Tag Archives: stress

Early Treatment Of Fibromyalgia More Effective, Research Suggests

ScienceDaily (Oct. 29, 2009) — People suffering from fibromyalgia have reduced activity in the parts of the brain that inhibit the experience of pain. Drugs that affect the CNS can be effective against the disease, and are thought to be even more so if administered early in its course, according to a new thesis from the Swedish medical university Karolinska Institutet.
See Also:
Health & Medicine

* Pain Control
* Fibromyalgia
* Joint Pain

Mind & Brain

* Caregiving
* Depression
* Brain Injury

Reference

* Chronic pain
* Phantom limb
* Functional neuroimaging
* Gate control theory of pain

“It’s a common misconception that fibromyalgia is a manifestation of mental problems,” says Karin B. Jensen, postgraduate at the Department of Clinical Neuroscience. “But in the studies that comprise my thesis, we’ve made careful measurements and have found no correlation at all between pain sensitivity in fibromyalgia patients and the degree of anxiety or depression they show.”

In one of the studies presented in the thesis, subjects had both thumbs pressed hard enough for them to feel the same degree of mild pain as healthy controls. Using functional magnetic resonance imaging (fMRI), researchers could show that the subjects had the same level of activity in the parts of the brain that deal with emotions as well assensory information from the thumb, regardless of which group they belonged to. However, the subjects with fibromyalgia had lower activity in a brain area that inhibits the experience of pain.

According to the team, treatment with drugs that work on the central nervous system (CNS), such as SNRI antidepressants, are effective against fibromyalgia. But this is not a question of treating depression but of other properties of these drugs.

“The patients who had had their pain symptoms for the shortest amount of time were those that responded best to the drug treatments tested,” says Karin B Jensen. “This shows how important it is that fibromyalgia is detected and taken seriously as early in its development as possible.”

Her thesis also confirms the existence of a relationship between genetics and pain regulation. Studies of healthy people revealed a relationship between a specific genetic variant and the effect of a morphine-like drug on repeated pain stimulation. The results suggest that the gene under study only affects the body’s pain regulating system in the presence of greater psychological stress. This knowledge, say the researchers, could one day make possible the development of customised medical treatments and thus better and more effective pain relief.

Fibromyalgia affects about two per cent of the population, women more so than men. The disease involves the enhancement of pain impulses, leaving sufferers highly sensitive to pain, which is both chronic and diffuse. Previously, the causes of the disease were unknown, and there were no objective measurements of the way the CNS processes pain. This, in turn, made many sufferers feel misunderstood and mistreated by the healthcare services and during rehabilitation.

Meeting the Challenges, Grieving Your Losses pg5

This entry is part of a series, Cambell meeting the challenges»

Grieving Your Losses
By Bruce Campbell

One of the greatest challenges of chronic illness is coming to terms with loss and the accompanying emotion, grief. While grief is usually associated with the death of a loved one, it can occur after any loss. And chronic illness brings with it many serious losses. We may be forced to give up our job, which provides income, companionship and challenge. We may lose friends and feel abandoned by family. We may have to give up cherished activities and groups. We may experience loss of control over our bodies. And we may have to let go of some of our goals, losing the future we had envisioned for ourselves. In sum, we experience the loss of the person we used to be.

The pervasiveness of loss presents us with one of our biggest tasks: bringing meaning to life when so much has been taken away. Dealing successfully with loss is crucial to dealing positively with chronic illness. Working through our grief can produce a double benefit. Not only are we resolving a key psychological issue in chronic illness, we may be helping ourselves physically as well. Grieving is associated with the flare-up of symptoms, so resolving feelings of loss can help control symptoms. It may produce even more dramatic effects as well. A recent study of HIV-positive men who had lost a close friend to AIDS found that those men who were able to find meaning in the loss had a significantly lower risk of dying of AIDS themselves in the following several years.

We will look at this topic from two perspectives. This article discusses how to work through loss. The next one will describe how to move beyond loss to build a new life.

Responses to Loss

There are several common responses to the losses brought by chronic illness. Sometimes these reactions are discussed in terms of the well-known stages of death described by Elizabeth Kubler-Ross in her book On Death and Dying. For most people, however, there is not a neat, orderly progression. Rather grief is a more individual process in which a person may experience some but not necessarily all of the emotions described below. Also, a person may experience some emotions more than once, or may feel two or more at the same time.

Denial and Disbelief

Receiving a diagnosis of CFIDS or fibromyalgia may produce relief, because finally you have a name for your suffering, but this initial reaction may be accompanied by shock and disbelief. Getting a diagnosis of CFIDS or fibromyalgia means being told you have a condition for which there are no consistently effective medical treatments and no cure. Common reactions include ignoring the disease by continuing to lead a busy life or seeking a cure by going from doctor to doctor or by trying special diets or treatments.

Denial can be an adaptive response, allowing you to adjust gradually to all that is different and to the uncertainty brought by the illness. Denial is a way to keep hope alive during a time in which your life has been turned upside down. But if you get stuck in this reaction, you won’t be able to face your situation realistically. The repeated unsuccessful attempts at a “miracle cure” may reinforce a sense of helplessness and despair. Self-management strategies such as pacing and stress reduction can counteract the sense of helplessness with experiences of control.

Anger

Frustration, rage, and envy are common reactions to loss and the experience of having your life changed by something over which you had no control. They are honest emotions that honor the recognition that life changed for no apparent reason, becoming much more difficult. Frustration can also be triggered by the experience of uncertainty. Symptoms wax and wane, making it difficult to plan.

Self-management strategies can reduce uncertainty. Taking regular rests, for example, can help make your life more predictable by reducing the swings between high symptoms and times of remission. Resting ahead of an event can make it more likely you can attend. A health log can enable you see patterns in your symptoms, showing you what makes your symptoms worse.

Feeling angry is normal and can have positive effects if it motivates you to work to feel better or moves you to channel your energy to help others. But anger can be destructive if it is expressed in a way that drives away people who want to help and on whom you may be dependent. Blowing-up, expressing anger by shouting or by being cruel is hurtful.

Guilt

Some people blame themselves becoming sick. You might tell yourself things like: “If only I had taken better care of myself” or “If only I managed stress better” or “If only I had paid better attention to my body.” The truth is that no one yet knows the cause of either CFIDS or fibromyalgia. It is probable that factors over which we have no control, such as genetically susceptibility, will be found to play a major role in both.

It may be helpful to remember that we live in a society that sometimes blames people for becoming sick. There is a common idea that if we eat right, exercise and have the right thoughts, we will avoid illness. But the truth is that we are vulnerable, with no control over our genes and subject to many forces we don’t understand.

Guilt can be helpful if it motivates you to take better care of yourself from here forward, but it can be a trap if you see your illness as a personal failure. Whatever happened before, you can exercise control only from here on through such strategies as getting adequate rest, relaxing to reduce stress, developing supportive relationships, accepting a reasonable load of responsibilities but not more, keeping pleasure in your life, and developing new interests.

Sadness and Depression

Depression and feelings of sadness are common in chronic illness, natural responses to loss, uncertainty, limits and the discomfort of ongoing symptoms. Depression is a response which lessens further stress or trauma by shutting down, allowing time to process what has already occurred. Depression may also be triggered by a long period of suffering before receiving a diagnosis. Years of inappropriate or insensitive treatment may engender a sense of hopelessness.

Usually depression eases over time. If it lasts, you will have a sense of despair and inertia. Several strategies may be helpful. First, using self-help techniques such as those discussed elsewhere in the first article on emotions can help you move forward, refuting the belief that all is hopeless. Second, you can work to change your thinking so that it is more realistic and helpful. See the discussion of Cognitive Behavioral Therapy (CBT) in the second article on emotions. Third, since a considerable number of CFIDS and fibromyalgia patients suffer from clinical depression, you may be helped by professional guidance and medications.

Acceptance

This complex reaction involves a combination of factors. On the one hand, it involves recognizing that life has changed, perhaps permanently and certainly for an extended period of time. Acceptance means letting go of your past life and also of the future as you had envisioned it before becoming ill. But at the same time, acceptance involves the willingness and even eagerness to build a new life. I call this combination acceptance with a fighting spirit.

This two-fold attitude was summarized by former CFIDS patient Dean Anderson, whose account of recovery is posted elsewhere on this site. He says that the key to his recovery was a certain kind of acceptance. He describes it not as resignation, but rather “an acceptance of the reality of the illness and of the need to lead a different kind of life, perhaps for the rest of my life.”

Fibromyalgia patient Joan Buchman describes a similar approach in another article posted here. She writes that while she did not choose to have fibromyalgia, she did have a choice about how to live with it. She reduced her symptoms through making lifestyle changes and developed a fulfilling life by “focusing on my many blessings.”

Both Dean and Joan came to an acceptance of the reality of their illness and the need to lead a different kind of life. They found the key to improvement lay in the combination of accepting the illness and disciplining themselves to live with hope within the limits it imposed.

Strategies for Moving Through Grief

Illness brings loss, which takes some time to process. What can help you move through your time of grief?

Use problem-solving. Respond to the emotions of chronic illness by problem-solving, as indicated in the examples above. One way to move through grief is to use its emotions as the impetus to adopt self-management strategies to remedy the situations that triggered the emotions.

Keep structure in your life. Having a routine provides a sense of stability and familiarity, counteracting the feelings of disorientation and uncertainty brought by loss. Writer Gail Cassidy suggests that routine also offers a distraction from loss. “Do not make any unnecessary major changes in your life during times of loss, as they can further add to the existing instability and anxiety.”

Avoid stress. Having to adjust to the many changes brought by illness is traumatic. In a situation in which you are already overloaded emotionally, it’s best to avoid people and situations that add more stress. Gail Cassidy suggests you “stay away from negative people and situations that trigger negative emotions.”

Acknowledge loss. Some people report they found it useful to make a public declaration of loss. One person in our program wrote a Christmas letter to friends to explain why they hadn’t heard from him. The letter said, in part: “I am sobered by the realization that it is highly unlikely that I will return to the level of functioning that I had before becoming ill and so probably will have to adjust to living a life with greater limits than before.” He reports writing the letter helped him accept his limits and, paradoxically, increased his resolve to improve.

Respond positively to self-pity. Almost everyone with chronic illness occasionally feels sorry for themselves. It’s not surprising that we would sometimes feel overwhelmed by emotions, given the losses and stresses we experience. Here are four ideas about how to fight back.

1. Recognize self-pity is a part of serious illness: Just as symptoms wax and wane, so do emotions. Acknowledging that self-pity is happening can take some of its power away. You might say something like “Oh, there’s self-pity again” or “I’m feeling sorry for myself.” Also, it can help to say consoling things like “I’ve felt this was before and it’s always blown over, so probably it won’t last this time either.”

2. Rest: Strong emotions are sometimes triggered by fatigue and other symptoms. In those instances, rest may help alleviate both physical symptoms and emotions.

3. Connect with others: Reach out via phone, email or in-person contact. Sometimes just being in touch can change a mood. At other times it helps to have your mood acknowledged.

4. Help others: Shift your attention off yourself onto what you can do for your family, friends or others in your life.

Meeting the Challenges, Building a Support Network pg4

This entry is part of a series, Cambell meeting the challenges»

Building a Support Network
By Bruce Campbell

Because being ill is so difficult, feeling understood and supported is a balm to the soul. Students in our groups report seeking out contact with fellow patients and also valuing the support and friendship offered by family and other non-patients. Creating new relationships, especially with fellow patients or others who are empathetic, can be a powerful antidote to frustration in relationships.

It is very healing to feel understood. Also, talking about your illness to friends avoids overburdening your family. And having friends with the same illness may give you the opportunity to help others, which can boost your self-esteem.

Your Support Network

In thinking about how to meet your practical and emotional needs, consider putting together a network of people who can help. Author Devin Starlanyl suggests that such a network contain at least five people. Some may offer practical help, such as grocery shopping, housecleaning or driving. Others may be companions for outings such as a visit to the coffee shop or a night at the movies. Still others may offer emotional support by listening and offering reassurance. In any case, it’s wise to have several people to fill these various needs, so that one person does not feel overburdened and burn-out.

A Confidant

It can be especially helpful to have a confidant, one person to whom you can turn for emotional support and an objective view of your life. That person could be your spouse, a good friend or perhaps a fellow patient. I was fortunate to have such a friend. We set aside some time at the first of each month to discuss how I was doing. We each assessed my status using the CFIDS/Fibromyalgia Rating Scale, then reviewed my logs for the previous month. I learned much from the discussions, recognizing patterns I wasn’t able to spot on my own. Just as important, the meetings communicated that I was not struggling alone with my illness, but rather that there was somebody who cared about me and wanted to help me get better. And she said the sessions helped her to feel useful, counteracting the sense of helplessness often experienced by people close to those who are seriously ill.


Support Groups & Classes

Support groups and self-help classes can be a good way to meet fellow patients. The experience of being in such groups can be helpful in a number of ways. Chronic illnesses, especially ones that are hidden and often stigmatized, are isolating. Contact with fellow patients can counteract isolation and provide an experience of being acknowledged and supported. Such contact can be a way to experience feeling understood, comforted and inspired. Groups can provide information, such as names of local doctors who treat CFIDS and fibromyalgia.

Also, groups offer a way to be helpful, thus counteracting the loss of self-esteem that often results from illness. And they can offer models of successful coping with illness, thus dispelling fear. Similar experiences are available now on the Internet, at online chat rooms and message boards.

The CFIDS Association of America maintains a state-by-state list of CFIDS support groups in the United States. They will mail a list of groups in your state at no cost. (You can contact them at 800/442-3437.) The Arthritis Foundation sponsors fibromyalgia support groups in many places and offers an online directory of their groups at their website: http://www.arthritis.org. Self-help classes for people with CFIDS and fibromyalgia include our Internet course and the in-person Arthritis Self-Help Course offered by the Arthritis Foundation. The latter includes material for fibromyalgia patients.

Not all efforts at support are successful. Some groups are negative in tone, reinforcing a sense of victimhood. Some, often the same groups, are dominated by one or a few people. Others focus on responding positively to illness and insure participation from all members who wish to speak.

I suggest you evaluate such experiences based on the effects they have on you. Contact with fellow patients, especially in a group, can be very powerful. When such contact is negative, it can reinforce isolation and a sense of victimhood. But in a supportive atmosphere, it can be helpful and even healing. Contact with other patients may leave you feeling upset at times, but the discomfort should be followed by a new perspective on your situation, and increased confidence about your ability to manage the illness. A good group is one in which you feel a sense of belonging, which gives you something positive to take home, either inspiration or practical tips, and which offers models of living successfully with illness.

Professional Support

Some people with CFIDS and fibromyalgia report being helped by psychotherapy. A sympathetic therapist can provide a confidant’s level of caring, offering an outsider’s view and providing continuity. If you’re interested, you might look for one who specializes in working with people who have chronic illness. A local support group is often a good source of leads. Therapy can also be helpful for couples, a place in which the strains created by living with long-term illness can be explored.

Meeting the Challenges, Strengthening Your Ties pg3

This entry is part of a series, Cambell meeting the challenges»

Strengthening Your Ties
By Bruce Campbell

As patients with serious but invisible illnesses, we face a number of problems in the area of relationships. First, our illness is not accepted or understood. We may have trouble convincing others that we have a serious illness that imposes major limits on us. We often hear “but you look so well,” and sometimes comments like “just pull yourself together and snap out of it.” We may be on the receiving end of well-meaning but unsolicited advice. Thus, getting others to understand and accept our situation is a major challenge.

Second, our limits create problems within the family. Having less energy makes it difficult to do as much as before. Both we and other members of the family may have difficulty adjusting expectations to fit our new limits. Others may have to assume new responsibilities, which sometimes generates resentment. We may feel guilty about not doing our share. Our limits may make us uncomfortably dependent on others.

Third, limits and the unpredictability of symptoms can make it difficult to maintain existing relationships outside the family. Being ill makes it harder to get together with people. We may be unable to socialize in ways we used to. We may find it difficult to honor commitments, sometimes having to cancel at the last minute. Energy limits, in combination with worries about being accepted, can discourage us from the effort to establish new relationships.

Also, our limits can feed fears about being abandoned. When we don’t have our former energy, we may fear that we will lose the ability to take care of ourselves or that those on whom we depend may leave us.

And finally, feeling sick and being dependent makes it much more difficult to be assertive than it might be otherwise. Sometimes we adopt others’ expectations for ourselves as our own and make our situation more difficult by pushing ourselves too far. Guilt over not being as active as we and others would like can lead to our doing too much.

So illness creates various challenges in the area of relationships. The rest of this article and all of the next one offer ideas to help you respond to relationship frustrations.

Assess Your Relationships

Being ill means we have less energy for relationships, making it likely that some relationships will end or be put on hold. This is one more example of how the limits imposed by illness force us to be selective in what we do.

One place to start your evaluation might be with the fact that CFIDS and fibromyalgia can make you feel more vulnerable to those who are negative or demanding. The cost of spending time with such people may be great enough to convince you that some relationships are not worth maintaining. You may decide to keep others and rates still others as essential. In our program, we refer to this conscious and deliberate approach as relationship triage: making explicit decisions about who to include in your support network, concentrating on the more valuable or necessary relations and letting others go.

You might think of your relationships as a series of concentric rings. In this scheme, the inner ring contains the most important people in your life, typically family and closest friends. People on the outer ring are casual acquaintances. In between there may be one or two other rings of people with varying levels of importance. You may develop different approaches to people in various rings, concentrating on those in the inner ring. Relationships on the outer rings may be easier to let go of.

The approach being suggested is summarized by Dr. David Spiegel of Stanford, who writes about relationships and chronic illness as follows: “Save your energy and use the illness as an excuse to disengage from unwanted social obligations. Simplify the relationships that are necessary but unrewarding, and eliminate the ones that are unnecessary and unrewarding.”

Set Limits

Assertiveness means setting safe limits for oneself, then communicating them to others. Make clear to yourself and to others the consequences of your trying to meet old expectations: intensification of symptoms and postponed improvement. Be as specific as possible in asking for help if others offer assistance. For example, you might ask if they would do grocery shopping, make a phone call, or drive you to a medical appointment.

It can be difficult to be assertive when feel dependent and fear abandonment. If that’s the case for you, it may help to practice saying your request to yourself or someone you trust before making it to the person whose help you want. In presenting your request, it may help to acknowledge that you understand the other person’s situation. You might say something like “I know my illness makes your life more difficult and that some things I say and do may be frustrating.”

Nurture Important Relationships

Work hard to nurture those relationships that are most important to you, especially that with your spouse or partner. Research suggests that relationships are more stable if there is an emphasis on the positive, so look for the good in one another and in the relationship. A study that charted the amount of time couples spent fighting versus interacting positively (touching, smiling, paying compliments, laughing, etc.) found that relations were stable and satisfying if the ratio of positive interaction to negative was five to one.


Working to improve communication can help increase understanding, uncover unrealistic expectations, and aid cooperative problem solving. To improve communication with your partner, consider the following suggestions.

1. Pick a good time. Select a time for important conversations when both you and your partner will be at your best. Find a time when you will not be distracted by pain or brain fog, and when your partner can give you good attention.

2. Be grateful and respectful. Treat your partner with respect, acknowledging their support and effort. Avoid demeaning comments, sarcasm and blaming. Acknowledge your part in family problems.

3. Practice problem solving. Focus on the difficulties caused by the illness, rather than personalizing problems. Think of “gripes and solutions”: describe complaints, then discuss possible solutions. Work on only one or two problems at a time.

4. Test your understanding. From time to time, check whether you have understood the other person’s position by restating it in your own words.

Do Your Part

Our illness affects those who are close to us. It alters dramatically the financial circumstances of most families, forces radical changes in how household tasks are divided up, and drastically reduces the number and scope of activities the family can do together. A healing approach to relationships can begin with our acknowledging to ourselves and then to others how our illness and behavior affects them.

Just like patients, family members too can feel isolated and helpless. They may experience loss because their dreams, too, are put on hold. And they may feel abandoned or feel frustrated at the restrictions on their lives. The unpredictably of symptoms and mood can affect others, as we may cancel plans at the last moment or respond with inappropriate emotion.

Acknowledge that your illness creates problems for others, for example having to take on additional responsibilities. Express your appreciation for their efforts. Acknowledge that the illness can make you unreliable. Out of respect for other people, warn them that you might have to cancel on short notice. To help maintain the relationship, tell them that you value them and that backing out does not mean you don’t like them.

Take responsibility for the problems your illness creates for others. For example, if your illness makes you moody, make a list of things you can do to help yourself feel better. When you are feeling irritable, you might listen to music, take a walk or have a brief rest. All can help you avoid inflicting your moods on others.

Educate Others (Selectively)

Patients are sometimes successful in educating others about their illness, but most put limits on their efforts. If you think educating others about your illness would help them to be more understanding and supportive, you might talk with them or give them something to read. The CFIDS Association of America has a pamphlet titled “For Those Who Care,” which is available from them and also can be downloaded from their web site: http://www.cfids.org. The Arthritis Foundation has a similar brochure for fibromyalgia. One person in our group gave the CFIDS pamphlet to her husband and children, asking that they read it as their birthday present to her.

Patients who have tried educating people in their lives report that this approach often requires patience and is not always successful. They have experienced positive responses at times but have also concluded that some people may never understand the illness or be sympathetic. One student said, “When I was first ill, I tried to educate everyone about CFIDS. Over time I came to see that some relationships were more central to my life than others. I also concluded that some people might never understand. I still make efforts to educate, but I’m more selective about who I approach and I’ve accepted that some may never understand.”

Embrace Solitude

Serious illness often forces people to spend much more time alone than before. While some find solitude frightening or boring, others see their illness as providing an opportunity to develop new solitary interests. Recognizing that they will be spending less time with people than before, they have seen the situation as a chance to do things like reading and art work that they didn’t have enough time for earlier in their lives. See, for example, JoWynn Johns’ article “In Praise of Solitude.”

Meeting the Challenges – Adjusting Thinking pg2

This entry is part of a series, Cambell meeting the challenges»

The last article discussed a number of ways to manage depression and worry. This article describes another technique for managing emotions: changing your thoughts.

The Connections Among Thoughts, Feelings and Actions

To understand the powerful effect that thoughts can have, imagine the reactions of two patients to an increase in symptoms following a short walk. One says: “Another setback! I’ll never get any better.” This person has a pessimistic way of interpreting experience. She sees specific events as examples of permanent, far-reaching negative forces. The thought “I’ll never get any better” tends to lead to frustration, depression and despair. The mood of despair is associated with learned helplessness, the sense of not having control and a belief that effort will not be effective.

Pessimistic thoughts can increase your suffering. Negative thoughts make you feel anxious, sad and hopeless, which in turn makes it difficult to act constructively. Worry and preoccupation with suffering may even intensify symptoms and trigger another round of negative thinking. The cycle can be very demoralizing and make it difficult to motivate yourself.

Being in a situation in which you seem to lack control can create a sense of helplessness. Modern psychology has coined the term learned helplessness to describe the lasting effects of an uncontrollable bad situation.

But just as feelings of pessimism and despair can be learned in response to experience, so can optimism. Imagine that the second patient responds to her increase in symptoms by saying: “I walked too far today.” She has a more optimistic way of seeing her experience. She sees an event as something specific, limited and temporary. Her thought is more hopeful. It suggests the person can learn from experience, that tomorrow need not be the same. The more optimistic mood is associated with the willingness and even eagerness to try again.

Negative thoughts can be quite common in chronic illness. Focusing on symptoms, for example, can lead to thoughts like “I’m always in pain.” Such thoughts lead to frustration and discouragement. An inner dialogue featuring the word “should” can also produce frustration and anger towards oneself. An examples is saying “I should be able to do more.” Self-esteem can be undermined by thoughts like “I’m useless.”

The Effect of Expectations on Emotions and Symptoms

A student in one of our early groups provided a good example of how thoughts can affect emotions and symptoms. At a birthday party one year, she took on the role of the good hostess, moving about and worrying whether everyone was having a good time. She found herself tired and cranky after an hour. For a similar party a year later, she decided to create a different expectation for herself. She imagined she was a queen who was observing the situation from a throne. Freed from her self-imposed expectation that she should make sure everyone enjoyed themselves, she found herself with good energy for more than two hours. By making a mental adjustment (changing her thoughts), she reduced her worry, extended her energy and reduced her symptoms.

In this article, we will explore how you can recognize and break the cycle in which negative thoughts and symptoms reinforce one another, so that you can use your thoughts to help you, rather than having them increase your suffering.

Recognizing Automatic Thoughts

The process of changing explanatory style from a pessimistic, helpless one to a more optimistic and hopeful one occurs in three steps. The first is learning to recognize one’s self-defeating thoughts. This is not easy to do because the thoughts are automatic and habitual, so deeply ingrained that they seem self-evident.

A technique for recognizing automatic thoughts is the Thought Record, which is described in the book Mind Over Mood by Dennis Greenberger and Christine Padesky. Using this form offers a way to become aware of your automatic thoughts and their effects on your mood and behavior. (You can find similar techniques in other books, such Learned Optimism by Martin Seligman, Feeling Good by David Burns or books by Albert Ellis.)

To see how this technique works, we’ll use an example of a patient who took a walk one day and felt very tired when she got home. Feeling discouraged, she asked herself what thoughts were going through her mind. The answer: “I’ll never get better. Every time I try something, it fails.” She wrote a description of the event in column 1 of the Thought Record. (See below.) In the second column, she recorded her emotions at the time, noting that she felt depressed and hopeless. And in the third, she wrote the thoughts going through her mind when the emotions were strongest: “I’ll never get better. Every time I try something, it fails.”

The purpose of this exercise is to help you gain some distance from your thoughts, to remove their taken-for-granted or self-evident character. Often we are more harsh and judgmental toward ourselves in our inner dialogue than we would be with others. Self-defeating thoughts often go through our minds when something upsetting occurs. Because these thoughts are automatic, they can be hard to recognize and it can take some time to develop this skill.

Evaluating Negative Thoughts

Once you have identified negative thoughts, the next step is to examine them for “reasonableness.” In evaluating your thoughts, ask yourself to what extent the thoughts are valid. Negative thoughts tend to ignore facts or to select only the worst aspects of a situation. One way to determine reasonableness is by asking “What is the evidence for and against my thoughts?” The idea is to suspend temporarily your belief that the thoughts are true, and instead look for both evidence that supports and evidence that refutes the thoughts. Writing down the evidence you find helps you gain distance from your thoughts and makes them less self-evident.

You use column 4 in the Thought Record for evidence for, and column 5 for evidence against. The patient in our example wrote in column 4 that she has frequent setbacks and that she had often felt worse after exercising. She wrote in column 5 that she had improved over the last year and knew that many CFIDS patients improve.

Your thoughts at moments of strong emotion may seem irrefutable, so it may help to have in mind some questions you can ask yourself in order to find evidence that does not support your thoughts.

Among them:

Do I know of situations in which the thought is not completely true all the time?

If someone else had this thought, what would I tell them?

When I felt this way in the past, what did I think that helped me feel better?

Five years from now, am I likely to view this situation differently?

Am I blaming myself for something not under my control?

Seeing Alternatives

In the first step, you identify your self-defeating thoughts by recording the thoughts associated with strong emotions. In the second step, you challenge the accuracy of the thoughts by testing them to find distortions and irrationalities. In the last step of the process, you propose a new understanding of your experience.

You use column 6 of the Thought Record for this purpose. What you write in column 6 should be either an alternative interpretation of your experience (if you refuted the thought) or a balanced thought that summarizes the valid points for and against (if the evidence was mixed). In either case, what you write should be consistent with the evidence you recorded in columns 4 and 5. Reviewing the evidence she had written in columns 4 and 5, our patient decided that the evidence was mixed. She wrote a balanced thought that combined the evidence for and the evidence against. “I have frequent relapses and don’t know if I will have lasting improvement. But I’ve made progress and that gives me hope.”

The Goal: More Realistic Thinking

The process described here involves changing deeply ingrained habits of thought. The long-term results can be dramatic, but improvement is gradual. The reason to use thought records is not to replace negative thoughts with positive but inaccurate ones. I am not suggesting you adopt something like the motto “every day, in every way, I am getting better and better.” Rather, the goal is to learn to see your situation in an accurate, yet hopeful way: retraining your habits of thought in a more realistic direction. The kind of thinking advocated here integrates all evidence both positive and negative. It should reduce your stress by helping you feel better, less anxious and sad. And, at the same time, it should help you to deal more effectively with your illness.

Bruce Campbell:Meeting the Challenges of LongTerm Illness

This entry is part of a series, Cambell meeting the challenges»

Depression & Worry
By Bruce Campbell

So far in this series, we have focused on symptom management, suggesting that you will help yourself control symptoms if you honor your limits and address the stresses in your life. But because long-term illness affects so many parts of life, managing it requires more than symptom management. The rest of the series discusses three challenges beyond controlling symptoms: managing emotions, getting support, and moving beyond loss to build a new life.

Emotions in Chronic Illness

Strong emotions like fear, anger, grief and depression are common reactions to having chronic illness. Such emotions are a normal and understandable response to being in a situation that isolates, creates tremendous uncertainty, brings loss and imposes limits.

Unfortunately, CFIDS and fibromyalgia seem to make emotional reactions even stronger than before and harder to control. This reaction seems part of the physical basis of the illness. The strength of emotions can create a vicious cycle. Emotions can intensify symptoms, which in turn may increase worry and depression. As one student in our program said: “My emotions are much more sensitive than ever before. I cry more easily, and I have less emotional reserve to listen to my teenagers and husband and talk with them about their concerns.”

Self-help can play a role in managing the emotional aspects of chronic disease. The stress reduction techniques described in an earlier article: Relaxation for stress reduction] in this series may be helpful. Relaxation, for example, can short-circuit the feedback effect in which symptoms and emotions reinforce one another. Also, changing your thinking, as outlined in the next article, may be useful. The techniques described there have been proven to be especially helpful in counteracting the effects of anxiety and depression. Another general approach is to identify those situations (and sometimes people) that trigger strong emotions and plan a strategy of response ahead of time. Often, avoiding or minimizing stressful situations can reduce emotions, as described in the last article.

With those general comments about feelings as background, let’s look at several emotions and how to manage them.

Depression

Depression is very common in chronic illness. This should not be surprising. After all, illness turns lives upside down, bringing great losses and tremendous uncertainty. Also, serious illness is isolating. We spend less time with people and more time alone. In addition, sometimes depression may be part of our illness, with real physical causes. Prolonged stress may alter the biochemistry of the body, causing depression.

Depression is often divided into two types: situational and biochemical. Both may apply to people with CFIDS and fibromyalgia. Situational depression, which means depression that occurs as a response to a particular set of circumstances, lends itself to self-management strategies such as those described below. But not all depression is best handled this way. If you are deeply depressed about your illness or you have biochemical depression, which has its roots in the chemistry of the brain, medication and professional help are indicated. Self-management strategies may also be helpful.

There are many things you can do to improve your situation. If you are depressed, you may not want to try, but remember that depression feeds on itself. Your attitude becomes a self-fulfilling prophecy. If you believe you can get better, you will take actions such as those listed below that have a good chance of helping.

Rest: Some depression seems to be associated with physical symptoms such as fatigue and pain. Resting to reduce these symptoms can also improve mood.

Reach Out to Others: Simple human contact is often very soothing. Calling a friend or getting together to talk, share a meal or see a movie counteracts the sense of isolation, preoccupation with problems and the low mood often associated with chronic illness. Just explaining yourself can often give you perspective. Fellow patients can be very helpful.

Get Out of the House: Just like contact with others, getting out of the house counteracts isolation and boredom, provides stimulation and can reduce depression.

Consider Medications: Tranquilizers and narcotic painkillers intensify depression. If you are depressed, it may be in part a medication side effect. Check with your doctor. On the other hand, if your depression is bio-chemical in origin, you may be helped by an anti-depressant.

Exercise: Exercise is a natural anti-depressant. It relieves tension, lessens stress and improves mood. Most exercise also involves being out of the house, thus bringing the adding benefits of a change of scene.

Practice Problem-Solving: Taking action to solve a problem lifts the spirit as well as having practical benefits. Doing something counteracts the sense of helplessness and replaces it with a sense of control and power. In the words of one student, “I handle emotions better if I do something rather than passively suffer.”

Do Something Pleasant: Doing something in which you can become absorbed distracts from bad moods and puts you in touch with positive forces. Such activities might include reading, playing or listening to music, sitting in the sun, solving jigsaw puzzles, doing needlework, spending time with friends, being out in nature and laughing.

Get Help: If you are seriously depressed, suicidal or have been depressed for some time, get help now. Phone a suicide prevention center, talk to your doctor, see a psychologist or call a friend. If your problems are less severe, consider seeing a psychotherapist. Look for one who has experience working with people who have chronic illness. A therapist can provide an outside view of your situation, help you to accept your illness and support you in your efforts to improve. If you have family tension because of illness, you might also consider couples or family counseling.

Establish Good Daily Habits: Keeping to a daily routine regardless of how you feel can help counteract depression. Your daily round of activities will depend on the severity of your illness, and might include things like getting dressed every day, making the bed, cooking meals, taking a walk and watching a favorite TV program. Forcing yourself to do these things even if you don’t want to counteracts the inertia of depression.

Help Others: Get involved with something larger than yourself to counteract the isolation and preoccupation with symptoms that often accompany illness and to rebuild self-esteem. We usually feel better if we do something for another person. Helping others might involve a regular commitment like helping to lead a support group or something as simple as a phone call to an older relative or checking in with an old friend.

Manage Your Stress: Controlling stress can help you manage your emotions, because stress tends to make emotions more intense. Living within your energy envelope and managing the stresses in your life will make emotions more manageable.

Fear and Anxiety

Fear and anxiety often accompany chronic illness. These reactions are common in situations in which we feel an increased vulnerability in combination with a decreased sense of power. Because of having a serious illness, we experience a loss of control over our bodies and over our ability to plan and predict. Our illness brings uncertainty about the future. We may be unclear about our prognosis and wonder whether we will improve and, if so, how much. We may worry about how far down we might slide and about becoming dependent or financially destitute.

Strategies like those below are often helpful with fear and worry reactions. For more suggestions, see “Fifty Tips on the Management of Worry without Using Medication” in the book Worry by Edward Hallowell.

Use Problem-Solving: Taking action to solve a problem has a double payoff. You reduce or eliminate a practical concern that is bothering you. Also, the process of taking action often reduces worry.

Practice Stress Reduction: Learning relaxation and other stress reduction techniques can help reduce the intensity of your emotional reactions and, by doing so, reduce the echo effect in which emotions and symptoms amplify one another. A regular stress reduction practice can also lower “background worry,” the ongoing anxiety that results from long-term stresses like chronic illness.

Change Your Thinking: If you have a tendency to think of the worst that might happen, you can take steps to short-circuit the process in which your thoughts increase your anxiety. One antidote is to retrain yourself to speak soothingly when worried, saying things like “I’ve been here before and survived” or “this is probably not as bad as it seems.” For more on this, see the next article in this series.

Connect with Other People: Feeling that you are part of something larger than yourself counteracts worry. Also, contact distracts you from preoccupation with your problems, and provides reassurance.

Exercise: One of the best treatments for worry, exercise is both relaxing and distracting.

Pleasurable Activity. Reading, music, good conversation and other activities in which you can become immersed help change mood.

Don’t Worry Alone: The act of sharing a worry almost always reduces its size and emotional weight. Discussion may help you find solutions, but almost always makes the worry feel less threatening. Putting a worry into words translates it from the realm of imagination into something concrete and manageable.

Medications: Just as drugs can help with depression, some people find that medications help them deal with anxiety. A drug will not be a complete solution to problems of anxiety, but it can be an important part of a comprehensive response.

Panic

About 10 percent of people with CFIDS experience an especially severe and frightening form of fear called panic attacks. These are brief episodes of terror in which a person may feel he or she is about to die. Symptoms may include chest pain, heart palpitations and dizziness. In spite of overwhelming fear, people survive but may live a life of dread, apprehensive about when the next attack may occur. This kind of fear is treatable. For discussions on how to conquer panic, see Edward Hallowell’s book Worry or Martin Seligman’s What You Can Change and What You Can’t.

Summary

In sum, you aren’t crazy to experience strong emotions in reaction to having your life turned upside down. It would be surprising if you didn’t respond that way. Emotions like depression and anxiety are common responses to situations of loss and uncertainty. But there are many things you can do to reduce the strength of these emotions. Like other aspects of chronic illness, emotions can be managed.

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