tirsdag, 07-12-2021

Peter R. Martin: Historical Vocabulary of Addiction

 

Mindfulness

 

        According to the current electronic version of the Oxford English Dictionary (OED), the noun mindfulness was formed within English by derivation of the adjective mindful (common current usage, “A mental state or attitude in which one focuses one's awareness on the present moment while also being conscious of, and attentive to, this awareness. Also: the cultivation and practice of this, especially as a therapeutic technique.”) and its combination with the suffix -ness (“Forming abstract nouns from adjectives, participles, adjectival phrases, and [more rarely] nouns, pronouns, verbs, and adverbs.”).  

        The adjective mindful was, in turn, formed within English by combination of the noun mind (“Mental and psychic faculty.  The seat of awareness, thought, volition, feeling, and memory; cognitive and emotional phenomena and powers considered as constituting a presiding influence; the mental faculty of a human being [especially as regarded as being separate from the physical]; [occasionally] this whole system as constituting a person's character or individuality”) and the suffix -ful (“Forming adjectives with the sense ‘full of, or [more generally] having or characterized by [what is expressed by the first element]’.”).

        Historically, the first meaning of mindfulness, now obsolete, is defined in OED as: “The quality or state of being conscious or aware of something; attention.”  The first use of the word in the English language is exemplified by a quotation of John Palsgrave  (c. 1485–1554), a priest and tutor in the royal household of Henry VIII of England, in his instructional textbook for Englishmen learning the French language L'esclarcissement de la langue francoyse (Palsgrave 1972): “Myndfulnesse, pencee.”

        The currently used meaning of mindfulness is defined in OED as: “A mental state or attitude in which one focuses one's awareness on the present moment while also being conscious of, and attentive to, this awareness.”  Thus, the sense of the word evolved significantly from its first use, simply noticing something or being aware, to denoting a highly active process that focuses the effort of attention.  This adaptation of meaning was needed, presumably, to describe some of the emerging influences from Asia on Western philosophy. 

        An early example appeared in the following quotation by Sir Monier Monier-Williams (1819–1899), the Boden Professor of Sanskrit at Oxford University (1889): “Extinction of lust, craving, and desire, and cessation of suffering are accomplished by perseverance in the noble eightfold path.., viz. right belief or views.., right mindfulness (sati..), [etc.].”  These are highly insightful observations about the role of learning in the etiology, consequences and treatment of drug use disorders and other addictive behaviors.  Buddhism, in which this quotation appeared, was intended by Monier-Williams to enhance Western understanding of the history of a spiritual tradition distinct from Christianity, practiced for centuries in distant parts of what was then the British Empire.  It was from Buddhist philosophy that spirituality (“The fact or condition of being spiritual…, especially in nature, outlook, or behaviour; attachment to or concern for spiritual [as opposed to worldly or material] matters or pursuits; spiritual quality or character.”) as distinct from Western concepts of religion (“A particular system of faith and worship”) was popularized in Europe and America in the second half of the 20th century through mindfulness techniques.  

        Accordingly, mindfulness refers also to the training necessary to be able to achieve such a state of consciousness, as described in OED: “the cultivation and practice of this, especially as a therapeutic technique…[or] ….as mindfulness meditation, etc.”  This suggests that the state induced during mindfulness may have therapeutic benefits for lessening suffering associated with many human medical and psychiatric conditions.  The etymology of the word invokes the spiritual realm and the role that mindfulness techniques have played in Eastern philosophies of living: “Frequently and originally with reference to Yoga philosophy and Buddhism…” 

        In the sense of a mental state or attitude, the etymologic discussion proceeds: “after Pali sati (as one of the steps of the Eightfold Path in fuller form sammā-sati right mindfulness); compare [this with the] Buddhist Sanskrit smṛtyupasthāna…but from the late 20th century [the technique was] increasingly taught and practised outside these contexts as a formal discipline, often involving meditation with a focus on, or acknowledgement of, one's emotions, thoughts, and bodily sensations.”  Coping with life’s stresses by acknowledging and addressing one’s “emotions, thoughts and bodily sensations” is preferable to dismissing them using problematic out-of-control and self-destructive behaviors that constitute drug use and other addictive disorders.  Therefore, practicing mindfulness techniques to manage the range of stimuli that have become associated with self-medication and related addictive behaviors are useful skills in self-management  and achieving recovery.  It is probably for this reason that the idea of spirituality has become foundational in the traditions and practice of 12-step mutual support programs for management of addiction (Miller 1990).

        Behavioral management (in contradistinction to religious healing) of a wide range of physical diseases began to emerge in Western medicine, likely reflecting the evolving curiosity concerning Eastern philosphies.  Scientifically, these approaches were the direct consequence of conceptualizing distressing emotions as responses to internal and environmental stimuli that can be intensely stressful for the organism (Cannon 1920; Pavlov and Gantt 1928; Selye 1937).  The reasoning was that some maladaptive emotions may be perceived as stress-inducing based on previous experiences and thus, they become the source of pathologic bodily and mental changes.  Control of these stress-inducing responses is not readily accessible to the affected individual as it is predominantly mediated by the autonomic nervous system.  However, as discussed in the next paragraph, they were shown to be modifiable using conditioning, as well as related mindfulness techniques that can be taught and learned.  (Note that in the construct of psychodynamics the lack of access to maladaptive responses are due to their being subconscious, and hence, requiring another approach to treatment, namely psychotherapy.) 

        The therapeutic value of mindfulness techniques was first deduced from demonstration that experimental tachycardia could be conditioned in dogs (Dykman and Gantt 1956) and that behavioral training could effectively control arterial blood pressure in non-human primates (Benson, Herd, Morse and Kelleher 1969).  These seminal findings were soon extended to the clinic by showing that treatment of hypertension was feasible using meditation techniques by reducing autonomic nervous system activation (Benson, Shapiro, Tursky and Schwartz  1971; Benson, Marzetta, Rosner and Klemchuk 1974).  In fact, the discipline of “mind-body medicine” continues to evolve to this day (Dossett, Fricchione and Benson 2020) and it has been demonstrated that the “relaxation response” as elicited by mindfulness techniques may be therapeutically useful within diverse domains of medicine and psychiatry.  There are now randomized, controlled trials that have suggested improved health outcomes and quality of life in many health conditions that are related to or are exacerbated by stress, including chronic pain, anxiety, depression, insomnia, post-traumatic stress disorder, weight control and obesity, cancer-related fatigue, inflammatory bowel disease, and cardiovascular disease (Zhang, Lee, Mak et al. 2021).

        After first reporting the benefits of meditation for hypertension control, Benson (1969) suggested that similar approaches should be explored for “alleviation of drug abuse.”  Benson’s proposal to those in the addiction field was initially met with skepticism, as indeed was the mind-medicine approach generally.  This uncertainty was described by Marlatt (2002), an innovator in the field of psychological treatment approaches to addiction, in recollections of how in 1970 he first became interested in the clinical applications of meditation. 

        After developing borderline hypertension “as an assistant professor faced with the publish-or-perish stress of academic life,” his physician recommended he engage in transcendental meditation (TD) as a desirable treatment approach, which Marlatt intially almost rejected.  He indicated that this was “in sharp conflict with my training as a budding behavioral psychologist, in which overt behavior was considered more scientifically objective than anything to do with subjective mental states, much less the ‘mind’.”   Marlatt and Gordon (1985) eventually  came to realize that mindfulness techniques have important clinical applications in treatment of addictive behavioral issues and became an advocate for these techniques. 

        Mindfulness is now appreciated as a protective trait on the risk/resilience spectrum for development of addictive disorders (Lau, Bishop, Segal et al. 2006) as well as a clinically measurable psychological attribute that is likely enhanced during addiction treatment and related to outcome (Leigh, Bowen and Marlatt 2005).  There are many other primary psychopathological symptoms, such as mood and anxiety, that are triggered by stressful experiences which may also predispose an individual to addiction and are improved by mindfulness interventions. 

        Hofman,  Sawyer, Witt and Oh (2010) conducted a meta-anlaysis of anxiety and mood symptoms in various clinical samples, including cancer, generalized anxiety disorder, depression and other psychiatric or medical conditions and found that mindfulness-based treatments were moderately effective in improving anxiety and mood symptoms.  One of the first longitudinal studies to document the effects of mindfulness on drug use and heavy drinking was reported by Bowen, Witkiewitz, Clifasefi et al. (2014).  There are now a large number of studies of variable quality, some randomized and nonrandomized control trials, of the treatment of drug use disorders with mindfulness-based interventions (Cavicchioli, Movalli and Maffei 2018). 

        As reported in the first meta-analysis of mindfulness treatment for substance misuse, mindfulness treatment is a positive intervention for substance use disorders, with a small effect on use, medium effect on craving and large effect on reducing the stress associated with these disorders (Li, Howard, Garland et al. 2017).  Recent studies have shown that mindfulness training has a promising potential for smoking cessation treatment (Oikonomou, Arvanitis and Sokolove 2017) and also improves significantly levels of pain, physical and emotional limitations, depression and anxiety compared to treatment as usual of opioid use disorder patients in methadone maintenance treatment (Cooperman, Hanley, Kline and Garland 2021).  A systematic review supported the efficacies of mindfulness-based interventions in both substance and behavioral addictions (Sancho, De Gracia, Rodríguez et al. 2018).  Therefore, mindfulness-based techniques rationally belong in comprehensive pharmacopsychosocial treatments of drug use disorders and behavioral addictions, predominantly augmenting the individual’s coping with stress (Martin, Weinberg and Bealer 2007). 

        The implementation of mindfulness-related techniques in medicine seem to have been motivated by fundamental studies of their physiological consequences.   Particularly influential was the systematic investigation of meditation by Wallace (1970) which concluded:

        “There were significant changes between the control period and the meditation period in all measurements.  During meditation, oxygen consumption and heart rate decreased, skin resistance increased, and the electroencephalogram showed specific changes in certain frequencies.  These results seem to distinguish the state produced by transcendental meditation from commonly encountered states of consciousness and suggest that it may have practical applications.”

        As the benefits of mindfulness techniques were increasingly employed in medicine and psychiatry, emerging research focused on associated neurobiologic changes (Dossett, Fricchione and Benson 2020; Zhang, Lee, Mak et al. 2021).  Mindfulness meditation is thought to exert its effects by enhanced self-regulation, including attention control, emotion regulation and self-awareness as deduced from neuroimaging studies (Tang, Hölzel and Posner 2015). 

        The anterior cingulate cortex (ACC) is particularly involved in attention and is the region in which changes in neural activity and/or brain structure have most consistently been reported in association with mindfulness meditation.  The ACC is part of a network implicated in self-regulation whose connectivity changes dramatically in development in late adolescence, thus increasing ACC activity and improving self-regulation.  Practicing mindfulness techniques also improves emotional regulation and reduces stress by engaging fronto-limbic networks involved in these processes.  Tang and colleagues (2007) reported that students given mindfulness-related training showed greater improvement in attention, lower anxiety, depression, anger, and fatigue, and higher vigor, a significant decrease in stress-related cortisol, and an increase in immunoreactivity.  

        Lazar, Kerr, Wasserman et al. (2005) found that brain regions associated with attention, interoception and sensory processing were of relatively greater volume in those who practiced meditation than in matched controls, including the prefrontal cortex and right anterior insula, between-group differences in prefrontal cortical thickness were most pronounced in older participants possibly offsetting age-related cortical thinning and the thickness of two of these brain regions correlated significantly with meditation experience.  Brewer, Worhunsky, Gray et al. (2011) found that meditation practice has the potential to affect self-referential processing and improve present-moment awareness by altering activation of default mode networks as the midline prefrontal cortex and posterior cingulate cortex, which support self-awareness.  Tang, Lu, Geng et al. (2010) reported that integrative body–mind training increases fractional anisotropy, an index indicating the integrity and efficiency of white matter, in the corona radiata, an important white-matter tract connecting the ACC to other structures.  

        Mindfulness techniques are a family of mental practices that encompass a wide array of exercises employing distinctive mental strategies.  Fox, Dixon, Nijeboer et al. (2016) systematically reviewed the functional neuroanatomy of various mindfulness practices in a meta-analysis of 78 functional neuroimaging (fMRI and PET) studies and found reliably dissociable patterns of brain activation and deactivation for four common styles of meditation (focused attention, mantra recitation, open monitoring and compassion/loving-kindness) and suggestive differences for three others (visualization, sense-withdrawal and non-dual awareness practices) and dissociable activation patterns congruent with the psychological and behavioral aims of each practice.  The insula, pre/supplementary motor cortices, dorsal ACC and frontopolar cortex were recruited consistently across multiple techniques with effects noted for both activations and deactivations, suggesting shared brain functions involved in a range of mindfulness techniques.

        The wide range of benefits for health that have been documented in association with practicing mindfulness techniques lends support to the term mind-body medicine (Dossett, Fricchione and Benson 2020) and is greatly reminiscent of the work of Franz Alexander (1891-1964), the Hungarian-born American physician and psychoanalyst who proposed that emotional tension can generate physical illness, coining the term psychosomatic disease (Alexander 1950).  Not only are brain neural connections associated with attention and self-awareness strengthened by practicing mindfulness techniques, but an emerging literature points to mindfulness techniques reducing systemic effects of exposure to stress during a lifetime. 

        Epel, Blackburn, Lin et al. (2004) reported that accelerated telomere shortening provided a cellular measure of the cumulative effects of stress on the organism during a lifetime.  The enzyme telomerase, through its influence on telomere length, is associated with health and mortality.   In a meta-analysis, Schutte and Malouff (2014) reported a moderate effect size for the beneficial effects of mindfulness meditation on telomerase activity in peripheral blood mononuclear cells.  A more recent meta-analytic study provided tentative support for a dose-dependent effect of meditation-based practices on telomere length (Schutte, Malouff and Keng 2020). 

        Mindfulness interventions that included yoga postures were associated in a meta-analysis with improved regulation of the sympathetic nervous system and hypothalamic-pituitary-adrenal system in various populations, including reduced evening cortisol, waking cortisol, ambulatory systolic blood pressure, resting heart rate, high frequency heart rate variability, fasting blood glucose, cholesterol and low density lipoprotein, compared to active controls (Pascoe, Thompson and Ski 2017). Possibly the extensive therapeutic consequences of practicing mindfulness techniques are mediated by changes in gene expression networks with general benefits to cellular health (Epel, Puterman, Lin et al. 2016) with implications for brain fitness and lowered susceptibility to diseases due to stress.

 

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October 14, 2021