Mindfulness-Based Interventions

for Physical Health 6

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We will try today to find the source of healing, which is

in our minds. . . . It is not farther from us than ourselves.

—Vaughan and Walsh (1992, p. 89)

I
n chapter 5 (this volume), we reviewed seminal and current
studies investigating the effects of mindfulness-based inter-
ventions on outcomes in populations with psychological dis-
orders and in healthy individuals. In this chapter, we use a
similar strategy to summarize the important research inves-
tigating the effects of mindfulness-based interventions that
have focused on physiological or medical outcomes in a vari-
ety of medical populations and in healthy populations. Of
note, many of the investigations of medical populations
focus on outcomes similar to those described in chapter 5,
such as stress levels, depression, mood states, anxiety, and
other psychological reactions to illness. A minority of the
studies looked at the direct impact of mindfulness-based
interventions on disease pathology or progression. Both types
of studies are summarized in this chapter. Populations studied
range widely from people with chronic pain and fibromyalgia
to people with heart disease, organ transplant, and cancer,
to mention just a few. The bulk of the research in this chapter
examined the effects of mindfulness-based stress reduction
(MBSR) interventions, so it is organized by disease type rather
than by type of intervention.

http://dx.doi.org/10.1037/11885-006 75
The Art and Science of Mindfulness: Integrating Mindfulness Into Psychology and the Helping
Professions, by S. L. Shapiro and L. E. Carlson
Copyright © 2009 American Psychological Association. All rights reserved.
 76 THE ART AND SCIENCE OF MINDFULNESS

Clinical Populations

PAIN
The earliest reports from J. Kabat-Zinn and colleagues focused on patients
with a broad mix of chronic pain syndromes (J. Kabat-Zinn, 1982;
J. Kabat-Zinn, Lipworth, & Burney, 1985; J. Kabat-Zinn, Lipworth,
Burney, & Sellers, 1987). The 1982 report evaluated 51 patients before
and after MBSR participation, documenting improvements in pain
levels as well as mood and other psychiatric symptoms on the Symptom
Checklist–90–R (SCL-90-R), a commonly used measure of psychological
symptomatology. A similar pre–post design was used in a larger sample of
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90 patients (including the original 51) and showed similar improvements

pre- to postintervention. J. Kabat-Zinn and colleagues also compared
these MBSR participants with a treatment-as-usual (TAU) group from a
pain clinic, finding that the MBSR patients had improved more than the
TAU group did on measures of mood, pain symptoms, and general psy-
chiatric distress. They then conducted a series of follow-up assessments
in 1987 with 225 patients with chronic pain who had completed MBSR
over a several-year period, showing that although pain ratings them-
selves had returned to baseline within about 6 months, other ratings of
general distress, psychological symptoms, and adherence to the mindful-
ness practices were maintained. The majority of the participants rated their
overall outcomes and the importance of the program to them as high.
Another report of MBSR for chronic pain appeared in 1999, also
using a pre–post assessment design (Randolph, Caldera, Tacone, & Greak,
1999). The 78 patients evaluated showed improvements on measures
of ratings and beliefs about pain, as well as improved mood on the Profile
of Mood States and fewer psychiatric symptoms on the SCL-90-R General
Severity Index.
One more recent study evaluated MBSR and massage for the man-
agement of chronic musculoskeletal pain in 30 pain patients randomly
assigned to MBSR, massage, or a no-intervention control condition
(Plews-Ogan, Owens, Goodman, Wolfe, & Schorling, 2005). Immedi-
ately postintervention, the massage group had more pain reduction and
improved mental health status compared with usual care, while the
MBSR group showed greater longer term (1 month) improvements in
mental health outcomes compared with usual care and the massage
condition. Thus, MBSR was more effective for enhancing mood in the
long term, but massage provided more immediate pain relief.
McCracken, Vowles, and Eccleston (2005) applied principles of
acceptance and commitment therapy (ACT) to a group of 108 chronic
pain patients who participated in a 3- to 4-week residential pain pro-
gram. Overall, participants reported increases in emotional, social, and
 Mindfulness-Based Interventions for Physical Health 77

physical functioning, and decreases in health care use. This team also
found that a measure of mindfulness (the Mindful Attention Awareness
Scale, or MAAS) was correlated with multiple measures of pain func-
tioning in 105 patients with chronic pain (McCracken & Vowles, 2007).
Beyond measures of pain itself, mindfulness accounted for significant
variance in depression, pain-related anxiety, and physical and psycho-
logical disability, such that patients with higher levels of mindfulness
had fewer symptoms. This group further analyzed the same data and
found that changes in acceptance accounted for unique variance in
outcomes beyond improvements due to changes in pain intensity and
catastrophic thinking (Vowles, McCracken, & Eccleston, 2007). In their
most recent study, this team replicated their findings in a new sample
of 171 patients with chronic pain, offering 3 to 4 weeks of ACT and
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mindfulness-based treatment in a group format, 5 days per week for

6 1⁄2 hrs each day. Significant improvements were reported pre- to post-
treatment on measures of pain, depression, pain-related anxiety, disabil-
ity, medical visits, work status, and physical performance. The process
variable of acceptance of pain was associated with improvements in all
outcome measures (Vowles & McCracken, 2008).
MBSR has been applied to the treatment of chronic lower back pain.
Carson et al. (2005) applied a variant of MBSR with an extended focus
on loving-kindness practice with 43 patients. Participants were randomly
assigned to the loving-kindness program or TAU; treatment participants
showed improvements in pain perception and psychological distress,
whereas there were no improvements in the control group. More loving-
kindness practice on a given day was associated with lower pain ratings
on that day and lower anger the following day. In older adults, Morone,
Greco, and Weiner (2008) recruited 37 participants with an average age
of 75 years who were randomized to MBSR or a wait-list control condi-
tion. Compared with the wait list, the MBSR participants showed signif-
icantly greater improvements on measures of chronic pain acceptance,
engagement in activities, and overall physical functioning. Another appli-
cation to chronic low back pain used an intervention called “breath
therapy,” which combines body awareness, breathing, meditation, and
movement, similar to the MBSR program (Mehling, Hamel, Acree, Byl,
& Hecht, 2005). Thirty-six patients with chronic low back pain were
randomized to breath therapy or standard physical therapy, and assessed
at baseline, posttreatment, and 6 months later. Both groups of patients
reported lower levels of pain, and those in breath therapy had greater
improvements in functional, physical, and emotional role performance,
while those in physical therapy improved more in vitality.
Although sample sizes in the randomized controlled trials (RCTs)
conducted in this area remain small, support for MBSR as a helpful
intervention for improving coping with pain symptoms and overall
adjustment in patients with chronic pain continues to mount. The
 78 THE ART AND SCIENCE OF MINDFULNESS

growing number of randomized comparison studies with either TAU or

other active treatments should result in more robust and convincing
evidence of the efficacy of mindfulness-based approaches for the treat-
ment of pain.
Fibromyalgia (FM) is another pain-related condition associated
with overall bodily stiffness, soreness, and pain trigger points located
throughout the body, in which symptoms seem to be exacerbated by
stress. Other symptoms include fatigue and sleep disturbance, and FM
is considered notoriously difficult to treat. An early report in 1993 with
pre–post assessments of 59 participants in MBSR showed improvements
on scales of well-being, pain, fatigue, sleep, coping, and FM symptoms,
as well as general symptomatology on the SCL-90-R (Kaplan, Golden-
berg, & Galvin-Nadeau, 1993). Patients were classified as “responders”
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if they showed moderate to marked overall improvement. By this def-

inition, 51% of the sample responded to the treatment. In 1994 another
study of patients with FM emerged (Goldenberg et al., 1994). In this
case, although the trial was not randomized, 79 participants in the MBSR
program were compared with two groups: those on a waiting list for the
program and those who had declined participation in the group. MBSR
participants showed greater improvements than both groups on mea-
sures of pain and sleep as well as FM impact and global severity of psy-
chological symptoms.
Weissbecker et al. (2002) were interested in investigating the effects
of MBSR on sense of coherence (which they describe as a disposition to
experience life as meaningful and manageable) in women with FM.
Ninety-one women with FM were randomly assigned to MBSR or a
wait-list control group. Compared with the control participants, pro-
gram participants reported a significant increase in their sense of coher-
ence after MBSR participation, and stronger sense of coherence was
related to lower levels of perceived stress and less depression.
Another large RCT was conducted by Astin et al. in 2003. The
researchers randomly assigned 128 patients with FM to a group com-
bining mindfulness meditation plus Qigong movement therapy or an
education support group control condition. A large number of outcome
measures including pain, disability, depression, and coping were assessed,
but although patients did improve over time, neither group proved
superior. This test of an active and likely efficacious control condition,
combined with a mind–body group somewhat different from traditional
MBSR, may account for these results.
A research group in Germany has also been studying the efficacy of
MBSR for FM (Grossman, Tiefenthaler-Gilmer, Raysz, & Kesper, 2007).
In a quasi-experimental design, 58 women were assigned to either MBSR
or an active support condition based on date of entry into the study.
The women in the MBSR condition showed greater improvement
pre–post on measures of pain, coping, quality of life, anxiety, depression,
 Mindfulness-Based Interventions for Physical Health 79

and somatic complaints, which were maintained 3 years later. Finally,

a recent RCT assessed the effects of MBSR on depression symptoms in
91 women with FM (Sephton et al., 2007). Women were randomized
to ether MBSR or a wait-list control group, and assessed pre–post and
2 months later with the Beck Depression Inventory. Those in the MBSR
group showed significantly more improvement on depression symp-
toms across all three time points.
Hence, MBSR seems to be an effective intervention for alleviating
symptoms common in FM such as pain, depression, and a range of psy-
chological outcomes, although it has yet to be tested against proven effi-
cacious active control conditions that would provide a tougher test of
overall efficacy.
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CANCER
There is a fairly significant body of work investigating the efficacy of
MBSR for patients with various types of cancer. In fact, this literature
itself has been reviewed on several occasions since 2005 (Carlson &
Speca, 2007; Lamanque & Daneault, 2006; Mackenzie, Carlson, &
Speca, 2005; Matchim & Armer, 2007; Ott, Norris, & Bauer-Wu, 2006;
J. E. Smith, Richardson, Hoffman, & Pilkington, 2005). Because of the
large number of these studies, this section is organized by type of out-
comes studied.

Psychological Outcomes
The bulk of the experimental work has been conducted by Carlson and
Mindful colleagues in Canada, beginning with an RCT in which 89 patients with
Reminder: Are a variety of cancer diagnoses were randomized to MBSR or a wait-list
you mindfully control condition (Speca, Carlson, Goodey, & Angen, 2000). Patients in
the MBSR program improved significantly more on mood states and
reading right
symptoms of stress than did those in the control condition, with large
now, bringing
improvements of approximately 65% on mood and 35% on stress
your full pres- symptoms. They specifically reported less tension, depression, anger,
ence to what concentration problems, and more vigor, as well as fewer peripheral
you are read- manifestations of stress (e.g., tingling in hands and feet), cardio-
ing, or do you pulmonary symptoms of arousal (e.g., racing heart, hyperventilation),
notice yourself
central neurological symptoms (e.g., dizziness, faintness), gastrointesti-
nal symptoms (e.g., upset stomach, diarrhea), habitual stress behavioral
to be distracted
patterns (e.g., smoking, grinding teeth, overeating, insomnia), anxiety
or rushing to and fear, and emotional instability compared with those still waiting
get through for the program. These patients, as well as the control group, were
the chapter? assessed 6 months after treatment completion, and similar benefits
were seen in both groups over the follow-up period (Carlson, Ursuliak,
Goodey, Angen, & Speca, 2001). In the combined group more home
 80 THE ART AND SCIENCE OF MINDFULNESS

practice was associated with greater decreases in overall mood distur-

bance, and the greatest improvements were seen on anxiety, depression,
and irritability.
Tacon, Caldera, and Ronaghan (2004) also investigated the effects
of MBSR on psychological outcomes in patients with cancer, conducting
a small pre–post study with 27 women diagnosed with breast cancer.
These women showed improvements over the MBSR course on measures
of stress and anxiety, as well as less hopelessness and anxious preoccu-
pation about cancer and greater internal locus of control. Bauer-Wu
and Rosenbaum (2004) adapted MBSR for individual use in isolated
hospitalized bone-marrow transplant (BMT) patients, finding immediate
effects on levels of pain and anxiety. Bauer-Wu and Rosenbaum (2004);
and Horton-Deutsch, O’Haver Day, Haight, and Babin-Nelson (2007)
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also investigated MBSR in 24 BMT patients; they provided six to eight

biweekly 20- to 40-minute individual sessions consisting of one-on-
one training in mindfulness with an experienced instructor, based on
an adaptation of the group MBSR curriculum. In 15 patients who
completed postassessments, less negative affect was reported after the
intervention despite increasing symptoms of nausea and appetite loss,
and patients found the program feasible, though they felt that train-
ing in mindfulness before hospitalization would have been optimal.
In the largest study, Hebert et al. (2001) randomly assigned 157 women
with breast cancer to MBSR, a nutrition education program, or usual
care groups. The outcome measures included dietary fat, complex
carbohydrates, fiber, and body mass. Not surprisingly, only the dietary
nutrition education program resulted in changes in body mass and fat
consumption postintervention. Results on the psychological measures
were not reported.
A unique modification on MBSR that has been applied to cancer
patients is mindfulness-based art therapy (MBAT), which combines the
principles of MBSR with other creative modalities. In an RCT (N = 111),
researchers compared the 8-week MBAT intervention with a wait-list
control in a heterogeneous cohort of women with mixed cancer types
receiving usual oncology care. Compared with the usual care group, the
MBAT participants had less depression, anxiety, and hostility as well as
fewer somatic symptoms of stress (Monti et al., 2005). Hence, mount-
ing evidence from both uncontrolled and a small number of controlled
studies supports the usefulness of MBSR for reducing psychological
symptoms such as stress, anxiety, irritability, and depression in a broad
range of individuals coping with cancer.
A recent qualitative and quantitative study was conducted with
13 women who had completed breast cancer treatment, with a focus on
exploring process variables related to changes over the course of MBSR
(Dobkin, 2008). The women experienced decreases in perceived stress
 Mindfulness-Based Interventions for Physical Health 81

and medical symptoms as well as improvements on mindfulness as

measured with the Mindful Attention Awareness Scale (MAAS). They
became more mindful, took better care of themselves, and tended to
view life as more meaningful and manageable. Themes identified by the
women in focus groups reflecting on their experience with MBSR were
(a) acceptance, (b) regaining and maintaining mindful control, (c) tak-
ing responsibility for what could change, and (d) cultivating a spirit of
openness and connectedness. In identifying the processes at work for
these women, alterations in levels of mindfulness and worldview were
highlighted.
Another process study using participants from the Calgary, Alberta,
program was reported by Brown and Ryan (2003). They found that
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increases in MAAS scores in 41 patients with early-stage breast or

prostate cancer who participated in MBSR predicted decreases in psy-
chological distress and a decline in stress and stress-related symptoms.
Carlson and Brown (2005) also compared MAAS scores in 122 patients
with cancer with 122 matched community control participants, and
showed that similar associations between higher mindfulness and lower
mood disturbance and stress symptoms were found in both samples,
enforcing the validity of the construct and measure of mindfulness in
this patient population.
In sum, the studies in patients with cancer investigating the allevi-
ation of suffering from psychological symptomatology such as anxiety
and depression, and the enhancement of outcomes such as greater
mindfulness and coping skills, support an important role for mindfulness-
based interventions.

Biological Outcomes
Thus far we have focused on the effects of MBSR in improving psy-
chological outcomes in patients with cancer, but a number of studies
have also been conducted investigating biological outcomes and health
behaviors, such as sleep. Carlson and colleagues (Carlson, Speca, Patel,
& Faris, 2007; Carlson, Speca, Patel, & Goodey, 2003, 2004) conducted
a pre–post MBSR intervention with 59 survivors of early-stage breast or
prostate cancer who were all at least 3-months posttreatment. Out-
comes included biological measures of immune, endocrine, and auto-
nomic function in addition to psychological variables. Similar to previous
studies, significant improvements were seen in overall quality of life,
symptoms of stress, and also in sleep quality. Immune function was
investigated by looking at the counts of a number of lymphocyte sub-
sets, including T cells and natural killer (NK) cells. In addition to cell
counts, their function was also assessed by measuring how much of four
different cytokines were secreted by the T and NK cells in response to
 82 THE ART AND SCIENCE OF MINDFULNESS

an immune challenge. Cytokines were either of the pro-inflammatory

or anti-inflammatory variety; pro-inflammatory processes have been
associated with several poorer outcomes in both cardiovascular and
cancer patients. Although there were no significant changes in the
overall number of lymphocytes or cell subsets, T cell production of
interleukin (IL)-4 increased and interferon gamma decreased, whereas
NK cell production of IL-10 decreased. These results are consistent
with a shift in immune profile from one associated with depressive
symptoms to a more normal profile. Patterns of change were also assessed
over a full year following program participation. Although compli-
cated, the pattern of change in cytokines over 1 year of follow-up sup-
ported a continued reduction in pro-inflammatory cytokines (Carlson
et al., 2007).
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This study also looked at salivary cortisol, because daily salivary cor-
tisol levels have been related to stress and health and are often dysreg-
ulated in cancer survivors; such dysregulation has been associated with
poorer disease outcomes. Salivary cortisol was assessed three times daily
both before and after program participation, and the shape of the pat-
tern of cortisol secretion throughout the day was assessed; abnormal
profiles have been associated with shorter survival in metastatic breast
cancer patients (Sephton, Sapolsky, Kraemer, & Spiegel, 2000). It is
interesting that these hormone profiles also shifted pre- to postinterven-
tion, with fewer evening cortisol elevations found post-MBSR and some
normalization of abnormal diurnal salivary cortisol profiles occurring
(Carlson et al., 2004). Over the year of follow-up, continuing decreases
in overall cortisol levels were seen, mostly because of decreases in
evening cortisol levels (Carlson et al., 2007). This is significant because
higher cortisol levels, particularly in the evening, are considered to
be an indicator of dysregulated cortisol secretion patterns and poorer
clinical outcomes.
Measures of autonomic system function have also been of interest
because cancer survivors are at high risk of cardiovascular disease because
of the toxicity of their cancer treatments. Hence, Carlson et al. (2007)
looked at the effects of MBSR on resting blood pressure and heart rate.
In a group of breast and prostate cancer survivors, overall resting systolic
blood pressure decreased significantly from pre- to post-MBSR. This
result is desirable as high blood pressure (hypertension) is the most sig-
nificant risk factor for developing cardiovascular disease.
In other work with biological outcomes, an innovative study by
J. Kabat-Zinn’s group looked at the effects of combining a dietary inter-
vention with MBSR on prostate-specific antigen (PSA) levels, an indicator
of the level of activity of prostate cancer cells in men with biochemically
recurrent prostate cancer (Saxe et al., 2001). They found that the com-
bined program resulted in a slowing of the rate of PSA increase in a pilot
 Mindfulness-Based Interventions for Physical Health 83

sample of 10 men, and they are currently conducting a larger RCT to ver-
ify this significant impact on such an important marker of biochemical
recurrence in prostate cancer.
One other study applied MBSR to low-income ethnic minority
women with abnormal Pap smears; Pap tests screen for early indications
of mutations that are precursors to cervical cancer (Abercrombie, Zamora,
& Korn, 2007). In this study Spanish- and English-speaking women par-
ticipated in a 6-week MBSR program, but although 51 women initially
enrolled, only 13 attended one or more classes, and only 8 women
attended four or more classes and provided data. Those who did com-
plete the study showed a significant reduction in anxiety pre- to postin-
tervention and evaluated the program positively. In focus group
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interviews they stated they were able to decrease stress in everyday life
and better able to cope with health problems.

Sleep Outcomes
In terms of sleep outcomes, an RCT by S. L. Shapiro et al. examined the
relationship between participation in an MBSR program and sleep qual-
ity and efficiency in a breast-cancer population (S. L. Shapiro, Bootzin,
Figueredo, Lopez, & Schwartz, 2003). They did not find statistically sig-
nificant relationships between participation in an MBSR group and sleep
quality; however, they did find that those who practiced more informal
mindfulness reported feeling more rested. Carlson and Garland (2005)
found a very high proportion of cancer patients with disordered sleep
(approximately 85%) in a general sample of 63 patients before attending
the MBSR program . In these patients, sleep disturbance was closely asso-
ciated with levels of self-reported stress and mood disturbance, and when
stress symptoms declined over the course of the MBSR program, sleep
also improved. Improvements were seen on the Pittsburgh Sleep Quality
Index subscales of subjective sleep quality, sleep efficiency, and hours of
sleep. On average, sleep hours increased by 1⁄2 to 1 hour per night. The
change in fatigue scores was also statistically significant, and associations
were found between fatigue and sleep at both pre- and postintervention,
such that more sleep difficulty was associated with greater fatigue. These
results were similar to previous ones regarding sleep, where Carlson et al.
(2003) found the percentage of patients who reported their sleep as
“good” improved from 40% before the program to 80% afterward,
reinforcing the more recent finding.
In summary, the MBSR research in cancer is perhaps the most
developed of all the different medical populations, but although a num-
ber of outcome domains have been assessed, there is nonetheless a need
for large-scale trials comparing MBSR with other active interventions in
these populations. There is also a need for studies of mediation and
 84 THE ART AND SCIENCE OF MINDFULNESS

dismantling studies to investigate which components of the program are

most active, and through which mechanisms they are producing change.

CARDIOVASCULAR DISORDERS
A good deal of meditation research using the transcendental meditation
(TM) approach has looked at patients with hypertension (high blood
pressure) and coronary heart disease and reported positive findings
(e.g., Jayadevappa et al., 2007; Schneider, Alexander, Staggers, Orme-
Johnson, et al., 2005; Schneider, Alexander, Staggers, Rainforth, et al.,
2005). This research has been reviewed elsewhere (Ospina et al., 2007;
Walton, Schneider, & Nidich, 2004), so here we focus only on recent
applications of mindfulness-based interventions.
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One study applied MBSR to 22 women with cardiovascular disease

in a small RCT comparing MBSR with a wait-list control group (Tacon,
McComb, Caldera, & Randolph, 2003). Compared with controls, women
in the MBSR group showed greater reductions in anxiety, better emo-
tional regulation, and less use of reactive coping styles after the inter-
vention. This group then went on to randomize 18 women with heart
disease to either an MBSR or no-treatment control group, and measured
resting levels of stress hormones, physical functioning, and cardiovascu-
lar responses to an exercise test before and after participation (McComb,
Tacon, Randolph, & Caldera, 2004). Although there were no statistically
significantly effects of the program on measures of stress hormones or
physical functioning, there was a trend toward better outcomes in the
MBSR group, and the women in the MBSR group did show slower
breathing frequency. The authors felt these trends may prove signifi-
cant in a larger study and that MBSR showed promise for improving
physiological markers in women with cardiovascular disease.
A well-designed study of 52 patients with hypertension randomized
participants to contemplative meditation practice or a no-treatment con-
trol and found decreases in heart rate and both systolic and diastolic blood
pressure as measured during 24-hour ambulatory monitoring and in reac-
tion to mental stress testing (Manikonda et al., 2008). In another study,
19 very ill elderly patients with congestive heart failure were randomized
to a meditation group that participated in weekly sessions and listened to
a meditation tape at home for 30 minutes, twice daily, for 12 weeks, or a
control group that attended only weekly meetings (Curiati et al., 2005).
The meditation group showed significantly greater improvements on
measures of quality of life, lower levels of norepinephrine (an excitatory
steroid), and better cardiopulmonary performance on exercise testing.
Although the research on strictly mindfulness-based approaches to
treating cardiovascular disease is quite preliminary, it does show prom-
ise for improving both psychological and biological outcomes that may
be important for disease progression.
 Mindfulness-Based Interventions for Physical Health 85

EPILEPSY
There remains an active debate in the literature about possible negative
effects of meditation in people with epilepsy (Jaseja, 2006a, 2007; St.
Louis & Lansky, 2006). On the positive side, studies primarily of TM
in epilepsy have documented beneficial changes in brain activity on
electroencephalogram monitoring, as well as improvements in epilepsy
symptoms (Fehr, 2006; Orme-Johnson, 2006; Swinehart, 2008). The
alternative hypothesis is that meditation practice may cause increased
neural synchrony in the brain, which may result in cognitive kindling
and hence a lower threshold for epileptic seizures (Lansky & St. Louis,
2006). This viewpoint is also supported with case studies of adverse
effects (Jaseja, 2006b).
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Despite this interest in meditation and epilepsy and some controversy

around the topic, no studies of MBSR have been published. However, one
group recently applied ACT to the treatment of patients with epilepsy,
beginning with an RCT comparing ACT with a usual care treatment in
27 South Africans (Lundgren, Dahl, Melin, & Kies, 2006). After 9 hours of
individual and group therapy, seizure frequency was significantly reduced
in the ACT group. One month after the intervention, 57% were seizure
free in the ACT group compared with none in the control group. Twelve
months later, 86% were seizure free in the ACT condition and only 8% in
the control group, and quality of life, personal well-being, and life satis-
faction measures improved more in the ACT group. When they looked at
potential mediators of this large improvement, changes in seizures, qual-
ity of life, and well-being were found to be partially mediated by epilepsy-
related acceptance or defusion, values attainment, and persistence in the
face of barriers (Lundgren, Dahl, & Hayes, 2008). Hence, patients had
learned to be more psychologically flexible, accepting of things as they
were with their illness, and not so tied into believing passing thoughts.
They were also more focused on persistently engaging in activities that
were highly valued and living in accordance with their own values.
This group then compared the ACT intervention with a yoga inter-
vention in patients with epilepsy (Lundgren et al., 2008; Lundgren,
Dahl, Yardi, & Melin, in press). A small group of 18 patients with con-
firmed drug-refractory epilepsy were randomly assigned to 12 sessions
of ACT or yoga and followed up for 1 year. Frequency and duration of
seizures were found to be reduced in both groups, and ACT did so sig-
nificantly more than did yoga. In addition, both groups improved sig-
nificantly on quality of life. Finally, another group, this one in India,
tested a combined yoga and meditation program in 20 patients who
practiced twice daily for 3 months (Rajesh, Jayachandran, Mohandas,
& Radhakrishnan, 2006). For the 16 patients who continued practice
beyond 3 months, 14 responded with 50% or greater reductions in
seizure frequency, and 6 of these were seizure-free for 3 months.
 86 THE ART AND SCIENCE OF MINDFULNESS

The research in mindfulness treatments for epilepsy is very prelim-

inary, but research does show potential for ACT in particular to be help-
ful with this patient population.

HIV/AIDS
Two studies have been conducted with people infected with the HIV virus,
and one with AIDS patients in palliative care. A pilot study of MBSR in
HIV-infected youth sought to determine the feasibility of this type of
intervention in 13- to 21-year-olds (Sibinga et al., 2008). Of 11 African
American youth who initially signed up, 7 attended at least one class and
5 finished the program. Interviews with those who completed the pro-
gram identified five themes: (a) improved attitudes (less negativity);
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(b) decreased reactivity and impulsivity; (c) improved behavior, less lash-
ing out; (d) improved self-care; and (e) the value of being in a group. On
average, they rated the importance of the group to them at 9.6 on a scale
from 1 to 10, indicating that although attrition was high, those youth
infected with HIV who were able to complete the program did benefit.
Another study investigated the impact of MBSR on immune and
endocrine measures in patients with HIV (Robinson, Mathews, & Witek-
Janusek, 2003). Using a nonrandomized design, researchers recruited
46 HIV-infected patients for either the MBSR or comparison groups
(assigned by patient preference), but only 24 completed the study.
Compared with the controls, participants in the MBSR group showed
an increase in NK cell activity and number, an important measure in
HIV infection. NK cells represent the main type of innate immunity in
the body and help to fight off opportunistic viral infections. There were,
however, no significantly different changes in mood or stress measures,
although they trended toward improvement in the MBSR group and
worsening in the control condition. In the final study, 58 patients with
late-stage AIDS in a palliative care setting were randomized to 1 month
of loving-kindness (metta) meditation, massage, both, or neither (A. L.
Williams et al., 2005). The meditation was self-administered through an
audiotape. The combined meditation and massage group showed the
most benefit in terms of greater overall quality of life and spirituality
compared with either treatment alone.

OTHER DIAGNOSES
A handful of studies have investigated the potential efficacy of mind-
fulness-based interventions in a wide variety of other medical conditions.
This section summarizes this eclectic group of studies to give a further
idea of some of the avenues of investigation that are being pursued.
A well-designed study by J. Kabat-Zinn et al. (1998) investigated
whether listening to guided mindfulness meditation recordings during
 Mindfulness-Based Interventions for Physical Health 87

phototherapy treatment for psoriasis lesions could speed the healing

process. Psoriasis is a disease characterized by rashlike lesions that can
occur anywhere on the body, and it is typically treated with photo-
therapy in what resemble upright tanning beds; symptoms are also known
to worsen during periods of high stress. Thirty-seven patients were ran-
domly assigned to the mindfulness or control conditions, and psoriasis
status was assessed objectively throughout treatment by direct inspec-
tion by both unblinded clinic nurses and blinded physician inspection
of patients, both in person and through evaluation of photographs of
the skin lesions. Several time points were determined: the first response
to treatment, the turning point where treatment was judged as work-
ing, the halfway point, and the final clearing point. The patients in the
mindfulness condition reached the halfway point and the clearing point
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significantly more rapidly than did those in the control condition, demon-
strating that simple mindfulness practice could enhance the treatment
response.
Two studies to date have investigated the effect of MBSR on rheuma-
toid arthritis, a painful autoimmune condition caused by swelling of the
joints (Pradhan et al., 2007; Zautra et al., 2008). In the first, 63 partici-
pants were randomized to MBSR or a wait-list control condition. Self-
report questionnaires evaluated depressive symptoms, psychological
distress, well-being, and mindfulness, and rheumatoid arthritis disease
activity was evaluated by a physician masked to treatment status. After
2 months, there were no differences between the groups, but at 6 months,
there were significant improvements in psychological distress, well-
being, depressive symptoms, and levels of mindfulness in the MBSR
group. The most recent study used multimodal outcome measures and
compared 144 participants randomly assigned to one of three conditions:
cognitive–behavioral therapy (CBT) for pain; mindfulness meditation and
emotion regulation therapy; or education only, which served as an atten-
tion placebo control (Zautra et al., 2008). The greatest improvements in
pain control and reductions in inflammatory cytokines were observed in
participants in the CBT pain group, however, both the CBT and mindful-
ness groups improved more in coping efficacy than did the education
control group. It is most striking that patients with a positive history of
depression benefited more from mindfulness on outcomes of both nega-
tive and positive affect and physicians’ ratings of joint tenderness, sug-
gesting that MBSR might be preferable to CBT for treating individuals
who struggle with depression.
A pilot study in 11 patients with Type II diabetes investigated the
impact of MBSR on indices of gylcemic control, given that stress has
been related to poorer control of blood sugar levels in this group
(Rosenzweig et al., 2007). At 1 month following the program, glyco-
sylated hemoglobin A1C (HbA1c), the measure of blood sugar levels, was
significantly reduced, as were measures of blood pressure, depression,
 88 THE ART AND SCIENCE OF MINDFULNESS

anxiety, and overall psychological distress. Another study compared

ACT plus a 1-day educational workshop with education only for man-
aging Type II diabetes in 81 patients (Gregg, Callaghan, Hayes, & Glenn-
Lawson, 2007). Those who participated in ACT therapy and learned how
to apply acceptance and mindfulness skills to difficult diabetes-related
thoughts and feelings were more likely to use adaptive coping and report
better self-care behaviors. They were also more likely to have HbA1c val-
ues in the target range. Through mediational analyses, changes in accept-
ance coping were shown to be partially responsible for the impact of the
ACT treatment on changes in HbA1c. These studies are promising in that
they show benefit not only in terms of psychological outcomes but also
on an important measure of disease progression in diabetes.
An innovative new application of MBSR has been reported for peo-
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ple with multiple sclerosis (MS) and their partners (Hankin, 2008). In
a nonrandomized design, 25 couples received MBSR and another 10
acted as a comparison group. The treatment group showed significant
decreases in anxiety as well as an increase in tolerance of uncertainty,
while the control group showed no changes in psychological outcomes.
Control participants reported a significant increase in MS-related symp-
toms whereas the MS symptoms for the treatment group remained sta-
ble. This result suggests that MBSR training might not only help couples
cope with the difficulties of a remitting and recurring disease like MS,
but also help to control symptom severity.
Rehabilitation for tinnitus, a constant ringing in the ears, was also
attempted through the use of four 1-hour sessions modeled on MBCT
(Sadlier, Stephens, & Kennedy, 2008). Twenty-five tinnitus sufferers
were consecutively allocated to either MBCT or a wait-list control.
Decreases were seen posttherapy as well as over a 4- to 6-month follow-
up on a measure of tinnitus severity in the MBSR group.
A number of small pilot studies have also been conducted with a
variety of different diseases and conditions. For example, Carmody,
Crawford, and Churchill (2006) investigated the potential for MBSR
training to help reduce the discomfort associated with menopause-
related hot flashes. A pilot study of 15 women experiencing several
moderate to severe daily hot flashes showed 40% reductions in the
severity of hot flashes as well as improved overall quality of life. A case
study of an adolescent with Prader-Willi syndrome, which is character-
ized by overeating and delay in the satiety response, showed decreases
in weight that were sustained over 3 years through a combination treat-
ment of exercise, healthy eating, and mindfulness training (Singh et al.,
2008). The improvements seen with the addition of the mindfulness
training were reported to be greater than with exercise and nutrition
alone. There is also interest in the application of MBSR to patients suf-
fering from chronic hepatitis C, but as yet no research data have been
published (Koerbel & Zucker, 2007).
 Mindfulness-Based Interventions for Physical Health 89

MIXED MEDICAL DIAGNOSES

A number of studies have conducted mindfulness-based interven-
tions on mixed groups of medical patients. A pre–post study by Reibel,
Greeson, Brainard, and Rosenzweig (2001) investigated MBSR in a group
of 121 patients with a variety of different medical diagnoses and saw
improvements on the usual measures of health-related quality of life
and physical and psychological symptomatology. There was a 28%
reduction in physical symptoms, a 44% reduction on the anxiety subscale
of the SCL-90-R, and a 34% reduction on the depression subscale, and
improvements were maintained over the course of a year of follow-up.
Another smaller German study of 21 patients with a variety of medical
diagnoses found improvements after MBSR on measures of emotional,
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physical, and general well-being, and qualitative interviews confirmed

high satisfaction and lasting symptom reduction (Majumdar, Grossman,
Dietz-Waschkowski, Kersig, & Walach, 2002).
A series of studies have been conducted with patients who were
recipients of organ transplants (Gross et al., 2004; Kreitzer, Gross, Ye,
Russas, & Treesak, 2005). Pilot work with 19 kidney, lung, or pancreas
transplant recipients showed improvement from baseline scores after
MBSR on measures of depression and sleep, and the beneficial effects
on sleep were maintained at a 3-month follow-up assessment, when
improvements in anxiety also became significant. Improvements on
sleep and anxiety were related to the amount of home mediation prac-
tice (Gross et al., 2004). Further follow-up assessment at 6 months post-
MBSR found continued improvements in sleep quality and duration as
well as for anxiety and depression (Kreitzer et al., 2005). A larger ongo-
ing RCT is under way in this same population but the results have not
yet been reported.

Physiological Outcomes in
Healthy Participants

The final section of this chapter summarizes studies that have investi-
gated the effects of mindfulness practices on physiological outcomes
that may have some potential bearing on disease outcomes but were
conducted largely on healthy individuals.
Massion et al. investigated differences between women who had
taken MBSR classes and continued to meditate regularly and non-
meditators on a measure of melatonin in the urine (Massion, Teas, Hebert,
Wertheimer, & Kabat-Zinn, 1995). Melatonin is the primary hormone
secreted by the pineal gland and controls cycles of sleeping and waking;
 90 THE ART AND SCIENCE OF MINDFULNESS

it has also been implicated in diseases such as cancer (Vijayalaxmi,

Thomas, Reiter, & Herman, 2002) and overall immune functioning
(Guerrero & Reiter, 2002). They found higher amounts of melatonin
metabolites in the urine of the meditators compared with the non-
meditators, speculating this might have health implications.
Another group investigated the impact of brief training in the mind-
fulness body scan on important cardiovascular measures in the lab
(Ditto, Eclache, & Goldman, 2006). In the first of two studies, 32 healthy
university students were randomly assigned to a body scan meditation,
progressive muscle relaxation, or a wait-list control condition, and prac-
ticed the assigned technique in two lab sessions 4 weeks apart. Those
who practiced the body scan showed increases in parasympathetic cardio-
vascular activity compared with the other conditions, indicating a
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greater relaxation response. In the second study, 30 different students

participated in two lab sessions in which they either practiced the body
scan or listened to an audiobook. In this study, women showed a larger
decrease in diastolic blood pressure during meditation, whereas the men
had increased cardiac output during meditation. The authors concluded
that there are both similarities and differences between the meditation
technique and other relaxing activities.
Heart rate variability is another prognostic measure for cardiovascu-
lar health, which was measured in a group of 35 experienced meditation
practitioners from Thailand (Phongsuphap, Pongsupap, Chandana-
mattha, & Lursinsap, in press). The expert meditators were compared
with 70 matched control participants. Cardiovascular parameters were
recorded during meditation practice for the experts or during quiet rest
for the control participants over a period of 4 weeks. Analysis of the fre-
quencies of heart rate variability showed synchrony of oscillations in cer-
tain specific frequencies during meditation. The authors concluded from
this analysis that meditation may have health benefits such as increas-
ing parasympathetic nervous system tone (associated with the relaxation
response) and improving efficiency of gas exchange in the lungs.
Finally, Davidson et al. (2003) provided MBSR training to healthy
Mindful workers from a biotechnology firm in a wait-list controlled trial, and
Reminder: measured the impact of the intervention on the production of antibody
Pause and ask titres in response to a standard influenza vaccine, a common measure
yourself what of the robustness of the immune response. The flu shot was given at the
end of the 8-week MBSR program, and antibody production was mea-
you just read.
sured 4 months later. Participants in the MBSR group showed signifi-
Can you cantly higher increases in antibody titres to the vaccination, indicating
remember it in a stronger immune response.
detail, or was This eclectic body of work on a handful of outcomes that may be
your mind important in terms of disease progression is just the beginning of explo-
wandering? ration into the potential benefits of mindfulness-based interventions on
physiological, endocrine, and immune outcomes.
 Mindfulness-Based Interventions for Physical Health 91

Summary

This chapter provided a whirlwind tour of the great variety of research

studies conducted on a wide range of different medical conditions.
Quality and depth of the research base across different conditions vary
significantly, with the most evidence compiled in cancer and pain con-
ditions, but continued work is being conducted across many domains.
This body of research is still very young and over the next 20 years, the
number, quality, and breadth of medical applications of mindfulness-
based interventions will only increase as researchers become more
knowledgeable and sophisticated in terms of design for these types of
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studies.