I’m a visual kind of girl, I need to see a diagram to help me conceptualise how the things I’ve been writing about recently all fit together. I’ve been looking at the various aspects of self regulation, emotions and executive functions and how this affects and is affected by stressors, of which chronic pain is certainly one.
Drawing again from Williams, Suchy and Rau, i’m going to try to describe how I think their model of executive functioning might influence the way I look at stress regulation in people with chronic pain.
This diagram is sort of upside down to me, but anyway, this is how I interpret it.
Initially we all have a genetic inheritance, or the genotype we were born with. This influences the way our neurotransmitter systems, brain circuitry, physiology and executive functioning work – but can be influenced developmentally by factors present either before birth, or during our formative years as children. The factors that can influence how our underlying systems work include attachments to others, trauma or abuse, opportunities for learning, stressors of many kinds and drugs.
These neurophysiological functions underpin our ‘personality’. As we know, different personality traits affect how we seek out and respond to stressors in the environment, including how much risk taking and novelty we enjoy, how much we react to the environment, how well we recover, and how we restore our functioning to homeostatis.
I see that in this diagram it looks like stress exposure, reactivity, recovery and restoration are linked in a unidirectional way – but I do wonder about this. At the same time, it does seem clear that each of these aspects of how we respond to stressors in turn affects that ‘black box’ of neurophysiological functioning. And the final outcome of these responses is seen in terms of physical and mental health outcomes.
I can see from this model how an acute trauma like a fracture, will be a stressor and directly affect the stress regulation factors – and at the same time will influence the neurophysiological circuitry. So in a vulnerable person, perhaps someone who has inherited less ability to regulate stressors or who has been unable to develop the potential of their genetic inheritance, the stress of an acute trauma could compromise their ability to self regulate, and in turn have much more trouble managing their acute pain – leading to a much greater potential for longterm disability.
What does this mean for clinicians?
As we learn more about how things like heart rate variability and other forms of self regulation can be trained and actually change how genes are expressed, I think we will have more of a basis for using biofeedback at an earlier stage and perhaps even as a preventive measure.
Appraisals, or how we view stressors, are directly addressed as part of CBT and ACT. Maybe again as a preventive measure, we can help kids develop skills in being aware of their own thought patterns and how to tolerate, or ‘sit with’ emotions that are usually considered unpleasant. From some of the research discussed in Willaims, Suchy and Rau, it seems that both too little stress and too much stress are not good for wellbeing – but a certain amount is helpful and can be one way to develop resilience. Helping our patients learn to tolerate negative emotions and thoughts through mindfulness has been shown to influence prefrontal cortex activation.
Fitness affects executive functioning through several pathways, so the inclusion of exercise or activity in chronic pain management has an evidence base (even if there is no evidence that any specific exercise is better than another – yay! I can justify gardening and bellydance much more happily than vacuum cleaning or going for a run!).
I hope to have tweaked your interest in both self regulation and executive functioning over the past little while, it’s been interesting to read about these areas – and to ponder about how I can use them in my practice. Let me know if you’d like to know anything more – leave a comment, or you can email me via the ‘About’ page. Don’t forget that you can subscribe using the RSS feed link at the top of the page, or you can bookmark and just visit. I write most days – and tomorrow is Friday Funnies (I can hear the groans from here!).
Williams, P., Suchy, Y., & Rau, H. (2009). Individual Differences in Executive Functioning: Implications for Stress Regulation Annals of Behavioral Medicine, 37 (2), 126-140 DOI: 10.1007/s12160-009-9100-0