Adapted from: Peper, E. & Harvey, R. (2022). Nausea and GI discomfort: A biofeedback assessment model to create a rational for training. Biofeedback, 50(1), 24–32. https://doi.org/10.5298/1081-5937-50.1.05
Abdominal discomfort and pain such as functional abdominal pain, acid reflux or irritable bowel affects many people. Teaching slower biofeedback-assisted HRV breathing with biofeedback is a useful strategy by which the person may be able to reduce symptoms. This essay provides detailed instruction for a first session assessment for clients who have abdominal discomfort (functional abdominal pain). Descriptions include how the physiological recording can be used to understand a possible etiology of the illness, to create a biological/evolutionary based explanation that is readily understood by the client, and finally to offer self-regulation suggestions to improve health.
Background of abdominal discomfort (irritable bowel syndrome, acid reflux, functional abdominal pain, recurrent abdominal pain)
Irritable bowel syndrome (IBS) affects 7% to 21% of the general population in Western cultures with a global prevalence estimated at around 11% (Fairbrass, Costantino, Gracie, & Ford, 2020). The chronic symptoms (i.e., lasting more than 30 days) usually include abdominal cramping, discomfort or pain, bloating, loose or frequent stools and constipation, which can significantly reduce the quality of life (Chey et al., 2015). A precursor of IBS in children is called recurrent abdominal pain (RAP), which affects 0.3% to 19% of school children (Chitkara et al., 2005). Both IBS and RAP appear to be functional illnesses, as no organic causes have been identified to explain the symptoms. IBS and RAP are contrasted to various types of diseases such as Crohn’s disease, inflammatory bowel disease or ulcerative colitis.
Multiple factors may contribute to IBS, such as genetics, food allergies, previous treatment with antibiotics, infections, psychological status and stress. More recently, dietary factors contributing to changes in the intestinal and colonic microbiome resulting in small intestine bacterial overgrowth have been suggested as another risk factor (Dupont, 2014). Generally, standard medical treatments (reassurance, dietary manipulation and of pharmacological therapy) are often ineffective in reducing IBS symptoms (Chey et al., 2015). On the other hand, complementary and alternative approaches such as biofeedback-assisted relaxation techniques (Davidoff & Whitehead, 1996; Goldenberg et al., 2019; Stern et al. 2014), autogenic training (Luthe & Schultz, 1969) and cognitive therapy are more effective than traditional medical treatment (Vlieger et al., 2008).
Biofeedback-assisted relaxation training typically moderates IBS or RAP symptoms by restoring balance in the nervous system (sympathetic/parasympathetic autonomic balance), such as through heart rate variability (HRV) breathing training. For example, Sowder et al. (2010) as well as Sun et al. (2016) demonstrated that functional abdominal pain can be reduced with HRV feedback training. In most cases, increased vagal tone was achieved by breathing at about six breaths per minute. While Taneja et al. (2004) reported that yogic breathing decreased diarrhea-predominant irritable bowel syndrome symptoms significantly more than conventional treatment in a randomized control study.Sympathetic/parasympathetic balance can be enhanced by increasing HRV, which occurs when a person breathes at their resonant frequency, which is usually 5–7 breaths per minute. For most people, the HRV training means breathing at much slower rate. A benefit of slow abdominal breathing appears to be a self-control strategy that can reduce symptoms of IBS, RAP and similar functional abdominal pain symptoms.
Mastery of effortless diaphragmatic breathing can be affected by injury, surgery or similar insults to the abdominal area (Peper et al., 2015). In addition, dysregulation of diaphragm, which is enervated by the phrenic nerve and the vagus nerve, along with dysregulation of other abdominal muscles appears to be associated with irritable bowel syndrome (Bordoni & Morabito, 2018). It is likely that slower biofeedback-assisted HRV breathing training restores abdominal muscles and diaphragmatic movement, theoretically by tonic and phasic regulation of the phrenic and vagal nerve activity (cf. Marchenko et al., 2015; Streeter et al., 2012). The theory, simply stated, is that HRV breathing training at an individual’s resonant frequency produces increases in regulatory neurotransmitters, particularly gamma amino butyric acid (GABA). Many of our students who complain of abdominal discomfort report reductions of symptoms following HRV breathing training.
Consistently for more than 40 years, we have taught undergraduate students a semester-long integrated stress management program that includes modified progressive relaxation, slow diaphragmatic breathing and changing internal language as outlined in the book, Make Health Happen, by Peper, Gibney & Holt (2002). At the end of each semester, numerous students report that their anxiety, gastrointestinal distress and other symptoms related to self-described IBS or RAP have decreased or disappeared (Peper et al., 2014; Peper, Miceli, & Harvey, 2016; Peper, Mason, Huey, 2017; Peper et al., 2020). Abdominal discomfort is prevalent experience of distress by college students. In our recent survey of 99 undergraduate students, 41% self-reported abdominal discomfort (25% irritable bowel or acid reflux), 86% self-reported anxiety, 70% neck and shoulder tension and 48% headaches. After practicing slower breathing (i.e., typically directing them to breath abdominally at a rate of about six breaths a minute) and focus on slower exhalation and allowing the air to flow in without effort as the abdominal wall expands, as a homework assignment for a week, many reported that their symptoms significantly decreased (Peper, Harvey, Cuellar, & Membrila, in press).
Case example illustrating how to use the physiological recording to guide the client discussion and provide motivation
A 16-year-old high school junior suffered from abdomen discomfort for years. The symptoms mainly consisted of frequent constipation, and when it occurred, great discomfort from nausea. After having been diagnosed and undergoing all the necessary tests by the gastroenterologist, there was no identifiable cause of the chief complaints. Biofeedback was suggested as an alternative to medications for symptom reduction. During the biofeedback assessment and training session, the client discussed what she would like to learn from the session. It was challenging for her to respond to those questions. Not being able to report what the client would like from a training session is also a very common experience when working with students. A useful strategy is to describe experiences of other students that the clients could relate to, and imply that their abdominal discomfort is somewhat commonplace in other students.
Discussed during the session was the link between being very sensitive and reactive to other people’s feeling and being concerned about what others think of her. The client nodded her head in agreement. When describing herself, she discussed being very perfectionistic using a scale from being lackadaisical/undemanding to being perfectionistic (i.e., self-oriented perfectionism, self-worth contingencies, concern over mistakes, doubts about actions, self-criticism, socially prescribed perfectionism, other-oriented perfectionism, hypercriticism; see Smith, Saklofske, Stoeber, & Sherry, 2016).
Furthermore, the client sat slouched in the chair. Possibly her slouched posture implied a state of powerlessness instead of empowerment, a state of being ready to react and protect (Carney, Cuddy, & Yap, 2010; Cuddy, 2012; Peper, Lin, & Harvey, 2017).
Working hypotheses. The client was very sensitive and continuously reacted to external and internal signals with sympathetic arousal, while masking her reactions. These ongoing flight/flight responses would decrease intestinal peristalsis and abdominal blood flow, which would result in nausea, constipation and abdominal distress. Namely, the body reacts to the stimuli as signals of danger and blood flow is shunted away from the abdomen into the large muscles to run and fight. To paraphrase Stanford University professor Robert Sapolsky (2004): Why should the body digest food and repair itself, if it is going to be the predator’s lunch? It is only when we are safe that we can digest and regenerate.
The session began by exploring how pressure on the abdomen could potentially affect experiences of nausea and abdominal distress. After explaining how the diaphragm descends and how abdominal content in the stomach can be displaced (spread out) during inhalation, we systematically changed her posture by placing and adjusting a small pillow behind her middle back so that she could sit tall. The tall posture resulted in an open feeling of empowerment not felt during slouching. She observed that breathing was slightly easier and felt there was more space in her abdomen. As she began to feel more comfortable during the training session, we discussed the impact of posture on the body. We also discussed the relationship between thoughts of perfectionism and abdominal discomfort. The discussion also included an exploration of why some people tend to curl-up and slouch in a protective posture (e.g., head down to protect the neck region and big bones of the arms and legs positioned to protect the core organs) when feeling self-consciousness or perfectionistic about body image.
Biofeedback monitoring for assessment
Psychophysiology was recorded with multichannel physiological system (Procomp Infinity System running Biograph Infinity software version 6.7.1, Thought Technology Ltd). Respiration was monitored with strain-gauge sensors placed around the abdomen and thoracic regions (for a discussion on sensor placement see Peper et al., 2016 and Chu et al., 2019). Blood volume pulse was recorded with the sensor placed on the left thumb. The thumb was used because the participant had small and cold fingers (for a discussion about blood volume pulse, see Peper et al, 2007 and Peper, Shafer, & Lin, 2010). Skin conductance was recorded with the sensor wrapped around the left index and middle fingers with the electrodes on the finger pads (for a discussion about skin conductance and normal values, see Khazan, 2019, and Shafer et al, 2016).
After sensors were attached and the signals explained, the client sat comfortably while looking at the screen. Unexpectedly the clinician clapped his hands and made a loud noise. The client reacted with a momentary startle and smile. The physiological response, showed an increase in skin conductance, decrease in pulse amplitude, decrease in abdominal diameter, and increase in heart rate, is shown in Figure 1.
Figure 1. Physiological response to a loud noise (clap) (1) increased skin conductance, (2) decrease in pulse amplitude, (3) decrease in decreased abdominal circumference, and (4) increased heart rate and decreased heart rate variability.
The client was aware that she reacted to the clap; however, she was totally unaware how much her body responded. The computer screen display of her physiological reaction made the invisible visible. It provided the opportunity to discuss how various body reactions related to heart rate, breathing, and skin conductance could contribute to experiences of abdominal discomfort.
She was unaware that skin conductance did not return to baseline levels for more than 20 minutes. An elevated skin conductance level may mean that the body’s reaction to the hand-clap noise triggered a defense reaction and maintained the increased sympathetic activity for more than 20 minutes. Having a sustained flight/fight reaction to external stimuli such as a hand-clap would most likely affect digestive and peristalsis processes, contributing to symptoms found in IBS and RAP. The observations made during biofeedback monitoring led to a discussion of how sympathetic activation affects the gastrointestinal track.
Blood volume pulse amplitude decreased, which indicated a decrease in blood flow through her hands, which would decrease hand temperature and again indicated a systemic sympathetic activation.
Abdominal circumference decreased, which indicated that she tightened her abdominal muscles as a protective response to the hand-clap. She was unaware of the abdominal muscles tightening; however, she stated that she was aware that her breathing had changed. The abdominal muscle, which pulled the abdomen in, took almost two minutes to relax. The sustained muscle constriction around the abdomen increased pressure around the core organs, which may contribute to ongoing abdominal discomfort. A fight-flight reaction includes body bracing (e.g. tightened muscles, head down to protect the neck, big bones of arms and legs curled to protect core organs), and she confirmed that she experienced neck and shoulder tensions.
The discussion of abdominal muscle tension led to another discussion of how holding your stomach in may relate to self-image. For example, tight clothing can contribute to constricted movement around the abdomen. Wearing corsets contributed to psychophysiological symptoms, mainly for women in the late 19th and early 20th centuries, during a time when women who wore very tight corsets were diagnosed with neurasthenia. Simply stated, neurasthenia was characterized as a condition of mental and/or physical fatigue with at least two of the following symptoms: dyspepsia, dizziness, muscular aches or pains, tension headaches, inability to relax, irritability and sleep disturbance.
“Dyspepsia” was the commonly reported symptom of neurasthenia, which included upset stomach, a gnawing or burning stomach pain, heartburn, bloating, and or burping, nausea, and vomiting. The constricted waist region that resulted from wearing a corset in the name of fashion compromises the functions of both digestion and breathing. When the person inhales, the abdomen cannot expand as the diaphragm is flattening and pushing downward. Thus, the person is forced to breathe more shallowly by lifting their ribs; this increases neck and shoulder tension as well as the risk of anxiety, heart palpitation, and fatigue (Cohen & White, 1947; Courtney, 2009).
It also can contribute to abdominal discomfort since the abdomen is being squeezed by the corset and forcing the abdominal organs upward. Even architects of the Victorian era recognized a need for a place to position a chair or chaise lounge, such as at the top of some stairs, because people wearing corsets could faint, pass out or otherwise experience breathlessness through the effort of climbing the stairs with restrictive clothing around their abdomen (Melissa, 2015). Many of these symptoms could be easily reduced by wearing looser clothing and learning slower diaphragmatic breathing. In modern times, a related phenomenon results when people wear items of clothing that are too tight around their waist or abdomen (e.g., tight jeans) in service to fashion trends often labeled as designer jean syndrome (MacHose & Peper, 1991; Stonehewer, 2009). Similarly, when people wear garments that are too tight around their chest or thoracic region (e.g., tight vests) in service to external protection (e.g., athletes, industrial workers, police or soldiers wearing heavy, restrictive gear), then restrictive ventilatory disorders can occur (Harty et al., 1999). Simply stated, when the muscles related to breathing are restricted from moving, respiration is affected.
The client’s heart rate increased and stayed high for more than 30 seconds. The first decrease in heart rate at about 20 seconds after the hand-clap was a long sigh of relief as breathing (i.e., oxygen/carbon dioxide exchange) started again. It took almost 90 seconds before breathing and heart rate returned to normal as reflected by measures of HRV. The computer screen showing increased heart rate was reviewed with the client to explain how her body reacted with a fight-flight response to the hand-clap, as well as how regulating breathing through biofeedback training could lower the heart rate and reduce the sympathetic activation and enhance the parasympathetic activation.
Body responds to cognitive stressful thoughts
After discussion about the psychophysiological response to the hand-clap (a physical external stressor) and how other external stressors (e.g., startling noise) or internal stressors (e.g., perfectionistic ruminations) could trigger a similar response of abdominal muscle tightening, the assessment was repeated by having her relax and then think about a mental stressor, as shown in Figure 2.
Figure 2. Physiological responses to thinking about a past stressor (1) increased skin conductance, (2) decreased pulse amplitude, (3) decreased abdominal circumference, and (4) increased heart rate and decreased HRV.
The physiological response pattern to thinking about a past stressor was similar to the bodily reaction to a loud noise. The skin conductance increased and blood volume pulse amplitude decreased immediately after hearing (e.g., anticipating) the task of evoking/thinking of a past stressor. Most likely, the initial response was triggered by performance anxiety, then 6 seconds later the heart rate increased and breathing changed as she began experiencing the somatic reaction evoked by the recall of a negative stressor. The recordings also showed that her pulse amplitude decreased. The decrease in pulse amplitude suggested that her hands would probably become colder, which was confirmed by her self-report that she often experienced cold hands and feet. She reported being aware of the feeling an emotional reaction, but mainly noticing the change of breathing in her chest, and she was unaware of the abdominal changes. The client was surprised by how her body reacted to emotional thoughts. The recording viewed on the computer screen demonstrated objectively that her thoughts (initial performance anxiety) had a physical effect on her body. Specifically, experiencing the emotions that were evoked by recalling the stressful memory had a direct effect on the body in the same way that a physical external threat leads to a fight-flight response.
Building a psychophysiological model
Using these recorded computer images reflecting physical reactions to the hand clap and emotional thoughts, the discussion focused on how abdominal discomfort could be the result of activating a normal biological survival response. Survival responses would occur hundreds of times throughout a day, especially when worrying. Each thought would evoke the response, and the awareness of body reaction would evoke another reaction. Similar to how awareness of blushing amplifies blushing.
The client shared that she was very sensitive and reactive especially when other people were upset. She reported feeling “cursed” by their sensitivity and reactivity. The linguistic metaphor that could be used to describe her reactions is “she could not stomach what was going on.”
The discussion about physiological reactions provided the client with a model how her disorder (IBS and RAP) could have developed and been maintained over the years. The model matched her subjective experience: when stressed, the discomfort often increased. The discussion shifted to reframing her internal labels. Instead of describing her sensitivity as a curse, the sensitivity was reframed and labeled a gift; namely, she could sense many people’s emotional reactions, to which they would react in a variety of ways. She just needed to learn how to manage this sensitivity. Once she learned to manage it, she would have many advantages in interpersonal relations at home and at work. She would be able to sense what other people are experiencing. By reframing her symptoms as a result of a survival physiological response pattern, it reduces self- blame and offers solutions about how to master and change reactions and thereby have more control in the world.
Training to demonstrate control is possible.
The discussion was followed by teaching her diaphragmatic breathing in sitting and lying down positions. As she had no history of abdominal injuries, similar to many of our students, she rapidly demonstrated slower diaphragmatic breathing as shown in Figures 3 and 4.
Figure 3. The client practiced a few slower diaphragmatic breaths in the sitting and reclining position, which increased heart rate variability, decreased skin conductance and increased blood volume pulse amplitude.
Figure 4. Practicing slower diaphragmatic breathing at about six breaths per minute in a reclining position increased HRV.
With tactile coaching, she demonstrated that she could breathe at about six breaths per minute with the heart rate increasing during inhalation and decreasing during exhalation. She reported feeling more relaxed and that the sensations of nausea had disappeared. Additionally, her hands felt warmer. This recording provided proof that there was hope and that she could do something about her body’s psychophysiological responses.
The discussion focused on how breathing affecting heart rate variability. Namely, if she allowed exhalation to occur without effort, her heart rate decreased (the vagal response of slowing the heart) and thereby increased the parasympathetic activation that would support digestion and gastrointestinal functioning. Often when people practice effortless diaphragmatic breathing, abdominal noises (borborygmus)– the gurgling, rumbling, or squeaking noise from the abdomen–occur and indicate that intestinal activity is being activated, and that food, liquids and digestive juice are moving through the intestines. It is usually a positive indicator that the person is relaxing and sympathetic activity has been reduced.
During the last part of session, we reviewed how posture affects physiology, emotions and cognitions, as well as how posture and breathing would be the first step in beginning to reduce symptoms and enhance health. To provide additional information using video and bibliotherapy/education, we suggested that she watches the embedded videos in the blogs listed at the end of the article.
Recommendations for future sessions and home practice
The recommended strategies for future sessions would focus on teaching the client to master slow diaphragmatic breathing and practicing that for 10–20 minutes per day. The teaching techniques would incorporate imagery to imagine air flowing down their arms and legs as she exhaled. . More importantly, the focus would shift to generalize the skill during the day; namely, whenever she would become aware of feeling stressed or observed herself holding her breath or breathing in her chest, she would use that as the cue to shift to slower abdominal breathing. Had the client continued training, future sessions would focus on mastering slower diaphragmatic breathing. The training would include relaxing the lower abdominal muscles during inhalation, increasing control of HRV, practicing imagining stress and use image to trigger slower breathing, and cognitive reframing practices to interrupt worrying and promote self-acceptance. The final goal is to generalize these skills into daily life as illustrated in the successful cases described in the following blogs
Blogs on posture:
Bordoni, B. & Morabito, B. (2018). Symptomatology correlations between the diaphragm and irritable bowel syndrome. Cureus, 10(7), e3036. https://doi.org/10.7759/cureus.3036
Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing: brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 10, 1363-1368. https://dx.doi.org/10.1177/0956797610383437
Chitkara, D. K., Rawat, D. J., & Talley, N. J. (2005). The epidemiology of childhood recurrent abdominal pain in Western countries: a systematic review. American journal of Gastroenterology, 100(8), 1868–1875. https://doi.org/10.1111/j.1572-0241.2005.41893.x
Chu, M., Nguyen, T., Pandey, V., Zhou, Y., Pham, H. N., Bar-Yoseph, R., Radom-Aizik, S., Jain, R., Cooper, D. M., & Khine, M. (2019). Respiration rate and volume measurements using wearable strain sensors. NPJ digital medicine, 2(1), 1–9. https://doi.org/10.1038/s41746-019-0083-3
Cohen, M. E. & White, P. D. (1947). Studies of breathing, pulmonary ventilation and subjective awareness of shortness of breath (dyspnea) in neurocirculatory asthenia, effort syndrome, anxiety neurosis. Journal of Clinical Investigation, 26(3), 520–529. https://doi.org/10.1172/JCI101836
Courtney, R. (2009). The functions of breathing and its dysfunctions and their relationship to breathing therapy. International Journal of Osteopathic Medicine, 12, 78–85. https://doi.org/10.1016/j.ijosm.2009.04.002
Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at: http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are
Davidoff, A. L., & Whitehead, W. E. (1996). Biofeedback, relaxation training, and cognitive behavior modification: Treatments for functional GI disorders, In Olden, K, W. (ed). Handbook of Functional Gastrointestinal Disorders. CRC Press, 361–384.
Dupont, H. L. (2014). Review article: evidence for the role of gut microbiota in irritable bowel syndrome and its potential influence on therapeutic targets. Alimentary Pharmacology & Therapeutics, 39(10), 1033–1042. https://doi.org/10.1111/apt.12728
Fairbrass, K. M., Costantino, S. J., Gracie, D. J., & Ford, A. C. (2020). Prevalence of irritable bowel syndrome-type symptoms in patients with inflammatory bowel disease in remission: a systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology, 5(12), 1053–162. https://doi.org/10.1016/s2468-1253(20)30300-9
Goldenberg, J. Z., Brignall, M., Hamilton, M., Beardsley, J., Batson, R. D., Hawrelak, J., Lichtenstein, B., & Johnston, B. C. (2019). Biofeedback for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews, (11). https://doi.org/10.1002/14651858.CD012530.pub2
Harty, H. R., Corfield, D. R., Schwartzstein, R. M., & Adams, L. (1999). External thoracic restriction, respiratory sensation, and ventilation during exercise in men. Journal of Applied Physiology, 86(4), 1142–1150. https://doi.org/10.1152/jappl.19184.108.40.2062
Khazan, I. (2019). A guide to normal values for biofeedback. Biofeedback, 47(1), 2–5. https://doi.org/10.5298/1081-5937-47.1.03
Luthe, W. & Schultz, J. H. (1969). Autogenic Therapy Volume II: Medical Applications. Grune & Stratton.
MacHose, M., & Peper, E. (1991). The effect of clothing on inhalation volume. Biofeedback and Self-Regulation, 16(3), 261–265. https://doi.org/10.1007/BF01000020
Marchenko, V., Ghali, M. G., & Rogers, R. F. (2015). The role of spinal GABAergic circuits in the control of phrenic nerve motor output. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 308(11), R916–R926. https://doi.org/10.1152/ajpregu.00244.2014
Melissa. (2015). Why women fainted so much in the 19th century. May 20, 2015. Downloaded October 2, 2021. http://www.todayifoundout.com/index.php/2015/05/women-fainted-much-19th-century/
Peper, E., Gibney, K. H., & Holt, C. F. (2002). Make Health Happen—Training Yourself to Create Wellness. Kendall/Hunt Publishing Company.
Peper, E., Gilbert, C. D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173–179. https://doi.org/10.5298/1081-5937-43.4.06
Peper, E., Groshans, G. H., Johnston, J., Harvey, R., & Shaffer, F. (2016). Calibrating respiratory strain gauges: What the numbers mean for monitoring respiration. Biofeedback, 44(2), 101–105. https://doi.org/10.5298/1081-5937-44.2.06
Peper, E., Harvey, R., Cuellar, Y., & Membrila, C.(in press). Reduce anxiety. NeuroRegulation.
Peper, E., Harvey, R., Lin, I. M., Tylova, H., & Moss, D. (2007). Is there more to blood volume pulse than heart rate variability, respiratory sinus arrhythmia, and cardiorespiratory synchrony? Biofeedback, 35(2), 54–61. https://www.researchgate.net/publication/259560204_Is_There_More_to_Blood_Volume_Pulse_Than_Heart_Rate_Variability_Respiratory_Sinus_Arrhythmia_and_Cardiorespiratory_Synchrony
Peper, E., Lin, I-M, & Harvey, R. (2017). Posture and mood: Implications and applications to therapy. Biofeedback, 35(2), 42–48. https://doi.org/10.5298/1081-5937-45.2.03
Peper, E., Lin, I-M, Harvey, R., Gilbert, M., Gubbala, P., Ratkovich, A., & Fletcher, F. (2014). Transforming chained behaviors: Case studies of overcoming smoking, eczema and hair pulling (trichotillomania). Biofeedback, 42(4), 154–160. https://doi.org/10.5298/1081-5937-42.4.06
Peper, E., Mason, L., Harvey, R., Wolski, L, & Torres, J. (2020). Can acid reflux be reduced by breathing? Townsend Letters-The Examiner of Alternative Medicine, 445/446, 44–47. https://www.townsendletter.com/article/445-6-acid-reflux-reduced-by-breathing/
Peper, E., Mason, L., Huey, C. (2017). Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback, 45(4), 83–87. https://doi.org/10.5298/1081-5937-45.4.04
Peper, E., Miceli, B., & Harvey, R. (2016). Educational model for self-healing: Eliminating a chronic migraine with electromyography, autogenic training, posture, and mindfulness. Biofeedback, 44(3), 130–137. https://www.aapb.org/files/publications/biofeedback/2016/biof-44-03-130-137.pdf
Peper, E., Shaffer, F., & Lin, I. M. (2010). Garbage in; Garbage out—Identify blood volume pulse (BVP) artifacts before analyzing and interpreting BVP, blood volume pulse amplitude, and heart rate/respiratory sinus arrhythmia data. Biofeedback, 38(1), 19–23. https://doi.org/10.5298/1081-5937-38.1.19
Sapolsky, R. (2004). Why Zebras Don’t Get Ulcers. Owl Books ISBN: 978-0805073690
Shaffer, F., Combatalade, D., Peper, E., & Meehan, Z. M. (2016). A guide to cleaner electrodermal activity measurements. Biofeedback, 44( 2), 90–100. https://doi.org/10.5298/1081-5937-44.2.01
Smith, M. M., Saklofske, D. H., Stoeber, J., & Sherry, S. B. (2016). The big three perfectionism scale: A new measure of perfectionism. Journal of Psychoeducational Assessment, 34(7), 670–687. https://doi.org/10.1177/0734282916651539
Sowder, E., Gevirtz, R., Shapiro, W., & Ebert, C. (2010). Restoration of vagal tone: a possible mechanism for functional abdominal pain. Applied Psychophysiology and Biofeedback, 35(3), 199–206. https://doi.org/10.1007/s10484-010-9128-8
Stern, M. J., Guiles, R. A., & Gevirtz, R. (2014). HRV biofeedback for pediatric irritable bowel syndrome and functional abdominal pain: A clinical replication series. Applied Psychophysiology and Biofeedback, 39(3), 287–291. https://doi.org/10.1007/s10484-014-9261-x
Stonehewer, L. (2009). Dysfunctional breathing for women’s health physiotherapists. Journal of the Association of Chartered Physiotherapists in Women’s Health, 104, 38–40. https://pogp.csp.org.uk/system/files/stonehewer_hr.pdf
Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical hypotheses, 78(5), 571–579. https://doi.org/10.1016/j.mehy.2012.01.021
Sun, X., Shang, W., Wang, Z., Liu, X., Fang, X., & Ke, M. (2016). Short-term and long-term effect of diaphragm biofeedback training in gastroesophageal reflux disease: An open-label, pilot, randomized trial. Diseases of the Esophagus, 29(7), 829–836. https://doi.org/10.1111/dote.12390
Taneja. I., Deepak, K.K., Poojary, G., Acharya, I.N., Pandey, R.M., & Sharma, M.P. (2004). Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: a randomized control study. Appl Psychophysiol Biofeedback, 29(1), 19-33. https://doi.org/10.1023/b:apbi.0000017861.60439.95
Vlieger, A. M., Blink, M., Tromp, E., & Benninga, M. A. (2008). Use of complementary and alternative medicine by pediatric patients with functional and organic gastrointestinal diseases: results from a multicenter survey. Pediatrics, 122(2), e446–e451. https://doi.org/10.1542/peds.2008-0266
Mindfulness-based strategies are drawn from ancient Buddhist practices and have found acceptance as one of the major behavioral medicine techniques of today (Hilton et al, 2016; Khazan, 2013). Throughout this blog the term mindfulness will refer broadly to a mental state of paying total attention to the present moment, with a non-judgmental awareness of inner and outer experiences (Baer, Smith, & Allen, 2004; Kabat-Zinn, 1994). This approach is the common core for many stress management approaches (Peper, Harvey, & Lin, 2019).
Transcendental meditation (TM), a form of concentrative meditation involving repetition of a sacred word or phrase known as a mantra, was a popular meditation technique introduced in the United States from India and participants reported improvement of mental and physical health (Wallace, 1970; Paul-Labrador et al, 2006; Rainforth et al, 2007; Hawkins, 2003). To make TM more acceptable for the western audience, Herbert Benson, MD, adapted and simplified the TM process and then labelled a core element, the ‘relaxation response’ (Benson, Beary, & Carol, 1974; Benson & Clipper, 1992). Instead of giving people a secret mantra and part of a spiritual tradition, he recommend using the word “one” as the mantra. Since that time numerous studies have demonstrated that when patients practice the relaxation response, many clinical symptoms were reduced.
In 1979, Jon Kabat-Zinn introduced a manual for a standardized Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center (Kabat-Zinn, 1994; Kabat-Zin, 2003). The eight-week program combined mindfulness as a form of insight meditation with mindful yogic movement exercises designed to focus awareness on body sensations, thoughts, feelings, and behaviors. Mindfulness based programs have become a predominant approach used in behavioral medicine.
Mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) combine mindfulness meditation training with cognitive therapy and is a useful approach to reduce a variety of mental and physical conditions such as stress, anxiety, depression, addiction, disordered eating, chronic pain, sleep disturbances, and high blood pressure (Andersen et al., 2013; Carlson, Speca, Patel, & Goodey, 2003; Fjorback, Arendt, Ørnbøl, Fink, & Walach, 2011; Greeson, & Eisenlohr-Moul, 2014; Hoffman et al., 2012; Marchand, 2012; Baer, 2015; Demarzo et al, 2015; Khoury et al, 2013; Khoury et al, 2015; Teasdale, Segal, & Williams, 1995; Kabat-Zinn, 1994; Kabat-Zin, 2003; Zimmermann, Burrell, , & Jordan, 2018). Although in most cases, MBSR is helpful, in some cases meditation can evoke negative physical and/or psychological outcomes and inhibit prosocial behavior (Kreplin et al, 2018; Lindahl et al, 2017). Based on this encouraging research, many people are learning to meditate on their own using meditation apps. However, there are many questions that can arise for people new to meditation – such as what is meditation, how do I do it, what are the challenges, and how is it helpful? Some people also develop misconceptions about what meditation is and can become discouraged.
Watch the outstanding presentation by Professor Jennifer Daubenmier presented for the Holistic Health Lecture Series, in which she discusses meditation myths and pragmatic tips for practice.
Andersen, S. R., Würtzen, H., Steding-Jessen, M., Christensen, J., Andersen, K. K., Flyger, H., … & Dalton, S. O. (2013). Effect of mindfulness-based stress reduction on sleep quality: Results of a randomized trial among Danish breast cancer patients. Acta Oncologica, 52(2), 336-344. https://doi.org/10.3109/0284186X.2012.745948
Baer, R., Smith, G., & Allen, K. (2004). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills. Assessment, 11, 191–206. https://doi.org/10.1177/1073191104268029
Benson, H., Beary, J. F., & Carol, M. P. (1974).The Relaxation Response. Psychiatry, 37(1), 37-46. https://www.tandfonline.com/loi/upsy20
Benson, H. & Clipper, M.Z. (1992). The Relaxation Response. Wings Books.
Carlson, L. E., Speca, M., Patel, K. D., & Goodey, E. (2003). Mindfulness‐based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Medicine, 65(4), 571-581. https://doi.org/10.1097/01.psy.0000074003.35911.41
Demarzo, M. M., Montero-Marin, J., Cuijpers, P., Zabaleta-del-Olmo, E., Mahtani, K. R., Vellinga, A., Vicens, C., López-del-Hoyo, Y., & García-Campayo, J. (2015). The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review. Annals of family medicine, 13(6), 573–582. https://doi.org/10.1370/afm.1863
Fjorback, L. O., Arendt, M., Ørnbøl, E., Fink, P., & Walach, H. (2011). Mindfulness‐Based Stress Reduction and Mindfulness‐Based Cognitive Therapy–A systematic review of randomized controlled trials. Acta Psychiatrica Scandinavica, 124(2), 102-119. https://doi.org/10.1111/j.1600-0447.2011.01704.x
Greeson, J., & Eisenlohr-Moul, T. (2014). Mindfulness-based stress reduction for chronic pain. In R. A. Baer (Ed.), Mindfulness-Based Treatment Approaches: Clinician’s Guide to Evidence Base and Applications, 269-292. San Diego, CA: Academic Press. https://www.academia.edu/8092878/Mindfulness_Based_Stress_Reduction_for_Chronic_Pain
Hawkins, M. A. (2003). Effectiveness of the Transcendental Meditation program in criminal rehabilitation and substance abuse recovery, Journal of Offender Rehabilitation, 36(1-4), 47-65. https://doi.org/10.1300/J076v36n01_03
Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., …Maglione, M. A. (2016). Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Annals of Behavioral Medicine, 51(2), 199-213. https://doi.org/10.1007/s12160-016-9844-2
Hoffman, C. J., Ersser, S. J., Hopkinson, J. B., Nicholls, P. G., Harrington, J. E., & Thomas, P. W. (2012). Effectiveness of mindfulness-based stress reduction in mood, breast-and endocrine-related quality of life, and well-being in stage 0 to III breast cancer: A randomized, controlled trial. Journal of Clinical Oncology, 30(12), 1335-1342. https://doi.org/10.1200/JCO.2010.34.0331
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion.
Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8, 73–107. https://www.proquest.com/openview/fef538e3ed2210c1201ef2a946faed43/1?pq-origsite=gscholar&cbl=29080
Khazan, I. Z. (2013). The clinical handbook of biofeedback: A step-by-step guide for training and practice with mindfulness. John Wiley & Sons.
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., Chapleau, M., Paquin, K., & Hofmann, S. G. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review, 33(6), 763-771. https://doi.org/10.1016/j.cpr.2013.05.005
Khoury, B., Sharma, M., Rush, S. E., & Fournier, C. (2015). Mindfulness-based stress reduction for healthy individuals: A meta-analysis. Journal of Psychosomatic Research, 78(6), 519-528. https://doi.org/10.1016/j.jpsychores.2015.03.009
Lindahl, J. R., Fisher, N. E., Cooper, D. J., Rosen, R. K, & Britton, W. B. (2017) The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLoSONE, 12(5): e0176239. https://doi.org/10.1371/journal.pone.0176239
Marchand, W. R. (2012). Mindfulness-based stress reduction, mindfulness-based cognitive therapy, and Zen meditation for depression, anxiety, pain, and psychological distress. Journal of Psychiatric Practice, 18(4), 233-252. https://doi.org/10.1097/01.pra.0000416014.53215.86
Paul-Labrador, M., Polk, D., Dwyer, J.H. et al. (2006). Effects of a randomized controlled trial of Transcendental Meditation on components of the metabolic syndrome in subjects with coronary heart disease. Archive of Internal Medicine, 166(11), 1218-1224. https://doi.org/10.1001/archinte.166.11.1218
Peper, E., Harvey, R., & Lin, I-M. (2019). Mindfulness training has themes common to other technique. Biofeedback. 47(3), 50-57. https://doi.org/10.5298/1081-5937-47.3.02
Rainforth, M.V., Schneider, R.H., Nidich, S.I., Gaylord-King, C., Salerno, J.W., & Anderson, J.W. (2007). Stress reduction programs in patients with elevated blood pressure: A systematic review and meta-analysis. Current Hypertension Reports, 9(6), 520–528. https://doi.org/10.1007/s11906-007-0094-3
Teasdale, J. D., Segal, Z., & Williams, J. M. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33, 25–39. https://doi.org/10.1016/0005-7967(94)e0011-7
Wallace, K.W. (1970). Physiological Effects of Transcendental Meditation. Science, 167 (3926), 1751-1754. https://doi.org/10.1126/science.167.3926.1
Erik Peper and Elyse Shafarman
After taking Alexander Technique lessons I felt lighter and stood taller and I have learned how to direct myself differently. I am much more aware of my body, so that while I am working at the computer, I notice when I am slouching and contracting. Even better, I know what to do so that I have no pain at the end of the day. It’s as though I’ve learned to allow my body to move freely.
The Alexander Technique is one of the somatic techniques that optimize health and performance (Murphy, 1993). Many people report that after taking Alexander lessons, many organic and functional disorders disappear. Others report that their music or dance performances improve. The Alexander Technique has been shown to improve back pain, neck pain, knee pain walking gait, and balance (Alexander technique, 2022; Hamel, et al, 2016; MacPherson et al., 2015; Preece, et al., 2016). Benefits are not just physical. Studying the technique decreases performance anxiety in musicians and reduces depression associated with Parkinson’s disease (Klein, et al, 2014; Stallibrass et al., 2002).
The Alexander Technique was developed in the late 19th century by the Australian actor, Frederick Matthias Alexander (Alexander, 2001). It is an educational method that teaches students to align, relax and free themselves from limiting tension habits (Alexander, 2001; Alexander technique, 2022). F.M Alexander developed this technique to resolve his own problem of becoming hoarse and losing his voice when speaking on stage.
Initially he went to doctors for treatment but nothing worked except rest. After resting, his voice was great again; however, it quickly became hoarse when speaking. He recognized that it must be how he was using himself while speaking that caused the hoarseness. He understood that “use” was not just a physical pattern, but a mental and emotional way of being. “Use” included beliefs, expectations and feelings. After working on himself, he developed the educational process known as the Alexander Technique that helps people improve the way they move, breathe and react to the situations of life.
The benefits of this approach has been documented in a large randomized controlled trial of one-on-one Alexander Technique lessons which showed that it significantly reduced chronic low back pain and the benefits persisted a year after treatment (Little, et al, 2008). Back pain as well as shoulder and neck pain often is often related to stress and how we misuse ourselves. When experiencing discomfort, we quickly tend to blame our physical structure and assume that the back pain is due to identifiable structural pathology identified by X-ray or MRI assessments. However, similar structural pathologies are often present in people who do not experience pain and the MRI findings correlate poorly with the experience of discomfort (Deyo & Weinstein, 2001; Svanbergsson et al., 2017). More likely, the causes and solutions involve how we use ourselves (e.g., how we stand, move, or respond to stress). A functional approach may include teaching awareness of the triggers that precede neck and back tension, skills to prevent the tensing of those muscles not needed for task performance, resolving psychosocial stress and improving the ergonomic factors that contribute to working in a stressed position (Peper, Harvey & Faass, 2020). Conceptually, how we are use ourselves (thoughts, emotions, and body) affects and transforms our physical structure and then our physical structure constrains how we use ourselves.
Watch the video with Alexander Teacher, Elyse Shafarman, who describes the Alexander Technique and guides you through practices that you can use immediately to optimize your health while sitting and moving.
See also the following posts:
Alexander, F.M. (2001). The Use of the Self. London: Orion Publishing. https://www.amazon.com/Use-Self-F-M-Alexander/dp/0752843915
Alexander technique. (2022). National Health Service. Retrieved 19 April, 2022/. https://www.nhs.uk/conditions/alexander-technique/
Deyo, R.A. & Weinstein, J.N. (2001). Low back pain. N Engl J Med., 344(5),363-70. https://doi.org/10.1056/NEJM200102013440508
Hamel, K.A., Ross, C., Schultz, B., O’Neill, M., & Anderson, D.I. (2016). Older adult Alexander Technique practitioners walk differently than healthy age-matched controls. J Body Mov Ther. 20(4), 751-760. https://doi.org/10.1016/j.jbmt.2016.04.009
Klein, S. D., Bayard, C., & Wolf, U. (2014). The Alexander Technique and musicians: a systematic review of controlled trials. BMC complementary and alternative medicine, 14, 414. https://doi.org/10.1186/1472-6882-14-414
Little, P. Lewith, W G., Webley, F., Evans, M., …(2008). Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ, 337:a884. https://doi.org/10.1136/bmj.a884
MacPherson, H., Tilbrook, H., Richmond, S., Woodman, J., Ballard, K., Atkin, K., Bland, M., et al. (2015). Alexander Technique Lessons or Acupuncture Sessions for Persons With Chronic Neck Pain: A Randomized Trial. Ann Intern Med, 163(9), 653-62. https://doi.org/10.7326/M15-0667
Preece, S.J., Jones, R.K., Brown, C.A. et al. (2016). Reductions in co-contraction following neuromuscular re-education in people with knee osteoarthritis. BMC Musculoskelet Disord 17, 372. https://doi.org/10.1186/s12891-016-1209-2
Stallibrass, C., Sissons, P., & Chalmers. C. (2002). Randomized controlled trial of the Alexander technique for idiopathic Parkinson’s disease. Clin Rehabil, 16(7), 695-708. https://doi.org/10.1191/0269215502cr544oa
Svanbergsson, G., Ingvarsson, T., & Arnardóttir RH. (2017). [MRI for diagnosis of low back pain: Usability, association with symptoms and influence on treatment]. Laeknabladid, 103(1):17-22. Icelandic. https://doi.org/10.17992/lbl.2017.01.116
Tuomilehto, J., Lindström, J., Eriksson, J.G., Valle, T.T., Hämäläinen, H., Ilanne-Parikka, P., Keinänen-Kiukaanniemi, S., Laakso, M., Louheranta, A., Rastas, M., et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N. Engl. J. Med., 344, 1343–1350. https://doi.org/10.1056/NEJM200105033441801
Uusitupa, Mm, Khan, T.A., Viguiliouk, E., Kahleova, H., Rivellese, A.A., Hermansen, K., Pfeiffer, A., Thanopoulou, A., Salas-Salvadó, J., Schwab, U., & Sievenpiper. J.L. (2019). Prevention of Type 2 Diabetes by Lifestyle Changes: A Systematic Review and Meta-Analysis. Nutrients, 11(11)2611. https://doi.org/10.3390/nu11112611
Most people breathe 22,000 breaths per day. We tend to breathe more rapidly when stressed, anxious or in pain. While a slower diaphragmatic breathing supports recovery and regeneration. We usually become aware of our dysfunctional breathing when there are problems such as nasal congestion, allergies, asthma, emphysema, or breathlessness during exertion. Optimal breathing is much more than the absence of symptoms and is influenced by posture. Dysfunctional posture and breathing are cofactors in illness. We often do not realize that posture and breathing affect our thoughts and emotions and that our thoughts and emotions affect our posture and breathing. Watch the video, A breath of fresh air: Breathing and posture to optimize health, that was recorded for the 2022 Virtual Ergonomics Summit.
The purpose of this blog is to describe how a university class that incorporated structured self-experience practices reduced self-reported anxiety symptoms. This approach is different from a clinical treatment approach as it focused on empowerment and mastery learning (Peper, Miceli, & Harvey, 2016).
As a result of my practice, I felt my anxiety and my menstrual cramps decrease. — College senior
When I changed back to slower diaphragmatic breathin, I was more aware of my negative emotions and I was able to reduce the stress and anxiety I was feeling with the deep diaphragmatic breathing.– College junior
More than half of college students now report anxiety (Coakley et al., 2021). In our recent survey during the first day of the spring semester class, 59% of the students reported feeling tired, dreading their day, being distracted, lacking mental clarity and had difficulty concentrating.
Before the COVID pandemic nearly one-third of students had or developed moderate or severe anxiety or depression while being at college (Adams et al., 2021. The pandemic accelerated a trend of increasing anxiety that was already occurring. “The prevalence of major depressive disorder among graduate and professional students is two times higher in 2020 compared to 2019 and the prevalence of generalized anxiety disorder is 1.5 times higher than in 2019” As reported by Chirikov et al (2020) from the UC Berkeley SERU Consortium Reports.
This increase in anxiety has both short and long term performance and health consequences. Severe anxiety reduces cognitive functioning and is a risk factor for early dementia (Bierman et al., 2005; Richmond-Rakerd et al, 2022). It also increases the risk for asthma, arthritis, back/neck problems, chronic headache, diabetes, heart disease, hypertension, pain, obesity and ulcer (Bhattacharya et al., 2014; Kang et al, 2017).
The most commonly used treatment for anxiety are pharmaceutical and cognitive behavior therapy (CBT) (Kaczkurkin & Foa, 2015). The anti-anxiety drugs are usually benzodiazepines (e.g., alprazolam (Xanax), clonazepam (Klonopin), chlordiazepoxide (Librium), diazepam (Valium) and lorazepam (Ativan). Although these drugs they may reduce anxiety, they have numerous side effects such as drowsiness, irritability, dizziness, memory and attention problems, and physical dependence (Shri, 2012; Crane, 2013).
Cognitive behavior therapy techniques based upon the assumption that anxiety is primarily a disorder in thinking which then causes the symptoms and behaviors associated with anxiety. Thus, the primary treatment intervention focuses on changing thoughts.
Given the significant increase in anxiety and the potential long term negative health risks, there is need to provide educational strategies to empower students to prevent and reduce their anxiety. A holistic approach is one that assumes that body and mind are one and that soma/body, emotions and thoughts interchangeably affect the development of anxiety. Initially in our research, Peper, Lin, Harvey & Perez (2017) reported that it was easier to access hopeless, helpless, powerless and defeated memories in a slouched position than an upright position and it was easier to access empowering positive memories in an upright position than a slouched position. Our research on transforming hopeless, helpless, depressive thought to empowering thoughts, Peper, Harvey & Hamiel (2019) found that it was much more effective if the person first shifts to an upright posture, then begins slow diaphragmatic breathing and finally reframes their negative to empowering/positive thoughts. Participants were able to reframe stressful memories much more easily when in an upright posture compared to a slouched posture and reported a significant reduction in negative thoughts, anxiety (they also reported a significant decrease in negative thoughts, anxiety and tension as compared to those attempting to just change their thoughts).
The strategies to reduce anxiety focus on breathing and posture change. At the same time there are many other factors that may contribute the onset or maintenance of anxiety such as social isolation, economic insecurity, etc. In addition, low glucose levels can increase irritability and may lower the threshold of experiencing anxiety or impulsive behavior (Barr, Peper, & Swatzyna, 2019; Brad et al, 2014). This is often labeled as being “hangry” (MacCormack & Lindquist, 2019). Thus, by changing a high glycemic diet to a low glycemic diet may reduce the somatic discomfort (which can be interpreted as anxiety) triggered by low glucose levels. In addition, people are also sitting more and more in front of screens. In this position, they tend to breathe quicker and more shallowly in their chest.
Shallow rapid breathing tends to reduce pCO2 and contributes to subclinical hyperventilation which could be experienced as anxiety (Lum, 1981; Wilhelm et al., 2001; Du Pasquier et al, 2020). Experimentally, the feeling of anxiety can rapidly be evoked by instructing a person to sequentially exhale about 70 % of the inhaled air continuously for 30 seconds. After 30 seconds, most participants reported a significant increase in anxiety (Peper & MacHose, 1993). Thus, the combination of sitting, shallow breathing and increased stress from the pandemic are all cofactors that may contribute to the self-reported increase in anxiety.
To reduce anxiety and discomfort, McGrady and Moss (2013) suggested that self-regulation and stress management approaches be offered as the initial treatment/teaching strategy in health care instead of medication. One of the useful approaches to reduce sympathetic arousal and optimize health is breathing awareness and retraining (Gilbert, 2003).
Stress management as part of a university holistic health class
Every semester since 1976, up to 180 undergraduates have enrolled in a three-unit Holistic Health class on stress management and self-healing (Klein & Peper, 2013). Students in the class are assigned self-healing projects using techniques that focus on awareness of stress, dynamic regeneration, stress reduction imagery for healing, and other behavioral change techniques adapted from the book, Make Health Happen (Peper, Gibney & Holt, 2002).
82% of students self-reported that they were ‘mostly successful’ in achieving their self-healing goals. Students have consistently reported achieving positive benefits such as increasing physical fitness, changing diets, reducing depression, anxiety, and pain, eliminating eczema, and even reducing substance abuse (Peper et al., 2003; Bier et al., 2005; Peper et al., 2014).
This assessment reports how students’ anxiety decreased after five weeks of daily practice. The students filled out an anonymous survey in which they rated the change in their discomfort after practicing effortless diaphragmatic breathing. More than 70% of the students reported a decrease in anxiety. In addition, they reported decreases in symptoms of stress, neck and shoulder pain as shown in Figure 1.
Figure 1. Self-report of decrease in symptoms after practice diaphragmatic breathing for a week.
Most students also reported an increase in mental clarity and concentration that improved their study habits. As one student noted: Now that I breathe properly, I have less mental fog and feel less overwhelmed and more relaxed. My shoulders don’t feel tense, and my muscles are not as achy at the end of the day.
The teaching components for the first five weeks included a focus on the psychobiology of stress, the role of posture, and psychophysiology of respiration. The class included didactic presentations and daily self-practice
- Diadactic presentation on the physiology of stress and how posture impacts health.
- Self-observation of stress reactions; energy drain/energy gain and learning dynamic relaxation.
- Short experiential practices so that the student can experience how slouched posture allows easier access to helpless, hopeless, powerless and defeated memories.
- Short experiential breathing practices to show how breathing holding occurs and how 70% exhalation within 30 seconds increases anxiety.
- Didactic presentation on the physiology of breathing and how a constricted waist tends to have the person breathe high in their chest (the cause of neurasthemia) and how the fight/flight response triggers chest breathing, breath holding and/or shallow breathing.
- Explanation and practice of diaphragmatic breathing.
Students were assigned weekly daily self-practices which included both skill mastery by practicing for 20 minutes as well and implementing the skill during their daily life. They then recorded their experiences after the practice. At the end of the week, they reviewed their own log of week and summarized their observations (benefits, difficulties) and then met in small groups to discuss their experiences and extract common themes. These daily practices consisted of:
- Awareness of stress. Monitoring how they reacted to daily stressor
- Practicing dynamic relaxation. Students practiced for 20 minutes a modified progressive relaxation exercise and observed and inhibit bracing pattern
- Changing energy drain and energy gains. Students observed what events reduced or increased their subjective energy and implemented changes in their behavior to decrease events that reduced their energy and increased behaviors that increase their enery
- Creating a memory of wholeness practice
- Practicing effortless breathing. Students practiced slowly diaphragmatic abdominal breathing for 20 minutes per day and each time they become aware of dysfunctional breathing (breath holding, shallow chest breathing, gasping) during the day, they would shift to slower diaphragmatic breathing.
Almost all students were surprised how beneficial these practices were to reduce their anxiety and symptoms. Generally, the more the students would interrupt their personal stress responses during the day by shifting to diaphragmatic breathing the more did they experience success. We hypothesize that some of the following factors contributed to the students’ improvement.
- Learning through self-mastery as an education approach versus clinical treatment.
- Generalizing the skills into daily life and activities. Practicing the skills during the day in which the cue of a stress reaction triggered the person to breathe slowly. The breathing would reduce the sympathetic activation.
- Interrupting escalating sympathetic arousal. Responding with an intervention reduced the sense of being overwhelmed and unable to cope by the participant by taking charge and performing an active task.
- Redirecting attention and thoughts away from the anxiety triggers to a positive task.
- Increasing heart rate variability. Through slow breathing heart rate variability increased which enhanced sympathetic parasympathetic balance.
- Reducing subclinical hyperventilation by breathing slower and thereby increasing pC02.
- Increasing social support by meeting in small groups. The class discussion group normalized the anxiety experiences.
- Providing hope. The class lectures, assigned readings and videos provide hope; since, it included reports how other students had reversed their chronic disorders such as irritable bowel disease, acid reflux, psoriasis with behavioral interventions.
Although the study lacked a control group and is only based upon self-report, it offers an economical non-pharmaceutical approach to reduce anxiety. These stress management strategies may not resolve anxiety for everyone. Nevertheless, we recommend that schools implement this approach as the first education intervention to improve health in which students are taught about stress management, learn and practice relaxation and diaphragmatic breathing and then practice these skills during the day whenever they experience stress or dysfunctional breathing.
I noticed that breathing helped tremendously with my anxiety. I was able to feel okay without having that dreadful feeling stay in my chest and I felt it escape in my exhales. I also felt that I was able to breathe deeper and relax better altogether. It was therapeutic, I felt more present, aware, and energized.
See the following blogs for detailed breathing instructions
Adams. K.L., Saunders KE, Keown-Stoneman CDG, et al. (2021). Mental health trajectories in undergraduate students over the first year of university: a longitudinal cohort study. BMJ Open 2021; 11:e047393. https://doi.org/10.1136/bmjopen-2020-047393
Barr, E. A., Peper, E. & Swatzyna, R.J. (2019). Slouched Posture, Sleep Deprivation, and Mood Disorders: Interconnection and Modulation by Theta Brain Waves. Neuroregulation, 6(4), 181–189 https://doi.org/10.15540/nr.6.41.181
Bhattacharya, R., Shen, C. & Sambamoorthi, U. (2014). Excess risk of chronic physical conditions associated with depression and anxiety. BMC Psychiatry 14, 10 (2014). https://doi.org/10.1186/1471-244X-14-10
Bier, M., Peper, E., & Burke, A. (2005). Integrated stress management with ‘Make Health Happen: Measuring the impact through a 5-month follow-up. Poster presentation at the 36th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback. Abstract published in: Applied Psychophysiology and Biofeedback, 30(4), 400. https://biofeedbackhealth.files.wordpress.com/2013/12/2005-aapb-make-health-happen-bier-peper-burke-gibney3-12-05-rev.pdf
Bierman, E.J.M., Comijs, H.C. , Jonker, C. & Beekman, A.T.F. (2005). Effects of Anxiety Versus Depression on Cognition in Later Life. The American Journal of Geriatric Psychiatry,13(8), 686-693, https://doi.org/10.1097/00019442-200508000-00007.
Brad, J., Bushman, C., DeWall, N., Pond, R.S., &. Hanus, M.D. (2014).. Low glucose relates to greater aggression in married couples. PNAS, April 14, 2014. https://doi.org/10.1073/pnas.1400619111
Chirikov, I., Soria, K. M, Horgos, B., & Jones-White, D. (2020). Undergraduate and Graduate Students’ Mental Health During the COVID-19 Pandemic. UC Berkeley: Center for Studies in Higher Education. Retrieved from https://escholarship.org/uc/item/80k5d5hw
Coakley, K.E., Le, H., Silva, S.R. et al. Anxiety is associated with appetitive traits in university students during the COVID-19 pandemic. Nutr J 20, 45 (2021). https://doi.org/10.1186/s12937-021-00701-9
Crane,E.H. (2013).Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. 2013 Feb 22. In: The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK384680/
Du Pasquier, D., Fellrath, J.M., & Sauty, A. (2020). Hyperventilation syndrome and dysfunctional breathing: update. Revue Medicale Suisse, 16(698), 1243-1249. https://europepmc.org/article/med/32558453
Gilbert C. Clinical Applications of Breathing Regulation: Beyond Anxiety Management. Behavior Modification. 2003;27(5):692-709. https://doi.org/10.1177/0145445503256322
Kaczkurkin, A.N. & Foa, E.B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues Clin Neurosci. 17(3):337-46. https://doi.org/10.31887/DCNS.2015.17.3/akaczkurkin
Kang, H. J., Bae, K. Y., Kim, S. W., Shin, H. Y., Shin, I. S., Yoon, J. S., & Kim, J. M. (2017). Impact of Anxiety and Depression on Physical Health Condition and Disability in an Elderly Korean Population. Psychiatry investigation, 14(3), 240–248. https://doi.org/10.4306/pi.2017.14.3.240
Klein, A. & Peper, W. (2013). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback, 41(4), 194–201. https://doi.org/10.5298/1081-5937-41.4.01
Lum, L. C. (1981). Hyperventilation and anxiety state. Journal of the Royal Society of Medicine, 74(1), 1-4. https://journals.sagepub.com/doi/pdf/10.1177/014107688107400101
MacCormack, J. K., & Lindquist, K. A. (2019). Feeling hangry? When hunger is conceptualized as emotion. Emotion, 19(2), 301–319. https://doi.org/10.1037/emo0000422
McGrady, A. & Moss, D. (2013). Pathways to illness, pathways to health. New York: Springer. https://link.springer.com/book/10.1007/978-1-4419-1379-1
Peper, E., Gibney, K.H., & Holt, C.F. (2002). Make health happen: Training yourself to create wellness. Dubuque, IA: Kendall/Hunt Publishing Company. https://he.kendallhunt.com/make-health-happen
Peper, E., Harvey, R., & Hamiel, D. (2019). Transforming thoughts with postural awareness to increase therapeutic and teaching efficacy. NeuroRegulation, 6(3),153-169. doi:10.15540/nr.6.3.1533-1 https://www.neuroregulation.org/article/view/19455/13261
Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood. Biofeedback.45 (2), 36-41. https://doi.org/10.5298/1081-5937-45.2.01
Peper, E., Lin, I-M, Harvey, R., Gilbert, M., Gubbala, P., Ratkovich, A., & Fletcher, F. (2014). Transforming chained behaviors: Case studies of overcoming smoking, eczema and hair pulling (trichotillomania). Biofeedback, 42(4), 154-160. https://doi.org/10.5298/1081-5937-42.4.06
Peper, E., MacHose, M. (1993). Symptom prescription: Inducing anxiety by 70% exhalation. Biofeedback and Self-Regulation 18, 133–139). https://doi.org/10.1007/BF00999790
Peper, E., Miceli, B., & Harvey, R. (2016). Educational Model for Self-healing: Eliminating a Chronic Migraine with Electromyography, Autogenic Training, Posture, and Mindfulness. Biofeedback, 44(3), 130–137. https://doi.org/10.5298/1081-5937-44.3.03
Peper, E., Sato-Perry, K & Gibney, K. H. (2003). Achieving Health: A 14-Session Structured Stress Management Program—Eczema as a Case Illustration. 34rd Annual Meeting of the Association for Applied Psychophysiology and Biofeedback. Abstract in: Applied Psychophysiology and Biofeedback, 28(4), 308. Proceeding in: http://www.aapb.org/membersonly/articles/P39peper.pdf
Richmond-Rakerd, L.S., D’Souza, S, Milne, B.J, Caspi, A., & Moffitt, T.E. (2022). Longitudinal Associations of Mental Disorders with Dementia: 30-Year Analysis of 1.7 Million New Zealand Citizens. JAMA Psychiatry. Published online February 16, 2022. https://doi.org/10.1001/jamapsychiatry.2021.4377
Shri, R. (2012). Anxiety: Causes and Management. The Journal of Behavioral Science, 5(1), 100–118. Retrieved from https://so06.tci-thaijo.org/index.php/IJBS/article/view/2205
Wilhelm, F.H., Gevirtz, R., & Roth, W.T. (2001). Respiratory dysregulation in anxiety, functional cardiac, and pain disorders. Assessment, phenomenology, and treatment. Behav Modif, 25(4), 513-45. https://doi.org/10.1177/0145445501254003
Pain is so different for each person. It can range from mildly distracting to totally debilitating. It can be the result from a medical procedure (post- surgical pain), a traumatic injury, disease, trauma or unknown causes. It is challenging to know what to do to reduce suffering and improve health and functioning. Should I take narcotics, have surgery, see a pain psychologist, have acupuncture, receive physical therapy, use biofeedback, change my diet, or get a massage? Should I exercise or rest? Should I follow my doctor’s recommendations?
Before you do anything, first listen to this podcast by pain psychologist, Rachel Zoffness, PhD. In this podcast she will explain what pain is; how it works; and how thoughts, emotions, and sensations are always interconnected. You will also learn the fundamentals of treating chronic pain and helping patients living with it. As one of my close friends stated, “I only wished I could have listened to this before, it would have saved years of suffering.” The podcast is Ologies with Alie Ward and the episode is Dolorology. The link for the episode is:
Rachel Zoffness, PhD, a pain psychologist, Visiting Professor at Stanford, and Assistant Clinical Professor at the UCSF School of Medicine. She serves on the Board of Directors of the U.S. Association for the Study of Pain, and the Society of Pediatric Pain Medicine. She is the author of The Pain Management Workbook and The Chronic Pain and Illness Workbook for Teens. She is a 2021 Mayday Fellow and consults on the development of integrative pain programs around the world.
Six years ago, I had a bilateral hernia repair, the surgeon was highly recommended and recognized as an expert in his field. Although the surgery was a mechanical success, the failure of the post-operative care resulted in severe urinary retention, multiple emergency room visits, and ongoing urinary difficulties. Six weeks after the surgery, I was still lugging a Foley catheter with a leg collection bag that drained my bladder. The surgeon had stated I could be back doing physical activities with a week (Peper, 2019). From my perspective the surgeon was a mechanic and not a gardener. The moment the mechanical structure was fixed in surgery, he had completed his work even if post-surgical complications arose.
Being a mechanic in medicine is an important role. The concept of being a mechanics is not limited to surgery, it can be applied to any treatment strategy when the practitioner focuses narrowly only on the presenting issue. A broken bone > align and put on a cast; hip pain due to the breakdown of cartilage > hip replacement surgery; depression > prescribe antidepressant medication; diabetes > prescribe medications to reduce blood sugar; hypertension > -prescribe anti-hypertensive medication; pain > prescribe opioids, etc. In many cases, healing is much more than mechanical interventions, it often includes post-operative care, exploring factors that may have contributed to disease onset, and retraining such as ongoing physical therapy for hip replacement surgery or teaching stress management, exercise, diet and lifestyle changes for people with diabetes.
Much of healing, especially for the treatment of chronic conditions, needs much more than a mechanical intervention. For example, type 2 diabetes, depression, or hypertension are triggered and maintained to a large extent by socio-economics inequalities and stressful lifestyles. Treatment needs to focus on healing and reduce the factors that created or now maintains the illness and support those factors that enhance healing. This is similar to the role of a gardener. Once planted, a successful gardener needs to be aware of, and support, all the factors that facilitate the plants growth (enough sunlight at the right time, appropriate watering and fertilizer, soil conditions, etc.).
These concepts are discussed in the superb article by Gavin Francis, MD and seminal book by Wayne Jonas, MD that describes how medicine needs to change and incorporate an holistic perspective to support and nurture the healing process.
Additional resource to optimize health and healing when needing surgery
Gavin, F. (2022). ‘We need to respect the process of healing’: a GP on the overlooked art of recovery. The Guardian. https://www.theguardian.com/world/2022/jan/04/we-need-to-respect-the-process-of-healing-a-gp-on-the-overlooked-art-of-recovery
Peper, E. Surviving and preventing medical errors. (2019). Townsend Letter-The Examiner of Alternative Medicine. 429, 63-69. https://www.townsendletter.com/article/429-surviving-and-preventing-medical-errors/
|Adapted from Peper, E., Covell, A., & Matzembacker, N. (2021). How a chronic headache condition became resolved with one session of breathing and posture coaching. NeuroRegulation, 8(4), 194–197. https://doi.org/10.15540/nr.8.4.194|
This blog describes the process by which a 32 year old woman student’s chronic headaches that she had since age eighteen was resolved in a single coaching session. The student suffered two or three headache per week a week which initially began when she was eighteen after using digital devices and encouraged her to slouch as she looked down. Although she describes herself as healthy, she reported having high level of anxiety and occasional depression. She self-medicated with 2 to 10 Excedrin tablets a week. It is possible that the chronic headaches could partially be triggered by caffeine withdrawal which get resolved by taking more Excedrins (Greben et al., 1980) since Excedrin contains 65 mg of caffeine as well as 250 mg of Acetaminophen which can be harmful to liver function (Bauer et al., 2021).
The behavioral coaching intervention
During the first day in class, the student approached the instructor and she shared that she had a severe headache. During their conversation, the instructor noticed that she was breathing in her chest without abdominal movement, her shoulders were held tight, her posture slightly slouched and her hands were cold. As she was unaware of her body responses, the instructor offered to guide her through some practices that may be useful to reduce her headache. The same strategies could also be useful for the other students in the class; since, headaches, anxiety, zoom fatigue, neck and shoulder tension, abdominal discomfort, and vision problems are common and have increased as people spent more time in front of screens (Charles et al., 2021; Ahmed et al., 2021; Bauer, 2021; Kuehn, 2021; Peper et al., 2021 ).
These symptoms may occur because of bad posture, neck and shoulder tension, shallow chest breathing, stress and social isolation (Elizagaray-Garcia et al., 2020; Schulman, 2002). When people become aware of their dysfunctional somatic patterns and change their posture, breathing pattern, internal language and implement stress management techniques, they often report a reduction in symptoms such as irritable bowel syndrome, acid reflux, neck and shoulder tension, or anxiety (Peper et al, 2017a; Peper et al, 2016a). Sometimes, a single coaching session can be sufficient to improve health.
Working hypothesis: The headaches were most likely tension headaches and not migraines and may be the result of chronic neck and shoulder tension which was maintained during chest breathing and the slouched head forward body posture. If she could change her posture, relax her neck and shoulders, and breathe diaphragmatically so that the lower abdomen widen during inhalation, most likely her shoulder and neck tension would decrease. Therefore, by changing posture from a slouched to upright position combined with slower diaphragmatic breathing, the muscle tension would be reduced and the headaches would decrease.
Breathing and posture changes
She was encouraged to sit upright so that the abdomen had space to expand (Peper et al., 2020). In addition, she needed to loosen the clothing around her waist to provide room for her abdomen to expand during inhalation instead of her chest lifting (MacHose & Peper, 1991). Allowing abdominal expansion can be challenging for many paticipants since they are self-conscious about their body image, as well holding their stomach in as an unconscious learned response to avoid pain after having had abdominal surgery, or as an automatic protective response to threat (Peper et al., 2015). The upright position also allowed her to sit tall and erect in which the back of head reaches upward towards the ceiling while relaxing and feeling gravity pulling her shoulders downward and at the same time relaxing her hips and legs.
With guided verbal and tactile coaching, she learned to master slower diaphragmatic breathing in which she gently and slowly exhaled by making a sound of pssssssst (exhaling through pursed lips) which tends to activate the transverse and oblique abdominal muscles and slightly tighten the pelvic floor muscles so that her lower abdomen would slightly constrict at the end of the exhalation (Peper et al., 2016). Then, by allowing the lower abdomen and pelvic floor relax so that the abdomen could expand in 360 degrees, inhalation occurred.
While practicing the slower breathing in this relaxed upright position, she was instructed to sense/imagine feeling a flow of down and through her arms and out her hands as she exhaled (as if the air could flow through straws down her arms). After a few minutes, she felt her headache decrease and noticed that her hands had warmed. After this short coaching intervention, she went back to her seat in class and continued to practice the relaxed effortless breathing while sitting upright and allowing her shoulders to melt downward.
The use of muscle feedback to demonstrate residual covert muscle tension
During class session, she volunteered to have her trapezius muscle monitored with electromyography (EMG). The EMG indicated that her muscles were slightly tense even though she reported feeling relaxed. With a few minutes of EMG biofeedback exploration, she discovered that she could relax her shoulder muscles by feeling them being heavy and melting.
Implementing home practice with a posture app
As part of the class homework, she was assigned a self-study for two weeks with the posture feedback app, Dario Desktop. The app uses the computer/laptop camera to monitor posture and provides visual feedback in a small window on the computer screen and/or an auditory signal each time she slouches as shown in Figure 1.
Figure 1. Posture feedback to signal to participant that the person is slouching.
To observe the effect of the posture breathing training, she monitored her symptoms for three days without feedback and then installed the posture feedback application on her laptop to provide feedback whenever she slouched. The posture feedback reminded her to practice better posture during the day while working on her computer and also do a few stretches or shift to standing when using the computer for an extended period of time. Each time the feedback signal indicated she slouched, she would sit up and change her posture, breathe lower and slower and relax her shoulders.
She also monitored what factors triggered the slouching. In additionally, she added daily reminders to her phone to remind her of her posture and to stretch and stand after each hour of studying. After two weeks she recorded her symptoms for three days for the post assessment without posture feedback.
The chronic headache condition which had been present for fourteen years disappeared and she has not used any medication since the first day of class. She reported after two weeks that her shoulder and back discomfort/pain, depression, anxiety and lack of motivation decreased as shown in Figure 2. At the fourteen week follow up, she continues to have no headaches and has not used any medication.
Figure 2. Changes in symptoms after implementing posture feedback for two weeks.
She used the desktop posture app every time she opened her laptop at home as often as 3-5 times per day (roughly 2-6 hours).In addition, when she felt beginning of discomfort or thought she should take medication, she would adjust her posture and breathe. While using the app, she identified numerous factors that were associated with slouching as shown in Figure 3.
Figure 3. Behaviors associated with slouching.
The decrease in depression, anxiety and increase in motivation may be the direct result of posture change; since, a slouched position tends to increase hopeless, helpless and powerless thoughts while the upright position tends to increase subjective felt energy and easier access to empowering and positive thoughts (Peper et al., 2017b; Veenstra et al., 2017; Wilson & Peper, 2004; Tsai et al., 2016). Most likely, a major factor that contributed to the elimination of her headaches was that she implemented changes in her behavior. One major factor was using posture feedback tool at home to remind her to sit tall and relax her shoulders while practicing slower diaphragmatic breathing. As she noted, “Although it was distracting to be reminded all the time about my posture, it did decrease my neck pain. With the pain reduction, I was able to sit at the computer longer and felt more motivated.”
The combination of slower lower abdominal breathing with the upright posture reversed her protective/defensive body position (tightening the muscle in the lower abdomen and pelvic floor and pressing the knees together while curling the shoulder forward for protection). The upright posture creates a position of empowerment and trust by which the lower abdomen could expand which supported health and regeneration. In addition, the upright posture allowed easier access to positive thoughts and reduced recall of hopeless, powerless, defeated memories. It is also possible that caffeine withdrawal was a co-factor in evoking headaches (Küçer, 2010). By eliminating the medication containing caffeine, she also eliminated the triggering of the caffeine withdrawal headaches.
This case example suggests that health care providers first rule out any pathology and then teach behavioral self-healing strategies that the clients can implement instead of immediately prescribing medications. These interventions could include slower and lower diaphragmatic breathing, upright posture feedback, muscle biofeedback training, hear rate variability training, stress management, cognitive behavior therapy and facilitating health promoting lifestyles modifications such as regular sleep, exercise and healthier diet. When students implement these behavioral changes as part of a five week self-healing program, many report significant decreases in symptoms such as headaches, anxiety, neck and shoulder pain, and gastrointestinal distress (Peper et al., 2016a).
Watch April Covell describe her experience with the self-healing approach to eliminate her chronic headaches.
See the following blogs for additional instructions how to breathe diaphragmatically.
Ahmed, S., Akter, R., Pokhrel, N. et al. (2021). Prevalence of text neck syndrome and SMS thumb among smartphone users in college-going students: a cross-sectional survey study. J Public Health (Berl.) 29, 411–416. https://doi.org/10.1007/s10389-019-01139-4
Bauer, A.Z., Swan, S.H., Kriebel, D. et al. (2021). Paracetamol use during pregnancy — a call for precautionary action. Nat Rev Endocrinol . https://doi.org/10.1038/s41574-021-00553-7
Charles, N. E., Strong, S. J., Burns, L. C., Bullerjahn, M. R., & Serafine, K. M. (2021). Increased mood disorder symptoms, perceived stress, and alcohol use among college students during the COVID-19 pandemic. Psychiatry research, 296, 113706. https://doi.org/10.1016/j.psychres.2021.113706
Elizagaray-Garcia, I., Beltran-Alacreu, H., Angulo-Díaz, S., Garrigós-Pedrón, M., Gil-Martínez, A. (2020). Chronic Primary Headache Subjects Have Greater Forward Head Posture than Asymptomatic and Episodic Primary Headache Sufferers: Systematic Review and Meta-analysis. Pain Med, 21(10):2465-2480. https://doi.org/10.1093/pm/pnaa235
Greden, J.F., Victor, B.S., Fontaine, P., & Lubetsky, M. (1980). Caffeine-Withdrawal Headache: A Clinical Profile. Psychosomatics, 21(5), 411-413, 417-418. https://doi.org/10.1016/S0033-3182(80)73670-8
Küçer, N. (2010). The relationship between daily caffeine consumption and withdrawal symptoms: a questionnaire-based study. Turk J Med Sci, 40(1), 105-108. https://doi.org/10.3906/sag-0809-26
Kuehn, B.M. (2021). Increase in Myopia Reported Among Children During COVID-19 Lockdown. JAMA, 326(11),999. https://doi.org/10.1001/jama.2021.14475
MacHose, M. & Peper, E. (1991). The effect of clothing on inhalation volume. Biofeedback and Self-Regulation 16, 261–265 (1991). https://doi.org/10.1007/BF01000020
Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49. https://doi.org/10.5298/1081-5937-44.1.03
Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179. https://doi.org/10.5298/1081-5937-43.4.06
Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017b). How posture affects memory recall and mood. Biofeedback. 45 (2), 36-41. https://doi.org/10.5298/1081-5937-45.2.01
Peper, E., Mason, L., Harvey, R., Wolski, L, & Torres, J. (2020). Can acid reflux be reduced by breathing? Townsend Letters-The Examiner of Alternative Medicine, 445/446, 44-47. https://www.townsendletter.com/article/445-6-acid-reflux-reduced-by-breathing/
Peper, E., Mason, L., Huey, C. (2017a). Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. (45-4). https://doi.org/10.5298/1081-5937-45.4.04
Peper, E., Miceli, B., & Harvey, R. (2016a). Educational Model for Self-healing: Eliminating a Chronic Migraine with Electromyography, Autogenic Training, Posture, and Mindfulness. Biofeedback, 44(3), 130–137. https://doi.org/10.5298/1081-5937-44.3.03
Peper, E., Wilson, V., Martin, M., Rosegard, E., & Harvey, R. (2021). Avoid Zoom fatigue, be present and learn. NeuroRegulation, 8(1), 47–56. https://doi.org/10.15540/nr.8.1.47
Schulman, E.A. (2002). Breath-holding, head pressure, and hot water: an effective treatment for migraine headache. Headache, 42(10), 1048-50. https://doi.org/10.1046/j.1526-4610.2002.02237.x
Tsai, H. Y., Peper, E., & Lin, I. M.* (2016). EEG patterns under positive/negative body postures and emotion recall tasks. NeuroRegulation, 3(1), 23-27. https://doi.org/10.15540/nr.3.1.23
Veenstra, L., Schneider, I.K., & Koole, S.L. (2017). Embodied mood regulation: the impact of body posture on mood recovery, negative thoughts, and mood-congruent recall. Cogntion and Emotion, 31(7), 1361-1376. https://doi.org/10.1080/02699931.2016.1225003
Wilson, V.E. and Peper, E. (2004). The effects of upright and slumped postures on the generation of positive and negative thoughts. Applied Psychophysiology and Biofeedback, 29(3), 189–195. https://doi.org/10.1023/b:apbi.0000039057.32963.34
It is the time of year when we once again make New Year resolutions, “I plan to exercise every day,” “I will stop drinking,” “I will eat less processed foods and more fruits and vegetables.” We use our will power and positive thoughts to begin these new activities; however, our will power often fades out and we quickly fall of the wagon. The reason vary such as, I had planned to jog today; however it is raining, I was planning to eat more vegies; however, I had dinner with a friend and ate a juicy hamburger, I had planned to meditate; however, I needed to help my son. So many other things took priority and the motivation disappeared..
Yet it is possible to be successful with starting and then maintaining new health promoting habits. The key is to increase the friction for the behaviors that you want to reduce and decrease the friction for behaviors that you want to increase. Friction is the extra work you need to do in order to do the task. For example, to eat fewer cookies, increase the friction by not having them in the house (you now have to go to the store to buy them) or by placing them somewhere where it takes greater effort to get them such as the top shelf for which that you need a small ladder to reach them. The extra effort (increased friction) brings awareness to the automatic behavior. At that point, you can interrupt your unconscious eating pattern and choose to do something else. On the other hand, to increase eating fruits, decrease the friction by having the fruit right in front of you on the table so that you can take one without thinking.
The key is to interrupt the habit chain of behavior you want to reduce and automate the habit chains of behaviors you want to increase. The more you do a behavior and the more pleasurable it is, the more likely will the new behaviore become an automatic habit. To learn how to change friction and how to be successful in creating new habits, listen to Shankar Vedantam Hidden Brain’s Podcast, Creatures of Habit.
Andrea Castillo and Erik Peper
We are what we eat. Our body is synthesized from the foods we eat. Creating the best conditions for a healthy body depends upon the foods we ingest as implied by the phrase, Let food be thy medicine, attributed to Hippocrates, the Greek founder of western medicine (Cardenas, 2013). The foods are the building blocks for growth and repair. Comparing our body to building a house, the building materials are the foods we eat, the architect’s plans are our genetic coding, the care taking of the house is our lifestyle and the weather that buffers the house is our stress reactions. If you build a house with top of the line materials and take care of it, it will last a life time or more. Although the analogy of a house to the body is not correct since a house cannot repair itself, it is a useful analogy since repair is an ongoing process to keep the house in good shape. Our body continuously repairs itself in the process of regeneration. Our health will be better when we eat organic foods that are in season since they have the most nutrients.
Organic foods have much lower levels of harmful herbicides and pesticides which are neurotoxins and harmful to our health (Baker et al., 2002; Barański, et al, 2014). Crops have been organically farmed have higher levels of vitamins and minerals which are essential for our health compared to crops that have been chemically fertilized (Peper, 2017),
Even seasonality appears to be a factor. Foods that are outdoor grown or harvested in their natural growing period for the region where it is produced, tend to have more flavor that foods that are grown out of season such as in green houses or picked prematurely thousands of miles away to allow shipping to the consumer. Compare the intense flavor of small strawberry picked in May from the plant grown in your back yard to the watery bland taste of the great looking strawberries bought in December.
The seasonality of food
It’s the middle of winter. The weather has cooled down, the days are shorter, and some nights feel particularly cozy. Maybe you crave a warm bowl of tomato soup so you go to the store, buy some beautiful organic tomatoes, and make yourself a warm meal. The soup is… good. But not great. It is a little bland even though you salted it and spiced it. You can’t quite put your finger on it, but it feels like it’s missing more tomato flavor. But why? You added plenty of tomatoes. You’re a good cook so it’s not like you messed up the recipe. It’s just—missing something.
That something could easily be seasonality. The beautiful, organic tomatoes purchased from the store in the middle of winter could not have been grown locally, outside. Tomatoes love warm weather and die when days are cooler, with temperatures dropping to the 30s and 40s. So why are there organic tomatoes in the store in the middle of cold winters? Those tomatoes could’ve been grown in a greenhouse, a human-made structure to recreate warmer environments. Or, they could’ve been grown organically somewhere in the middle of summer in the southern hemisphere and shipped up north (hello, carbon emissions!) so you can access tomatoes year-round.
That 24/7 access isn’t free and excellent flavor is often a sacrifice we pay for eating fruits and vegetables out of season. Chefs and restaurants who offer seasonal offerings, for example, won’t serve bacon, lettuce, tomato (BLT) sandwiches in winter. Not because they’re pretentious, but because it won’t taste as great as it would in summer months. Instead of winter BLTs, these restaurants will proudly whip up seasonal steamed silky sweet potatoes or roasted brussels sprouts with kimchee puree.
When we eat seasonally-available food, it’s more likely we’re eating fresher food. A spring asparagus, summer apricot, fall pear, or winter grapefruit doesn’t have to travel far to get to your plate. With fewer miles traveled, the vitamins, minerals, and secondary metabolites in organic fruits and vegetables won’t degrade as much compared to fruits and vegetables flown or shipped in from other countries. Seasonal food tastes great and it’s great for you too.
If you’re curious to eat more of what’s in season, visit your local farmers market if it’s available to you. Strike up a conversation with the people who grow your food. If farmers markets are not available, take a moment to learn what is in season where you live and try those fruits and vegetables next time to go to the store. This Seasonal Food Guide for all 50 states is a great tool to get you started.
Once you incorporate seasonal fruits and vegetables into your daily meals, your body will thank you for the health boost and your meals will gain those extra flavors. Remember, you’re not a bad cook: you just need to find the right seasonal partners so your dinners are never left without that extra little something ever again.
Sign up for Andrea Castillo’s Seasonal, a newsletter that connects you to the Bay Area food system, one fruit and vegetable at a time. Andrea is a food nerd who always wants to know the what’s, how’s, when’s, and why’s of the food she eats.
Baker, B.P., Benbrook, C.M., & Groth III, E., & Lutz, K. (2002). Pesticide residues in conventional, integrated pest management (IPM)-grown and organic foods: insights from three US data sets. Food Additives and Contaminants, 19(5) http://www.tandfonline.com/doi/abs/10.1080/02652030110113799
Barański, M., Średnicka-Tober, D., Volakakis, N., Seal, C., Sanderson, R., Stewart, G., . . . Leifert, C. (2014). Higher antioxidant and lower cadmium concentrations and lower incidence of pesticide residues in organically grown crops: A systematic literature review and meta-analyses. British Journal of Nutrition, 112(5), 794-811. https://doi.org/10.1017/S0007114514001366
Cardenas, E. (2013). Let not thy food be confused with thy medicine: The Hippocratic misquotation,e-SPEN Journal, I(6), e260-e262. https://doi.org/10.1016/j.clnme.2013.10.002
Peper, E. (2017). Yes, fresh organic food is better! the peper perspective. https://peperperspective.com/2017/10/27/yes-fresh-organic-food-is-better/