Transcript Mindfulness, CBT and Symptom Reduction: What Works

Mindfulness, CBT and Symptom
Reduction: What Works
William Collinge, PhD, MPH
Collinge and Associates, Inc.
Treating and Preventing (TAP) Chronic Pain Conference
October 2015, Arlington, VA
Learning Objectives
1. Describe the state of the evidence for use of interventions
employing mindfulness, cognitive and behavioral principles
for fibromyalgia and chronic pain.
2. Contrast the strengths and limitations of the various available
means of delivery of mindfulness, cognitive and behavioralbased interventions in fibromyalgia and chronic pain—inperson, self-directed, and online interventions.
3. Describe the role of mindfulness, cognitive and behavioralbased interventions within the larger context of an
integrative approach to treatment of fibromyalgia and
chronic pain.
Disclosure Information
TAP Conference/Oct. 9, 2015
William Collinge, PhD, MPH
Disclosure of Relevant Financial Relationships
I have the following financial relationships to disclose:
Employee of Collinge and Associates, Inc.
Disclosure of Off-Label and/or Investigative Uses
I will not discuss off label use and/or investigational use in my
presentation.
Outline
• Frame of Reference
• Cognitive and Behavioral Interventions
– Mindfulness-Related Approaches
– CBT
– Energy Psychology
– The Fibromyalgia Wellness Project (NIH study)
Frame of Reference
The CSS Paradigm
Muhammad Yunus, MD
• Such terms as “medically unexplained symptoms,”
“somatization,” “somatization disorder,” and “functional
somatic syndromes” in the context of CSS should be
abandoned.
• The concept of disease-illness dualism has no rational basis
and impedes proper patient-physician communication,
resulting in poor patient care.
• CSS seems to be a useful paradigm and an appropriate
terminology for FMS and related conditions.
• The disease-illness, as well as organic/non-organic dichotomy,
should be rejected.
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Source: Yunus MB. Central Sensitivity Syndromes: A New Paradigm and Group
Nosology for Fibromyalgia and Overlapping Conditions, and the Related Issue of
Disease versus Illness. Semin Arthritis Rheum 2008:37:339-352.
Source: Robert Bennett, MD. Understanding Pain and Pain Amplification,
www.myalgia.com.
How can CNS sensitivity be mitigated?
Cognitive and Behavioral
Interventions
Stress and Coping Theory
Problem-Focused Coping
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Stress reduction
Relaxation response
Energy psychology research
Lifestyle/behavior inputs that impact CNS
Chronobiology -- patterns of activity, rest, eating
Nutrition and other self-care habits
Emotion-Focused Coping
• Managing anxiety, depression, anger, helplessness,
hopelessness
• Minimizing the stress burden on CNS
• Positive psychology: peace, ease, optimism, meaning,
satisfaction (beneficial CNS effects)
Mindfulness-Related Approaches
Core Concepts
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Mindfulness is a synonym for awareness
Pure awareness = thoughtless awareness
Awareness is that which is aware
Objects of awareness are what we are aware of
– Thoughts
– Feelings
– Sensations
– Perceptions
Attention is focused on objects of awareness
Attendere (Lat.) − “to stretch towards”
Mindfulness-Related Approaches
Core Concepts
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Non-judgmental allowing & accepting “what is present”
Resistance exacerbates symptoms
Letting go (“resting as awareness”) reduces symptoms
Mindfulness is “cultivated” by being aware of being aware…
– In activities of daily living
– In specific practices
Movement
Meditation
Eating
Mindfulness-Related Approaches
Delivery
• Origins in mindfulness meditation
– Traditional “insight” or vipassana meditation
– Common framework for many community-based groups
• Mindfulness-Based Stress Reduction (MBSR)
– Structured, manualized 8-week group program
– Homework with awareness practices and yoga
• Mindfulness-Based Cognitive Therapy
– One-on-one therapy with a clinician, or group
– A fusion of CBT and mindfulness concepts
• Online programs with and without professional contact
Mindfulness-Related Approaches
Evidence
• 573 PubMed clinical trials: 48 on brain effects, 63 on pain, 7
on FM
• Heart rate variability
• Inflammatory responses
• Immuno-modulation and enhancement
• Altered EEG brain wave activity in turn affects pain responses
• Sympathetic nervous system reactivity
• Benefits in FM: symptom levels, symptom impact, disability,
quality of life, depression, anxiety, fatigue, psychological
flexibility, self-efficacy for coping with pain, positive
engagement in relationships, positive affect, decreased
relationship stress
CBT
Core Concepts
• Changing patterns of thinking…
– Automatic thoughts and thought streams
– Self-defeating thoughts and behaviors
– Cognitive distortions, “all or nothing” thinking
• “Health-positive” thoughts and behaviors
• Re-framing the “meaning” of symptoms
• More flexible attitude and expectations
• Homework…
– Diaries for self-reflection, tracking stressors and symptoms
– Setting priorities, limits and boundaries
– Adopting stress management and self-care practices
CBT
Delivery
• One-on-one with a therapist
• Group programs
– May include health education content (e.g., nutrition, etc.)
– May include stress reduction practices (e.g., mind/body)
– Social support is a strong component
• Reading
• Journaling
• Diaries and tracking systems
• Online self-directed programs
• Mobile apps
CBT
Evidence
• 1,521 PubMed clinical trials: 48 on brain effects, 140 on pain,
27 on FM
• Modulates brain networks involved in anxiety
• Benefits in FM: lower FIQ and tenderpoint scores, pain and
other symptom levels, catastrophizing, negative mood and
disability levels, quality of life, depression, anxiety, fatigue,
psychological flexibility, self-efficacy for coping with pain,
positive engagement in relationships, positive affect,
relationship stress, sleep quality, insomnia
• Economic evaluation concludes more cost-effective than FDArecommended drugs and usual care in FM
Energy Psychology
Core Concepts
• Human energy system interface with CNS
• Imaginal exposure paired with stimulation of meridian
points reduces midbrain hyper-arousal
• Counter-conditioning of midbrain responses to traumatic
memories or negative emotional content
• Inhibition of anxiety
• Rapid desensitization to traumatic stimuli
• Works with aspects and layers of emotional response
Energy Psychology
Delivery
• Usually taught by clinician as a self-care practice in a brief
series of 1-on-1 sessions
• Involves tapping prescribed set of meridian points during
“imaginal exposure”
• Does not induce re-traumatization, thus more accessible for
highly traumatized people
• Instruction also available online, via video and print
• Personal practice to reinforce de-activation of conditioned
midbrain responses
• No adverse side effects
Energy Psychology
Core Concepts
Energy Psychology
Evidence
• 4,101 PubMed clinical trials on acupuncture or acupressure: 237 on
brain effects, 1,449 on pain, 25 on FM
– Release of opioids, serotonin and gaba
– Regulates cortisol, reduces pain, slows heart rate, decreases
anxiety, shuts off the stress response, induces relaxation
• EEG studies with energy psychology techniques
– Down-regulation of stress responses during recall of traumatic
incidents (Diepold, 2008; Lambrou, 2003; Swingle, 2004)
• EFT in Veterans with PTSD
– Significant reductions in psychological distress and symptoms to
below diagnostic levels, sustained at 6 months (Church, 2013)
Energy Psychology
Evidence
The Fibromyalgia Wellness Project
National Institute of Arthritis, Musculoskeletal and Skin Diseases
Grant #2R44AR52640-02
William Collinge, PhD, MPH, Principal Investigator
Paul Yarnold, PhD and Rob Solysik, MS, Co-Investigators
Collinge and Associates, Inc., Eugene, OR
Core Concepts
• Mindfulness, cognitive and behavioral principles
• Customizable for the individual
• Personal health informatics
– Inputs (behaviors, treatments, etc.)
– Outcomes (symptoms, wellness)
• Chronobiology and chronotherapy
• Longitudinal data collection
• N-of-1 analytical methods
• Data-driven feedback
Study Design
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Web-based
Publicized through advocacy organizations
Self-report data
International sample
Self-directed participation
Recommended use 3+ times per week
Single-subject analysis (N-of-1 methods)
Longitudinal, repeated measures
Intervention Components
• SMARTLog (3+ times/week, around 5 minutes)
– Builds the user’s personal database of symptom patterns
and the inputs that affect them.
• Solver (“black box”)
– Analyzes the user’s database to discover input strategies
that lead to reduced symptoms.
• Profile (personal-data-driven guidance)
– Personalized feedback tells the user what works to reduce
symptoms.
SMARTLog
Solver
Profile
Inputs Tracked in SMARTLog
• Patterns of sleep and rest
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Bedtimes
Sleep latency
Number of awakenings
Duration of awakenings
Time arising
Duration of daytime naps.
• Meals and snacks
– Timing
– Size
• Self-care practices
– Bathing & hydrotherapy
– Mind/body/spirit practices
– Exercise
Duration
Exertion level
• Patterns of activity: duration,
exertion level, satisfaction
level and stressfulness of…
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Work & school
Domestic activity
Social activity
Recreation/play
Travel/commuting time
Screen time (TV, computer)
Away from home
• Overall activity level
• Unique inputs (user-defined)
– Medications, dosages, therapies,
foods, supplements, stressors, or
activities not listed earlier.
Outcomes Tracked in SMARTLog
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Pain
Memory problems
Gastrointestinal problems
Depression
Fatigue
Concentration problems
Stiffness
Sleep difficulties
Other – user-defined
Sample Profile Statements
• Your pain is likely to improve if your bedtime is no later than 9:40
pm.
• Your digestive problems are likely to improve if your intensity of
exercise is no more than 2.
• Your fatigue is likely to improve if your dosages of Lyrica are no
more than 75 mg.
• Your sleep problems are likely to improve if your total screen time
(TV, computers) is less than 55 minutes.
• Your anxiety is likely to improve if your evening meal time is no later
than 5:45 pm.
• Your stiffness is likely to improve if your afternoon nap is no more
than 32 minutes.
• Your concentration is likely to improve if you get up after 6:55 am.
883 Study Applicants
Demographics
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95% female
91% white
Mean age 46
58% college degree
45% employed part/full time
35% disabled
73% have partner or spouse
97% professionally diagnosed
88% USA
Concurrent conditions
• CFS 33%
• Osteoarthritis 28%
• Gastroesophageal 26%
• Hypertension 23%
• Asthma 18%
• Diabetes 9%
• Rheumatoid 5%
• Arrhythmia 5%
Results in 497 Users
• A dose-response relationship was found for frequency and
duration of use.
• Moderate use (3+ times/wk for 3 months) = significantly
increased likelihood of clinically significant improvement in…
- Pain
- Concentration problems
- Depression
- Memory problems
- Fatigue
- Gastrointestinal problems
• Heavy use (4.5+ times/wk for 5 months) = all the above plus…
- Stiffness
- Sleep difficulties
• Above findings obtained independent of Profile statements.
• With Profile statements effect strengths were amplified.
Updated Version: AwareHealth (2015)
• Expanded range of health conditions
– 65 selectable symptoms
– 11 selectable “wellness” outcomes (spiritual well-being,
optimism, productivity, energy, self-acceptance, etc.)
• Includes tracking wireless (EMR) device exposure
– Re: electromagnetic sensitivity, EMR effects
• Customizable “unique inputs” section
– For medications, dosages, foods, substance use, therapies,
stressors, weather, environment, etc.
Availability of AwareHealth
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Fall 2015
Web and mobile app for all device platforms
Users subscribe for 3 months, 6 months or 12 months use
Fundraising for advocacy organizations
Access at www.AwareHealth.org
Thank you!
Contact info:
William Collinge, PhD, MPH
Collinge and Associates, Inc.
3480 Kincaid Street, Eugene, OR 97405
Tel (541)632-3502
Email [email protected]
Websites:
www.Collinge.org
www.AwareHealth.org