Mindfulness in Medicine
*Journal of the American Medical Association* (Vol. 300 No. 11, September 17) includes an article: “Mindfulness in Medicine.”
David S. Ludwig, MD, PhD, & Jon Kabat-Zinn, PhD, are the authors.
Here are some excerpts:
Mindfulness refers to a meditation practice that cultivates present
moment awareness. In the past 30 years, interest in the therapeutic uses
of mindfulness has increased, with more than 70 scientific articles on
the topic published in 2007. Meditation practices, including
mindfulness, have come to the attention of neuroscientists investigating
consciousness and affect regulation through mental training and to
psychotherapists interested in personal development and interpersonal
relationships. In this Commentary, we define mindfulness, consider
possible mechanisms, explore clinical applications, and identify
challenges to the field.
Mindfulness and Its Relationship to Medicine
Mindfulness involves attending to relevant aspects of experience in a
nonjudgmental manner. Historically a Buddhist practice, mindfulness can
be considered a universal human capacity proposed to foster clear
thinking and open-heartedness. As such, this form of meditation requires
no particular religious or cultural belief system. The goal of
mindfulness is to maintain awareness moment by moment, disengaging
oneself from strong attachment to beliefs, thoughts, or emotions,
thereby developing a greater sense of emotional balance and well-being.
The original purpose of mindfulness in Buddhism–to alleviate suffering
and cultivate compassion–suggests a potential role for this practice
with medical patients and practitioners.[1] Much cardiovascular disease,
diabetes, cancer, and other chronic illness is caused or exacerbated by
modifiable lifestyle factors, and lifestyle modification constitutes
primary or ancillary treatment for most medical conditions. An aim of
mindfulness practice is to take greater responsibility for one’s life
choices. Thus, mindfulness may promote a more participatory medicine by
engaging and strengthening an individual’s internal resources for
optimizing health in both prevention of and recovery from illness. For
intractable disease, meditative techniques that alter and refine
awareness may modulate the subjective experience of pain or improve the
ability to cope with pain and disability.
Implicitly, at least, mindfulness has always been part of good medical
practice, facilitating the physician’s compassionate engagement with the
patient. Epstein[2] suggests that “mindfulness is integral to the
professional competence of physicians” in promoting effective clinical
decision making and reducing medical errors. Indeed, the connection
between medicine and meditation is underscored by their shared
etymological origins in the Latin word mederi, which means “to heal.”
Mechanisms
There are many ways that mindfulness might influence susceptibility to,
or ability to recover from, disability and disease. These may include
(1) decreased perception of pain severity;
(2) increased ability to tolerate pain or disability;
(3) reduced stress, anxiety, or depression;
(4) diminished usage of, and thereby reduced adverse effects from
analgesic, anxiolytic, or antidepressant medication;
(5) enhanced ability to reflect on choices regarding medical treatments (eg, decision
to seek a second opinion);
(6) improved adherence to medical treatments;
(7) increased motivation for lifestyle changes involving diet, physical
activity, smoking cessation, or other behaviors;
(8) enriched interpersonal relationships and social connectedness; and
(9) alterations in biological pathways affecting health, such as the
autonomic nervous system, neuroendocrine function, and the immune
system. Most of these possibilities have not been rigorously examined.
Nevertheless, psychological stress has been linked to numerous medical
conditions.
Moreover, preliminary data suggest that mindfulness practice has a
profound and perhaps unique effect on brain function. In a study using
functional magnetic resonance imaging in 27 undergraduate students in
Los Angeles, California, Creswell et al[3] found that individual
disposition toward mindfulness was associated with widespread prefrontal
cortical activation and reduced bilateral amygdala activity during an
affect-labeling task, after controlling for various psychometric
covariates. Using electroencephalogram (EEG), Lutz et al[4] found that
highly experienced Buddhist monks produced, during meditation, long-
distance phase synchrony (suggestive of large-scale neural coordination)
and gamma activity with a higher amplitude than any reported in a state
of health. Davidson et al[5] randomly assigned participants in a corporate
setting to a mindfulness-based stress reduction group or a wait list
control group and reported increased left-sided anterior activation by
EEG (patterns associated with positive emotional experience) in the
stress reduction group. This group also demonstrated a greater increase
in antibody titers to influenza vaccine, and the magnitude of the EEG
change predicted the magnitude of antibody response. Tang et al[6]
reported that undergraduates in a Chinese university randomly assigned
to a mind/body intervention that included mindfulness showed lower
salivary cortisol and higher salivary IgA concentrations in response to
psychological stress (mental arithmetic task) compared with control
students who were given an intervention of equal intensity that focused
on relaxation. Thus, mindfulness training may be an effective way to
positively regulate brain, endocrine, and immune function, influencing
physiological and psychological variables important to well-being.
Clinical Applications
Pain, stress, coping, and quality of life comprise the original focus of
medical research into mindfulness. In 1982, Kabat-Zinn[7] reported
descriptive data from medical patients with chronic pain of 6 months to
48 years’ duration who received training in mindfulness-based stress
reduction. Among the 51 participants who completed the program (88% of
the 58 total enrolled), perceived pain decreased significantly during
the intervention, with half reporting a reduction of at least 50%. In a
study of 109 patients, aged 27 to 75 years, with various types of
cancer, Speca et al[8] found that compared with a wait-list control group,
those randomly assigned to the mindfulness group experienced
improvements of 65% in mood disturbance and 31% in symptoms of stress.
Others have found beneficial effects of mindfulness training on
acceptance of pain, severity of general medical symptoms, physical
functioning, and ability to cope with daily life.
Recently, a number of specific medical conditions have become the
subject of study. Based on research involving individuals with a history
of 3 or more episodes of major depression,[9] the National Health Service
in the United Kingdom recommends mindfulness-based cognitive therapy.
Mindfulness training has shown preliminary evidence of efficacy in the
treatment of psoriasis, type 2 diabetes, sleep disturbance, attention-
deficit hyperactivity disorder, and other conditions. Mindfulness, or
lack thereof, may have special relevance for obesity and eating
disorders. In one study, lean and obese young adults were given a meal
of soup in special bowls that, unbeknownst to them, slowly refilled as
their contents were consumed. These individuals ate 73% more than those
who consumed soup from normal bowls. Of particular note, they did not
believe they had consumed more, nor did they report being more satiated
than the other participants.[10] Thus, mindfulness could inform not only
the choice of what to eat but also the awareness of having eaten enough.
In a pilot study, a small group of young women with bulimia nervosa
reported a reduction in emotional and behavioral extremes and greater
self-acceptance after mindfulness training.[11] The use of mindfulness
training in pain, hypertension, myocardial ischemia, inflammatory bowel
disease, human immunodeficiency virus, and substance abuse is presently
under investigation in research supported by the National Institutes of
Health (NIH).
<snip>
Conclusion
The current age has been referred to as one of “continuous partial
attention.” E-mail, cell phones, and other technology invade nearly
every moment of waking life. Economic pressures demand ever-increasing
productivity, even as time to enjoy the fruits of labor declines. These
factors adversely affect the health care system overall and diminish the
patient-physician relationship. In this context, mindfulness may hold
promise as a potential way to help prevent and treat disease, increase
ability to cope with pain and chronic illness, reduce stress in patients
and practitioners, foster compassion, improve quality of care and reduce
medical errors. High-quality, mechanism-oriented studies and randomized
controlled trials of mindfulness in medicine are needed.
[end excerpts]
The author note provides the following contact information: David S.
Ludwig, MD, PhD, Department of Medicine, Children’s Hospital Boston, 300
Longwood Ave, Boston, MA 02115 (<david.ludwig@childrens.harvard.edu>).
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