neuroslologla e esqulsas

em medlLao
Lllsa P. kozasa
ellsahk2006[yahoo.com.br

CuAL C ALL uA MLn1L nA SAuL?
PlsLrlco sobre o papel da menLe:
! A menLe e lmporLanLe no LraLamenLo das
doenas (Medlclna 1radlclonal Chlnesa e
Ayurvedlca: mals de 2000 anos aLrs).
! ara PlpcraLes (400 dC), o LraLamenLo s
podla ocorrer conslderando-se a auLude,
lnunclas amblenLals, e remedlos
naLurals, deverlam ser conslderados os
aspecLos morals e esplrlLuals.
! no CcldenLe, nos seculos 16 e 17 ocorreu
a separao enLre a dlmenso esplrlLual
ou emoclonal do corpo nslco, com o
8enasclmenLo e o llumlnlsmo.
Canon na decada de 20 mosLra a relao
enLre esLresse e resposLa
neuroendcrlna e Selye mals Larde,
dlscuLe os efelLos deleLerlos do esLresse
sobre o corpo.
Resgate da relao mente-corpo
8eecher descreve o efelLo placebo" em
soldados que receblam sallna ao lnves de
morna (2 Cuerra Mundlal).
33 dos efelLos Lerapuucos de qq
lnLerveno medlca podem ser
aLrlbuldos a crena.
Intervenes Mente-Corpo
AumenLam a capacldade da
menLe afeLar a funo e os
slnLomas nslcos.
Aumenta a capac|dade para o
auto-cu|dado e auto-
conhec|mento (promoo de
sade).
A MLDI1AC L UMA k1ICA
MLN1L-CCkC.
(NCCAM-National Center for Complementary and Alternative Medicine)
uenlndo MedlLao:
abr|r-se a cada
momento com
consc|nc|a
ca|ma (Dav|ch,
2002).
uenlo operaclonal :
! um procedlmenLo que uullza-se de alguma
Lecnlca especlca (claramenLe denlda)
! envolvendo esLado alLerado de consclncla
! com relaxamenLo muscular em algum ponLo
do processo
! relaxamenLo da lglca
! e um esLado necessarlamenLe auLo-lnduzldo
! uullzando um arunclo de auLo-
focallzao (Cardoso eL al, 2004)

-Wallace,8k. hyslologlcal eecLs of
LranscendenLal medlLauon. Sclence 167 (926):
1731-4,1970.
*um quarLo esLado de consclncla
-8enson, P. uecreased blood-pressure ln
pharmachologlcal LreaLed hyperLenslve pauenLs
who regularly ellclLed Lhe relaxauon response.
LanceL 1(7832):289-91,1974.

MLul1AC L ClLnClA
TRABALHOS PIONEIROS DE IMPACTO
or que o
|nteresse
crescente em
med|tao???
Cerca de 30 dos enLrevlsLados reporLaram LransLorno
menLal nos ulumos 12 meses.
19,9 LransLorno de ansledade, 11 de humor, 4,3
conLrole de lmpulsos e 3,6 abuso de subsLnclas.

(esLes LransLornos envolvem algum nlvel de desregu|ao emoc|ona|- Cross &
Levenson, 1997)
Mental Disorders in Megacities: Findings from the Sa o
Paulo Megacity Mental Health Survey, Brazil
Laura Helena Andrade
1
*, Yuan-Pang Wang
1
, Solange Andreoni
2
, Camila Magalha es Silveira
1
,
Clovis Alexandrino-Silva
1
, Erica Rosanna Siu
1
, Raphael Nishimura
3
, James C. Anthony
4
,
Wagner Farid Gattaz
5
, Ronald C. Kessler
6
, Maria Carmen Viana
1
1Section of Psychiatric EpidemiologyLIM 23, Department and Institute of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil, 2Department of
Preventive Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil, 3Institute of Social Research, University of Michigan, Ann Arbor, Michigan, United States
of America, 4Department of Epidemiology, College of Human Medicine, Michigan State University, East Lansing, Michigan, United States of America, 5Laboratory of
NeuroscienceLIM 27, Department and Institute of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, Brazil, 6Department of Health Care Policy, Harvard
Medical School, Boston, Massachusetts, United States of America
Abstract
Background: World population growth is projected to be concentrated in megacities, with increases in social inequality and
urbanization-associated stress. Sao Paulo Metropolitan Area (SPMA) provides a forewarning of the burden of mental
disorders in urban settings in developing world. The aim of this study is to estimate prevalence, severity, and treatment of
recently active DSM-IV mental disorders. We examined socio-demographic correlates, aspects of urban living such as
internal migration, exposure to violence, and neighborhood-level social deprivation with 12-month mental disorders.
Methods and Results: A representative cross-sectional household sample of 5,037 adults was interviewed face-to-face using
the WHO Composite International Diagnostic Interview (CIDI), to generate diagnoses of DSM-IV mental disorders within 12
months of interview, disorder severity, and treatment. Administrative data on neighborhood social deprivation were
gathered. Multiple logistic regression was used to evaluate individual and contextual correlates of disorders, severity, and
treatment. Around thirty percent of respondents reported a 12-month disorder, with an even distribution across severity
levels. Anxiety disorders were the most common disorders (affecting 19.9%), followed by mood (11%), impulse-control
(4.3%), and substance use (3.6%) disorders. Exposure to crime was associated with all four types of disorder. Migrants had
low prevalence of all four types compared to stable residents. High urbanicity was associated with impulse-control disorders
and high social deprivation with substance use disorders. Vulnerable subgroups were observed: women and migrant men
living in most deprived areas. Only one-third of serious cases had received treatment in the previous year.
Discussion: Adults living in Sao Paulo megacity had prevalence of mental disorders at greater levels than similar surveys
conducted in other areas of the world. Integration of mental health promotion and care into the rapidly expanding Brazilian
primary health system should be strengthened. This strategy might become a model for poorly resourced and highly
populated developing countries.
Citation: Andrade LH, Wang Y-P, Andreoni S, Silveira CM, Alexandrino-Silva C, et al. (2012) Mental Disorders in Megacities: Findings from the Sao Paulo Megacity
Mental Health Survey, Brazil. PLoS ONE 7(2): e31879. doi:10.1371/journal.pone.0031879
Editor: Monica Uddin, Wayne State University, United States of America
Received September 22, 2011; Accepted January 14, 2012; Published February 14, 2012
Copyright: 2012 Andrade et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The Sao Paulo Megacity Mental Health Survey was funded by the State of Sao Paulo Research Foundation, Brazil (FAPESP Grant 03/00204-3, URL: http://
www.fapesp.br/materia/176/projeto-tematico/projeto-tematico.htm). Instrument development was supported by the Foundation for Science and Technology of
Vitoria, Esp rito Santo, Brazil (Fundo de Apoio a` Cie ncia e Tecnologia do Munic pio de Vito ria - FACITEC 002/2003). The sub-project on violence and trauma was
supported by the Secretaria de Seguranca Pu blica of the State of Sao Paulo, Brazil. The Sao Paulo Megacity Mental Health Survey is carried out in conjunction with
the World Health Organization World Mental Health (WMH) Survey Initiative. The authors thank the WMH staff for assistance with instrumentation, fieldwork, and
data analysis. The main coordination center activities, at Harvard University, were supported by the United States National Institutes of Mental Health
(R01MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849, R01-MH069864, and
R01 DA016558), the Fogarty International Center (FIRCA R03-TW006481), the Pan American Health Organization, the Eli Lilly and Company Foundation, Ortho-
McNeil Pharmaceutical, Inc., GlaxoSmithKline, Bristol-Myers Squibb, and Shire. The authors declare that the funders of the SPMHS had no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript. The authors also declare that the commercial funders of the Harvard coordination
center had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: Andrade lhsgandr@usp.br
Introduction
World population growth over the next quarter-century is
projected to be heavily concentrated in urban areas, especially in
megacities of the developing world, with area population greater
than 10 million. Associated trends may include increases in social
and economic inequalities, stressors linked to rapid urbanization,
and related deterioration in health, particularly mental illnesses [1].
This process has already started in a number of sentinel areas that
can be studied to provide a forewarning of the future of health in
developing countries. Although its unique historical, economic, and
cultural backgrounds distinguish the Sao Paulo Metropolitan Area
(SPMA) from other megacities in the developing world, it could be
viewed as one such area and it was chosen to conduct the Sao Paulo
PLoS ONE | www.plosone.org 1 February 2012 | Volume 7 | Issue 2 | e31879
P evldnclas de que a lnLervenes
baseadas em medlLao promovem:
8eduo de esLresse (uavldson,
2012- naLure neurosclence)
Melhor regulao emoclonal
(Coldln, 2012- Soc Cogn AecL neuroscl)
8eduo de slnLomas de
ansledade (kozasa, 2008- sychologlcal
8eporL)
8eduo de slnLomas de
depresso (!aln, 2012- sychosomaucs)
- kabaL-Zlnn, !. An ouLpauenL program ln
behavloral medlclne for chron|c pa|n pauenLs
based on Lhe pracuce of mlndfulness
medlLauon: Lheoreucal conslderauons and
prellmlnary resulLs. Cen Posp sychlaLry 4(1):
33-47,1982
A techn|que ca||ed 'MINDIULNLSS 8ASLD
S1kLSS kLDUC1ICN' teaches how to step back
from pa|n and the worr|es of ||fe (Newsweek).
Culuvaung Lmouonal 8alance- CL8
A base ter|ca envo|ve mtodos trad|c|ona|s de tre|namento da mente como a
med|tao e mtodos de consc|nc|a e gerenc|amento das emoes.

Sobre os efe|tos do Cu|nvanng Lmonona|
8a|ance:
82 professoras dlvldas em dols grupos: CL8 e llsLa de espera
C grupo CL8 re|atou reduo de afetos neganvos, rum|nao, depresso,
ans|edade e aumento de afetos pos|nvos e !"#$%&'#()) comparados ao
grupo conLrole.
C LrelnamenLo aumentou o reconhec|mento de emoes nos ouLros
(mlcro-expresses), a capacldade de proLeger-se de esLresse soclal, a
compa|xo e reduz|u comportamento hosn| em um LesLe de lnLerao
marlLal. A malorla dos efelLos se manLeve aps 3 meses do Lermlno do
LrelnamenLo.
Cs que medlLaram mals uveram alnda menor reauvldade da presso
arLerlal duranLe uma Larefa esLressora.
Cs achados sugerem que o aumento da consc|nc|a de processos
menta|s pode |nuenc|ar o comportamento emoc|ona| e suportam o
benehc|o de |ntegrar teor|as]prncas contemp|anvas com mode|os
ps|co|g|cos e mtodos de regu|ao emoc|ona|.


Cual emoo as pessoas gosLarlam de
mudar?
A MAlC8lA uAS LSSCAS CCS1A8lA uL
MuuA8 A 8AlvA
or que as pessoas querem mudar a
ralva?
orque causa danos para ns
mesmos e para os ouLros.
A vonLade de ferlr a parte da
ra|va que nos co|oca em
prob|emas.
A ralva dlsLorce a realldade e nos
leva a compreender mal a
realldade.

Mlndfulness 8ased Cognluve
1herapy (M8C1)
8esulLs of a meLa-
analysls lndlcaLe LhaL
M8C1 ls an eecuve
lnLervenuon for
relapse prevenuon ln
pauenLs wlLh
recurrenL Muu ln
remlsslon, aL leasL ln
case of Lhree or more
prevlous Muu
eplsodes (leL, 2011-
Cllnlcal sychology 8evlew)
Melhora do esLresse
relaclonado ao cncer
(Chandwanl, 2012- Lvldence 8ased
ComplemenLary and AlLernauve
Medlclne)
Melhora da auvldade
lmunolglca (uavldson, 2004)
8eduo de recaldas no
consumo de lcool e ouLras
drogas com M88(8owen,
2009- SubsL Abuse)
Melhora em slnLomas de
bromlalgla (kozasa, 2012)
Melhora da lnsnla em
mulheres na ps
menopausa (Afonso, 2012)
Menopause: The Journal of The North American Menopause Society
Vol. 19, No. 2, pp. 186/193
DOI: 10.1097/gme.0b013e318228225f
* 2012 by The North American Menopause Society
Yoga decreases insomnia in postmenopausal women: a randomized
clinical trial
Rui Ferreira Afonso, MSc,
1
Helena Hachul, MD, PhD,
1,2
Elisa Harumi Kozasa, PhD,
1,3
Denise de Souza Oliveira, BS,
1
Viviane Goto, BS,
1
Dinah Rodrigues, BS,
4
Sergio Tufik, MD, PhD,
1
and Jose Roberto Leite, PhD
1
Abstract
Objective: The practice of yoga has been proven to have positive effects on reducing insomnia. Studies have also
shown its effects on reducing climacteric symptoms. To date, however, no studies that evaluate the effects of yoga on
postmenopausal women with a diagnosis of insomnia in a randomized clinical trial have been conducted. The aim of
this study was to evaluate the effect of yoga practice on the physical and mental health and climacteric symptoms of
postmenopausal women with a diagnosis of insomnia.
Methods: Postmenopausal women not undergoing hormone therapy, who were 50 to 65 years old, who had an
apnea-hypopnea index less than 15, and who had a diagnosis of insomnia were randomly assigned to one of three
groups, as follows: control, passive stretching, and yoga. Questionnaires were administered before and 4 months after
the intervention to evaluate quality of life, anxiety and depression symptoms, climacteric symptoms, insomnia severity,
daytime sleepiness, and stress. The volunteers also underwent polysomnography. The study lasted 4 months.
Results: There were 44 volunteers at the end of the study. When compared with the control group, the yoga group
had significantly lower posttreatment scores for climacteric symptoms and insomnia severity and higher scores for
quality of life and resistance phase of stress. The reduction in insomnia severity in the yoga group was significantly
higher than that in the control and passive-stretching groups.
Conclusions: This study showed that a specific sequence of yoga might be effective in reducing insomnia and
menopausal symptoms as well as improving quality of life in postmenopausal women with insomnia.
Key Words: Yoga Y Postmenopause Y Insomnia Y Sleep disorders.
C
limacterium is the phase in a womans life that cor-
responds to the gradual transition from a reproduc-
tive to a nonreproductive stage. It begins around the
age of 40 years, when the first endocrine alterations are
detected. These alterations signify not only the exhaustion of
ovary follicles but also the desynchronization of the neural
signals in the hypothalamus and central nervous system.
Menopause takes place within the climacteric phase, at around
the age of 50 years, and is characterized by at least 12 months
of amenorrhea.
1,2
The most prevalent symptoms of women entering meno-
pause are vasomotor ones, which account for 70% to 80% of
symptoms.
3,4
These vasomotor symptoms are considered at
least partially responsible for sleep disorders after meno-
pause.
5,6
Many women present with sleep disorders after
menopause.
7
An epidemiological study conducted in Sao
Paulo found that 81.6% of the interviewees had sleep com-
plaints, and 52.1% of the respondents complained of insom-
nia.
8
Sleep problems tend to increase with age
9
and are more
frequent in women during the menopausal transition.
10
A study
that used both subjective (questionnaires) and objective (poly-
somnography) evaluations showed that 61% of postmeno-
pausal women had subjective sleep complaints. The objective
evaluation, however, revealed that 83% of women had sleep
alterations.
7
Hormone therapy (HT), that is, the exogenous replacement
of the hormones produced by the ovaries, can be used to relieve
climacteric symptoms. However, after some studies correlated
HT with a significant increase in coronary diseases, breast
cancer, stroke, and thromboembolism,
11
many women discon-
tinued HT. Since that time, hormonal treatment has become
much more individualized, with the physician and the patient
considering its risks and benefits. Therefore, an increasing
number of women have opted for other kinds of treatment,
12
such as increasing soy in the diet and using acupuncture and
Received February 16, 2011; revised and accepted June 2, 2011.
From the
1
Departamento de Psicobiologia, Universidade Federal de Sao
Paulo;
2
Departamento de Ginecologia, Universidade Federal de Sao Paulo;
3
Nucleo de Estudos em Saude Coletiva e da Fam lia, Universidade Nove de
Julho; and
4
International Yoga Teachers Association, Sao Paulo, SP, Brazil.
Funding/support: This work was supported by Associa0ao Fundo de
Incentivo a` Psicofarmacologia, Funda0ao de Amparo a` Pesquisa do Estado
de Sao Paulo (FAPESP), FAPESP/Centros de Pesquisa, Inova0ao e Difusao
(98/143030-3 to S.T.), and Conselho Nacional de Desenvolvimento Cien-
t fico e Tecnologico.
Financial disclosure/conflicts of interest: The authors declare no conflicts
of interest, with the exception of Dinah Rodrigues, who developed the
sequence of yoga exercises evaluated in this study and teaches it to
woman in menopause.
Address correspondence to: Helena Hachul, MD, PhD, Rua Napoleao
de Barros, 925 CEP 04024-002, Sao Paulo, SP, Brazil. E-mail:
helenahachul@psicobio.epm.br; helena.hachul@hotmail.com
186 Menopause, Vol. 19, No. 2, 2012
Copyright 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
Statistical analysis
The statistical program SPSS (version 17 for Windows)
was used for the data analyses. Means and SDs were used
to characterize the groups. A general linear model of repeated
measures was used to investigate the effects on the scores of
the questionnaires.
RESULTS
Of the 213 women who initially contacted our service, 83
met the inclusion criteria and were referred for polysom-
nography. Of these, 22 volunteers were excluded for having
an apnea-hypopnea index greater than 15. Before the inter-
vention, some volunteers left after they had been allocated to
the groups. One volunteer in the control group had no interest
in the study and, therefore, did not begin the procedure. Six
volunteers did not begin the group passive-stretching sessions:
one was excluded because she began treatment with fluox-
etine, one was not interested, two volunteers did not have the
time availability, one volunteer had her period, and one vol-
unteer had a health problem and began a treatment program
that prevented her from remaining in the study. Nine volun-
teers in the yoga group did not begin the treatment because of
the following reasons: three of them lived too far from the
location where the procedure was conducted, three did not
have the time availability, two had no interest, and one left
without providing any justification. No adverse effects were
reported for the procedures (Fig. 1).
Forty-four volunteers enrolled in and completed the study.
The passive-stretching group had a significantly lower score
for the exhaustion phase of stress when compared with the
control group, but not with the yoga group; however, no other
differences were detected among the groups in the pretreat-
ment stage (Table 1).
The evaluation of the treatment effect for each group when
the pretreatment and posttreatment stages were compared
showed that the yoga group experienced major improvements
in the parameters evaluated, including a significant reduction
in their BAI, BDI, KMI, ISI, and MENQOL scores and in the
three phases of stress (alert, resistance, exhaustion) evaluated
by the ISSL. The passive-stretching group had a significant
reduction only in the ISI score, whereas the control group had
a small but significant reduction in the symptoms of the alert
phase of stress (Tables 1 and 2).
In evaluating only the posttreatment phase, the yoga group
did not differ from the passive-stretching group in any of the
parameters. It did, however, present significantly lower KMI,
TABLE 1. Results of questionnaires scores
Control group Passive stretching Yoga
Pre Post Pre Post Pre Post
Mean SE Mean SE Mean SE Mean SE Mean SE Mean SE
BAI 13.7 2.5 13.5 1.9 12.2 2.5 10.2 1.9 15.3 2.5 8.8
a
1.9
BDI 16.8 2.0 14.8 1.9 12.4 2.1 10.9 1.9 15.1 2.0 11.0
a
1.9
KMI 22.3 2.6 19.9
b
2.1 18.1 2.7 14.6 2.2 17.4 2.6 12.4
a,b
2.1
ISI 15.2 1.2 13.7
b,c
1.2 16.9 1.2 11.4
a,c
1.3 14.1 1.2 9.7
a,b,c
1.2
MENQOL 134.6 11.2 127.2
b
10.8 114.6 11.6 101.6 11.1 118.5 11.2 88.1
a,b
10.8
ISSL (alert) 5.5 0.6 4.1
a
0.7 4.5 0.6 3.9 0.7 3.9 0.6 2.6
a
0.7
ISSL (resistance) 7.5 0.8 7.2
b
0.7 5.6 0.9 5.1 0.7 6.0 0.8 4.1
a,b
0.7
ISSL (exhaustion) 10.1
d
1.2 7.4 0.9 5.6
d
1.3 4.6 0.9 8.1 1.2 5.2
a
0.9
Comparison between pretreatment and posttreatment of three groups: control, passive stretching, and yoga (P G 0.05). Pre, pretreatment; Post, posttreatment; BAI,
Beck Anxiety Inventory; BDI, Beck Depression Inventory; KMI, Kupperman Menopausal Index; ISI, Insomnia Severity Index; MENQOL, Menopause-Specific
Quality of Life Questionnaire; ISSL, Inventory of Stress Symptoms for Adults.
a
Comparison between the preintervention and postintervention moments of each group.
b
Comparison of the groups in the postintervention moment.
c
Comparison if the effect of treatment had difference between groups.
d
Comparison of the groups in the preintervention moment.
TABLE 2. G and observed power (OP) of the applied questionnaires (intragroup and between-group comparison)
Intragroup comparison Between-group comparison
Before After Time Group Before After
F P G OP F P G OP F P G OP F P G OP
BAI 5.56 0.02 0.12 0.63 2.29 0.11 0.10 0.44 0.37 0.69 0.02 0.11 1.63 0.21 0.07 0.32
BDI 6.65 0.01 0.14 0.71 0.69 0.51 0.03 0.16 1.15 0.33 0.05 0.24 1.37 0.27 0.06 0.28
KMI 9.02 0.01 0.18 0.84 0.41 0.67 0.02 0.11 1.02 0.37 0.05 0.22 3.23 0.05 0.14 0.58
ISI 29.51 0.00 0.42 1.00 2.85 0.07 0.12 0.53 1.51 0.23 0.07 0.30 2.52 0.06 0.11 0.48
MENQOL 8.33 0.01 0.17 0.80 1.42 0.25 0.07 0.29 0.88 0.42 0.04 0.19 3.39 0.02 0.14 0.61
ESS 0.06 0.81 0.00 0.06 1.16 0.32 0.05 0.24 0.13 0.88 0.01 0.07 1.13 0.33 0.05 0.24
ISSL (alert) 972 0.01 0.19 0.86 0.54 0.59 0.03 0.13 1.68 0.20 0.08 0.33 1.49 0.24 0.07 0.30
ISSL (resistance) 3.79 0.06 0.09 0.48 1.25 0.30 0.06 0.26 1.30 0.29 0.06 0.27 4.97 0.01 0.20 0.78
ISSL (exhaustion) 20.18 0.01 0.33 0.99 1.49 0.24 0.07 0.30 3.32 0.05 0.14 0.60 2.66 0.08 0.12 0.50
BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; KMI, Kupperman Menopausal Index; ISI, Insomnia Severity Index; MENQOL, Menopause-
Specific Quality of Life Questionnaire; ISSL, Inventory of Stress Symptoms for Adults; ESS, Epworth sleepiness scale.
Menopause, Vol. 19, No. 2, 2012 189
YOGA DECREASES INSOMNIA SYMPTOMS
Copyright 2012 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
FIBROMYALGIA (MFP PERES, SECTION EDITOR)
The Effects of Meditation-Based Interventions
on the Treatment of Fibromyalgia
Elisa H. Kozasa & Luiza H. Tanaka & Carlos Monson &
Stephen Little & Frederico Camelo Leao & Mario P. Peres
Published online: 21 June 2012
#Springer Science+Business Media, LLC 2012
Abstract Meditation is the third most commonly requested
complementary and alternative medicine (CAM) therapy
reported in a US survey. Those who suffer from chronic
pain are those who most frequently use CAM therapies. This
review aims to evaluate whether meditation-based interven-
tions can help the treatment of fibromyalgia. A PubMed
search was conducted using the terms fibromyalgia and
meditation, or mindfulness, or mantra or relaxation
response. We selected articles which clearly described a
meditation intervention being used in the treatment of fibro-
myalgia. Only four articles were classified with score 3 in
the Jadad scale. Another seven articles were included in this
review. Most of the results indicate improvement in
fibromyalgia-related symptoms in patients who participated
in a meditation-based intervention. Considering only 4 of
the 13 studies achieved a score of 3 on the Jadad scale,
researchers of meditation interventions should discuss the
best methodologic control for these studies.
Keywords Fibromyalgia
.
Meditation
.
Mindfulness
.
Pain
Introduction
In 1990, the American College of Rheumatology estab-
lished a classification criteria for fibromyalgia which
includes having pain in more than three locations in the
body for more than three months, accompanied by specific
tender points. In total, 18 points were defined9 on each
side of the body. On one hand, a diagnosis of fibromyalgia
can then be made when there is severe discomfort in the
presence of pressure applied to 11 out of 18 of these tender
points [1]. On the other hand, however, there is no gold
standard for diagnosing fibromyalgia and no specific lab-
oratory test for it. As a result, it can be sometimes difficult to
distinguish fibromyalgia from other central pain disorders,
such as chronic fatigue syndrome [2].
It is also important to note the high prevalence of psy-
chiatric disorders in patients with fibromyalgia. An attempt
to develop a scale in order to diagnose fibromyalgia which
does not require a physical or tender point examination
E. H. Kozasa (*)
:
M. P. Peres
Instituto do Crebro,
Inst. Israelita de Ensino e Pesquisa Albert Einstein,
Av. Albert Einstein, 627/701,
CEP 05601-901, So Paulo, SP, Brazil
e-mail: ehkozasa@gmail.com
E. H. Kozasa
Department of Psychobiology, Universidade Federal de So Paulo,
So Paulo, SP, Brazil
L. H. Tanaka
Escola Paulista de Enfermagem,
Universidade Federal de So Paulo,
So Paulo, SP, Brazil
C. Monson
Centro Cochrane do Brasil, Universidade Federal de So Paulo,
So Paulo, SP, Brazil
S. Little
Centro Integrado de Oncologia e Hematologia,
Hospital Israelita Albert Einstein,
So Paulo, SP, Brazil
F. C. Leao
Proser, Instituto de Psiquiatria,
Faculdade de Medicina da Universidade de So Paulo,
So Paulo, SP, Brazil
M. P. Peres
Programa de Ps-Graduao em Neurologia/Neurocincias,
Universidade Federal de So Paulo,
So Paulo, SP, Brazil
Curr Pain Headache Rep (2012) 16:383387
DOI 10.1007/s11916-012-0285-8
American Academy for Pain Management
Melhora em sintomas de fibromialgia
Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 20I3, Article ID 3I3I49, 8 pages
http://dx.doi.org/I0.II33/20I3/3I3I49
Research Article
A Yoga and Compassion Meditation Program Reduces Stress in
Familial Caregivers of Alzheimers Disease Patients
M. A. D. Danucalov,
1,2
E. H. Kozasa,
1,3
K. T. Ribas,
2
J. C. F. Galdurz,
1
M. C. Garcia,
1
I. T. N. Verreschi,
4
K. C. Oliveira,
4
L. Romani de Oliveira,
1
and J. R. Leite
1

Department of Psychobiology, Universidade Federal de S ao Paulo-UNIFESP, , Rua Napole ao de Barros,

- S ao Paulo, SP, Brazil

Departiment of Research, Instituto Appana Mind de Desenvolvimento Humano, - S ao Paulo, SP, Brazil

Instituto do C erebro, Hospital Israelita Albert Einstein, - S ao Paulo, SP, Brazil

Department of Medicine, Division of Endocrinology, Universidade Federal de S ao Paulo-UNIFESP, - S ao Paulo, SP, Brazil
Correspondence should be addressed to E. H. Kozasa; ehkozasa@gmail.com
Received I3 December 20I2; Accepted 29 March 20I3
Academic Editor: Luciano Bernardi
Copyright 20I3 M. A. D. Danucalov et al. Tis is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Familial caregivers of patients with Alzheimers disease exhibit reduced quality of life and increased stress levels. Te aim of
this study was to investigate the efects of an 8-week yoga and compassion meditation program on the perceived stress, anxiety,
depression, and salivary cortisol levels in familial caregivers. A total of 46 volunteers were randomly assigned to participate in a
stress-reduction programfor a 2-month period (yoga and compassion meditation programYCMP group) ( = 25) or an untreated
group for the same period of time (control group) ( = 21). Te levels of stress, anxiety, depression, and morning salivary cortisol of
the participants were measured before and afer intervention. Te groups were initially homogeneous; however, afer intervention,
the groups diverged signifcantly. Te YCMP group exhibited a reduction of the stress ( < 0.05), anxiety ( < 0.000001), and
depression ( < 0.00001) levels, as well as a reduction in the concentration of salivary cortisol ( < 0.05). Our study suggests
that an 8-week yoga and compassion meditation program may ofer an efective intervention for reducing perceived stress, anxiety,
depression, and salivary cortisol in familial caregivers.
1. Introduction
Te aging of the worldwide population has contributed to
the increasing incidence of dementia-causing chronic degen-
erative diseases, notably Alzheimers disease [I]. Alzheimers
disease is the most common form of dementia and is charac-
terized as a progressive brain disorder with loss of reasoning,
memory, language skills, and the ability to maintain an inde-
pendent life [2]. Te caregivers of Alzheimers disease patients
are typically family members [3]. Te physical and mental
burden imposed on caregivers frequently results in poor
quality of life [4]. Te physical, mental, social, and fnancial
burden to which caregivers are exposed to might result in an
increased risk of acute myocardial infarction and death [3
7]. Among the several psychosocial contexts experienced by
caregivers, the following are particularly noteworthy: stress,
social exclusion, depression, emotional isolation, burnout of
personal relationships, loss of life perspectives, sleep disor-
ders, and abuse of psychotropic substances [8I3]. Several
studies of Alzheimers disease patients and caregivers stress
the importance of the medical team orienting the familial
caregivers beginning in the earliest stages of disease, and
plans for such support interventions have been suggested
in the literature [I4I6]. Yoga and meditation are among
the modalities of intervention that might be applied to this
population.
One of the most appropriate defnitions of yoga is found
in documents dated approximately 2,000 years ago, namely,
Patanjalis Yoga sutras. One of such sutras defnes yoga as
follows: yoga is the restriction of the fuctuations of mind-
stuf [I7]. Tus, one of the aims of yoga is the development
of mindfulness; several meditation techniques exhibit similar
Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 20I3, Article ID 3I3I49, 8 pages
http://dx.doi.org/I0.II33/20I3/3I3I49
Research Article
A Yoga and Compassion Meditation Program Reduces Stress in
Familial Caregivers of Alzheimers Disease Patients
M. A. D. Danucalov,
1,2
E. H. Kozasa,
1,3
K. T. Ribas,
2
J. C. F. Galdurz,
1
M. C. Garcia,
1
I. T. N. Verreschi,
4
K. C. Oliveira,
4
L. Romani de Oliveira,
1
and J. R. Leite
1

Department of Psychobiology, Universidade Federal de S ao Paulo-UNIFESP, , Rua Napole ao de Barros,

- S ao Paulo, SP, Brazil

Departiment of Research, Instituto Appana Mind de Desenvolvimento Humano, - S ao Paulo, SP, Brazil

Instituto do C erebro, Hospital Israelita Albert Einstein, - S ao Paulo, SP, Brazil

Department of Medicine, Division of Endocrinology, Universidade Federal de S ao Paulo-UNIFESP, - S ao Paulo, SP, Brazil
Correspondence should be addressed to E. H. Kozasa; ehkozasa@gmail.com
Received I3 December 20I2; Accepted 29 March 20I3
Academic Editor: Luciano Bernardi
Copyright 20I3 M. A. D. Danucalov et al. Tis is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Familial caregivers of patients with Alzheimers disease exhibit reduced quality of life and increased stress levels. Te aim of
this study was to investigate the efects of an 8-week yoga and compassion meditation program on the perceived stress, anxiety,
depression, and salivary cortisol levels in familial caregivers. A total of 46 volunteers were randomly assigned to participate in a
stress-reduction programfor a 2-month period (yoga and compassion meditation programYCMP group) ( = 25) or an untreated
group for the same period of time (control group) ( = 21). Te levels of stress, anxiety, depression, and morning salivary cortisol of
the participants were measured before and afer intervention. Te groups were initially homogeneous; however, afer intervention,
the groups diverged signifcantly. Te YCMP group exhibited a reduction of the stress ( < 0.05), anxiety ( < 0.000001), and
depression ( < 0.00001) levels, as well as a reduction in the concentration of salivary cortisol ( < 0.05). Our study suggests
that an 8-week yoga and compassion meditation program may ofer an efective intervention for reducing perceived stress, anxiety,
depression, and salivary cortisol in familial caregivers.
1. Introduction
Te aging of the worldwide population has contributed to
the increasing incidence of dementia-causing chronic degen-
erative diseases, notably Alzheimers disease [I]. Alzheimers
disease is the most common form of dementia and is charac-
terized as a progressive brain disorder with loss of reasoning,
memory, language skills, and the ability to maintain an inde-
pendent life [2]. Te caregivers of Alzheimers disease patients
are typically family members [3]. Te physical and mental
burden imposed on caregivers frequently results in poor
quality of life [4]. Te physical, mental, social, and fnancial
burden to which caregivers are exposed to might result in an
increased risk of acute myocardial infarction and death [3
7]. Among the several psychosocial contexts experienced by
caregivers, the following are particularly noteworthy: stress,
social exclusion, depression, emotional isolation, burnout of
personal relationships, loss of life perspectives, sleep disor-
ders, and abuse of psychotropic substances [8I3]. Several
studies of Alzheimers disease patients and caregivers stress
the importance of the medical team orienting the familial
caregivers beginning in the earliest stages of disease, and
plans for such support interventions have been suggested
in the literature [I4I6]. Yoga and meditation are among
the modalities of intervention that might be applied to this
population.
One of the most appropriate defnitions of yoga is found
in documents dated approximately 2,000 years ago, namely,
Patanjalis Yoga sutras. One of such sutras defnes yoga as
follows: yoga is the restriction of the fuctuations of mind-
stuf [I7]. Tus, one of the aims of yoga is the development
of mindfulness; several meditation techniques exhibit similar
Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 20I3, Article ID 3I3I49, 8 pages
http://dx.doi.org/I0.II33/20I3/3I3I49
Research Article
A Yoga and Compassion Meditation Program Reduces Stress in
Familial Caregivers of Alzheimers Disease Patients
M. A. D. Danucalov,
1,2
E. H. Kozasa,
1,3
K. T. Ribas,
2
J. C. F. Galdurz,
1
M. C. Garcia,
1
I. T. N. Verreschi,
4
K. C. Oliveira,
4
L. Romani de Oliveira,
1
and J. R. Leite
1

Department of Psychobiology, Universidade Federal de S ao Paulo-UNIFESP, , Rua Napole ao de Barros,

- S ao Paulo, SP, Brazil

Departiment of Research, Instituto Appana Mind de Desenvolvimento Humano, - S ao Paulo, SP, Brazil

Instituto do C erebro, Hospital Israelita Albert Einstein, - S ao Paulo, SP, Brazil

Department of Medicine, Division of Endocrinology, Universidade Federal de S ao Paulo-UNIFESP, - S ao Paulo, SP, Brazil
Correspondence should be addressed to E. H. Kozasa; ehkozasa@gmail.com
Received I3 December 20I2; Accepted 29 March 20I3
Academic Editor: Luciano Bernardi
Copyright 20I3 M. A. D. Danucalov et al. Tis is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Familial caregivers of patients with Alzheimers disease exhibit reduced quality of life and increased stress levels. Te aim of
this study was to investigate the efects of an 8-week yoga and compassion meditation program on the perceived stress, anxiety,
depression, and salivary cortisol levels in familial caregivers. A total of 46 volunteers were randomly assigned to participate in a
stress-reduction programfor a 2-month period (yoga and compassion meditation programYCMP group) ( = 25) or an untreated
group for the same period of time (control group) ( = 21). Te levels of stress, anxiety, depression, and morning salivary cortisol of
the participants were measured before and afer intervention. Te groups were initially homogeneous; however, afer intervention,
the groups diverged signifcantly. Te YCMP group exhibited a reduction of the stress ( < 0.05), anxiety ( < 0.000001), and
depression ( < 0.00001) levels, as well as a reduction in the concentration of salivary cortisol ( < 0.05). Our study suggests
that an 8-week yoga and compassion meditation program may ofer an efective intervention for reducing perceived stress, anxiety,
depression, and salivary cortisol in familial caregivers.
1. Introduction
Te aging of the worldwide population has contributed to
the increasing incidence of dementia-causing chronic degen-
erative diseases, notably Alzheimers disease [I]. Alzheimers
disease is the most common form of dementia and is charac-
terized as a progressive brain disorder with loss of reasoning,
memory, language skills, and the ability to maintain an inde-
pendent life [2]. Te caregivers of Alzheimers disease patients
are typically family members [3]. Te physical and mental
burden imposed on caregivers frequently results in poor
quality of life [4]. Te physical, mental, social, and fnancial
burden to which caregivers are exposed to might result in an
increased risk of acute myocardial infarction and death [3
7]. Among the several psychosocial contexts experienced by
caregivers, the following are particularly noteworthy: stress,
social exclusion, depression, emotional isolation, burnout of
personal relationships, loss of life perspectives, sleep disor-
ders, and abuse of psychotropic substances [8I3]. Several
studies of Alzheimers disease patients and caregivers stress
the importance of the medical team orienting the familial
caregivers beginning in the earliest stages of disease, and
plans for such support interventions have been suggested
in the literature [I4I6]. Yoga and meditation are among
the modalities of intervention that might be applied to this
population.
One of the most appropriate defnitions of yoga is found
in documents dated approximately 2,000 years ago, namely,
Patanjalis Yoga sutras. One of such sutras defnes yoga as
follows: yoga is the restriction of the fuctuations of mind-
stuf [I7]. Tus, one of the aims of yoga is the development
of mindfulness; several meditation techniques exhibit similar
4 Evidence-Based Complementary and Alternative Medicine
were performed using sofware Statistica version I0.I, and the
signifcance level was established as 0.05.
3. Results
Before the intervention, both groups were statistically homo-
geneous with respect to the following variables: male gender
(YCMP, = 3, I2%) (CG, = 2, I0%) and female gender
(YCMP, = 22, 88%) (CG, = 19, 90%); educational level,
complete elementary education (YCMP, = 1, 4%) (CG, =
0, 0%), complete secondary education (YCMP, = 11, 44%)
(CG, = 5, 24%), and complete higher education (YCMP,
= 13, 32%) (CG, = 16, 76%); family income (minimum
wage, MW = BRL 622.00) up to fve times the MW (BRL
3,II0.00) (YCMP, = 6) (CG, = 7), more than fve and up
to I0 times the MW (BRL 3,II0.00 to BRL 6,220.00) (YCMP,
= 11) (CG, = 6), over I0 times the MW (above BRL
6,220.00) (YCMP, = 8), (CG, = 8); age (YCMP, 55.5 8.1
years), (CG, 53.48.2 years); and length of caregiving (YCMP,
4.2 3.3 years) (CG, 5.7 3.7 years).
Te participants in the YCMP group reported I00%com-
mitment to the suggested program. Tis level of adherence
was most likely facilitated by the relative fexibility of the
program, as the live sessions couldbe attendedat fve diferent
times and at three diferent locations in the city of S ao Paulo.
Further, the use of the DVD for practice at home facilitated
the optimal rate of adherence to the protocol.
Table I shows the frequency of distribution of the phases
of stress manifestation in both groups. Before the interven-
tion, the groups were statistically similar in this regard:
2
( > 0.05). No participant in any group was in either the
absent or alert stages, 86% in the CG and 80% in the
YCMP group were in the phase of resistance, I4% in the CG,
and I2% in the YCMP group were in the phase of quasi-
exhaustion, and only 2 individuals in the YCMP group were
in the phase of exhaustion. However, afer intervention, the
groups exhibited statistically signifcant diferences:
2
( <
0.05). No participant in the CG group was in either the
absent or alert phase, whereas 68% of the participants in the
YCMP shifed to the phase characterized by absence of stress
manifestations. Table I further demonstrates that statistically
signifcant diagnostic changes occurred in the YCMP group.
Before the intervention, 20 volunteers were in the phase of
resistance, and none of the volunteers was in the phase of
absence. Afer the intervention, only 8 volunteers were in the
phase of resistance, and the other I7 volunteers were in the
phase of absence of stress: McNemars test ( < 0.05). Conver-
sely, the CGdid not exhibit any statistically signifcant change
between the beginning and the end of intervention.
Table 2 demonstrates that the average depression (BDI)
and anxiety (BAI) scores exhibited statistically signifcant
interactions with the time point and group factors. Tese
interactions suggest that the groups profles difered over
time. Both variables exhibited a signifcant reduction in the
YCMP group in addition to a diference between the groups
afer the intervention. Te YCMP group exhibited a 3I.2%
reduction in the BDI score afer the intervention, whereas
the CG exhibited an increase of 9.3% at the same time point.
T.nii I: Frequency of the distribution of the phases of stress
manifestation among the sampled individuals according to group
before and afer intervention.
Phases of stress manifestation
Before
intervention
Afer
intervention
Control group Control group
Absence 0 (0) 0 (0)
Alert 0 (0) 0 (0)
Resistance I8 (86) I6 (76)
Quasiexhaustion 3 (I4) 4 (I9)
Exhaustion 0 (0) I (3)
YCMP group YCMP group
&
Absent 0 (0) I7 (68)

Alert 0 (0) 0 (0)

Resistance 20 (80) 8 (32)

Quasiexhaustion 3 (I2) 0 (0)

Exhaustion 2 (8) 0 (0)
Data described as frequency (percentage);
&
< 0.05: difers from control
group, chi-square test;

< 0.05: difers from time-point before interven-
tion, McNemars test.
YCMP: yoga and compassion meditation program.
Te YCMP group exhibited a 49.4% reduction in the BAI
score, whereas the CG exhibited an increase of I0% at the
same time point.
Table 3 presents the salivary cortisol concentration values
corresponding to the average of the two measurements on
the frst sampling day (day one), the average of the two
measurements on the second sampling day (day two), and
the average of the four measurements performed over both
days (day one and day two). Te YCMP group exhibited a
statistically signifcant reduction in the salivary cortisol level
on day two (not in day one), as well as a reduction in the
average of day one + day two before and afer intervention.
Te diferences, according to the table, are not signifcant in
group factor, but they are signifcant in time and interaction
factors. Te control group did not exhibit any signifcant
change. Some samples had an insumcient volume of saliva
to perform cortisol analysis and were lost as a result. On the
frst day of the preintervention phase for the YCMG group,
we lost 20% of the saliva samples for cortisol analysis, and on
the second day we lost I8%, giving an overall loss of I9%. In
the same group, in the post-intervention phase, we lost 30%,
26% and 28% of saliva samples, respectively, for the same
reason. Tere were also losses in the CG: on the frst day of
the preintervention phase there was a loss of II.90% of the
samples, I4.29% on the second day, giving an overall loss of
I3.I0%. Inthe post-interventionphase, we lost I4.29%, 28.37%
and 2I.43%, respectively.
4. Discussion
Te present study sought to establish whether an interven-
tion using yoga and compassion meditation exercises could
change stress, anxiety, and depression scores and reduce the
salivary cortisol levels of familial caregivers of Alzheimers
Evidence-Based Complementary and Alternative Medicine 3
T.nii 2: Scores of depression and anxiety measured by BDI and BAI of familial caregivers of Alzheimers disease patients before and afer
intervention.
Before Afer time-point(I.44) group(I.44) inter(I.44)
BDI
Control group I4.7 (9.3) I6.I (I0.2) I6.3 2.0 34.7
YCMP group I6.0 (7.8) 8.2 (4.6)
&
< 0.001 = 0.16 < 0.000001
BAI
Control group I9.9 (I0.2) 2I.9 (I0.6) I2.9 9.6 32.3
YCMP group I7.6 (9.4) 8.7 (3.3)
&
< 0.001 < 0.001 < 0.00001
Data are described as the mean (standard deviation);

< 0.001 difers from the time point before the intervention in the corresponding groupTukeys
test;
&
< 0.001 difers from the control group in the corresponding time pointTukeys test.
YCMP: yoga and compassion meditation program.
T.nii 3: Salivary cortisol concentration (ng/dL) of familial caregivers of Alzheimers disease patients before and afer intervention.
Before Afer time-point(I.33) group(I.33) inter(I.33)
Cortisol day I
Control group 339.4 (I32.6) 33I.I (33.7) 3.64 0.I0 3.3I
YCMP group 743.9 (I40.7) 404.4 (49.3) = 0.06 = 0.76 = 0.08
Before Afer time-point(I.32) group(I.32) inter(I.32)
Cortisol day 2
Control group 674.7 (I8I.7) 673.2 (86.3) 7.42 0.00004 7.33
YCMP group 937.6 (I7I.3) 408.I (8I.3)

< 0.05 = 0.99 < 0.05

Before Afer time-point(I.40) group(I.40) inter(I.40)
Cortisol days I and 2
Control group 64I.3 (I37.6) 368.0 (38.03) 8.38 0.02 3.97
YCMP group 823.0 (I3I.2) 424.6 (33.3)

< 0.001 = 0.88 < 0.05

Data are described as the mean (standard deviation);

< 0.05 difers from the time point before the intervention in the corresponding groupTukeys test.
YCMP: yoga and compassion meditation program.
disease patients. Among the most relevant fndings were the
changes in the stress manifestation phases of the participants
in the YCMP group from the categories of resistance ( =
20), quasiexhaustion ( = 3), and exhaustion ( = 2)
to absence ( = 17) and resistance ( = 8), thereby
demonstrating the efectiveness of the intervention. Te
changes exhibited by the YCMP group in the stress indices
measured by LSSI suggest that our program was able to
reverse the stress-related symptoms exhibited by that group
(Table I).
Elevations in the hypothalamic pituitary adrenal (HPA)
axis are common occurrences under conditions of chronic
psychological stress and result in increased cortisol levels.
Such occurrences are associated with hippocampal volume
loss and memory impairment and might increase the risk
of dementia in older adults [4446], eventually creating a
vicious circle, whereby familial caregivers of patients with
Alzheimers disease become future patients. Kang et al. [47]
applied a program similar to the one used in this study
and observed a statistically signifcant reduction in the stress
and anxiety levels of I6 nursing students paired with I6
volunteers, who constituted the control group. In the study,
the intervention group performed the suggested program,
comprising one weekly session, with each session lasting
from one hour and a half to two hours over two months.
Te intervention group exhibited a statistically signifcant
reduction in the stress and anxiety scores, thus indicating
that this type of intervention might be useful to reduce stress
in the healthcare professionals directly involved with patient
care tasks [47]. Te literature includes further evidence
indicating that the application of these practices might be
useful when applied to caregivers [22, 27], and our study
corroborates such fndings.
Our data demonstrate statistically signifcant reduction
in the depressive symptoms among the participants in the
YCMP group. An emergent body of evidence points to
the possible therapeutic efects of the practice of aerobic
or anaerobic exercises on depression [4830]. Such exer-
cises, meanwhile, might be either mindful or nonmind-
ful physical exercises. A systematic review analyzed pos-
sible therapeutic diferences between these two types of
exercise. Te analyzed results were provided by I2 studies
that complied with the methodological criteria applied by
the authors for inclusion in that review. According to the
authors, both mindful and nonmindful exercises proved to
be efective in reducing depression symptoms [30]. It is
worth noting that among other activities, the volunteers
in our study were subjected to the practice of hatha yoga,
which includes physical exercise, most of them anaero-
bic, to achieve that same goal. Nevertheless, our results
Interventions shown to Aid Executive Function Development in
Children 412 Years Old
*
Adele Diamond
1
and Kathleen Lee
1
1
University of British Columbia and Childrens Hospital, Vancouver, BC Canada
Abstract
To be successful takes creativity, flexibility, self-control, and discipline. Central to all those are
executive functions, including mentally playing with ideas, giving a considered rather than an
impulsive response, and staying focused. Diverse activities have been shown to improve
childrens executive functions computerized training, non-computerized games, aerobics, martial
arts, yoga, mindfulness, and school curricula. Central to all these is repeated practice and
constantly challenging executive functions. Children with worse executive functions initially,
benefit most; thus early executive-function training may avert widening achievement gaps later.
To improve executive functions, focusing narrowly on them may not be as effective as also
addressing emotional and social development (as do curricula that improve executive functions)
and physical development (shown by positive effects of aerobics, martial arts, and yoga).
What will children need to be successful? What programs are successfully helping children
develop those skills in the earliest school years? What do those programs have in common?
Four qualities will probably be key to success - creativity, flexibility, self-control, and
discipline. Children will need to think creatively to devise solutions never considered before.
Theyll need working memory to mentally work with masses of data, seeing new
connections among elements. Theyll need flexibility to appreciate different perspectives
and take advantage of serendipity. Theyll need self-control to resist temptations, and avoid
doing something theyd regret. Tomorrows leaders will need to have the discipline to stay
focused, seeing tasks through to completion.
All of those qualities are executive functions (EFs), the cognitive control functions needed
when you have to concentrate and think, when acting on your initial impulse would be ill-
advised. EFs depend on a neural circuit in which prefrontal cortex is central. Core EFs are
cognitive flexibility, inhibition (self-control, self-regulation), and working memory (1).
More complex EFs include problem-solving, reasoning, and planning. EFs are more
important for school readiness than is IQ (2). They continue to predict math and reading
competence throughout all school years (e.g., 3). Clearly, to improve school readiness and
academic success, targeting EFs is crucial. EFs remain critical for success throughout life (in
career [4] and marriage [5]) and for mental and physical health (6, 7).
*
This manuscript has been accepted for publication in Science (will appear in 2011).
This version has not undergone final editing. Please refer to the complete version of record at http://www.sciencemag.org/. The
manuscript may not be reproduced or used in any manner that does not fall within the fair use provisions of the Copyright Act without
the prior, written permission of AAAS
address correspondence to: Adele Diamond, Canada Research Chair Professor of Developmental Cognitive Neuroscience,
Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC Canada V6T 2A1,
adele.diamond@ubc.ca, phone: 604 822 7220, fax: 604 822 7232.
NIH Public Access
Author Manuscript
Science. Author manuscript; available in PMC 2011 August 23.
Published in final edited form as:
Science. 2011 August 19; 333(6045): 959964. doi:10.1126/science.1204529.
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Interventions shown to Aid Executive Function Development in
Children 412 Years Old
*
Adele Diamond
1
and Kathleen Lee
1
1
University of British Columbia and Childrens Hospital, Vancouver, BC Canada
Abstract
To be successful takes creativity, flexibility, self-control, and discipline. Central to all those are
executive functions, including mentally playing with ideas, giving a considered rather than an
impulsive response, and staying focused. Diverse activities have been shown to improve
childrens executive functions computerized training, non-computerized games, aerobics, martial
arts, yoga, mindfulness, and school curricula. Central to all these is repeated practice and
constantly challenging executive functions. Children with worse executive functions initially,
benefit most; thus early executive-function training may avert widening achievement gaps later.
To improve executive functions, focusing narrowly on them may not be as effective as also
addressing emotional and social development (as do curricula that improve executive functions)
and physical development (shown by positive effects of aerobics, martial arts, and yoga).
What will children need to be successful? What programs are successfully helping children
develop those skills in the earliest school years? What do those programs have in common?
Four qualities will probably be key to success - creativity, flexibility, self-control, and
discipline. Children will need to think creatively to devise solutions never considered before.
Theyll need working memory to mentally work with masses of data, seeing new
connections among elements. Theyll need flexibility to appreciate different perspectives
and take advantage of serendipity. Theyll need self-control to resist temptations, and avoid
doing something theyd regret. Tomorrows leaders will need to have the discipline to stay
focused, seeing tasks through to completion.
All of those qualities are executive functions (EFs), the cognitive control functions needed
when you have to concentrate and think, when acting on your initial impulse would be ill-
advised. EFs depend on a neural circuit in which prefrontal cortex is central. Core EFs are
cognitive flexibility, inhibition (self-control, self-regulation), and working memory (1).
More complex EFs include problem-solving, reasoning, and planning. EFs are more
important for school readiness than is IQ (2). They continue to predict math and reading
competence throughout all school years (e.g., 3). Clearly, to improve school readiness and
academic success, targeting EFs is crucial. EFs remain critical for success throughout life (in
career [4] and marriage [5]) and for mental and physical health (6, 7).
*
This manuscript has been accepted for publication in Science (will appear in 2011).
This version has not undergone final editing. Please refer to the complete version of record at http://www.sciencemag.org/. The
manuscript may not be reproduced or used in any manner that does not fall within the fair use provisions of the Copyright Act without
the prior, written permission of AAAS
address correspondence to: Adele Diamond, Canada Research Chair Professor of Developmental Cognitive Neuroscience,
Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC Canada V6T 2A1,
adele.diamond@ubc.ca, phone: 604 822 7220, fax: 604 822 7232.
NIH Public Access
Author Manuscript
Science. Author manuscript; available in PMC 2011 August 23.
Published in final edited form as:
Science. 2011 August 19; 333(6045): 959964. doi:10.1126/science.1204529.
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unes execuuvas do cerebro
Crlauvldade, exlbllldade,
auLo-conLrole e dlsclpllna.
8rlncar com as ldelas"
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lnves de lmpulslva
ManLer-se focado.

(funes de conLrole cognluvo necessrlas para
pensar, se concenLrar e lnlblr lmpulsos, planear,
resolver problemas. Cerebro: corLex pre-fronLal)
ue anv|dades me|horam a
funo execunva em cr|anas?
1relno compuLadorlzado (ex:
cogmed)
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!ogos e exerclclos aerblcos
Artes marc|a|s (modo trad|c|ona|)
oga
Ateno p|ena (m|ndfu|ness)
Curr|cu|o esco|ar (Lx: Montessor|)
(mals compleLas: funes cognluvas
habllldades emoclonals soclals nslcas)
Cerebro e medlLao
A complexa Larefa menLal da medlLao
oferece uma lmporLanLe anela para a
consclncla, pslcologla e experlncla
humanas, a relao menLe-corpo,
processamenLo emoclonal e cognluvo, e
a correlao blolglca da experlncla
esplrlLual.
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auvao do crLex
pre-fronLal (C),
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medlLauvo pela
prprla vonLade
(newberg e lversen,
2003).
C crLex pre-fronLal e
responsvel pela escolha das
opes e esLraLeglas
comporLamenLals e pela
manuLeno da aLeno.
CrLex pre-fronLal
gluLamaLo
nucleo reucular do Llamo
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orlenLao espaclal e da dlsuno do eu e do
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monges que medlLaram enLre 10.000 e
30.000 horas por 10 a 40 anos,mosLram
que o crLex pre-fronLal esquerdo e mals
auvo duranLe o esLado medlLauvo que o
dlrelLo, e parece que ele esL relaclonado
a pensamenLos mals posluvos.
Lles Lambem apresenLam malor
proporo de ondas gama e slncronla
dos hemlsferlos cerebrals que o grupo
conLrole.
lsLo evldencla que o cerebro e capaz de
ser Lrelnado e slcamenLe modlcado de
manelra que amals se lmaglnou
anLerlormenLe.
O crtex pr-frontal, e a insula anterior direita so mais espessos
em meditadores que praticam 40 min por dia do que em indivduos
que no meditam. Diferenas entre grupos so mais pronunciadas
nos individuos mais idosos. So rea envolvidas na ateno e
processamento sensorial.
Meditation experience is associated with increased cortical
thickness
Sara W. Lazar
a
, Catherine E. Kerr
b
, Rachel H. Wasserman
a,b
, Jeremy R. Gray
c
, Douglas N.
Greve
d
, Michael T. Treadway
a
, Metta McGarvey
e
, Brian T. Quinn
d
, Jeffery A. Dusek
f,g
,
Herbert Benson
f,g
, Scott L. Rauch
a
, Christopher I. Moore
h,i
, and Bruce Fischl
d,j
aPsychiatric Neuroimaging Research Program, Massachusetts General Hospital
bOsher Institute, Harvard Medical School, Boston, Massachusetts
cDepartment of Psychology, Yale University, New Haven, Connecticut
dAthinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston
eGraduate School of Education, Harvard University, Cambridge
fMind/Body Medical Institute, Chestnut Hill
gDepartment of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
hDepartment of Brain and Cognitive Sciences, Massachusetts Institute of Technology
iMcGovern Institute for Brain Research
jComputer Science and AI Lab (CSAIL), Massachusetts Institute of Technology, Cambridge,
Massachusetts, USA.
Abstract
Previous research indicates that long-term meditation practice is associated with altered resting
electroencephalogram patterns, suggestive of long lasting changes in brain activity. We hypothesized
that meditation practice might also be associated with changes in the brains physical structure.
Magnetic resonance imaging was used to assess cortical thickness in 20 participants with extensive
Insight meditation experience, which involves focused attention to internal experiences. Brain
regions associated with attention, interoception and sensory processing were thicker in meditation
participants than matched controls, including the prefrontal cortex and right anterior insula. Between-
group differences in prefrontal cortical thickness were most pronounced in older participants,
suggesting that meditation might offset age-related cortical thinning. Finally, the thickness of two
regions correlated with meditation experience. These data provide the first structural evidence for
experience-dependent cortical plasticity associated with meditation practice.
Keywords
insula; meditation; plasticity; prefrontal cortex
Correspondence and requests for reprints to Sara W. Lazar, PhD, Room 2609,149 13th St. Charlestown, MA 02129, USA Tel: + 1617
724 7108; fax: + 1617 726 4078; e-mail: lazar@nmr.mgh.harvard.edu.
Sponsorship:This work was supported by NIH/NCCAMK01AT00694-01, NCRR (P41RR14075), the MINDInstitute, and CDCGrants
H75/CCH119124 and H75/CCH123424.C.K. was supported by Grant R21AT002860-02.
NIH Public Access
Author Manuscript
Neuroreport. Author manuscript; available in PMC 2006 February 6.
Published in final edited form as:
Neuroreport. 2005 November 28; 16(17): 18931897.
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Aumento da concentrao de
substncia cinzenta aps 8
semanas de treinamento de
Mindfulness Based Stress
Reduction (MBSR)
Regies cerebrias
envolvendo aprendizagem,
memria, controle
emocional, autoconscincia
corporal.

Change in gray matter concentration (GMC) within
the clusters in the posterior cingulate cortex (A), the
temporo-parietal junction (B), the lateral cerebellum
(C) and the cerebellar vermis/brainstem (D) in the
MBSR and control group. Error bars show 95%
confidence interval.
Mindfulness practice leads to increases in regional brain gray matter density
Britta K. Hlzel
a,b,
, James Carmody
c
, Mark Vangel
a
, Christina Congleton
a
, Sita M. Yerramsetti
a
,
Tim Gard
a,b
, Sara W. Lazar
a
a
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
b
Bender Institute of Neuroimaging, Justus Liebig Universitt Giessen, Germany
c
University of Massachusetts Medical School, Worcester, MA, USA
a b s t r a c t a r t i c l e i n f o
Article history:
Received 26 March 2010
Received in revised form 9 August 2010
Accepted 11 August 2010
Available online xxxx
Keywords:
Meditation
Mindfulness
Voxel-based morphometry
Gray matter
Magnetic resonance imaging
Hippocampus
Posterior cingulate
Therapeutic interventions that incorporate training in mindfulness meditation have become increasingly
popular, but to date little is known about neural mechanisms associated with these interventions.
Mindfulness-Based Stress Reduction (MBSR), one of the most widely used mindfulness training programs,
has been reported to produce positive effects on psychological well-being and to ameliorate symptoms of a
number of disorders. Here, we report a controlled longitudinal study to investigate prepost changes in brain
gray matter concentration attributable to participation in an MBSR program. Anatomical magnetic resonance
(MR) images from 16 healthy, meditation-nave participants were obtained before and after they underwent
the 8-week program. Changes in gray matter concentration were investigated using voxel-based
morphometry, and compared with a waiting list control group of 17 individuals. Analyses in a priori regions
of interest conrmed increases in gray matter concentration within the left hippocampus. Whole brain
analyses identied increases in the posterior cingulate cortex, the temporo-parietal junction, and the
cerebellum in the MBSR group compared with the controls. The results suggest that participation in MBSR is
associated with changes in gray matter concentration in brain regions involved in learning and memory
processes, emotion regulation, self-referential processing, and perspective taking.
2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Mindfulness meditation has been reported to produce positive
effects on psychological well-being that extend beyond the time the
individual is formally meditating. Over the last three decades
mindfulness meditation practices have been increasingly incorporat-
ed into psychotherapeutic programs, to take advantage of these
benets (cf. Baer, 2003; Grossman et al., 2004). A large body of
research has established the efcacy of these mindfulness-based
interventions in reducing symptoms of a number of disorders,
including anxiety (Roemer et al., 2008), depression (Teasdale et al.,
2000), substance abuse (Bowen et al., 2006), eating disorders (Tapper
et al., 2009), and chronic pain (Grossman et al., 2007), as well as
improving well-being and quality of life (e.g., Carmody and Baer,
2008). Mindfulness meditation involves the development of aware-
ness of present-moment experience with a compassionate, non-
judgmental stance (Kabat-Zinn, 1990). It has been suggested that this
process is associated with a perceptual shift (Carmody, 2009), in
which one's thoughts and feelings are recognized as events occurring
in the broader eld of awareness.
Neuroimaging studies have begun to explore the neural mechan-
isms underlying mindfulness meditation practice with techniques such
as electroencephalography (EEG) (Davidson et al., 2003; Slagter et al.,
2007) and functional magnetic resonance imaging (MRI) (Farb et al.,
2007; Lutz et al., 2008; Farb et al., 2010; Goldin and Gross, 2010).
Recently, several cross-sectional anatomical MRI studies have demon-
strated that experienced meditators exhibit a different gray matter
morphometry in multiple brain regions when compared with non-
meditating individuals (Lazar et al., 2005; Pagnoni and Cekic, 2007;
Hlzel et al., 2008; Luders et al., 2009; Vestergaard-Poulsen et al., 2009;
Grant et al., 2010). While most of the brain regions identied have been
reported in only one of these studies, the divergent results are likely due
to differences in participant characteristics, type of meditation, and data
analysis methods (see Table 1). Group differences in the hippocampus
and the right anterior insula, however, have each been identied in at
least two of the studies. Furthermore, activation in both regions has
been reported during meditative states (hippocampus (Lazar et al.,
2000; Hlzel et al., 2007); insula (Farb et al., 2007; Lutz et al., 2008)).
The hippocampus is known to be critically involved in learning and
memory processes (Squire, 1992), and in the modulation of emotional
control (Corcoran et al., 2005; Milad et al., 2007), while the insula has
been postulated to play a key role in the process of awareness (Craig,
2009) functions which have been shown to be important in the
process and outcomes of mindfulness training (Bishop et al., 2004;
Shapiro et al., 2006; Ortner et al., 2007).
Psychiatry Research: Neuroimaging xxx (2010) xxxxxx
Corresponding author. Massachusetts General Hospital, 120 2nd Avenue, Charles-
town, MA 02129, USA. Tel.: +1 617 724 2256; fax: +1 617 643 7340.
E-mail address: britta@nmr.mgh.harvard.edu (B.K. Hlzel).
PSYN-09681; No of Pages 8
0925-4927/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pscychresns.2010.08.006
Contents lists available at ScienceDirect
Psychiatry Research: Neuroimaging
j our nal homepage: www. el sevi er. com/ l ocat e/ psychr esns
Please cite this article as: Hlzel, B.K., et al., Mindfulness practice leads to increases in regional brain gray matter density, Psychiatry
Research: Neuroimaging (2010), doi:10.1016/j.pscychresns.2010.08.006
Publicao na special issue da Neuroimage:
Neuroergonomics: the human brain in action
at work
8ra|n reg|ons more acnvated |n the |ncongruent than the congruent tasks |n
non-med|tators compared w|th regu|ar med|tators (medlal fronLal gyrus,
mlddle Lemporal gyrus, lenuform nucleus, precenLral gyrus and posLcenLral
gyrus ).
Brain Imaging Analysis Can Identify Participants under
Regular Mental Training
Joa o R. Sato
1
, Elisa H. Kozasa
2,3
, Tamara A. Russell
4
, Joa o Radvany
2
, Luiz E. A. M. Mello
5
,
Shirley S. Lacerda
2
, Edson Amaro Jr
2
*
1UFABC Univ. Federal do ABC, Santo Andre , Brazil, 2Instituto do Ce rebro, Hospital Israelita Albert Einstein, Sao Paulo, Brazil, 3Department of Psychobiology UNIFESP
Univ. Federal De Sao Paulo, Sao Paulo, Brazil, 4Kings College London, Institute of Psychiatry, London, United Kingdom, 5Department of Physiology, Univ. Federal de Sao
Paulo, Sao Paulo, Brazil
Abstract
Multivariate pattern recognition approaches have become a prominent tool in neuroimaging data analysis. These methods
enable the classification of groups of participants (e.g. controls and patients) on the basis of subtly different patterns across
the whole brain. This study demonstrates that these methods can be used, in combination with automated morphometric
analysis of structural MRI, to determine with great accuracy whether a single subject has been engaged in regular mental
training or not. The proposed approach allowed us to identify with 94.87% accuracy (p,0.001) if a given participant is a
regular meditator (from a sample of 19 regular meditators and 20 non-meditators). Neuroimaging has been a relevant tool
for diagnosing neurological and psychiatric impairments. This study may suggest a novel step forward: the emergence of a
new field in brain imaging applications, in which participants could be identified based on their mental experience.
Citation: Sato JR, Kozasa EH, Russell TA, Radvany J, Mello LEAM, et al. (2012) Brain Imaging Analysis Can Identify Participants under Regular Mental Training. PLoS
ONE 7(7): e39832. doi:10.1371/journal.pone.0039832
Editor: Dante R. Chialvo, National Research & Technology Council, Argentina
Received February 1, 2012; Accepted May 28, 2012; Published July 3, 2012
Copyright: 2012 Sato et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Fundacao de Amparo a Pesquisa do Estado de Sao Paulo - FAPESP 2010/01394-4 Brazil and Instituto Israelita de Ensino e Pesquisa Albert Einstein. The
funders had no role in study design, analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: edsonjr@einstein.br
Introduction
Pioneers in neuroscience studied patients with lesions and
associated behavioural abnormalities, such as the classic case of
Phineas Gage [1], in order to determine aspects of brain function.
The advent of neuroimaging provided sufficient detail to enable
the detection of brain damage in vivo, by the naked eye, and
created the basis for neuroradiology [2]. Modern advances in
neuroimaging, along with the use of computers, have resulted in
more precise automated quantitative analysis. However, subtle
differences in images were still difficult to identify accurately, until
the application of Machine Learning methods for classification of
brain images, such as Support Vector Machine (SVM [3]).
These computational methods of pattern recognition have been
used to aid discrimination of clinical brain pathologies associated
with easily identifiable behavioural disorders [4,5]. Indeed, most
studies focus on identifying participants with psychiatric or
neurological conditions. However, less is known about the ability
of these methods to classify the mental habits of a non-clinical
population based only on information extracted from the brain.
For example, suppose clinicians observe a group of subjects on a
street market. It may not be too difficult to diagnose a person with
autism. However, in the same scene it will be difficult to guess
whether a person practices some form of mental training such as
meditation.
Previous research has revealed that meditation can be
associated with changes in brain function and morphology. For
example, Lutz et al. [6] demonstrated that long-term Buddhist
meditation practitioners were able to self-induce sustained
electroencephalographic high-amplitude gamma-band oscillations
and phase-synchrony during meditation. This was particularly
apparent at lateral frontoparietal electrodes. Kozasa et al. [7]
compared the neural activity of non-meditators and meditators
during a task which assessed attention (the Stroop Word-Color
Task). Non-meditators showed greater activity than meditators in
the right medial frontal, middle temporal, precentral and
postcentral gyri and the lentiform nucleus. There were no regions
with greater activity in meditators relative to non-meditators.
Therefore, non-meditators required greater neural activation
compared to regular meditators to achieve equivalent behavioural
performance. This supports the hypothesis that meditation
training results in greater efficiency via improved sustained
attention and impulse control.
In addition, there is evidence that long-term meditation practice
is associated with increased cortical thickness. Lazar et al. [8]
reported that prefrontal cortex and right anterior insula were
thicker in meditators compared to matched controls. These areas
are thought to be involved in attention, interoception and sensory
processing. Alternatively, Holzel et al. [9] compared Vipassana
meditators with non-meditators and found greater grey matter
concentration in the right anterior insula, left inferior temporal
gyrus and right hippocampus.
The current study looks to build on this previous research by
asking: is it possible to determine whether a person regularly
meditates using only their structural brain image? We set out to
explore this question by classifying participants by their expertise
in meditation and then attempting to identify subtle differences
between participants engaged in regular meditation and those who
PLoS ONE | www.plosone.org 1 July 2012 | Volume 7 | Issue 7 | e39832
the information from the specific test subject removed at first-level
leave-one-out analysis was only used to estimate prediction
accuracy and was not contained within the SVM training data.
The feature selection, classification, and accuracy estimation were
performed via the following steps:
Step 1) Leave one subject out of the sample (first-level leave-
one-out);
Step 2) Remove the effects of gender and age from each
feature (predictor variable) of the training data by
using a multiple linear regression analysis. The
corrected training data are the residuals of this
regression;
Step 3) Normalize each feature of the corrected training data
to have mean zero and variance one. This data is
referred as the normalized training data;
Step 4) Leave-one-out implementation:
Step 4.1) Leave another subject out of the normalized
training data (second-level leave-one-out);
Step 4.1.a) Train the linear SVM using the respective
normalized training data and its label vector
(which specifies the groups).
Step 4.1.b) Rank the SVM decision function coefficients
(hyperplane coefficients) by their absolute
values. This step will provide a rank vector
describing the relevance of each feature to the
groups discrimination;
Step 4.1.c) Feature selection: Remove the most irrele-
vant feature from the normalized training
data;
Step 4.1.d) Train the SVM using the normalized
training data obtained in step 4.1.c;
Figure 1. Classification of regular meditators and non-meditators using support vector machines (SVM). Regions identified by the SVM
as containing discriminative information used to consistently predict the groups (right precentral gyrus, left entorhinal cortex, right pars opercularis
cortex, right basal putamen, and bilateral thalamus). These five regions were selected by SVM in an all leave-one-subject-out iterations, with 94.87%
accuracy. The bottom of the figure depicts the projection values of each subject and the decision boundary.
doi:10.1371/journal.pone.0039832.g001
Identification of Subjects under Mental Training
PLoS ONE | www.plosone.org 3 July 2012 | Volume 7 | Issue 7 | e39832
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