Pain, Mood, & Meditation- Where does Spirituality fit? Amy Wachholtz, PhD, MDiv UMass Medical School Psychiatry Day, 2009

Outline Bio-psycho-social-spiritual model of pain What are the mechanisms linking meditation and pain? Who uses Prayer/Meditation to cope with pain? When do people use Prayer/Meditation for pain? What does spirituality add to meditation for pain coping?

Question #1 What is Pain?

Typical Pain Cycle

Gate/Neuromatrix Theory of Pain Thoughts Behaviors Emotions I feel good! Ouch! Gate Injury Signals Melzack & Wall, 1965

Influences on Chronic Pain Biological Factors Spiritual Factors Chronic Pain Bio-psycho-social model of pain:::Gate control theory (Melzack & Wall, 1965)/ Neuromatrix theory of pain (Melzack, 1999) New model incorporates spiritual factors as well (McKee & Chappel, 1992; Sulmasy, 2002) Bio-psycho-social-spiritual model of chronic pain Social Factors Psychological Factors

Question #2: What are the mechanisms linking meditation and pain?

What role does meditation play? Secular meditation & pain MBSR (Kabat-Zinn) Relaxation response (Benson) Spiritual meditation & pain TM Yoga Loving-Kindness Beyond the Relaxation Response Religious Tradition based meditation

Meditation Pathways and Pain Positive Mood Internalized Locus of Control Self-Efficacy Anxiety Distraction from Problems Decreased Focus on the Body Reduced Pain Frequency Increased Pain Tolerance Decreased Pain Sensitivity Meditation

(Adapted from: Wachholtz, Pearce & Koenig, 2007) Altered Perceptions Changed Mood Changed Social Interactions Changed Behaviors Physiological/Neurological Changes Altered neurotransmitter levels Altered sleep Altered HPA activity levels Altered threshold for recognizing distress signals Psycho-Social Changes Meaning Making Attributions Self-Efficacy Distraction Social Support Instrumental Support Relaxation Possible Unique R/S Factor Spiritual Support Spiritual Growth Spiritual Meaning Making Attributions Additional Efficacy Beliefs Spiritual Beliefs and Practices Positive vs. Negative Public vs. Private Intrinsic vs. Extrinsic Existential vs. Religious -Kevin Seybold has done some work on identifying the physiological pathways through which R/S may affect pain.

Common R/S Coping Tools Prayer Spiritual Meditation Hope Reading faith-based literature Finding spiritual role models for coping Seeking spiritual support/connection Church attendance Seeking instrumental support Religious reappraisal

Question #3: Who uses prayer/meditation to cope with pain?

National Health Interview Survey 2002-2007 (Wachholtz & Sambamthoori, 2009) Older (>33 years) Female More Educated (> High School) African-American (vs. white) Have chronic mental or physical health issues: depression, chronic headaches, back and/or neck pain Prayer use study Studied 2055 nationwide households on use of CAM (including prayer).

Question #4: When do people use prayer/meditation to cope with pain?

Religious/spiritual coping AND secular coping- not either/or The initial spiritual pain coping response to acute pain (self-directive), is the least likely spiritual coping response to chronic pain (collaborative) (Dunn & Horgas, 2004) Terminal stage illnesses with co-morbid pain (Yates, et al., 1981; Ironson, et al, 2002) Long-term chronic pain (Abraido-Lanza, et al., 2004; Glover-Graf, et al., 2007) Uncontrollable, intermittent pain (Harrison, et al., 2005) When other coping mechanisms fail and spiritual coping is efficacious (Keefe, et al., 2001; Pargament, 2002) Religious/spiritual coping AND secular coping- not either/or Abraido-Lanza, AF.; Vasquez, E; Echeverria, S E., (2004) En las Manos de Dios [in God's Hands]: Religious and Other Forms of Coping among Latinos with Arthritis. Journal of Consulting and Clinical Psychology, 72, 91-102

Question #5: What does spirituality add to meditation?

Intervention Studies Spiritual interventions affect physiological outcomes (Carlson, Bacaseta, and Simanton, 1988; Ironson, et al., 2002, Pargament et al., 2005; Wenneberg, et al., 1997 ) Increase pain tolerance in healthy, non-chronic pain individuals (Wachholtz & Pargament, 2005) Doubled pain tolerance to laboratory induced acute pain task Meditation inherently spiritual? Comparing spiritual vs. secular interventions on pain

Intervention Studies Improved pain tolerance among a chronic pain group (Wachholtz & Pargament, 2008) 4 weeks Decreased pain frequency Greater pain tolerance Acute- laboratory induced pain Chronic- decreased rescue medication usage Limited change in pain sensitivity Greater decrease in negative mood Greater decrease in anxiety

Buddhist Loving-Kindness Cancer patients (Carson, et al, 2008) Migraineurs Pilot Study (Wachholtz, 2009) 4 week class, 4 week follow up Increased spiritual experiences Elevated pain tolerance Fewer headaches (n.s.)

Summary Pain a multi-dimensional disorder including physiological, psychological, social and spiritual components Prayer and spiritual meditation used by many with chronic pain Multiple psychological and physiological pathways that support its use Spiritual meditation may be a useful resource with unique additive components for patients with a spiritual/religious background

Thank You Amy.Wachholtz@umassmemorial.org