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.

 


Provide hope and purpose: Focus on the good for all!

Erik Peper and Derek DoylefigureSource: https://devinepartners.com/2015/12/03/positive-news-sheds-light-this-winter/

“Fear stops action; hope initiate action.”

-Tali Sharot, PhD., author of Influential mind

Observe how you feel after you read the following two news reports:

Report 1. The graduating class at Atlanta’s historically black Morehouse College got the surprise of a lifetime on Sunday when commencement speaker and billionaire Robert F. Smith announced that he wasn’t just there to give the nearly 400 graduating seniors a nice motivational speech — he was also going to pay off their student debt.

“On behalf of the eight generations of my family that have been in this country, we’re gonna put a little fuel in your bus,” Smith, the founder of the investment firm Vista Equity and the richest black person in the United States, told the newest graduates of the prestigious all-male college. “This is my class, 2019. And my family is making a grant to eliminate their student loans.” (Lockhart, 2019).

News report 2: Gerry Dean Zaragoza, 26, is accused of fatally shooting his father and brother at a San Fernando Valley apartment before killing his ex-girlfriend at a gas station in North Hollywood, Los Angeles authorities said. He then is thought to have killed someone on a bus as police were searching for him during the 12-hour manhunt, Los Angeles police said. (Andrew Blankstein and Doha Madani (2019).

Which story made you feel more fearful and defensive; which story made you feel more positive and likely to help others?

The effect of incessant news

With the headlines screaming about killing, the endless repeating and commenting on tweeting lies  that evoke hatred, the creation of concentration camps and separating children from their immigrant mothers, or Representatives and Senators  focusing on winning the next election instead of focusing on the common good, we become fearful, discouraged and hopeless about the future. Surrounded by negative news we become apathetic, freeze in place, and close down to protect against loss.

Having traveled in the last few years to Japan, India, the Netherlands, Spain, Poland, Italy, and Canada, we observed that the USA is becoming a failed state.  The failing infrastructure of bridges and roads, the student debt that locks students into years of servitude, and the millions of people bankrupted by medical bills are only a few of the symptoms of our failing state and lack of positive vision. The more we allow ourselves to be bombarded by negative visual and auditory messages, the more we feel hopeless and powerless. We do not want to react out of hatred and disgust.  We want to focus on possibilities and be motivated by positive role models that will encourage positive action. Where is the inspirational vision for the future and the “Restoration Story” of how to get there? (Monbiot, 2019). We need a common mission for all to contribute to in our own unique and special way.

The images, words and thoughts that we allow to enter our brain become the hypnotic template for tomorrow’s action.  There is a  difference in saying, “I do not want hatred, fear and degrading commentary” versus “I want to learn from the inspirational work, aspirations and visions of nation builders and participate in this process.”

If you say to yourself, “I do not want to eat a piece of pie,” then that thought  evokes the image of piece of pie, which you may reject by saying “No.” This means that you are rehearsing eating the sweets and thus strengthening the desire.  If on the other hand you say to yourself, ‘I choose to eat more fruits and vegetables,” you are strengthening that desire. The thoughts help you identify the presence of fruits and vegetables more easily. Just as when you plan a vacation to Hawaii. All of a sudden there seems to be adds about Hawaii everywhere.

What we remember the next day depends upon what we focused upon earlier.  What we focus our attention and emotions on before going to sleep is what is stored in permanent memory and more likely to be remembered and acted upon the next day. Be careful what to look at and watch before going to sleep. It also impacts our physical and mental health. Children whose parents were emotionally upset and continue to watch the collapse of the World Trade Center buildings many times during the 9/11 terrorist attack experienced more stress symptom (including difficulty concentrating, difficulty falling asleep, losing temper/irritability, and nightmares) and 47% were worried about their own safety or the safety of loved ones (Hooker and Friedman, 2005).

Ask yourself, what images, speech and thoughts  you allow to enter your brain? In most cases, the news focuses upon destructive acts that evoke fear and implicitly reduce actual action.  Similarly, we can watch violent and toxic program on different streaming media such as Netflix, YouTube or Amazon Prime. As a result, we see the world much more dangerous than it  is.  Thus, we hover over children because we now think that they would be abducted by strangers (Amber Alert).  This increases the  public’s moral panic yet it is not clear if there has been an actual  increase in stranger child abduction in the last fifty years (Zgoba, 2006).

People who watch the news before going to sleep perceive their neighborhood as significantly more dangerously as compared to those who do not watch the news.  Because they believe their neighborhood is more dangerous, they avoid going out and by not going out make the neighborhood less communal and friendly. The information supports our negativity bias which focuses our attention on things that are dangerous or threatening (Soroka & McAdams, 2015)..

We have a choice to focus on what we would like instead of allowing to be bombarded by negative toxic messages and images.  This does not mean we stick our heads in the sand and are unaware, it means that we choose carefully how to balance the messages we receive. Instead of watching and listening to repeated negative news, listen or read (to) the news once during the day and then fill the day with positive news that evokes hope, good deeds and better possibilities for our communities.

Consider an experiment for a day or so..

Try searching and discovering some good news to share with family and friends. Watch their reaction and then extend the experiment for a few days seeking and sharing positive news.

Watch and listen to positive media such as:

  • GoodNews Network: The website, with its archive of 21,000 positive news stories from around the globe, confirms what people already know—that good news itself is not in short supply; the broadcasting of it is. https://www.goodnewsnetwork.org
  • TED Ideas worth spreading. TED is a global community, welcoming people from every discipline and culture who seek a deeper understanding of the world. We believe passionately in the power of ideas to change attitudes, lives and, ultimately, the world. https://www.ted.com/#/

After a few days or a week, ask how do you feel?

  • Are you more optimistic?
  • Do you feel safer and more relaxed?
  • Is sleep more restorative?

If you are like many others, you would feel slightly more hopeful, optimistic and positive.

What we allow to enter our brain becomes the template for the choices we make.

References

Blankstein, A. & Madani, D. (2019). Gunman suspected killing least three people in California shooting spree. NBC News, July 26, 2019.

Hooker, K.E., & Friedman, H. (2005). Responding to the psychological needs of children after 9/11: A review of the literature.

Lockhart, P.R. (2019). The Morehouse debt cancellation and the growing black student debt crisis. VOX Media. May 20, 2019.

Monbiot, G. (2019). The new political story that could change everything. TEDSummit.

Sharot, T. (2019). The influential mind-What the brain reveals about our power to change others. New York: Henry Holt and Company

Soroka, S. & McAdams, S. (2015). News, politics, and negativity. Political Communication, 32(1), 1-22.

Zgoba, K.M. (2006). Spin doctors and moral crusaders: the moral panic behind child safety legislation. Criminal Justice Studies, 17(4), 385-404.


Do self-healing first

20170611_160113

“I am doing very well, and I am very healthy. The vulvodynia symptoms have never come back. Also,my stomach (gastrointestinal discomfort) has gotten much, much better. I don’t really have random pain anymore, now I just have to be watchful and careful of my diet and my exercise, which are all great things!”  —A five-year follow-up report from a 28-year-old woman who had previously suffered from severe vulvodynia (pelvic floor pain).

Numerous clients and students have reported that implementing self-healing strategies–common sense suggestions often known as “grandmother’s therapy”—significantly improves their health and find that their symptoms decreased or disappeared (Peper et al, 2014). These educational self-healing approaches are based upon a holistic perspective aimed to reduce physical, emotional and lifestyle patterns that interfere with healing and to increase those life patterns that support healing. This may mean learning diaphragmatic breathing, doing work that give you meaning and energy, alternating between excitation and regeneration, and living a life congruent with our evolutionary past.

If you experience discomfort/symptoms and worry about your health/well-being, do the following:

  • See your health professional for diagnosis and treatment suggestions.
    • Ask what are the benefits and risks of treatment.
    • Ask what would happen if you if you first implemented self-healing strategies before beginning the recommended and sometimes invasive treatment?
  • Investigate how you could be affecting your self-healing potential such as:
    • Lack of sleep
    • Too much sugar, processed foods, coffee, alcohol, etc.
    • Lack of exercise
    • Limited social support
    • Ongoing anger, resentment, frustration, and worry
    • Lack of hope and purpose
  • Implement self-healing strategies and lifestyle changes to support your healing response. In many cases, you may experience positive changes within three weeks. Obviously, if you feel worse, stop  and reassess. Keep a log and monitor what you do so that you can record changes.

This self-healing process has often been labeled or dismissed as the “placebo effect;” however, the placebo effect is the body’s natural self-healing response (Peper & Harvey, 2017).  It is impressive that many people report feeling better when they  take charge and become active participants in their own healing process. A process that empowers and supports hope and healing. When participants change their life patterns, they often feel better. Their health worries and concerns become reminders/cues to initiate positive action such as:

  • Practicing self-healing techniques throughout the day (e.g., diaphragmatic breathing, self-healing imagery, meditation, and relaxation)
  • Eating organic foods and eliminating processed foods
  • Incorporating daily exercise and movement activities
  • Accepting what is and resolving resentment, anger and fear
  • Taking time to regenerate
  • Resolving stress
  • Focusing on what you like to do
  • Be loving to yourself and others

For suggestions of what to do, explore some of the following blogs that describe self-healing practices that participants implemented to improve or eliminate their symptoms.

Acid reflux (GERD) https://peperperspective.com/2018/10/04/breathing-reduces-acid-reflux-and-dysmenorrhea-discomfort/

Anxiety https://peperperspective.com/2019/03/24/anxiety-lightheadedness-palpitations-prodromal-migraine-symptoms-breathing-to-the-rescue/

Dyspareunia https://peperperspective.com/2017/03/19/enjoy-sex-breathe-away-the-pain/

Eczema https://peperperspective.com/2015/03/07/interrupt-chained-behaviors-overcome-smoking-eczema-and-hair-pulling/

Headache https://peperperspective.com/2016/11/18/education-versus-treatment-for-self-healing-eliminating-a-headaches1/

Epilepsy https://peperperspective.com/2013/03/10/epilepsy-new-old-treatment-without-drugs/

Irritability/hangry https://peperperspective.com/2017/10/06/are-you-out-of-control-and-reacting-in-anger-the-role-of-food-and-exercise/

Hot flashes and premenstrual symptoms https://peperperspective.com/2015/02/18/reduce-hot-flashes-and-premenstrual-symptoms-with-breathing/

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

Irritable bowel syndrome (IBS) https://peperperspective.com/2017/06/23/healing-irritable-bowel-syndrome-with-diaphragmatic-breathing/

Math and test anxiety https://peperperspective.com/2018/07/03/do-better-in-math-dont-slouch-be-tall/

Neck stiffness https://peperperspective.com/2017/04/06/freeing-the-neck-and-shoulders/

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

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

Psoriasis https://peperperspective.com/2013/12/28/there-is-hope-interrupt-chained-behavior/

Smoking https://peperperspective.com/2015/03/07/interrupt-chained-behaviors-overcome-smoking-eczema-and-hair-pulling/

Surgery https://peperperspective.com/2018/03/18/surgery-hope-for-the-best-but-plan-for-the-worst/

Trichotillomania (hair pulling) https://peperperspective.com/2015/03/07/interrupt-chained-behaviors-overcome-smoking-eczema-and-hair-pulling/

Vulvodynia https://peperperspective.com/2015/09/25/resolving-pelvic-floor-pain-a-case-report/

References

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.

Peper, E. & Harvey, R. (2017). The fallacy of the placebo-controlled clinical trials: Are positive outcomes the result of “indirect” treatment effects? NeuroRegulation, 4(3–4), 102–113.

 


Biofeedback, breathing and health

In the video interview recorded at the 2018 Conference of the New Psychology Association, Jagiellonian University, Krakow, Poland,  Erik Peper, PdD, defines biofeedback and suggests three simple breathing and imagery approaches that we can all apply to reduce pain, resentment and improve well-being.


Breathing reduces acid reflux and dysmenorrhea discomfort

“Although difficult and going against my natural reaction to curl up in the response to my cramps, I stretched out on my back and breathed slowly so that my stomach got bigger with each inhalation.  My menstrual pain slowly decreased and disappeared.

“For as long as I remember, I had stomach problems and when I went to doctors, they said, I had acid reflux. I was prescribed medication and nothing worked. The problem of acid reflux got really bad when I went to college and often interfered with my social activities. After learning diaphragmatic breathing so that my stomach expanded instead of my chest, I am free of my symptoms and can even eat the foods that previously triggered the acid  reflux.”

In the late 19th earlier part of the 20th century many women were diagnosed with Neurasthenia.  The symptoms included fatigue, anxiety, headache, fainting, light headedness, heart palpitation, high blood pressure, neuralgia and depression. It was perceived as a weakness of the nerves. Even though the diagnosis is no longer used, similar symptoms still occur and are aggravated when the abdomen is constricted with a corset or by stylish clothing (see Fig 1).

Fig 1a

Figure 1. Wearing a corset squeezes the abdomen.

The constricted waist compromises the functions of digestion and breathing. When the person inhales, the abdomen cannot expand as the diaphragm is flattening and pushing down. Thus, the person is forced to breathe more shallowly by lifting their ribs which increases neck and shoulder tension and the risk of anxiety, heart palpitation, and fatigue. It also can contribute to abdominal discomfort since abdomen is being squeezed by the corset and forcing the abdominal organs upward.  It was the reason why the room on top of stairs in the old Victorian houses was call the fainting room (Melissa, 2015).

During inhalation the diaphragm flattens and attempts to descend which increases the pressure of the abdominal content.  In some cases this causes the stomach content to be pushed upward into the esophagus which could result in heart burn and acid reflux.  To avoid this, health care providers often advice patients with acid reflux to sleep on a slanted bed with the head higher than their feet so that the stomach content flows downward. However, they may not teach the person to wear looser clothing that does not constrict the waist and prevent designer jean syndrome. If the clothing around the waist is loosened, then the abdomen may expand in all directions in response to the downward movement of the diaphragm during inhalation and not squeeze the stomach and thereby pushing its content upward into the esophagus.

Most people have experienced the benefits of loosening the waist when eating a large meal. The moment the stomach is given the room to spread out, you feel more comfortable.   If you experienced this, ask yourself, “Could there be a long term cost of keeping my waist constricted?”  A constricted waist may be as harmful to our health as having the emergency brake on while driving for a car.

We are usually unaware that shallow rapid breathing in our chest can contribute to symptoms such as anxiety, neck and shoulder tension, heart palpitations, headaches, abdominal discomfort such as heart burn, acid reflux, irritable bowel syndrome, dysmenorrhea and even reduced fertility (Peper,  Mason, & Huey, 2017; Domar, Seibel, & Benson, 1990).

Assess whether you are at risk for faulty breathing

Stand up and observe what happens when you take in a big breath and then exhale.  Did you feel taller when you inhaled and shorter/smaller when you exhaled?

If the answer is YES, your breathing pattern may compromise your health.   Most likely when you inhaled you lifted your chest, slightly arched your back, tightened and raised your shoulders, and lifted your head up while slightly pulling the stomach in. When you exhaled, your body relaxed and collapsed downward and even the stomach may have relaxed and expanded. This is a dysfunctional breathing pattern and the opposite of a breathing pattern that supports health and regeneration as shown in figure 2.

Fig 2a

Figure 2.  Incorrect and correct breathing. Source unknown.

Observe babies, young children, dogs, and cats when they are peaceful.  The abdomen is what moves during breathing.   While breathing in, the abdomen expands in all 360 degrees directions and when breathing out, the abdomen constricts and comes in.   Similarly when dogs or cats are lying on their sides, their stomach goes up during inhalation and goes down during exhalation.

Many people tend to breathe shallowly in their chest and have forgotten—or cannot– allow their abdomen and lower ribs to widen during inhalation (Peper et al, 2016). These factors include:

  • Constriction by the modern corset called “Spanx” to slim the figure or by wearing tight fitting pants. In either case the abdominal content is pushed upward and interferes with normal healthy breathing.
  • Maintaining a slim figure by pulling the abdomen (I will look fat when my stomach expands; I will suck it in).
  • Avoiding post-surgical abdominal pain by inhibiting abdominal movement. Numerous patients have unknowingly learned to shallowly breathe in their chest to avoid pain at the site of the incision of the abdominal surgery such as for hernia repair or a cesarean operation. This dysfunctional breathing became the new normal unless they actively practice diaphragmatic breathing.
  • Slouching as we sit or watch digital screens or look down at our cell phone.

Observe how slouching affects the space in your abdomen.

When you shift from an upright erect position to a slouched or protective position the distance between your pubic bone and the bottom of the sternum (xiphoid process) is significantly reduced.

  • Tighten our abdomen to protect ourselves from pain and danger as shown in Figure 3.

Fig 3a

Figure 3. Erect versus collapsed posture. There is less space for the abdomen to expand in the protective collapsed position. Reproduced by permission from Clinical Somatics (http://www.clinicalsomatics.ie/).

Regardless why people breathe shallowly in their chest or avoid abdominal and lower rib movement during breathing, by re-establishing normal diaphragmatic breathing many symptoms may be reduced.  Numerous students have reported that when they shift to diaphragmatic breathing which means the abdomen and lower ribs expand during inhalation and come in during exhalation as shown in Figure 4, their symptoms such as acid reflux and menstrual cramp significantly decrease.

Fig 4a

Figure 4. Diaphragmatic breathing. Reproduced from:  www.devang.house/blogs/thejob/belly-breathing-follow-your-gut.

Reduce acid reflux

A 21-year old student, who has had acid reflux (GERD-gastroesophageal reflux diseases) since age 6, observed that she only breathed in her chest and that there were no abdominal movements.  When she learned and practiced slower diaphragmatic breathing which allowed her abdomen to expand naturally during inhalation and reduce in size during exhalation her symptoms decreased. The image she used was that her lungs were like a balloon located in her abdomen. To create space for the diaphragm going down, she bought larger size pants so that her abdominal could spread out instead of squeezing her stomach (see Figure 5).

squeezing the stomach

Figure 5. Hydraulic model who inhaling without the abdomen expanding increases pressure on the stomach and possibly cause stomach fluids to be pushed into the esophagus.

She practiced diaphragmatic breathing many times during the day. In addition, the moment she felt stressed and tightened her abdomen, she interrupted this tightening and re-established abdominal breathing.  Practicing this was very challenging since she had to accept that she would still be attractive even if her stomach expanded during inhalation. She reported that within two weeks her symptom disappeared and upon a year follow-up she has had no more symptoms For a detailed description how this successfully cured irritable bowel syndrome see: https://peperperspective.com/2017/06/23/healing-irritable-bowel-syndrome-with-diaphragmatic-breathing/

Take control of menstrual cramps

Numerous college students have reported that when they experience menstrual cramps, their natural impulse is to curl up in a protective cocoon. If instead they interrupted this natural protective pattern and lie relaxed on their back with their legs straight out and breathe diaphragmatically with their abdomen expanding and going upward during inhalation, they report a 50 percent decrease in discomfort (Gibney & Peper, 2003). For some the discomfort totally disappears when they place a warm pad on their lower abdomen and focused on breathing slowly about six breaths per minute so that the abdomen goes up when inhaling and goes down when exhaling. At the same time, they also imagine that the air would flow like a stream from their abdomen through their legs and out their feet while exhaling.  They observed that as long as they held their abdomen tight the discomfort including the congestive PMS symptoms remained.  Yet, the moment they practice abdominal breathing, the congestion and discomfort is decreased. Most likely the expanding and constricting of the abdomen during the diaphragmatic breathing acts as a pump in the abdomen to increase the lymph and venous blood return and improve circulation.

Conclusion

Breathing is the body-mind bridge and offers hope for numerous disorders. Slower diaphragmatic breathing with the corresponding abdomen movement at about six breaths per minute may reduce autonomic dysregulation. It has profound self-healing effects and may increase calmness and relaxation. At the same time, it may reduce heart palpitations, hypertension, asthma, anxiety, and many other symptoms.

References

DeVault, K.R. & Castell, D.O. (2005). Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. The American Journal of Gastroenterology, 100, 190-200.

Domar, A.D., Seibel, M.M., & Benson, H. (1990). The Mind/Body Program for Infertility: a new behavioral treatment approach for women with infertility. Fertility and sterility, 53(2), 246-249.

Gibney, H.K. & Peper, E. (2003). Taking control: Strategies to reduce hot flashes and premenstrual mood swings. Biofeedback, 31(3), 20-24.

Johnson, L.F. & DeMeester, T.R. (1981).  Evaluation of elevation of the head of the bed, bethanechol, and antacid foam tablets on gastroesophageal reflux. Digestive Diseases Sciences, 26, 673-680. https://www.ncbi.nlm.nih.gov/pubmed/7261830

Melissa. (2015). Why women fainted so much in the 19th century. May 20, 2015.  Donloaded October 2, 1018. http://www.todayifoundout.com/index.php/2015/05/women-fainted-much-19th-century/

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.

Peper, E., Mason, L., Huey, C. (2017).  Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. (45-4)

Stanciu, C. & Bennett, J.R.. (1977). Effects of posture on gastro-oesophageal refluxDigestion, 15, 104-109. https://www.karger.com/Article/Abstract/197991

 

 

 

 


Be careful what you think*

“I couldn’t belief it.  I thought that I was strong and yet, I could not resist the downward pressure when I recalled a hopeless and helpless memory. Yet a minute later, I could easily resist  the downward pressure on my arm when I thought of a positive and empower memory.  I now understand how thoughts affect me.”

Thoughts/emotions affect body and body affects thoughts and emotions is the basis of the psychophysiological principle formulated by the biofeedback pioneers Elmer and Alice Green. The language we use, the thoughts we contemplate, the worries and ruminations that preoccupy us may impact our health.

Changing thoughts is the basis of cognitive behavior therapy and practitioners often teach clients to become aware of their negative thoughts and transform the internal language from hopeless, helpless, or powerless to empowered and positive. Think and visualize what you want and not what you do not want. For example, state, “I have studied and I will perform as best as I can” or  “I choose to be a non-smoker instead of stating, “I hope I do not fail the exam” or “I want to stop smoking.” The more you imagine what you what in graphic detail, the more likely will it occur.

Most people rationally accept that thoughts may affect their body; however, it is abstract and not a felt experience.  Also, some people have less awareness of the mind-body connection unless it causes discomfort.  Our attention tends to be captured by visual and auditory stimuli that constantly bombard us so that we are d less aware of the subtle somatic changes.

This guided practice explores what happens when you recall helpless, hopeless, powerless or defeated memories as compared to recalling empowering positive memories. It allows a person to experience–instead of believing—how thoughts impact the body. 98% of participants felt significantly weaker after recalling the helpless, hopeless, powerless or defeated memories. Once the participants have experienced the effect, they realize how thoughts effect their body.

The loss of strength is metaphor of what may happen to our immune system and health.  Do you want to be stronger or weaker? The challenge in transforming thoughts is that they occur automatically and we often doubt that we can change them. The key is to become aware of the onset of the thought and transform the thought.  Thoughts are habit patterns and the more you practice a habit, the more it becomes automatic.  Enjoy the experiential exercise, Mind-body/Bodymind-connection: Muscle testing.

*I thank Paul Godina, Jung Lee and Lena Stampfli for participating in the videos.

The practice was adapted from, Gorter, R. & Peper, E. (2011). Fighting Cancer-A Non Toxic Approach to Treatment. Berkeley: North Atlantic.


Do better in math: Don’t slouch-Be tall!

“When I saw the exam questions, I blanked out and slouched in defeat. Then I shifted to an erect/tall position and took a diaphragmatic breath. All of a sudden I remembered the answer.”                                                                                                                        College student

Anticipating that math is difficult, experiencing test anxiety, blanking out on exams, or being scared when asked to give class presentation are common experiences of many students.  Their thoughts include, “I am not good enough,“What will the other students think,”  “I am embarrassed and can’t remember what to say,” or “I only thought of the correct answer after it was all over.” Many students report some test anxiety: 32% report severe test anxiety, fear of math and blanking out on exams while less than 10 percent report minimal test anxiety, fear of math and blanking out on exams.

When students anticipate that they will perform poorly on an exam or class presentation, they tend to sit in a slouched or collapsed position, coincident with feelings of powerlessness, hopelessness and defeat. This posture not only communicates to others that they are powerless and defeated, it also decreases their self-esteem, mood and cognitive performance.  In previous research, Tsai et al (2016) and Peper et al (2017) observed that when participants sat in a slouched posture, they could access hopeless, helpless, powerless and defeated memories much more easily than when they sat in the upright/erect position.  In the upright position it was much easier to access positive and empowering memories. For numerous participants they also experienced being captured and flooded by emotions associated with defeat and hopelessness when they slouched. These feelings and memories associated with a slouched posture may affect how we feel and perform. Nair et al (2015) found that adopting an upright seated posture in the face of stress can maintain self-esteem, reduce negative mood, and increase positive mood as compared to a slumped posture. Furthermore, sitting upright increases rate of speech and reduces self-focus.” Posture may also affect our hormone levels. Harvard Social Psychologist Amy Cuddy has reported that sitting in a slouched posture (powerless position) decreased testosterone (the hormone associated dominance and assertiveness) and increased cortisol (the hormone associated with stress) and performance on a stressor test (Cuddy, 2012; Carney et al, 2010). 

This blog points out how posture significantly impacts math performance especially for students who have test anxiety, are fearful of math, and blank out on exams and is adapted from our published research article, 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 

In our study 125 university students participated. Half the students sat in an erect position while the other half sat in a slouched position and were asked to mentally subtract 7 serially from 964 for 30 seconds. They then reversed the positions before repeating the math subtraction task beginning at 834. They rated the math task difficulty on a scale from 0 (none) to 10 (extreme).

Fig 1 Slouch collapse positionFigure 1. Sitting in a collapsed position and upright position (photo from: http://news.sfsu.edu/news-story/good-posture-important-physical-and-mental-health)

The students rated the mental math significantly more difficult while sitting slouched than while sitting erect as shown in Figure 2.

Fig 2 difficulty in math by positionFigure 2. The subjective rating of difficulty in performing the serial 7 math subtraction when sitting in a collapsed or upright position.

For the students with the lowest 30% test anxiety, math difficulty and blanking out scores, there was no significant difference between slouched and erect positions in mental math performance.  More importantly, students with the highest 30% test anxiety, math difficulty and blanking out scores rated the math task significantly more difficult and some could not do it at all and blanked out in the slouched position as compared to the erect position as shown in Figure 3.

Fig 3 30 percent math performanceFigure 3. Effect of posture on math performance for students with test anxiety, math difficulty and blanking out.

 The students with the highest test anxiety, math difficulty and blanking out scores also reported significantly more somatic symptoms as compared with those with the lowest scores as shown in Figure 4.

Fig 4 SymptomsFigure 4. Self-reported symptoms associated with the highest and lowest 30% of summed test anxiety, math difficulty and blanking out.

Discussion

Posture affects mental math and inhibit abstract thinking. By incorporating posture changes clinicians and teachers may help students improve performance.  The slouched position was associated with increased difficulty in performing a math subtraction task for 15 seconds, especially for students reporting higher test anxiety, math difficulty and blanking out on exams. In contrast, slouched position had no significant effect on students who reported that they were not stressed about performance. For participants who report higher test anxiety, math difficulty and blanking out they also reported significant increase in breathing difficulty, neck and shoulder tension, headaches, depression and anxiety. Most likely, the students attribute physiological reactions such as increased heart rate and breathing changes negatively, which amplifies their negative self-perception and exacerbates their anxiety symptoms which then may inhibit their cognitive ability to perform on math tasks.

The slouched position combined with the somatic symptoms activate are part of the a “defense reaction.” The slouch posture evokes a classically conditioned response to protect oneself under conditions of perceived physical threat. The activation of this defense pattern is associated with reduced levels of abstract thinking and frontal cortical deactivation as observed in this study.  This biological defense response is triggered when the person expects the situation to be ‘dangerous’ and include conditions of social-evaluative threat. By changing posture to an erect/upright posture appears to inhibit the defense reaction; thus, the person may perform better on cognitive tasks. 

Summary

Head-upright/erect postures may make it easier to access ‘positive and empowering’ thoughts and memories, thereby helping students, especially those who are anxious or fearful of math and blank-out during exams,   Anxious students who also slouch may benefit from training with a posture feedback  devices such as the UpRight Go™[1].  We recommend that students use posture feedback to become aware of the situations that are associated with slouching, such as ergonomic factors (looking down at the screen), being tired, or having depressive thoughts or feeling of powerless and defeat. 

The moment students experience the feedback that they are slouching, they become aware and have the option to shift to an upright posture and perform interventions to counter the factors that caused the slouching.  These interventions included ergonomic changes of their computer or laptop, transforming self-critical thoughts to empowering thoughts, or taking a break or performing movements. When students practice these interventions for four weeks, they report an increase of confidence, decrease in stress levels and an improvement in health and performance (Colombo et al, 2017; Harvey et al, in press). Equally important is to teach the participants self-regulation strategies  such as slower breathing, heart rate variability training, and muscle relaxation to reduce symptoms. The training needs to be generalized and practiced at home, school or work.

We recommend that students guide themselves through the posture positions as described in this research while performing mental math to experience how posture impacts performance. This experiential practice may increase motivation to be tall since the participant can now have a choice based upon self-experience.

Take home message echoes what your mother said, “Don’t slouch. Sit up tall!” 

  • If you feel secure and safe, posture has little to no effect on performance–you can be collapsed or slouched.
  • If you are anxious and fearful, sitting tall/erect may improve your performance.
  • If you want to become aware when you slouch, posture feedback from a wearable posture feedback device such as an UpRight Go can provide vibration feedback each time you slouch. The feedback can be the reminder to sit tall and change your thoughts.
  • If you automatically slouch while working at the computer or sitting in chair, change your furniture so that you sit in an upright position while studying or watching digital devices.
  • If you experience significant somatic symptoms (e.g., headaches, breathing difficulty, neck and shoulder tension, or depression and anxiety) learn self-regulation skills such as slower diaphragmatic breathing and heartrate variability training in conjunction with transforming negative self-talk to positive self-talk to improve performance.

Changing posture may also impact other areas of one’s life besides improving math performance as illustrated by the report from a mother of ten-year old boy.  

”At the moment I am trying to be aware of the situation in front of me rather that reacting to it. For example, yesterday my son who is 10 had a bad mood and I did not know what had happened, and he at first refused to tell me. Because I was aware of the posture information I could help him open up by making him change his posture without knowing. He became more open and told me what had happened earlier and I could help him move forward.”

REFERENCES

Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 21(10), 1363–1368.

Colombo, S., Joy, M., Mason, L., Peper, E., Harvey, R., & Booiman, A.C. (2017). Posture Change Feedback Training and its Effect on Health. Poster presented at the 48th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Chicago, IL March, 2017. Abstract published in Applied Psychophysiology and Biofeedback.42(2), 147.

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

Harvey, R., Mason, L., Joy, M., & Peper, E. (in press). Effect of Posture Feedback Training on Health, Applied Psychophysiology and Biofeedback. 

Nair, S., Sagar, M., Sollers, III, J., Consedine, N. & Broadbent, E.  (2015). Do Slumped and Upright Postures Affect Stress Responses? A Randomized Trial. Health Psychology, 34(6), 632–641.

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

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.

[1] UpRight Go is produced by Upright Technologies. LTD, Ha’atzmaut 56, Yehud 5630425, Israel  https://www.uprightpose.com