Mindfulness - Maine Psychological Association

Maine Psychological Association Annual Meeting 2012
Anne Uecker PhD
Edmund N Ervin Pediatric Center
MaineGeneral Medical Center
(e.g., perceiving feelings and
emotions without having to react to them);
(e.g., remaining present with sensations and feelings even when
they are unpleasant or painful);
/(not on) automatic pilot,
concentration/nondistraction (e.g., breaking or spilling things because of
carelessness, not paying attention, or thinking of something else;
(e.g., easily putting beliefs, opinions,
and expectations into words);
(e.g., criticizing oneself for having
irrational or appropriate emotions).
Goal: To attempt to SNAG you to consider to
practice and promote mindfulness
A Daniel Siegel acronym for
Mindfulness meditation carves new channels in
the streambeds of the mind (Richardson and Begley,
Interface of Cognition, Emotions and
the Brain
Self Directed Neuroplasticity
Social Affective Neuroscience
Contemplative Neuroscience
(Jeffrey Schwartz)
(Richard Davidson)
(Richard Davidson)
Bold 9 year old children (those who
had less behavioral inhibition, in the
terminology of the experiment) had
greater left than right activity in their
prefrontal cortex, whereas the shy
(more behaviorally inhibited) children
had greater right than left activity.
This was the first time the asymmetry
was linked to anything that was not
clearly an emotion: This time, leftright asymmetry was seen in
conjunction with being bold or shy.
Up to and greater than 52,000 hours
Some of Richard Davidson’s early
My Expertise Chart
(to qualify my experience with regard to the present topic)
A view of the human brain
• Able to focus attention
for a longer period of
• Less susceptible to
• Better Top-Down
• Improved Body
• Bottom-Up control
(awareness of actual
Insight Meditation Society
---Barre, MA
Studies: Mindfulness vs Relaxation
(Does mindfulness complement multitasking)
– Focused Attention: strengthens the ability to stay
focused and ignore distracting information
• 8 week program: Cohen , Darlene (2004). The one who is
not busy: Connecting with Work in a Deeply Satisfying Way.
– Open Monitoring: strengthens the ability to attend to
a succession of stimuli without being drawn in by any
one of them.
• Relaxation: progressive tensing and relaxing,
aided by relaxation imagery
(Does mindfulness complement multitasking)
• RESULTS___________________________________________
Overall Time improved, but no effect of group
group as compared to control and relaxation
Meditation reduced task switching
, whereas C and R groups decreased their time per activity.
Expectation of benefit was greater in the relaxation group
Task Memory improved in both the relaxation and meditation group
as compared to R group (Positive and Negative Affect Scale)
Greater Mindfulness as assessed with the Mindful Awareness Attention Scale (see end slide)
– Fractional anisotropy: index for measuring white
matter integrity. Higher FA value related to
improved performance.
• Axial Diffusivity: associated with axon morphological
• Radial Diffusivity: implicates the character of the
Studies: Mindfulness vs Relaxation
Continuum of Time
• Tang et al (series of studies 2010-2012) showed 4 wks of integrative bodymind training (11 total hours) enhanced FA in several brain areas involved
in communication to and from the anterior cingulate, including the corpus
callosum and superior corona radiata.
• Also a two week, 5 hour group.
• Also, a one week.
• This series of studies has shown short term meditation to increase the
ability to resolve conflict in a cognitive task, altered neural activity in the
ACC, and improved connectivity of the ACC to other brain regions.
(Brain regions do not act in isolation. Path analysis diagram with functional interactions)
Open Monitoring
• The quality of open, nonjudgmental
awareness implies a balance, so you do not
get stuck on an engaging stimulus but are,
instead, open to all stimuli.
Caudate Nucleus
--and more rewards-• Brian Knutson, a neuroeconomist and an expert in the
involvement of the pleasure center of the brain in
motivating financial decisions, is now studying if similar
brain areas are activated for altruistic reasons. Can
extending compassion to another person look the same in
the brain as anticipating something good for oneself? And
who better to test than Tibetan monks, who have spent
their lives pursuing a state of selfless nonattachment?
• The “monk study” at Stanford is part of an emerging field of
meditation science that has taken off in the last decade
with advancements in brain image technology, and
popular interest.
Social Neuroscience
Body Awareness
Intrapersonal Acceptance
Empathy and Compassion toward others
Impulse Control
Cortical Midline Structures
--Self Development--
Social Neuroscience
Circuit Nodes
• Dorsolateral Prefrontal Cortex: motor planning, working memory,
organization, and regulation
• Anterior Cingulate: enables executive attention by detecting the presence of
conflicts emerging from incoming streams of information processing
• Ventromedial frontal cortex areas
– cognitive control to inhibit prepotent responses, or engage in tasks where
inhibition required, such as set switching or memory retrieval.
– The middle prefrontal areas are essential for social communication as well as for
• Insula: internal bodily states, emotions, self awareness, social interactions
• Temporoparietal: mediating the first person perspective of bodily states
• Superior Temporal: in imitation not merely to passively register biological
motion, but to actively represent visuomotor correspondence between one’s
actions and others.
• Amygdala: Emotions. Particularly sensitive to fear and negative emotions.
Self Awareness
The Insula
• Ventromedial Frontal Cortex – Insula
Body Awareness – Self Regulation Activations
Insula – Brain Midline Area Activations
• Another study by Lazar, Kerr, Wasserman, Gray, Greve,
& Treadway (2005) revealed an increased thickness of
two parts of the brain: (1) the middle prefrontal area,
bilaterally, and (2) a related neural circuit, the insula,
which was particularly thicker on the right side of the
brain. The degree of thickness in these areas was
correlated with length of time spent practicing
mindfulness meditation.
• An extensive review of many studies (Cahn & Polich,
2006) reveals a range of activations, especially in
middle prefrontal areas (anterior cingulate), with
mindfulness meditation.
Interoception: Our Sixth Sense
interoceptive awareness,
especially in subjective feelings associated with
internal states. Associated with the limbic
– Activation in imaging studies most likely to occur
together with mPFC in self-referential tasks, esp as
emotional self-relatedness increases.
– Proposed to integrate a wealth of information, such as
interoceptive sensations, which cumulate in a concept
of awareness anteriorly.
Insular Neuroplasticity – Heart rate
• British researchers have found through neuroimaging
that people who are more accurate in estimating
their heart rate also have a larger insula; and, the
larger the insula, the better the estimate.
Interestingly, higher insula activation is associated
with greater awareness not only of physical
sensations but also of emotions.
Narration: Left Shift
Midline Structures
• But if ongoing narration, perhaps even without words in
the form of a witnessing awareness or an internal observer,
is truly a function of the
, then there would
be a
on the
attention with active narrative observation) and perhaps
also a
(nonverbal selfreflection and meta-awareness in the medial prefrontal)
with viscera representation.
and synthesize the findings of
the left sided/approach shift that Davidson and colleagues
have noted (Davidson et al., 2003) and Lazar’s middle
prefrontal and right-sided insula findings (Lazar et al.,
2005). From: Siegel, Daniel J. The Mindful Brain: Reflection
and Attunement in the Cultivation of Well-Being .
Insula and Default Mode Network (DMN)
• Right fronto-insular
cortex has been shown to
play a critical role in
switching between
central-executive and
default-mode network
(which is the resting state
network, most evident in
states of daydreaming,
mind wandering and
projections into the past
and future)
• Successful meditators
might be equipped with a
better ability to switch on
and off the DMN.
Richard Davidson
• A disorder of disrupted context
• Individuals who fail to regulate their affective responses in
a context-sensitive fashion may have a functional
impairment of the hippocampus.
• Amygdala, Medial Prefrontal Cortex, and
Hippocampal Function in PTSD (Shin et al,
• Similar neurocircuitry in depression and
• Task specific increases in gray matter supposed to be
related to improved functioning.
• Increased gray matter generally presumed related to
repeated activation of an area.
• Insula, hippocampus, temporo-parietal junction,
temporal gyrus, anterior and posterior cingulate cortex,
cerebellum, middle prefrontal regions, orbitofrontal,
amygdala, brainstem …
– Quick functional changes, but also structural changes, for
example shown by correlations between years of
experience and a priori defined structures of interest.
Holzel et al. 2009
Holzel et al. 2009
• Luders, Toga et al. 2009: Right Orbito-frontal (11,
12, 47) and Right Hippocampus. Both implicated
in emotional regulation and response control.
– May result in increased behavioral flexibility.
– May possess the underlying neural correlates that
allow disengagement from automatic thoughts.
• Subject group were active meditators with an age range
of 30-71 years.
• A complicating factor is metabolism and other changes
associated with age.
Brain Biases in Meditation Research
Neuroplasticity: Mindfulness
folding pattern assumed to be
under the influence of genetic control; degree of
folding has been shown to continue to change in
childhood and adolescence. Environmental
factors may have a modulating impact.
modifiable by experience, and
affects information processing by regulating the
velocity and synchrony of impulse conduction
between distant cortical regions.
Luders et al 2012
• Mean curvature across
thousands of vertices
on individual surface
• 50 meditators-50
• Age range 24 – 71 years
• Years of Meditation
practice 4 – 46 years
(19.8 years + 11.4)
Duration Meditation Minutes in
a Week
Meditators 1 - 49
The Unique Brain Anatomy of Meditation Practioners: Alterations in Cortical Gyrification
Luders, Kurth, Mayer, Toga, Narr and Gaser, 2012.
Mindfulness and Development
Children through ….
Susan Kaiser-Greenland
Some recent PubMed Abstracts
(for independent review by audience)
Grey matter thickness was measured in 18 meditators and 18 controls. Subjective reports of
attentional absorption were modestly higher in meditators and across the entire sample correlated positively with
cortical thickness in several regions corresponding to cingulo-fronto-parietal attention networks. Within these
regions the meditation group had greater cortical thickness which was positively related to the extent of prior
training. Evidence suggesting that meditative practice activates these cortical are as, improves attention and
may ameliorate symptoms of ADHD by targeting vulnerable brain regions is discussed. Grant et al (2012).
Cortical thickness, mental absorption and meditative practice: possible implications for disorders of attention.
Biological Psychiatry.
• Cognitive Abilities: Mindfulness meditation practices (MMPs) are a subgroup of meditation
practices which are receiving growing attention. The present paper reviews current evidence about the effects of
MMPs on objective measures of cognitive functions. Five databases were searched. Twenty three studies
providing measures of attention, memory, executive functions and further miscellaneous measures of cognition
were included. Fifteen were controlled or randomized controlled studies and 8 were case-control studies. Overall,
reviewed studies suggested that early phases of mindfulness training, which are more concerned with the
development of focused attention, could be associated with significant improvements in selective and executive
attention whereas the following phases, which are characterized by an open monitoring of internal and external
stimuli, could be mainly associated with improved unfocused sustained attention abilities. Additionally, MMPs
could enhance working memory capacity and some executive functions. However, many of the included studies
show methodological limitations and negative results have been reported as well, plausibly reflecting differences
in study design, study duration and patients' populations. Accordingly, even though findings here reviewed
provided preliminary evidence suggesting that MMPs could enhance cognitive functions, available evidence
should be considered with caution and further high quality studies investigating more standardized mindfulness
meditation programs are needed. Chisea et al (2011) Doe s mindfulness training improve cognitive abilities? A
systematic review of neuropsychological findings. Clin Psychol Rev.
Some recent PubMed Abstracts
(for independent review by audience)
• Aging:
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. Lazar et al. (2005). Meditation experience is associated with increased
cortical thickness. Neuroreport.
• PTSD: DESIGN: Posttraumatic stress disorder (PTSD) symptoms, depression, functional
status, behavioral activation, experiential avoidance, and mindfulness were assessed at
baseline, and 2 and 6 months after enrollment.
RESULTS: At 6 months, there were significant improvements in PTSD symptoms
(standardized effect size, d = -0.64, p< 0.001); depression (d = -0.70, p<0.001); behavioral
activation (d = 0.62, p<0.001); mental component summary score of the Short Form-8 (d =
0.72, p<0.001); acceptance (d = 0.67, p<0.001); and mindfulness (d = 0.78, p<0.001), and
47.7% of veterans had clinically significant improvements in PTSD symptoms.
CONCLUSIONS: MBSR shows promise as an intervention for PTSD and warrants further
study in randomized controlled trials. J Clin Psychol. 2012
Some recent PubMed Abstracts
(for independent review by audience)
Major depressive disorder (MDD) is currently ranked the third leading cause of disability in the world.
Treatment-Resistant Depression (TRD) causes the majority of MDD's disability. Strikingly, 50% of individuals with MDD will
fail to remit with two adequate trials of antidepressant medications, thus qualifying as treatment resistant. Current
pharmacological and psychotherapeutic treatment strategies for TRD are limited in effectiveness so new interventions are
needed. Mindfulness-Based Cognitive Therapy (MBCT) is a new psychotherapeutic treatment with established efficacy in
preventing relapse of depression for individuals in complete remission. MBCT is a group-based, 8-week intervention that
uses mindfulness meditation as its core therapeutic technique. It teaches people to have a different relationship to
depressive thoughts and feelings. Strategies are focused on decreasing rumination, enhancing self-compassion, increasing
acceptance and decreasing avoidance. This modified version of MCBT, which includes the use of metaphor and adaptations
of the original intervention will be discussed through the clinical case of a woman with long-standing TRD. A brief review of
the current MBCT literature and future directions for the treatment of TRD are discussed. Eisendrath S, et al. 2011. Adapting
Mindfulness-Based Cognitive Therapy for Treatment-Resistant Depression: A Clinical Case Study. Cogn Behav Pract.
Anxiety. While cognitive behavior therapy has been found to be effective in the treatment of generalized anxiety disorder
(GAD), a significant percentage of patients struggle with residual symptoms. There is some conceptual basis for suggesting
that cultivation of mindfulness may be helpful for people with GAD. Mindfulness-based cognitive therapy (MBCT) is a group
treatment derived from mindfulness-based stress reduction (MBSR) developed by Jon Kabat-Zinn and colleagues. MBSR uses
training in mindfulness meditation as the core of the program. MBCT incorporates cognitive strategies and has been found
effective in reducing relapse in patients with major depression (Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway,
V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive
therapy. Journal of Consulting and Clinical Psychology, 6, 615-623).METHOD: Eligible subjects recruited to a major academic
medical center participated in the group MBCT course and completed measures of anxiety, worry, depressive symptoms,
mood states and mindful awareness in everyday life at baseline and end of treatment.RESULTS: Eleven subjects (six female
and five male) with a mean age of 49 (range=36-72) met criteria and completed the study. There were significant reductions
in anxiety and depressive symptoms from baseline to end of treatment.CONCLUSION: MBCT may be an acceptable and
potentially effective treatment for reducing anxiety and mood symptoms and increasing awareness of everyday
experiences in patients with GAD. Future directions include development of a randomized clinical trial of MBCT for GAD.
Evans et al 2008. Mindfulness-based cognitive therapy for generalized anxiety disorder. J Anxiety Disord.
Mindfulness Based Individual Therapy for OCD and Anxiety
The OCD Center of Los Angeles offers therapy for the treatment of OCD and related anxiety based
conditions, with a strong emphasis on Mindfulness Based Cognitive Behavioral Therapy
(MBCBT). Among the conditions we treat are:
• Pure Obsessional OCD (Pure O)
• Perinatal / Postpartum OCD
• Child / Adolescent OCD
• Body Dysmorphic Disorder (BDD)
• Hypochondria / Health Anxiety
• Phobias
• Panic Disorder
• Social Anxiety / Social Phobia
• Trichotillomania
• Dermatillomania / Compulsive Skin Picking
• Olfactory Reference Syndrome
Also a good information resource: http://www.ocdla.com/mindfulness-cbt-ocd-anxiety.html
• OCD: Jeffrey Schwartz. Coined the term “Self
Directed Neuroplasticity.”
– The Mind and the Brain: Neuroplasticity and the Power of Mental
– Brain Lock: Free Yourself from Obsessive-Compulsive Disorder
– You Are Not Your Brain: The 4-Step Solution for Changing Bad Habits,
Ending Unhealthy Thinking, and Taking Control of Your Life
Some recent PubMed Abstracts
(for independent review by audience)
Pain Sensitivity: Meditators had significantly lower pain sensitivity than
controls. Assessed across all subjects, lower pain sensitivity was associated
with thicker cortex in affective, pain-related brain regions including the
anterior cingulate cortex, bilateral parahippocampal gyrus and anterior
insula. Comparing groups, meditators were found to have thicker cortex in the
dorsal anterior cingulate and bilaterally in secondary somatosensory cortex.
Grant JA, et al. (2010) Cortical thickness and pain sensitivity in zen meditators.
Substance Abuse: Relapse Prevention. Surfing the Urge. Internet Resource:
Useful Web Sites
• Mindful Awareness Research Center at UCLA
• Inner Kids: http://www.susankaisergreenland.com/innerkids.html
• UCSD Center for Mindfulness:
(many additonal websites at location)
• Mind and Life Institute: http://www.mindandlife.org/
• www.mindfulschools.org
Some References
Chan, B.R. and Polich, J. (2006). Meditation States and Traits: EEG, ERP and Neuroimaging Studies. Psychological Bulletin.
Davidson, R.J. (2012). The Emotional Life of the Brain. How Its Unique Patterns Affect the Way You Think, Feel, and Live—and How You Can Change
Them. Hudson Street Press.
Davidson, R.J. and McEwen, B. (2012). Social influences on neuroplasticity: Stress and interventions to promote well-being. Nature Neuroscience.
Holzel, B. et al (2008). Investigation of mindfulness meditation practitioners with voxel-based morphometry. Social Cognitive and Affective
Neuroscience. S
Holzel, B. et al (2010). Mindfulness practice leads to increases in regional gray matter density. Psychiatry Research: Neuroimaging.
Holzel, B. et al (2010). Stress reduction correlates with structural changes in the amygdala. Social Cognitive and Affective Neuroscience.
Holzel, B. et al (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective.
Perspectives on Psychological Science.
Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness.
Lazar et al. (2005). Meditation experience is associated with increased cortical thickness. Neuroreport.
Levy, D.M. et al (2012). The Effects of Mindfulness Meditation Training on Multitasking in a High Stress Environment. Graphics Interface..
Luders, E et al. (2009). The underlying anatomical correlates
Luders, E et al. (2012). The unique brain anatomy of meditation practitioners: alterations in cortical gyrification. Frontiers in Human Neuroscience.
Pfeiffer, J. & Peake, S.J. (2012). Self-development: Integrating cognitive, socioemotional, and neuroimaging perspectives. Developmental Cognitive
Sedlmeir, P. et al (2012). The Psychological Effects of Meditation: A Metaanalysis. Psychological Bulletin.
Shin, L.M.et al. (2006). Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD. An. NY Acad Sci
Siegel, D.J. (2007). The MindfulBrain: Reflection and Attunement in the Cultivation of Well-Being.
Siegel, Daniel J. (2007-04-17). The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being . Norton. Kindle Edition.
Slagter, H.A. et al .., Davidson, R.J. (2009). Theta Phase Synchrony and Conscious Phase Perception: Impact of Intensive Mental Training. Journal of
Cognitive Neuroscience.
Tang,Y-Y. et al. (2012). Mechanisms of White Matter Change. Proceedings of the National Academy of Science.
You Tube:
Hanson, R.The Neurology of Awakening. http://www.youtube.com/watch?v=mK_ngFJWx-g
Siegel, D.J. Hand Model of the Brain. http://www.youtube.com/watch?v=gm9CIJ74Oxw
Davidson, RJ. Tranform your Mind, Change your Brain. http://www.youtube.com/watch?v=7tRdDqXgsJ0
Mindful Attention Awareness Scale
(Brown and Ryan (2003); referenced in Levy et al 2012 [available on the internet])
Day-to-Day Experiences
Instructions: Below is a collection of statements about your everyday experience. Using the 1-6 scale below, please
indicate how frequently or infrequently you currently have each experience. Please answer according to what really
reflects your experience rather than what you think your experience should be. Please treat each item separately from
every other item.
1 2 3 4 5 6 (Almost Always; Very Frequently; Somewhat Frequently; Somewhat Infrequently; Very Infrequently; Almost Never)
I could be experiencing some emotion and not be conscious of it until some time later. 1 2 3 4 5 6
I break or spill things because of carelessness, not paying attention, or thinking of something else. 1 2 3 4 5 6
I find it difficult to stay focused on what’s happening in the present. 1 2 3 4 5 6
I tend to walk quickly to get where I’m going without paying attention to what I experience along the way. 1 2 3 4 5 6
I tend not to notice feelings of physical tension or discomfort until they really grab my attention. 1 2 3 4 5 6
I forget a person’s name almost as soon as I’ve been told it for the first time. 1 2 3 4 5 6
It seems I am “running on automatic,” without much awareness of what I’m doing. 1 2 3 4 5 6
I rush through activities without being really attentive to them. 1 2 3 4 5 6
I get so focused on the goal I want to achieve that I lose touch with what I’m doing right now to get there. 1 2 3 4 5 6
I do jobs or tasks automatically, without being aware of what I'm doing. 1 2 3 4 5 6
I find myself listening to someone with one ear, doing something else at the same time. 1 2 3 4 5 6
I drive places on ‘automatic pilot’ and then wonder why I went there. 1 2 3 4 5 6
I find myself preoccupied with the future or the past. 1 2 3 4 5 6
I find myself doing things without paying attention. 1 2 3 4 5 6
I snack without being aware that I’m eating. 1 2 3 4 5 6
Five Facet Mindfulness Questionnaire
1- never or very rarely; 2 - rarely; 3 – sometimes true; 4 – often true; 5 – very often or always true.
1. When I’m walking, I deliberately notice the sensations of my body moving.
2. I’m good at finding words to describe my feelings.
3. I criticize myself for having irrational or inappropriate emotions.
4. I perceive my feelings and emotions without having to react to them.
5. When I do things, my mind wanders off and I’m easily distracted.
6. When I take a shower or bath, I stay alert to the sensations of water on
my body.
7. I can easily put my beliefs, opinions, and expectations into words.
8. I don’t pay attention to what I’m doing because I’m daydreaming,
worrying, or otherwise distracted.
9. I watch my feelings without getting lost in them.
10. I tell myself I shouldn’t be feeling the way I’m feeling.
11. I notice how foods and drinks affect my thoughts, bodily sensations, and
12. It’s hard for me to find the words to describe what I’m thinking.
13. I am easily distracted.
14. I believe some of my thoughts are abnormal or bad and I shouldn’t think
that way.
15. I pay attention to sensations, such as the wind in my hair or sun on my
16. I have trouble thinking of the right words to express how I feel about
17. I make judgments about whether my thoughts are good or bad.
18. I find it difficult to stay focused on what’s happening in the present.
19. When I have distressing thoughts or images, I “step back” and am aware
of the thought or image without getting taken over by it.
20. I pay attention to sounds, such as clocks ticking, birds chirping, or cars
21. In difficult situations, I can pause without immediately reacting.
22. When I have a sensation in my body, it’s difficult for me to describe
it because I can’t find the right words.
23. It seems I am “running on automatic” without much awareness of
what I’m doing.
24.. When I have distressing thoughts or images, I feel calm soon after.
25. I tell myself that I shouldn’t be thinking the way I’m thinking.
26. I notice the smells and aromas of things.
27. Even when I’m feeling terribly upset, I can find a way to put it into
28. I rush through activities without being really attentive to them.
29. When I have distressing thoughts or images I am able just to notice
them without reacting.
30. I think some of my emotions are bad or inappropriate and I
shouldn’t feel them.
31. I notice visual elements in art or nature, such as colors, shapes,
textures, or patterns of light and shadow.
32. My natural tendency is to put my experiences into words.
33. When I have distressing thoughts or images, I just notice them and
let them go.
34. I do jobs or tasks automatically without being aware of what I’m
35. When I have distressing thoughts or images, I judge myself as good
or bad, depending what the thought/image is about.
36. I pay attention to how my emotions affect my thoughts and
37. I can usually describe how I feel at the moment in considerable
38. I find myself doing things without paying attention.
39. I disapprove of myself when I have irrational ideas.

similar documents