Zindel V. Segal, Ph.D., C.Psych Distinguished Professor of Psychology in Mood Disorders

Zindel V. Segal, Ph.D., C.PsychZindel V. Segal, Ph.D., C.PsychDistinguished Professor of Psychology in Mood DisordersDistinguished Professor of Psychology in Mood Disorders

Department of PsychologyDepartment of Psychology

University of Toronto ScarboroughUniversity of Toronto Scarborough

How Do Mindfulness-Based Interventions Promote Adaptive Clinical and Neural Pathways of

Emotion Regulation?

What do the Dalai Lama, Aaron Beck and Sigmund Freud Share in Common?

Situation Emotion 0 - 100%

Automatic Thought (AT)

Evidence to support your AT

Evidence Against your AT

Balanced/ Alternative Viewpoint

Re-rate Mood 0 –100%

I asked my sister to look after my son so that my husband and I could go out for dinner. She said no. She said I should spend more time with him now that I am back from the hospital.

Guilty 70% Rejected 80%

She is telling me how to raise my son.

My son said he is worried about me. My husband is doing most of my chores.

My son has made 2 new friends at school. I make sure to read to my son every night before bed.

Having depression doesn’t automatically make me a bad mother. When I condemn myself it is often the depression speaking.

Guilty 40% Rejected 40%

I am a bad mother.

Learning how to Regulate Distressing Emotions is Aided

by…

InsightMetacognitionDecenteringMindfulnessMentalizationCognitive Defusion

What is Mindfulness?What is Mindfulness?

MindfulnessMindfulness is a type of awareness that is is a type of awareness that is developed by paying attention in a particular developed by paying attention in a particular way: on purpose, in the present moment, and way: on purpose, in the present moment, and without judgment. without judgment.

Like any Like any skillskill it takes practice. it takes practice.

Accesses the present moment, thereby clarifying Accesses the present moment, thereby clarifying the range of the range of choiceschoices that are available to you. that are available to you.

Training Once Offered in Monasteries Is Training Once Offered in Monasteries Is Now Increasingly Available In Health and Now Increasingly Available In Health and

Mental Health CareMental Health Care

Eating MindfullyEating Mindfully

Scanning the Body Scanning the Body

Mindful Walking or StretchingMindful Walking or Stretching

Mindfulness of the BreathMindfulness of the Breath

Mindfulness of Thoughts Mindfulness of Thoughts

Episode

Symptoms

RecoveryTreatment

Episode

Episode

Depressive and Anxiety Disorders are Frequently Recurrent

Hollon, et al., 2005

What Is Required to Help Patients Become their Own Therapists?

Sadness

Worthless

Unloved

Stupid

Failure

Hopeless

Representation of negative views of self and emotion in semantic memory following an

episode of depression

Sadness

Worthless

Unloved

Stupid

Failure

Hopeless

Each additional episode of depression strengthens these links.

+

++

+

++

+

+

SadnessWarm

Curious

Ambitious

Worthless

Unloved

Stupid

Failure

Honest Hopeless

Generous

These Modes of Mind Can Be Retriggered Even When Depression is Not Present and Inhibit Positive Information

From Coming to Mind

+

++-

-

-

-+

++

+

+

-

-

-

-

Two Ways of Knowing

Mindfulness Based Cognitive Therapy Mindfulness Based Stress Reduction

8 weekly group sessions2 Hours per session, 8-12 participantsCommon diagnostic composition – depression / anxiety

Gradient of Attentional Focus in Mindfulness Training

TangibleTangible

IntangibleIntangible

• Mindful EatingMindful Eating• Body ScanBody Scan• Mindful Walking or Mindful Walking or

StretchingStretching• Sitting with the BreathSitting with the Breath• Sitting with Sounds Sitting with Sounds • Sitting with Thoughts Sitting with Thoughts • Sitting with a Difficulty Sitting with a Difficulty

Mindfulness Meditation Trains 2 Types of Attention (Lutz et al., 2008)Lutz et al., 2008)

Open MonitoringOpen Monitoring

• No explicit focus on objects of awareness.

• Non-evaluative labeling of experience.

Focal AttentionFocal Attention

• Directing attention on a chosen object.

• Detecting mind wandering.

Benefits of MBCT Depend on Practice Between Group Sessions

• 40 minute Body Scan• Mindfulness of a routine activity

• 40 minute Body Scan• Mindfulness of a routine activity

• 40 minute mindfulness of Breath / or mindful stretching/Yoga

• 3 minute breathing space

• 40 minute mindfulness of emotion / or mindful walking

• 3 minute breathing space

• 40 minute mindfulness of difficult emotions• 3 minute coping breathing space

• 40 minute mindfulness of difficult emotions• 3 minute coping breathing space

• 40 minute practice of your choice• 3 minute coping breathing space

• The rest of your life

S1: Awareness and Automatic Pilot

S2: Living in our Heads

S3: Gathering the Scattered Mind

S4: Recognizing Territory of Aversion

S5: Allowing / Letting Be

S6: Thoughts Are Not Facts

S7: Taking Best Take Care of Myself

S8: Maintaining and Extending NewLearning

ANCHORED IN EMOTIONALLY TURBULENT WATERS

Pre-Post Effect Size Estimates in Mindfulness Pre-Post Effect Size Estimates in Mindfulness Based Treatments – AnxietyBased Treatments – Anxiety

Funnel plot of precision by Hedges’s g for Anxiety measures = .63 (Hofmann et al., 2010)

Pre-Post Effect Size Estimates in Mindfulness Based Treatments - Depression

Funnel plot of precision by Hedges’s g for Depression measures = .59 (Hofmann et al., 2010)

Challenges Remain on the Efficacy Front

Geschwind et al., 2011

MBCT Increases Momentary Positive

Emotions

1. Experience Sampling 6 days pre and 6 days post MBCT.

2. Assessed Domains of Positive Affect, Pleasant Activity and Reward.

3. Compared MBCT to Wait List Control Group.

The ‘Present-Moment’ PathwayThe ‘Present-Moment’ Pathway

(Craig, 2004)

(Craig, 2009)

Attending to the BreathAttending to the BreathBreath Monitoring

(masking out exec function areas)Breath Monitoring Changes

Mindfulness Trained > Waitlisted Controls

Right insula is uniquely related to Mindfulness Training

Farb et al., Cerebral Cortex, 2012Farb et al., SCAN, 2013

Neural Changes Associated with Mindfulness & Sadness Challenge

Terms of Endearment (1983)

The Champ (1979)

HGTV (Crafts & Gardening)

Neutral Clips Sad Clips

Vs.

Following exposure to sadness...Following exposure to sadness...

Evaluation network goes up…

Present moment networkgoes down..

Mindfulness Training: Reducing Mindfulness Training: Reducing the Tradeoff…the Tradeoff…

Post. Midline Reduced

Control MBSR

Insula / ClaustrumRestored

Control MBSR

x = 8

x = 35

Sensory Representations MatterSensory Representations Matter

Right insula reductions may be maladaptive…

Restoration of activity to baseline

during emotion challenge is protective

Farb et al, 2010

Mood Linked Responses in Medial Prefrontal Cortex Predict Relapse @18 Months in Recurrent Unipolar Depression

Farb et al., 2011

Keune et al., 2013

State Effects of Mindfulness Increase Approach and Acceptance: Increases in Relative Right Frontal Hemispheric Asymmetry

Density of Practice Across 3 Treatment Types Within a Single

Week

050

100150200250300350400

# Minutes of Practice perWk.

Trad.Psychotherapy

CBT

MindfulnessIntervention

LESS A TREATMENT – MORE A WAY OF LIFE

Conclusions• Mindfulness is relevant to affect regulation.

• Can be integrated into standard treatments for mood and anxiety disorders.

• Benefits depend upon continued practice.

• Neural evidence of increased interoceptive competence combined with approach helps modulate frontal driven fear and ruminative processing.

Future Research Questions• Consensus definition of practice metrics needed.

• Relationship of participants’ practice to behavioural outcomes?

• Relationship of instructor’s practice to behavioural outcomes?

• Maintenance of behavioural and neural changes;

– Thunderclap or Drip Feed model best fit the data?