Being mindful about mindfulness

I’m generally a supporter of mindfulness practice. It’s been a great discipline for me as I deal with everyday life and everything. I don’t admit to being incredibly disciplined about “making time for meditation” every day – that is, I don’t sit down and do the whole thing at a set time each day – but I do dip in and out of mindfulness throughout my day. While I’m brushing my teeth, slurping on a coffee, driving, sitting in the sun, looking at the leaves on the trees, cuddling my Sheba-dog I’ll bring myself to the present moment and take a couple of minutes to be fully present. Oddly enough I don’t do this nearly as often when I’m cold (like this morning when it’s about 8 degrees in my office!), or when I’m eating parsnip (ewwwww!), or waiting to see a dentist. Or perhaps that’s not odd at all, because I wonder if we have a skewed view on mindfulness and what it’s about.

My reason for writing this post comes from reading Anhever, Haller, Barth, Lauche, Dobos & Cramer (2017) recent review of mindfulness-based stress reduction for treating low back pain. In it, they found “MBSR was associated with short-term improvements in pain intensity (4 RCTs; mean difference [MD], −0.96 point on a numerical rating scale [95% CI, −1.64 to −0.34 point]; standardized mean difference [SMD], −0.48 point [CI, −0.82 to −0.14 point]) and physical functioning (2 RCTs; MD, 2.50 [CI, 0.90 to 4.10 point]; SMD, 0.25 [CI, 0.09 to 0.41 point]) that were not sustained in the long term.” There were only seven RCTs included in the study, with a total of only 864 participants, and many of the studies had no active control groups, so my interpretation is that there are flaws in many of the studies examining MBSR, and that it’s difficult to draw any conclusions, let alone strong conclusions.

Where do we go wrong with mindfulness? The first point about the studies included in Anhever and colleagues paper is that there is a difference between mindfulness in general and mindfulness based stress reduction – and although the difference may be minimal, it’s nevertheless worth understanding. MBSR is a full programme that includes mindfulness as one element (Kabat-Zinn, 1982). Mindfulness is a key component, yes, but the programmes include other elements.  The second point is that perhaps we’re assuming mindfulness to be something that it isn’t –  I suspect, from reading numerous articles in both the popular media and research papers, that mindfulness is being applied as another form of relaxation.

Relaxation training was introduced as part of a behavioural approach to managing stress. In pain management it’s been part of programmes since the 1970’s, particularly using forms of progressive muscle relaxation (See Dawn & Seers, 1998). The intention is to provide an experience that is incompatible with tension, and to develop the capability to down-regulate the body and mind to mitigate the stress response that is so often part of persistent pain.

Relaxation training can take many forms, and breath control is a common component. I use it often for myself, and when working with clients – I’m aiming to show people that although they may not be able to control heart rate or blood pressure, they can control breath and muscle tension. It’s useful especially as part of sleep management.

The thing with relaxation training is it’s entire purpose is to help downregulate an upregulated nervous system. Mindfulness, on the other hand, is not.

What is mindfulness about if it’s not about relaxation? Well, mindfulness has been defined in many different ways, but the one I especially like is by Kabat-Zinn (1990) “a process of bringing a certain quality of attention to moment-by-moment experience”.  This definition can be further unpacked by examining its components: “Mindfulness begins by bringing awareness to current experience—observing and attending to the changing field of thoughts, feelings, and sensations from moment to moment—by regulating the focus of attention.” (italics are mine) –  this quote is from Bishop, Lau, Shapiro and colleagues (2004) and is from a paper looking at defining mindfulness in an operational way (so we can be aware of what it means in practice, or as we teach others). These authors go on to say that this process leads to a feeling of being very alert to what is occurring in the here and now. I like to remind people that it’s about being here rather than remembering or anticipating what might.

So at least one part of mindfulness is learning how to attend to what YOU want to attend to, rather than being dragged back to memories, or forward to predictions, or to experiences or moments that you don’t want to notice at that moment.  The definition also points to noticing and experiencing what is happening, rather than thoughts or ruminations about what you’re experiencing. For people living with persistent pain, I think this is an invaluable tool for dealing with the interruptive effects of pain on attention.

A second aspect of mindfulness is an attitude – one of curiosity. When being mindful, you’re not trying to produce any particular state, instead you’re being curious about what you are experiencing, whether it’s something you’d ordinarily want to experience – or not. This approach to experience is really similar to what we’re aiming for in persistent pain management – acknowledging and being willing to experience what is, rather than attempting to avoid that experience, or quickly change it to something more palatable.

Now this aspect of mindfulness is often brought to bear on new and pleasant experiences – sometimes people are asked to mindfully eat a raisin, or mindfully examine a ballpoint pen (one of my favourites). But it’s also just as valid to bring this attitude to bear on less than pleasant experiences like my cold fingers and legs (it’s cold in my office this morning). Or to pain and where it is – and where it isn’t.

So I wonder if part of our approach to using mindfulness in pain management is incorrect. If we’re intending people to come away from mindfulness feeling relaxed and calm, perhaps we’re doing it wrong. If we think people should feel better after mindfulness, again, perhaps we’re doing it wrong. Sometimes, yes, these are the effects we’ll have. Other times, not so much. What we will always develop, over time, however, is better ability to focus attention where we want it to go, and more openness to being present to what is rather than struggling against it. And I think those are incredibly valuable tools in life, not just persistent pain management. And perhaps, just perhaps, if we began viewing our use of mindfulness in these ways, the outcomes from RCTs of mindfulness might show more of what it can do.

 

Anheyer, D., Haller, H., Barth, J., Lauche, R., Dobos, G., & Cramer, H. (2017). Mindfulness-based stress reduction for treating low back pain: A systematic review and meta-analysis. Annals of Internal Medicine, 1-9. doi:10.7326/M16-1997

Dawn, Carroll, and Kate Seers. “Relaxation for the relief of chronic pain: a systematic review.” Journal of advanced nursing 27.3 (1998): 476-487.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your mind to face stress, pain and illness. New York:Dell.

Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General hospital psychiatry, 4(1), 33-47. doi:http://dx.doi.org/10.1016/0163-8343(82)90026-3

More Managing Migraines without Medication

Anyone familiar with migraine will know the first signs of an impending attack. What might be a little less familiar is the precursor to the “first signs”, and what may also be unfamiliar is the thoughts that accompany those first symptoms. Today I want to talk about ways to manage this phase of a migraine – without medication.

As an aside, some people have suggested that there are ways to completely get rid of migraine, often suggesting that one of the problems could be around the numerous nerves that innervate the face, neck and scalp. One of the common suggestions is to have chiropractic or osteopathic treatment to “do something” to the nerves in this area. I put the “do something” in quotation marks because I really don’t know what the something’s are. This is not to say that I don’t think this kind of treatment works, more that I am not familiar with the purported mechanisms for how hands on treatment helps. My focus is, however, on what individuals can do for themselves to manage a migraine when or if, or even alongside, other treatments have not been completely successful. Or perhaps because of individual choice not to pursue other treatments.

One of the unique aspects of being human is our ability to think about situations in certain ways.  These cognitions allow us to prepare for what might occur in light of what has happened in the past and what we predict might happen in the future.  But as many of us know, the accuracy both of our memories and our ability to pull together all the relevant information is not exactly high.  We’re inclined to notice only salient features, recall recent events, emotionally-laden events, unusual or novel events – and make predictions from “rules of thumb” or heuristics.  These shortcuts reduce cognitive burden, but also reduce accuracy.

‘Nuff said – how we evaluate the early warning signs of migraine has an effect on at least two things: our emotions and our actions.  Let me explain.

Some of the “early warning signs” for migraine can be, for me, floating sparkles that float up and across my field of vision.  When I see them my first thought is “Oh no, when is it going to hit?”

What sort of emotion do you think I generate with that thought? Yes – you’re probably right, it’s fear or loathing! Dread, maybe.  Whatever the name you give to this thought, the effect is to increase my heart rate, skin conductance, respiration, and probably blood pressure.  There are probably other physiological changes that my body goes through because I’ve learned to associated those sparkley lights with the onset of nausea and headache.  The thing is, that no matter how accurate my thought is – it’s not going to settle my headache! And the physiological changes are not going to help either.

A cognitive behavioural approach to this common situation is to take the view that I can self manage my headache because I can learn to view my situation differently – and take action to change my response.  That’s the bottom line of self managing chronic pain.  Nothing is quite as empowering as knowing that there are things that I can do to feel more in control, to reduce my distress, to feel more confident about managing my situation.

Often just by recognising the effect of the thought “oh no, here we go again” can interrupt the process of winding up the body’s response to migraine aura.  Add to that some skills in self regulation – particularly breathing diaphragmatically and releasing muscle tension – along with a coping statement like “I can manage with this if I just take some time now”, and we have a much more positive take on what living with a migraine might be like.

In terms of actions, thoughts influence emotions, and emotions can influence actions (though not inevitably or we’d all still be like two year olds, having tantrums in the supermarket!) We do learn associations quickly, and this means that we can mistakenly associate the onset of migraine symptoms with something unassociated.  In this way, triggers can be mistakenly identified, and with the usual advice being to avoid triggers, lead to a life full of restrictions.  It can be quite hard to break that incorrect association because of the intermittent nature of headache.

Actions can, however, also be directed by thoughts.  If I catch myself thinking “oh no, here’s another afternoon of hiding in the dark and feeling rotten”, replace that thought with a coping one “if I take a few minutes to relax, breathe deeply, and make some alternative plans”, I might be able to slightly modify what I need to do and even avert the migraine.  Even if I continue to have the headache, I’m more likely to be able to keep doing things that need to be done.  Even when triggers are present.

By learning to keep doing some things even when a migraine is present, the anxiety associated with being around a trigger can be reduced so at least I’m not winding my migraine up, and I may even be able to tolerate that possible trigger in the future.

I don’t want anyone to think I’m suggesting that this completely abolishes the migraine.  I know only too well that it doesn’t! However in combination with medications when necessary, it does mean migraines don’t dominate completely.

Kelman L (2004). The premonitory symptoms (prodrome): a tertiary care study of 893 migraineurs. Headache, 44 (9), 865-72 PMID: 15447695
Thorn, B., Pence, L., Ward, L., Kilgo, G., Clements, K., Cross, T., Davis, A., & Tsui, P. (2007). A Randomized Clinical Trial of Targeted Cognitive Behavioral Treatment to Reduce Catastrophizing in Chronic Headache Sufferers The Journal of Pain, 8 (12), 938-949 DOI: 10.1016/j.jpain.2007.06.010

Managing Migraines without Medication

Ahhh, migraine – psychedelia without the high… nausea without the alcohol…

The diagnostic criteria: A) At least 5 attacks fulfilling B-D; B) lasting untreated 4-74 hours; C) two of the following: unilateral, pulsating, moderate or severe pain intensity, worsening with physical activity; D) one of the following: nausea and/or vomiting, photophobia or phonophobia; E) not attributed to another disorder. (International Classification of headache disorders, 2004) (go here for one of the most comprehensive sites on migraine)

The main treatment for migraine is to use medication – best evidence to date suggests:  “Only two pharmacological treatments have been shown to be effective in placebo-controlled randomized trials: topiramate and local injection of botulinum toxin. Both therapies are effective in patients with chronic migraine with and without medication overuse. “ (Diener, Holle, Dodick, 2011)

As one of the many people who have migraine to NOT find these two medications helpful, and someone who has slightly unusual migraine symptoms (my main symptom is nausea, with headache being secondary), it’s taken a long time for me to reach a clear-cut diagnosis for migraine.  In the meantime I’ve had to learn to “live with” my migraines without pharmacology.  No easy matter when even the best say “Most of the time migraines resolve with sleep. Occasionally, and especially in children, vomiting stops migraine.” (from Migraine Aura Foundation)

What helps migraine – apart from sleep and vomiting?

I’m going to start with the approaches that I commonly use in the Pain Management Centre for people with migraine.  Please note: these are NOT a panacea for all migraines, and they work most effectively in combination.  Please don’t use what I’m writing as a substitute for seeing a health care provider – you and your health care provider need to work together.

1. Assessment: Step one for managing migraines is carrying out a good assessment to identify triggers (antecedents).  This is one occasion when diaries for recording headaches and activities over a month or so.  I’m generally not keen on pain diaries because they so often focus the person on their pain, but in the case of intermittent headaches the diary method is really useful.  It’s helpful to briefly record activities, “stress” level, aura, headache intensity, sleep and food/drink intake.  This might help identify triggers – but having identified them, avoiding them is not always the best approach!  Instead, it might be more preferable to consider ways of managing the overall vulnerability to migraine – more on this below.
2. Self-regulation training: Self-regulation refers to a wide range of strategies to influence alertness and ability to achieve a given activity.  In the context of migraine management, it usually refers to using things like biofeedback modalities to help train the person to up and down-regulate their physiological activity.  I find this has to be conducted alongside cognitive therapy so the person remembers to use self-regulation, and to help manage the automatic thoughts that often occur both because of having a migraine and as a response to using different strategies.
3. Cognitive therapy: This refers to recognising automatic thoughts, intermediate beliefs/attitudes, and core beliefs, and working with these to interpret events in a different way.  This approach helps people to reflect on why they feel the way they do about situations and establish whether these are “working” to help them achieve what is important and valued in their life.  Even if an interpretation of a situation is accurate, it may not be helpful.
4. Effective communication: This might seem a strange one to put into migraine management, but something I have found is that emotional stress from interpersonal conflict is one of the “hidden” triggers for migraine.  Effective communication can be called “assertive” communication, but I find this to be a very value-laden term.  Being able to communicate effectively involves listening, hearing, interpreting then developing an honest and respectful response.
5. Activity management: Yes, that old standby of timetables, planning, prioritising and putting off – oh, perhaps not that last one!  Seriously though, establishing a paced activity pattern that avoids “boom and bust” patterns, or “pain contingent” patterns really helps, especially on a day when a migraine has started.  Stopping everything isn’t an option for many people, so maintaining a “minimum” plan for those days can be useful.

Self-regulation training – some details

While learning self-regulation without biofeedback is perfectly fine, for some good reasons, various biofeedback modalities enhance the learning.

Biofeedback involves monitoring physiological processes usually considered involuntary or that are modulated outside of conscious awareness. The three most common forms of biofeedback for headache treatment are: thermal, electromyographic (EMG), and electrodermal.  I tend to use Galvanic Skin Response (GSR) rasther than electrodermal, simply because it’s available to me and also because it gives me (and the person I’m working with) a good “overall” assessment of alertness.

There are many things that you can do with biofeedback, but I usually begin by attaching the leads and showing the graphs on the computer monitor.  We talk for a while until the person’s graphs show they’re stabilising into a baseline state.

I then usually begin with a Stroop test to establish “working under stress”.  This is a test where people are asked to read words for colours, with the words printed in different colours from how they read.  For example GREEN RED BLUE.  This gives me some information on the parameters the person usually demonstrates “stress”.

I then progress to learning to breathe.  “Not so difficult”, you say – well, it’s surprising how few people demonstrate effective breathing and control of breathing.  I almost always begin with respiration – to firstly use diaphragmatic breathing, then to slow the breathing down, and finally, with a respiration monitor around the person’s chest, I might help them look at the S pattern they create on the monitor.  This helps them to create slow, regular and full breathing that smoothly inflates and deflates the lungs.

Then I often move onto some animated programmes – one of my favourites is the Wild Divine set called “Relaxing Rhythms”.  It monitors heart rate, heart rate variability and GSR, and has a number of really good animations that help people to develop control.

More on migraine management soon!

Grazzi, L., & Andrasik, F. (2010). Non-pharmacological approaches in migraine prophylaxis: behavioral medicine Neurological Sciences, 31 (S1), 133-135 DOI: 10.1007/s10072-010-0306-5
Paola Schiapparelli • Gianni Allais • Ilaria Castagnoli Gabellari •
Sara Rolando • Maria Grazia Terzi • Chiara Benedetto (2010). Non-pharmacological approaches in migraine prophylaxis: Part ii Neurological Sciences, 31 (S1), 137-139 DOI: 10.1007/s10072-010-0307-4

Friday Meditation

As you know, Friday is about getting ready for the weekend.  Today I decided not to pass on some of the horrendous puns shared with me by one of my esteemed colleagues (although I may drop just one in because I can!).  Instead I thought this poem is a chance to consider being ‘in the now’, something clinicians working in pain management really need.

Salutation To The Dawn

Look to this day!

For it is life, the very life of life.

In its brief course

Lie all the verities and realities of your existence:

The bliss of growth,

The glory of action,

The splendor of achievement,

For yesterday is but a dream

And tomorrow is just a vision,

And today well lived makes every yesterday a dream of happiness

And every tomorrow a vision of hope.

Look well, therefore to this day!

Such is the salutation to the dawn.

Kalidasa

 

Oh, a pun?  As you read this, remember I have to work with the person who passed it on…sigh…

She was only a whiskey maker, but he loved her still.

A rubber band pistol was confiscated from algebra class, because it
was a weapon of math disruption.

No matter how much you push the envelope, it’ll still be
stationery.

A dog gave birth to puppies near the road and was arrested for
littering.

I wondered why the baseball kept getting bigger.  Then it hit me.

Two fish swim into a concrete wall.  One turns to the other and says
‘Dam!’

Friday Funnies!

After a strenuous week (well, OK, maybe two days is not quite a week) – here’s SuperTherapist and featuring for the first time, Puddy, her cat!

Why is it that cat’s always get the last word?

Sleep – Posts from 2010

Sleep is so important for wellbeing (ask any young parent!), and yet many people with chronic pain have really poor and unrefreshing sleep, and very poor sleep habits.  Some pain conditions show changes to the quality of the sleep stages (such as fibromyalgia for example), to the point where these changes can almost be diagnostic, while many people with chronic pain also have low mood in which sleep disruption is a common feature.

I’ve written about sleep several times over the past year, and today I provide links to some of these posts for your education and enjoyment.

Sleep problems in chronic pain and what helps – Pain can be associated with a sense of poorer quality sleep, and could well have been a factor influencing the onset of insomnia, it’s often other factors that maintain unsatisfying sleep.

Thinking about sleep – or not – CBT responses to common thoughts and beliefs when introducing sleep management.

Oh, to sleep – CBT for insomnia in chronic pain – Cognitive-behavioral therapy for insomnia (CBT-I) is a well-established approach for helping people return to a refreshing sleep pattern, this study describes research about four strategies.

If you’re not asleep, get out of bed! – Sleep restriction as a strategy for optimising time in bed actually asleep.

To sleep, perchance to dream – different types of pain problem can link to different types of sleep problem.

Don’t forget that an effective strategy for helping with sleep onset is deep relaxation, and mindful attention to sensations such as the contact of the body on the bed, the breath in and out, and attending to each body part without necessarily changing the position can all help to ease into sleep.  I’ve also used ambient sound recordings – for me the sound of the sea is particularly relaxing – and recordings like this can mask street noises provided that the recording can remain on all night.  It’s better to learn to send yourself to sleep without external aids like recordings where possible, because if you wake during the night and haven’t learned the art of going to sleep by yourself, you’ll need those same aids at that point in time too.

Friday Funnies

SuperTherapist decided that if she gave out any advice today, she may just need to fear for her life, so she asked me to help out. SuperTherapist may need your help to vanquish the peripheralist demons from her memory – therapeutic videos to soothe the soul.

If you haven’t heard them before – and you get a chance to see them live – just GO! These guys are at least partially responsible for the odd sounds coming from my house over the last day…

And an example of virtuosity of another kind…

Enjoy your weekend!

Friday Funnies!

It’s nearly the weekend! Time to kick back, relax and snigger.

It’s true – apparently The Doors, Talking Heads and relaxation music are.. ahem… Not In Fashion Any More.  And I do wish I’d taken this advice!

Why bother with happiness? Broaden and build theory & Chronic pain

Readers may be wondering why I’ve come over all happy clappy and jolly joy germ – well, I realised I’d been writing a lot about experimental and theoretical factors found to influence vulnerability to chronic pain, but I had been writing less about ways to help people cope more effectively with chronic pain.

I do have a soft spot for positive psychology because, as we can see in most of the major journals, psychological studies have primarily been interested in what goes wrong, why people may struggle to cope with their pain, and other aspects of vulnerability. Yet more people than not live well with their chronic pain, and rarely seek help for their pain – maybe we can learn something from how these people cope, and in doing so, help people who do need treatment develop some of those skills. This is the topic of my PhD – Living well with chronic pain.

Building on yesterday’s post about ways to increase positive emotions (I talked about savouring – recalling past positive experiences; being ‘in the moment’ in present positive experiences; anticipating future positive experiences) I want to briefly discuss why on earth positive experiences might be useful. Apart from just feeling good in the moment!

The ‘broaden and build’ theory provides a framework for understanding the utility of positive experiences – especially the value of having positive emotions during tough times.  In this theory, developed by Fredrickson (2001), both positive and negative emotions have useful functional effects.  From an evolutionary viewpoint, there has to be some sort of adaptive value in having emotions and in the broaden and build theory it is posited that negative emotions help with generating “action tendencies that focus and narrow thoughts and actions (to prepare the body for fight or flight)” (and I guess we’re all pretty familiar with this response, especially in Christchurch after the quake!), while positive emotions “broaden ones thoughts and actions, and by consequence build important personal resources.”

In other words, negative emotions help us reduce the number of action options so we can active and use them quickly, while positive emotions help us generate ‘out of the box’ options, those creative, flexible, innovative ideas that can solve a problem – you know those overnight ‘aha!’ moments when the solutions just fall into place.

The empirical support for these two opposing but complementary emotion-elicited strategies is pretty good – we are familiar with the idea that by relaxing and thinking of good times, peaceful moments and happy events, autonomic arousal generated by ‘stress’ is reduced.   When there is no pressure to perform, people are often able to experiment and make mistakes and by doing so, arrive at unusual and exciting new possibilities – put a time pressure on and the options are narrowed and people revert to ‘tried and true’ behavioural repertoires.

Psychological resilience, or ‘bounce-back’ is possibly more common than not, according to Tugade and Fredrickson.  They suggest that under short-term traumatic events (perhaps the death of a loved one, or, closer to home, an earthquake with disruption to homes, services and businesses) it’s normal to temporarily experience negative emotions – but the general life trajectory continues in similar directions as before the event.  And for the majority of people in Christchurch, for example, despite the disruption we’ve experienced, life goes on.  For a smaller number – life is disrupted much more seriously.  Yet – in a couple of years, while the events of the last few months will be remembered, for more people than not, life plans and direction will be going along reasonably smoothly.

Of course this situation is different when the event is not short term, as in chronic pain.

The point that Tugade and Fredrickson make is that if resilience is commonplace, maybe it is also something individuals can learn, at least to a greater or lesser extent.

Back to the theory and how it might apply in chronic pain.  Some people seem more able to bounce back than others – and one factor in this resilience, according to Tugade and Fredrickson, is that people who are high in general or trait resilience, might be more able to draw on positive emotions than people lower in this trait.  For example, some people find it easy to use humour to cope with stressful times; some use relaxation – allowing time to interpret and assess problems before acting; some use exploration – looking at possibilities and options before taking action; and others use gratitude or hope – looking for the ‘silver lining’ or being thankful for ‘small mercies’ as my Grandmother would have said.

There is a relationship between the ability to access positive emotions through these strategies and physiological responses.  Research cited in the paper by Tugade and Fredrickson found that “although both low and high resilient individuals experienced equal levels of cardiovascular arousal and subjective negative experience in response to a stressor, high trait resilient individuals exhibited faster cardiovascular recovery from negative emotional arousal. Additionally, ‘‘bouncing back’’ to cardiovascular baseline levels was partially mediated by resilient people’s experiences of positive emotion in the midst of distress (Tugade and Fredrickson, 2004).”

What does this mean for people with chronic pain?

Well it is well known that people with chronic pain can have difficulty down-regulating autonomic arousal.  Things like heart rate and respiration rate, skin conductance and EMG can be readily increased – but people with chronic pain, even when they’re only recalling a time when their pain was high, find it reasonably difficult to reduce these readings.  There are a range of programmes for biofeedback that can help people recognise their own body responses and just by giving visual feedback, can help people develop skills to down-regulate.  Clinicians could enhance this process by helping people to remember happy times, or plan future positive events, or even simply be mindful of what is happening right now, as strategies to help people become more able to reduce their level of arousal.

What might this mean?

Well, resilient people seem to be able to recognise their own levels of arousal quite quickly – and then recruit resources to manage these situations quickly.  Tugade and Fredrickson consider that one strategy resilient people use is ” effectively harnessing positive emotions to their advantage when coping, and they do so with a seeming intuitive sensibility.” They go on to suggest that by experiencing positive emotions, the short term effect is to broaden the range of behavioural options, making it more likely that they will find a solution to a difficult situation.  They suggest that over time, and with repeated experiences of positive emotions, this broadened mindset might become habitual. Success breeding success.

So, quite apart from the need to help people in distress from their pain to generate short-term, ‘do-able’ goals to increase self efficacy, it seems that by being able to succeed and feeling good about doing so, people can develop skills over time that support resilience.  Sort of like banking a range of coping resources based on creative and positive options that can be adapted to suit changing circumstances.

What can we do to help?

Step one is to recognise that resilience could be something we learn.  Yes, some people have more innate resilience than others, but they also use skills that, over time, become more and more flexible and responsive.  To help generate this resilience, helping people become more aware of good things that generate positive experiences seems an important step. 

This might include things like scheduling pleasant events, writing down three things that have been positive each day, sitting for some peaceful time to simply appreciate something from nature, setting small goals – and achieving them, noticing unhelpful thinking and letting go of these thoughts in order to focus on what is important and valuable in the here and now.

I can see an enormous potential in helping people with chronic pain use these positive strategies – and who knows, it might even help us as clinicians?!

Tugade, M., & Fredrickson, B. (2006). Regulation of Positive Emotions: Emotion Regulation Strategies that Promote Resilience Journal of Happiness Studies, 8 (3), 311-333 DOI: 10.1007/s10902-006-9015-4

Sleep problems in chronic pain & what helps

I have written about sleep problems in people with chronic pain several times. It is one of those aspects of dealing with pain that inevitably arise as I talk with people about energy, their activity through the day, and their mood. Many people blame the pain for their sleep problems, which is unsurprising really – once you’re awake in the middle of the night, there’s not a lot else to think about! But it seems like while pain might be associated with a sense of poorer quality sleep, and could well have been a factor influencing the onset of insomnia, it’s often other factors that maintain unsatisfying sleep.

What are those factors?
Well, one of the first ones is ‘general affective disturbance’ – in other words, feeling low or flat, whether frankly depressed or not, can lead to changes in sleep architecture. Sleep architecture refers to the patterns of brain activity that are normal and expected in people throughout their sleep. People who are depressed demonstrate shortening of the time from sleep onset to the appearance of the first REM period (short REM latency), while people with fibromyalgia show specific and distinctive abnormalities in the stage 4 deep sleep. During sleep, individuals with fibromyalgia are constantly interrupted by bursts of brain activity typical of being awake, limiting the amount of time they spend in deep sleep.  It’s also thought that people with central sensitisation syndrome (such as CRPS, irritable bowel, pelvic pain, migraine etc) have similar changes to their sleep pattern – and fatigue is often a feature characterising these problems.

It’s not only disorders that affect sleep architecture: some medications and common substances also affect sleep, including alcohol, coffee and common sleeping pills.

While we can’t ‘fix’ the chronic pain condition, we can treat depression, and we can help people identify any of the substances that might alter sleep patterns.

More often than not there are other things that also contribute to maintaining poor sleep.  Some studies suggest that poor sleep is maintained by the amount of attention focused on pain, the ways in which pain is interpreted (particularly sad, or irritated responses to pain), and thought patterns particularly before going to sleep (rumination or brooding on pain).  These are aspects of sleep management that may not always be addressed in general pain management programmes which often provide sleep hygiene.

A thorough assessment of sleep problems is an important part of developing an appropriate management strategy.  Sleep assessments in this case don’t refer to being wired up at night btw – and I’m not referring to sleep problems caused by sleep apnea or snoring.

A sleep assessment should cover things like:

– time of going to bed, and the pre-sleep rituals

– time to sleep onset, number and timings of sleep awakenings as well as the length of time awake at these times (not to mention what the person does at these times such as eating, getting out of bed, having a smoke or coffee …)

– waking time, and how refreshed the person feels at this time

– naps and timing of exercise during the day

– coffee, alcohol, tobacco and other substances taken

These relate directly to ‘sleep hygiene’ aspects of sleep 0r things like keeping the bed as a place associated only with sleep (not worrying, watching TV or arguing with others), and developing a regular pattern to going to sleep including relaxation.  This is another good handout on sleep hygiene.

Now while simple sleep hygiene can be helpful for many people, there are several other strategies that have good evidence to support their use in insomnia.

These methods are all included in what is called Cognitive Behavioural Therapy for Primary Insomnia.  This is described by Tang as ‘a multi-component treatment that seeks not only to teach patients about sleep and factors affecting sleep (eg homestatic regulation, circadian rhythm, age, social and work schedule) but also to work with the patient toward minimisng unwanted arousal at bedtime and altering sleep habtis to increase  sleep propensity and regularity.  More cognitively oriented therapy involves interventions that aim to address worries and beliefs about sleep, particularly anxiety-provoking thoughts like ‘I’m losing control over my sleep’ and safety seeking behaviours (like drinking extra coffee or spending longer in bed).’

CBT-I can include psychoeducation, sleep hygiene, relaxation training, cognitive therapy, sleep restriction, stimulus control therapy, paradoxical training, biofeedback and imagery training. Of these strategies, relaxation, sleep restriction and stimulus control therapy have the most support from research as stand-alone interventions.  CBT-I has been repeatedly shown to be effective for remedying insomnia, and found as effective as hypnotics in the acute treatment phase, with the benefit of providing long-term results.

Despite this positive finding, between 43% to 85% of people don’t respond to even intensive CBT-I treatment when stringent outcome criteria are applied.  When Tang reviewed the content of three RCT’s for insomnia for people with chronic pain, she found that much of the content relied upon behavioural interventions – but research in other population shows that it’s just as important to address beliefs and attitudes about sleep.  Maybe this is an area to focus on a little more in pain management programmes also.

Tomorrow I’ll discuss some of the cognitive strategies and especially the sort of thoughts and beliefs that people can have about sleep – but I’ll write about this after I’ve had a sleep!

Tang, N. (2009). Cognitive-behavioral therapy for sleep abnormalities of chronic pain patients Current Rheumatology Reports, 11 (6), 451-460 DOI: 10.1007/s11926-009-0066-5