Beyond Symptom Management: Mindfulness for Chronic Pain

Hosted by John A. Renner, Jr., MD, DLFAPA

Professor of Psychiatry Boston University School of Medicine

Director, Addiction Psychiatry Residency Training Boston University Medical Center and

VA Boston Healthcare System

June 1, 2016

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PCSS-O Goals

Prescription Pain Medications and Heroin: A Changing Picture

June 1, 2016

Beyond Symptom Management: Mindfulness for Chronic Pain

Ronald D. Siegel, Psy.D Assistant Professor of Psychology, Part Time Harvard Medical School Member, Board of Directors Institute for Meditation and Psychotherapy

Identify three core components of mindfulness

Describe cognitive, affective, behavioral components of chronic pain cycles

Specify how mindfulness practice can help to interrupt chronic pain cycles

Learning Objectives

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West Virginia University School of Public Health

June 21, 2016 Noon – 1 p.m. Eastern

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Beyond Symptom Management:

Mindfulness for Chronic Pain

Ronald D. Siegel, Psy.D.

Center for Mindfulness and CompassionCambridge Health Alliance

Harvard Medical School

Disclosure

Neither I nor my spouse has any financial relationship with commercial interest to disclose.

Chronic Back Pain

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Bad Back?

The Orthopedic Story

What’s the Evidence?• 2/3 of people who have never suffered

from serious back pain have the same sorts of “abnormal” back structures that are often blamed for the pain

• Millions of people who suffer from chronic back pain show no “abnormalities” in their backs

• Many people continue to have pain after “successful” surgical repair

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“Smoking Gun” Studies

• What countries have chronic back pain epidemics?

• Who gets chronic back pain?

• What is the quickest way out of acute back pain?

Autonomic Nervous System

HPA Axis

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A Well-Adjusted Brain

Cartesian Model of Pain

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Cold Pressor Test

Gate Control Models of Pain

• Pain is not proportional to extent of tissue damage

• Pain is exacerbated by fear

• Chronic back pain is thus due to botheffects of muscle tension and increased sensitivity to pain

Not Imaginary Pain

• While psychological stressors of all types can contribute to chronic back pain, the pain is not imagined or “All in the head”

• Caused by real muscle tension

• Patients need to hear this repeatedly

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Mindfulness for Rehabilitation

1. Medical Evaluation

2. Cognitive Restructuring

3. Resuming Normal Activity

4. Working with Negative Emotions

Mindfulness

What is Mindfulness?

• Sati in PaliConnotes awareness, attention, & remembering

• Also includesNon-judgmentAcceptanceKindness & friendliness

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Therapeutic Mindfulness

1. Awareness

2. Of present experience

3. With acceptance

Mindfulness Practice is Not:

• Having a “blank” mind

• Becoming emotionless

• Seeking bliss

• Escaping pain

The Story of theTwo Arrows

When touched with a feeling of pain, the uninstructed run-of-the-mill person sorrows, grieves, & laments, beats his breast, becomes distraught. So he feels two pains, physical & mental. Just as if they were to shoot a man with an arrow and, right afterward, were to shoot him with another one, so that he would feel the pains of two arrows (Salllatha Sutta [The Arrow] ).

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(Pain) x (Resistance) = Suffering

• Pain can be observed to be separate from “suffering”

• Apparently solid pain states are observed to be like frames in a movie, ever-changing

Pain is Inevitable, Suffering is Optional

• Suffering Includes:Grimacing, wincing, bracing.Aversive thoughts.Wishes for relief.Self-punitive thoughts.Anger, fear, depression regarding condition.

Mindfulness for Experimentally Induced Pain

• Compared to novices, Experienced Meditators:

find pain less unpleasantcan observe pain less reactivelyfind that open monitoring reduces pain unpleasantnesshave less anticipatory pain anxiety

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Insula

• Associated with interoception

Visceral and “gut” feelingsProcesses transient body sensations

• Activated during meditation practice

Prefrontal Cortex (PFC)

• Evaluates emotional responses and regulates emotion

“Yes, looks like a lion, but lions aren’t found here, so it’s probably a beige rock”

Neurobiology of Mindfulness and Pain

• Meditators practicing mindfulness when exposed to pain:

had decreased activity in the lateral prefrontal cortex (lPFC) – evaluates sensation

had increased activation in the posterior insula – registers sensation

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Beyond Relaxation Training

• Not controlling physiological arousal

• MindfulnessFosters cognitive changeIncreases symptom tolerance Increases capacity to choose whether to act on urgesUncovers emotions

Mindfulness & Cognitive Restructuring

Seeing Thoughts as Thoughts

• Mindfulness increases cognitive flexibility

• Seeing role of beliefs in the problem

• Not pain sensations themselves, but our reactions that determine suffering

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Enhancing Metacognitive Awareness

• Notice prevalence of anxious thought and feeling

• Notice future-oriented catastrophizing

• Notice “budgeting” activity

Mindfulness & Resuming Normal Life

Creative Hopelessness

• Attempts to get rid of pain intensify and perpetuate disorder

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Relinquishing Control

• Letting go of quest to fix alleviate pain

• Useful to control behavior

• Impossible to control sensations

Resuming Lost Activities

• Exposure and response prevention central to treating kinesiophobia

• Resume activities often enough to be convinced that they are not damaging

The Importance of Exercise

• Strength, flexibility, and endurance training

To treat kinesiophobiaTo rehabilitate muscles

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In the Gym

• Implosion treatment

Ignores Back School instructions

• Potential for rapid recovery

• Potential for refusal, drop out

In the Consultation Room

• Begin with activities that are:EasyPleasurable or rewardingCan be done 3 or more times/week

• Continue until no longer fearedConvinced it doesn’t make pain worse

Friends and Family

• To support patient in expanding activityStop protecting patient from pain

Encourage normal activity

• Treat fear in significant othersPsychoeducation

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Increasing Symptom Tolerance

• Pain as object of awareness

• Bring attention to wider area if necessary

Working with Intentions

• Pain is distinct from urge to eliminate it

• Attention can be brought to urge to alleviate pain

• Urge arises, reaches crescendo, and passes

Mindfulness & Working with Negative Emotions

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Opening to Painful Emotions

• Experiential avoidance increases anxiety & muscle tension

• Mindfulness practice Enhances interoceptionDevelops affect awareness and tolerance

MBSR vs CBT vs TAU Chronic Low Back Pain

• Meaningful improvement in disabilityMBSR 60.5%CBT 57.7%TAU 44.1% P=.04

• Meaningful improvement in pain distressMBSR 43.6%CBT 44.9%TAU 26.6% P=.01

Cherkin, et al. JAMA 4/16

Other Pain Disorders

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Same 4 Steps

1. Medical Evaluation

2. Cognitive Restructuring

3. Resuming Normal Activity

4. Working with Negative Emotions

Other Muscle Tension Disorders

• Dynamics very similar to chronic back pain

Headaches; TMJ; neck, knee, foot, wrist, shoulder pain

• Need to rule out treatable causesThen follow same steps

Hyperacusis

• Fear of discomfort amplifies sound

• Avoidance hyper-sensitizes hearing

• Mindful acceptance resolves disorder

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Fibromyalgia

“. . .we are creating an illness rather than curing one.“

-- Dr. Frederick Wolfe

Is it Serious?

• Danger of insufficient response to distress

Neglecting medical evaluation and treatment

• Danger of excessive response to distress

Maladaptive pursuit of pain relief

For recorded meditations, visit:www.mindfulness-solution.com

email:rsiegel@hms.harvard.edu

For back pain worksheets, visit:www.backsense.org