Motivation and emotion/Book/2015/Mindfulness and anxiety

Overview
Lucy is a fit and healthy 22-year-old woman. She has similar goals, values, and behaviours to most people her age. However, Lucy suffers from anxiety. Her thoughts snowball and go on to cause her extreme stress. Study tasks, job applications, finishing a book, and going to the gym are some of the many thoughts that whirl around her head. These kinds of thoughts - what we are going to do, want to do, and should do are part of our every day thought process. But these thoughts make Lucy panic. She doesn’t move from her bed, sitting and staring at the wall, as if in a trance. The thoughts in her head pile further and turn into a mountain. ‘I can’t do this’ she thinks to herself. It feels as though someone squeezes her chest - she gasps for air and starts to hyperventilate. ‘I can’t do this’ she keeps thinking. Her hands shake uncontrollably and tingles dance on her face. Her body is hot but at the same time she feels nothing. The world around her disappears.

This book chapter aims to explain how anxiety can be dealt with through practices of mindfulness. Mindfulness is one's ability to be aware of present moment experiences without attachment, or aversion to that experience (Arch & Craske, 2006). When we are mindless (not practicing mindfulness) we may experience worry and anxiety, such as Lucy's anxiety (Andrews et al, 2010). This can lead to significant declines in our well-being. By using mindfulness practice we can reduce anxiety and increase emotional well-being (Baer, 2011).

What is anxiety?
Anxiety is an emotion that is identified in several psychological disorders that causes snowballing worries, obsessive thinking, compulsive behaviour, apprehension, tension, nervousness, and lack of awareness (beyondblue.org.au, 2015; Spielberger, 2010; Eysenck, Derakshan, Santos,& Calvo, 2007). Anxiety is a cerebral emotion and, when it is intense, it fogs the mind, producing mental tiredness while also keeping the person focused on negative emotions (psychologistworld.com, 2015). Physiological symptoms of anxiety include a racing heart, tightening of the chest, and hot and cold flushes.

Symptoms and causes
All people experience anxiety at some point in their life, particularly through stressful periods in social contexts and times of personal pressure. Someone with generalised anxiety disorder (GAD) is characterised by a person who for six months or more and on more days than not feels very worried, finds it hard to stop worrying, making it difficult to do every day activities, restlessness, difficulty concentrating, and feeling irritable, making GAD chronic, impairing and enduring (beyondblue.org.au, 2015; Andrews et al, 2010). Table 1 shows the characteristics associated with some other anxiety disorders.



Causes of anxiety vary between individuals, and can often be a combination of:
 * Family history of mental health problems,
 * Ongoing stressful events like family/relationship problems,
 * Major emotional shock following trauma,
 * Verbal, sexual, or emotional abuse,
 * The loss of a loved one,
 * Physical health problems such as asthma or heart disease,
 * Substance use
 * Personality factors (beyondblue.org.au, 2015).

Worry is a central feature of many anxiety disorders and is a factor in anxiety’s persistence over time due to its self-sustaining quality (Mineka & Zinbarg, 2006). When people worry, their emotional and physical responses to aversive imagery are actually suppressed. This suppression creates a maladaptive thinking pattern of worrying about something because the initial feeling of worry is not dealt with correctly (Mineka & Zinbarg, 2006).

Quality of life
Some levels of anxiety under certain circumstances helps us grow up safely and judge risk protectively, however constantly feeling anxious has long-term negative effects on our physiological health as well as our social relationships and our self-concept (mindhealthconnect.org.au, 2015). Enduring anxiety can create further problems in one's life such as increased risk of coronary heart disease, as well as an increase in the risk of suicide (Roest, Martens, Jonge, & Denollet, 2010; Fawcett, 2013). Medication such as Benzodiazepine is frequently taken to reduce the symptoms and increase well-being, however, there are many unwanted side effects. These include drowsiness, lack of energy, clumsiness, confusion, and depression, which and can create further stress (healthguide.org, 2015). Symptoms of anxiety are both cognitive and physiological. + TRUE. - FALSE.
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What is mindfulness?
Mindfulness has been defined as the non-judgmental awareness of experience in the present moment (Hölzel, Lazar, Gard, Schuman-Olivier, Vago & Ott, 2011). It is thought to involve the cultivation of concentration, attention, and non-judging acceptance towards whatever one is experiencing in the present moment (Arch & Craske, 2006). The subjective feeling of mindfulness is that of a heightened state of involvement and wakefulness or being in the present, and when one is actively practicing mindfulness, the whole individual is involved (Langer & Moldoveanu, 2000). Mindfulness re-collects awareness into the present, remembering oneself so that one's actions are purposeful and appropriate, grounded in time and place (Sujato, 2012). Mindfulness can be understood in secular terms as the mental ability to focus on the direct and immediate perception of the present moment with a state of non-judgemental awareness, voluntarily suspending evaluative cognitive feedback (Kohls, Sauer & Walach, 2009).

Positive effects of mindfulness

Langer and Moldoveanu (2000) identified three major categories of social issues that mindfulness has positive effects on: health, business, and education. Perceived control has been shown to have very positive effects on stress reduction and health through increased perception of control, and decreased adverse health symptoms in elderly populations (Langer & Moldoveanu, 2000). Studies of mindfulness in a business context have shown that increases in mindfulness are correlated with increased creativity and decreased burnout (Langer & Moldoveanu, 2000). Mindfulness in learning was encouraged by introducing information about objects in a conditional way and through adding perspective by using language like ‘could be’ or ‘from the perspective of..’ rather than in absolute terms (‘is’, ‘can only be’) which is defined as mindless (Langer & Moldoveanu, 2000). Research in education has also identified attentional processes. Most assume in the education sector that paying attention means to “hold an image still as if focusing a camera”. Research has found that if people are instructed to vary the stimulus and mindfully notice new things about it, then attention improves and increases appeal of the task and memory (Langer & Moldoveanu, 2000).

History
The capacity to evoke mindfulness is developed using various meditation techniques that originate from Buddhist spiritual practice (Bishop et al, 2004). Historically, mindfulness has been called “the heart” of Buddhist meditation and resides at the core of the teachings of the Buddha (Kabat-Zinn, 2003). These teachings are traditionally described by the Sanskrit word dharma, which carries the meaning ‘the laws of physics’ or ‘the way things are’ (Kabat-Zinn, 2003). Dharma is a description of the nature of the mind, emotion, suffering and its potential release, based on practices that cultivate processes aimed at systematically training various aspects of the mind and heart through mindful attention (Kabat-Zinn, 2003). The practice of mindfulness is not simply a Buddhist practice, as it is an inherent human capacity present within all of us (Kabat-Zinn, 2003). It is evident that the tradition of Buddhism has generated effective ways to refine and cultivate our capacity to be mindful (Kabat-Zinn, 2003). Mindfulness has been applied to many diverse areas, and in contemporary psychology has been adopted as an approach for increasing awareness and responding skilfully to mental processes that contribute to emotional distress and maladaptive behaviour (Bishop, 2004).

The Buddhist Psychological Model (BPM)

Grabovac and Willett (2011) developed the BPM in order to understand mindfulness-based interventions. Awareness of an object occurs when either a stimulus enters our field of perception and makes contact with a sense organ or when an object of cognition (thought, memory, emotion) arises in the mind, either of which lasting only a brief moment in time (Grabovac & Willett, 2011). Awareness can be on one object at a time only, and because they are fleeting, they often go unnoticed and can serve as the key trigger to a chain reaction of thoughts, emotions, and actions that can lead to suffering (Grabovac & Willett, 2011).

The BPM model identifies habitual reactions to feelings such that we are averse to unpleasant and attached to pleasant feelings, and depending on our past experience, culture, and other factors our reaction will be pleasant, unpleasant or neutral (Grabovac & Willett, 2011). Mental elaboration occurs when we are attached or averse to the feelings arising with the mental events themselves, creating additional mental events (Grabovac & Willett, 2011). This proliferation in the mind can feed on itself, can end up having little to do with the actual mental event that started the attachment or aversion, and actually reinforces the habitual reactions to feelings that are directly resultant in suffering (Grabovac & Willett, 2011). Improvement in well-being from use of mindfulness occurs when sensory and mental events are allowed to naturally arise and fall away, still feeling pleasant, unpleasant, or neutral, without further cognitive processing arising from either attachment or aversion (Grabovac & Willett, 2011).

Mechanisms
Scholars have identified three mechanisms of mindfulness shown in Table 2 (Carmody, Baer, Lykins, & Olendzki, 2009; Shapiro et al, 2006). Mindfulness cultivated in this way changes the perspective of the person practicing mindfulness, and this concept is called reperceiving. Reperceiving refers to the ability to observe one’s thoughts and feelings as temporary events in the mind not necessitating particular responses, rather than reflections of the self that are necessarily true or important (Carmody et al, 2009). Reperceiving results in greater clarity and objectivity and facilitates additional direct mechanisms such as self-regulation, values clarification, and cognitive and emotional flexibility (Carmody et al, 2009). The very nature of an experience is changed through one's ability to step outside of that immediate experience and simply witness it through mindfulness practice of meditation (Shapiro et al., 2006).

Through intentionally bringing the attitudes of patience, compassion and non-striving to the attentional practice, one develops the capacity to not continually strive for pleasant experiences, or to push aversive experiences away (Shapiro et al, 2006).

{Which of the following is not a descriptor of mindfulness? - Attention to moment-by-moment experience. - Recollecting awareness into the present moment. +Constantly seeking positive events. - A heightened state of involvement and wakefulness.
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Mindfulness managing anxiety
Literature examining mindfulness-based approaches has found clinical improvements for people suffering from many problems including depression, anxiety, pain, and stress (Baer, 2011). Treatments that also integrate mindfulness with other strategies such as dialectical behaviour therapy and acceptance and commitment therapy have strong support for their efficacy (Baer, 2011). Mindfulness-based psychological interventions are effective in alleviating distress and enhancing well-being (Kang, Gruber & Gray, 2013). Roemer et al (2009) note that mindfulness practice enhances emotion regulation abilities. Mindfulness decreases both over engagement (attachment) and under engagement (avoidance) with emotions while facilitating healthy, adaptive engagement that promotes clarity and functional use of emotional responses (Roemer et al, 2009). It is suggested that mindfulness-based techniques reduce the cognitive component of anxiety e.g., the prominence of worry in sufferers of anxiety, as well as the maladaptive thought process that go with it (Roemer & Orsillo, 2002; Kang et al, 2013). Kang et al (2013) reviewed theoretical and empirical work suggesting that mindfulness can facilitate the discontinuation of such automatic mental operations.

Mindfulness-based stress reduction (MBSR)
Much of the interest in the clinical applications of mindfulness has been sparked by the introduction of Mindfulness-based stress reduction (MBSR), a manualised treatment program originally developed for chronic pain management (Kohls et al, 2009). Since the establishment of MBSR in 1979, Jon Kabat-Zinn and his colleagues have trained over 15,000 participants in mindfulness meditation (Roemer & Orsillo, 2007). MBSR is now used widely to treat emotional and behavioural disorders and is the main form of mindfulness currently being studied and practiced by Western researchers and clinicians (Bishop et al, 2004; Rapgay, Bystritsky, Dafter & Spearman, 2009). The core foundation of MBSR is the belief that no matter the condition, there is more right with you than is wrong with you, that MBSR requires one to “be” rather than “to do”, and to adopt the “way of not knowing” (Roemer & Orsillo, p.135). In addition to these core principles, there are seven key attitudes that form the basis of mindfulness practice as taught in MBSR: nonjudging; patience, beginner’s mind; trust; non=striving; acceptance; and letting go (Roemer & Orsillo, p. 136). MBSR is generally delivered in a classroom setting once a week for eight weeks, with classes going for two to two and a half hours in length (Roemer & Orsillo, p. 137). Activities include practice of mindfulness methods, discussions aimed at strengthening the practice within the individual, and applying mindfulness to the participant's specific situation (Roemer & Orsillo, 2007).

Efficacy of MBSR has been researched; with such research aiming to understand how well MBSR works in the treatment of, and reduction of, symptoms of those with various anxiety-related disorders. Goldin and Gross (2010) assessed the effect of MBSR on those with social anxiety disorder (SAD) through identifying related changes in brain-behaviour indices of emotional reactivity and regulation of negative self-beliefs in those with SAD. The results found that those who completed MBSR showed improvement in anxiety and depression symptoms, self-esteem, decreased negative emotion experience, and increased activity in brain regions associated with attentional deployment (Goldin & Gross, 2010).

Acceptance and commitment therapy (ACT)
Acceptance and commitment therapy (ACT) focuses on the mechanism of acceptance and elaborates on this mechanism through mindfulness practice (Roemer & Orsillo, 2002). ACT targets three goals:
 * 1) Reducing the use of strategies aimed at avoiding private events, such as thoughts, feelings, memories, or bodily sensations.
 * 2) Decreasing the client’s literal response to their own thoughts (e.g., recognising that having the thought, “I’m hopeless” does not mean that the person’s life is truly hopeless)
 * 3) Increasing the client’s ability to make and keep commitments to behaviour change, based on his or her own values.

Clients identify valued goals in their lives and commit to actions that are consistent with these values (Roemer & Orsillo, 2002). The use of mindfulness techniques as a way of integrating acceptance into change-based therapies emphasises the non-judging, non-evaluative nature of mindful attention, as well as its association with controlled rather than automatic processing (Roemer & Orsillo, 2002). In ACT, mindfulness is an important element in altering habitual patterns of worry, as well as being associated with relaxation techniques that are considered essential in treatments for generalised anxiety disorder (GAD). GAD is characterised by chronic focus on potential events in the future, and mindfulness requires focus on the present-moment experiences, which provides an alternative response that can facilitate adaptation to this habit (Roemer & Orsillo, 2002). This adaptation of mindfulness into ACT demonstrates the importance of this therapy in the treatment of anxiety (Roemer & Orsillo, 2002).

Research has found that ACT has shown to be a more effective treatment than other treatments. Avdagic, Morrissey, and Boschen (2014) conducted a study comparing ACT and Cognitive Behavioural Therapy (CBT) for those with GAD. Thirty eight participants were measured pre, post, and three months following the treatment of either ACT or CBT (Avdagic et al, 2014). The results indicated that there was a more significant reduction in worrying symptoms from pre- to post-treatment for the ACT group than the CBT group and at treatment completion nearly 79% of those in the ACT group achieved reliable change compared to 47% in the CBT group (Avdagic et al, 2014).

Other mindfulness based anxiety treatments
Dialectical behaviour therapy (DBT), an approach that has been shown to reduce self-mutilation and suicidal behaviour in chronically suicidal patients with borderline personality disorder, provides training in mindfulness meditation to foster improvements in affect tolerance (Bishop et al, 2004). DBT uses mindfulness techniques to increase a person's ability to observe, participate spontaneously, and to focus on effectiveness (Baum, Kuyken, Bohus, Heidenreich, Michalak & Steil, 2010). Rather than focusing on changing distressing thoughts and feelings, DBT focuses on learning to accept those thoughts and feelings (Baum et al, 2010).

Mindfulness-based cognitive therapy (MBCT) combines training in mindfulness meditation with cognitive therapy (Bishop et al, 2004). This combination has been shown to significantly reduce the rate of relapse in recurrent major depression (Bishop et al., 2004). MBCT has been shown to have a positive impact on the reduction of anxiety symptoms in individuals with anxiety disorders (Kangas, 2014). MBCT incorporates cognitive strategies and has been found effective in reducing relapse in patients (Evans, Ferrando, Findler, Stowell, Smart, & Haglin, 2008). Evans et al (2008) conducted a study trialling MBCT for GAD sufferers. As a group, the participants experienced a significant decrease in their anxiety, tension, worry, and depressive symptoms following an eight week course of mindfulness-based cognitive therapy. Kim et al (2009) also conducted a study in order to determine the merit of MBCT in the treatment of patients with panic disorder (PD) and GAD. The findings of the study revealed significantly greater decreases in anxiety scores for those in the MBCT group (Kim et al, 2009). These results indicate that MBCT can relieve anxiety in those with GAD while also preventing relapse of depression in those with depressive disorder (Kim et al, 2009).

Mindfulness-Based Stress Reduction (MBSR) was originally developed for chronic pain management + TRUE. - FALSE.
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Measuring mindfulness
As mindfulness has been recently been incorporated into a number of psychological treatments, different scales have been developed that assess mindfulness in individuals undergoing these therapies. This better refines mindfulness practice and provides individuals with an understanding of their improvement, motivating them to continue (Kohls et al, 2009; MacKillop & Anderson, 2007). Some of the scales include the The Toronto Mindfulness Scale and the The Cognitive and Affective Mindfulness Scale, as well as the following:
 * The Mindfulness and Attention Awareness Scale (MAAS) is a self-report measure of mindfulness (MacKillop & Anderson, 2007). It is one of the most popular measures of mindfulness due to its theoretically consistent relationships to brain activity (Van Dam, Earleywine & Borders, 2010). Its purpose is to measure a conceptualisation of mindfulness as the “the presence or absence of attention, and awareness of, what is occurring in the present moment (MacKillop & Anderson, 2007).
 * The Kentucky Inventory of Mindfulness Scale (KIMS) measures four mindfulness skills of observing, describing, acting with awareness, and accepting without judgement (Baer, Smith, & Allen, 2004). The KIMS was based on the conceptualisation of mindfulness skills described in DBT (Baum et al, 2010).
 * The Five Facets Mindfulness Questionnaire is an instrument that represents elements of mindfulness. The five facets are similar to the KIMS, but also with non-reactivity to inner experience (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). The 39-item questionnaire has proved reliable and valid in assessing different aspects of mindfulness in community and student samples (Bohlmeijer, Klooster, Fledderus, Veehof, Baer, 2011).
 * The Freiburg Mindfulness Inventory is a valid and reliable questionnaire for measuring mindfulness. It is suited for generalised contexts where the knowledge of the Buddhist history of mindfulness is not expected. The inventory characterises your experience of mindfulness (Walach, Buchheld, Buttenmuller, Kleinknecht, & Schmidt, 2006)

Conclusion
Anxiety is an emotion as well as a disorder. Characterised by various cognitive and physiological symptoms including racing heart, worry, stress, and maladaptive thought processes that make these symptoms endure over time (beyondblue.com, 2015). Anxiety can arise from various manifestations of events, having impact on quality of life. Such that it can increase the risk of co-morbidity with other diseases, such as heart disease (Roest et al., 2013). Mindfulness is important in the treatment of anxiety as it allows an individual to be aware of present moment experience without judgement. That is, one experiences events and emotions without attachment or aversion to it, allowing the individual to let things arise and fall without negativity (Sujato, 2012). Through three mechanisms of intention, attention, and attitude, mindfulness has been applied to clinical treatment of anxiety. There are a range of mindfulness techniques used and it is these therapies that have shown continued efficacy in the management of anxiety and thus improvement in quality of life (Baer, 2011). Measurement of mindfulness is also important as it allows the individual to understand their improvement and motivates them to practice mindfulness often (Kohls et al., 2009).