Strategies to Gain Acceptance for Wellness/Mind-Body Programs by Skeptical Residents

and Clinical Faculty: Stress PhysiologyMichael D. Lumpkin, PhD

Professor of Integrative Physiology and BiochemistryGeorgetown University School of Medicine

2017 CENTILE INTERNATIONAL CONFERENCEGeorgetown University Medical Center

Washington, DC October 24, 2017

Disclosures

I have no conflicts of interest to disclose

2 Main Types of Stress

Acute Stress: Survive and thrive

Chronic Stress: Can lead to dysfunction/disease

Excess Chronic Stress can result in Burnout

Acute Stres s :The 1 s t

Yea r Medica l Student

TheBurned Out Resident or

Clinical Faculty

Hypothalamus

Hypothalamus: Integrative Center of the Brain

Neural Connections:Cognitive-Emotional-Autonomic

Hypothalamus/CRH=Master StressHormone

Hypothalamus/CRH

Stimulates

Hypothalamus/CRH

Inhibits

Adrenals

Kidney

PosteriorPituitary Gland

Hypothalamus

AnteriorPituitary Gland

ACTH

StressCircadian

rhythm

CRH

(-)Glucocorticoids,

Catecholamines, etc..Glucocorticoids,

Catecholamines, etc..

Muscle:Net loss of aminoAcids (glucose)

Liver:Deamination of

proteins into amino acids,

gluconeogenesis (glucose)Fat Cells:

Free fatty acid

mobilizationHeart rate:Increased

Immune system:altered

Hypothalamopituitary adrenal (HPA) axis

Cortisol

1. CRH injected into brain ventricles increases locomotor activity

2. CRH facilitates the acoustic startle response

3. CRH produces increased responsiveness to “stress” in an open field test

4. CRH has an “anxiogenic-like” effect in the operant conflict test

5. CRH produces enhanced suppression of responding in conditioned emotional response test

6. CRH produces a dose-dependent facilitation of stress-induced fighting

7. CRH produces “anxiogenic-like” response in the plus maze

8. CRH produces a dose-dependent taste aversion and place aversion

Behavioral (Neurotransmitter) Effects of Corticotropin-Releasing Hormone (CRH)

CRH drives Major Depression in the Brain

Over-activation of CRH-ACTH-CORTISOL System inClinically Depressed Patients

Chronic Stress with High Cortisol may lead toAppearance of “Cushing’s-like” Features

CORTISOL high CORTISOL low

Moderate Loss of Resiliency

STRE

SS

HO

RMO

NE

LE

VEL

TIME

Optimal Pattern

Stressor

Severe Loss of Resiliency

Stressor

Stressor

Physiology of the Stress Response

Importance of the return to baseline…..if not, then:

Sustained high cortisol damages/destroys the neurons mediating cortisol negative feedback restraint on CRH

Chronic stress impairs memory, learning due to damage to hippocampal neurons with hippocampal volume reduction

Excess cortisol causes many metabolic substrate derangements (hyperglycemia, proteolysis, fat deposition)

Inhib itory e ffe cts

Decreases periphera l b lood lym phocytes , eos inophils , basophils , m onocytes , and neutrophils

Inhib its p roduction of IL-1 , IL-2 , IL-2 recep tor, γ-interferon Inhib its FC recep tor express ion Inhib its in vitro and in vivo prolifera t ion of T lym phocytes

to antigens and m itogens Inhib its m any m onocyte functions , includ ing antigen presenta t ion, lym phokine

production, d ifferentia t ion, and pha gocytos is Inhib its im m unoglobulin p roduction in vivo Inhib its T suppressor cell function in vivo and in vitro

Effects of Glucocorticoids in the Immune System

Stress on the GI Tract

Fullness Bloating

DiarrheaInflamed BowelDisrupts Cell BarriersAntibodies to Food

AntigensFood Sensitivities

Sympathetic nerves/norepinephrine,

frequent contraction

Chronic stress increases sympathetic drive to arterialblood vessels like coronary arteries and arterioles

Smooth muscle cellshypertrophy

Resting vesseldiameter reduced

Resting blood pressureIncreased

Extreme or Chronic stress, major constriction, loss of blood flow, myocardial infarction?

What is the Relationship of Stress to Cancer?

Beta receptor antagonistStress hormone blocker

Potent beta receptor agonist

Metastasis

The Chronic Stress

Cascade to Disease

Other HypothalamicReleasing Hormones Inhibited

Pituitary HormonesDecreased

Major hormonal and organ system impairment/failure

Proinflam m atory Cytokines

The most commonly studied interventions have involved mindfulness, stress

management, and small group discussions, and the results suggest that these strategies

can be effective approaches to reduce burnout domain scores.

Mind-Body Medicine: Therapies Meditation

Imagery

Biofeedback

Autogenic Training (self-hypnosis)

Breathing Techniques

Exercise

Yoga, Tai Chi

Group Support

Efficacy of Mind-Body Therapies Cons iderable Evidence

Coronary Artery Disease (cardiac rehabilitation) Headaches Insomnia Incontinence Chronic low back pain Disease and treatment-related symptoms of cancer Improving post-surgical outcomes

Astin et al Mind-Body Medicine: State of the Science, Implications for Practice. J Am Board Fam P ract16 :131 -147 , 2003

Benefits of Biofeedback Increased awareness and confidence in relaxation skills

Control over “involuntary” functions

Examples: recurrent migraine headache treatment of Raynaud’s disease urinary incontinence arthritis

Let’s try an Experiment Using your Mind-Body Physiology to Manage

Stress and Improve Resiliency:

Autogenic Biofeedback with aSimple Monitor

Neural Connections:Cognitive-Emotional-Autonomic

Hypothalamus/CRH=Master StressHormone

Mind-Body Medicine practices reduce stresssignaling to the hypothalamus and decrease CRH,lower stress hormone levels & reduce sympathetic activity.Result: Vasodilation, more blood flow to skin, increased warming.

Sympathetic nerves/norepinephrine,

frequent contraction

Chronic stress increases sympathetic drive to arterialblood vessels like coronary arteries and arterioles

Smooth muscle cellshypertrophy

Resting vesseldiameter reduced

Resting blood pressureIncreased

Extreme or Chronic stress, major constriction, loss of blood flow, myocardial infarction?