Grief, Stress, and the Body:
Using Integrative Medicine
to Cope with Loss
Larry Bergstrom MD FACP
Integrative Medicine
Division of Consultative Medicine (CMED)
Mayo Clinic Scottsdale AZ
bergstrom.larry@mayo.edu
Joanne Cacciatore, PhD
Arizona State University
School of Social Work
Goals and Declarations
1) To define Integrative Medicine
2) To recognize the Medicine Wheel of
Health
3) To know the three basic elements of
health
Declarations: None
“Our greatest glory is not in never
falling, but in rising every time
we fall.”
Confucius
Stress
A physical, chemical, or emotional factor
that causes bodily or mental tension and
may be a factor in disease causation
Stimulates Sympathetic Nervous System
•Adrenaline
•Cortisol
Increases blood pressure, heart rate,
affects coagulation system, immune
system, blood sugar, sleep
An Exercise:
Rate Your Stress
• Scale: 1-10, 10 is worst stress
An Exercise:
Rate Your Stress
• Scale: 1-10, 10 is worst stress
• Includes health, finances, family,
neighbors, in-laws, work, global
warming, politics, etc.
An Exercise:
Rate Your Stress
• Scale: 1-10, 10 is worst stress
• Includes health, finances, family,
neighbors, in-laws, work, global
warming, politics, etc.
• How much of the day do you think
about things on your stressor list?
Rate Your Stress
• 1/10- Perfect idyllic life
• 5/10- Saber-toothed tiger is in the
neighborhood somewhere
• 10/10- He’s breathing in your face
Conventional Treatment of Stress
Potential Complications of Chronic
Stress
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Heart disease
Sleep problems
Digestive problems
Depression
Obesity
Memory impairment
Worsening of skin conditions, eczema
Mortality and Bereavement
• Question: Does death of a child increase
mortality of the mother?
• 69,224 mothers age 20–50 from National
Longitudinal Mortality Survey, 9 yr follow-up,
• Results: Death of a child increases risk of
death of mother by 133% especially in first 2
years. Not related to mother’s education or
marital status, family size, the child’s cause
of death or the gender of the child.
Espinosa, J. Econ. Hum. Biol. (2012), http://dx.doi.org/10.1016/j.ehb.2012.06.002
Conventional Medicine
• Focuses on treatment of physical
disease, defined by measureable
parameters; physical exam, lab tests,
imaging, pathology, etc.
• Successful treatment is eradication or
amelioration of the physical disease
• Ideal for acute care
Definition- Integrative Medicine
Comprehensive system that emphasizes
wellness and healing of the whole person
as major goals, above and beyond
suppression of a specific somatic disease.
Views the patient as whole people with minds
and spirits as well as bodies and includes
these dimensions into diagnosis and
treatment.
BMJ. 2001;322:119-120.
Integrative/Integrated Medicine
Combines treatments from conventional
medicine and CAM for which there is
some high-quality scientific evidence of
safety and effectiveness.
National Center for Complementary and Alternative Medicine website
Integrative Medicine Consultation
Review:
• Medical condition(s)
• Conventional Medical Therapies
• Patient’s past and current use of CAM
therapies.
• Potential interactions of CAM therapies
with Conventional medical therapies
Discern patient’s attitudes towards potential
therapies; the patient’s value system.
Integrative Medicine Consultation
Develop an Integrated treatment plan
incorporating:
• Exercise
• Nutrition
• Stress reduction
• Complementary and Alternative
treatments tailored to the patient’s
value system.
How can we make the patient healthier?
The Medicine Wheel
-Physical Health
• This is Western, Conventional medicine,
defined by measurement
• Examination
• X-rays
• Blood tests
• Tests give us name of
the disease which we then
treat the disease; however, what about
when all tests are normal?
Disease
dis·ease
A disordered or incorrectly
functioning organ, part, structure, or
system of the body resulting from the
effect of genetic or developmental errors,
infection, poisons, nutritional deficiency or
imbalance, toxicity, or unfavorable
environmental factors
Illness
Patients suffer illnesses which are
discrepancies between states of being
and perceived role performances.
The Medicine Wheel
-Emotional Health
Emotional Health
• Interface of Stress and Health
through the sympathetic
nervous system.
• “Fight or Flight”
• Saber-tooth Tiger analogy
• Patient rates stress level from
1 to 10, low to high
The Medicine Wheel
-Emotional Health
Coping skills learned when younger are
used to deal with stressful situations.
Many people are:
• Perfectionist
• People pleasers
• Ultra responsible
• Theme- “need for control”, “lack of trust”
• Very difficult to say “no” to anyone
• Black and white thinking
The Medicine Wheel
-Emotional Health
Mind-Body Medicine: enhance the mind's
capacity to affect bodily function and
symptoms. ↓ physical effects of Stress.
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Prayer
Meditation
Yoga, Tai Qi, QiGong
Biofeedback
Breathing Techniques
Exercise
Rumination
Inward: Ruminating about the past:
• Regret
• Anger
Ruminating about the future:
• Fear
• Anxiety
Outward Living in the present
• In front of you
• Focused on the moment
Mindfulness
“Mindfulness means paying attention in a
particular way; On purpose, in the
present moment, and nonjudgmentally.”
Jon Kabat-Zinn
Mindfulness Exercise
• Take 5 minutes
• Pen and Paper
• Find a peaceful and relaxing picture
• Describe what you see in a nonjudgmental manner
• Write it down
Therapeutic use of slow breathing
Many favorable effects on the cardiovascular
system and respiratory function
• Decrease in vascular resistance: BP
• Increase in peripheral blood flow
• Improved exercise tolerance
• Induce a sense of calm
• Decrease anxiety
RESPeRATE
Proven in 10 clinical trials
to lower blood pressure
naturally.
No side effects except
for relaxation.
Reduces stress
Heart Math
Combining Mindfulness
and
Paced Breathing
Think “I Am”
Think “At Peace”
Breath in
Breath out
5 Seconds
5 Seconds
6 Breaths/Minute
The Medicine Wheel
Mental Health
Neurochemistry- Psychiatry
• Target symptoms
• sleep
• appetite
• concentration
• energy
• sex drive
• Anxiety may be separate
biochemical disorder
• Treatment- Antidepressants, correction of
sleep disorder
Target symptoms of Acute
Grief/Depression
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Sleep disturbance
Appetite disturbance
Concentration difficulties
Poor energy
• Stamina
• initiative
• Loss of sex drive
• Passive death thoughts
• Hopelessness
The Medicine Wheel
Spiritual Health
History question:
• Do you have a spiritual
part of your life that is
helpful to you?
• What gives your life
meaning?
• Defined by the patient.
• May be religious but not necessarily
Spiritual Effect of Illness
Meaning
Practices developed during health
• satisfying, fulfilling, enjoyable
• “charge our batteries”
Illness, life changes may prevent engaging
in them
• Deprives of energy, enjoyment, sense
of control
• Can’t live up to self-expectations
Spirituality
The question:
•“Do you have a spiritual part of your life?”
•“What gives your life meaning?”
Spirituality
• Activities developed during health
• Satisfying, fulfilling, enjoyable
• Charge up our batteries
• May all be lost through accident, illness
other life changes and lead to a
“spiritual crisis”
What gives our life meaning?
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Work
Faith
Family
Hobbies
Volunteering
Pets
Art
Sports
To be a parent
Spirituality
In Short:
•“Why do you get out of bed each day?”
Spiritual Effect of Illness
• The Ideal- State of health when one is
able to do what is needed to feel fulfilled
and give life meaning.
• Developed during period of health
“Spiritual Crisis”
• The Reality of illness- State of health with
illness/disability. When one is unable to
do the things that give life meaning.
Meaning and grief- Case 1
50 y/o women
• 6 years ago, adopted son, age 13, killed
while riding his bicycle
• She grieves but remains positive
• “I miss him terribly but he was a gift that
I would not have otherwise. I am grateful
for the time he was here.”
Meaning and grief- Case 2
45 y/o man
• 3 y/o daughter died 5 years ago
• He decided no God could allow such a
thing to happen
• Deacon but abandoned his church
• Divorced
• Became a Hedonist- lives for pleasure
only, because there is nothing beyond
what we can see.
Resilience
A dynamic process (not a personality trait)
encompassing positive adaptation within
the context of significant adversity.
Resilience is the result of individuals being
able to interact with their environments
and the processes that either promote
well-being or protect them against the
overwhelming influence of risk factors
Resilience
• The process by which we find new
things to give our lives meaning when
the prior ones are unavailable or no
longer possible
Resilience and Outcomes
• Better physical
health
• Higher meaning in life
• Well being
• Greater problem
focused coping
• More adaptive
• Lower anxiety and neuroendocrine
response to stress
depression
Kobasa S.C. et al. J Psychosom Res 1985; Maddi S.R. Am Psychol 2005;
Hull J.G. et al. J Pers Soc Psychol 1987; Brosschot J.F. et al. Psychosom
Med 1998; Maddi S.R. et al. Am J Drug Alcohol Abuse 1996
The Medicine Wheel
-Community
Community
We do not live our lives in
isolation; our community
should be as supportive
to our health as we are to
theirs. Community is the
background to the
Medicine Wheel.
The Medicine Wheel
-Community
Community
We do not live our lives in
isolation; our community
should be as supportive
to our health as we are to
theirs. Community is the
background to the
Medicine Wheel.
Integrative Medicine
Shift question from:
•“How do we treat your disease?
to
•“ How can we help you become healthy?
Patient-centered Outcomes research- What
is most meaningful to the patient?
Integrative Medicine
Grief
• Five fundamental needs
• Exercise
• Nutrition
• Hydration
• Rest
• Social support: main variable in
determining high vs. low grief.
Exercise for You
Cumulative Survival time based on ↑ or ↓ changes in
exercise capacity after exercise training and ↑ vs ↓
baseline psychosocial stress
Milani 2009
Integrative Nutritional Plan
• Utilizing food as a source of health and
energy
• Emphasis is on food first
• Supplements are supplements to food
• Supplements are used to fill in where
diet cannot cover everything.
• Mediterranean/Anti-inflammatory diet
Nutrition- Mediterranean Diet Pyramid
http://www.oldwayspt.org/images/pyramid_med.pdf
Mediterranean Diet
• Fish- (wild ocean) 3 x weekly
• Fish oil- EPA + DHA = 1000 mg daily
• Fiber- 35 gm/d
• Olive oil (Canola oil- high temp cooking)
• Whole grain products (less processed)
• Soy- Soy milk 8 oz, tofu 3 oz, soy nuts,
edemame (isoflavones)
• Nuts- walnuts, pecan, almonds (Sterols)
Mediterranean Diet
• Fruit- dark skinned fruit (Flavinoids)
• blueberries, blackberries, purple grapes
• red wine, purple grape juice 2-4 oz/d
• grape seed extract
• Vegetables- ½ of diet, Not all greens!
• Green tea 3 c/d (EGCG)
Mediterranean Diet
• Lean meats- chicken (without skin)
• Red meat- (4 legs, hooves) eat once a
month at most (source of omega 6)
• Probiotic- yogurt, kefir, probiotic
supplement
• Avoid
• Partially hydrogenated oil (trans fat)
• High fructose corn syrup
Supplements
Mood, Anxiety, Sleep
• Inositol- may help depression, panic,
OCD. 6-8 gm 2x/d
• SAMe- may help depression, athritis.
Dose 200-800 mg 2x/d. may take 2
months to work. Do not take with
antidepressants or if have bipolar
disorder
• 5-HTP- may help depression. 150-300
mg/d, may help sleep
Supplements
Mood, Anxiety, Sleep
• St. John's wort- may help mild to
moderate depression. 300 mg 3x/d.
interacts with many medicines
• Kava- may help anxiety. 100 mg 3x/d.
May not be safe (liver failure)
• Passionflower- may help anxiety and
sleep. 45 drops or tea or 90 mg tab.
Supplements
Mood, Anxiety, Sleep
• Skullcap- may help anxiety and sleep.
Tea or alcohol extract
• Theanine- may help anxiety. 200
mg/day
• Valerian- may help sleep. extract 400900 mg up to 2 hours before bedtime
• Lemon balm-may help sleep. tea from
flowers
Supplements
Mood, Anxiety, Sleep
• Chamomile tea- may help sleep
• Hops- may help sleep. dose/?
• Lavender- may help sleep. tincture (1:5
in 50% alcohol) 60 drops/d
• Melatonin- may help sleep. Take 1 hr
before bed, dose 1-20 mg, take biggest
dose tolerated without side effect, take
x 6 wks. Quit if no benefit.
Questions for you
• Are you eating regularly?
• Are you skipping meals?
• Are you losing weight?
• Are you putting on weight?
• Is your refrigerator well-stocked?
• Are you shopping for empty calories
and avoiding food that your body
needs?
Positive Thinking and Grief
• positive thinking was inversely related to
measures of depression, anxiety, and
traumatic grief symptomatology
• Findings- Among bereaved individuals,
low positive thinking is a cognitive
feature of depression that is relatively
independent of anxiety and traumatic
grief symptomatology.
Intentionally interpret life with higher
principles: Daily Themes
Monday
Gratitude
Tuesday
Compassion
Wednesday
Acceptance
Thursday
Higher Meaning
Friday
Forgiveness
Saturday
Celebration
Sunday
Reflection / Prayer
Integrative Medicine