Review of Paul M. Lehrer & Robert L. Woolfolk (eds.). (2021). Principles and practice of stress management (fourth edition). Guilford.

Lehrer and Woolfolk are major figures who have led the field of stress management for four decades. Here they have assembled a gifted team of expert authors, ranging from Jonathan Smith on relaxation to Alice Meuret and Thomas Ritz on capnometric training to Shirley Telles and colleagues on yoga for stress management. The text Principles and Practice of Stress Management has long provided the most comprehensive scientifically informed resource for understanding stress and stress management. The fourth edition updates the scientific research, introduces new topics, and sharpens the focus in many chapters. Nevertheless, the preface of the fourth edition emphasizes the continued relevance of this book for the lay audience, human beings seeking guidance for managing their life stress.

Review of I. Z. Khazan (2019), Biofeedback and Mindfulness in Everyday Life: Practical Solutions for Improving Your Health and Performance. W. W. Norton and Company.

Dr. Inna Khazan is the preeminent authority on integrating biofeedback with mindfulness. She wrote Biofeedback and Mindfulness in Everyday Life for biofeedback clients, individuals seeking self-improvement, clinicians, performance coaches, and students. Part I, Physiological Principles, describes the major biofeedback modalities, breathing physiology, and heart rate variability. Part II, Mindfulness, reviews the Foundations of Mindfulness, Mindfulness Meditation, Mindfulness-Based Skills, and Compassion and Self-Compassion. Part III, Applications to Common Challenges, addresses Sleep, Stress and Performance, Anxiety and Fear, Anger, Interpersonal Communication, Pain, Sadness and Depression, and Shame and Guilt. Two appendices contain Meditation Scripts and a Sample List of Biofeedback Devices. Khazan masterfully explains the science supporting biofeedback, mindfulness-based interventions, and self-regulation. Biofeedback and Mindfulness in Everyday Life provides a step-by-step guide for building resilience and emotional flexibility and addressing challenges like anxiety, depression, and pain.

Rhythmic Skeletal Muscle Tension Increases Heart Rate Variability at 1 and 6 Contractions Per Minute.

Breathing at the resonance frequency (~ 6 breaths per min) produces resonance effects on baroreflex gain, blood pressure, vascular tone, and therapeutic benefits. Evgeny Vaschillo and Paul Lehrer have emphasized that the stimulation frequency is critical for producing resonance effects in the cardiorespiratory system. Although clinicians overwhelmingly use paced breathing to increase HRV, other promising methods exist. Vaschillo, Lehrer, and colleagues have shown that presenting non-respiratory stimulation at 0.1 Hz-pictures with an emotional valence or rhythmical muscle tensing-amplifies oscillations in heart rate, blood pressure, and vascular tone. Participants in the present study included 49 undergraduate students randomly assigned to one of six different orders of 5-min trials of 1, 6, and 12 muscle contractions per min (cpm), separated by 3-min buffer periods intended to minimize carryover. This randomized controlled trial replicated the Vaschillo et al. (Psychophysiology 48:927-936, 2011. https://doi.org/10.1111/j.1469-8986.2010.01156.x ) finding that 6-cpm RSMT can produce a PkFreq of ~ 0.10 Hz, similar to 6-bpm RF breathing. RSMT at 1 and 6 cpm increased five time-domain metrics (HR Max-HR Min, RMSSD, SDNN, TI, and TINN), one frequency-domain metric (LF power), and three non-linear metrics (D2, SD1, SD2) significantly more than RSMT at 12 cpm. There were no differences between 1 and 6 cpm on these measures. The 1-cpm rate (~ 0.02 Hz) may have stimulated the hypothesized vascular tone baroreflex between 0.02 and 0.055 Hz. RSMT at 1 or 6 cpm provides clients with an alternative exercise for increasing HRV for patients who find slow-paced breathing challenging or medically unsafe.

Improving Anti-Neurodegenerative Benefits of Acetylcholinesterase Inhibitors in Alzheimer's Disease: Are Irreversible Inhibitors the Future?

Decades of research have produced no effective method to prevent, delay the onset, or slow the progression of Alzheimer's disease (AD). In contrast to these failures, acetylcholinesterase (AChE, EC 3.1.1.7) inhibitors slow the clinical progression of the disease and randomized, placebo-controlled trials in prodromal and mild to moderate AD patients have shown AChE inhibitor anti-neurodegenerative benefits in the cortex, hippocampus, and basal forebrain. CNS neurodegeneration and atrophy are now recognized as biomarkers of AD according to the National Institute on Aging-Alzheimer's Association (NIA-AA) criteria and recent evidence shows that these markers are among the earliest signs of prodromal AD, before the appearance of amyloid. The current AChE inhibitors (donepezil, rivastigmine, and galantamine) have short-acting mechanisms of action that result in dose-limiting toxicity and inadequate efficacy. Irreversible AChE inhibitors, with a long-acting mechanism of action, are inherently CNS selective and can more than double CNS AChE inhibition possible with short-acting inhibitors. Irreversible AChE inhibitors open the door to high-level CNS AChE inhibition and improved anti-neurodegenerative benefits that may be an important part of future treatments to more effectively prevent, delay the onset, or slow the progression of AD.

Cholinergic transmission during nicotine withdrawal is influenced by age and pre-exposure to nicotine: implications for teenage smoking.

Adolescence is a unique period of development characterized by enhanced tobacco use and long-term vulnerability to neurochemical changes produced by adolescent nicotine exposure. In order to understand the underlying mechanisms that contribute to developmental differences in tobacco use, this study compared changes in cholinergic transmission during nicotine exposure and withdrawal in naïve adult rats compared to (1) adolescent rats and (2) adult rats that were pre-exposed to nicotine during adolescence. The first study compared extracellular levels of acetylcholine (ACh) in the nucleus accumbens (NAc) during nicotine exposure and precipitated withdrawal using microdialysis procedures. Adolescent (postnatal day, PND, 28-42) and adult rats (PND60-74) were prepared with osmotic pumps that delivered nicotine for 14 days (adolescents 4.7 mg/kg/day; adults 3.2 mg/kg/day; expressed as base). Another group of adults was exposed to nicotine during adolescence and then again in adulthood (pre-exposed adults) using similar methods. Control rats received a sham surgery. Following 13 days of nicotine exposure, the rats were implanted with microdialysis probes in the NAc. The following day, dialysis samples were collected during baseline and following systemic administration of the nicotinic receptor antagonist mecamylamine (1.5 and 3.0 mg/kg, i.p.) to precipitate withdrawal. A second study compared various metabolic differences in cholinergic transmission using the same treatment procedures as the first study. Following 14 days of nicotine exposure, the NAc was dissected and acetylcholinesterase (AChE) activity was compared across groups. In order to examine potential group differences in nicotine metabolism, blood plasma levels of cotinine (a nicotine metabolite) were also compared following 14 days of nicotine exposure. The results from the first study revealed that nicotine exposure increased baseline ACh levels to a greater extent in adolescent versus adult rats. During nicotine withdrawal, ACh levels in the NAc were increased in a similar manner in adolescent versus adult rats. However, the increase in ACh that was observed in adult rats experiencing nicotine withdrawal was blunted in pre-exposed adults. These neurochemical effects do not appear to be related to nicotine metabolism, as plasma cotinine levels were similar across all groups. The second study revealed that nicotine exposure increased AChE activity in the NAc to a greater extent in adolescent versus adult rats. There was no difference in AChE activity in pre-exposed versus naïve adult rats. In conclusion, our results suggest that nicotine exposure during adolescence enhances baseline ACh in the NAc. However, the finding that ACh levels were similar during withdrawal in adolescent and adult rats suggests that the enhanced vulnerability to tobacco use during adolescence is not related to age differences in withdrawal-induced increases in cholinergic transmission. Our results also suggest that exposure to nicotine during adolescence suppresses withdrawal-induced increases in cholinergic responses during withdrawal. Taken together, this report illustrates important short- and long-term changes within cholinergic systems that may contribute to the enhanced susceptibility to tobacco use during adolescence.

Traumatizing Disorders of "Everyday Life".

Grounded in clinical examples, the text focuses on the challenges posed by working at a historical moment that, if fully taken in, presents us all-patients and analysts/therapists-with "more than mind can endure." This "too muchness" makes it particularly difficult to maintain our consulting rooms as "safe" spaces. The basic question: how to preserve a sense of safety in our clinical work while we simultaneously remain open to the disruptive and often unrepresentable dangers that surround and infiltrate us.

A randomized phase I study of methanesulfonyl fluoride, an irreversible cholinesterase inhibitor, for the treatment of Alzheimer's disease.

AIMS: To ascertain the tolerability profile of single and repeated oral doses of methanesulfonyl fluoride (MSF, SNX-001) in healthy aged subjects, and to determine the degree of erythrocyte acetylcholinesterase (AChE) inhibition induced by MSF after single and repeated oral doses. METHODS: To calculate properly the kinetics and the duration of AChE inhibition, the effects of MSF were also studied in rodents. These experiments suggested that MSF administered three times per week should provide safe and efficacious AChE inhibition. In a randomized placebo-controlled phase I study, 3.6 mg, 7.2 mg or 10.8 mg MSF were then orally administered to 27 consenting healthy volunteers (aged 50 to 72 years). After a single dose phase and a 1 week wash-out period, the subjects received the same doses three times per week for 2 weeks. RESULTS: Twenty-two out of the 27 subjects completed the study. Four patients withdrew due to adverse events (AEs) and one for non-compliance. Erythrocyte AChE was inhibited by a total of 33%, 46%, and 62% after 2 weeks of 3.6 mg, 7.2 mg and 10.8 mg MSF, respectively. No serious AEs occurred. The most frequent AEs were headache (27%), nausea (11%) and diarrhoea (8%). CONCLUSIONS: MSF proved to be well tolerated even with repeated oral dosing. It is estimated that MSF provided a degree of AChE inhibition that should effectively enhance memory. This molecule deserves to be tested for efficacy in a pilot randomized controlled study in patients with Alzheimer's disease.

Current Practices, Experiences, and Views in Clinical Hypnosis: Findings of an International Survey.

An online survey of 691 clinicians who use hypnosis was conducted in 31 countries to gain a broad real-world picture of current practices, views, and experiences in clinical hypnosis. Among 36 common clinical uses, stress reduction, wellbeing and self-esteem-enhancement, surgery preparations, anxiety interventions, mindfulness facilitation, and labor and childbirth applications were the most frequently rated as highly effective (each by ≥70% of raters) in the clinicians' own experience. Adverse hypnosis-associated effects had been encountered by 55% of clinicians but were generally short-lived and very rarely judged as serious. The most common hypnosis approaches used were Ericksonian (71%), hypnotic relaxation therapy (55%), and traditional hypnosis (50%). Almost all respondents reported regularly using other therapeutic modalities alongside hypnosis. Among a range of client variables potentially affecting therapy, most clinicians rated hypnotist-client rapport (88%) and client motivation (75%) as very or extremely important factors for successful hypnotherapy. The majority of respondents had conducted hypnosis treatment via teletherapy, and 54% of those estimated it to be as effective as in-person treatment.

Guidelines for the Assessment of Efficacy of Clinical Hypnosis Applications.

Research on the efficacy of hypnosis applications continues to grow, but there remain major gaps between the science and clinical practice. One challenge has been a lack of consensus on which applications of hypnosis are efficacious based on research evidence. In 2018, 6 major hypnosis organizations collaborated to form the Task Force for Establishing Efficacy Standards for Clinical Hypnosis. This paper describes a Guideline for the Assessment of Efficacy of Clinical Hypnosis Applications developed by the Task Force, which makes 10 specific recommendations. The guideline is intended to be a tool for those who want to assess the quality of existing evidence on the efficacy of clinical hypnosis for any particular indication. The paper also discusses methodological issues in the interpretation and implementation of these guidelines. Future papers will report on the other products of the Hypnosis Efficacy Task Force, such as best practice recommendations for outcomes research in hypnosis and an international survey of researchers and clinicians on current practice and attitudes about hypnosis.

On Having Whiteness.

Whiteness is a condition one first acquires and then one has-a malignant, parasitic-like condition to which "white" people have a particular susceptibility. The condition is foundational, generating characteristic ways of being in one's body, in one's mind, and in one's world. Parasitic Whiteness renders its hosts' appetites voracious, insatiable, and perverse. These deformed appetites particularly target nonwhite peoples. Once established, these appetites are nearly impossible to eliminate. Effective treatment consists of a combination of psychic and social-historical interventions. Such interventions can reasonably aim only to reshape Whiteness's infiltrated appetites-to reduce their intensity, redistribute their aims, and occasionally turn those aims toward the work of reparation. When remembered and represented, the ravages wreaked by the chronic condition can function either as warning ("never again") or as temptation ("great again"). Memorialization alone, therefore, is no guarantee against regression. There is not yet a permanent cure.

Anti-Neurodegenerative Benefits of Acetylcholinesterase Inhibitors in Alzheimer's Disease: Nexus of Cholinergic and Nerve Growth Factor Dysfunction.

Alzheimer's disease (AD) is a progressive neurodegenerative disorder that is increasingly viewed as a complex multi-dimensional disease without effective treatments. Recent randomized, placebo-controlled studies have shown volume losses of ~0.7% and ~3.5% per year, respectively, in the basal cholinergic forebrain (CBF) and hippocampus in untreated suspected prodromal AD. One year of donepezil treatment reduced these annualized rates of atrophy to about half of untreated rates. Similar positive although variable results have also been found in volumetric measurements of the cortex and whole brain in patients with mild cognitive impairment as well as more advanced AD stages after treatments with all three currently available acetylcholinesterase (AChE) inhibitors (donepezil, rivastigmine, and galantamine). Here we review the anti-neurodegenerative benefits of AChE inhibitors and the expected parallel disease-accelerating impairments caused by anticholinergics, within a framework of the cholinergic hypothesis of AD and AD-associated loss of nerve growth factor (NGF). Consistent with the "loss of trophic factor hypothesis of AD," we propose that AChE inhibitors enhance acetylcholine-dependent release and uptake of NGF, thereby sustaining cholinergic neuronal viability and thus slowing AD-associated degeneration of the CBF, to ultimately delay dementia progression. We propose that improved cholinergic therapies for AD started early in asymptomatic persons, especially those with risk factors, will delay the onset, progression, or emergence of dementia. The currently available competitive and pseudo- irreversible AChE inhibitors are not CNS-selective and thus induce gastrointestinal toxicity that limits cortical AChE inhibition to ~30% (ranges from 19% to 41%) as measured by in vivo PET studies in patients undergoing therapy. These levels of inhibition are marginal relative to what is required for effective symptomatic treatment of dementia or slowing AD-associated neurodegeneration. In contrast, because of the inherently slow de novo synthesis of AChE in the CNS (about one-- tenth the rate of synthesis in peripheral tissues), irreversible AChE inhibitors produce significantly higher levels of inhibition in the CNS than in peripheral tissues. For example, methanesulfonyl fluoride, an irreversible inhibitor reduces CNS AChE activity by ~68% in patients undergoing therapy and ~80% in cortical biopsies of non-human primates. The full therapeutic benefits of AChE inhibitors, whether for symptomatic treatment of dementia or disease-slowing, thus would benefit by producing high levels of CNS inhibition. One way to obtain such higher levels of CNS AChE inhibition would be by using irreversible inhibitors.

Physiological Monitoring to Enhance Clinical Hypnosis and Psychotherapy.

Physiological monitoring provides a useful access into the patient's affective state during hypnotically assisted therapeutic sessions. Physiological monitoring identifies autonomic dysregulation and can also display the process of restoring autonomic regulation via hypnosis and other quieting strategies. Commonly used modalities for physiological monitoring are identified, and clinical illustrations of how psychophysiological monitoring can be used in hypnosis and hypnotically assisted psychotherapy are provided. Clinicians may benefit from including psychophysiological knowledge in hypnosis education. Physiological monitoring may enhance hypnosis interventions for some disorders; however, more research is needed for evaluation of efficacy.

On three strands of meaning associated with the word nigger used during the course of a psychoanalytic treatment.

The author presents an overview of recent clinical/theoretical work on the construction of otherness in structured forms of hatred. He then uses clinical material to demonstrate three interwoven strands of meaning attached to the word nigger, a pejorative used frequently by a patient during the course of a psychoanalytic treatment. As used by this patient, one strand is projective and the other essentialist. The author then reflects on his own use of the pejorative in the text--a third strand of meaning he describes as depressive.

The Most Beautiful Man: An Integration of Hypnosis and Biofeedback for Depression and Dissociation.

Hypnosis and biofeedback techniques are evidence-based psychophysiological therapies that can be applied with a wide variety of medical and mental health disorders. Research shows efficacy for anxiety, depression, post-traumatic stress disorder (PTDS), chronic pain, hypertension, fibromyalgia, and a host of other disorders. Hypnosis and biofeedback can also augment the effectiveness of psychotherapy. The author utilizes the case narrative of a 36-year-old woman, presenting with postpartum depression and dissociative features, to illustrate the integration of biofeedback training, physiological monitoring, self-hypnosis, hypnotic age regression, and affective journaling into dynamic psychotherapy. The hypnotic techniques and the affective journaling assisted in the retrieval of critical traumatic events during the patient's adolescence, and a combination of breath training, self-hypnosis, and biofeedback aided the patient in self-calming.

Is Combining an Anticholinergic with a Cholinesterase Inhibitor a Good Strategy for High-Level CNS Cholinesterase Inhibition?

The currently approved cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) produce gastrointestinal toxicity which limits dosing to that which produces only about 25% to 35% CNS cholinesterase inhibition in Alzheimer's disease patients undergoing treatment, below the minimum therapeutic target of about 40% to 50% CNS inhibition considered necessary to treat cognitive impairment. A recent strategy for producing high-level CNS acetylcholinesterase (AChE) inhibition (50% or higher) is to co-administer a muscarinic anticholinergic with the AChE inhibitor to block the dose-limiting cholinergic overstimulation of the gastrointestinal system, allow more robust AChE inhibition in the CNS, and improve efficacy in the treatment of Alzheimer's disease. Unfortunately, most common muscarinic anticholinergics, including solifenacin, readily penetrate the CNS and are directly associated with long-term exacerbation of the underlying neuropathology of Alzheimer's disease and increased brain atrophy. The co-administration of an anticholinergic with an AChE inhibitor is a rational strategy for improving efficacy in the symptomatic treatment of dementia, but there are significant long-term risks that have not yet been considered. For long-term safety against accelerating the underlying disease processes in Alzheimer's disease, anticholinergics used to increase the tolerability of AChE inhibitors should not penetrate, or have very limited penetration, of the blood-brain barrier. Neurotrophic-mediated mechanisms by which cholinergic drugs may affect neurodegeneration in Alzheimer's disease are explored and improved treatment options are suggested.

Hypnosis, anesthesia, pain management, and preparation for medical procedures.

Hypnosis has a long history of use for anesthesia and pain management, as well as in assisting patient to prepare for medical procedures. This article reviews the history of hypnosis applications in clinical medicine and dentistry. Research on hypnotic susceptibility or hypnotic ability shows that the ability to respond effectively to hypnosis is a relatively stable trait, partially heritable, and measurable by means of several standard procedures. Persons low in hypnotic ability may benefit from alternative therapeutic interventions; however, the majority of medical patients will benefit from the integration of adjunctive hypnotic therapies into their medical and dental care. The article closes with a discussion of the stronger evidence-based applications of hypnosis in healthcare, and the need for well-trained certified hypnosis practitioners.

In utero methanesulfonyl fluoride differentially affects learning and maze performance in the absence of long-lasting cholinergic changes in the adult rat.

There is increasing evidence that acetylcholinesterase (AChE) may have various specific developmental roles in brain development. Nevertheless, specific effects of AChE inhibition during early brain development have not been adequately described. Therefore, methanesulfonyl fluoride (MSF), an irreversible AChE inhibitor that shows high selectivity for the CNS was used to produce AChE inhibition in utero to study subsequent adult behaviors, sleep, and cholinergic markers. Rats exposed to MSF in utero showed a deficit in spatial learning tasks using appetitive motivation but, surprisingly, they performed equally well or better than controls when aversive motivation was used. One hypothesis was that MSF treatment in utero affected the response to stress. Tests of anxiety however showed no differences in basal levels of anxiety. Studies of sleep behavior, however, indicated a higher level of REM sleep which is only seen during the light phase of male rats exposed to MSF in utero as compared to controls. No differences in cholinergic markers in the brains of adults were found except that females exposed to MSF in utero had a higher level of ChAT activity in the synaptosomal fraction of the hippocampus. Even so, whether cholinergic alterations accompany the in utero MSF exposure remains to be determined. The failure to find widespread changes in cholinergic markers in the adult brains suggests changes in behaviors should be further investigated by testing the participation of postsynaptic mechanisms, measuring of cholinergic markers during earlier development periods and the possible participation of other neurotransmitter systems to clearly reveal the role of the cholinergic system following in utero MSF exposure.

I hurt so: hypnotic interventions and palliative care for traumatic brain injury.

This article presents a case study in which self-hypnosis, hypnosis-assisted psychotherapy, and palliative care strategies were provided within a multi-modal integrative treatment program for a 38-year-old woman with traumatic brain injury (TBI) secondary to motor vehicle accident. Self-hypnosis was helpful in anxiety reduction and pain management. Hypnosis-assisted psychotherapy was beneficial in de-sensitizing many post-traumatic memories, and in managing post-concussion pain, including neuropathic pain and post-traumatic migraine headaches. A variety of palliative care techniques and spiritual interventions were applied to enhance sleep, moderate cognitive deficits, and enhance quality of life.

On thinking and not being able to think: reflections on viewing the Abu Ghraib photos.

Using experiences from childhood, from encounters with contemporary art, from clinical experience, and, most elaborately, from an initial viewing of the Abu Ghraib photos, the author argues that the interpretability of experience depends upon its being legible. This legibility, in turn, depends upon the interpreter maintaining contact with his/her own capacities for thought, and, more fundamentally, with the vitally necessary community of others with whom he/she shares those capacities.