Mindfulness-Based Stress Reduction, Mindfulness-Based Cognitive Therapy, and Zen Meditation for Depression, Anxiety, Pain, and Psychological Distress Mindfulness has been described as a practice of learning to focus attention on moment-bymoment experience with an attitude of curiosity, openness, and acceptance. Mindfulness practices have become increasingly popular as complementary therapeutic strategies for a variety of medical and psychiatric conditions. This paper provides an overview of three mindfulness interventions that have demonstrated effectiveness for psychiatric symptoms and/or pain. The goal of this review is to provide a synopsis that practicing clinicians can use as a clinical reference concerning Zen meditation, mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT). All three approaches originated from Buddhist spiritual practices, but only Zen is an actual Buddhist tradition. MBSR and MBCT are secular, clinically based methods that employ manuals and standardized techniques. Studies indicate that MBSR and MBCT have broad-spectrum antidepressant and antianxiety effects and decrease general psychological distress. MBCT is strongly recommended as an adjunctive treatment for unipolar depression. The evidence suggests that both MBSR and MBCT have efficacy as adjunctive interventions for anxiety symptoms. MBSR is beneficial for general psychological health and stress management in those with medical and psychiatric illness as well as in healthy individuals. Finally, MBSR and Zen meditation have a role in pain management. (Journal of Psychiatric Practice 2012;18:233–252) KEY WORDS: mindfulness, meditation, unipolar depression, anxiety, mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), Zen meditation
In recent years, practices and interventions involving mindfulness have become increasingly popular as complementary mind-body therapeutic strategies for a variety of medical and psychiatric conditions. As a consequence, there is a rapidly expanding sci-
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WILLIAM R. MARCHAND, MD
entific literature documenting trials of mindfulness practices (MPs). These studies include those investigating the enhancement of psychological well being among individuals with general medical conditions as well as research involving the use of MPs as specific treatment interventions for psychiatric illness. Many investigations have been preliminary in nature and authors of reviews1,2 have described methodological limitations in some studies. However, several recent articles have reported results of very high quality research that were published in journals with very high impact factors. Two examples of such publications are the work of Zeidan and colleagues on brain mechanisms supporting the modulation of pain by mindfulness meditation, published in the Journal of Neuroscience,3 and that of Segal and colleagues on mindfulness-based cognitive therapy (MBCT) for relapse prophylaxis in recurrent depression, published in the Archives of General Psychiatry.4 Studies such as these indicate that both the utilization of MPs for psychiatric illness and investigations of underlying neural mechanisms should now be considered in the mainstream of scientific discourse. Furthermore, MBCT is now included as a group intervention in the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Major Depressive Disorder.5 Given the attention MPs have received in the media as well as in the scientific literature, practicing clinicians need to be familiar with these interventions. Such knowledge is critical in order to be able to respond to questions from both patients and the genMARCHAND: George E. Wahlen VAMC and University of Utah, Salt Lake City. Copyright ©2012 Lippincott Williams & Wilkins Inc. Please send correspondence to: William R. Marchand, MD, VHASLCHCS 151, 500 Foothill Drive, Salt Lake City, UT 84148.
[email protected] This work was supported by a Department of Veterans Affairs Career Development Award. Additional support was provided by the resources and the use of facilities at the VA Salt Lake City Health Care System. The author declares no conflicts of interest. DOI: 10.1097/01.pra.0000416014.53215.86
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eral public. Furthermore, clinicians will need adequate information to determine if and when referrals for mindfulness-based interventions are appropriate as well as how to discuss such referrals with patients. This review focuses on three meditation practices aimed specifically at developing mindfulness6 and for which there is enough evidence to recommend their clinical use: Zen meditation, mindfulness-based stress reduction (MBSR) and MBCT. It is important to note that several additional interventions, such as Vipassana meditation, acceptance and commitment therapy,7 and dialectical behavior therapy8 are often also referred to as “mindfulness” approaches.9 However, these three interventions are beyond the scope of this article, and readers are referred to a recent review by Chiesa and Malinowski9 for more information about these methods.
MINDFULNESS AND MINDFULNESS MEDITATION Mindfulness is a state of consciousness during which one consciously attends to his or her moment-tomoment experience.10 It has been described as a practice of learning to focus attention and awareness on moment-by-moment experience with an attitude of curiosity, openness, and acceptance. In other words, practicing mindfulness is simply experiencing the present moment, without trying to change anything.11,12 Awareness is focused on external sensory inputs, such as auditory, olfactory, and visual stimuli, as well as internal sensations, such as proprioception and pain. Furthermore, attention is specifically focused on awareness of the internal workings of the mind,11 including thoughts and emotions. Thus, during mindfulness, one becomes an observer of one’s own stream of consciousness (the flow of thoughts in the conscious mind). An analogy frequently used by practitioners is that one may observe thoughts coming and going like clouds in the sky. A key feature of mindfulness is the ability to observe thoughts and emotions with some detachment, so that they do not carry one away. The word “meditation” derives from Latin meditari, which means to engage in contemplation or reflection.9 Meditation encompasses a number of practices generally aimed at bringing mental processes under voluntary control through focusing attention and awareness.13 One definition is that meditation is a practice of mental silence, in which
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the activity of the mind is minimized without reducing the level of alertness.14 Meditation is often divided into two main categories, mindful and concentrative styles.15 Mindful styles are characterized by open, nonjudgmental awareness of sensory inputs and include a meta-awareness of the ongoing contents of thought, whereas concentrative types of meditation involve focused attention on a given object such as an image or a mantra, while excluding potential sources of distractions.9 Mindfulness meditation practice has been defined as a “scaffolding” used to develop the state, or skill, of mindfulness.16 Thus, meditation refers to a specific technique, such as seated meditation (discussed below) used to develop mindfulness or for self-exploration or spiritual growth. In contrast, mindfulness is a state of mind that can be experienced during meditation or at any time during one’s daily life. A general aim of mindfulness practices is the development of mindfulness skills during meditation, which can be increasingly utilized in other situations throughout one’s day. With regard to terminology, mindfulness and other meditation practices are often included in the general term, contemplative practices.9 However, it has been pointed out9 that this term is potentially misleading, as contemplation suggests an active engagement with a specific content of thought or experience, while, in contrast, mindfulness emphasizes nonengagement with specific content. In addition to the general description of mindfulness provided above, a more detailed understanding is likely to be useful for clinicians. One practical model has been developed by Shapiro and colleagues.17 They proposed three essential components of mindfulness: 1) intention, 2) attention, and 3) attitude. It is important to note that these are not thought of as separate stages, but rather intertwined aspects of a single process. This model may be particularly useful for clinicians because these core components are readily understandable and can be used in discussions with patients, for example, when recommending MPs as a complementary treatment. Intention The component of intention is the why behind an individual’s practice.17 In Buddhist traditions, the intent was primarily the attainment of enlightenment and thus liberation from suffering for oneself
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as well as for other sentient beings. For patients with depression, anxiety, or pain, the initial intention will likely be to decrease these symptoms, in other words, self-regulation. However, there is evidence that, as meditators practice over time, their intentions may shift along a continuum from self-regulation, to selfexploration, and finally to self-liberation.18 The same study also found that outcomes were correlated with intentions. For example, those whose goal was selfregulation attained self-regulation and those whose goal was self-exploration attained self-exploration.18 One potential advantage of MPs is that they offer the possibility of self-exploration and spiritual growth in addition to symptom reduction. Thus, patients who have an interest in these outcomes may be particularly good candidates for complementary treatment with MPs. Attention Attention is the component of mindfulness that facilitates awareness of moment-to-moment experience.17 In MPs, new practitioners are first educated about the benefits of paying attention to the here and now. Methods of meditation are then taught to achieve the ability to maintain this awareness. The eventual goal is not only maintaining moment-to-moment awareness while meditating but also, as described above, throughout one’s day-to-day life. Attitude The final component in Shapiro et al.’s model is attitude.17 This aspect has to do with how one pays attention to the here and now. Mindfulness requires focusing attention on moment-by-moment experience with an attitude of curiosity, openness, and acceptance. This attitude promotes self-acceptance and compassion for the self. It is also thought to facilitate the capacity not to continually strive for pleasant experiences or to push aversive experiences away but rather to accept things as they are.17
BRIEF REVIEW OF THE THREE PRACTICES The following section provides a brief overview of the three mindfulness practices discussed in this article. For a more detailed review of the characteristics of these and other MPs, please see the recent article by Chiesa and Malinowski.9
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Zen Meditation MPs originated in Buddhist spiritual practices.19 Zen is a traditional Buddhist approach to mindfulness,20,21 while, in contrast, MBSR and MBCT are secular, clinically based group therapy methods that utilize manuals and standardized techniques. However, it is important to note that Zen can be practiced as a secular means to achieve mindfulness.6 This method can be used by those with any religious orientation as well as by individuals without any spiritual beliefs at all. Most Zen centers in the United States serve a mix of Buddhist and nonBuddhist practitioners and support the secular use of this approach to mindfulness. Furthermore, most Zen teachers welcome prospective students whose primary motivation may be to decrease stress rather than to gain spiritual growth. Zen primarily involves the practice of developing mindfulness by means of seated meditation.20,21 During meditation periods, known as Zazen, practitioners sit silently without moving on either a cushion or in a chair.21 In order to develop mindfulness, Zen meditation typically focuses on awareness of the breathing pattern. Beginners start by counting breaths,9 but more advanced practitioners simply sit with a focus on the here and now (including the breath), known as Shikantaza.22 Zen meditation can be practiced alone or with a group. However, Zen centers typically provide opportunities throughout the week for students to meditate in a group setting. Another Zen technique used in some traditions is koan study. Koans are riddle-like sayings that are unsolvable by logic.9 Practitioners focus on a specific koan during meditation with the aim of solving it. Among other things, koan study facilitates the shifting of perspective from one’s ego-based world view. This may facilitate the reperceiving associated with the psychological mechanisms of mindfulness (see discussion below). Zen centers typically provide a variety of offerings for community practitioners, in addition to frequent opportunities for sitting together in short meditation sessions. These typically include lectures on Zen and meditation as well as meditation retreats lasting from 1 to several days. Mindfulness-Based Stress Reduction (MBSR) MBSR was developed by Dr. Jon Kabat-Zinn at the University of Massachusetts Medical Center as a
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secular method of utilizing Buddhist mindfulness in mainstream psychology and medicine.11 In addition to mindfulness, MBSR includes education about stress as well as training in coping strategies and assertiveness. The mindfulness component includes sitting meditation, a body scan (focusing on bodily sensations), and hatha yoga. The body scan is a process during which attention is moved from region to region of the entire body. The hatha yoga practice incorporates stretches, postures, and breathing exercises aimed at relaxing and strengthening the musculoskeletal system. Finally, MBSR involves the cultivation of a number of attitudes, including becoming an impartial witness to one’s own experience, acceptance of things as they actually are in the present moment, and not censoring one’s thoughts and allowing them to come and go.11 Mindfulness-Based Cognitive Therapy (MBCT) MBCT was developed by Zindel Segal, Mark Williams, and John Teasdale.23 MBCT is based on MBSR and combines the principles of cognitive therapy with those of mindfulness to prevent relapse of depression. MBCT, like MBSR, utilizes secular mindfulness techniques including seated meditation. The program specifically teaches recognition of deteriorating mood with the aim of disengaging from selfperpetuating patterns of ruminative, negative thoughts that contribute to relapse.23 Summary The three MPs described above have several similarities and differences that clinicians need to be aware of. Key characteristics are summarized in Table 1. In Zen, seated meditation (which may include koan study) is the primary intervention. This may be supplemented and supported by lectures, individual meetings with a teacher, and opportunities to engage in meditation retreats ranging in length from 1 day to several months. MBSR and MBCT utilize meditation programs that include sitting meditation (similar to Zen), a body scan, and hatha yoga.11,23 All three MPs incorporate an educational component. In Zen, these are classically known as Dharma talks. The term “Dharma” is associated with a number of eastern philosophical traditions and has several meanings. In the context of lectures by Zen teachers, it typically refers to the teachings and doc-
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trines of Buddhism. MBSR includes education about stress and coping strategies.11 As described above, MBCT specifically teaches recognition of deteriorating mood with the goal of disengagement from patterns of ruminative thought that contribute to depressive relapse.23 Perhaps the most important difference among the three MPs is in their overall aim. Zen is a religious and spiritual practice. The ultimate goal is attaining insight about the true nature of reality in general and of the self in particular. This state of mind, known as awakening, is believed to facilitate freedom from suffering, which is the result of an incorrect understanding of reality. In contrast, the purpose of MBSR and MBCT is to gain relief from psychiatric and physical symptoms.
HOW DO MINDFULNESS INTERVENTIONS WORK? Studies suggest that MPs may target mood, anxiety, and pain symptoms through several mechanisms. The processes underlying the effects of MPs can be discussed in terms of both psychological and biological mechanisms. While not mutually exclusive, this distinction is useful for discussion purposes. Psychological Mechanisms Shapiro et al. posited that the fundamental psychological mechanism of MPs is one of shifting perspective, which they termed reperceiving.17 In their model, reperceiving occurs as a result of the mindfulness components of intention, attention, and attitude described above. Reperceiving is defined as a fundamental shift in perspective, so that one is able to step back from, and be less identified with, one’s own thoughts and emotions.17 In other words, by paying nonjudgmental attention to the contents of their consciousness, practitioners gain awareness that they are greater than their thoughts and emotions.17 As Shapiro et al. pointed out, this could be expressed as, “this pain is not me” or “this depression is not me.” Becoming less identified with one’s emotions and cognitions results in these mental processes losing power. For example, negative thoughts may be less likely to lead to depression, and negative affect may be less likely to persist. Furthermore, reperceiving may also lead to a realization that self is only a psychological concept made up of changing
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Table 1. Characteristics of three mindfulness practices Characteristics
Practices Zen meditation
MBSR
MBCT
Seated mindfulness meditation
Yes
Yes
Yes
Koan study
Yes (depending on tradition)
No
No
Meditation instruction
Yes
Yes
Yes
Religious/spiritual versus secular
Religious/spiritual, but frequently practiced as secular mindfulness and self-exploration technique
Secular
Secular
Group therapy format
Instruction and meditation typically occur in a group format but not considered “group therapy”
Yes
Yes
Body scan
No
Yes
Yes
Hatha yoga
No
Yes
Yes
Cognitive therapy
No
No
Yes
Aim to develop insight about the true nature of self and reality in order to achieve freedom from suffering
Yes
No
No
Aim to alleviate unwanted physical and psychological symptoms
May be initial motivation, but can progress to more spiritual purposes over time
Yes
Yes
Duration of intervention
Unlimited
Limited; often Limited; often provided as an provided as an 8-session intervention 8-session intervention
MBSR = mindfulness-based stress reduction, MBCT = mindfulness-based cognitive therapy
memories, beliefs, sensations, and ideas.17 Thus, by practicing mindfulness, one becomes less identified with the concept of self and less attached to an egocentric world view. This shift in perception can facilitate increased compassion and concern for both self and others. Moreover, it can lead to decreased distress when the concept of self is threatened, whether the threat is actual (e.g., old-age and death) or perceived (e.g., negative thinking about the self). Considerable evidence supports the model proposed by Shapiro et al., including a study suggesting that reperceiving is associated with MBSR,24 as well as studies indicating that meditation practices improve attention.25–30 This model is also consistent with evidence that MPs appear to decrease psychological and physical distress, at least in part, by altering aspects of self-referential thinking (dis-
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cussed in detail below). This includes both the extent and content of thoughts about self as well as one’s understanding of, and emotional response to, these cognitions. A large literature implicates dysfunctional self-referential thinking in the etiology of mood and anxiety disorders. Aberrant self-schemas (beliefs and ideas about self) form the basis for some models of the psychology of depression, for example Beck's classic approach to depression31 and a model developed by Teasdale et al.32 Furthermore, studies going back several decades that have investigated a variety of populations suggested complex relationships between self-concept and depression. In general, these investigations indicated an association between low self-concept and/or negative selfschemas and depression.33–37 Moreover, there is com-
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pelling evidence that processing of self-referent information is abnormal in affective illness.38–41 Other research also suggests that an association exists between self-esteem and mood and anxiety disorders, including bipolar disorder,39,42 generalized anxiety disorder,43 obsessive-compulsive disorder,44,45 PTSD,46–48 social phobia,49,50 and panic disorder.51 Finally, the effectiveness of interventions targeting negative schemas through cognitive therapy for the treatment of mood disorders is well established.5,52–55 However, in addition to the content of thoughts about self (i.e., schemas and self-esteem), the extent and type of self-referential thinking is also important. Individuals with unipolar depressive illness demonstrate increased self-focus.56,57 Excessive selffocus in general is associated with negative affect58 and self-focused rumination is associated with depression,59–61 including depressive relapse.62 With regard to the type of self-referential thinking, there is evidence that two general modes exist: narrative and experiential self-reference. Narrative selfreference is a concept of self that is extended in time and includes both memories of the past and intentions for the future.63 In particular, the narrative sense of self is made up of memories of subjective experiences linked across time. An important feature of narrative self-reference is stimulus independent thought (SIT), which we commonly think of as mind wandering64 or stream of consciousness. SIT production is automatic, occurs in the absence of a strong requirement to respond to external stimuli,65 and depends on central executive resources.66 A particular type of narrative self-reference, or SIT, relevant for mood, anxiety, and pain symptoms is analytical self-focused rumination (thinking analytically about self and symptoms). This self-referential thinking is generally maladaptive67 and associated with overgeneral autobiographical memory,68 global negative self-judgments,69 and dysphoria.70,71 In contrast to narrative self-referential thinking, experiential self-reference is the experience of self in the immediate moment without a narrative component. Mindfulness practices aim to develop experiential self-reference. Experiential self-focus is adaptive.68,72 Therefore, interventions that increase mindfulness and/or decrease analytical self-referential ruminations may be effective in reducing depressive, anxiety, and pain symptoms. Studies indicate that MPs decrease rumination27,62,73,74 and exert ben-
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efit as a result of both increasing mindfulness75–77 and decreasing rumination.62 Thus, the reperceiving and de-identification with self suggested by Shapiro et al.17 may manifest as changes in the extent and content of narrative self-referential thinking, which ultimately lead to improvements in affective and anxiety symptoms. Shapiro et al.17 posited four additional mechanisms that may also contribute to positive outcomes from MPs: 1) self-regulation and self-management, 2) emotional, cognitive, and behavioral flexibility, 3) values clarification, and 4) exposure. Self-regulation and exposure may both decrease mood, anxiety, and pain symptoms. Reperceiving allows one to stand back and witness, rather than be controlled by, an unpleasant sensation.17 This shift in perspective may increase one’s ability to self-regulate by utilizing more adaptive coping skills and being less prone to maladaptive responses. In addition, an increased ability to tolerate uncomfortable emotions or sensations may result in greater exposure to the discomfort and thus eventual desensitization. Recent evidence suggests that MPs do in fact enhance emotional regulation and decrease emotional reactivity.78–84 Cognitive and behavioral flexibility may facilitate more adaptive responding in general and values clarification may result in choosing behaviors more congruent with one’s core values.17 Both of these effects could lead to behavioral changes that increase psychological well-being. Furthermore, evidence suggests that psychological flexibility may enhance pain tolerance.85 Finally, MPs may exert benefits by enhancing compassion,86 specifically including patience and kindness directed toward the self.11,81,87 Self-compassion is a predictor of psychological health,88 and the development of increased caring for self appears to contribute to the effectiveness of MPs.77 Neurobiological Mechanisms A number of recent studies have provided information regarding the biological mechanisms that may underlie the cognitive and emotional effects of the MPs described above. In general, considerable evidence now indicates that meditation and MPs have an impact both on brain function3,78,89–101 and structure.102,103 Primary effects on several key brain regions are discussed in the following sections.
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Cortical midline structures and insula. The medial surface of the cortex may be particularly relevant for neurobiological mechanisms underlying the effects of MPs. Most of the anterior and posterior medial cortex has been characterized as an anatomical and functional unit known as the cortical midline structures (CMS).104 The CMS are involved in self-referential thinking,104–106 specifically including SIT.106,107 There is evidence that decreased activation of the CMS is correlated with decreased SIT.65 Thus, the CMS are likely important brain regions associated with the narrative type of self-referential thinking and SIT. The CMS are part of the default mode network,108,109 and there is evidence that the narrative type of self-reference is, in fact, the default mode of self-referential thinking.89,107 Finally, the CMS are involved in emotional processing110,111 and with the experience of sadness.112 Thus, these regions may serve as the neurobiological link between self-referential thinking and emotional dysregulation in mood disorders. The right anterior insula is important for explicit subjective awareness113–115 and thus has been thought to be important for experiential self-awareness (mindfulness). There is now evidence from a study by Farb et al. that experiential self-focus as a result of mindfulness training initially decreases CMS activation and that, over time, further decreases in CMS activation occur along with increased activation of the insula and other regions.89 This pattern suggests that shifting neural processing from the CMS to the insula is likely an important neurobiological mechanism associated with the change from narrative to experiential self-reference. The same study also found that mindfulness training resulted in uncoupling of the strong functional connectivity between the CMS and the right insula. The authors concluded that their findings supported the dualmode hypothesis of self-awareness (narrative and experiential).89 They also concluded that their results suggested a fundamental neural dissociation of these modes of self-representation. More basic momentary self-reference is associated with evolutionarily older neural regions (e.g., insula), in which self-awareness in each moment arises from the integration of basic interoceptive and exteroceptive bodily sensory processes. In contrast, the narrative mode of self-reference may represent an overlearned mode of information processing that has become automatic through practice and involves the CMS.
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As described above, evidence indicates that selfperception and processing of self-referent information is abnormal in affective disorders,38–41 with a shift toward excessive self-focused thinking.56,57 Furthermore, negative mood is associated with SIT.116 Finally, there is now direct evidence that selfreferential processing activates the CMS and that this neural response is associated with negative affectivity in healthy individuals.117 Studies using a variety of methodologies suggest functional alterations in the CMS in both unipolar118–123 and bipolar124–132 spectrum disorders. Of particular interest, research indicates that abnormal self-referential processing in unipolar illness is mediated by neural response in cortical (and subcortical) midline structures.121,133 Increased CMS activation has also been observed during rumination among depressed individuals134 and depressive symptoms have been shown to correlate with the degree of CMS activity during a self-negative judgment task.133 Finally, research now indicates that MPs have an impact on CMS activation, with both decreased89,97,100 and increased79,80,135 activation of portions of the CMS reported. Some studies suggest that MPs are associated with increased activation of the dorsal anterior cingulate cortex (dACC) subregion of the CMS.76,80,118 This may be a result of the role of this region in cognitive monitoring.136 MPs enhance focus on monitoring moment-by-moment experience and thus would be expected to be associated with increased dACC activation. The studies discussed above suggest that one important neurobiological mechanism underlying the effectiveness of MPs for mood disorders may be alterations in CMS activation associated with narrative self-referential thinking and SIT. This shift may be accompanied by increased activation of the insula89 associated with a change toward more experiential self-focus. Increased insula activation has been reported by a number of investigations of MPs;3,89,94,98 however, decreased activation has also been reported.97 Of particular note is the recent work by Zeidan et al.,3 which demonstrated that meditation-induced reductions in pain intensity ratings were associated with increased activity in the anterior insula as well as the ACC. Their investigation is noteworthy not only because of these findings, but also because their results were published in a very prestigious journal (The Journal of Neuroscience). This example illustrates the high quality of studies
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now being conducted to enhance our understanding of the neural mechanisms of MPs. As with mood disorders, evidence indicates that CMS regions are also associated with anxiety disorders137 as well as sensations of pain intensity and unpleasantness.138,139 Thus, the benefit of MPs for anxiety and pain symptoms may also be associated with modulation of CMS function. With regard to pain, MP-associated pain reduction is associated with increased activation of the insula.3,94 In addition, increased activation of the dACC in response to pain as well as decreased functional connectivity between this region and the dorsolateral prefrontal cortex have been reported among meditators.94 Finally, a number of structural imaging studies have found that MPs are associated with alterations in gray matter in the dACC,140 posterior CMS,102 and insula.103,140 Lateral prefrontal cortex. The lateral prefrontal cortex plays a key role in broad aspects of executive behavioral control141 and emotional regulation.142,143 Specifically, cognitive control of emotional response appears to occur by way of lateral prefrontal control of the amygdala response.144 Evidence indicates that anxious individuals require increased recruitment of lateral prefrontal cortex to decrease negative emotions,145 suggesting a loss of top down emotional regulation in this condition. There is also evidence that meditation increases activation of this region.135,146 Thus, meditation may decrease emotional symptoms as a result of augmenting lateral prefrontal emotional control processes. In contrast, decreased activation of this region, along with uncoupling of the dACC, has been associated with pain response among meditators.94 In this case, it is thought that decreased lateral prefrontal activity represents down regulation of the cognitive-evaluative component of pain.94 Amygdala. The amygdala is best thought of as a group of distinct subcortical structures that play a key role in emotional processes (for a brief review, see Marchand 2010).147 It is thought that one role of the amygdala is to be a threat detector, since extensive sensory input and stimuli suggesting danger result in activation of this region. Outputs from the amygdala subsequently result in fear-related behaviors, such as fight or flight and freezing and startle responses. Thus, it is not surprising that activation of
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the amygdala is associated with both anxiety137,148,149 and depression.150 Some evidence78,94 indicates that MPs may be associated with decreased activation of the amygdala, although increased activation has also been reported.98 Thus, MPs may exert some benefit by decreasing amygdala response, and this might occur as a result of directly decreasing amygdala reactivity in some way or by enhancing top down control as described above. Cortico-basal ganglia circuitry. The corticobasal ganglia circuits are feedback loops that include the cortex, basal ganglia, and thalamus. Information first travels from the cortex to the basal ganglia structures, then on to the thalamus, and finally back to the cortex. These circuits are involved with processing emotional, cognitive, and motor information (for recent detailed reviews, see Marchand 2010147 and Marchand and YurgelunTodd 2010151). Furthermore, there is compelling evidence that these circuits exhibit abnormal functioning in mood151 and at least some anxiety disorders.152–156 Several studies suggest that MPs increase activation of the basal ganglia98,100,135,146 and thalamus.94 It is not currently known whether these changes contribute to the effects of MPs on mood, anxiety, or pain symptoms, possibly through enhanced control of cognitive and emotional processing. Future studies are needed to investigate this and other possibilities. However there is evidence that MPs may prevent age-related structural changes in the striatum and this may be associated with preservation of cognitive function.157 Hippocampus. The hippocampal region is associated with memory functions.158–160 Evidence suggests that some mindfulness and meditation practices may be associated with increased activation of the hippocampus.76,80,117 Gray matter changes have also been reported in this region in association with these practices.103,140 These changes may be associated with cognitive benefits of mindfulness practices but this has not been established by research. Other brain regions. In addition to the regions discussed above, evidence indicates that mindfulness and meditation practices may also have effects in other regions of the brain. Changes in activation have been reported in temporal,135 occipital,98 and parietal regions.98 With regard to effects on brain
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Table 2. Brain regions implicated in the neurobiology of affective disorders, anxiety, and pain that are affected by mindfulness/meditation practices Brain region
Role in affective and anxiety Primary impact of meditation/ mindfulness practices disorders and pain
Possible psychological effect
CMS (other than dACC)
Decreased SIT and Narrative self-reference,104–107 Decreased89,97,100 and 110,111 emotional processing, pain increased79,80,135 activation,* altered narrative self-referential thinking intensity/unpleasantness138,139 gray matter concentrations102
dACC
Cognitive monitoring136
Increased activation,94,98,161 altered Enhanced monitoring of momentary experience gray matter concentrations140
Insula
General subjective awareness,113–115 experiential self-awareness89
Increased activation,3,89,94,98 altered gray matter concentrations103,140
Heightened experiential self-awareness
Lateral prefrontal cortex
Executive control,141 emotional regulation142–144
Increased activation,135,146 decreased activation in response to pain94,*
Improved top down emotional control, down regulation of cognitiveevaluative component of pain
Amygdala
Threat detection,147 fear response147
Decreased activation78,94
Attenuated emotional reactivity
Cortico-basal ganglia circuitry
Cognitive, emotional, and motor Increased activation of basal functions128,132 ganglia and/or thalamus,82,94,98,127,129,135 attenuation of age-related structural changes157
Hippocampus
Enhanced cognitive function
Increased activation,94,98,135 altered Unknown gray matter concentrations103,140
*Both increased and decreased activation have been reported, which is likely a result of differences in study methods. Nonetheless, these results suggest functional changes as a result of mindfulness practices and further studies will be necessary to disambiguate these findings. CMS = cortical midline structures; dACC = dorsal anterior cingulate cortex; SIT = stimulus independent thought
structure, changes in gray matter concentrations have been reported in temporal regions102,103 and cerebellum.102 Summary. The primary effects of MPs on the brain regions discussed above are summarized in Table 2. Other Biological Mechanisms In addition to directly altering brain activation and structure, there is evidence that MPs may be associated with other beneficial central and peripheral physiological changes. The hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system are peripheral components of the human stress system.162 Stress-
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induced activation of the HPA axis and autonomic system results in systemic elevations of glucocorticoids and catecholamines, which act to maintain homeostasis and influence the immune response.162 Chronic elevations can have negative effects and preliminary evidence suggests a link between the cortisol response and ruminative thinking.163 A number of studies suggest that MPs and meditation may have an impact on the cortisol awakening response164 and reduce cortisol levels,22,25,165,166 although conflicting results have been reported.167,168 Some evidence suggests that these practices may also be associated with decreased basal sympathetic activation169 and improved immune function.25,165,166,170 There is also evidence that decreased blood pressure22,91,166,171 may be an outcome associated with MPs. Finally, an
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important study by Britton et al. demonstrated that MBCT is associated with a pattern of sleep changes similar to that seen in positive responders to antidepressants.172 Summary of Psychological and Biological Mechanisms of Action While the mechanisms underlying the effects of MPs remain incompletely understood, a large body of literature suggests that several psychological and biological processes may be associated with these practices. From a psychological/cognitive perspective, MPs appear to enhance participants’ ability to focus attention on the present moment, including one’s own stream of consciousness. Developing the ability to become a neutral observer of one’s emotional and cognitive activity appears to facilitate a process of reappraisal, along with a shift from narrative to experiential self-referential thinking. This change facilitates detachment from negative sensations, emotions, and cognitions, so that these phenomena become less disturbing. On a neurobiological level, these psychological changes appear to be primarily associated with altered activation of the CMS and increased activation of the insula. Changes in activation also frequently occur in the lateral prefrontal cortex, amygdala, hippocampus, and basal ganglia. Finally, alterations in peripheral components of the stress system may be associated with improvements in blood pressure, cortisol levels, and immune function.
EVIDENCE FOR THE EFFECTIVENESS OF MINDFULNESS-BASED PRACTICES A number of relatively recent reviews and metaanalyses have provided useful information about the potential effectiveness of MPs in general, as well as specifically in the treatment of psychiatric disorders. The goal of this article is not to duplicate those efforts but rather to provide a synthesis of the available information in a format that may be useful for practicing clinicians. As described above, the literature suggests that a number of general psychological and physiological benefits may be associated with MPs and meditation in general (Table 3). The remainder of this section focuses on evidence for the effectiveness and potential benefits specifically associated with Zen meditation, MBSR, and MBCT.
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Table 3. Potential general benefits of mindfulness practices Improved attention25–30 Decreased ruminative thinking27,62,73,74 Attenuated emotional reactivity78–84 Enhanced self-compassion11,81,87 Lower blood pressure22,91,166,171 Possible improved immune function25,165,166,170 Possible reduced cortisol levels22,25,165,166 Early evidence of possible enhanced cognition173,174
Zen Meditation A few studies have investigated Zen meditation. Several studies suggest that Zen results in decreased pain sensitivity94,140,175 and stress reduction.91 A recent review also concluded that this practice is effective in reducing blood pressure.1 Preliminary evidence also suggests that regular practice may have neuroprotective effects and reduce the cognitive decline associated with normal aging.157 Mindfulness-Based Stress Reduction A very large literature supports the effectiveness of MBSR. Examples include studies suggesting effectiveness for depressive78,176–178 as well as anxiety symptoms,178–181 including PTSD,176 social anxiety disorder,78,182 and generalized anxiety disorder.183 However, a comparison with group cognitive behavioral therapy (CBT) for social anxiety disorder found that the CBT intervention was more effective than MBSR.182 In addition, MBSR has been shown to decrease pain and increase pain coping and acceptance184–190 and may improve insomnia.191,192 Evidence indicates that MBSR improves general mental health,193 and many studies indicate improved psychological functioning among individuals with a variety of medical disorders.164,177,178,184,194–200 However, MBSR is also effective for healthy people,181,201 and some evidence indicates that MBSR may be beneficial for psychological functioning among health care professionals.202–204 Although most studies have been conducted with adults, recent research also suggests a benefit for adolescents.205–207 Finally, a recent systematic review concluded that MBSR has shown efficacy for a number of physical conditions, as well as for
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Table 4. Areas of symptom improvement associated with three MPs Zen meditation
MBSR
MBCT
Blood pressure1
Depression78,176–178
Unipolar depression relapse prevention2,4,210–214,227
Pain tolerance90,91,136
Pain tolerance184–190
Acute unipolar depression214,228,229
Stress tolerance91
Anxiety78,176,17–183
Residual unipolar depression2,215
Psychological
functioning164,177,178,181,184,194–204
Treatment-resistant unipolar depression216 Bipolar disorder217–220 Anxiety183,221,222,225
MP = mindfulness practice; MBSR = mindfulness-based stress reduction, MBCT = mindfulness-based cognitive therapy
healthy subjects.1 Despite the evidence of effectiveness described above, a meta-analysis of eight studies concluded that MBSR provides only small effects in the reduction of depression, anxiety, and psychological distress in people with chronic medical illness.180 Furthermore, two recent rigorous studies found benefit equivalent to, but not better than, an active control condition.208,209 Issues related to reliability of studies and conflicting results are discussed below. Mindfulness-Based Cognitive Therapy Many studies have indicated that MBCT, like MBSR, is effective for a variety of different conditions. Evidence suggests that MBCT is effective in the treatment of a number of psychiatric conditions, including unipolar depression relapse prevention,4,210–214 residual unipolar depression,2,215 treatment-resistant unipolar depression,216 bipolar disorder,217–220 generalized anxiety disorder,183,221 panic disorder,221,222 hypochondriasis223,224 and social phobia.225 In addition, there is evidence that it may be of benefit for chronic fatigue syndrome.226 The strongest evidence is for relapse prevention in unipolar illness.2,4,210–215,227 Recent meta-analyses2,227 have concluded that MBCT is effective for reducing relapses in those with three or more prior episodes. Additional conclusions from one of these studies2 were that effectiveness for relapse prevention was similar to antidepressants at 1 year and that augmentation with MBCT could be useful for reducing residual depressive symptoms. A subsequent study4 provided compelling evidence confirming that, for depressed patients, MBCT offers protection against relapse equal to that of maintenance antidepressant pharmacotherapy. Recent evidence suggests efficacy
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for those experiencing a current episode as well as for those in remission.228,229 Furthermore, a recent study found that MBCT appeared to be as effective as CBT in the treatment of current depression.214 A recent review and meta-analyses addressed the effectiveness of MPs for reducing symptoms of anxiety and depression, with a specific focus on patients with anxiety disorders and depression.230 Thirty-nine studies using MBSR or MBCT or interventions closely modeled on these treatments were included in the analysis. Results indicated that, in patients with anxiety disorders and depression, MPs were associated with large effect sizes of 0.97 and 0.95 for improving anxiety and depression, respectively. The authors concluded that mindfulness-based therapy improves symptoms of anxiety and depression across a relatively wide range of severity and even when these symptoms are associated with other disorders.230 It is important to note that this study supports the use of these interventions for acute treatment. Summary The evidence for the effectiveness and potential benefits of Zen meditation, MBSR, and MBCT is summarized in Table 4. The available literature suggests that the MPs reviewed here warrant consideration as interventions in a variety of clinical situations. However, it has been pointed out1,2,9 that many studies have substantial methodological limitations and many investigations have been criticized for their lack of scientific rigor.9 One of the most significant criticisms concerns the lack of high-quality, randomized controlled studies that utilized adequate comparators.9 One concern is the frequent use of a waiting list as a comparator, which does not allow for distinguish-
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ing between specific and nonspecific effects of MPs.1 Other limitations include absence of control groups, absence of randomization or randomization details, small sample size, absence of follow-up measures, reliance on self-report instruments, and a variety of differences across interventions.1,9,193 It is important to note that two recent rigorous studies suggest that MBSR may not demonstrate greater benefit than active control conditions.208,209 However, the authors of one of these studies suggested that the methods that contributed to the rigor of the study may have confounded the results.208 The authors of the other study pointed out that their results indicated that MBSR is effective, just not more effective than another active (control) intervention.209 These authors also pointed out that an 8 week intervention, including home practice, may not provide enough meditation time to result in maximum benefits.209 With regard to MBCT, one recent rigorous study stands out. In this investigation,4 MBCT was compared to maintenance antidepressant pharmacotherapy, which is the current standard of care. As described above, MBCT was found to offer protection against relapse/recurrence on a par with that of maintenance antidepressant pharmacotherapy.4 Thus, in comparison to a clearly active control that is the standard of care, MBCT demonstrated equal efficacy. Furthermore, another compelling study found that MBCT appears to be as effective as CBT in the treatment of current depression.214 Thus, while strong evidence for the use of MPs currently exists, additional studies are needed to further delineate the indications for their use and resolve some conflicting results. An important concern is the lack of long-term adherence data. The percentage of patients who may experience a recurrence of symptoms as a result of discontinuing or decreasing frequency of practice is unknown but could be substantial.
SUGGESTED GUIDELINES AND PRACTICAL CONSIDERATIONS While further research is needed, enough evidence exists to develop some general guidelines for the use of Zen meditation, MBSR, and MBCT in clinical practice as adjunctive interventions (Table 5). MBCT is strongly recommended as an adjunctive intervention for maintenance treatment/relapse prevention in unipolar depressive illness. This intervention should also be considered as an adjunctive
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approach for acute and residual unipolar depressive symptoms. Both MBSR and MBCT are recommended as adjunctive treatments for anxiety symptoms. MBSR and Zen meditation may be beneficial for pain management. MBSR is indicated for general psychological health and/or stress management among those with medical or psychiatric illness as well as healthy individuals. None of these interventions can currently be recommended as monotherapy except for MBSR for psychological health and stress management among healthy individuals. An important issue for clinicians who may want to refer patients for these interventions involves determining whether a referral is likely to be beneficial for a given individual. Evidence is currently limited concerning patient characteristics that may be associated with a good response to MPs. However, a few investigations provide some guidance. As with any prospective treatment, patient preference is important. This may be especially true for MPs, and it may be prudent only to refer patients who are relatively enthusiastic about trying these approaches.208,231 A related concept is the level of commitment to an ongoing meditation practice. Some evidence suggests that meditation-associated changes in brain function may require extensive practice.232 Furthermore, considerable research indicates that greater meditation practice is associated with more improvement on some outcome measures.75,178,186,215 Thus, the most important considerations may be desire to try an MP and willingness to engage in a regular practice of seated meditation. A few other factors may contribute to a positive response to MPs. For example, a recent study found that individuals with higher levels of the trait mindfulness at pretreatment would benefit more from MBSR.233 Although some mindfulness scales are available, a formal assessment may not be practical in most clinical situations. However, a thorough discussion of the components of MPs (Table 1) and potential benefits (Tables 3 and 4) may help providers at least gauge whether these interventions are likely to be a good fit for a given patient. There is evidence that MBCT decreases rumination62,215 and that rumination is important in the process of depressive relapse.62 Thus, patients who are prone to rumination and narrative self-referential thinking may be particularly good candidates for MPs. However, a recent study of MBCT234 found that depressed individuals with high levels of cognitive
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Table 5. Suggested guideline for the use of three mindfulness practices Condition
Zen
MBSR
MBCT
Monotherapy Adjunctive to conventional interventions for depression
No
No
No
No
No
Yes*
Unipolar depression: treatment of acute Monotherapy and residual symptoms Adjunctive to conventional interventions for depression
No
No
No
No
Yes
Yes*
Bipolar disorder: acute and maintenance treatment
No
No
No
No
No
Yes
No
No
No
No
Yes*
Yes*
No
No
No
Yes
Yes*
No
Yes
Yes*
No
Yes
Yes*
No
No
No
No
Yes*
Yes*
No
Unipolar depression: maintenance treatment and relapse prevention
Anxiety disorders
General psychological health and/or stress management among those with medical or psychiatric illness
Monotherapy Adjunctive to conventional interventions for bipolar disorder Monotherapy Adjunctive to conventional interventions for anxiety disorders Monotherapy Adjunctive to conventional interventions for the primary disorder and/or other complementary approaches
General psychological health and/or stress management among healthy individuals Pain
Monotherapy Adjunctive to other self-help and/or complementary approaches Monotherapy Adjunctive to conventional pain management methods
* = strongest evidence; MBSR = mindfulness-based stress reduction, MBCT = mindfulness-based cognitive therapy
reactivity, brooding, and depressive rumination had difficulty engaging in MBCT. Thus, such individuals may need ongoing support and encouragement from the referring clinician. Along those lines, there is some indication that feelings of distress can be associated with mindfulness practice.235 Thus, regular follow-up with the referring provider may also be important to monitor for any adverse response to the intervention. Such follow-up may also help ensure long-term adherence to the recommended meditation practice. One difficulty that clinicians may encounter is how to refer patients for MPs. A useful resource is the University of Massachusetts Medical School Center for Mindfulness website (www.umassmed.edu/cfm /stress/index.aspx). The site provides information about MBSR. A search page (w3.umassmed.edu /MBSR/public/searchmember.aspx) also facilitates the location of practitioners who have participated in Center for Mindfulness approved training programs. Another resource is the American Zen Teachers Association (AZTA) website (www.americanzen-
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teachers.org/index.html), which provides a database of Zen Practice Centers with AZTA teachers.
CONCLUSIONS A large literature now exists documenting investigations of MBCT, MBSR, and, to a lesser extent, Zen meditation. Some studies suffer from methodological deficiencies and unanswered questions remain. Nonetheless, these MPs show considerable promise and the available evidence indicates that their use is currently warranted in a variety of clinical situations. In particular, MBCT is strongly recommended as an adjunctive treatment for unipolar depression. The evidence suggests that both MBSR and MBCT have efficacy as adjunctive interventions for anxiety symptoms. MBSR is beneficial for general psychological health and stress management in those with medical and psychiatric illness as will as healthy individuals. Finally, MBSR and Zen meditation have a role in pain management.
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