
Standard
Maintenance
Day-Long CET
Workshop
(9 mo – 18 sessions)
(9 mo – 6 sessions)
(in month 13)
Intervention Groups
Control Group
Coping Self-Efficacy
Percent Change from Baseline to Post (3 months)
20%
14%
15%
CET vs. MCC (p=.02)
10%
6%
5%
0%
CET Groups (N=112)
Changes Project
MCC (N=61)
Positive States of Mind
Percent Change from Baseline to Post (3 months)
10%
8%
CET vs. MCC (p=.02)
5%
0%
-1%
-5%
CET Groups (N=112)
Changes Project
MCC (N=61)
Personal Growth
Percent Change from Baseline to Post (3 months)
20%
15%
15%
10%
CET vs. MCC (p=.003)
5%
0%
-1%
-5%
CET Groups (N=112)
Changes Project
MCC (N=61)
Coping Self-Efficacy
0.75
Standardized Mean Change from Baseline
0.5
0.25
0
CET Groups
MCC
-0.25
0
3
6
Month in Study
Changes Project
9
12
Positive States of Mind
0.75
Standardized Mean Change from Baseline
0.5
0.25
0
CET Groups
MCC
-0.25
0
3
6
Month in Study
Changes Project
9
12
Personal Growth
0.5
Standardized Mean Change from Baseline
CET Groups
MCC
0.25
0
-0.25
0
3
6
Month in Study
Changes Project
9
12
Making the Case

There are pathways by which positive
emotions influence health and well-being

Positive emotions are not the inverse of
negative emotions

Can positive emotional states be
increased and maintained – YES!

Tools you can use -
BREATHE
Suggest: Add Positive Affect to
Mind-Body Medicine
•
Research is demonstrating healthenhancing effects of positive
mind-body approaches
• HIV
• Metabolic syndrome
• Cancer
Positive Affect:
One of many CAM approaches


Set a goal beyond returning
patients to a disease-free
state
Strive to encourage
 personal growth
 enhanced well-being
CAM Approaches
That encourage people to
actively participate in choices
to enhance their resilience,
prevent illness and Improve the
quality of their lives
In Appreciation
Michael Antoni
Jill Bormann
Brian Berman
Charles Carver
Sheldon Cohen
Sheldon Cohen
Richard Davidson
Susan Folkman
Barbara Fredrickson
Frederick Hecht
Gail Ironson
Laura Lee Johnson
Jon Kabat-Zinn
Elizabeth Kimbrough
Trish Magyari
Judith Moskowitz
Crystal Park
Sarah Pressman
Carol Ryff
Saki Santorelli
Andrew Steptoe
Catherine Stoney
Esther Sternberg
Joey Taylor
Carl Thoresen
Redford Williams
Eileen Ziegler
David Anderson
Please visit us!
www.osher.ucsf.edu