You’ve probably heard of mindfulness. These days, it’s everywhere, like many ideas and practices drawn from Buddhist texts that have become part of mainstream Western culture.
But a review published today in the journal Perspectives on Psychological Science shows the hype is ahead of the evidence. Some reviews of studies on mindfulness suggest it may help with psychological problems such as anxiety, depression, and stress. But it’s not clear what type of mindfulness or meditation we need and for what specific problem.
The study, involving a large group of researchers, clinicians and meditators, found a clear-cut definition of mindfulness doesn’t exist. This has potentially serious implications. If vastly different treatments and practices are considered the same, then research evidence for one may be wrongly taken as support for another.
At the same time, if we move the goalposts too far or in the wrong direction, we might lose the potential benefits of mindfulness altogether.
So, what is mindfulness?
Mindfulness receives a bewildering assortment of definitions. Psychologists measure the concept in differing combinations of acceptance, attentiveness, awareness, body focus, curiosity, nonjudgmental attitude, focus on the present, and others.
It’s equally ill-defined as a set of practices. A brief exercise in self-reflection prompted by a smart-phone app on your daily commute may be considered the same as a months-long meditation retreat. Mindfulness can both refer to what Buddhist monks do and what your yoga instructor does for five minutes at the start and end of a class.
To be clear, mindfulness and meditation are not the same thing. There are types of meditation that are mindful, but not all mindfulness involves meditation and not all meditation is mindfulness-based.
Mindfulness mainly refers to the idea of focusing on the present moment, but it’s not quite that simple. It also refers to several forms of meditation practices that aim to develop skills of awareness of the world around you and of your behavioral patterns and habits. In truth, many disagree about its actual purpose and what is and isn’t mindfulness.
What’s it for?
Mindfulness has been applied to just about any problem you can think up – from relationship issues, problems with alcohol or drugs, to enhancing leadership skills. It’s being used by sportsmen to find “clarity” on and off the field and mindfulness programs are being offered at school. You can find it in workplaces, medical clinics, and old age homes.
More than a few popular books have been written touting the benefits of mindfulness and meditation. For example, in a supposedly critical review Altered Traits: Science Reveals How Meditation Changes your Mind, Brain and Body, Daniel Goleman argues one of the four benefits of mindfulness is improved working memory. Yet, a recent review of about 18 studies exploring the effect of mindfulness-based therapies on attention and memory calls into question these ideas.
Another common claim is that mindfulness reduces stress, for which there is limited evidence. Other promises, such as improved mood and attention, better eating habits, improved sleep, and better weight control are not fully supported by the science either.
And while benefits have limited evidence, mindfulness and meditation can sometimes be harmful and can lead to psychosis, mania, loss of personal identity, anxiety, panic, and re-experiencing traumatic memories. Experts have suggested mindfulness is not for everyone, especially those suffering from several serious mental health problems such as schizophrenia or bipolar disorder.
Research on mindfulness
Another problem with mindfulness literature is that it often suffers from poor research methodology. Ways of measuring mindfulness are highly variable, assessing quite different phenomena while using the same label. This lack of equivalence among measures and individuals makes it challenging to generalise from one study to another.
Mindfulness researchers rely too much on questionnaires, which require people to introspect and report on mental states that may be slippery and fleeting. These reports are notoriously vulnerable to biases. For example, people who aspire to mindfulness may report being mindful because they see it as desirable, not because they have actually achieved it.
Only a tiny minority of attempts to examine whether these treatments work compare them against another treatment that is known to work – which is the primary means by which clinical science can show added value of new treatments. And a minority of these studies are conducted in regular clinical practices rather than in specialist research contexts.
A recent review of studies, commissioned by the US Agency for Healthcare Research and Quality, found many studies were too poorly conducted to include in the review and that mindfulness treatments were moderately effective, at best, for anxiety, depression, and pain. There was no evidence of efficacy for attention problems, positive mood, substance abuse, eating habits, sleep or weight control.
What should be done?
Mindfulness is definitely a useful concept and a promising set of practices. It may help prevent psychological problems and could be useful as an addition to existing treatments. It may also be helpful for general mental functioning and well-being. But the promise will not be realised if problems are not addressed.
The mindfulness community must agree to key features that are essential to mindfulness and researchers should be clear how their measures and practices include these. Media reports should be equally specific about what states of mind and practices mindfulness includes, rather than using it as a broad term.
Mindfulness might be assessed, not through self-reporting, but in part using more objective neurobiological and behavioural measures, such as breath counting. This is where random tones could be used to “ask” participants if they are focused on the breath (press left button) or if their mind had wandered (press right button).
Researchers studying the efficacy of mindfulness treatments should compare them to credible alternative treatments, whenever possible. Development of new mindfulness approaches should be avoided until we know more about the ones we already have. Scientists and clinicians should use rigorous randomised control trials and work with researchers from outside the mindfulness tradition.
And lastly, mindfulness researchers and practitioners should acknowledge the reality of occasional negative effects. Just as medications must declare potential side effects, so should mindfulness treatments. Researchers should systematically assess potential side effects when studying mindfulness treatments. Practitioners should be alert to them and not recommend mindfulness treatments as a first approach if safer ones with stronger evidence of efficacy are available.
Mental disorders are traditionally seen as rather like flowering bulbs. Above the ground we see their symptoms, but we know their source lies hidden beneath the surface. If we treat the symptoms without addressing the cause – cut off the flower without uprooting the bulb – they will just flower again later.
The idea that each mental disorder has an underlying cause is itself deeply rooted. We imagine that underneath the clinical symptoms of schizophrenia or depression there is an underlying disease entity. If treatment is to be effective and lasting rather than merely symptomatic it must target that concealed origin.
People have had many ideas about the form the unseen cause might take. Medieval physicians imagined a “stone of folly” that had to be surgically removed from a mad person’s head before sanity could prevail. Funnily enough, the best known painting of such an operation, Hieronymus Bosch’s The extraction of the stone of madness, shows the “stone” to be a flower bulb.
More recently, psychiatrists often suppose the hidden cause is neural, such as a brain disease or chemical imbalance. Psychologists sometimes prefer to invoke specific cognitive malfunctions or conflicts. What unifies them is the idea that a cluster of symptoms can be traced back to an underlying pathology.
This way of thinking makes perfect sense in some areas of medicine. A collection of bodily symptoms often points to an underlying disease process. Scarlet fever is revealed by a bright red rash, fever and a sore throat, all caused by an underlying bacterial infection. It would be folly to treat it symptomatically. Pacifying the rash with wet towels, taming the fever with aspirin and drinking tea with honey to soothe the throat would not attack the hidden, microbial cause.
Unfortunately mental disorder is not like infectious disease. Rarely is there a single, identifiable cause underlying a group of symptoms. Most psychiatric symptoms spring from a tangled multiplicity of causes. In addition, many symptoms are not specific to a single condition.
Billions of research dollars have been spent trying to locate the unique hidden cause of each mental disorder. The results have been spectacularly disappointing, not because mental health researchers are inept but because the causes of mental disorder are extremely complex.
To extend the botanical metaphor, mental disorders are less like flowering bulbs than like bamboo. An interconnected network of underground roots (hidden causes) generates many visible stems (symptoms). No stem can be traced back to a single root, and no root feeds a single stem.
The network approach to mental disorder
If there is no one-to-one link between symptoms and hidden causes, maybe we are better off putting aside the search for those causes. A new way of thinking about mental disorder argues just that, proposing that we focus full attention on symptoms instead.
Rather than seeing symptoms as manifestations of hidden disease entities – as the tip of an iceberg – this “network approach” tells us to examine how symptoms relate to one another. It argues the symptoms of a disorder cluster together not because they share a hidden cause but because they interact with and potentially reinforce one another.
The network approach to mental disorder, developed by Dutch psychologists Denny Borsboom, Angelique Cramer and colleagues, represents each symptom as a node in network. It draws links between these nodes to reveal the symptoms that are most strongly related, such as which ones influence other symptoms most powerfully and extensively.
For example, loss of appetite and weight loss are both symptoms of major depression. If researchers found they were closely related, and appetite loss drives weight loss, then an arrow would be drawn from the former to the latter. By this means a group of dynamically related symptoms can be represented by a network diagram.
Several features of the resulting networks are particularly interesting. Certain symptoms can be shown to be central, related to many others, whereas others are more peripheral. Certain symptoms primarily cause others, whereas some symptoms are primarily caused by others.
Because mental disorders are seen as mutually reinforcing symptoms, clinicians should target central symptoms that cause many others. Successfully treating these symptoms should have broadly beneficial effects. It should reduce other existing symptoms and prevent the spread to new symptoms.
Certain symptoms may also be bridges from one disorder network to another. For example, sleep disturbance among people with post-traumatic stress disorder (PTSD) may cause fatigue, and fatigue may serve as a bridge to the depression network by activating concentration problems and guilt.
Researchers have carried out network analyses of several disorders, using similar computational tools as those used in social network analysis, an approach to mapping relations among people. One study of several substance use problems showed that using the substance more than planned was usually the most central symptom. It was strongly related to having worse withdrawal symptoms and needing more of the substance to get the same effect (“tolerance”).
Several studies have explored anxiety disorders. A study of social anxiety showed that avoidance of potentially threatening social situations was a central symptom and thus a prime target for treatment. Research on PTSD following a catastrophic earthquake in China showed that sleep difficulty and hypervigilance for future threats had especially potent influences on other symptoms.
Turning to depression, a study of short term fluctuations in symptoms revealed the centrality of loss of pleasure in the symptom network. It activated an assortment of other symptoms including sadness, loss of energy and interest in activities and irritability. In contrast, sadness, crying and a loss of interest in sex were incidental.
Another study showed that depressed people whose symptoms were more densely connected were more likely to have persistent depression two years later. This finding accords with the network view that symptoms of mental disorders can be self-reinforcing. People whose symptom networks form a tighter web may therefore have greater difficulty overcoming their problems.
The network approach has several important implications. For researchers, it suggests that the search for single causes of mental disorders is quixotic. Of course, symptoms have an assortment of social and neurobiological sources, but these sources are highly unlikely to be unique to one condition.
For practising psychiatrists and psychologists the network view implies that symptoms should be taken seriously in their own right and not seen merely as pale manifestations of underlying disease. Treatments should directly target particular symptoms, not a fictitious hidden cause.
Boorsboom and Cramer make this point amusingly in regard to major depression.
If [depression] does not exist as an entity that exists independently of its symptoms (like a tumour does), attempting to treat it analogous to the way medical conditions are treated (cutting away the tumour) is like trying to saddle a unicorn.
The network approach also has a strong message for all of us who care about mental health and illness. We should abandon the last vestiges of our belief that mental disorders are best seen as medical diseases. The symptoms of depression, PTSD, or social anxiety don’t point to an underlying disorder. They are the disorder.
Eating disorders are complex mental illnesses that have one of the highest death rates of any psychiatric disorder. Among people with anorexia nervosa – who commonly deprive themselves of food due to an obsessive fear of gaining weight – this rate is more than five times greater than in the general population.
All eating disorders are associated with significant, wide-ranging physical health complications such as starvation, cardiac arrest (sudden loss of heart function), kidney problems, food intolerance and fits. These are among the leading causes of hospitalisation for mental-health-related issues in Australia.
Because serious medical complications so frequently accompany eating disorders, they defy classification solely as mental illnesses. They should be viewed as complex health-care issues requiring urgent and multidisciplinary care.
Yet many health-care providers have not been provided with enough basic education and training to be able to recognise and respond appropriately to someone presenting with an eating disorder. So despite their severity, eating disorders often go unrecognised.
This leads to substantial economic costs for the Australian health system and devastating effects for sufferers, loved ones and the communities that surround them.
What are eating disorders?
Eating disorders have been around through recorded history. Even an ancient Egyptian tomb painting depicts a noble self-inducing vomiting.
There are several types of eating disorders. These include anorexia nervosa, bulimia nervosa and binge eating disorder. Collectively, these are characterised by abnormal eating behaviours, poor body image, overemphasis on weight and shape, and extreme weight-control behaviours.
In the case of anorexia, such behaviours lead to severe weight loss and often life-threatening complications. Vomiting, laxative abuse and excessive exercise can be features of both anorexia and bulimia, as can binging and purging.
Unlike the severe weight loss associated with anorexia, bulimia is characterised by the presence of binging and usually purging at a relatively normal weight. Binge eating disorder features frequent binging, in the absence of purging or other compensatory behaviours, which often leads to significant weight gain.
Who gets eating disorders?
There are psychological, environmental and biological (including genetic) risk factors for developing eating disorders. A genetic predisposition in combination with poor body image is one of the strongest predictors of disordered eating.
Poor body image has been reported in nearly half of Australian women and over one-third of Australian men. Disturbingly, the rate of body-image concerns is even greater in children and adolescents. A study of Australian children found up to 61% of girls and boys between the ages of eight and 11 are trying to control their weight.
Around 10% of the Australian population will experience an eating disorder in their lifetime, and the rate is increasing. For example, one study observed a two-fold increase in disordered eating between 1995 and 2005 in South Australia. And a more recent study in the same state observed a more than two-fold increase in extreme dieting and binge eating between 1998 and 2008.
While the reasons for this increase have not yet been fully explored, they may be related to increasing concerns about weight in the general Australian population.
Contrary to the long-held belief eating disorders are the domain of wealthy young females, the greatest increase has been observed in older people, males and those in lower socio-demographic groups.
This may be due, at least in part, to inadequate access to treatment, differences in people seeking treatment, or detection in under-represented groups, and stigma surrounding the development of a disorder commonly associated with a specific (different) group in the community.
How are they treated?
A number of evidence-based treatments are available for eating disorders. It is important to note that no single approach will be effective for all individuals.
Structured, psychological therapies are considered the cornerstone of treatment for eating disorders. For adolescents with anorexia, this takes the form of family-based therapy. This involves helping the whole family support the person with the disorder.
In adults with eating disorders, evidence shows a minimum of 20 sessions of cognitive behaviour therapy (CBT) – which challenges learnt ways of thinking – is necessary. In severe cases of anorexia, at least 40 CBT sessions that include a strong emphasis on restoring healthy eating attitudes and behaviours are required.
A multidisciplinary team is best equipped to address the complex nutritional, medical and psychological needs of someone with anorexia.
Increasing funding to improve outcomes
The total social and economic costs of eating disorders in Australia exceed A$69 billion per year. These costs can be reduced with early detection.
Most people with eating disorders go a long time before receiving adequate care. One study of over 10,000 adolescents found that, while nearly 90% of those with an eating disorder contacted a service provider for help, in only a minority (3-28%) of cases were the services specifically for their eating disorder.
Factors such as denial, shame, stigma and a lack of recognition of eating disorder symptoms by health-care professionals are likely contributors to this discrepancy.
Medicare provides Australians with funding for ten sessions with an allied mental-health professional (such as a psychologist or social worker). This is below the minimum treatment recommendation of 20 sessions for all eating disorders.
We should not accept a system that prevents people with a severe life-threatening mental illness from accessing a treatment that is available, effective and will save costs in the long term.
Federal Health Minister Greg Hunt recently requested the Medicare Benefits Schedule Review Taskforce investigate increasing Medicare coverage to treat people with an eating disorder. We urgently need early identification of eating disorders and the delivery of quality, targeted treatments at evidence-supported durations.
This article was co-authored by Tina Peckmezian, Principal Research Officer at The Butterfly Foundation.
What would you think was happening to you if out of nowhere your heart started to race, you were drenched in sweat, you found yourself trembling uncontrollably, short of breath, with chest pain and feeling nauseated, dizzy and lightheaded as though you might faint?
You might also be feeling very cold or very hot, with tingling sensations in your fingers and toes. You might feel removed from the world around you – as though it wasn’t real – and be worried that you might lose control or that you are going insane. You might try to work out what is happening and conclude you are having a heart attack or dying.
A panic attack is a sudden, intense feeling of fear or discomfort with at least four of the signs described above. For some people, a panic attack can come out of nowhere, like a sudden thunderstorm from a clear blue sky. For other people, panic attack may be more predictable, such as an abrupt escalation of a milder anxiety about giving a speech or speaking to someone in authority.
Just as a panic attack can follow an experience of relative calm or of mild anxiety, panic can resolve to a relatively calm state or to ongoing, less intense symptoms. But the symptoms of panic attack are severe and frightening. Many people experiencing a panic attack believe they are seriously ill and seek medical help.
What is happening to the body?
Often one of the first symptoms of a panic attack is hyperventilating (rapidly breathing in and out), which upsets the natural balance of oxygen and carbon dioxide in our system. One view says a low level of carbon dioxide in the blood directly triggers the symptoms of panic, such as feeling lightheaded and dizzy. When we breathe quickly we also build up oxygen in our blood. Paradoxically, too much oxygen is also associated with feeling short of breath.
Hyperventilation causes many of the other symptoms of a panic attack such as dizziness, blurred vision, tingling, muscle tension, chest pain, heart rate increases, nausea and temperature changes.
People who experience panic misinterpret the bodily signs of hyperventilation as indicating immediate physical danger and believe they have little control over the symptoms. When we then say things to ourselves such as “I might be having a heart attack” and “I can’t cope with this”, the anxiety gets worse.
In a 2013 study, researchers showed when people with no history of panic inhaled air with increased carbon dioxide they reported fear, discomfort and panic symptoms. People with a history of panic attack experience these symptoms at lower concentrations of carbon dioxide, suggesting they are hypersensitive to this internal signal for danger.
Panic attacks can occur with a range of diagnosed mental illnesses, including anxiety disorders, depressive disorders and substance use disorders, as well as physical illnesses, especially illnesses that affect heart function, breathing, balance and digestion. It is very important to understand and deal with panic attacks so they don’t lead to a more serious condition known as panic disorder.
People with panic disorder have a history of panic attacks and worry they will have further panic attacks. They change the way they live to ensure they do not have another panic attack. They avoid activities like exercise that cause feelings similar to panic attack (shortness of breath, sweating) and avoid situations where they fear another panic attack may occur. This avoidance brings many additional problems, as social, family and occupational worlds shrink due to fear of panic.
What should you do if you have a panic attack?
Panic attacks are common, with almost 23% of a people from a large US study of the general population reporting at least one panic attack during their lives. Panic attacks are more common in females than males. They are also more common in family members of people with panic disorder.
Panic attacks are more common among people who believe symptoms of anxiety are dangerous and harmful, rather than annoying and uncomfortable. They are also more likely if you are under emotional pressure, have been ill, are tired, are hungover or smoke.
As many of the symptoms of panic attack are physical and can be caused by a number of physical conditions, the first thing to do if you have symptoms like the ones described here is to see your doctor to check whether there is a medical reason for the symptoms.
If the symptoms are due to panic, then there are effective psychological approaches for controlling panic attacks. These focus on:
monitoring and slowing breathing, as overbreathing causes many panic sensations
correcting the interpretations about what the symptoms mean by looking at the things we say to ourselves before, during and after a panic attack. It is very important to remember the symptoms are “just anxiety” and are not life-threatening.
There is useful information about panic attack and how to cope with it available through Lifeline.
Lynne Harris, Professor of Psychological Sciences, School of Psychological Sciences, Australian College of Applied Psychology and Honorary Assoc Prof with the Faculty of Health Sciences, University of Sydney
A growing number of scientists are coming to the conclusion that depression is at least as much a physical condition as it has to do with the mind.
One explanation is inflammation, which is caused by a part of the immune system that gets called into action when the body suffers a wound, the Guardian reports.
A set of proteins called cytokines sets off this inflammation in the body. This process is why people tend to feel down when they fall ill.
And so scientists think the brain may be tricked into feeling depressed through a process akin to an allergic reaction.
Read more at the Guardian