Clinical Handbook of Mindfulness (51 page)

This burgeoning area of investigation is beginning to reveal some of the

ways in which paying attention on purpose, cultivating inner attitudes of

acceptance and non-judgment, and setting meaningful intentions such as

to direct lovingkindness toward oneself or others can actually modify brain

activity, including perception, higher order cognition, and emotion regula-

tion
(Cahn & Polich, 2006;
Siegel, 2007;
Wallace, 2006).
One recent analysis based on a comprehensive review of the current scientific literature spanning

neuroscience and meditation concluded that neural plasticity may indeed

enable humans, including adults, to gradually transform mindful
states
into

traits
based on repeated exposure to experiential shifts in perspective, emo-

tional processing, and behavioral responses
(Begley
,
2007).
A landmark clinical intervention study by Davidson,
Kabat-Zinn et al. (2003)
demonstrated for the first time that systematic mindfulness training in a real-world setting can produce observable changes in the brain, namely greater left pre-

frontal activation, which has previously been associated with positive emo-

tion. Of particular interest, the study by Davidson,
Kabat-Zinn et al. (2003)

further revealed a connection between change in the brain, and change in

the body, as greater intervention-related shifts toward left prefrontal activa-

tion corresponded with more vigorous antibody responses to influenza vac-

cination. The connection between changes in central nervous system activ-

ity and peripheral immune function is well established
(Ader, 2007).
Two very recent examples of the power of the mind to change the brain include

modification of attentional subsystems following eight weeks of group-based

mindfulness meditation training
(Jha et al., 2007),
as well as enhanced prefrontal cortex regulation of affect through labeling negative emotions, a core

mindfulness skill
(Creswell, Way, Eisenberger, & Lieberman, 2007).

Finally, behavioral scientific evidence suggests that mindfulness prac-

tice can positively impact health-related behaviors through its effects on

cognitive, affective, and physiological self-regulation. Specifically, mindful-

ness practice appears to increase behavioral flexibility in conditions previ-

ously associated with maladaptive rigidity, such as fear-related avoidance of

Chapter 10 Mindfulness and Anxiety Disorders

181

normal everyday activities. A “third wave” of behavioral psychotherapies has

recently emerged in which mindfulness- and acceptance-based approaches

have been combined with traditional cognitive-behavioral treatment of anx-

iety and other emotionally dysregulated conditions, including depression,

chronic pain, eating disorders, and borderline personality disorder (Baer, Fis-

cher, & Huss,
2006b;
Hayes, 2005; Lau & McMain, 2005).
These new integrated psychotherapies include mindfulness-based cognitive therapy (MBCT)

for active depression and anxiety as well as the prevention of depressive

relapse
(Finucane & Mercer, 2006;
Segal et al., 2002);
acceptance and commitment therapy (ACT) for anxiety disorders and chronic pain (Eifert &

Forsyth,
2005; Dahl, Wilson, Luciano, & Hayes, 2005);
dialectical behavior therapy (DBT) for borderline personality disorder
(Linehan, 1993);
and mindfulness-based eating awareness training (MB-EAT) for binge eating disorder
(Kristeller, Baer, & Quillian-Wolever, 2006).
The primary objective of integrating mindfulness meditation with traditional CBT is to increase treatment efficacy by exploring the relationship between acceptance of one’s

present moment experience as a catalyst of desired behavior change, includ-

ing modification of self-destructive ways of thinking, feeling, and acting (Lau

& McMain,
2005).

There is a burgeoning literature to support the integration of mindfulness-

and acceptance-based strategies with traditional change-based strategies in

the treatment of anxiety disorders in particular. This area of clinical inves-

tigation has recently been reviewed in special journal issues, professional

handbooks, and practitioner’s treatment guides (for detailed reviews see

Borkovec, 2002; Craske & Hazlett-Stevens, 2002; Eifert & Forsyth, 2005;
Germer,
2005;
Orsillo & Roemer, 2005; Roemer, Salters-Pedneault, & Orsillo,

2006; Roemer & Orsillo, 2002;
Wells, 2002).
In addition, several literature reviews have concluded that mindfulness-based stress reduction programs in

both controlled research and real-world community settings have produced

clinically significant reductions in anxiety, mood disturbance, and stress-

related physical symptoms
(Baer, 2003;
Brantley
,
2005;
Grossman, Niemann, Schmidt, & Walach,
2004; Lazar, 2005;
Shigaki, Glass, & Schopp, 2006;
Smith, Richardson, Hoffman, & Pilkington,
2005).

Whereas a number of different mindfulness-based clinical interventions

have demonstrated effectiveness in ameliorating maladaptive cognition, neg-

ative affect, and somatic symptoms, one should note that the core intention

of mindfulness practice centers around personal growth, transformation, and

the pursuit of what is possible, meaningful, and truly valued in life despite

any particular diagnosis, limitation, or pathology (Shapiro, Schwartz, & San-

terre,
2002).
By virtue of progressively awakening to one’s senses, core values, intended life direction, and even spiritual purpose, mindfulness practice

may be effectively coupled with other positively oriented behavior-change

interventions like hypnosis to further increase contact with what is affirm-

ing, comforting, and fulfilling
(Lynn, Das, Hallquist, & Williams, 2006).

Illustrative Case Report

Background:
“John” is 25-year-old, single, Caucasian male graduate student

with an 18-month history of treatment refractory hypertension, non-cardiac

chest pain, and irregular heartbeat. He was referred for psychotherapeutic

182

Jeffrey Greeson, Jeffrey Brantley

management of anxiety and recurrent panic attacks. Extensive biomedical

workup prior to psychotherapy revealed no known medical cause for his

physical or psychological symptoms, which were consistent with a diagno-

sis of panic disorder. Hypertension was reportedly non-responsive to com-

bination treatment with a beta-blocker (Toprol XL) and diuretic (hydrox-

ychlorothiazide; average blood pressure reading before and after medica-

tion = 145
/
95). The client reported that healing touch, breathwork with

heartrate variability (HRV) biofeedback, and yoga instruction had been

“somewhat beneficial” in reducing physical symptoms and anxiety, but

not blood pressure. Several months of individual counseling for the treat-

ment of anxiety and panic was reportedly “not helpful.” Current self-care

activities included yoga 5 days per week, running 1 day per week, avoid-

ing foods with processed sugar and added sodium, eating more fruits and

vegetables, and nightly deep breathing with sound therapy. The client

denied illicit substance use and reported minimal alcohol use (1 drink per

month). Family psychiatric history was significant for anxiety in mother and

father.

Intervention:
Nine individual therapy sessions, which included a combi-

nation of formal mindfulness training, anxiety-specific cognitive-behavioral

skills training, and supportive psychotherapy to aid the client in clarifying

his vision of optimal health, wholeness, and life direction. Treatment goals

included the following: (1) ability to tolerate distressing physical symptoms

without panic, (2) reduction in muscle tension, including chest pain, and (3)

reduction in blood pressure. Each session emphasized formal mindfulness

meditation practice (i.e., awareness of breath; body scan; mindfulness of

thoughts, feelings, physical sensations, and sounds), cognitive-behavioral

strategies to reduce anxiety and related physiological symptoms (e.g., cog-

nitive restructuring, exposure therapy with response prevention), and self-

help readings to reinforce learning and to provide structured mindfulness-

based exercises (e.g., the book
Calming Your Anxious Mind
). In-session

meditation practices were recorded for home use. During the course of treat-

ment, “John” stated that he experienced a shift in his relationship to worri-

some thoughts, noting that “[his] feelings are temporary.” In addition, “John”

stated that he was “not focusing on what
could
happen, but focusing on

what
is
happening.” The client further described a shift in his relationship to

“strange pains” and other unpleasant physical sensations, noting that “[his]

experience of chest tightness dissipated with allowance.” Notably, “John”

did not experience a panic attack during his 9 weeks of therapy, which he

attributed to the shifts in perspective he experienced. Midway through ther-

apy, he described feeling “a bit nervous, but okay” in situations that he typi-

cally feared and avoided, such as flying and being outdoors in remote areas.

By the end of treatment, “John” had experienced a significant reduction in

self-reported levels of anxiety and muscle tension, as well as a decrease in

blood pressure readings following his regular yoga, breathwork, and mind-

fulness exercises. He insightfully reported discovering how to “be in control

by letting go.” Moreover, “John” was no longer avoiding formerly feared social

situations. He reported actively engaging with co-workers, community mem-

bers, and spiritual guides. And at the final session he enthusiastically shared

that he had become engaged to his long-time girlfriend, because “[he] was

no longer afraid.” Taken together, the multimodal intervention approach with

Chapter 10 Mindfulness and Anxiety Disorders

183

mindfulness as a core self-regulatory skill resulted in marked improvements

the client’s quality of life, including mental, physical, and social functioning.

Illustrative Mindfulness Practice: “Awareness of Breath”

Paying attention on purpose to your breath sensations is an effective way

to reconnect with your inner experience as it is unfolding moment to

moment.

(1) Notice and follow the full duration of an in breath
. . .
an out breath
. . .
and the spaces between them
. . .
.

(2) Noticing the physical sensations of the breath with a sense of curios-

ity and kind attention
. . .
allowing the sensations to unfold moment to

moment
. . .
breath by breath
. . .
observing as best you can
. . .
.

(3) Noticing whether your attention is on the breath in this moment
. . .
and

if it is not, where did the mind go
. . .
perhaps it began thinking, telling

some sort of story about your experience, or analyzing
. . .
just noticing

these thoughts or judgments as mere events in the field of your own

spacious awareness
. . .
.

(4) Noticing the transient nature of these mental events as you continue

to surf the rising and falling waves of the in breath and the out

breath
. . .
consciously choosing to acknowledge and let go of thoughts,

feelings, body sensations, or impulses with the next exhale
. . .
.

(5) Gently escorting your attention back to your focus on the present

moment
. . .
using the sensations of the breath as your anchor for

mindfulness
. . .
dropping back into your direct experience of what is here

in the present moment whenever you choose
. . .
.

(6) And whenever you are ready, reorienting to the room
. . .
noticing

where your body makes contact with the furniture
. . .
perhaps stretching

gently
. . .
and gradually opening your eyes.

Future Directions

A growing body of scientific literature demonstrates that mindfulness- and

acceptance-based treatment approaches to anxiety work, in part by creat-

ing a fundamental shift in perspective toward one’s inner life. Much work,

however, remains to be done across conceptual, definitional, and research

fronts applied to mindfulness-based interventions for fear and anxiety. In

addition, there is theoretical and empirical support for the concept that pay-

ing attention on purpose to the inner experience of fear and anxiety with

a sense of openness, curiosity, and acceptance can actually change one’s

experience by directly modifying habitual circuits and mind/body feedback

loops in the brain. Additional research is needed to examine more deeply

the aspects of consciousness, including awareness, attention and intention,

which may be used to effectively self-regulate mind-brain-body-behavior sys-

tems implicated in anxiety and anxiety disorders. Questions that await fur-

ther inquiry include: Who benefits most (and least) from mindfulness training