Mindfulness, CBT and Symptom Reduction: What Works

William Collinge, PhD, MPHCollinge and Associates, Inc.

Treating and Preventing (TAP) Chronic Pain ConferenceOctober 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 behavioral-based interventions in fibromyalgia and chronic pain—in-person, self-directed, and online interventions.

3. Describe the role of mindfulness, cognitive and behavioral-based interventions within the larger context of an integrative approach to treatment of fibromyalgia and chronic pain.

Disclosure InformationTAP Conference/Oct. 9, 2015William 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 UsesI 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 ParadigmMuhammad 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 BehavioralInterventions

Stress and Coping Theory

• 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

Problem-Focused Coping

• Managing anxiety, depression, anger, helplessness, hopelessness

• Minimizing the stress burden on CNS• Positive psychology: peace, ease, optimism, meaning,

satisfaction (beneficial CNS effects)

Emotion-Focused Coping

Mindfulness-Related ApproachesCore 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 awarenessAttendere (Lat.) − “to stretch towards”

Mindfulness-Related ApproachesCore 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

MovementMeditationEating

Mindfulness-Related ApproachesDelivery

• 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 ApproachesEvidence

• 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

CBTCore 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

CBTDelivery

• 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

CBTEvidence

• 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 FDA-recommended drugs and usual care in FM

Energy PsychologyCore 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 PsychologyDelivery

• 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 PsychologyCore Concepts

Energy PsychologyEvidence

• 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 PsychologyEvidence

The Fibromyalgia Wellness Project

National Institute of Arthritis, Musculoskeletal and Skin DiseasesGrant #2R44AR52640-02

William Collinge, PhD, MPH, Principal InvestigatorPaul 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

• 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.

Intervention Components

SMARTLog Solver Profile

• 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

DurationExertion 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.

Inputs Tracked in SMARTLog

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.

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%

883 Study Applicants

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.

• 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.

Updated Version: AwareHealth (2015)

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, MPHCollinge and Associates, Inc.

3480 Kincaid Street, Eugene, OR 97405Tel (541)632-3502

Email william@collinge.org

Websites:www.Collinge.org

www.AwareHealth.org