Improve Tolerance of Distress and Psychological State with Mindfulness

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Improve Tolerance of Distress and Psychological State with Mindfulness

 

By John M. de Castro, Ph.D.

 

“Distress Tolerance skills are used to help us cope and survive during a crisis, and helps us tolerate short term or long term pain (physical or emotional). Tolerating distress includes a mindfulness of breath and mindful awareness of situations and ourselves.” – DBT Self Help

 

Psychological distress is related to an increase in physiological stress responses. That is, when the individual is anxious, ruminating, or having negative emotions, the physiology including the hormonal system reacts. The increased activity can be measured in heightened stress hormones in the blood and increased heart rate, blood pressure etc. These physiological stress responses on the short-term are adaptive and help to fight off infection, toxins, injury, etc. Unfortunately, psychological distress is often persistent and chronic and resulting in chronic stress which in turn can produce disease.

 

Many of the symptoms of psychological distress have been shown to be related to a lack of mindfulness. Anxiety is often rooted in a persistent dread of future negative events while rumination is rooted in the past, with persistent replaying of negative past events. Since mindfulness is firmly rooted in the present it is antagonistic toward anything rooted in the past or future. Hence, high levels of mindfulness cannot coexist with anxiety and rumination. In addition, high mindfulness has been shown to be related to high levels of emotion regulation and positive emotions. So, mindfulness would appear to be an antidote to psychological distress.

 

In today’s Research News article “Dimensions of distress tolerance and the moderating effects on mindfulness-based stress reduction.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6130202/ ), Gawrysiak and colleagues recruited participants in an 8-week Mindfulness-Based Stress Reduction (MBSR) program. The program was specifically developed to improve coping with stress and consisted of weekly 2.5-hour group training sessions with home practice and included meditation, body scan, yoga practices, and discussion. They were measured before and after training for distress tolerance, perceived stress, and positive and negative emotions.

 

They found that following the MBSR program the participants demonstrated significant increases in distress tolerance and vigor and decreases in perceived stress, anger, confusion, depression, fatigue, and tension. In addition, they found that participants who were low in distress tolerance had the greatest decreases in perceived stress after the program while those high in distress tolerance had the least change.

 

Hence, they found that the MBSR program improved the psychological state in the participants. This is in line with previous research that demonstrated that mindfulness training improves psychological and physiological responses to stress and improves emotions. What this study contributes is the understanding that MBSR  improves that participants  ability to cope with psychological distress. Importantly, they also found that the participants who benefited the most were the ones who had the least ability to cope with distress to begin with. This suggests that one of the reasons that MBSR training is beneficial is that it improves the individuals ability to deal effectively with tough emotions and situations which, in turn, improves the individuals ability to deal effectively with stress. This, then, improves their emotional state.

 

So, improve tolerance of distress and psychological state with mindfulness.

 

“Mindfulness helps you go home to the present. And every time you go there and recognize a condition of happiness that you have, happiness comes.” — Thich Nhat Hanh

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Gawrysiak, M. J., Leong, S. H., Grassetti, S. N., Wai, M., Shorey, R. C., & Baime, M. J. (2016). Dimensions of distress tolerance and the moderating effects on mindfulness-based stress reduction. Anxiety, Stress, and Coping, 29(5), 552–560. http://doi.org/10.1080/10615806.2015.1085513

 

Abstract

Background and Objectives:

This study examined the relationship between distress tolerance and psychosocial changes among individuals participating in Mindfulness-Based Stress Reduction (MBSR). The objective of the analysis was to discern whether individuals with lower distress tolerance measured before MBSR showed larger reductions in perceived stress following MBSR.

Design and Methods:

Data were collected from a sample of convenience (n = 372) using a quasi-experimental design. Participants completed self-report measures immediately prior to course enrollment and following course completion.

Results:

Perceived stress, distress tolerance, and mood states showed favorable changes from pre- to post-MBSR in the current study. Baseline distress tolerance significantly moderated reductions on perceived stress, supporting the primary hypothesis that individuals with lower baseline distress tolerance evidenced a greater decline in perceived stress following MBSR. For a one-unit increase on the self-reported baseline Distress Tolerance Scale, reported perceived stress scores decreased by 2.5 units (p < .0001).

Conclusions:

The finding that individuals with lower baseline distress tolerance evidenced a greater decline in perceived stress may offer hints about who is most likely to benefit from MBSR and other mindfulness-based treatments. Identifying moderators of treatment outcomes may yield important benefits in matching individuals to treatments that are most likely to work for them.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6130202/

Mindfulness Promotes Health and Well-Being in Stressed College Students

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Mindfulness Promotes Health and Well-Being in Stressed College Students

 

By John M. de Castro, Ph.D.

 

“Student life can be stressful, but that doesn’t mean students have to let stress take over their lives. By incorporating mindfulness and meditation into daily routines, students can not only relieve the pressure, but also improve their memory, focus and ultimately their grades.“ – Todd Braver

 

In the modern world education is a key for success. Where a high school education was sufficient in previous generations, a college degree is now required to succeed in the new knowledge-based economies. There is a lot of pressure on students to excel so that they can be admitted to the best universities and there is a lot of pressure on university students to excel so that they can get the best jobs after graduation. This is particularly true in highly rated, elite, universities. This stress might in fact be counterproductive as the increased pressure can actually lead to stress and anxiety which can impede the student’s physical and mental health, well-being, and school performance.

 

It is, for the most part, beyond the ability of the individual to change the environment to reduce stress, so it is important that methods be found to reduce the college students’ responses to stress; to make them more resilient when high levels of stress occur. Contemplative practices including meditation, mindfulness training, and yoga practice have been shown to reduce the psychological and physiological responses to stress. Indeed, these practices have been found to reduce stress and improve psychological health in college students. So, it would seem important to examine various techniques to relieve the stress and its consequent symptoms in college students.

 

In today’s Research News article “There Is No Performance, There Is Just This Moment: The Role of Mindfulness Instruction in Promoting Health and Well-Being Among Students at a Highly-Ranked University in the United States.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871302/ ), Kerrigan and colleagues recruited college students from an elite university and provided them with an 8-week Mindfulness-Based Stress Reduction (MBSR) program. The program was specifically developed to improve coping with stress and consisted of weekly 2.5-hour group training sessions with home practice and included meditation, body scan, yoga practices, and discussion. They were interviewed before and after training on “personal goals, priorities, and background; current and past stressors and coping strategies; motivations to participate in the program; experiences with the program; barriers to attendance and practice of program techniques; and impact and future use of the MBSR tools and methods.”

 

The students described the high pressure, stressful, competitive environment of the university, their challenging schedules of academic studies, extracurricular activities, and volunteer work, and family pressure to succeed. About half of the participants reported chronic health conditions as a result of the stress. Reducing this stress was their primary motivation for participating in the MBSR program. They described the MBSR program as cultivating mindfulness, attention to the present moment and non-judgement. Non-judgement was particularly important as it stood in stark contrast to the competitive environment of the university. They also indicated that the program allowed them to step back and reframe their current existence and their lives. They described the benefits that they obtained from the MBSR program of reducing stress and anxiety and improving coping skills. They also reported improved relationships and academic performance.

 

These qualitative results suggest that participation in Mindfulness-Based Stress Reduction (MBSR) program was of great benefit to these stressed college students, reducing their responses to stress and their self-judgement, and improving their mindfulness, productivity and overall well-being. These results mirror those seen with controlled quantitative studies. This suggests that participation in an MBSR program should be recommended for college students.

 

So, promote health and well-being in stressed college students with mindfulness.

 

“a mindfulness intervention can help reduce distress levels in college students during a stressful exam week, as well as increase altruistic action in the form of donating to charity.” – Julia Galante

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

Kerrigan, D., Chau, V., King, M., Holman, E., Joffe, A., & Sibinga, E. (2017). There Is No Performance, There Is Just This Moment: The Role of Mindfulness Instruction in Promoting Health and Well-Being Among Students at a Highly-Ranked University in the United States. Journal of Evidence-Based Complementary & Alternative Medicine, 22(4), 909–918. http://doi.org/10.1177/2156587217719787

 

Abstract

Mindfulness-based stress reduction (MBSR) has been shown to improve health outcomes across populations. We explored the feasibility, acceptability, and initial effects of a pilot MBSR program at a highly-ranked university in the United States. We conducted 23 in-depth interviews with 13 students. Interviews explored stressors and coping mechanisms, experiences with MBSR, and its reported impact and potential future use. Interviews were analyzed using thematic content and narrative analyses. Results indicated that students are exposed to a very high level of constant stress related to the sheer amount of work and activities that they have and the pervasive surrounding university culture of perfectionism. MBSR offered an opportunity to step back and gain perspective on issues of balance and priorities and provided concrete techniques to counter the effects of stressors. We conclude that MBSR and mindfulness programs may contribute to more supportive university learning environments and greater health and well-being among students.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871302/

 

Increase Self-Efficacy with Tai Chi

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Increase Self-Efficacy with Tai Chi

 

By John M. de Castro, Ph.D.

 

“The science of Tai Chi is just now catching up with and substantiating what Tai Chi practitioners have known for centuries – Tai Chi often leads to more vigor and energy, greater flexibility, balance and mobility, and an improved sense of well-being.  Cutting-edge research now lends support to long-standing claims that Tai Chi favorably impacts the health of the heart, bones, nerves and muscles, immune system, and the mind.” – Peter Wayne

 

Self-efficacy is the belief in one’s ability to succeed in specific situations or accomplish a task. It is an important characteristic for the individual’s ability to effectively navigate the complex and stressful environments in the modern world. It is an important foundation for success in many areas of life. So, methods that could help to improve the development of self-efficacy may be very helpful for the individual throughout the course of their life. A relatively simple method to do this is Mindfulness training. Indeed, it has been shown to significantly improve self-efficacy.

 

Tai Chi is gentle and safe mindfulness practice. It is appropriate for all ages including the elderly and for individuals with illnesses that limit their activities or range of motion. It is inexpensive to administer, can be performed in groups or alone, at home or in a facility, and can be quickly learned. In addition, it can be practiced in social groups. This can make it fun, improving the likelihood of long-term engagement in the practice. So, Tai Chi practice would appear to be an almost ideal gentle mindfulness training and light exercise to improve psychological health and well-being and perhaps self-efficacy.

 

In today’s Research News article “Effects of Tai Chi on Self-Efficacy: A Systematic Review.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114250/ ), Tong and colleagues reviewed and summarized the published research literature on the effectiveness of Tai Chi practice to improve self-efficacy. Their review of the literature revealed 27 studies, 20 of which were randomized controlled trials.

 

They report that the vast majority of the studies found that engaging in Tai Chi practice produced significant improvement in self-efficacy. This was true for college students and the elderly and for patients with diseases including arthritis, heart failure, Chronic Obstructive Pulmonary Disease (COPD), and other diseases. Unfortunately, although significant improvement were observed relative to baseline, many of the studies were of low quality or involved small numbers of participants resulting in a lack of significant differences compared to control groups.

 

Obviously, more research is needed employing stronger research designs and larger numbers of participants. But, the existing published research suggests that Tai Chi practice is a safe and effective method to improve self-efficacy in a wide range of people with or without diseases. Hence, this simple, inexpensive, convenient, safe, and fun practice may improve the participants ability to successfully conduct their lives, improving health and well-being.

 

So, increase self-efficacy with Tai Chi.

 

“In the search for effective ways to experience positive outcomes in the all-important life aspects such as overall health, well-being and mortality, one of the sleeper strategies to consider involves adopting an ancient Chinese practice called tai chi.” – Suzanne Kane

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Tong, Y., Chai, L., Lei, S., Liu, M., & Yang, L. (2018). Effects of Tai Chi on Self-Efficacy: A Systematic Review. Evidence-Based Complementary and Alternative Medicine : eCAM, 2018, 1701372. http://doi.org/10.1155/2018/1701372

 

The purpose of this systematic review is to summarize and update the readers regarding clinical studies that have investigated the effects of Tai Chi on self-efficacy and to describe their limitations and biases. Nine electronic databases were searched from the establishment of the database until August 10, 2017. All randomized controlled trials (RCTs), nonrandomized controlled studies (NRSs), quasi-experimental studies, or studies with pre-post design were included if they clearly defined a Tai Chi intervention and evaluated self-efficacy outcomes. We categorized these 27 studies into the “disease category” and the “population category,” based on the types of participants. This systematic review summarizes the effects of Tai Chi on self-efficacy in various populations and found that Tai Chi appeared to have positive effects on self-efficacy in some populations. Fifteen research studies showed that Tai Chi had significant positive effects on self-efficacy, while 11 studies did not; only one study found a negative outcome at the follow-up. In addition, it is unclear which type, frequency, and duration of Tai Chi intervention most effectively enhanced self-efficacy. Tai Chi appears to be associated with improvements in self-efficacy. Definitive conclusions were limited due to the variation in study designs, type of Tai Chi intervention, and frequency, and further high-quality studies are required.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114250/

 

Decrease Cardiovascular Disease Risk with Yoga

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Decrease Cardiovascular Disease Risk with Yoga

 

By John M. de Castro, Ph.D.

 

“Yoga is designed to bring about increased physical, mental and emotional well-being. Hand in hand with leading a heart-healthy lifestyle, it really is possible for a yoga-based model to help prevent or reverse heart disease. It may not completely reverse it, but you will definitely see benefits.” – M. Mala Cunningham

 

Cardiovascular disease is the number one killer, claiming more lives than all forms of cancer combined. “Heart disease is the leading cause of death for both men and women. About 610,000 people die of heart disease in the United States every year–that’s 1 in every 4 deaths. Every year about 735,000 Americans have a heart attack.” (Centers for Disease Control). A myriad of treatments has been developed for heart disease including a variety of surgical procedures and medications. In addition, lifestyle changes have proved to be effective including quitting smoking, weight reduction, improved diet, physical activity, and reducing stresses. Cardiac rehabilitation programs for patients recovering from a heart failure, emphasize these lifestyle changes. Unfortunately, for a variety of reasons, 60% of heart failure patients decline participation, making these patients at high risk for another attack.

 

Safe and effective alternative treatments for cardiovascular disease are contemplative practices, such as meditation, tai chi, and yoga, have also been shown to be helpful for heart health. These practices have also been shown to be helpful for producing the kinds of lifestyle changes needed to prevent heart disease such as smoking cessation, weight reduction, and stress reduction. Indeed, yoga practice is both a mindfulness training technique and a physical exercise. As such, it would seem particularly interesting to explore as a treatment to reduce the risk of cardiovascular disease.

 

In today’s Research News article “Yoga as an Alternative and Complimentary Therapy for Cardiovascular Disease: A Systematic Review.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871178/ ),  Haider and colleagues reviewed and summarized the published research literature on the effects of yoga practice on risk factors for cardiovascular disease.

 

They found 12 published studies, 7 of which were randomized controlled trials. There were large differences in the methodology, duration of practice, and measures employed in these studies. Nevertheless all 12 studies reported significant improvements in at least one cardiovascular disease risk factor. These included “both physical and mental factors, including body mass index, blood pressure, cholesterol, anxiety, depression, quality of life, weight, and pulmonary function.” Hence, the published research literature suggests that yoga practice is a safe and effective treatment that can reduce risk factors for cardiovascular disease.

 

So, decrease cardiovascular disease risk with yoga.

 

“A large number of studies show that yoga benefits many aspects of cardiovascular health. There’s been a major shift in the last five years or so in the number of cardiologists and other professionals recognizing that these benefits are real.” – Hugh Calkins

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Haider, T., Sharma, M., & Branscum, P. (2017). Yoga as an Alternative and Complimentary Therapy for Cardiovascular Disease: A Systematic Review. Journal of Evidence-Based Complementary & Alternative Medicine, 22(2), 310–316. http://doi.org/10.1177/2156587215627390

 

Abstract

Cardiovascular disease is a leading cause of disability and death worldwide. Yoga, a mind-body exercise, utilizes breathing techniques with low-impact physical activity that may be an alternative treatment for cardiovascular disease. The purpose of this systematic review was to examine yoga interventions for patients at-risk for and/or suffering from cardiovascular disease. The inclusion criteria for interventions were (a) published in the English language between 2005 and 2015; (b) indexed in MEDLINE/PubMed, CINAHL, or Alt HealthWatch; (c) employed a quantitative design; and (d) applied a yoga intervention. Twelve interventions met the inclusion criteria, of which, all documented significant improvements in one or more factors associated with cardiovascular disease. Limitations to the studies in this review included a lack of studies adhering to the inclusion criteria, small sample sizes, and high attrition rates. Despite the limitations, this review demonstrates the clear potential yoga has as an alternative and complementary means to improve cardiovascular disease risk.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871178/

 

Improve Anxiety and Depression with Online Mindfulness Training

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Improve Anxiety and Depression with Online Mindfulness Training

 

By John M. de Castro, Ph.D.

 

“So many people who want and would benefit from mindfulness meditation training do not ever receive it because of schedules, location, and / or an aversion to being in live groups. Offering mindfulness training in an Internet format allows these people to actually receive the training benefits. We are lucky to live in a world where such alternative formats are available.” – Helané Wahbeh

 

Mindfulness training has been shown through extensive research to be effective in improving physical and psychological health and particularly with the physical and psychological reactions to stress. They have been shown to be very helpful in treating anxiety and depression. The vast majority of the mindfulness training techniques, however, require a certified trained therapist. This results in costs that many clients can’t afford. In addition, the participants must be available to attend multiple sessions at particular scheduled times that may or may not be compatible with their busy schedules and at locations that may not be convenient.

 

As an alternative, mindfulness training programs have been developed to be implemented over the internet. These have tremendous advantages in decreasing costs, making training schedules much more flexible, and eliminating the need to go repeatedly to specific locations. But, the question arises as to the effectiveness of these programs in inducing mindfulness and improving the treatment of anxiety and depression. In today’s Research News article “). Online mindfulness-enhanced cognitive behavioural therapy for anxiety and depression: Outcomes of a pilot trial.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112099/ ), Kladnitski and colleagues addressed this issue.

 

They recruited participants through social media who were diagnosed with either generalized anxiety disorder, social phobia, panic disorder, agoraphobia, obsessive compulsive disorder, and/or major depressive disorder. They completed a 7-week online program of cognitive behavioral therapy (CBT) with mindfulness training. CBT that is designed to address and change maladaptive thought patterns that lead to psychological problems and includes behavioral activation, cognitive restructuring, and graded exposure. They added online mindfulness training also to the program. The entire program was similar to the Mindfulness-Based Cognitive Therapy (MBCT) program. The participants were measured online before, during, and after the 7-week program and 3 months later for psychiatric symptoms, psychiatric distress, depression, anxiety, mental well-being, disability, worry, rumination, experiential avoidance, emotion regulation, and mindfulness.

 

They found that engagement in the program was low with only 59% of the original participants completing the 7-week program. All of the measures showed significant improvements with moderate to large effect sizes after training compared to baseline and these improvements persisted 3 months later. So, the 7-week online program or cognitive behavioral therapy (CBT) with mindfulness training reduced the psychological pain and improved the psychological well-being of adults with anxiety or depressive disorders.

 

These results need to be interpreted with caution because of the high drop out rates. The individuals who were not being helped or even harmed by the program may have dropped out leaving only those participants who were improving. Future work needs to improve retention rates for the treatment to be seen as useful. Also, the lack of an active control condition opens the study up to a large array of potential confounds.

 

But, it has been well established in a number of well controlled studies that mindfulness improves the symptoms and mental well being of patients with anxiety and depression. The present study simply demonstrates that presentation of the treatment online is similarly effective. By being able to provide the treatment online it greatly reduces costs, makes the treatment more widely available even to remote locations, and makes it convenient for the patients. That is why it is so important to establish its effectiveness of the online program in relieving the suffering of anxiety and depression patients.

 

So, improve anxiety and depression with online mindfulness training.

 

“participants who completed the online mindfulness course reported significantly lower levels of perceived stress, depression and anxiety.” – Be Mindful

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Kladnitski, N., Smith, J., Allen, A., Andrews, G., & Newby, J. M. (2018). Online mindfulness-enhanced cognitive behavioural therapy for anxiety and depression: Outcomes of a pilot trial. Internet Interventions, 13, 41–50. http://doi.org/10.1016/j.invent.2018.06.003

 

Abstract

Transdiagnostic internet-delivered cognitive behavioural therapies (iCBT) are effective for treating anxiety and depression, but there is room for improvement. In this study we developed a new Mindfulness-Enhanced iCBT intervention by incorporating formal and informal mindfulness exercises within an existing transdiagnostic iCBT program for mixed depression and anxiety. We examined the acceptability, feasibility, and outcomes of this new program in a sample of 22 adults with anxiety disorders and/or major depression. Participants took part in the 7-lesson clinician-guided online intervention over 14 weeks, and completed measures of distress (K-10), anxiety (GAD-7), depression (PHQ-9), mindfulness (FFMQ) and well-being (WEMBWS) at pre-, mid-, post-treatment, and three months post-treatment. Treatment engagement, satisfaction, and side-effects were assessed. We found large, significant reductions in distress (Hedges g = 1.55), anxiety (g = 1.39), and depression (g = 1.96), and improvements in trait mindfulness (g = 0.98) and well-being (g = 1.26) between baseline and post-treatment, all of which were maintained at follow-up. Treatment satisfaction was high for treatment-completers, with minimal side-effects reported, although adherence was lower than expected (59.1% completed). These findings show that it is feasible to integrate online mindfulness training with iCBT for the treatment of anxiety and depression, but further research is needed to improve adherence. A randomised controlled trial is needed to explore the efficacy of this program.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112099/

 

Improve Mindfulness Treatment Outcomes with Home Practice

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Improve Mindfulness Treatment Outcomes with Home Practice

 

By John M. de Castro, Ph.D.

 

 “An average course student practices 30 minutes daily at home, but the good news is that nevertheless, this practice is related to positive benefit. This can be measured as reduced stress, pain, better well-being and so on.” – Science Daily

 

Over the last several decades, research and anecdotal experiences have accumulated an impressive evidential case that the development of mindfulness has positive benefits for the individual’s mental, physical, and spiritual life. Mindfulness appears to be beneficial both for healthy people and for people suffering from a myriad of illnesses. It appears to be beneficial across ages, from children to the elderly. And it appears to be beneficial across genders, personalities, race, and ethnicity. The breadth and depth of benefits is unprecedented. There is no other treatment or practice that has been shown to come anyway near the range of mindfulness’ positive benefits.

 

With impacts so great it is important to know how to optimize the development of mindfulness. Most forms of training require or strongly suggest that the participants practice at home. It is not established, however, how important this home practice is to the beneficial outcomes of mindfulness practice. In today’s Research News article “The Utility of Home-Practice in Mindfulness-Based Group Interventions: A Systematic Review.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968057/ ),  Lloyd and colleagues reviewed and summarized the published research literature on the benefits of home practice in association with Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT).

 

They found 14 controlled studies, 8 of which employed MBSR and 6 employed MBCT treating a total of 725 participants. All of these studies used self-report measures of home practice that varied considerably in technique and variables measured. MBSR and MBCT trainings require home practice of 45 minutes per day for 6 days a week (270 minutes). They report that the studies found that actual home practice varied considerably from study to study ranging from 15% to 88% of the recommended amount. The results reported on the impact of home practice on clinical and non-clinical outcome measures were mixed partially due the wide differences in reporting techniques, analyses reported and procedures. Of the 14 reviewed studies only 7 examined the relationship between home-practice and clinical outcomes, of these 4 found that home-practice predicted small but significant improvements on clinical outcome measures.

 

Hence, there are indications suggesting that home practice may be useful for improving the clinical outcomes of mindfulness training. But, the research is so widely different that it is impossible to reach firm conclusions. There is a great need for more attention to the topic employing more standardized assessment techniques. It is important to establish what are the necessary components of practice to produce benefits. The reviewed studies suggest that home practice may be beneficial. This should help in the future in better delineating and refining the most beneficial training techniques.

 

So, improve mindfulness treatment outcomes with home practice.

 

“mindfulness home practice may have a small but positive effect on treatment outcomes, however the strength of this association was not found to depend on the length of time people spent practicing.” – Elena Marcus

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

Lloyd, A., White, R., Eames, C., & Crane, R. (2018). The Utility of Home-Practice in Mindfulness-Based Group Interventions: A Systematic Review. Mindfulness, 9(3), 673–692. http://doi.org/10.1007/s12671-017-0813-z

 

Abstract

A growing body of research supports the efficacy of mindfulness-based interventions (MBIs). MBIs consider home-practice as essential to increasing the therapeutic effects of the treatment. To date however, the synthesis of the research conducted on the role of home-practice in controlled MBI studies has been a neglected area. This review aimed to conduct a narrative synthesis of published controlled studies, evaluating mindfulness-based group interventions, which have specifically measured home-practice. Empirical research literature published until June 2016 was searched using five databases. The search strategy focused on mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and home-practice. Included studies met the following criteria: controlled trials, participants 18 years and above, evaluations of MBSR or MBCT, utilised standardised quantitative outcome measures and monitored home-practice using a self-reported measure. Fourteen studies met the criteria and were included in the review. Across all studies, there was heterogeneity in the guidance and resources provided to participants and the approaches used for monitoring home-practice. In addition, the guidance on the length of home-practice was variable across studies, which indicates that research studies and teachers are not adhering to the published protocols. Finally, only seven studies examined the relationship between home-practice and clinical outcomes, of which four found that home-practice predicted improvements on clinical outcome measures. Future research should adopt a standardised approach for monitoring home-practice across MBIs. Additionally, studies should assess whether the amount of home-practice recommended to participants is in line with MBSR/MBCT manualised protocols. Finally, research should utilise experimental methodologies to explicitly explore the relationship between home-practice and clinical outcomes.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968057/

 

Improve Quality of Life in Cancer Patients with Mindfulness

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Improve Quality of Life in Cancer Patients with Mindfulness

 

By John M. de Castro, Ph.D.

 

“Results show promise for mindfulness-based interventions to treat common psychological problems such as anxiety, stress, and depression in cancer survivors and to improve overall quality of life.” — Linda E. Carlson

 

Receiving a diagnosis of cancer has a huge impact on most people. Feelings of depression, anxiety, and fear are very common and are normal responses to this life-changing and potentially life-ending experience. But cancer diagnosis is not necessarily a death sentence. Over half of the people diagnosed with cancer are still alive 10 years later and this number is rapidly increasing. But, surviving cancer carries with it a number of problems. Insomnia is a common occurrence in the aftermath of surviving breast cancer.

 

Mindfulness training has been shown to help with cancer recovery and help to alleviate many of the residual physical and psychological symptoms, including stress,  sleep disturbance, and anxiety and depression. But, most research is with western populations and there are very few that study the effectiveness of mindfulness training with Asian populations.

 

In today’s Research News article “Effects of a Mindfulness Meditation Program on Quality of Life in Cancer Outpatients: An Exploratory Study.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041936/ ), Chang and colleagues recruited Taiwanese outpatient cancer patients and separated them into a usual care group and a mindfulness meditation group. Mindfulness meditation was taught in once a month for 3 months 2.5-hour sessions focusing on sitting insight meditation. The participants were expected to practice at home daily. They were measured before and after training and 3 month later for quality of life, including subscales for physical health, psychological health, social relationships, and environment.

 

They found that the mindfulness meditation group had significant improvements in their quality of life including all 4 subscales while the usual care group did not. These improvements in quality of life were sustained 3 months later. These results are similar to previously reported improvements in quality of life in cancer patients produced by mindfulness training. But, these findings extend these to include oriental populations. Hence mindfulness training appears to be a safe and effective treatment to improve the well-being and relieve the suffering of patients from all over the world with various forms of cancer.

 

So, improve quality of life in cancer patients with Mindfulness.

 

“mindfulness-based meditation can help ease the stress, anxiety, fear, and depression that often come along with a breast cancer diagnosis and treatment.” – BreastCancer,org

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

Chang, Y.-Y., Wang, L.-Y., Liu, C.-Y., Chien, T.-J., Chen, I.-J., & Hsu, C.-H. (2018). The Effects of a Mindfulness Meditation Program on Quality of Life in Cancer Outpatients: An Exploratory Study. Integrative Cancer Therapies, 17(2), 363–370. http://doi.org/10.1177/1534735417693359

 

Abstract

Objective. Numerous studies have investigated the efficacy of mindfulness meditation (MM) in managing quality of life (QoL) in cancer populations, yet only a few have studied the Asian population. The aim of this exploratory study is to evaluate the effect of a MM program on the QoL outcomes in Taiwanese cancer outpatients. Methods. Patients with various cancer diagnoses were enrolled and assigned to the MM group and usual care (UC) group. The meditation intervention consisted of 3 sessions held monthly. The outcomes of the whole intervention were measured using the World Health Organization Quality of Life (WHOQOL-BREF) instrument. Results. A total of 35 participants in the MM group and 34 in the UC group completed the study. The results showed that the postintervention scores were significantly higher than the preintervention scores in the MM group. In the UC group, there was no significant difference between preintervention and postintervention scores, except for the lower environment domain scores. There was no significant difference between the follow-up scores and postintervention scores in the MM group, indicating that improvement can be maintained for 3 months after completing the MM course. Conclusions. The present study provides preliminary outcomes of the effects on the QoL in Taiwanese cancer patients. The results suggest that MM may serve as an effective mind–body intervention for cancer patients to improve their QoL, and the benefits can persist over a 3-month follow-up period. This occurred in a diverse cancer population with various cancer diagnoses, strengthening the possibility of general use.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6041936/

 

Improve Chronic Conditions with Mindfulness Taught over the Internet

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Improve Chronic Conditions with Mindfulness Taught over the Internet

 

By John M. de Castro, Ph.D.

 

“It’s important for people living with health conditions to recognize what they are feeling, instead of trying to push painful thoughts and emotions away, which can actually amplify them. For those living with serious medical conditions, mindfulness can help them accept and respond to difficult feelings, including fear, loneliness and sadness. By bringing mindfulness to emotions (and the thoughts that may underlie them), we can begin to see them more clearly and recognize that they are temporary.” – Shauna Shapiro

 

Mindfulness training has been shown through extensive research to be effective in improving physical and psychological health and particularly with the physical and psychological reactions to stress. The vast majority of the mindfulness training techniques, however, require a certified trained therapist. This results in costs that many clients can’t afford. In addition, the participants must be available to attend multiple sessions at particular scheduled times that may or may not be compatible with their busy schedules and at locations that may not be convenient. This makes delivery to individuals in remote locations nearly impossible.

 

As an alternative, applications over the internet and on smartphones have been developed. These have tremendous advantages in decreasing costs, making training schedules much more flexible, eliminating the need to go repeatedly to specific locations, and being available to patients in remote areas. But, the question arises as to the level of compliance with the training and the effectiveness of these internet applications in inducing mindfulness and improving physical and psychological health in chronically ill patients.

 

In today’s Research News article “Digital Characteristics and Dissemination Indicators to Optimize Delivery of Internet-Supported Mindfulness-Based Interventions for People With a Chronic Condition: Systematic Review.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107686/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123540/  ), Russell and colleagues review and summarize the published research literature on the effectiveness of internet based mindfulness training programs for the treatment of patients with chronic diseases. They identified 10 randomized controlled studies that contained a control group where mindfulness training was performed over the internet. The patients were afflicted with chronic pain in 3 of the studies, and in single studies with fibromyalgia, heart disease, cancer post-treatment, anxiety disorder, major depressive disorder, residual depressive symptoms, and psychosis.

 

They found that internet-based mindfulness interventions in general had significant beneficial effects that improved patient functioning in comparison to the control groups. Half of the studies reported follow-up measurements that reflected persisting benefits. They noted that when measured participant adherence to the programs was in general low.

 

Hence, it appears that internet-based mindfulness interventions are safe and effective treatments for the well-being of patients with chronic diseases. This is potentially very important as these interventions can be administered inexpensively, conveniently, and to large numbers of patients regardless of their locations, greatly increasing the impact of the treatments.

 

There are some caveats. The majority of the participants by far were women and there was no study that compared the efficacy of the internet-based intervention to the comparable face-to-face intervention or another treatment. So, it was recommended that future studies include more males and a comparison to another treatment.

 

So, improve chronic conditions with mindfulness taught over the internet.

 

“MBSR programs might not reverse underlying chronic disease, but they can make it easier to cope with symptoms, improve overall well-being and quality of life and improve health outcomes.” – Monika Merkes

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

Russell, L., Ugalde, A., Milne, D., Austin, D., & Livingston, P. M. (2018). Digital Characteristics and Dissemination Indicators to Optimize Delivery of Internet-Supported Mindfulness-Based Interventions for People With a Chronic Condition: Systematic Review. JMIR Mental Health, 5(3), e53. http://doi.org/10.2196/mental.9645

 

Abstract

Background

Internet-supported mindfulness-based interventions (MBIs) are increasingly being used to support people with a chronic condition. Characteristics of MBIs vary greatly in their mode of delivery, communication patterns, level of facilitator involvement, intervention period, and resource intensity, making it difficult to compare how individual digital features may optimize intervention adherence and outcomes.

Objective

The aims of this review were to (1) provide a description of digital characteristics of internet-supported MBIs and examine how these relate to evidence for efficacy and adherence to the intervention and (2) gain insights into the type of information available to inform translation of internet-supported MBIs to applied settings.

Methods

MEDLINE Complete, PsycINFO, and CINAHL databases were searched for studies assessing an MBI delivered or accessed via the internet and engaging participants in daily mindfulness-based activities such as mindfulness meditations and informal mindfulness practices. Only studies using a comparison group of alternative interventions (active compactor), usual care, or wait-list were included. Given the broad definition of chronic conditions, specific conditions were not included in the original search to maximize results. The search resulted in 958 articles, from which 11 articles describing 10 interventions met the inclusion criteria.

Results

Internet-supported MBIs were more effective than usual care or wait-list groups, and self-guided interventions were as effective as facilitator-guided interventions. Findings were informed mainly by female participants. Adherence to interventions was inconsistently defined and prevented robust comparison between studies. Reporting of factors associated with intervention dissemination, such as population representativeness, program adoption and maintenance, and costs, was rare.

Conclusions

More comprehensive descriptions of digital characteristics need to be reported to further our understanding of features that may influence engagement and behavior change and to improve the reproducibility of MBIs. Gender differences in determinants and patterns of health behavior should be taken into account at the intervention design stage to accommodate male and female preferences. Future research could compare MBIs with established evidence-based therapies to identify the population groups that would benefit most from internet-supported programs.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123540/

 

Improve Physical and Mental Health in Obesity with Dieting and Yoga Practice

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Improve Physical and Mental Health in Obesity with Dieting and Yoga Practice

 

By John M. de Castro, Ph.D.

 

“The mental component of yoga—the deep breathing, positive meditation and awareness—can boost confidence for people of all waistlines. “Yoga helps give you insight, and perhaps that insight can help you make better choices and eliminate negative self-talk.” – Abby Lentz

 

Obesity has become an epidemic in the industrialized world. In the U.S. the incidence of obesity, has more than doubled over the last 35 years to currently around 35% of the population, while two thirds of the population are considered overweight or obese (Body Mass Index; BMI > 25). Although the incidence rates have appeared to stabilize, the fact that over a third of the population is considered obese is very troubling. This is because of the health consequences of obesity. Obesity has been found to shorten life expectancy by eight years and extreme obesity by 14 years. This occurs because obesity is associated with cardiovascular problems such as coronary heart disease and hypertension, stroke, metabolic syndrome, diabetes, cancer, arthritis, and others.

 

Obviously, there is a need for effective treatments to prevent or treat obesity. But, despite copious research and a myriad of dietary and exercise programs, there still is no safe and effective treatment. Mindfulness is known to be associated with lower risk for obesity, alter eating behavior and improve health in obesity. This suggests that mindfulness training may be an effective treatment for overeating and obesity alone or in combination with other therapies. Yoga practice has been shown to have a myriad of physical and psychological benefits. These include significant loss in weight and body mass index (BMI), resting metabolism, and body fat in obese women with Type 2 diabetes, reduce weight and improve health in the obese. Hence it would seem reasonable to investigate the benefits of yoga in combination with a dietary plan on the weight and body composition of the obese.

 

In today’s Research News article “Twelve Weeks of Yoga or Nutritional Advice for Centrally Obese Adult Females.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107686/ ), Telles and colleagues recruited overweight and obese women (BMI>25) and randomly assigned them to either practice yoga or receive nutrition education. Yoga was practiced for 75 minutes, 3 days per week for 12 weeks and consisted of postures, breathing exercises, meditation, and relaxation. Nutrition education occurred for 45 minutes, once a week for 12 weeks. Both groups also were placed on a vegetarian dietary plan consisting in 1900-2000 Kcal per day. Participants were measured before and after training for body size, food intake, physical activity, and quality of life and plasma levels of fats.

 

Both groups saw improvements in body size including reductions in waist circumference, sagittal abdominal diameter, hip circumference, BMI, body shape index, conicity index, abdominal volume index, and body roundness index. Hence, the diet was successful in reducing body size. The groups also showed significant decreases in plasma total cholesterol, and increases in general self-esteem, and total quality of life. The yoga group, however, had a significantly greater reduction in body shape index, and plasma total cholesterol and very low density lipoproteins (VLDL). They found that the women between the ages of 30 to 45 years who practiced yoga had the greatest benefits while there was little benefit in the nutritional education group. For the women between the ages of 46 to 59 years both groups showed comparable benefits.

 

These results suggest that overweight and obese women who are dieting show significant improvements in body size, blood fats, and quality of life regardless of whether they receive additional yoga practice or nutritional education, with yoga practice producing slightly better results. But, yoga practice has significantly greater effectiveness for the younger women. This suggests that yoga practice is an effective treatment in combination with dieting for the improvement of obese women’s body size, plasma characteristics, and quality of life, particularly for women between the ages of 30-45 years. This is important as the combination of yoga practice and dieting may be an effective strategy to improve the health and well-being of overweight and obese women.

 

So, improve physical and mental health in obesity with dieting and yoga practice.

 

“Yoga does not offer quick weight loss. However, it does offer long lasting effects. Initially, you may feel that you aren’t making any progress with weight loss but you’ll start feeling more active and alive inside. Eventually, the body will start responding and come back in good shape.” – Art of Living

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Telles, S., Sharma, S. K., Kala, N., Pal, S., Gupta, R. K., & Balkrishna, A. (2018). Twelve Weeks of Yoga or Nutritional Advice for Centrally Obese Adult Females. Frontiers in Endocrinology, 9, 466. http://doi.org/10.3389/fendo.2018.00466

 

Abstract

Background: Central obesity is associated with a higher risk of disease. Previously yoga reduced the BMI and waist circumference (WC) in persons with obesity. Additional anthropometric measures and indices predict the risk of developing diseases associated with central obesity. Hence the present study aimed to assess the effects of 12 weeks of yoga or nutritional advice on these measures. The secondary aim was to determine the changes in quality of life (QoL) given the importance of psychological factors in obesity.

Material and Methods: Twenty-six adult females with central obesity in a yoga group (YOG) were compared with 26 adult females in a nutritional advice group (NAG). Yoga was practiced for 75 min/day, 3 days/week and included postures, breathing practices and guided relaxation. The NAG had one 45 min presentation/week on nutrition. Assessments were at baseline and 12 weeks. Data were analyzed with repeated measures ANOVA and post-hoc comparisons. Age-wise comparisons were with t-tests.

Results: At baseline and 12 weeks NAG had higher triglycerides and VLDL than YOG. Other comparisons are within the two groups. After 12 weeks NAG showed a significant decrease in WC, hip circumference (HC), abdominal volume index (AVI), body roundness index (BRI), a significant increase in total cholesterol and LDL cholesterol. YOG had a significant decrease in WC, sagittal abdominal diameter, HC, BMI, WC/HC, a body shape index, conicity index, AVI, BRI, HDL cholesterol, and improved QoL. With age-wise analyses, in the 30–45 years age range the YOG showed most of the changes mentioned above whereas NAG showed no changes. In contrast for the 46–59 years age range most of the changes in the two groups were comparable.

Conclusions: Yoga and nutritional advice with a diet plan can reduce anthropometric measures associated with diseases related to central obesity, with more changes in the YOG. This was greater for the 30–45 year age range, where the NAG showed no change; while changes were comparable for the two groups in the 46–59 year age range. Hence yoga may be especially useful for adult females with central obesity between 30 and 45 years of age.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107686/

 

Improve Sleep in Fibromyalgia Patients with Mindfulness

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Improve Sleep in Fibromyalgia Patients with Mindfulness

 

By John M. de Castro, Ph.D.

 

“Now, I do live in the moment, and it is quite beautiful, I feel at peace, I feel much more confident and I am able to look to the future with confidence. I am much more compassionate with myself and everyone else. I now accept that this illness is not my fault and it is now 100 per cent easier to deal with the primary pain that comes with fibromyalgia by eliminating the secondary suffering of worry and anxiety.” – Lesa Vallentine

 

Fibromyalgia is a mysterious disorder whose causes are unknown. It is very common affecting over 5 million people in the U.S., about 2% of the population with about 7 times more women affected than men. It is characterized by widespread pain, abnormal pain processing, sleep disturbance, and fatigue that lead to psychological distress. Fibromyalgia may also have morning stiffness, tingling or numbness in hands and feet, headaches, including migraines, irritable bowel syndrome, sleep disturbances, thinking and memory problems, and painful menstrual periods. The symptoms are so severe and debilitating that about half the patients are unable to perform routine daily functions and about a third have to stop work. Although it is not itself fatal, suicide rates are higher in fibromyalgia sufferers.

 

There are no completely effective treatments for fibromyalgia. Symptoms are generally treated with pain relievers, antidepressant drugs and exercise. But, these only reduce the severity of the symptoms and do not treat the disease directly. Mindfulness practices have also been shown to be effective in reducing pain from fibromyalgia. But, it is unclear, however, if mindfulness training can reduce the sleep disturbances and insomnia that accompany fibromyalgia.

 

In today’s Research News article “Effects of Mindfulness Training on Sleep Problems in Patients With Fibromyalgia.” (See summary below or view the full text of the study at: https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01365/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_755938_69_Psycho_20180904_arts_A ), Amutio and colleagues recruited patients diagnosed with fibromyalgia and randomly assigned them to a no-treatment control condition or to receive 7 weeks of Flow Meditation practice. They met in groups once a week for 2 hours and practiced daily at home. Flow Meditation consisted of mindfulness exercises from Mindfulness-Based Stress Reduction (MBSR) training, mindfulness techniques used in acceptance and commitment therapy, and exposure to and debate on metaphors and exercises used in Zen and Vipassana meditation. The participants were measured before and after training and 3 months later for insomnia, sleep quality, daytime sleepiness, and sleep impairments.

 

They found that in comparison to baseline and the control group the mindfulness trained group had significant increases in sleep quality and significant decreases in insomnia, daytime sleepiness, and sleep impairments. These effects varied from moderate to large and did not diminish over the 3-month follow-up period. So, mindfulness training appears to be a safe, effective, and lasting treatment for the sleep problems occurring with fibromyalgia. These are very significant improvements as lack of sleep by fibromyalgia patients contributes mightily to the reduced quality of life and overall health of the sufferers. This combined with the previously observed reduction in perceived pain produced by mindfulness training suggests that this training is an excellent alternative or supplemental treatment for fibromyalgia.

 

Improve Sleep in Fibromyalgia Patients with Mindfulness.

 

“Mindfulness may be able to help patients learn to direct their attention away from pain, inhibit the central nervous system’s ability to perceive pain. reduce distressing thoughts and feelings that come with pain, which can keep them from making the pain worse, enhance body awareness, which may lead to improved self-care, promote deep muscle relaxation, lessening tension and irritability, and create a buffer against stress-related symptoms” – HealthLine

 

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Amutio A, Franco C, Sánchez-Sánchez LC, Pérez-Fuentes MdC, Gázquez-Linares JJ, Van Gordon W and Molero-Jurado MdM (2018) Effects of Mindfulness Training on Sleep Problems in Patients With Fibromyalgia. Front. Psychol. 9:1365. doi: 10.3389/fpsyg.2018.01365

 

Fibromyalgia syndrome (FMS) is a complex psychosomatic pain condition. In addition to generalized pain and various cognitive difficulties, new FMS diagnostic criteria acknowledge fatigue and sleep problems as core aspects of this condition. Indeed, poor sleep quality has been found to be a significant predictor of pain, fatigue, and maladaptive social functioning in this patient group. While there is promising evidence supporting the role of mindfulness as a treatment for FMS, to date, mindfulness intervention studies have principally focused on dimensions of pain as the primary outcome with sleep problems either not being assessed or included as a secondary consideration. Given the role of sleep problems in the pathogenesis of FMS, and given that mindfulness has been shown to improve sleep problems in other clinical conditions, the present study explored the effects of a mindfulness-based intervention known as Flow Meditation (Meditación-Fluir) on a range of sleep-related outcomes (subjective insomnia, sleep quality, sleepiness, and sleep impairment) in individuals with FMS. Adult women with FMS (n = 39) were randomly assigned to the 7 weeks mindfulness treatment or a waiting list control group. Results showed that compared to the control group, individuals in the mindfulness group demonstrated significant improvements across all outcome measures and that the intervention effects were maintained at a 3 month follow-up assessment. The Meditación-Fluir program shows promise for alleviating sleep problems relating to FMS and may thus have a role in the treatment of FMS as well as other pain disorders in which sleep impairment is a central feature of the condition.

https://www.frontiersin.org/articles/10.3389/fpsyg.2018.01365/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_755938_69_Psycho_20180904_arts_A