# COPING WITH FUNCTIONAL GASTROINTESTINAL DISORDERS



## eric (Jul 8, 1999)

With permissionFYI"http://www.med.unc.edu/ibs The UNC Center for Functional GI& Motility Disorders1USING RELAXATION:COPING WITH FUNCTIONAL GASTROINTESTINAL DISORDERSKenneth R. Jones, Ph.D.Research Assistant Professor of Medicine/Clinical PsychologistSteve Heymen, MSInstructor of Medicine/Certified Biofeedback TherapistTEN RELAXING BEHAVIORSRelaxation training is a integral component of behavioral therapies for managing chronic pain, promotinghealth, and helping patients cope with life-threatening illness such as breast cancer. Relaxation can alsoassist in managing functional GI disorders.HOW CAN RELAXATION HELP?Research has shown that relaxation provides several health benefits including: decreasing excess arousalproduced by worry or anxiety, managing insomnia, buffering the adverse physiological responses tostress, and increasing pain tolerance while decreasing some of the symptoms associated with chronic pain.Relaxation training is also a vital part of any stress management program and is a component of manycognitive-behavioral treatment programs for problems such as headache, depression, anxiety, andphobias.Many researchers and health professionals believe that relaxation provides two important functions1) as a coping skill that can be used immediately when a person is stressed, overly aroused, or inpain, and(2) by preventing some of the damaging effects of stress.Daily practice of relaxation lowers arousal that is associated with wear and tear on the body. Regular useof relaxation enables one to calm the body before beginning stressful activities and has been associatedwith improvements in the immune system as well as improved survival of cancer patients. Thus, dailypractice of relaxation makes a person generally more relaxed, better prepared to manage daily demands,and better able to buffer the long-term effects of stress, while also providing a tool to use when things getout of hand.For individuals with functional GI disorders, relaxation appears to help by dampening the pain, managingthe arousal naturally associated with physical distress, empowering the patient with self-help skills, andmanaging irritability which is a very common consequence of chronic pain.WHAT IS RELAXATION?The skill of achieving a deep state of relaxation has been pursued throughout much of recorded historyand is a key element in many religious, cultural, and philosophical traditions. Contemporary healthscientists have attempted to specify what relaxation is and identify how to teach people to relaxeffectively. It is helpful to view relaxation from the perspective of three integrated systems in the body:the brain, the skeletal muscle system, and the autonomic nervous system.http://www.med.unc.edu/ibs The UNC Center for Functional GI& Motility Disorders2THE BRAIN/COGNITIONuring and following relaxation, individuals typically report experiencing less rapid thinking and anincreased ability to focus thoughts and maintain concentration. The quality of thought is also reported tobe calm and restful in nature. Herbert Benson, MD, an accomplished researcher of the healthy effects ofrelaxation, describes the thinking state of relaxation as a "passive attitude," perceived as a peacefulwillingness to just let thoughts flow in a natural, non-directed or non-controlled manner.Relaxation produces a particular pattern of bioelectrical brain activity as recorded in theelectroencephalogram (EEG). The EEG of non-relaxed individuals shows relatively low voltage highfrequency brain activity that is not synchronized. When deeply relaxed, the dominant frequency of brainnerve firings slows, portions of the brain appear to fire in a synchronized fashion, and a high voltage slowfrequency pattern can be recorded. We refer to this EEG pattern as alpha activity. Everyone producessome alpha activity prior to falling asleep. Difficulty producing alpha activity is associated with sleeponset insomnia. Because we can record alpha and give people feedback on how well they are producingalpha states, we can use alpha feedback as one way to teach relaxation skills (see biofeedback, below).THE MUSCLES:When relaxed, there are two changes in muscular activity. First, relaxed people are very still. If they moveat all, they do so slowly and gently. Second, muscle tone is greatly diminished when people relax. Muscletone is the background level of muscle tightness in between overt muscle movements. Many of us getsore, aching muscles in our lower backs and shoulders or develop muscle tension headaches when muscletone is too high for too long.THE AUTONOMIC NERVOUS SYSTEM:The third system that changes with relaxation is the autonomic nervous system. This is the part of thenervous system outside of our brain and spinal cord that controls digestion, blood circulation, and otherour basic biological processes. The Latin-based word "autonomic," literally translates in English to"automatic." This nervous system controls parts of our body that we do not normally have to attend to,like when our heart beats or the level of activity of our gastrointestinal system. This autonomic nervoussystem has two branches, the sympathetic nervous system and the parasympathetic nervous system. Thesympathetic and parasympathetic systems activate different parts of the body in different ways, but theytend to act like the two sides of an old-fashioned scale -- when the sympathetic system is activated, theparasympathetic system is less activated and vice-versa.Generally, the sympathetic nervous system is activated when you are challenged, stressed, or faced with adangerous situation. When we are anxious, frightened, or in pain, we know that our heart beats moreforcefully and races, our palms sweat, and we suddenly feel very awake and alert. By contrast, we tend tobe more parasympathetically activated when out of danger and environmental demands are low. Underparasympathetic activation, the organs take care of "vegetative" or housekeeping functions such asdigesting meals, converting blood sugars for long-term storage, and moving nutrients to cells whilemoving waste away.Breathing is an interesting physiological process as it is controlled voluntarily and by the autonomicnervous system, such as when we sleep, lose consciousness, or do not need to voluntarily regulate ourbreathing for activities such as speaking. Research studies suggest that many parts of the autonomicnervous system tend to follow the activity of breathing. Under sympathetic activation, breathing tends tobe rapid, shallow, and less rhythmic. During relaxation and parasympathetic activation, breathing is slow,http://www.med.unc.edu/ibs The UNC Center for Functional GI& Motility Disorders3deep, and has a regular rhythm. Because one can voluntarily change breathing patterns and because theautonomic nervous system tends to mimic what is going on with breathing, a relaxed breathing patterncan be a successful way to gain control over automatic physiological processes.These three systems, the brain/cognition, the muscles, and the autonomic nervous system, are integratedby brain centers including: the limbic system (governing emotions), the hypothalamus (controlling basicbiological/behavioral processes), and the reticular activating system (regulating arousal). The threesystems tend to work in a coordinated fashion. When an individual changes the pattern of responding inone system, this affects the other systems. Thus, if one becomes very still and reduces muscle tone, thereis a tendency for the brain and autonomic nervous system to generally reflect relaxation. Methods ofproducing relaxation tend to focus on one system, combinations of these systems, or all three.KEY ELEMENTS IN LEARNING TO RELAX:Like any skilled act, relaxation skills are developed through practice. For a patient to show any lastingbenefit from relaxation training, research has indicated that a minimum of four training/therapy sessionsis critical. Researchers have found that patients will continue to show skill development over the first 10relaxation training sessions, but generally, patients do not show additional benefit from more than 10sessions. Regular practice of relaxation appears to be critical in learning how to become deeply relaxedand producing health benefits from relaxation. If one has difficulty in becoming relaxed, special coachingor individual tailoring of a relaxation technique may be required (see Seeking Professional Assistance,below).WHICH METHOD IS BEST FOR ME?There are subtle differences produced by various methods of teaching relaxation. Nevertheless,researchers have repeatedly found that any systematic program of relaxation appears to produce positivechanges in physiologic and psychological states for most people. Thus, one should choose a relaxationtraining program that feels comfortable to them. Various training programs are available through collegecontinuing education programs such as yoga, transcendental mediation, or self-hypnosis. Many self-helpbooks, guided relaxation tapes, or music-based relaxation recordings are also available. Biofeedback canalso be a very powerful relaxation technique. Biofeedback is a psychological self-regulation techniqueusing feedback from one's body reflected through a computer. Several studies have also shown thathypnosis is helpful to irritable bowel syndrome patients. Hypnosis therapies for functional GI disordersinclude both relaxation and suggestions for how to cope with functional GI problems.THE BASICS:Roger Poppen has done a good deal of research attempting to identify in the most basic way, what one hasto do to produce relaxation. He has broken this down into10 basic behaviors that you may want to try (seebox).SEEKING PROFESSIONAL ASSISTANCE:Health psychologists and other behavioral medicine specialists regularly teach relaxation skills to helpindividuals cope with medical problems or reduce health risks. A health psychologist can also assist thosewho have difficulty learning to relax when a more individualized relaxation program is required. If youhave difficulty finding a health psychologist, ask your health care providers for a referral, call your statepsychological association, or contact a behavioral pain management program.http://www.med.unc.edu/ibs The UNC Center for Functional GI& Motility Disorders4TEN RELAXING BEHAVIORS:Most individuals prefer practicing relaxation in a recliner chair in a quiet room (TVoff).Head: The head is motionless and well supported by a pillow or recliner chair, and thehead is centered with the midline of the body.Eyes: Eyelids are lightly closed with smooth appearance and there is no motion of theeyes (one may want to focus on an object low and distant in the room before closingthe eyes).Mouth: The lips are parted at the center of the mouth and the front teeth are slightlyparted.Throat: There is an absence of motion and the neck centered with midline.Shoulders: Shoulders are rounded (dropped) and symmetric.Body: The body is still. The torso, hips and legs are symmetric in regard to midline.The muscles are still and the body is fully supported by the chair.Hands: The hands should rest on chair arms or lap. The fingers are still and should begently curved.Feet: The feet and toes are still. The toes are pointed away from each other such thatthe feet form a V.Quiet: You should make no vocalizations or loud respiratory sounds.Breathing: Breathing pattern should be slower than when aroused, deep, and regularin rhythm.After getting into a relaxed state, just simply remain still and enjoy this state for10-20 minutes. If you feel yourself becoming tenser, review the list of relaxedbehaviors. If you have trouble with worrisome thoughts, try focusing on yourbreathing and thinking about breathing out tension and breathing in deeperrelaxation.Adapted from Poppen, R (1988), Behavioral Relaxation Training & Assessment, New York: PergamonPress."http://www.med.unc.edu/medicine/fgidc/using_relaxation.pdf


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