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STRESS MANAGEMENT
Stress may currently be the most important factor in the disease
process. It is estimated that over 75% of medical office visits
are lifestyle related, of which stress is a major factor. Stress
has the potential for interfering with the body's self-regulation
process or homeostasis (McEwen and Stellar 1993). It can contribute
to mental confusion, tension and physical fatigue. Stress, inappropriately
managed, makes any other problem a person has, worse! If someone
is struggling with anxiety, depression, or other mental difficulty,
adding stress to that person's life will exacerbate the situation
and interfere with recovery. Stress is like putting an extra
load on a person. It will compromise a person's ability to cope,
to think clearly and to physically respond.
Stress, inappropriately managed, will compromise
a person's effectiveness physically, emotionally and cognitively.
It cuts across all other areas of a person's life, leaving one
less capable. Whether we are discussing tension headaches, irritable
bowel, hypertension, insomnia and even autoimmune diseases,
stress will typically be the cause or a major contributory factor.
Biofeedback's primary but not sole function is to minimize the
impact of stress through autonomic self-regulation.
Most people will tell you that they are more likely
to get sick and even expect to get sick during a stressful period
in their lives. The evidence is overwhelming that stress affects
tumor growth, and impedes healing, in other words, impacts immune
system functioning. (Kiecolt-Glaser, J.K. 1995.) We can see
the impact of stress on one's ability to get adequate sleep
and even be able to rest.
As a result, managing stress, which can also be
referred to as managing arousal levels, underlies all behaviorally
based treatment of physical disease. Furthermore, stress is
a major factor in the etiology of emotional distress (Heim et.
al 2000). Biofeedback as a tool for lowering arousal should
be the centerpiece in any treatment program. It will be noted
below that the influence of biofeedback can extend far beyond
autonomic self-regulation to the many factors contributory to
self-efficacy, confidence and a greater sense of security in
the world. For this reason, biofeedback training needs to be
integrated with consideration for the other mediating factors
in managing stress to strengthen its impact and the durability
of that impact.
Definitions
Let's first get our definitions and descriptions
in alignment. There are two equally important sides of the stress
equation along with their mediating factors. There are those
things that cause us to react, how we interpret these stimuli
and our reaction. These can be referred to as "Stressors"
internal assessment or appraisal, and our "Stress reaction"
respectively.
"Stressors" or stress triggers
Any stimulus that triggers our stress reaction
can be referred to as a stressor or a stress trigger. These
are the things in the environment that we determine as threatening
or signal danger. Things that are thought to be "Taxing
or life threatening" in the words of Hans Selye (1982).
In addition, they can be stimuli that come from inside us: illness
and tissue damage itself will cause the body to go through its
stress response. These things may be a real threat, however,
simply thinking that we are in danger, even if it isn't real,
will trigger the stress response.
Life events scales
There have been a number of assessment tools created
that are based on stressful life events. The most commonly used
is the Holmes and Rahe "Social readjustment ratings scale"
(Holmes and Rahe, 1967). This scale weighted each of the items
as to its impact on the individual going through the experience.
Research has also attempted to develop scales for specific cultures,
such as that of Zheng and Lin (1994). These authors demonstrated
the importance of "Culture specific" scales as they
reported that approximately 75% of items on their scale studied
in Mainland China were not even included in previously studied
Western scales.
There have been literally thousands of research
articles examining the relationship between life events and
disease. For reviews see Dohrenwend and Dohrenwend (1974) and
Barrett, Rose, and Klerman (1979).
Research into life event scales as a measure of
a person's vulnerability to disease is based on the intuitive
notion that events have a quantifiable stressful impact. In
fact, there is a small but significant correlation between identified
stressful events and disease. As events become more impactful,
such as the loss of a spouse, and as the events become more
frequent within a limited period of time, this correlation is
more evident.
Research supports the impact of life stressors
on the psychophysiological and biochemical correlates of homeostatic
imbalance. Pardine et al. (1982) for example, found that subjects
experiencing a high frequency of stressful life events demonstrated
a slower recovery of cardiovascular baseline following a laboratory
stressor compared to those with fewer stressful events. Also,
Kiecolt-Glaser et al. (1986) found impaired immune system functioning
in medical students during exam time with an enhancement following
relaxation training.
The correlation however appears to account for
less than 20% of the variance in the stress-disease process
(Perkins 1982). The major reason for this low correlation is
the important "appraisal" aspect of stress.
At the other end of the life event scale is the
relationship of "Daily hassles" to health status.
Daily hassles, as the name implies, refers to the repeated or
chronic strains of everyday life. Research has shown that this
measure demonstrated a stronger association with somatic health
than life events scores (DeLongis et al, 1982).
Appraisal: Internal Mechanisms
Danger, threat and pressure are not objective
or absolute. There is an important assessment or appraisal that
is made of the external and internal environment that determines
whether and to what extent we express the stress response. This
assessment of danger and need for adjustment, determines whether
we engage with our stress response, also known as our body's
"Fight or Flight" response. Many factors are incorporated
in this appraisal including our baseline view of the world as
safe or dangerous, and personality factors such as our self-confidence
or assessment of one's ability to successfully cope with life
as well as the specific stressor. Research has demonstrated
that perceptual stance is a major factor in the interpretation
of experience. For example, the emotional reaction to an injection
of adrenaline can be experienced as anger or as euphoria depending
on the experimentally manipulated context (Schachter, 1970).
Much of managing stress therefore is incorporated within these
variables of appraisal.
A study that examined the roles of life events
and appraisal was performed by Garrity et al. (1977). In looking
at life events and health status, he included a self-report
measure of "psychophysiological strain". It was this
measure of strain that determined whether the stressful events
correlated with health status.
Biofeedback most commonly is employed to train
decreased arousal in the process of stress management. One of
the reasons why researchers have reported ambiguous results
using biofeedback, is the lack of attention to the appraisal
and personality factors of stress. These factors impact an individual's
resistance (conscious and unconscious) to managing their stress,
following through with the practice of stress management techniques
(including biofeedback) and even with letting go and relaxing.
They also impact the frequency, intensity and duration of the
stress response. Thus cognitive and personality factors should
be taken into account when using biofeedback in order to enhance
and insure its effectiveness. The relationship of biofeedback
to these issues will be further addressed. [When they are taken
into account, biofeedback can play a role by affecting one's
confidence and ability at self-control.]
Stress response
The stress response is our body's natural mechanism
for coping with emergencies, threats, and the need for adjustment.
This has been identified as the "Fight or Flight"
response by Walter Cannon (1929) and refers to how our body
mobilizes for any demand made upon us. We are ready to either
fight the threat or run away from it.
The concern of the stress response follows from
the early writings of Claude Bernard (1879) who recognized the
importance of living organisms maintaining a constant internal
environment despite changes in the external environment. To
the extent that this balance or homeostasis is disturbed, or
threatened, the organism is placed at risk.
The stress response was further elucidated by
Hans Selye, whose research uncovered the three phases of what
he referred to as a Generalized Adaptation Response, or GAS.
Selye defines stress as the nonspecific result of any demand
upon the body (1974). Non-specific in that he considered all
demands upon the organism's adaptability - including emotional
arousal, fatigue, pain, fear, effort, humiliation, loss of blood
and even success - to evoke the same stereotypical stress response.
The three phases of a stress response include: state of alarm,
stage of resistance and the third phase, the stage of exhaustion.
Selye describes the depletion of "adaptation energy"
and wear and tear on the body as a result of the GAS. Although
adaptation energy is a hypothetical construct and is not something
as yet measurable, it is a useful way of describing the impact
of stress. Stress that is not appropriately handled, causes
a depletion of this energy leading to organismic breakdown and
vulnerability to disease.
Based on a non-specificity model of stress and
disease, any difference in type of disorder that is developed,
e.g. headaches, gastrointestinal or hypertension, would depend
on the individual's particular genetic-constitutional factors.
While there is clearly a non-specific, general
activation process that contributes to the stress response,
there is also considerable evidence of a more stimulus specific
response pattern as well as an organism specific response pattern.
(Lacey and Lacey, 1965, Roessler and Engel 1974). For example,
two response patterns that can be identified are a fight or
flight, mentioned above, and a "freeze" response.
These can be distinguished typically by opposite heart rate
reactions.
Overall we can say that a stress response model
should take into account the specific stimulus and its intensity,
a specific organism which allows for both the personal appraisal
of the stimulus as well as the genetic-constitutional factors
and finally the stress response patterning. These variables
include the differential impact of emotions such as anger and
fear. (Ax, 1953).
The stress response is an important survival mechanism.
In fact, simply saying that it is a survival mechanism says
that the body tends to go all out. There are no "tomorrows"
with survival coping; if you don't do it today, there is no
tomorrow! This life or death focus has additional consequences:
first, we take no chances. While in other areas of life one
may make a calculated guess, and perhaps unconsciously employ
a "minimax" approach, i.e. a minimum response that
gets the maximum benefit, with survival, there is less risk
taking which leads to individual strategies where a response
can occur even when there is a 1 % chance of the catastrophic
expectation. This also indicates that we will also have resistance
to any attempt to control or limit this response.
The use of biofeedback to monitor and assess the
stress response: Stress Profiling
There is a wide range of parameters that can be
measured to derive a picture of an individual's relationship
to stress and psychophysiological balance. In addition to the
various physiological parameters, within each parameter are
the questions of baseline levels, response reactivity - or the
intensity and sensitivity of the response - and its duration,
or time it takes to return to baseline. With some measures,
such as the pattern of heart rate inter-beat intervals - also
referred to as respiratory sinus arrhythmia's (RSA) - the pattern,
and its relationship to other physiological measures is important.
The most common assessment physiological variables
include:
" Skin temperature measured at the finger. This is a function
of blood flow, which in turn is partly determined by stress
activation.
" Electrodermal response. Skin conductance. This has been
studied in a number of ways, including skin resistance, skin
conductance reaction and baseline.
" Muscle tension. This is determined by monitoring the
electrical activity at the neuromuscular junction. Increasing
levels of electrical activity reflect increasing levels of muscle
contraction.
" Respiration: Breathing is directly affected by stress
as well as emotional holding patterns. There is also a correlation
between activation of sympathetic and parasympathetic mechanisms
during inhalation and exhalation respectively.
" Blood volume pulse.
" Respiratory sinus arrhythmia's.
" Electroencephalogram.
There is evidence, as well as it making intuitive
sense, that people who demonstrate more reactive physiological
arousal mechanisms would be more vulnerable to organ breakdown
and the disease process (Adler & Matthews, 1994). Gannon,
et al found that those individuals with greater physiological
arousal to or slower recovery from a laboratory stressor were
more vulnerable to environmental stress than those who were
less reactive or faster to recover (1989). Patients with psychosomatic
disorders respond more intensely when stressed, particularly
in the symptomatic system. (Malmo and Shagass, 1949; Sternbach,
1966). Thus, the psychophysiological profile helps identify
risk factors as well as pointing to where biofeedback training
will be most useful.
A typical psychophysiological stress profile or
protocol would include a number of segments, each separated
by a baseline period. Figure 1 presents one such protocol. The
profile always begins with a baseline period. Many clinicians
have the patient sit for five to ten minutes for this baseline.
Psychophysiological Stress Profile
1 A 2 B 3 C 4 R
1 = Initial baseline period
A = First stressor: Fast breathing
2 = Baseline restoring
B = Second stressor: Math problem (serial sevens)
3 = Baseline restoring
C = Third stressor: Talk about stress in one's life
4 = Baseline restoring
R = Ask client to relax
Baseline is a significant measure, since all future measures
are important in their relationship to baseline. Important considerations
for taking baseline include: time of day, any medications taken
by the client and when the medications were taken, mood, environmental
considerations including room temperature and external distractions.
The goal would be to control and keep constant any variable
that impacts baseline. When measuring electroencephalogram it
is more important for the subject to remain still and to take
both an eyes open and an eyes closed baseline.
An initial baseline period is followed by various
stress inducing procedures that are interspersed by rest periods.
A good profile will include a physical stressor, such as fast,
deep breaths; a mental stressor such as a series of math problems
solved out loud, which also addresses performance anxiety; and
finally either a discussion of a real life stressful situation
of the subject, or their visualization of this stressor. Rest
periods are typically two to five minutes. The rest periods
should be long enough to track the patient's ability to return
to baseline. The profile can conclude by examining the patient's
initial pretraining ability to relax.
Factors that need to be considered in assessing
the profile include:
" baseline levels compared to a normal range.
" the intensity of reaction to the various stress presentations.
" which of the psychophysiological variables is most reactive.
" speed of recovery of baseline.
" ability to relax.
The clinician's ability to identify important
aspects of a patient's profile come primarily from one's experience
over time with their specific instrumentation. Although instrument
makers strive for standardization, it is not possible to control
for all environmental factors as well as a clinician's style.
One can expect greater consistency with the same bioinstrumentation
configuration and clinician. Under similar conditions, it is
then possible to begin accumulating data and an ongoing comparison
from patient to patient.
Even with this process however, it is important
to note that there isn't one single pattern of physiological
responding. Williams (1986) and others refer to two or more
patterns of physiological responding to stress. In particular,
Williams describes two different patterns, one referred to as
an immobilization response found, for example with mental arithmetic
and the other found with reaction time stressors as well as
emotional stress. These patterns differed with respect to hormone
secretion, with increases in epinephrine and cortisol occurring
with mental arithmetic and not with the second pattern.
Lacey (1950) examined stress response patterns
in a group of twelve women. He compared an array of measures
including systolic and diastolic blood pressure, palmar conductance,
heart rate and heart rate variability. He found that there was
no consistent response pattern across physiological systems.
The psychophysiological stress profile serves
a number of purposes. To begin with, it is an effective way
to begin a biofeedback program with a client. Efficacy of the
biofeedback process is an important consideration in developing
motivation and expectation of the program. The profile offers
an opportunity first to demonstrate changes in physiology and
then to correlate the changes to the client's cognitive or emotional
processes. For many clients who are out of touch with their
body this is a significant process. For many, this validates
the mind-body connection and how their physical symptoms can
be caused by mental and emotional variables.
Factors to consider in the profile include physiological
reactivity. This is the degree to which a response system changes
to any of the presented stressors. Reactivity has been demonstrated
to be correlated with symptom development (Blascovich, &
Katkin, 1993, Haynes et al., 1991). Reactivity can be the result
of genetic factors, or developmental conditioning, including
trauma.
Duration of response also referred to as recovery
of baseline is another significant variable to note during the
assessment process. The speed of recovery of baseline is a good
indication of the flexibility of the system being examined.
People who take longer to return to baseline demonstrate impaired
resilience and are extending the exposure of their body to the
wear and tear of stress.
As an initial introduction to biofeedback either
respiration or EMG can be used to do initial relaxation training
at the end of an assessment session. These modalities are selected
because of their direct voluntary control and the ease with
which to demonstrate the feedback learning paradigm.
Normal pattern
The stress response as it has evolved is designed to be in balance
with its complement, the parasympathetic response. This has
been referred to as the relaxation response, and the quieting
reflex and can also be considered the body's recuperative or
restorative mechanism. That is, it is this mechanism that engages
the body in restoring resources used up during stress. While
the sympathetic response focuses the organism outward, the parasympathetic
response is a more inward focus.
When these two mechanisms are in balance, the
body is functioning optimally. Functionally it means that the
body's mechanisms for mobilization are in balance with the maintenance
functions. Under these conditions, an organism is most capable
of fending off disease, in maintaining musculoskeletal flexibility
and in keeping blood pressure in a normal range.
The good side of stress
People frequently confuse stress as something
that is only negative. But it needs to be recognized that it
is a basic adaptive as well as protective mechanism of the body.
Let's look at the benefits when we are engaging the stress response
in an appropriate way. Activation of the stress response makes
the resources and energy of the body available to the organism.
In moderation, the stress response makes one more alert and
helps to focus and concentrate. This helps in problem solving
as well as to feel safe.
The relationship between the stress response and
performance is typically seen as the classical inverted "U"
curve. Performance improves with increases in stress. However,
there is an optimal range, where performance peaks. With further
increases in stress performance follows a decremental process.
This can be the result of less muscle control with increased
tension, or it can be from response stereotypy that inhibits
a flexible response or a fast response.
One of the typical difficulties in stress management
training is that it is difficult for an organism to make the
subtle discrimination of level of stress response. Since it
is a defensive and mobilization mechanism, there is an unconscious
drive to maintain and even increase the stress response for
protection. There is consequently a resistance to modulating
this response.
Why does there have to be such a thing as stress
management?
Normally the body wants to heal, to restore and
to be as healthy as possible. It is designed that way. So why
is it necessary to figure out ways to manage the stress response?
Why doesn't the body simply manage itself?
Ideally there shouldn't be any conflict between
the stress response - which is geared to protection in the moment,
and the maintenance functions of the body - which constitute
more long-term protection and health. However, the long and
short-term functions of the body can be in conflict. When this
happens, the short-term survival mechanisms usually win out.
In today's world, there are countless stimuli
that trigger danger and the need for mobilization. But very
few, if any, signals that allow one to breath that sigh of relief.
This results in the continual triggering of the stress response.
As you will see below, this picture is compounded by early childhood
trauma - chronic or acute.
Through the conditioning process we associate
many more stimuli with the need to protect and defend, thus
turning on the stress response. Biofeedback is a technology
for training a person to reduce sympathetic activation, i.e.,
the stress response, or to activate the parasympathetic branch
of the autonomic nervous system. Once again, we can think in
terms of the three variables of activation: frequency, intensity
and duration. To this we can add the ultimate lowering of baseline
physiological measures.
The effectiveness of biofeedback is modulated however, by the
frequency, intensity and duration with which a person turns
on the stress response. Furthermore, psychological issues can
cause a person to resist the biofeedback training. Thus, to
be most effective, biofeedback needs to be integrated into a
program that examines the other issues of stress management.
The two modern day mismatches
Another way of looking at today's stress management
problem is what I refer to as the "two mismatches".
Mismatch number one has to do with the difference between the
environment in which our stress response evolved versus the
environment in which we find ourselves using the response. Or,
between the environment of the former Hunter/Gatherer society
and the modern industrial information society.
This first mismatch results in a stress response
that doesn't fit. This refers to the topography of the response.
We still maintain a stress response that prepares us for "Fight
or flight". It is a defensive preparatory response with
greater and greater levels of energy being generated. This mobilization
triggers the hypothalamic-pituitary-cortical axis with its autonomic
and neurohumoral activation. In the former environment in which
this response adapted, the energy would then be expended through
physical activity, followed by a period of rest.
Today's environment however, presents an entirely
different set of demands.
Present day stressors require a more anticipatory response;
one in which alertness dominates over mobilization. Which usually
require thinking and the skilled use of technology which actually
does most of the "work". With today's stressors there
is a distinction between threat and attack; between mental and
physical response. The environmental demands of modern society
and culture usually require restraint, finesse, subtlety, and
assertiveness without the extreme physical response. In other
words, it does not involve tense muscles as much as an alert
mind. The old response topography is not an adaptive response
any more; in fact it is potentially self-destructive.
The result of this mismatch is that the mechanism that should
help your body maintain homeostasis or balance, is overshooting
the mark, and it keeps overshooting the mark, in its attempt
to defend.
Unfortunately, since the stress response is a
survival mechanism it is very difficult to overcome. It is hard,
after all, to go against our instincts. For this reason, there
is considerable resistance to modulating the stress response.
For biofeedback to be most effective, this conflict needs to
be addressed.
This resistance is heightened by the association
of biofeedback and stress management with "slowing down",
relaxing and taking it easy. Since the stress response is so
important to an organism, there needs to be some way that they
can have permission to modulate it with the relaxation response.
The second mismatch that impacts stress management
is the difference between the environment in which we learn
how to use the stress response and the environment in which
we use it: that is, between the environment of our childhood
and our adult environment.
We begin life with an instinctual stress response.
Then we learn, based on our experience, how and when to utilize
this response. In other words, we have a response that automatically
gets triggered if there is danger to our survival, but we then
must determine when and where we are in danger.
We learn to use the stress response at a time
in our development when we are insecure, and dependent. It is
a time when we are not able to protect ourselves. We are vulnerable,
lack confidence, and feel inferior to adults.
Of course, it is as an infant, and a child, that
we first experience fears of survival: "are my needs for
nourishment and shelter going to be met?". This gets expanded
to "How are my needs going to be met, and then, "it
is my parents who satisfy my needs." So, it then becomes
of ultimate importance to have parents close and attentive,
to have them love you and want to give to you. In other words,
in these early years of your life, you are overly dependent
on others to meet your needs. This leads to the development
of strategies to assuring that one's parents will meet those
needs.
Now, any threat to a child's relationship with
their parents will be taken as a threat to survival. This gives
parents power, while the child feels impotent. Here is where
the problems begin. The child learns the following information
that does not translate into adaptive adult behavior:
¢ You don't have power.
¢ You are at the mercy of others - specifically your parents.
¢ You come from a sense of "lack", since others
have what you need.
¢ You internalize your parent's view of the world, no matter
how incorrect it is.
¢ Your needs become tied to your parents'.
This can be likened to Seligman's concept of learned
helplessness, where animals who were unable to escape from shock,
learned that they did not have control, so later they continued
to act as if they did not have control, even when they did.
This is very significant since a sense of control can reduce
the impact of stress (Kobasa et al 1981).
The result of these childhood issues is a particular
"stance" toward the rest of the world: More defensive,
more alert, and more vigilant. The outside world is bigger than
you, and more powerful - thus there is fear; and this results
in the stress response being triggered more readily. It also
results in an ongoing psychophysiological bracing as if continually
expecting an attack.
Certain childhood environments exaggerate this
phenomenon while other environments and cultures tend to buffer
the child from these factors. For example uncertainty, lack
of security, and abusive treatment and trauma will intensify
this effect. Enhancing security, providing love, attention,
acceptance and self-efficacy will minimize this effect.
In indigenous societies, there are rituals that
adolescents are lead through to help them make the transition
into the adult world. The ritual serves to help the person shed
many of the attachments of their childhood. It is usually a
transformative experience used to help the adolescent feel like
they have become an adult, with all the responsibilities and
power that the adults carry.
In such societies, the elders help the transfer
of power to the new generation, after all it is in the interest
of the entire group to have the young adults feel such a sense
of power and responsibility. Unfortunately, in more modern cultures
this custom or ritual has been neglected.
Personality factors
One of the ways that we learn to deal with this
sense of inadequacy is by developing a persona. This is a healthy
aspect of development. We create an image that is presented
to the outside world. This image is designed to maximize success
in getting one's needs met.
The problem occurs when there is a discrepancy
between this image that is projected and what one truly believes
about oneself. The greater this discrepancy, the more uncomfortable
in the persona, and the greater the tension and fear of being
discovered. The greater this discrepancy, the more easily the
stress response gets triggered.
Since the stress response occurs when there is
an appraisal of danger, the more self-confidance, the fewer
the situations that will trigger the stress response. Also,
the more one feels positive self-regard, the more likely to
perform self-care aspects of stress management, of which biofeedback
is included.
Emotional Factors
Emotions have a psychophysiological component.
Emotions that have not been acknowledged or fully addressed
contribute to an individual's ongoing physical holding pattern
(Reich, 1945; Lowen 1958). Sometimes referred to as bands of
tension around the body, these patterns interfere with relaxed
breathing, affect blood flow and contribute to chronic muscle
tension.
When emotions and their sources are addressed,
and the client is able to physically release them, there is
a more supple tone to the body. It enhances physical flexibility.
This allows for the more effective training of biofeedback.
Comprehensive Stress Management Approach
The basic focus of any biofeedback assisted stress
management program is on two facts: 1) A person's stress response,
or habitual bracing patterns have become more and more conditioned
to environmental stimuli, and 2) The body gradually adapts or
numbs itself to higher and higher levels of tension or arousal.
These more frequent and higher levels are typically only recognized
when the person becomes disturbed by the symptoms of stress:
headaches, muscular aches and pains, insomnia, fatigue, hypertension
and gastrointestinal aches.
One way of looking at this process is that the
increased conditioning of the stress response results in the
deconditioning of the body's homeostatic mechanisms. For example,
some people find it uncomfortable when instructed to deepen
their breathing. This is because the intracostal muscles that
expand the chest are not used to stretching.
Biofeedback and other relaxation techniques can
be the core of a total approach to stress management. Thus biofeedback
training, in some sense, is a reconditioning of the body's relaxation
mechanisms in order to restore homeostasis.
Personality and cognitive factors come into play in the stress
management process because some people cannot give themselves
permission to relax, or feel it isn't safe. This can result
in unconscious sabotaging of the process. A person who experienced
childhood trauma for example, may unconsciously trigger their
arousal mechanism when they are becoming too relaxed, as a protective
mechanism. This and the avoidance of feelings are probably the
main causes of relaxation induced anxiety.
Arousal reduction or autonomic deactivation
The primary model for biofeedback assisted stress
management as well as most approaches to psychophysiological
disorders is one of arousal reduction or reducing tension. This
is also the basis for assessment of the psychophysiological
stress profile. We expect to observe elevated baselines or specific
physiological reactivity to a stressful situation or imagined
stressful situation, or a slow return to baseline. Unfortunately
the research is not clear-cut.
If we examine the literature on tension headaches,
for example, it appears that most studies report differences
between pain patients and controls, in either baseline EMG readings
or readings during stress, from temporalis, frontalis or trapezius
muscles (e.g. Schoenen et al. 1991; Hatch et al. 1992), although
some studies do not show such differences (e.g. Flor and Turk,
1989; Marcus 1992). Furthermore, if we look at the correlation
between change in EMG and reduced headaches, here again, the
results are ambiguous.
There are a couple of reasons for these discrepancies.
The first has to do with where and what is being measured and
the second has to do with the difficulty recreating real life
situations in the office or laboratory. In the psychophysiological
profile described above, by using three different stressors
and monitoring multiple end-organ response systems, one is more
likely to observe relationships between reported symptoms and
the psychophysiology.
It is also not uncommon to be able to train response
control, such as raising peripheral temperature or lowering
skin conductance levels without a shift in baseline. These patients
will typically note a reduction in their symptoms. In other
words it appears that there is an enhanced resiliency of the
system even though resting levels may not change.
Our stress response is only one of two responses
programmed into our nervous system, the other is the autonomic
parasympathetic response of recuperation. Clients presenting
with stress related symptoms, have lost resiliency of their
autonomic system. In particular, there is a reduced ability
to turn on these parasympathetic mechanisms. Most frequently,
this is indicated by difficulty with sleep pattern, various
musculoskeletal aches or the dysregulation of other bodily systems.
Autonomic imbalance is the result of activating
the stress response too frequently, too intensely and for too
long a duration. The management of stress therefore becomes
the adjustment of these three variables. Biofeedback and other
relaxation training paradigms can be considered the retraining
of parasympathetic activation or arousal deactivation. Here
we approach the problem at its biological roots, restoring autonomic
balance.
Employing multiple response systems in stress
management training is like cross training for conditioning.
In addition, with multiple systems there is a greater likelihood
of achieving initial success and thus positive reinforcement.
The effectiveness of biofeedback however, lies in embedding
it within a more comprehensive stress management approach. For
example, biofeedback can reduce the intensity of one's stress
response. If however, at the same time a person's catastrophic
expectations result in the frequent triggering of the stress
response, the benefits will be negated. Alternately, if a person
is hypervigilant due to childhood trauma, they will be more
resistant to biofeedback training, and may unconsciously sabotage
the process. In other words, cognitive and personality factors
need to be simultaneously addressed.
Choosing which modalities to train
We have many ways of monitoring the physiological
changes that represent aspects of the stress response. The first
step in determining which modalities to utilize during training
comes from the evaluation of the psychophysiological stress
profile. One would want to focus on the modality that demonstrates
the greatest lability or divergence from an optimal baseline
during the profile. It may be that this modality is related
to the presenting symptoms. In other words, muscle tension for
a headache patient and skin temperature for a person with hypertension.
This can be referred to as symptom specificity
as well as individual response specificity, and has been frequently
demonstrated. For example, Moos and Engel (1962) demonstrated
that arthritic and hypertensive patients had more reactive musculoskeletal
and blood pressure responses respectively.
An alternate strategy might be to focus on a modality
that is less disturbed. This system may be easier to train,
thus giving the client early initial success. This success is
very important in creating efficacy for the process and motivation
for the client. As mentioned above, it can be useful to train
multiple systems for enhanced autonomic conditioning and resilience
and to maximize generalization to the real world.
Initial training sessions may also include a demonstration
and training of the opposite response. For example, brief hyperventilation
will typically cause an alteration in skin conductance. If the
client is then given instructions/strategies to relax, it will
be easier to observe a reduction in the skin conductance level,
from this elevated level. If EMG is being monitored, introduction
of the progressive relaxation procedure will accomplish a similar
demonstration about muscle tension. This is where the client
is asked to tense a particular muscle or group of muscles prior
to relaxing them. In general, training of responses in both
directions enhances psychophysiological control.
It is reasonable to expect the client initially
to be somewhat activated due to the newness of the situation.
This is referred to as the orienting response. Thus, an initial
increase in indicators of arousal may occur. Clients should
be somehow prepared for this experience in order to minimize
a negative cognitive-emotional-physiological reaction.
In fact, overall, how a client is oriented to
the biofeedback process is very important. Many people, particularly
those with stress related problems, are self-critical and/or
have performance anxiety. These clients, particularly those
with a Type A character, will approach biofeedback with the
same intensity and pressure that they place on all their other
activities. In other words, simply engaging in the process and
observing their physiological responses will trigger tension.
The client "tries" to succeed in the same manner that
they expend effort in other tasks. When they are not completely
successful their self-criticism adds to this process. These
factors can place an overwhelming burden on the biofeedback
training.
It is for these reasons that the client needs
to be appropriately prepared and oriented to the training. The
following factors need to be emphasized:
1) This is a training process not a test.
2) Training occurs no matter which direction the signal goes.
3) Initially there isn't an absolute goal only a desired direction
for the signal.
4) Avoid responding to questions regarding what a "normal"
response should look like.
5) This process, to be successful, needs to be approached differently
then all client's other activities, that is: it is a process
of letting go. It does not benefit the client to "Try hard",
since this itself creates tension.
6) The process is working even when client does not see the
results.
7) Much of the learning is unconscious, outside of clients awareness.
8) Length of training varies from person to person.
9) Initially the experience may feel uncomfortable or disorienting
and that this is normal.
10) If the client shows up and does the prescribed home practice,
they will be successful.
Generalization of training
Using biofeedback to manage stress requires transferring
the training from the relatively safe office environment to
the outside world. This involves four steps:
1) Regular practice of a relaxation response.
2) Greater and ongoing awareness/monitoring of tension.
3) Incorporation of learned skills.
4) Generalization procedures to better associate the trained
calmness to stressful life situations.
1) Regular practice of a relaxation response.
People experiencing stress related problems have impaired ability
to turn off sympathetic mechanisms. As noted previously, the
client can be considered to be out of condition with respect
to their autonomic nervous system and related physiology. Practice
is required to recondition these mechanisms. For example, initially
when doing peripheral skin temperature biofeedback it is not
uncommon to achieve an initial increase in temperature. This
increase however may not be maintained since the small muscles
surrounding the blood vessels are unable to maintain the change.
2) Greater and ongoing awareness of tension.
Since there is an habituation to musculoskeletal tension, it
is important to set up some type of stimulus, or reminder system
throughout the day to check in with one's body to notice any
bracing or holding, or inappropriate breathing pattern.
First, one should expect a person to revert to
existing body tension patterns, even seconds after a relaxation
exercise. A very useful technique during biofeedback is to focus
on tension in the shoulders, aided by EMG monitoring. After
a period of biofeedback in which the EMG levels decrease, shift
the focus to other modalities and other parts of the body. When
you return to the shoulders and EMG a few minutes later, invariably
the tension level will have gone back up.
This demonstrates both tension patterns as well
as muscle memory of tension levels. The body wants to return
to its most familiar orientation, even if this is one of tension.
It is easy to help the client realize that if this takes place
in the office, it is certainly occurring out in the world, particularly
the work environment. Periodic reminders are therefore needed
to help the client notice this increase in tension. A simple
"Body-scanning" technique involves having the client
bring their awareness through their body, stopping at the various
muscle groups, and noting any holding, tension or other form
of bracing.
This is part of an awareness training process.
Stress management first involves noticing an imbalance in order
to make the physiological adjustment. By setting up these reminders,
it is possible to begin shifting the long-term pattern.
3) Incorporation of learned skills into one's
daily routine:
Following the body-scanning, a very simple process of a series
of relaxation breaths (diaphragmatic breathing) and releasing
muscle tension as learned in the biofeedback will be effective
in resetting tension levels.
4) Generalization procedures to better associate
the trained calmness to stressful life situations:
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