So, if self regulation is about exerting control over thoughts, feelings, actions and physiology, how does it work?
When I skipped through some Google references last night (o font of all knowledge!) I found a good number of sites referring to self regulation and children – but not nearly as many relating to adults, or the long-term results of limited self regulation. Curious in our world where kids get to ‘express themselves’ and are protected from disappointment, have few challenges set (especially those where they have to persist with difficult tasks), and don’t need to think about consequences for themselves because parents and teachers do it for them… Hmmmm
When I got to reading though, self regulation really is what much of pain management is all about. It is all about learning to manage emotions, thoughts, social relationships, coping, behaviour and physical activity – and managing sleep and fatigue. As Solberg Nes, Roach & Segerstrom state ‘self regulation is important for good functioning … and pain is associated with deficits in self regulation and executive functions…’ The real challenge in chronic pain is because pain reduces the ‘coping reserve’, these things are harder to do, and maybe require more replenishment than before the pain started – or maybe because there were deficits in coping, the chronic pain becomes problematic.
Emotion regulation – chronic pain is linked with feeling bad, it’s part of the definition of chronic pain! To moderate both joy and sadness and express them appropriately for any given situation requires both upregulation (to ‘look happy’ when things are feeling not so good, or to focus on the good in the face of not so good), and downregulation (calming down when irritable or using that energy in a positive way).
Solberg Nes, Roach & Segerstrom record that Functional MRI studies have linked activity in the prefrontal cortex to emotional regulation, and that the activity of self regulating emotions is linked also with executive functions – they affect each other. One study cited in this paper suggests that suppressing anger can increase sensitivity to pain – giving further support to the ‘mindfulness’ and ‘acceptance’ approach to allowing emotions to flow past rather than actively suppressing or focusing on them.
Thought regulation – in order to regulate emotions, it’s necessary to regulate thoughts. Chronic pain, especially pain that lacks a specific diagnosis, or pain that is then perceived to be ‘forever’ (you know the words ‘you’ll need to learn to live with this, there’s nothing we can do…’) generates worry, and worry is essentially perseverating on negative thoughts. Being able to switch attention from one thing to another is an executive function that can be affected by negative rumination, and it’s thought that ‘deficits in executive functions may make an individual more prone to rumination’. Helping people with chronic pain allow their thoughts to pass by (again a concept of mindfulness and acceptance) may help reduce the fatiguing effects of rumination and alter the emotional impact.
Social regulation – if there is one thing that people with chronic pain fail to recognise, it’s the impact of their non-verbal behaviour on others. To interact effectively, we need to not only regulate our actual emotions and thoughts, but we also need to regulate how we present. People with chronic pain often report difficulty dealing with the effects of pain on relationships, feeling misunderstood, having trouble negotiating changing roles, and coping with the effect of ‘looking well’ while feeling wretched. I do wonder whether we give nearly enough attention to the ways in which social interactions are affected in people with chronic pain, and whether we give them tools to manage this more effectively, especially attending to non-verbal pain behaviours.
Coping – active coping is about remaining engaged in living despite pain, while passive coping often involves avoiding, disengaging from and reducing the level of activity despite pain. Active coping is almost entirely about regulating despite ‘not feeling like it’ or being fatigued. In order to develop more active approaches to living life with pain, therapists are faced with helping people develop skills like setting goals, persisting despite delayed gratification, remaining engaged ‘when we don’t feel like it’, and recognising both thoughts and emotions and that they can be influenced.
Physical activity – Keeping on doing things despite pain has been consistently shown to improve not only physical condition but also emotional, social and general quality of life. Therapist intervention to establish goals for physical activity that are within reach, and that provide some positive feedback, along with developing the self regulatory ‘muscle’ in gradual increments is one way to create change that becomes self-generating.
If chronic pain involves central nervous system dysfunction, and from most accounts the majority of chronic pain does, it’s entirely feasible for physiological deficits due to reduced ability to self-regulate to also be present. There are not too many patients I’ve seen who don’t report breath-holding, or at least limited use of diaphragmatic breathing, have trouble regulating their breathing rate or their heart rate, and indeed, heart rate variability, which is an ‘index of the fluctuation in the time interval between normal heartbeats’, controlled by the central autonomic network and thought to be an indicator of self-regulation. The central autonomic network consists of several brain structures such as the ventromedial prefrontal cortices, anterior cingulate, hypothalamus, amygdala, insula and the periaqueductal gray. This set of structures regulates many of the aspects of homeostasis, including the rhythm of the heart. People with chronic pain often present with lower HRV, suggesting again that self regulatory deficits are present.
I was really interested in this next section on neuroendocrine abnormalities that are present in people with chronic pain – mainly because of the effect of these abnormalities on cognition, and particularly executive function. I was aware of dysregulation of the HPA and HPG axes, leading to changes in the release of various hormones including cortisol. The importance of this is in terms of regulating levels of blood glucose and metabolism of blood glucose. The brain relies on effective availability of glucose for adequate functioning – if this is impaired, even slightly, it could affect sensitive functions such as those required for executive functioning, making it difficult for people with chronic pain to access and persist with tasks that demand high level executive functioning.
What do we do about this?
Once again, I’m struck by how this information simply reinforces the basic pain management strategies that have been used for a long time. Goal setting, working with thoughts and emotions, developing skills to upregulate and downregulate physiology, exercising and basically ‘living well’ all play a part in normalising input to the brain – and allowing executive functions to be supported. At the same time I’m aware that the information coming from neurophysiology supports the notion that the central nervous sysem is not only always involved in the experience of chronic pain, but can be influenced through nonmedical means. The ‘dividing line’ between body and mind has never been slimmer – roll on the day when it no longer exists.
Solberg Nes, L., Roach, A., & Segerstrom, S. (2009). Executive Functions, Self-Regulation, and Chronic Pain: A Review Annals of Behavioral Medicine, 37 (2), 173-183 DOI: 10.1007/s12160-009-9096-5