Multiple sclerosis is a chronic illness; people have it for a lifetime. Because it is a disease of decades—not days—it is can be hard for people to believe that how they manage MS every day makes much difference in the long run. But all sorts of research—on the brain, on aging, on MS—increasingly supports the idea that it does. At the Rocky Mountain MS Center we believe that a three-part treatment strategy to protect the brain and promote brain health offers the best chance to minimize the lifetime impact of MS.
The use of disease-modifying therapies to reign in the damage MS does in the brain is one important part of this strategy. Another is regular physical and mental exercise, social engagement, and active participation in life to promote brain resilience and build cognitive reserve. Wellness strategies—a good diet, exercise, adequate sleep, stress management—to prevent the development of secondary medical problems like heart disease, obesity, and diabetes that strain the system and ultimately strain the brain form the important third part of this approach.
Although stress management always makes the list of wellness strategy “must-dos,” for most of us stress is an unavoidable fact of everyday life that we mostly manage by trying to avoid it. Until fifty years ago, no one even paid much attention to stress as a health issue, although some people with MS have long insisted that it makes them worse and contributes to exacerbations. Today we recognize that chronic stress—whether someone has MS or not—is a risk factor for all kinds of medical problems, and learning how to manage it is important for our overall wellness.
There are lots of healthy and unhealthy ways to deal with stress. Drinking too much is one. Ridding our lives of drain-ing but unimportant commitments, regular exercise, and long vacations, are probably more healthy options. In the past few decades, and especially in the past few years, mindfulness has begun to receive an incredible amount of attention as another strategy, not only to reign in stress but also to promote brain resilience and build cognitive reserve.
This issue of InforMS will look explore stress—what it is, how it affects our health— and some of the mindfulness-based strategies that are prescribed to manage it.
WHY IS STRESS A PROBLEM?
The human body is a complex, interactive system that is simultaneously very stable and very adaptive. Our body strives to be in a well-regulated equilibrium—homeostasis—that we maintain by constantly changing. Stress can be loosely defined as those times when the demands of our internal or external environment strain our capacity to maintain this equilibrium. How we deal with stress is a complicated interaction of physiology, personality and environment.
The human body has a metabolic strategy to manage threats to its stability—the stress response—that provides us with the physiological resources to manage life-threatening situations and survive. It comes from an older part of the brain, the limbic system, which developed in simpler times when the threats we faced were terrifying but fairly unambiguous. “Fight or flight” describes the limited options available to our ancestors. The possible outcomes of their conflicts were pretty straightforward: they escaped, were victorious in battle, or they were lunch. End of story. The stresses they confronted were enormous, but they didn’t last long, and the body, if there still was a body, could then turn off the stress response and relax.
The stress response is controlled by the autonomic nervous system, which maintains the basic operations of the human body and regulates such functions as heart rate, digestion and immune functioning. Most of the actions of the autonomic nervous system are independent of conscious control, but some, such as breathing, work in tandem with the conscious mind. These systems keep the body on track and maintain our physiologic infrastructure.
The stress response is non-specific, which means that it responds to all threats in pretty much the same way. Triggering it is automatic in the face of a severe threat and is the physiological equivalent to dialing 911. It is primarily mediated by two hormones, adrenaline and cortisol, that circulate in our blood all the time, but at increased levels during times of stress. These hormones alter metabolism. Adrenalin pro-vides the body with a rush of available energy so that it has increased resources to deal with whatever the threat. Cortisol helps get that energy to the organs that most need it by turning off all non-essential activities. Energy is rushed to the heart, lungs and muscles and diverted from non-essential functions such as digestion and growth. Until the stress response is shut down these hormones—especially cortisol—continue to circulate in the blood at elevated levels.
The importance of shutting down the stress response after a crisis is over cannot be overstated. It is critical to our general health to have normally low levels of the stress hormones, especially cortisol. Chronically elevated levels of cortisol are implicated in many common diseases—from altered thyroid functioning to heart disease.
OUR COMPLICATED RELATIONSHIP WITH STRESS
The threats we face today are different from those faced by our ancestors. What threatens our equilibrium today is less quantifiable, immediate, and more psychological—fears of terrorism, global warming, 24-hour news cycles that bombard with us with unsolvable problems, perpetual traffic jams, computer crashes, and chronic slow-moving diseases, like multiple sclerosis.
Humans have a more complicated relationship with stress than other animals. Our stress response is also turned on by thoughts and emotions, so we use it to manage psychological threats even though this isn’t what it was designed to do. It does this anyway, because automatic activation of the stress response is our default setting.
We have another feature that further complicates our ability to manage stress—the frontal lobes. This is the part of the brain that allows us to create, organize, anticipate and problem solve. It is also the part of the brain that keeps us awake at night imagining disastrous scenarios that might—but probably won’t—happen in the future. Like the stress response, this worry response can operate outside of our awareness.
THE IMPACT OF STRESS
The net result of unremitting psychological stressors is an elevated level of stress hormone that affects our metabolism just as it would if we were fighting off a predator, but with a critical difference. A physical threat and the accompanying stress response will usually resolve fairly soon. A psychological threat can go on endlessly and so can the stress response.
When we chronically use the “stress response” to manage unending, psychological stresses that lack clear-cut solutions we deplete the metabolic resources that are available to fund our general health and any other emergency. Stress management is all about learning to conserve this resource.
SO WHAT CAN WE DO ABOUT STRESS?
The stress response is automatic. It is our default setting. But there are elements of stress that are more variable. Understanding what these are gives us a window into the things that perhaps we can learn to manipulate.
DON’T BELIEVE EVERYTHING YOU THINK
According to neurobiologist Robert Sapolsky, there are some specific attributes of psychological stressors that can make a stress response bigger or smaller. The perception that we have some control over what’s happening to us can diminish the stress response. This can be actual control or just the perception of control. Predictive information that allows us to anticipate what’s coming next can also decrease the impact of a psychological stressor. A lack of predictability alone can trigger a stress response.
A stress response is less likely when a person has an outlet for frustration. Exercise is a classic stress reliever because it provides both a distraction and a mechanism for discharging all the energy generated by the stress. Finally the stress response is more likely to be triggered when we perceive that a situation is getting worse and when we feel socially isolated.
Although the stress response is automatic, many of the factors that influence it are not. The event is neutral. Stress comes from the meaning we attach to it. There are many different ways to tame the stress response and dampen power. Mindfulness approaches do this by interrupting the automatic nature of the process.
Mindfulness is an imprecise term. In general, it refers to different strategies for focusing awareness and attention. It descends from the Buddhist meditation tradition but in the last few decades it has morphed in scope and expanded in popularity. A variety of approaches—ranging from the religious to the strictly secular—hang out under the mindfulness umbrella, and people use them for multiple reasons—as paths for personal and spiritual growth, as medical interventions to reduce pain and manage stress, as tools to improve college test scores.
Meditation, an aspect of mindfulness, has been a spiritual practice for several millennia. Mindfulness meditation, a healthcare intervention to manage stress, has been with us since the 1970s. Today, programs that teach different iterations of mindfulness are found in such diverse places as cancer centers, primary care clinics, the US military, yoga retreat centers, elementary schools and American corporate boardrooms. Mindfulness is the focus of lots of research.
In 1980, there were no research publications on mindfulness. In 2012, there were close to 500. Although there is little consensus about what mindfulness is, how it works, precisely how, why, and for what it’s helpful, the mounting data does suggest that it’s potentially useful for lots of things, including managing the stress, mood and quality of life problems that are common in chronic illness. For that reason, patients are often encouraged to go get some mindfulness training. But does that actually look like?
MINDFULNESS: ONE SIZE DOES NOT FIT ALL
A common misconception about mindfulness is that it necessarily involves quietly sitting still and meditating. For some people, that wouldn’t relieve stress, it would cause it. Fortunately, mindfulness can be found different forms, and some use techniques in addition to or instead of meditation.
THE RELAXATION RESPONSE—TAKE A DEEP BREATH AND COUNT TO TEN
Herbert Benson, a physician, researcher, and professor at Harvard Medical School pioneered much of the early research on interventions to reign in the stress response. When he began studying relaxation techniques in the 1970s, some of his first research subjects were practitioners of Transcendental Meditation. Ultimately, his research established the efficacy of meditation as an intervention to reduce stress and led him to develop a stress management protocol—the relaxation response.
The relaxation response is the opposite of the stress response. The autonomic nervous system brings us the stress response via the sympathetic nervous system. It also brings us the relaxation response via the parasympathetic nervous system. Because these two systems cannot operate at the same time, we can deactivate the stress response by simply activating the relaxation response. When we do this, our metabolism gets a break.
The relaxation response, in common with many mindfulness approaches, focuses on breathing. Why, beyond the obvious reason, is breathing so important? Most of the functions of the autonomic nervous system operate outside of conscious control, but some, such as breathing, work in tandem with the conscious mind. How we breathe is something we can consciously regulate, so focusing on breathing provides us some access to this otherwise automatic process.
There are other ways besides the one Benson teaches to invoke the relaxation response. Yoga, meditation, and progressive muscle relaxation can each help decrease the body’s physiological response to chronic stress.
MINDFULNESS VERSUS MINDLESSNESS: CHANGING YOUR MIND
Another Harvard professor, social psychologist Ellen Langer, also began studying mindfulness in the 1970s. For the past 35 years she and her colleagues have researched mindfulness as a tool to enhance creativity and forestall the effects of aging, but with a twist: she studies mindfulness from a practical, Western perspective that involves neither meditation nor sitting still.
For Langer, mindfulness is the antithesis of mindlessness. We get into trouble because we are mindless. We want predictability, which we can’t have, because things are always in flux. We become frustrated and stressed when things don’t go the way we think they should.
Mindfulness is achieved when we pay attention to the present and explore situations for novelty. Langer encourages us, in the face of setbacks, to ask the question, “Is it a catastrophe or an inconvenience?” Often, at the root of what is eventually viewed as amazing innovation, was something originally seen as a disaster. The ubiquitous Post-It Note is the classic example of product development failure—glue that didn’t stick very well—that actually worked out rather nicely.
As an antidote to mindlessness, Langer suggests that we make it a habit to notice five new things about the people with whom we commonly interact and the places we go. “When we travel we expect everything to be new and so we notice, become engaged, and enjoy ourselves. When we’re not on vacation, we suffer from an illusion of stability and think everything is still the same. Everything is always changing and looks different from different perspectives. Bringing that expectation of not knowing to our daily lives will encourage us to actually notice and be in the present.”
The ability to change our focus and see different perspectives is a skill. At the most basic is the classic optical illusion. Artist Sarah Richter (see Sensory Paradox) is another example. The diagnosis of multiple sclerosis and the accompanying vertigo and visual changes rocked her world. However, that experience forced her, literally, to see the world differently and eventually took her art in an entirely new and innovative direction.
MINDFULNESS-BASED STRESS REDUCTION
In the 1980s, Jon Kabat-Zinn, a molecular biologist working with patients at the University of Massachusetts Hospital, developed an eight-week stress reduction program to help people manage severe chronic pain. His approach, mindfulness-based stress reduction, or MBSR, incorporates yoga, meditation, and body scans, and is probably the best known of the mindfulness programs. The Center for Mindfulness at University of Massachusetts has trained thousands of instructors in MBSR, the method commonly used in clinics, hospitals and treatment programs.
Kabat-Zinn describes mindfulness as “paying attention, in a particular way, on purpose, in the present moment, non-judgmentally.” When we practice “paying attention,” we change our ability to notice and to voluntarily direct our attention. Our brains have a limited capacity to attend to things. When we are stressed this capacity becomes depleted. We have trouble determining what is important and what needs attention. As a result, we can be easily distracted by and over-reactive to things that are not important and have trouble focusing on the things that are. Stress results from too much focus on things that don’t matter and too little focus on things that do.
There are many different forms of meditation. According to mindfulness expert and researcher Richard Davis, “The word ‘meditation’ is equivalent to a word like ‘sports’ in the U.S. It’s a family of activity, not a single thing.” Different meditative practices require different mental skills, and may have different effects on the brain but have in common a non-judgmental aware-ness. Meditation aids the development of mindfulness and is central to it, but mindfulness is more than meditation.
DO THEY WORK?
The initial aim of mindfulness programs, in whatever their form, was as a tool to help people manage stress. For the most part, most people—from researchers and experts, to skeptics and fans—would agree that they generally help people do that. And, very likely, they have other benefits as well. For example, a recent review in JAMA found that mindfulness is modestly effective at helping people manage anxiety, depression and pain. Studies of their effects on people with MS have found similar results. They can have a positive impact on mood, anxiety, quality of life, pain and fatigue.
In the past decade or so, re-searchers have been looking beyond the stress-reducing effects of mindfulness and have begun to explore the impact these interventions might have on the structure and function of the brain. This is difficult re-search to do for lots of reasons: because there aren’t uniform definitions of mindfulness, there aren’t clear ways to measure it, it’s hard to get control groups, study samples are small, and on and on. So, although studies are suggesting some intriguing findings about the potential benefits of mindfulness and meditation, this research is in its infancy and there is no consensus about what it does and how any of it works.
That is not, however, the impression one might get when reading reports in the popular press. Stories abound about the staggering power of mindfulness—that it improves neuroplasticity, increases gray matter, kills pain better than morphine, helps us resist the temptation to indulge in sweets, slows aging, improves your company’s bottom line, cures addictions, reduces hospital admissions . . . Seemingly the only claims that haven’t been made it its behalf are that it will whiten your teeth and remove the dents in your car bumper.
Is it all hype? No, probably not. The popular press is prone to over-interpret or misinterpret the results of scientific studies. The actual research literature is less effusive. Almost no one disputes the potential of these programs to help diminish the physiological responses to stress. And that, by itself, could be a tremendous boon, even if it didn’t whiten your teeth. Being more focused and less reactive could help you see alternatives and possibilities, which could make you feel more hopeful and inclined to try some new things, which would increase your participation in life, which could improve your energy.
IS IT WORTH A TRY?
Probably, if you are stressed, anxious, tired, in pain, depressed, overwhelmed or just plain curious. Regular use of any of these approaches is likely to be helpful for a wide range of stress-related problems. However, all of these—whether learning to relax, or to meditate, or to turn off automatic pilot and pay attention—are skills and as is true with any skill, the more you practice,
the better you get. None of them will work if you don’t actually do them.
There are a lot of different ways to give it a try. There are brief meditation and mindfulness programs that can be accessed online. A search for MBSR programs will reveal both online and local options. There are all sorts of other online options as well.
YES, THERE IS AN APP FOR THAT
In fact, there are hundreds. There is also just a touch of irony that the cell phone—which practically invented distraction, and certainly helped to perfect it —is now the source of multiple applications to remedy it. Nonjudgmentally, however, we will let that thought go…
There have been a number of reviews of iPhone and Android apps in the past few years. Probably the most comprehensive was done in 2015 by a group in Australia that conducted a very systematic search for mindfulness meditation phone apps. They found more than 500 that they then screened for, among other things, the quality of instruction provided and the types of meditations included. That whittled the list down to 23. These were then rated according to how engaging, easy to use, and attractive they were. The top five were: Headspace, Smiling Mind, iMindfulness, Mindfulness Daily, and Buddhify 2.
Some are free. Some offer a free introductory package. To see the full review, and view details about all 23 apps, see: http://tinyurl.com/InforMS-mindfulapps1
For another review that includes several apps not included in the review above: http://tinyurl.com/InforMS-mindfu-lapps2
The Internet abounds with information and websites about mindfulness, relaxation, and meditation. There is a wealth of general information and guided medita-tions websites. One of many, many is www. franticworld.com. It offers general information and a selection of guided meditations.
To get more information about the different approaches mentioned in this article:
- To learn more about Herbert Benson and the relaxation response: www.bensonhenryinstitute.orgm
- To learn more about Ellen Langer, http://tinyurl.com/InforMS-Langer
- To learn more about mindfulness-based stress reduction (MBSR): http://tinyurl.com/InforMS-stressreduction
- The National Institutes for Health Center for Complementary and Integrative Health offers some general information about meditation: http://tinyurl.com/InforMS-meditation
- For more information about the neuroscience behind mindfulness: http://tinyurl.com/InforMS-mindful-science
Mindfulness also has its own magazine: Mindful, available on newsstands everywhere.
And, if none of the above appeal to you, there is also a line of mindfulness coloring books to provide “anti-stress therapy for busy people.” These are available through Amazon, Barnes and Noble, Powell’s and others.