Autogenic Training for Stress Management and Relaxation in

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Autogenic Training for Stress Management and
Relaxationin Chronic Pain Management

• Shelagh Wright

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Biopsychosocial perspective

• Is best approach to understand causes treatments
  and management of
• chronic pain syndrome,
• fibromyalgia pain syndrome and
• chronic fatigue immune deficiency

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System wide conditions

• require multidisciplinary approach
• focus on
• coping
• effective symptom management
• improving quality of life

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Critical dimension of chronic pain

• experience of suffering because of sense of no
  relief in sight
• Sense of no control and helplessly wondering what
  may happen next
• can result in anxiety, depression and learned
  helplessness
• People with chronic pain may withdraw and isolate
  themselves and experience fragmentation of sense
  of self

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Reestablishing sense of control

• Over persistent symptoms becomes of paramount
  importance
• Improving coping skills helps to reestablish
  control and to improve the reactive depression

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Psychobiological disregulaton

• term coined by Schwartz in 1979
• emphasises the need to explore the
  neuroendocrine, developmental and intrapsychic
  factors in the pathogenesis of chronic disorders
• if disruption occurs in one system, in time this
  will result in a system wide state of disorder
  and disregulation

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Autogenic Training

• Developed by respected neuropsychiatrist Johannes
  Schultz,
• Used throughout the world for 70 years
• Homeostatic self regulatory brain mechanism
• When a person is exposed to excessive, disturbing
  stimulation (either physical or emotional) the
  brain has the potential to utilize natural
  biological processes to reduce the disturbing
  consequences (neutralisation)

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Autogenic Training

• Originated at beginning of 20th century from
  research on hypnosis by SchultzAims to enable the
  person, through passive concentration, to revert
  from sympathetic activity to parasympathetic
  activity
• Designed to reinforce the organisms natural
  tendency for homeostasis (Luthe Schultz, 1969)

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Distress Negative Stress

• Crushes
• Oppresses
• Unusual events carried beyond rational limits

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Eustress Positive Stress

• Motivates
• Excites
• Energizes

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Three different approaches to stress

• An engineering, or stimulus based approach
• A medicophysiological, or response based approach
  
• A dynamic psychophysiological response,
  intervening between stimulus and response,
  mediated by cognitions (thoughts)

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Fight or flight response

• phrase coined by Walter Cannon, 1914
• survival instinct to fight or run
• biological purpose to cope with physical
  stressors

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Fight or flight response

• increased heart rate
• increased ventilation
• constriction of peripheral blood
  vessels/circulation
• increased serum glucose levels

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Fight or flight response

• increased free fatty acid mobilization
• increased blood clotting
• increased muscular strength
• decreased gastric movement
• increased perspiration to cool body temperature

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Anger and Fear

• two emotions associated with the stress
  response
• anger
• fear
• anger produces the urge to fight
• fear promotes the urge to run and hide

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Stress hormones
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2 core systems

• HPA hypothalamic-pituitary-adrenal complex
• SAM sympathetic-adrenal medullary
• Both under influence of hypothalamus

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Stress as a process

• a person experiences a range of changing emotions
  (feelings)
• these feelings affect a persons behaviour
• a persons behaviour impacts upon those around
  him or her

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Coping as a process

• coping is what a person thinks and does in a
  stressful encounter and how these thoughts and
  actions change as the situation unfolds
• coping is
• context dependent
• influenced by appraisals and resources
• refers to efforts to manage, not the success of
  those efforts

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Problem-focused coping

• problem-solving
• decision making
• information gathering
• goal setting

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Emotion-focused coping 2 types

• Maladaptive
• smoking
• Excessive alcohol consumption
• sickness absence
• substance abuse

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Emotion-focused coping 2 types

• Adaptive
• stress control techniques
• aimed at changing internal environment
• change perception of stressor
• increase sense of control and efficacy

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The Relaxation Response (Benson, 1974)

• Counteracts harmful effects of stress
• Requirements
• quiet environment (not essential)
• mental device
• passive attitude
• comfortable position (not essential)

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The relaxation response promotes

• A decreased heart rate
• Lowered metabolism
• Decreased rate of breathing
• Slower brain waves

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Relaxation Techniques

• Deactivate the five senses
• Decrease stimuli and their associated perception
• Replace stimuli and perceptions with
• non-threatening sensations that
• promote the relaxation response

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Cognitive-behavioural techniques for relaxation

• progressive muscle relaxation
• guided imagery
• autogenic training
• meditation
• music therapy
• breathing techniques
• yoga

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AT requirements

• 3 basic positions
• Use of diary during trainee programme
• Regular daily practice
• Use of body scan prior to AT session
• Use of cancelling technique after AT session
• Support with lifestyle adjustments-ideally
  reduce alcohol, caffeine, increase exercise,
  healthy diet quit smoking

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Autogenic Training

• Six standard exercises focus on body awareness of
• Limbs Heaviness and warmth
• Heart and circulatory system
• Breathing
• Nervous system
• AT trainee learns to experience passive
  concentration

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Some physiological changes during AT

• Heaviness reduction of muscle tone, BP,increase
  in skin resistance
• Warmth peripheral vasodilation
• Heart Reduction of heart rate improved O2
  utilisation
• Breathing shift from thoracic to abdominal
  breathing
• Sunrays increased blood flow to gastric mucous
• Cool forehead?beta ?alpha theta waves in ECG

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Autogenic Training (AT)

• Perceived Benefits
• for a Group of People
• Attending
• ARC Cancer Support Centre
• Shelagh Wright Autogenic Trainer
• Ursula Courtney Director,
• Dorothy Crowther CEO Wirral Centre for Autogenic
  Training

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Objectives of study

• Do patients with cancer who have undergone AT
  experience
• reduction in anxiety /or distress ?
• improved mood?
• improved coping ?
• improved sleep ?

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A validation study of AT

• 35 participants in six consecutive groups
• 18 participants diagnosed with cancer fully
  participated in study 15 females, 3 males
• Type and stage of cancer varied mostly breast
• Ages ranged from 30-75years
• Participants either pain free or pain fully
  controlled

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A validation study of AT

• The Hospital Anxiety and Depression Scale
  (Zigmond Snaith, 1983)
• The Profile of Mood States (McNair, Lorr
  Dropplemam, 1971)

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A validation study of AT study design

• Pre-post questionnaire
• Written evaluation

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A validation study of AT procedure

• Permission sought and given by the Board of ARC
  Cancer Support Centre
• medical consent /screening obligatory for each
  participant
• explanation of the method of AT provided
• optional inclusion in study emphasised

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A validation study of AT procedure

• Prior to study participants were asked to
  complete
• consent form
• HADS POMS questionnaires
• Health questionnaire

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AT programme involved

• 4 Training periods x 10 weeks, 2 x 9 weeks
• Learning a series of standard mental exercises
• Each exercise practised 3 times x 3 times per day
• Each week built on previous week
• Participants required to keep a diary
• At end of AT course participants were asked to
  complete HADS POMS
• Participants were asked to give personal
  evaluations of the course

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A validation study of AT Results

• Quantitative results showed reduction in
• Tension/anxiety HADS ( t2.782, d.f. 17, plt 0.01)
  
• Anger/hostility POMS (t2.449, d.f. 16, plt0.01)
• Increased vigour approached significance POMS
  (t2.032 d.f. 16 plt0.059)

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Participants qualitative evaluation of AT

• a useful method to reduce anger and tension
• very helpful for sleep induction
• promotes a calming effect a useful stress
  management technique
• promotes a greater overall sense of well-being
• facilitates a focus on self, inner feelings and
  their expression
• a means of increasing effort, self-encouragement
  and help

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Participants qualitative evaluation of AT

• Participants considered AT beneficial for
• increasing coping ability with many aspects of
  the cancer experience
• improving confidence and sense of control and
  mastery
• all participants viewed AT as beneficial

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Impact of CBT/CT on QoL (for patients with
cancer/chronic pain)

• increase sense of self-efficacy/mastery/coping
• reduce helplessness/hopelessness/
  anxiety/distress
• promote relaxation response/ break
  pain-anxiety-tension cycle
• provide support promote overall well-being
  fulfil psychological need

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People requiring monitoring by physician or
mental health professional

• People with
• severe anxiety
• major depressive illness
• active psychosis
• severe manic episode
• dissociative identity disorder
• severe distress shortly after a trauma
• thought disorder due to psychological or organic
  causes

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AT Relaxation Technique Requirements

• Use with coping strategies
• Know several techniques
• Regular practice
• Frequency
• Duration

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References

• Benson, H. (1975, 2000) The Relaxation Response.
  New York, Avon.
• Bird, J Pinch ,C (2002) Autogenic Therapy.
  Self-help for mind and body. Dublin, Newleaf
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  basis of stress management. In S. Palmer W.
  Dryden (Eds), Stress Management and Counselling
  Theory, Practice, Research Methodology. London,
  Cassell.
• Kanji N. (2000) Management of pain through
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  Nursing and Midwifery 6,143148.
• Kanji N. Ernst E. (2000) Autogenic training for
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• Kermani, K. (1996) Autogenic Training The
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• Linden, W. Autogenic Training A Clinical Guide.
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• Crowther, D. Autogenic Training In D Rankin-Box,
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• Sadigh, MR. Autogenic Training A Mind Body
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• Wright, S., Crowther, D, Courtney, U. (2002) A
  quantitative and qualitative pilot study of the
  perceived benefits of autogenic training for a
  group of people with cancer.European Journal of
  Cancer Care, 11, 122-130.