Reduce initial dose of the virus and optimize your immune system

Erik Peper and Richard Harvey

COVID-19 can sometimes overwhelm young and old immune systems and in some cases can result in ‘Severe Acute Respiratory Syndrome’ pneumonia and death (CDC (2020). The risk is greater for older people who may simultaneously be dealing with cancers, heart disease, diabetes, emphysema or other health issues.  As we age the immune system deteriorates  (immunosenescence) which reduces the response of the adaptive immune system that needs to respond to the virus infection (Aw, Silva & Palmer, 2007; Osttan, Monti, Gueresi, et al., 2016).

Severity of disease may depend upon initial dose of the virus

In a brilliant article, How does the coronavirus behave inside a patient? We’ve counted the viral spread across peoples; now we need to count it within people, assistant professor of medicine at Columbia University and cancer physician Siddhartha Mukherjee points out that severity of the disease may be related to the initial dose of the virus.  Namely, if you receive a very small dose (not too many virus particles), they will infect you; however, the body can activate its immune response to cope with the infection.  The low dose exposure act similar to vaccination.  If on the other hand you are exposed to a very high dose then your body is overwhelmed with the infection and is unable to respond effectively.  Think of a forest fire. A small fire can easily be suppressed since there is enough time to upgrade the fire-fighting resources; however, during a fire-storm with multiple fires occurring at the same time, the fire-fighting resources are overwhelmed and there is not enough time to recruit outside fire-fighting resources.

As Mukherjee points out this dose exposure relationship with illness severity has a long history. For example, before vaccinations for childhood illnesses were available, a child who became infected at the playground usually experienced a mild form of the disease.  However, the child’s siblings who were infected at home develop a much more severe form of the disease.

The child infected in the playground most likely received a relatively small dose of the virus over a short time period (viral concentration in the air is low).  On the other hand, the siblings who were infected at home by their infected brother or sister received a high concentration of the virus over an extended period which initially overwhelmed their immune system. Higher virus concentration is more likely during the winter and in well insulated/sealed houses where the air is recirculated without going through HEPA or UV filters to sterilize the air. When there is no fresh air to decrease or remove the virus concentration, the risk of severity of illness may be higher.

The risk of becoming sick with COVID-19 can only occur if you are exposed to the coronavirus and the competency of your immune system. This can be expressed in the following equation.Risk ratioThis equation suggests two strategies to reduce risk:  reduce coronavirus load/exposure and strengthen the immune system.

What can you do to reduce the dose of virus exposure

Assume that everyone is contagious even though they may appear healthy.  Research suggests that people are already contagious before developing symptoms or are asymptomatic carriers who do not get sick and thereby unknowingly spread the virus. Dutch researchers have reported that, “The proportion of pre-symptomatic transmission was 48% for Singapore and 62% for Tianjin, China (Ganyani et al, 2020). Thus, the intervention to isolate people who have symptoms of COVID-19 (fever, dry cough, etc.) most likely will miss the asymptomatic carriers who may infect the community without awareness.  Only if you have been tested, do you know if you been exposed or recovered from the virus. To reduce exposure the dose of virus exposure, do the following.

  1. Follow the public health guidelines:
    • Social distancing (physical distancing while continuing to offer social support)
    • Washing your hands with soap for at least 20 seconds.
    • Not touching your face to prevent microorganisms and viruses to enter the body through mucosal surfaces of the nose mouth and eyes.
    • Cleaning surfaces which could have been touched by other such as door bell, door knobs, packages.
    • Wearing a mask and gloves to reduce spreading the virus to others.
  1. Increase fresh air to reduce virus concentration. By increasing the fresh outside air circulation, you dilute the virus concentration that may be shed by an infected asymptomatic or sick person. Thus, if you are exposed to the virus, you may receive a lower dose and increase the probability that you experience a milder version of the disease. To increase fresh air (this assumes that outside air is not polluted), explore the following:
    • Open the windows to allow cross ventilation through your house or work setting. One of the major reasons that the flu season spikes in the winter is that people congregate indoors to escape weather extremes. People keep their windows closed to conserve heat and reduce heating bill costs. Lack of fresh air circulation increases the viral density and risk of illness severity (Foster, 2014).
    • Use an exhaust fans to ventilate a building. By continuously replacing the inside “stale” air  with fresh outside air, the concentration of the virus in the air is reduced.
    • Use High-efficiency particulate air (HEPA) air purifiers to filter the air within a room. These devices will filter out particles whose diameter is equal to 0.3 µ m. They will not totally filter out the virus; however, they will reduce it.
    • Avoid buildings with recycled air unless the heating and air conditioning system (HAC) uses HEPA filters.
    • Wear a mask to protect other people and your community. The mask will reduce the shedding of the virus to others by people with COVID-19 or those who are asymptomatic carriers.

How to strengthen your immune system to fight the virus

The immune system is dynamic and many factors as well as individual differences affect its ability to fight the virus.  It is possible that a 40 year-old person may have an immune systems that functions as a 70 year old, while some 70 year-olds have an immune system that function as a 40 year-old. Factors that contribute to immune competence include genetics, aging, previous virus exposure, and lifestyle (Lawton, 2020).

By taking charge of your lifestyle habits through an integrated approach, you may be able to strengthen your immune system (Alschuler et al, 2020; Lawton, 2020). The following tables, adapted from the published articles by Lawton (2020) and Alschuler et al, (2020), list some of the factors that may strengthen or weaken the immune system.

Factors that strengthen the immune system

increase immune competence

Factors that may weaken the immune system

decrease immune competence

These factors have been superbly summarized by the World Health Organization Director General Dr. Tedros Adhanom in his presentation, Practical tips how to keep yourself safe.

REFERENCES

Abhanon, T. (2020 March 26). Practical tips how to keep yourself safe.

Alschuler, L., Weil, A., Horwitz, R. Stamets, P., Chiasso, A.M., Crocker, R., & Maizes, V. (2020 March 26). Integrative considerations during the CPVID-19 pandemic. Explore, 26.

Aw, D., Silva, A. B., & Palmer, D. B. (2007). Immunosenescence: emerging challenges for an ageing population. Immunology120(4), 435–446.

CDC (2020, March 26). Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. Morbidity and Mortality Weekly Report. CDC. March 26, 2020.

Foster, H. (2014 December 1). The reason for the season: why flu strikes in winter. SITN Science in the News

Ganyani, T., Kremer, C., Chen, D., Torneri, A, Faes, C., Wallinga, J., & Hensm N. (2020).    Estimating the generation interval for COVID-19 based on symptom onset data     doi:https://doi.org/10.1101/2020.03.05.20031815

Lawton, G. (2020). You’re only as young as your immune system. New Scientist, 245(3275), 44-48.

Mukherjee, S. (2020). How does the coronavirus behave inside a patient? We’ve counted the viral spread across peoples; now we need to count it within people. The New Yorker, April 6, 2020.

Ostan, R., Monti, D., Gueresi, P., Bussolotto, M., Franceschi, C., & Baggio, G. (2016). Gender, aging and longevity in humans: An update of an intriguing/neglected scenario paving the way to a gender-specific medicine. Clinical Science, 130(19), 1711-1725.

 

 

 

 


Reduce TechStress at Home

Adapted from the upcoming book, Peper, E., Harvey, R., & Faass, (in press). Tech Stress: How Technology Is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. Berkeley: North Atlantic Books.

fig 1 extended neck

Numerous people report that working at the computer at home is more tiring than working in the office.  Although there are obvious advantages to working at home, there are also disadvantages (e.g., no space to work, challenging ergonomics, no escape from the family, lack of nonverbal cues used to communicate, less informal sharing at the water cooler, increased multitasking by working and having to take care of the children).

A major challenge is having a comfortable work space in your home.  This may mean finding a place to put the computer, keyboard and screen.  For some it is the kitchen table, desk in the corner of the bedroom, or coffee table while other it is in a totally separate room.

Incorrect ergonomic arrangement and stressed work style often increases neck, shoulder discomfort and aggravates eye strain and tiredness. Regardless how your digital work space is organized, implement the following life and work style suggestions and ergonomics recommendations to promote health.

LIFE AND WORK STYLE SUGGESTIONS

Take many, many, many breaks.  Movement breaks will reduce the covert static tension that builds up as we sit in static positions and work at the computer.

  • Every few minutes take a small break such as stand up and wiggle or role your shoulders. When performing the movements, stop looking at the screen and look around the room or out the window.
  • Every 30 minutes get up walk around for and move your body. Use timers to notify you every 30 minutes to take a break (e.g., cellphone alarms or personal digital assistants such as Hey Google, Siri, or Alexa).

Improve vision.

  • Take vision breaks to reduce eye fatigue.
    • Every few minutes look away from the screen and into the far distance and blink. If at all possible look outside at green plants which relaxes the near vision induced tension.
    • Blink and blink again. When working at the computer we reduce our blinking rate. Thus, blink each time you click on a new link, finishing entering a column of numbers, etc.
    • Close your eyes by letting the eye lids drop down as you also relax your jaw. Imagine a hook on top of your head which is pulling your head upward and at the same time drop your shoulders.
  • Reduce glare and bright backgrounds
    • Arrange your computer screen at 90 degrees to the brightest light source.
    • Have a darker background behind you when participating in video conferencing (e.g., Zoom, Skype, GoToMeeting, WhatsApp, FaceTime). Your face will be visible.

Regenerate

  • When stressed remember to breathe. As you inhale let your stomach expand as you exhale let the air flow out slowly.
  • Stop watching and listening to the negative news (check the news no more than once a day). Watch positive and humorous movies.
  • Get fresh air, go for a walk, and be in the sun
  • Reconnect with friends and share positive experiences.
  • Remind yourself, that this too shall pass.

ERGONOMIC RECOMMENDATIONS: MAKE THE WORLD YOURS

Good ergonomics means adapting the equipment and environment to you and not the other way around. Optimizes the arrangement of the chair, desk, keyboard, mouse, camera, screen and yourself as shown in Figure 1.

Workstation-Setup1

Figure 1. Recommended arrangement for working at the computer.

Arrange the laptop

The laptop is challenging because if your hands are at the right height for data entry on the keyboard, then you must look down to see the screen.  If the screen at the right height, then you have to raise your hands to reach the keyboard. There are two solutions for this challenge.

  1. Use an external keyboard and mouse, then raise the laptop so that the top of the screen is at eye level. Use a laptop stand or a stack of books to raise the lap top.
  2. Use an external monitor for display, then use the laptop as your keyboard.

If these solutions are not possible, take many, many, many breaks to reduce the neck and shoulder stress.

Arrange the computer workstation

  1. Adjust the chair so that your forearms can rest on the table without raising your shoulders. This may mean sitting on a pillow. If the chair is then too high and your legs dangle, create a foot stool on which you can rest your feet.
  2. Adjust the monitor so that the top of the screen is at eye level. If the monitor is too low, raise it by putting some books underneath it.
  3. If possible, alternate standing and sitting while working.

RESOURCES

Ergonomic suggestions for working at the computer and laptop.

https://peperperspective.com/2014/09/30/cartoon-ergonomics-for-working-at-the-computer-and-laptop/

https://peperperspective.com/2014/02/24/optimizing-ergonomics-adapt-the-world-to-you-and-not-the-other-way-around/

11 tips for working at home

https://www.bakkerelkhuizen.com/knowledge-center/11-productivity-tips-for-homeworkers/?utm_campaign=US+-+19+03+20&utm_source=Newsletter&utm_medium=email

How our digital world activates evolutionary response patterns.

https://peperperspective.com/2020/01/17/evolutionary-traps-how-screens-digital-notifications-and-gaming-software-exploits-fundamental-survival-mechanisms/

https://peperperspective.com/2018/02/10/digital-addiction/

How posture affects health

https://peperperspective.com/2019/07/01/dont-slouch-improves-health-with-posture-feedback/

https://peperperspective.com/2019/05/21/relieve-and-prevent-neck-stiffness-and-pain/

https://peperperspective.com/2017/11/28/posture-and-mood-implications-and-applications-to-health-and-therapy/

https://peperperspective.com/2019/01/23/head-position-it-matters/


Coronavirus risk in context: How worried should you be?

The coronavirus which causes coronavirus disease 2019 (COVID-19) appears to be a highly contagious disease. Some older people and those who are immune compromised are more at risk.  The highest risk are for older people who already have cardiovascular, diabetes, respiratory disease, and hypertension. In addition, older men over 80 years are much more at risk; however, the majority are smokers who have a compromised pulmonary system. Previous meta analysis showed that smoking was consistently associated with higher risk of hospital admissions after influenza infection. Nevertheless, it is reasonable to assume that over time all most all of us will become exposed to the virus, a few will get very sick, and even fewer will die.

The preliminary data suggests that most people who become infected may not even know they are infectious.  The absolute risk that one would die of this disease is low although if you do become very sick it may be more dangerous than the normal flu; however, the fear of this disease may be out of proportion compared to other health risks. For detailed analysis and graphic summaries see the updated research reports on the Coronavirus disease (COVID-19) by Our World in Data and Information is beautiful. These reports make data and research on the world’s largest problems understandable and accessible.

It is worthwhile to look at the absolute risk of COVID-19.  To read that more than 51,000 people world wide have died in the last three months is terrifying especially with the increasing death rate in Italy and Europe; however, it needs to be understood in context of the size of the population.  The epicenter of this disease was Wuhan and Hubei Provence, China with a total population of about 60 million people.  Each year about 427,200 people die in the Wuhan and Hubei Province (the annual death rate in China is 7.12 deaths per 1000 people). Without this new viral disease, about 71,200 people would have died during the same two month period.  The question that has not been discussed is how much did the total death rate increase.  Would it be possible that some of the people who died would have died of other natural causes such as the flu?

The World Health Organization (WHO) and governments around the world should be lauded for their attempt to reduce the spread of the virus. On March 6, 2020, the United States Congress allocated $8. billion dollars to fight and prevent the spread of COVID-19. 

This funding will only partially prevent the spread of the virus because some people have no choice but to go to work when they are sick–they do not receive paid sick leave! This is true for about 30 percent of the American workers who have no coverage at work or the millions of self-employed workers (e.g. gig/freelance workers, waiters, cashiers, drivers, nannies, house cleaners).

To reduce the risk of the spreading COVID-19, anyone who feels sick or thinks they have been exposed, should receive paid sick leave so that they can stay home and self-isolate. The paid sick leave should be Federally funded and provide basic income for those whose income would be lost if they did not work.  Although it is possible that a few people will cheat and take the paid sick leave when they are well, this is worth the risk to keep the rest of population healthy. To provide possible relief, at the moment the House and Senate are working on a greater than $1 trillion dollar stimulus package. 

Personal and government responses to health risks are not always rational. 

Funding for health and illness prevention is driven by politics. For example, gun violence results in more than 100,000 people being injured each year and more than 36,000 killed—an average of 100 per day. Gun violence is a much more virulent disease than COVID-19 and more than 1.7 million Americans have died from firearms since 1968.

The Federal Government response to this gun violence epidemic has been minimal. For the first time since 1996 did the 2020 federal budget include $25 million funding for the CDC and NIH to research reducing gun-related deaths and injuries.

It is clear that the government response does not always focuses its resources on what would reduce injury and death rates the most.  Look at the difference in the national response to COVID-19 virus that has killed more than 5,780 people in the USA ($8.5 billion for the initial response) as compared gun violence that kills 36,000 people a year in the USA ($25 million).

Be realistic about the actual risk of COVID-19 without succumbing to fear.

COVID-19 is a pandemic and I expect that 30% to 70% of us will be infected this year.  Hopefully, in the next 18 months an effective vaccine will be developed.  In the mean time, there is no known treatment, thus optimize health and reduce the exposure to the coronavirus. Use the same precautions and treatment as you would do for the flu.

To make sense of the danger of COVID-19, look at it in context to the flu. Depending upon the severity the  flu, 9,000,000 to 45,000,000 people get sick from flu and between 12,000 to 61,000 die from its complications. as shown below in Figure 1.  

influenza-burden-chart2-960pxFigure 1. The estimated U.S. influenza burden by year (from: https://www.cdc.gov/flu/about/burden/index.html)

This year the CDC estimates that there have been 20,000 to 40,000 deaths in the United States so far this year.  For comparison that is a thousand times  more deaths in the United States than have been blamed on the coronavirus so far.

 


Evolutionary traps: How screens, digital notifications and gaming software exploits fundamental survival mechanisms

Erik Peper and Richard Harvey

If athletes, psychologists, business executives, actors, students, politicians, job seekers and others use mental and actual rehearsal to improve their performances, would repeated watching of violent and aggressive streaming-videos, or playing hours and hours of first-shooter computer games be a form of rehearsal for aggressive behavior?

Arguably, mental and actual rehearsal is positively associated with improving health, such as preparing for an athletic competition or an academic exam and is negatively associated with health when playing aggressive, violent first-person shooter video games, or continuously watching aggressive or violent content on a variety of streaming platforms. Rehearsal–whether physical or in our imagination–impacts our health and performance in school, sports, therapy, politics, business and health.  Choose to rehearse activities that improve health and well-being.

  • Athletes use mental rehearsal to improve sports performance (Peper & Aita, 2017; Schenk & Miltenberger, 2019).
  • Surgeons use mental rehearsal and actual practice to improve performance (Spiotta et al., 2018).
  • Psychologists use cognitive behavioral therapy (CBT) rehearsal techniques to reduce anxiety and depression (Dobson & Dobson, 2018; Yamada et al, 2018; Cook, Mostazir, & Watkins, 2019)
  • Successful business executives rehearse presentations before a staff meeting (Couch & Citrin, 2018).
  • Actors and performers spend hours and days rehearsing their roles so that they portray and act it realistically during the performance .
  • Students take practice exams so that they will perform better on the actual exam.
  • Politicians, lawyers, and many others rehearse and practice being able to answer unexpected questions.
  • Job seekers rehearse elevator pitches so that they transmit in a few words what is important

Mechanisms of rehearsal

Both mental and physical rehearsal strengthens neurochemical connections in the brain so that the rehearsed behaviors become more automated, fluid and unconscious.  There is a saying in neurosciences,  “Neurons that fire together wire together.” –the more you rehearse a task, the more those specific neurological pathways are strengthened, leading to automatic and efficient outcomes.

We now spend hours a day being exposed to digital displays on our phones, computers, gaming consoles and other digital devices, immersing ourselves in content reflecting life promoting, positive behavior and sometimes violent, negative behavior. Children and adults spend much of their free time looking at screens, texting, playing computer games, updating social media sites with moment by moment accounts of sometimes trivial activities, or going down the rabbit hole by following one hyperlinks after another.  As we do this, we are unaware how much time has frittered away without actually doing anything productive. Below are some recent estimates of ‘daily active user’ minutes per day that uses a screen.

  • Facebook about an hour per day
  • Instagram just under an hour per day
  • Texting about 45 minutes per day
  • Internet browsing, about 45 minutes per day
  • Snapchat, about 30 minutes per day
  • Twitter, about 25 minutes per day

Adolescents interact with media for over 40 hours per week, or around 6 hours per day!

In spending much of our time with the screens, we rehearse a variety of physical body postures as well as a variety of cognitive and behavioral states that impact our physical, mental, emotional and social health.  Many researchers have lamented the loss of some social skills that develop during physical face-to-face contact.  The colloquial phrase, Use it or lose it, raises several questions about what is being lost when we spend so much of our waking time interacting with screens instead actually with other people?

It is almost impossible not to be distracted by the digital screen.  The powerful audiovisual formats override our desire to do something different that some of us become enslaved to watching streaming videos, playing computer games or texting. Moreover, the ongoing visual and auditory notifications from our apps interrupts and/or capture our attention. Why is it difficult to turn away from visual or auditory stimuli?  The answer has roots in our survival.

To attend to stimuli is an automatic evolutionary survival response. If we did not attend, we would not survive–Is the slight movement to the far right, just at the edge of our peripheral vision, a predator ready to attack?

tigera

Tiger in Kanha National Park, Madhya Pradesh, India 

Each time a stimulus occurs, we need to check it out to see if it is friend or foe, safety or danger. The response is so automatic that we are unaware that we have reacted until after we have responded. We all have experienced this. When a computer screen or cellphone screen is held by the stranger next to us, we automatically look at their screen and we may even begin to read their emails. Although we know that peering at some else’s screen is not proper, we are still feel compelled to do it!

Similarly, screens displaying computer games and other media can capture or hijack our attention by the rapid scene changes, primarily because the content is programmed so we receive intermittent rewards for our responses.  For example, the sound or visual notifications from our apps, cellphone messages, or social media trigger an impulse to scan the environment for information that may be critical to our survival. Even without receiving notifications, we may anticipate or project that there may be new information on our social media accounts, and sometimes we become disappointed when the interval between notifications is long.  One student talking to another might say: “Don’t worry, they’ll respond; It’s only been 30 seconds.” Anticipating responses from the media can interrupt what we are otherwise doing.  For example, rather than finish our work, we check for updates on social media, even though we probably know that there are no new important messages to which we would have to respond right away.

The mechanisms that help us survive by scanning our environment for predators may  now become an evolutionary trap and is exploited  to capture as many eyeballs as possible to increase market share, advertising revenue, and corporate bottom line.

We usually blame the individual for lack of self-control instead of blaming the designers of the digital apps, games and displays who have exploited this biological survival mechanism.  We expect that children have voluntary control as their brains are developing–but how could they not react to the stimuli that for thousands of generations, helped them to survive. It is similar to asking children to have control and say “No” to fast foods and sweets. The foods that were previously necessary for survival represented by moderate amounts of ‘salt, fat, acid, heat and sweet’ tastes are often found in excess in our modern commercial or packaged ‘fast food nation’ making it likely that people may fall into an evolutionary trap related to what they eat.

Presently, high levels of exposure to violent and aggressive streaming videos and computer games can be harmful as they provide the practice to rehearse violence, killing and aggression mentally. It would be too strong a statement to assert that everyone who plays violent video games will become delinquent, criminal or homicidal in an extreme form of aggression.  According to the American Psychological Association Task Force on Video Game Violence in 2017, it may be asserted that high frequency, long duration, high intensity interactions with violent video games or similar media content is highly associated with angry and aggressive thoughts, desensitization to violence, and decreases in empathy or helping others (Calvert et al., 2017).  Some forms of social media interactions also lead to a form of social isolation,  loneliness (phoneliness) (Christodoulou, G., Majmundar, A., Chou, C-P, & Pentz, M.A., 2020; Kardaras, 2017).   Digital content requires the individual to respond to the digital stimuli, without being aware of the many verbal and nonverbal communication cues (facial expressions, gestures, tone of voice, eye contact, body language, posture, touch, etc) that are part of social communication (Remland, 2016). It is no wonder that more and more adolescents experience anxiety, depression, loneliness, and attention deficit disorders with a constant ‘digital diet’ that some have suggested include not only media, but junk food as well .

The negative impact of watching digital media was prescient by Jerry Mander, one of the leading visionaries of the 20th century, in his 1978 book, Four Arguments for the Elimination of Television, as well as by Joseph C. Pearce, author of books on human development and child development, in his 1993 book, Evolution’s End.

More recently, two superb books detail the harm that the digital revolution has brought, along with recommended strategies for how to use modern technologies wisely and live successfully in an e-world.  We are not saying to avoid the beneficial parts of the digital age.   We are saying to be aware how some material and digital platforms prey upon our evolutionary survival mechanisms.  Unfortunately, most people —especially children– have not evolved skills to counter the negative impacts of some types of media exposure.  It may take parental control and societal policies to mitigate the damage and enhance the benefits of the digital age. We highly recommend the following two books.

Glow Kids by Nicholas Kardaras, PhD describes the impact of excessive texting and computer gaming as well as strategies how to use digital media wisely

Deep Work by Cal Newport, PhD describes the impact of constant interruptions and offers rules for focused success in a distracted world.

book covers

References:

Calvert, S. L., Appelbaum, M., Dodge, K. A., Graham, S., Nagayama Hall, G. C., Hamby, S., Fasig-Caldwell, L. G., Citkowicz, M., Galloway, D. P., & Hedges, L. V. (2017). The American Psychological Association Task Force assessment of violent video games: Science in the service of public interest. American Psychologist, 72(2), 126–143. https://doi.org/10.1037/a0040413

Christodoulou, G., Majmundar, A., Chou, C-P, & Pentz, M.A. (2020). Anhedonia, screen time, and substance use in early adolescents: A longitudinal mediation analysis. Journal of Adolescence, 78, 24-32.

Cook L, Mostazir M, Watkins E, (2019). Reducing Stress and Preventing Depression (RESPOND): Randomized Controlled Trial of Web-Based Rumination-Focused Cognitive Behavioral Therapy for High-Ruminating University Students. J Med Internet Res, 21(5):e11349

Couch, M. A., & Citrin, R. (2018). Retooling leadership development. Strategic HR Review, 17(6), 275-281.

Dobson, D. & Dobson, K.S. (2018). Evidence-Based Practice of Cognitive-Behavioral Therapy, 2nd ed. New York: Guilford Press.

Kardaras, N. (2017).  Glow Kids, New York: St. Martin’s Griffin

Mander, J. (1978).  Four arguments for the Elimination of Television. New York: William Morrow Paperbacks.

Newport, C. (2019). Deep Work. New York: Grand Central Publishing

Pearce, J. C. (1993). Evolution’s End. New York: Harper One

Peper, E. & Aita, J. (2017). Winning the Gold in Weightlifting Using Biofeedback, Imagery and Cognitive Change. Biofeedback, 45(4), 77-82

Remland, M.S. (2016). Nonverbal Communication in Everyday Life, 4th ed.  London: Sage Publications Ltd.

Schenk, M. & Miltenberger, R. (2019). A review of behavioral interventions to enhance sports performance. Behavior Interventions, 33(2), 248-279.

Spiotta, A.M, Buchholz, A.L., Pierce, A. K., Dahlkoetter, J., & Armonda, R. (2018).  The Neurosurgeon as a High-Performance Athlete: Parallels and Lessons Learned from Sports Psychology. World Neurosurgery, 120, e188-e193

Yamada, F., Hiramatsu, Y., Murata, T., Seki, Y., Yokoo, M., Noguchi, R., … & Shimizu, E. (2018). Exploratory study of imagery rescripting without focusing on early traumatic memories for major depressive disorder. Psychology and Psychotherapy: Theory, Research and Practice91(3), 345-362.

 

 


Reduce stress, anxiety and negative thoughts with posture, breathing and reframing

This post has been adapted from 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 

When locked into a position, options appear less available. By unlocking our body, we allow our brain to unlock and become open to new options.

Changing positions may dissolve the rigidity associated with a fixed position. When we step away from the conflict, take a walk, look up at the treetops, roof lines and clouds, or do something different, we loosen up and new ideas may occur. We may then be able see the conflict from a different point of view that allows resolution.

When stressed, anxious or depressed, it is challenging to change. The negative feelings, thoughts and worries continue to undermine the practice of reframing the experience more positively. Our recent study found that a simple technique, that integrates posture with breathing and reframing, rapidly reduces anxiety, stress, and negative self-talk (Peper, Harvey, Hamiel, 2019). 

Thoughts and emotions affect posture and posture affects thoughts and emotions. When stressed or worried (e.g., school performance, job security, family conflict, undefined symptoms, or financial insecurity), our bodies respond to the negative thoughts and emotions by slightly collapsing and shifting into a protective position. When we collapse/slouch, we are much more at risk to:

When we are upright and look up, we are more likely to:

Experience how posture affects memory and the feelings (adapted from Alan Alda, 2018)

Stand up and do the following:

  1. Think of a memory/event when you felt defeated, hurt or powerless and put your body in the posture that you associate with this feeling. Make it as real as possible . Stay with the feeling and associated body posture for 30 seconds. Let go of the memory  and posture. Observe what you experienced.
  2. Think of a memory/event when you felt empowered, positive and happy put your body in the posture that you associate with those feelings. Make it as real as possible. Stay with the feeling and associated body posture for 30 seconds. Let go of the memory and posture. Observe what you experienced.
  3. Adapt the defeated posture and now recall the positive empowering memory while staying in the defeated posture. Observe what you experience.
  4. Adapt the empowering posture and now recall the defeated hopeless memory while staying in the empowered posture. Observe what you experience.

Almost all people report that when they adapt the body posture congruent with the emotion that it was much easier to access the memory and feel the emotion. On the other hand when they adapt the body posture that was the opposite to the emotions, then it was almost impossible to experience the emotions. For many people, when they adapted the empowering posture, they could not access the defeated hopeless memory. If they did access that memory, they were more likely be an observer and not be involved or emotionally captured by the negative memory.

Comparison of Posture with breathing and reframing to Reframing 

The study investigated whether  changing internal dialogue (reframing)  or combining posture change and breathing with changing internal dialogue would reduce stress and negative self-talk more effectively.

The participants were 145 college students (90 women and 55 men) average age 25.0 who participated as part of a curricular practice in four different classes.

After the students completed an anonymous informational questionnaire (history of depression, anxiety, blanking out on exams, worrying, slouching), the classes were divided into two groups. They were then asked to do the following:

  • Think of a stressful conflict or problem and make it as real as possible for one minute. Then let go of the stressful memory and  do one of the two following practices.
    • Practice A: Reframe the experience positively for 20 seconds.
    • Practice B: Sit upright, look up, take a breath and reframe the experience positively for 20 seconds.
  • After doing practice A or practice B,  rate the extent to which your negative thoughts and anxiety/tension were reduced, from 0 (not at all) to 10 (totally).
  • Now repeat this exercise except switch and do the other practice.  (Namely, if you did A now you do B; if you did B now you do A).

RESULTS

Overwhelmingly students reported that sitting erect, breathing and reframing positively was much more effective than only reframing as shown in Figure 1 and 2.figure 1Figure 1. Percentage of students rating posture, breath and reframing practice (PBRP) as more effective than reframing practice (RP) in reducing negative thoughts, anxiety and stress.slides Figure 2. Self-rating of reduction of negative thoughts and anxiety/tension

Stop reading. Do the practice yourself. It is only through experience that you know whether posture with breathing and reframing is a more beneficial than simply reframing the language.

Implications for education, counseling, psychotherapy. 

Our findings have implications for education, counseling and psychotherapy because students and clients usually sit in a slouched position in classrooms and therapeutic settings. By shifting the body position to an erect upright position, taking a breath and then reframing, people are much more successful in reducing their negative thoughts and anxiety/stress. They report feeling much more optimistic and better able to cope with felt stress as shown by representative comments in table 1.

Reframing Posture, breath and reframing
After changing my internal language, I still strongly felt the same thoughts. I instantly felt better about my situation after adjusting my posture.
I felt a slight boost in positivity and optimism. The negative feelings (anxiety) from the negative thoughts also diminished slightly. The effects were much stronger and it was not isolated mentally. I felt more relief in my body as well.
Even after changing my language, I still felt more anxious. Before changing my posture and breathing, I felt tense and worried. After I felt more relaxed.
I began to lift my mood up; however, it didn’t really improve my mood.  I still felt a bit bad afterwards and the thoughts still stayed. I began to look from the floor and up towards the board. I felt more open, understanding and loving. I did not allow myself to get let down.
During the practice, it helped calm me down a bit, but it wasn’t enough to make me feel satisfied or content, it felt temporary. My body felt relaxed overall, which then made me feel a lot better about the situation.
Difficult time changing language. My posture and breathing helped, making it easier to change my language.
I felt anger and stayed in my position. My body stayed tensed and I kept thinking about the situation. I felt anger but once I sat up straight and thought about breathing, my body felt relaxed.
Felt like a tug of war with my thoughts. I was able to think more positively but it took a lot more brain power to do so. Relaxed, extended spine, clarity, blank state of mind.

Table 1. Some representative comments of practicing reframing or posture, breath and reframing.

The results of our study in the classroom setting are not surprising.  Many us know to take three breaths before answering questions, pause and reflect before responding, take time to cool down before replying in anger, or wait till the next day before you hit return on your impulsive email response.

Currently, counseling, psychotherapy, psychiatry and education tend not to incorporate body posture as a potential therapeutic or educational intervention for teaching participants to control their mood or reduce feelings of powerlessness.  Instead, clients and students often sit slightly collapsed in a chair during therapy  or in class.  On the other hand, if individuals  were encouraged to adopt an upright posture especially in the face of stressful circumstances it would help them maintain their self-esteem, reduce negative mood, and use fewer sadness words as compared to the individual in a slumped and seated posture (Nair, Sagar, Sollers, Consedine, & Broadbent, 2015).

THE VALUE OF SELF-EXPERIENCE

What makes this study valuable is that participants compare for themselves the effects of the two different interventions techniques to reduce anxiety, stress and negative thoughts. Thus, the participants have an opportunity to discover which strategy is more effective instead of being told what to do.  The demonstration is even more impressive when  done in groups because nearly all participants will report that changing posture with breathing and reframing is more beneficial.

This simple and quick technique can be integrated in counseling and psychotherapy by teaching clients this behavioral technique to  reduce stress. In Cognitive Behavioral Therapy (CBT), sitting upright can help the individual replace a thought with a more reasonable one. In third wave CBT, it can help bypass the negative content of the original language and create a metacognitive change, such as, “I will not let this thought control me.”   

It can also help in Acceptance and Commitment Therapy (ACT) since changing one’s body posture may facilitate the process of “acceptance” (Hayes, Pistorello, & Levin, 2012). Adopting an upright sitting position and taking a breath is like saying “I am here, I am present, I am not escaping or avoiding.” This change in body position represents movement from inside to outside, movement from accepting the unpleasant emotion related to the negative thoughts toward a “commitment” to moving ahead, contrary to the automatic tendency to follow the negative thought. The positive reframing during body position or posture change is not an attempt to color reality in pretty colors, but rather a change of awareness, perspective, and focus that helps the individual identify and see some new options for moving ahead toward commitment according to one’s values. This intentional change in direction is central in ACT and also in positive psychology (Stichter, 2018).

CONCLUSION AND RECOMMENDATIONS

We suggest that therapists, educators, clients and students get up out of their chairs and incorporate body movements when they feels overwhelmed and stuck. Finally,  this study points out that mind and body are affected by each other. It provides another example of the psychophysiological principle enunciated by Elmer Green (1999, p 368):

“Every change in the physiological state is accompanied by an appropriate change in the mental-emotional state, conscious or unconscious; and conversely, every change in the mental-emotional state, conscious or unconscious is accompanied by an appropriate change in the physiological state.”

The findings of this study echo the ancient spiritual wisdom that is is central to the teaching of  the Zen Master, Thich Nhat Hanh.  He recommends that his students recite the following at any time:

Breathing in I calm my body,
Breathing out I smile,
Dwelling in the present moment,
I know it is a wonderful moment.

References

Alda, A. (2018). If I Understood You, Would I have This Look on My Face?: My Adventures in the Art and Science of Relating and Communicating. New York: Random House Trade Paperbacks.

Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at: www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are

Green, E. (1999). Beyond psychophysics, Subtle Energies & Energy Medicine, 10(4), page 368.

Hayes, S. C., Pistorello, J., & Levin, M.E. (2012). Acceptance and Commitment Therapy as a unified model of behavior change. The Counseling Psychologist 40(7), 976-1002.

Michalak, J., Mischnat, J., & Teismann, T. (2014). Sitting posture makes a difference-embodiment effects on depressive memory bias. Clinical Psychology and Psychotherapy, 21(6),

Nair, S., Sagar, M., Sollers, J. 3rd, Consedine, N., & Broadbent, E. (2015). Do slumped and upright postures affect stress responses? A randomized trial. Health Psychology, 34(6), 632-641. 

Peper, E., Booiman, A., Lin, I.M., & Harvey, R. (2016). Increase strength and mood with posture. Biofeedback. 44(2), 66–72.

Peper, E., Harvey, R., & Hamiel, D. (2019) Transforming thoughts with postural awareness to increase therapeutic and teaching efficacy.  NeuroRegulation, 6(3), 153-169.

Peper, E., Harvey, R., Mason, L., & Lin, I-M. (2018). Do better in math: How your body posture may change stereotype threat response. NeuroRegulation, 5(2), 67-74.

Peper, E. & Lin, I-M. (2012). Increase or decrease depression: How body postures influence your energy level. Biofeedback, 40(3), 126–130.

Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood. Biofeedback, 45(2), 36-41.

Risking, J.H. & Gotay, C.C. (1982). Physical posture: Could it have regulatory or feedback effects on motivation and emotion? Motivation and Emotion, 6(3), 273-298.

Stichter, M. P. (2019). Positive psychology and virtue: Values in action. The Journal of Positive Psychology, 14(1).

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.

Westfeld, G.E. & Beresford, J.J. (1982). Erectness of posture as an indicator of dominance or success in humans. Motivation and Emotion, 6(2), 113-131.

 

 


Toning quiets the mind and increases HRV more quickly than mindfulness practice

Adapted from: Peper, E., Pollack, W., Harvey, R., Yoshino, A., Daubenmier, J. & Anziani, M. (2019). Which quiets the mind more quickly and increases HRV: Toning or mindfulness? NeuroRegulation, 6(3), 128-133. 

Disruptive thoughts, ruminations and worrying are common experiences especially when stressed. Numerous clinical strategies such as cognitive behavioral therapy attempt to teach clients to reduce negative ruminations (Kopelman-Rubin, Omer, & Dar, 2017). Over the last ten years, many people and therapists practice meditative techniques to let go and not be captured by negative ruminations, thoughts, and emotions.  However, many people continue to struggle with distracting and wandering thoughts.

Just think back when you’re upset, hurt, angry or frustrated. Attempting just to observe without judgment can be very, very challenging as the mind keeps rehearsing and focusing on what happened. Telling yourself to stop being upset often doesn’t work because your mind is focused on how upset you are. If you can focus on something else or perform physical activity, the thoughts and feelings often subside.

Over the last fifteen years, mindfulness meditation has been integrated and adapted for use in behavioral medicine and psychology (Peper, Harvey, & Lin, 2019). It has also been implemented during bio- and neurofeedback training (Khazan, 2013; Khazan, 2019).  Part of the mindfulness instruction is to recognize the thoughts without judging or becoming experientially “fused” with them. A process referred to as “meta-awareness” (Dahl, Lutz, & Davidson, 2015). Mindfulness training combined with bio- and neurofeedback training can improve a wide range of psychological and physical health conditions associated with symptoms of stress, such as anxiety, depression, chronic pain, and addiction (Creswell, 2015, Khazan, 2019).

Mindfulness is an effective technique; however, it may not be more effective than other self-regulations strategies (Peper et al, 2019). Letting go of worrying thoughts and rumination is even more challenging when one is upset, angry, or captured by stressful life circumstances. Is it possible that other strategies beside mindfulness may more rapidly reduce wandering and intrusive thoughts?  In 2015, researchers van der Zwan, de Vente, Huiznik, Bogels, & de Bruin found that physical activity, mindfulness meditation and heart rate variability biofeedback were equally effective in reducing stress and its related symptoms when practiced for five weeks.

Our research explored whether other techniques from the ancient wisdom traditions could provide participants tools to reduce rumination and worry. We investigated the physiological effects and subject experiences of mindfulness and toning.  Toning is vocalizing long and sustained sounds as a form of mediation. (Watch the video  the toning demonstration by sound healer and musician, Madhu Anziani  at the end of the blog.)

COMPARING TONING AND MINDFULNESS

The participants were 91 undergraduate college students (35 males, 51 females and 5 unspecified; average age, 22.4 years, (SD = 3.5 years).

After sitting comfortably in class, each student practiced either mindfulness or toning for three minutes each. After each practice, the students rated the extent of mind wandering, occurrence of intrusive thoughts and sensations of vibration on a scale from 0 (not all) to 10 (all the time).  They also rated pre and post changes in peacefulness, relaxation, stress, warmth, anxiety and depression. After completing the assessment, they practice the other practice and after three minutes repeated the assessment.

The physiological changes that may occur during mindfulness practice and toning practice was recorded in a separate study with 11 undergraduate students (4 males, 7 females; average age 21.4 years. Heart rate and respiration were monitored with ProComp Infiniti™ system (Thought Technology, Ltd., Montreal, Canada).  Respiration was monitored from the abdomen and upper thorax with strain gauges and heartrate was monitored with a blood volume pulse sensor placed on the thumb.

After the sensors were attached, the participants faced away from the screen so they did not receive feedback.  They then followed the same procedure as described earlier, with three minutes of mindfulness, or toning practice, counterbalanced.  After each condition, they completed a subjective assessment form rating experiences as described above.

RESULTS:  SUBJECTIVE FINDINGS

Toning was much more successful in reducing mind wandering and intrusive thoughts than mindfulness. Toning also significantly increased awareness of body vibration as compared to mindfulness as shown in Figure 1.0 Intrusive wandering thoughts comparison

Figure 1. Differences between mindfulness and toning practice.

There was no significant difference between toning and mindfulness in the increased self-report of peacefulness, warmth, relaxation, and decreased self-report of anxiety and depression as shown in Figure 2.

Figure 2. No significant difference between toning and mindfulness practice in relaxation or stress reports.0 relax comparison

RESULTS: PHYSIOLOGICAL FINDINGS

Respiration rate was significantly lower during toning (4.6 br/min) as compared to mindfulness practice (11.6 br/min); heart rate standard deviation (SDNN) was much higher during toning condition (11.6) (SDNN 103.7 ms) than mindfulness (6.4) (SDNN 61.9 ms). Two representative physiological recording are shown in Figure 3.

0 physiological comparison black white a

Figure 3. Representative recordings of breathing and heart rate during mindfulness and toning practice. During toning the respiration rate (chest and abdomen) was much slower than during mindfulness and baseline conditions.  Also, during toning heart rate variability was much larger than during mindfulness or baseline conditions.

DISCUSSION

Toning practice is a useful strategy to reduce mind wandering as well as inhibit intrusive thoughts and increase heart rate variability (HRV). Most likely toning uses the same neurological pathways as self-talk and thus inhibits the negative and hopeless thoughts. Toning is a useful meditation alternative because it instructs people to make a sound that vibrates in their body and thus they attend to the sound and not to their thoughts.

Physiologically, toning immediately changed the respiration rate to less than 6 breaths per minute and increases heart rate variability. This increase in heart rate variability occurs without awareness or striving. We recommend that toning is integrated as a strategy to complement bio-neurofeedback protocols. It may be a useful approach to enhance biofeedback-assisted HRV training since toning increases HRV without trying and it may be used as an alternative to mindfulness, or used in tandem for maximum effectiveness.

TAKE HOME MESSAGE

1) When people report feeling worried and anxious and have difficulty interrupting ruminations that they first practice toning before beginning mindfulness meditation or bio-neurofeedback training.

2) When training participants to increase heart rate variability, toning could be a powerful technique to increase HRV without striving

TONING DEMONSTRATION AND INSTRUCTION BY SOUND HEALER MADHU ANZIANI

For the published article see: Peper, E., Pollack, W., Harvey, R., Yoshino, A., Daubenmier, J. & Anziani, M. (2019). Which quiets the mind more quickly and increases HRV: Toning or mindfulness? NeuroRegulation, 6(3), 128-133.

REFERENCES

Creswell, J. D. (2015). Mindfulness Interventions. Annual Review of Psychology, 68, 491-516.

Dahl, C. Lutz, A., & Davidson, R. J. (2015). Reconstructing and deconstructing the self: Cognitive mechanisms in meditation practice. Trends in Cognitive Science, 19(9), 515-523.

Khazan, I. Z. (2013). The Clinical Handbook of Biofeedback: A Step-by-Step Guide for Training and Practice with Mindfulness. John Wiley & Sons.

Khazan, I. Z. (2019). Biofeedback and Mindfulness in Everyday Life.  New York: W. W. Norton & Company.

Kopelman-Rubin, D., Omer, H., & Dar, R. (2017). Brief therapy for excessive worry: Treatment model, feasibility, and acceptability of a new treatment. Journal of Psychotherapy Integration, 29(3), 291-306. 

Peper, E., Harvey, R., & Lin, I-M. (2019).  Mindfulness training has themes common to other technique. Biofeedback. 47(3),

van der Zwan, J. E., de Vente, W., Huizink, A. C., Bogels, S. M., & de Bruin, E. I.  (2015). Physical activity, mindfulness meditation, or heart rate variability biofeedback for stress reduction: A randomized controlled trial. Applied Psychophysiology and Biofeedback, 40(4), 257-268. https://doi.org/10.1007/s10484-015-9293-x

 


Hope for teens with pain

Erik Peper, PhD and Rachel Zoffness, PhD*

 KM was 14 years old when he came to my (Zoffness) office for treatment. He’d been diagnosed with migraine and cyclical vomiting syndrome and had been in bed for about 3 years. He had long, unwashed hair; was a sickly, pasty white; and rocked himself back and forth from the pain. He’d seen 15 doctors and had been prescribed 30 medications, including occipital nerve injections and Thorazine. Nothing had worked. Like most teens with chronic pain, KM was depressed, stressed, and terrified he’d never get his life back.

We started Cognitive Behavioral Therapy (CBT), beginning with pain neuroscience education. This involved teaching KM and his family how pain works in the brain, and how thoughts, emotions, physical sensations and behaviors work together to trigger and maintain flares. He then learned a variety of cognitive, behavioral and mind-body techniques to help manage and change pain. His parents received parent-training to support him behind the scenes. After a few weeks of treatment, KM was able to get out of bed and walk to the corner mailbox. After a few more weeks, he was able to walk his dog to the dog park and get a haircut. Within a few months he was jogging around the block, then running. As his functioning increased, his brain desensitized and his body strengthened, his pain started to recede. Gradually he returned to school and social relationships, eventually rejoining his soccer team. I attended his high school graduation a year ago. He got onstage and told the audience that, if you’d told him 4 years ago that he’d graduate high school, he’d never have believed you. He is currently in college, successfully managing his pain, living his important life.

Chronic pain (CP) in teens can be devastating. Teens are already tasked with managing the turbulence of hormone changes, social stress, academic stress, social media, family dynamics, and developing autonomy and independence. CP impacts not only the teen, but also the entire family. Because CP is framed as a biomedical problem, it is frequently treated with opioids and other minimally-helpful (and sometimes harmful) medications. Opioids are ineffective for long-term treatment of chronic pain, and are only useful in acute crises or to control pain at the end of life (Dowell, 2016; King et al, 2011).

Although we typically think of chronic pain as an issue primarily affecting adults coping with issues such as post-surgical pain and arthritis, CP affects up to 1 in 3 youth in the USA – more than 10 million children and teens (Friedrichsdorf,  2016; ).  Pain impacts self-esteem, hope, and functioning, relegating teens to their beds and denying them normal educations and healthy social interactions.  Like adults, teens often feel powerless and blamed.  In a superb workbook, The Chronic Pain & Illness Workbook for Teens, psychologist Rachel Zoffness describes what pain is; how pain is constructed by the brain; how mind, body and emotions interact to affect pain; and offers a sequence of assessments and practices to reduce pain and improve health in language children and teens can easily understand.  The approach combines cognitive behavioral therapy (CBT) with imagery, mindfulness, breathing, handwarming with biofeedback, and somatic practices (Turk & Gatchel, 2018; Peper, Gibney, & Holt, 2002).

This simple graphic of the pain cycle is helpful to clients (see Fig. 1).

pain cycle

 Fig 1. CBT Pain Cycle

The pragmatic practices in this book offer tools and guided instructions that any child or teen can use for themselves, with parents, or with health providers.  Therapists can use and adapt these activities with their clients of all ages. Although these scientifically-supported pain management techniques are written for teens, they can equally be used with adults. Below are two of many different practices described in the book that are useful for chronic pain.

Practice 1: Assessment: What sets off your pain?

The first step is to help youth identify factors that “trigger” – or set off – their pain. It’s helpful to define a trigger as a difficult emotion, situation, or event that causes pain to increase. Difficult situations and events of all kinds – biological, social, etc (situational triggers) can trigger difficult thoughts and emotions (cognitive and emotional triggers), and vice versa. For example, Adam was recovering from back surgery (situational trigger), got into a big fight with his sister about the car (situational trigger), and became angry and frustrated (emotional trigger). He felt the anger in his body, his muscles got hot and tight, and his back started spasming. Gina is an example of the reverse. She believed that nothing could cure her fibromyalgia (cognitive trigger), which made her feel depressed and hopeless (emotional trigger). She stayed home for weeks on end without school, friends, or distractions (situational trigger), and started feeling worse.

We can help youth with pain by asking:

  • What emotions trigger your pain?
    • Frustration
    • Anger
    • Stress
    • Anxiety
    • Loneliness
    • Sadness
  • What situations trigger your pain?
    • Not getting enough sleep
    • Arguing with family members
    • Inflammation after physical therapy
    • Missing fun events because you’re sick
    • Thinking about upcoming exams
    • Doctor’s appointments and hospital visits

Sometimes, the teen needs to keep a log for a week to identify the situations or triggers related to the pain.  Once these have been identified then the teen can explore strategies to reduce the negative reactivity triggered by the emotions or situations.

Practice 2: Changing the voice of pain (Note: this is a summary of a longer activity)

One technique we use in CBT for chronic pain is identifying and tracking cognitive distortions, also known as “thinking traps.” I (Zoffness) call these traps “Pain Voice.” This is the catastrophic, pessimistic, critical, and negative voice that tells us awful, worrisome things, particularly about our pain or health.

For example:

Pain Voice pretends she can predict the future, and says it’s going to be terrible. She says: “You’ll never get better. Nothing will ever help you.” But since she can’t predict the future (who can?), Pain Voice is a liar! Pain Voice is also very bossy about what you can and can’t do: “You can’t see your friends this week,” or “You can’t go for a bike ride, and you definitely can’t have any fun.” Science teaches us that negative thoughts increase pain by turning up the brain’s “pain dial,” so we must make sure not to listen to or believe them. To stop Pain Voice, we first catch negative thoughts.

As soon as you learn how to recognize Pain Voice, you gain the power to change negative thoughts into more helpful “Wise Voice” thoughts. One way to bust Pain Voice is to start tracking your negative thoughts. First, list these critical, self-defeating, catastrophic Pain Voice thoughts. Notice if they’re helpful or harmful. Then check and question them, thoughtfully determining whether they’re the truth or a trap. Next, gather evidence as to why Pain Voice might be wrong by asking yourself, is this thought a fact? What evidence do I have that this thought might not be true? What else might happen other than what I’m predicting? Write out your Wise Voice responses, and use them to fight back every time you hear Pain Voice!

Jason’s example: Jason had terrible, daily back pain and hadn’t gone outside in 6 weeks. His friends texted, inviting him to watch a movie. Immediately he heard the thought, “I can’t go, I’m broken. If I leave my house my pain will spike and I won’t be able to function.” He recognized this as his Pain Voice and knew he had to fight back. He sat down with his worksheet and filled in the answers: yes, the thoughts were harmful, not helpful, and they were trying to trap him! He examined the evidence and wrote the Wise Voice thought, “This negative prediction is not a fact, it’s a trap. I’ve had back pain for 2 years, and sometimes going out and seeing friends actually reduces my pain.” Tuning into his Wise Voice gave him the strength to get the social support and distraction he needed to feel a little better! He went to his friend’s house, watched movies, ate popcorn, giggled, and had a great time. For the first time in 6 weeks, his pain went down. An example of his log is shown in table 1.

 Situation

Pain Voice

Helpful or Harmful?

Trap or

Truth

Wise Voice
Returning to school after missing 3 weeks If I go back to school, I’ll be so far behind that I won’t understand anything the teacher is talking about. Harmful Trap This negative prediction is not a fact. I’m smart and competent, I’ll probably understand some things. Last time I was behind, I made up the work and everything was fine.
 

 

Pain flare-up

 

 

 

I can’t handle this! Harmful Trap This negative prediction is not a fact. I’ve had 42 pain flare-ups this year, and I handled all of them. I’ve proven that I’m strong and resilient. There is a 0% chance I can’t handle this.

Table 1. Example from Jason’s log

Summary: There is hope for youth with chronic pain. Interventions like CBT, mindfulness, biofeedback and other mind-body approaches are scientifically-supported and have evidence of effectiveness. Adhering to the biopsychosocial model – targeting biological, psychological and social factors – is proven to be the most effective treatment for chronic pain across conditions and ages. For more information, see Rachel Zoffness’ book, The chronic pain & illness workbook for teens,  for pragmatic treatment practices and user-friendly pain education. 

book cover

References

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA315(15), 1624-1645.

Friedrichsdorf, S. J., Giordano, J., Desai Dakoji, K., Warmuth, A., Daughtry, C., & Schulz, C. A. (2016). Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints. Children (Basel, Switzerland)3(4), 42. doi:10.3390/children3040042

King, S., Chambers, C., Huguet, A., MacNevin, R., McGrath, P., Parker, L., & MacDonald, A. (2011). The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain152(12), 2729-2738.

Peper, E. Gibney, K.H., & Holt, C.F. (2002). Make Health Happen-Training Yourself to Create Wellness. Kendall Hunt Publishing. ISBN-13: 978-0787293314

Turk, D. C., & Gatchel, R.J. (2018). Psychological approaches to pain management-A Practionere’s Handbook.  New York: The Guilford Press, ISBN-13: 978-1462528530

Zoffness, R. (2019). The Chronic Pain & Illness Workbook for Teens. Oakland, CA; New Harbinger Publications, ISBN: 978168403352

*Dr. Rachel Zoffness is a pain psychologist, consultant, writer and educator in Northern California’s East Bay specializing in chronic pain and illness.