Gary E. Schwartz

Effects of Mindfulness-Based Stress Reduction on Medical and Premedical Students

The inability to cope successfully with the enormous stress of medical education may lead to a cascade of consequences at both a personal and professional level. The present study examined the short-term effects of an 8-week meditation-based stress reduction intervention on premedical and medical students using a well-controlled statistical design. Findings indicate that participation in the intervention can effectively (1) reduce self-reported state and trait anxiety, (2) reduce reports of overall psychological distress including depression, (3) increase scores on overall empathy levels, and (4) increase scores on a measure of spiritual experiences assessed at termination of intervention. These results (5) replicated in the wait-list control group, (6) held across different experiments, and (7) were observed during the exam period. Future research should address potential long-term effects of mindfulness training for medical and premedical students.

Neuroanatomical correlates of pleasant and unpleasant emotion.

Substantial evidence suggests that a key distinction in the classification of human emotion is that between an appetitive motivational system association with positive or pleasant emotion and an aversive motivational system associated with negative or unpleasant emotion. To explore the neural substrates of these two systems, 12 healthy women viewed sets of pictures previously demonstrated to elicit pleasant, unpleasant and neutral emotion, while positron emission tomographic (PET) measurements of regional cerebral blood flow were obtained. Pleasant and unpleasant emotions were each distinguished from neutral emotion conditions by significantly increased cerebral blood flow in the vicinity of the medial prefrontal cortex (Brodmanns area 9), thalamus, hypothalamus and midbrain (P < 0.005). Unpleasant was distinguished from neutral or pleasant emotion by activation of the bilateral occipito-temporal cortex and cerebellum, and left parahippocampal gyrus, hippocampus and amygdala (P < 0.005). Pleasant was also distinguished from neutral but not unpleasant emotion by activation of the head of the left caudate nucleus (P < 0.005). These findings are consistent with those from other recent PET studies of human emotion and demonstrate that there are both common and unique components of the neural networks mediating pleasant and unpleasant emotion in healthy women.

The Levels of Emotional Awareness Scale: a cognitive-developmental measure of emotion.

The Levels of Emotional Awareness Scale (LEAS) is based on a new cognitive-developmental model of emotional experience. The scale poses evocative interpersonal situations and elicits descriptions of the emotional responses of self and others which are scored using specific structural criteria. Forty undergraduates (20 of each sex) were tested. Interrater reliability and intratest homogeneity of the LEAS were strong. The LEAS was significantly correlated with two measures of maturity: the Washington University Sentence Completion Test (SCT) of Ego Development, and the Parental Descriptions Scale-a cognitive-developmental measure of object representation. In addition, the LEAS correlated positively with openness to experience and emotional range but not with measures of specific emotions, repression or the number of words used in the LEAS responses. These findings suggest that it is the level of emotion, not the specific quality of emotion, that is tapped by the LEAS.

Right hemisphere lateralization for emotion in the human brain: Interactions with cognition

Right-handed subjects tend to look to the left when answering affective questions. The relative shift in gaze from right to left is accentuated when the questions also involve spatial manipulation and attenuated when the questions require verbal manipulation. The data support the hypothesis that the right hemisphere has a special role in emotion in the intact brain, and that predictable patterning of hemispheric activity can occur when specific combinations of cognitive and affective processes interact.

Impaired verbal and nonverbal emotion recognition in alexithymia.

Although clinical observations suggest that alexithymic individuals have a deficit in their ability to recognize emotional stimuli and that this deficit is not simply due to a problem in verbal labeling, these two hypotheses have not been empirically confirmed.Three hundred eighty participants in a community survey without current or past histories of psychiatric disorder completed two independent measures of alexithymia [the Levels of Emotional Awareness Scale (LEAS) and the Toronto Alexithymia Scale (TAS-20)] and the Perception of Affect Task (PAT), a 140-item measure of the ability to match emotion stimuli. The PAT includes four subtasks that require the subject to match verbal or nonverbal emotion stimuli with verbal or nonverbal emotion responses. The subtasks include matching sentences and words (verbal-verbal), faces and words (nonverbal-verbal), sentences and faces (verbal-nonverbal), and faces and photographs of scenes (nonverbal-nonverbal). Across the entire sample, higher (alexithymic) TAS-20 and lower LEAS scores were both correlated with lower accuracy rates on each of the subtasks of the PAT (p <.001), accounting for 10.5% and 18.4% of the variance, respectively. Fifty-one subjects met TAS-20 criteria for alexithymia. Alexithymic individuals scored lower than other subjects on purely nonverbal matching, purely verbal matching, and mixed verbal-nonverbal matching (all p <.001). These results suggest that alexithymia is associated with impaired verbal and nonverbal recognition of emotion stimuli and that the hallmark of alexithymia, a difficulty in putting emotion into words, may be a marker of a more general impairment in the capacity for emotion information processing.

Is alexithymia the emotional equivalent of blindsight

A fundamental tenet of psychosomatic medicine is that interference with the experience and expression of emotions can have an adverse affect on health (Taylor 1987). Early in this century it was observed that the onset and course of certain physical diseases were adversely affected by the repression of certain conflictual ideas and their accompanying affects (Alexander 1950). A later alternative view was that a deficit or developmental arrest in the capacity for symbolic mental representation of emotion was the core problem in patients with psychosomatic disorders, typified by a diminished ability to identify and describe feelings (Ruesch 1948). This latter view has evolved into the concept of alexithymia, a term coined by Sifneos in 1972 meaning “absence of words for emotion” (Sifneos 1972). Sifneos and Nemiah posited that the deficit in the capacity for symbolization of emotion (in verbal behavior, fantasy, and dreams) resulted in a variety of manifestations, including abnormal physiology resulting in disease, a propensity for impulsive behavior, discomfort with and avoidance of social relationships, and an impaired capacity for self-care and self-regulation (Nemiah and Sifneos 1970). Subsequent research has revealed that alexithymia is associated with a variety of other psychiatric disorders, including posttraumatic stress disorder (PTSD), substance abuse and dependence, somatization, eating disorders, and panic disorder (Taylor et al 1991; Jimerson et al 1994; Parker et al 1993). It is not known whether the manifestations of alexithymia are similar or different in these various clinical contexts. Recent research has also demonstrated that alexithymia is associated with deficits in the recognition of both verbal and nonverbal emotional stimuli (Lane et al, in press). To obtain a current consensus about the essential features of alexithymia, Haviland and Reise (1996) recently generated a prototypical description of alexithymic individuals derived from 13 experts using the Q-sort method. The results of this survey are presented in Table 1. Alexithymic individuals manifest bland or flattened affect, tend to be somatically preoccupied, express themselves through action and nonverbal behavior, are interpersonally distant, become disorganized under stress, lack imagination and insight, and tend to be socially conforming. Early descriptions of alexithymic individuals included diminished facial expressions, which have been confirmed in recent empirical work (McDonald and Prkachin 1990), but also noted occasional brief, intense, dramatic outbursts of emotion such as tearfulness that end as abruptly as they From the Department of Psychiatry (RDL, GLA, GES, AWK) and Department of Neurology (GLA, GES, AWK), University of Arizona College of Medicine, and Department of Psychology, University of Arizona (RDL, GLA, GES, AWK), Tucson, Arizona. Address reprint request to Richard D. Lane, MD, Department of Psychiatry, Arizona Health Sciences Center, 1501 N. Campbell Avenue, Tucson, AZ 85724. Received January 18, 1996.

The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: An exploratory study

OBJECTIVE The diagnosis of breast cancer, the most common type of cancer among American women, elicits greater distress than any other diagnosis regardless of prognosis. Therefore, the present study examined the efficacy of a stress reduction intervention for women with breast cancer. METHODS As part of a larger, randomized, controlled study of the effects on measures of stress of a mindfulness-based stress reduction (MBSR) intervention for women with breast cancer, the current analyses examined the effects on sleep complaints. RESULTS Analyses of the data indicated that both MBSR and a free choice (FC) control condition produced significant improvement on daily diary sleep quality measures though neither showed significant improvement on sleep-efficiency. Participants in the MBSR who reported greater mindfulness practice improved significantly more on the sleep quality measure most strongly associated with distress. CONCLUSION MBSR appears to be a promising intervention to improve the quality of sleep in woman with breast cancer whose sleep complaints are due to stress.

Stress Management in Medical Education: A Review of the Literature.

Purpose To review systematically clinical studies providing empirical data on stress-management programs in medical training. Method The authors searched Medline and PSYCHINFO from 1966 to 1999. Studies were included if they evaluated stress-management programs for medical trainees (medical students, interns, or residents); reported empirical data; and had been conducted at allopathic medical schools. Results Although the search yielded over 600 articles discussing the importance of addressing the stress of medical education, only 24 studies reported intervention programs, and only six of those used rigorous scientific method. Results revealed that medical trainees participating in stress-management programs demonstrated (1) improved immunologic functioning, (2) decreases in depression and anxiety, (3) increased spirituality and empathy, (4) enhanced knowledge of alternative therapies for future referrals, (5) improved knowledge of the effects of stress, (6) greater use of positive coping skills, and (7) the ability to resolve role conflicts. Despite these promising results, the studies had many limitations. Conclusion The following considerations should be incorporated into future research: (1) rigorous study design, including randomization and control (comparison) groups, (2) measurement of moderator variables to determine which intervention works best for whom, (3) specificity of outcome measures, and (4) follow-up assessment, including effectiveness of future patient care.

An olfactory-limbic model of multiple chemical sensitivity syndrome: possible relationships to kindling and affective spectrum disorders.

This paper reviews the clinical and experimental literature on patients with multiple adverse responses to chemicals (Multiple Chemical Sensitivity Syndrome-MCS) and develops a model for MCS based on olfactory-limbic system dysfunction that overlaps in part with Posts kindling model for affective disorders. MCS encompasses a broad range of chronic polysymptomatic conditions and complaints whose triggers are reported to include low levels of common indoor and outdoor environmental chemicals, such as pesticides and solvents. Other investigators have found evidence of increased prevalence of depression, anxiety, and somatization disorders in MCS patients and have concluded that their psychiatric conditions account for the clinical picture. However, none of these studies has presented any data on the effects of chemicals on symptoms or on objective measures of nervous system function. Synthesis of the MCS literature with large bodies of research in neurotoxicology, occupational medicine, and biological psychiatry, suggests that the phenomenology of MCS patients overlaps that of affective spectrum disorders and that both involve dysfunction of the limbic pathways. Animal studies demonstrate that intermittent repeated low level environmental chemical exposures, including pesticides, cause limbic kindling. Kindling (full or partial) is one central nervous system mechanism that could amplify reactivity to low levels of inhaled and ingested chemicals and initiate persistent affective, cognitive, and somatic symptomatology in both occupational and nonoccupational settings. As in animal studies, inescapable and novel stressors could cross-sensitize with chemical exposures in some individuals to generate adverse responses on a neurochemical basis. The olfactory-limbic model raises testable neurobiological hypotheses that could increase understanding of the multifactorial etiology of MCS and of certain overlapping affective spectrum disorders.

Sex Differences in Emotional Awareness

The present study examined sex differences in the complexity and differentiation of people’s representations of emotional experience. Female participants from seven different samples, ranging in age, scholastic performance, socioeconomic status, and culture, scored higher on a performance test of emotional awareness than did male participants. Women consistently displayed more complexity and dif ferentiation in their articulations of emotional experiences than did men, even when the effect of verbal intelligence was controlled. Together, the findings suggest that a sex difference in display of emotional awareness is a stable, highly generalizable effect. Implications of these findings are presented.