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. --- 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 • • • • • • 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 • • • • 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 • • • • 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 • • • • • • • • 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 – – – – – – 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… – – – – – – – 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 • • • • • • • • • 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 • • • • • • • • • 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 • • • • • 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 william@collinge.org Websites: www.Collinge.org www.AwareHealth.org