New brain study sheds light on how mindfulness reduces suffering associated with pain

Mindfulness has been shown in numerous studies to effectively attenuate pain, but a new study about to be published suggested that the way in which this reduction happens is much different than other, more typical coping mechanisms. These findings go to the heart of the difference between pain and suffering, by elucidating the different patterns of brain activation associated with each and showing how suffering is reduced throughout the practice of mindfulness, even when the sensation of pain is present.

In a study comparing meditators to non-meditators by researchers from Giessen University in Germany, Maastricht University in the Netherlands, and Massachusetts General Hospital, much was learned about the neural processes involved in the reduced suffering in the face of pain experienced by meditators. The findings of this study were recently published ahead of print in the journal Cerebral Cortex.

Mindfulness refers to a specific inner stance of purposefully paying attention to experiences in the present moment in a nonjudgmental way. For example attention is focused on the sensory aspects of a sensation alone, rather than the cognitive and emotional reactions to those sensory experiences. In mindfulness, these sensory aspects are investigated with curiosity and acceptance. Instead of being reactive and judgmental of sensations, people become fully aware of the experience in the present moment and relate to it in an objective and neutral way.

Thirty-four healthy individuals participated in the study; 17 of them were experienced mindfulness meditators. While brain activation of participants was measured in the MRI scanner at Giessen University, participants received mildly painful electric shocks on the left lower arm. Participants were instructed to relate to the shocks in different ways: with mindfulness, and with a normal, daily life stance. Participants were then asked to rate the intensity and unpleasantness of the shocks, and the anticipatory anxiety in regard to receiving the shocks.

During the practice of mindfulness, experienced meditators experienced the pain as significantly less unpleasant. In addition they reported less anticipatory anxiety, even though they didn’t perceive the intensity of the sensations differently. The MRI images revealed interesting changes in brain activation during the state of mindfulness in mindfulness meditators: increased activation in brain regions that are involved in processing the sensory aspects of the pain experience (posterior insula/secondary somatosensory cortex), but decreased activation in brain regions that are involved in regulating pain through reappraisal (lateral prefrontal cortex). Thus, the meditators fully experienced the pain, but they suffered less from it.

This pattern of brain activation is in sharp contrast to other psychological pain modulation strategies: When participants reduce pain by reappraising it (i.e., a cognitive reinterpretation), there is an increase in activation in the lateral prefrontal cortex. Activation in sensory brain areas on the other hand typically decreases. While the pattern of brain activation revealed in this new study is in sharp contrast to other pain modulation strategies, it is well-aligned with theories of mindfulness.

“The increased activation in sensory pain areas in the brain, that we found during the practice of mindfulness seems to be aligned with the increased focus on the sensory aspects of the pain that meditators report”, says Tim Gard, first author of the study. “Simultaneously we saw decreased brain activation in brain regions that are involved in reappraisal. During the state of mindfulness, meditators seem to be in contact with the present moment experience as it is, without reappraising or evaluating it.”

“It is very interesting that the pattern of brain activation that we observed during the attenuation of pain in a state of mindfulness is in sharp contrast to other forms of pain modulation”, says Tim Gard. “It indicates that mindfulness really is a different way of reducing pain. These findings might have interesting clinical implications. The revealed unique mechanisms of pain modulation might be utilized to improve or develop new strategies for the management of chronic pain”, according to Tim Gard. “While the current study investigated the effects of the state of mindfulness on pain perception in healthy subjects, future studies are required to test whether the findings can be generalized to chronic pain.”

Reference:

Gard, T., Hölzel, B.K., Sack, A.T., Hempel, H., Lazar, S.W., Vaitl, D., & Ott, U.: Pain attenuation through mindfulness is associated with decreased cognitive control and increased sensory processing in the brain. Cerebral Cortex, published online on December 15 2011, doi: 10.1093/cercor/bhr352

http://cercor.oxfordjournals.org/content/early/2011/12/14/cercor.bhr352.abstract

MBSR & Fibromyalgia a Preliminary Study

Mindfulness-based Contemplative Training Reduces Avoidance and Facilitates Disengagement from Threat in Women Diagnosed with Fibromyalgia
David Vargo

Eight-week courses in mindfulness-based contemplative training focusing on specific meditation and yoga practices have been shown to have explicit benefits for many clinical disorders, especially with relation to treating stress, targeting emotion dysregulation, and attentional processes, yet little research has explored the effects of these practices in the context of bias.
Attentional bias is a tendency to focus on one aspect of the environment over others. A bias may arise through varied mechanisms, but is driven by evolutionarily shaped mechanisms. Attentional bias will influence how one perceives and processes information in the present moment, from the past, and how one anticipates the future. Humans typically have their attention automatically captured by fear-relevant stimuli, and for good reason, to avoid danger and threat of harm. Persistent attentional bias to threat cues in the environment will typically result in increased perception of danger, hypervigilance, and often frequent or intense experiences of anxiety. Although it may appear that an enhanced sensitivity to detecting threat is advantageous, hypervigilance is not necessarily adaptive, as it consists of persistent intensified monitoring and attentional fixedness at the expense of ongoing cognitive demands and a continually active sympathetic nervous system. Hypervigilance may also generalize to innocuous stimuli, wherein non-threatening stimuli are determined to be threatening. Thus, bias becomes a distorted interpretation of one’s experience, with consequences that could lead to chronic anxiety and stress-mediated pathology. Interestingly, there is now evidence that hypervigilant processing could be occurring without conscious awareness, such that very early stages of sensory processing (e.g., < 300 ms from stimulus exposure) are detecting possible threat-related cues. Once a threatening cue is detected, automatic and strategic forms of emotion regulation processing typically follow. Automatic forms of processing have the potential to operate below conscious awareness as well, and are typically over-trained, habitual responses to threat. Strategic forms of processing are more volitional, and cognitive in quality. Avoidance is one emotion regulation strategy that occurs at both automatic and strategic time-courses for the purpose of reducing elaborative or evaluative processing and deflating the threat value of the stimulus. When avoidance becomes habitual, it also can be maladaptive.
Both hypervigilance and avoidance have been found to contribute to the exacerbation of chronic pain and disability, and a vulnerability to pathological emotional states in chronic pain disorders like fibromyalgia (FM). FM is a disorder characterized by diffuse tenderness and widespread chronic pain, and is often accompanied by impaired cognitive, emotional, and physical functioning. Although various external stimuli such as infection, trauma and stress may contribute to development of FM, recent studies have emphasized the role of hypervigilance and avoidance of pain-related information. Pain-related information are cues in the environment or recalled from one’s memory and can be anything from images, sounds, certain trigger words (e.g., sharp, pounding, throbbing), or even people that remind one of a past experience of pain. Because these cues have previously been associated with pain, a heightened sensitivity towards such pain-related information develops and leads to a generalized pattern of hypervigilance.
My colleagues from the Utah Center for Exploring Mind-Body Interactions and I recently published a preliminary study in Cognitive Therapy and Research that investigated attentional bias of pain-related threat between women diagnosed with FM who went through an 8-week course of mindfulness-based contemplative training and an age-matched comparison control group of female FM individuals. The mindfulness-based training program was designed to accommodate the physical limitations of the FM population, but modeled after curriculum for Mindfulness-based Stress Reduction (MBSR) (see paper for exact modifications). A well validated dot-probe task (see paper for methodology of task) was used to explore early versus later stages of attentional bias processing of pain-related threat words. The rapid exposure of cues at short durations (100 ms) intended to capture automatic stages of processing by limiting attention to early sensory-perceptual stages, while longer cue durations (500 ms) intended to capture initial strategic forms of cognitive processing. The data indicated that individuals from the control group appeared to be hypervigilant-avoidant in their processing of pain-related threat, such that pain-related words were rapidly detected and avoided without much time for conscious elaboration. This form of avoidance is presumed to be a highly conditioned, automatized form of processing. Individuals from the control group also appeared to have difficulty disengaging from pain-related threat once strategic, elaborative processing was possible. This lingering engagement with negative stimuli slowed their response time on the dot-probe task, such that processing of threatening stimuli was assumed to interfere with the necessary processing for the task at hand (i.e., keyboard press indicating position of dot-probe). One may speculate that the mental stickiness that is typically described as a target for Buddhist meditation practices could also be explained by disengagement difficulty. Extended elaborative processing has also been implicated in ruminative cognition, a maladaptive, repetitive evaluation of one’s experience in a negative context.
The individuals exposed to mindfulness training demonstrated significantly less avoidance of threat than individuals from the control group and also disengaged more rapidly at later stages of processing. These results suggest that mindfulness training reduces avoidance of pain-related threat at early levels of attention processing, and facilitates disengagement from threat at later stages of processing. Furthermore, it appears that effects of mindfulness training on early attentional threat processing do not remain stable after long-term follow-up. The enduring effects of mindfulness training on attentional bias were assessed 6-months after completion of the mindfulness-based program. With little to no continued meditation practice, the apparent effects on attentional bias were reduced. What did remain was a lack of attentional bias towards pain-related threat in comparison to neutral words.
The take-home message for this preliminary study is that mindfulness training for individuals diagnosed with FM appears to increase engagement with and decrease avoidance of pain-related information that normally leads to anxiety and emotion dysregulation. Furthermore, mindfulness training appears to decrease time of lingering or “mental stickiness” with pain-related information. Further studies will have to investigate whether the decreases in bias after 6 months with little to no continued practice were indicative of a linear trend towards maladaptive avoidant emotion regulation strategies, or a stabilization of attention over time, in which no bias remains between threat and neutral stimuli. This study is the first preliminary evidence for the effect of mindfulness training on attentional bias. Future studies are also needed to clarify changes from pre- to post-meditation training using a mixed level of analysis, so that within and between group comparisons can be properly made.

David R. Vago, Ph.D.
Harvard Medical School
Brigham & Women’s Hospital
Dept. of Psychiatry

reference:
Vago, D.R. & Nakamura, Y. (2011). Selective attentional bias towards pain-related threat in fibromyalgia: Preliminary evidence for effects of mindfulness meditation training. Cognitive Therapy and Research, 6(35), 581-594. doi: 10.1007/s10608-011-9391-x

Cancer: Listening for a Mindful Life

By Regina Huelsenbeck, PhD

I can remember that day. I was home from college for Thanksgiving break. I had picked up my best friend for lunch; we were going shopping, and then later, out for the evening. We had quite the day planned… I just needed to stop by my pediatrician’s office for a quick checkup. I had a lump on the side of my neck; it had been there since spring of my freshman year. It was now fall of my sophomore year and it had gotten much larger, so I finally decided to tell someone. I didn’t think it was really anything. I was 19 years old and my world did not have the space for such notions. The doctor however, looked pretty worried, and sent us over to an ENT (ear, nose & throat) surgeon who immediately took a needle biopsy.

A few days later, we got the biopsy results. We had just gone to see the movie The Bodyguard (yes, Whitney Houston). I was riding in the back seat of our car, with that same friend when my mother got the call. She turned around from the front seat, phone to her ear, and announced, “Its Hodgkin’s, Regina”. … … “I have cancer?” It did not compute. The feeling I had is still so hard to describe. I wasn’t even in that car anymore. I was physically sitting in the backseat looking out the window. But psychically, upon hearing those malignant words I had popped into another reality. I had left the world of the healthy-living-well people and was sinking down into what can only be described as an underworld.

Illness is the night side of life, a more onerous citizenship.  Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick.  Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place. ~Susan Sontag

With sickness comes isolation, sometimes vivid dreams, visitations in fever induced states and reflection; it is indeed another world. However, the lights of illness have a unique way of illuminating forgotten energies and disconnected pieces. In this respect, illness can and often does become an opportunity for reconnection, an anamnesis.

Through my journey into that underworld, I wondered how and why I got cancer. I have come to believe not only that I became ill for many reasons but that I was the only one who could uncover those reasons. No one else was qualified. No one could really tell me how I contracted cancer, exactly what I did or why I had it… I had lymphoma, and “they” really didn’t know and still don’t know what causes it. No one can truly provide a linear causal reason.

And that’s not the point anyway. The point is not necessarily what caused it; the point is really where this line of questioning took me, what this exile from the land of the fast movers and healthy shakers did for me.

Obviously, the journey was not all roses and inspirational change. It was hard and lonely and painfully self-reflective. I was also pretty pissed off. I was angry about missing out on what I considered to be the life I was “supposed to be living”. I was sick and I was tired. I was worried about the boy who no longer wanted to date me because I had cancer. I was worried that I had no hair and I was worried about being different from all my peers.

The angry part of me was not concerned with macrobiotics, death, meditation, mindfully cutting vegetables (something my macrobiotic instructor insisted upon- it wasn’t enough to simply prepare the dang recipes, everything had to be done a certain way: which I now understand, but then, not so much) or larger existential questions. A larger part of me, however, woke up because of my cancer experience. This part of me had questions and was ready to explore! This part of me truly blossomed after treatments were over and remission set in. This part of me did wonder about the benefits of slowly, mindfully cutting vegetables.

I became extremely interested in illness and the mind-body connection. I attended a conference on healing sponsored by the Institute of Noetic Sciences. My career and truly my life’s passion grew from the basic interconnected ideas discussed in this conference.  I was enlivened! I now had even more questions about the mind-body connection, healing and consciousness.

I returned to college and changed my major (fashion merchandising) to nutrition and minored in psychology. I found my true love studying the psyche and set out to become a clinical psychologist (FYI: a very long road). 745 years later, I completed my doctoral dissertation on the experience of living with cancer. I also penned a chapter for Newsweek journalist Jamie Reno’s book of lymphoma survivor tales: Hope Begins in the Dark. Much of this article was taken from that chapter. Today I work mindfully with others struggling to heal, understand and integrate the cancer experience. I am grateful for this work, the questions which continue to emerge and the answers that flow from the spirit of each client.

So the saying goes that a “gift” is contained within life’s tragic experiences.   Although if you’re in the midst of chemo and someone suggests that cancer is a gift, you may envision yourself punching them in the head (believe me I get it!) But maybe, just maybe, you might consider taking a walk on the inside, and beginning to listen for your message. Illness sometimes presents itself to offer a wake-up call for more conscious living, a new direction or a new perspective. Perhaps it’s simply an opportunity to slow down, but more likely, it has come for a reason. You are the only one who can uncover and then begin to live into those discoveries. Through the uncertainty of illness blooms a new order, a new understanding, a new consciousness, something is healed and perhaps a new enlivened path is revealed.

Take a Walk on the Inside:

1.      Regular Sitting Mindfulness Meditation practice (sign up for MBSR class here)

2.      Journaling: “Bones, Dying into Life” by Marion Woodman, “Writing for your Life” by Deana Metzger, “Rebirth” by Deborah Ludwig, or take course with Sharon Bray: “Writing through Cancer”. Next workshop begins Feb 28^th (more information here)

3.      Yoga:  Stacy McCarthy The Soul of Yoga

4.      Mindful Psychotherapy (check out my web page here)

5.      Mindfully preparing food and cutting vegetables (I had to put that in for my macrobiotic teacher)

6.      How to Book: Mindfulness-Based Cancer Recovery by Linda E. Carlson & Michael Speca.

Sources:

Myss, C.  (Speaker).  (1993).  Why people don’t heal. Institute of Noetic Sciences.  Boca Raton, FL.

Newman, M.  (1994).  Health as expanding consciousness.  New York, NY:  National League for Nursing Press.

Robbins, J.  (1998).  Reclaiming our health:  Exploding the medical myth and embracing the sources of true healing.  Tiburon, CA:  H J Kramer, Inc.

Sontag, S.  (1989).  Illness as metaphor and AIDS and its metaphors. New York, NY:  Picador U

Fight or Dance: You get to choose!

Shauna Shapiro and her colleagues (reference below) wrote about the mechanisms of mindfulness and highlighted “reperceiving” as a fundamental shift in perspective that arises out of the practice of mindfulness. This is not just an interesting theoretical point, it has real consequences.

Consider the case of a patient suffering from chronic pain who learns, through the practice of mindfulness, that his “awareness of pain is not actually in pain”. This reperceiving of what was previously a very personal and self-identified experience affords the patient, in an instant, a whole range of possible behavioral and attitudinal responses to the pain that he cannot directly control. These responses may include some degree of acceptance, accommodation or creative responding that can be characterized as psychological flexibility.

This shift was highlighted with remarkable clarity by a participant in MBSR who had significant amounts of chronic pain, and had suffered with it for many years. This experience led to depression, anxiety and frequent suicidal thoughts when he encountered reminders of the likelihood that his pain would never go away. One day in psychotherapy after completing the MBSR class he noted “I’ve always been a fighter. I wrestled, I played football (and often played hurt), I became successful in business by being tough and competitive, and when I got injured and the pain persisted after multiple surgeries, I fought with the pain too. After taking the class and practicing meditation, I found that instead of fighting with my pain, I could dance with it. That’s huge!” Thus, in a simple but fundamental act of reperceiving (described as “an orthogonal rotation in consciousness” by Kabat-Zinn), this man was able to discover an option that had always been available to him but completely lost in his focus solely upon the pain itself. The profound possibilities inherent in that reperceiving (e.g. dancing rather than fighting with pain) forms a foundation for the type of fundamental changes and transformations that people experience through mindfulness practice.

What are you fighting with and could you consider dancing with it instead?

Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness. J Clin Psychol, 62(3), 373-386

Fascinating New Article on Meditation and Pain: Referring to “No Appraisal” vs “Re-Appraisal”

The journal Pain has scheduled an article for publication in a future issue: “A non-elaborative mental stance and decoupling of executive and pain-related cortices predicts low pain sensitivity in Zen meditators.” The authors are Joshua A. Grant, Jerome Courtemanche, and Pierre Rainville.

ABSTRACT:

Concepts originating from ancient Eastern texts are now being explored

scientifically, leading to new insights into mind/brain function. Meditative practice, often viewed as an emotion regulation strategy, has been associated with pain reduction, low pain sensitivity, chronic pain improvement, and thickness of pain-related cortices.

Zen meditation is unlike previously studied emotion regulation

techniques; more akin to ‘no appraisal’ than ‘reappraisal’. This implies the cognitive evaluation of pain may be involved in the pain-related effects observed in meditators.

Using functional magnetic resonance imaging and a thermal pain paradigm

we show that practitioners of Zen, compared to controls, reduce activity in executive, evaluative and emotion areas during pain (prefrontal cortex, amygdala, hippocampus). Meditators with the most experience showed the largest activation reductions. Simultaneously, meditators more robustly activated primary pain processing regions (anterior cingulate cortex, thalamus, insula). Importantly, the lower pain sensitivity in meditators was strongly predicted by reductions in functional connectivity between executive and pain-related cortices.

Results suggest a functional decoupling of the cognitive-evaluative and

sensory-discriminative dimensions of pain, possibly allowing practitioners to view painful stimuli more neutrally. The activation pattern is remarkably consistent with the mindset described in Zen and the notion of mindfulness. Our findings contrast and challenge current concepts of pain and emotion regulation and cognitive control; commonly thought to manifest through increased activation of frontal executive areas. We suggest it is possible to self-regulate in a more ‘passive’ manner, by reducing higher-order evaluative processes, as demonstrated here by the disengagement of anterior brain systems in meditators.

The author note provides the following contact information: Joshua

Grant, Departement de physiologie, Universite de Montreal, Montreal, QC, Canada H3C3J7; <joshua.grant@umontreal.ca>

Springer Publishes New Journal: Mindfulness

How nice to see a major publishing firm come out with a scientific journal dedicated solely to the study of mindfulness. The first volume contains several interesting and intriguing articles.

Mindfulness, Volume 1, 2010

Which article gets your interest? We would love to know . . .

Further Evidence of the Distinction Between Sensation & Distress in Pain

This study provides some insight into how pain is experienced in the brain and the potential power of mindfulness practice in impacting that experience. We often talk about distinguishing between sensation and distress when it comes to pain, and this study provides some insight into how that works and how mindfulness might play a role in reducing distress and thereby improving the quality of life of those in pain. Check it out!