Does Mindfulness Have a Role in the Treatment of Fibromyalgia Syndrome?

Does Mindfulness Have a Role in the Treatment of Fibromyalgia Syndrome?

Fibromyalgia syndrome is a poorly understood chronic pain disorder. An estimated 3% of adults are reported to suffer from fibromyalgia, with higher levels of occurrence in females compared to males. The main symptoms of fibromyalgia syndrome are all-over body pain, tiredness, difficulty in sleeping, and cognitive dysfunction such as memory impairment. There is also a high level of association between fibromyalgia syndrome and poor quality of life, mental health issues such as depression and anxiety, irritable bowel syndrome, and unemployment.

Some of the reasons why fibromyalgia syndrome is believed to be a controversial illness are as follows:

1. Individuals with fibromyalgia are reported to exert a higher burden upon healthcare resources when compared with individuals diagnosed with other chronic illnesses.

2. Research has shown that individuals with fibromyalgia often experience difficulty in having their illness diagnosed, and often feel that their needs and symptoms are poorly understood by the medical profession.

3. A diagnosis of fibromyalgia is primarily based upon the exclusion of other illnesses, the patient’s medical history, and their reaction to pressure being gently applied to ‘tender points’. In other words, there isn’t a reliable laboratory test for fibromyalgia syndrome (e.g., blood test, x-ray) and this means that it is difficult to be 100% certain that a given individual is genuinely suffering from the illness.

The current treatment-of-choice for fibromyalgia syndrome is the use of psychopharmacology (principally antidepressants) coupled with non-pharmacological approaches such as physical exercise, cognitive-behavioural therapy, self-help, and/or psycho-education. However, pharmacological treatments for fibromyalgia have shown only a limited degree of effectiveness, and many patients withdraw from treatment due to the side-effects of antidepressants as well as low levels of symptom reduction.

The lack of convincing treatment efficacy outcomes for existing pharmacological and non-pharmacological fibromyalgia interventions has led to the empirical evaluation of alternative treatment approaches. Since there exists evidence (which varies in quality and quantity) supporting the use of mindfulness in treating each of the individual symptoms of fibromyalgia syndrome (e.g., chronic pain, sleep disturbance, fatigue, depression, anxiety, and cognitive dysfunction), mindfulness-based interventions have been an obvious candidate in terms of investigating their effectiveness for treating the illness.

A systematic review and meta-analysis comprising six randomised and non-randomised controlled trials of mindfulness-based stress reduction (MBSR) for individuals with fibromyalgia (674 participants in total) found that individuals receiving MBSR experienced significant short-term improvements in quality of life and pain compared to individuals in the non-meditating control groups. A further systematic review (incorporating a range of intervention study designs) examined the findings from ten studies of mindfulness meditation (702 participants in total). The review concluded that mindfulness led to significant improvements in both physical symptoms (e.g., pain, sleep quality, functionality) and psychological symptoms (e.g. depression, anxiety, perceived helplessness).

In terms of the possible mechanisms by which mindfulness helps to alleviate the symptoms of fibromyalgia syndrome, the most widely proposed explanation is that mindfulness helps to increase perceptual distance from somatic pain and distressing psychological stimuli. By mindfully observing painful bodily sensations, it appears that individuals suffering from fibromyalgia (and other pain disorders) can begin to objectify and almost distance themselves from their pain. The same applies to feelings of psychological distress and fatigue that are often associated with musculoskeletal pain. Mindfully observing feelings of distress, frustration and low mood appears to weaken the intensity of such feelings, and to help create the ‘psychological space’ necessary for other – more psychologically adaptive – feelings and thought processes to arise.

Based on findings from a randomised controlled trial of an online mindfulness-based intervention, it has been suggested that stronger treatment outcomes can actually be achieved by using mindfulness not just as a means of improving patient’s ability to cope with pain and psychological distress, but as a means of helping improve patients’ ability to engage in effective social and interpersonal interactions. In other words, given the complexity of fibromyalgia syndrome, it appears that in order to maximise treatment effectiveness, mindfulness interventions targeting fibromyalgia should be purpose-designed and encourage participants to draw on both psychological and social resources.

In terms of other potential mechanisms of action, there is evidence to suggest that mindfulness leads to changes in neurological pain pathways, reduced levels of ruminative thinking and self-preoccupation, and improvements in spirituality. This latter potential mechanism is important because cross-sectional studies involving individuals with fibromyalgia have specifically identified a positive correlation between spirituality and positive affect (i.e., as levels of spirituality increase so do positive mood states), and a negative association between spirituality and symptoms of depression and anxiety (i.e., as levels of spirituality increase in individuals with fibromyalgia, their levels of depression and anxiety decrease).

Findings indicate that purpose-designed mindfulness-based interventions may have a role to play in the treatment of fibromyalgia syndrome. However, at present the overall quality of the evidence is weak and there is a need to replicate and consolidate findings using methodologically robust randomised controlled trials.

Ven Edo Shonin and Ven William Van Gordon

 

Further Reading

Branco, J. C., Bannwarth, B., Failde, I., Abello Carbonell, J., Blotman, F., Spaeth, M., … Matucci-Cerinic, M. (2010). Prevalence of fibromyalgia: a survey in five European countries. Seminars in Arthritis and Rheumatism, 39, 448-55.

Cramer, H., Haller, H., Lauche, R., & Dobos, G. (2012). Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complementary and Alternative Medicine, 12, 162.

Davis, M. C., & Zautra, A. J. (2013). An online mindfulness intervention targeting socioemotional regulation in fibromyalgia: results of a randomized controlled trial. Annals of Behavioural Medicine, 46, 273-284.

Dennis, N. L., Larkin, M., & Derbyshire, S. W. G. (2013). ‘A giant mess’ – making sense of complexity in the accounts of people with fibromyalgia. British Journal of Health Psychology, 18, 763-781.

Häuser, W., Wolfe, F., Tölle, T., Üçeyler, N., & Sommer, C. (2012). The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis. CNS Drugs, 26, 297-307.

Henke, M., & Chur-Hansen, A. (2014). The effectiveness of mindfulness-based programs on physical symptoms and psychological distress in patients with fibromyalgia: a systematic review. International Journal of Wellbeing, 4, 28-45.

Hickie, I., Pols, R. G., Koschera, A., & Davenport, T. (2004). Why are Somatoform Disorders so Poorly Recognized and Treated? In: G. Andrews & Henderson S. (Eds). Unmet Need in Psychiatry: Problems, Resources, Responses (pp. 309-323). Cambridge: Cambridge University Press.

Hughes, G., Martinez, C., Myon, E., Taïeb, C., & Wessely, S. (2005). The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice. Arthritis and Rheumatism, 54, 177-183.

Jones, K. D., Sherman, C. A., Mist, S. D., Carson, J. W., Bennett, R. M., & Li, F. (2012). A randomized controlled trial of 8-form Tai chi improves symptoms and functional mobility in fibromyalgia patients. Clinical Rheumatology, 31, 1205-1214.

Langhorst, J., Klose, P., Dobos, G. J., Bernardy, K, & Häuser, W. (2013). Efficacy and safety of meditative movement therapies in fibromyalgia syndrome: a systematic review and meta-analysis of randomized controlled trials. Rheumatology International, 33, 193-207.

Lauche, R., Cramer, H., Dobos, G., Langhorst, J., & Schmidt, S. (2013). A systematic review and meta-analysis of mindfulness-based stress reduction for the fibromyalgia syndrome. Journal of Psychosomatic Research, 75, 500-510.

Moreira-Almeida, A., & Koenig, H. G. (2008). Religiousness and spirituality in fibromyalgia and chronic pain patients. Current Pain and Headache Reports, 12, 327-332.

Nüesch, E., Häuser, W., Bernardy, K., Barth, J., & Jüni, P. (2013). Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: network meta-analysis. Annals of the Rheumatic Diseases, 72, 955-962.

Peterson, E. L. (2007). Fibromyalgia – Management of a misunderstood disorder. Journal of the American Academy of Nurse Practitioners. 19, 341-348.

Rimes, K. A., & Wingrove, J. (2013). Mindfulness-based cognitive therapy for people with chronic fatigue syndrome still experiencing excessive fatigue after cognitive behaviour therapy: a pilot randomized study. Clinical Psychology and Psychotherapy, 20, 107-117.

Scott, M., & Jones, K. (2014). Mindfulness in a fibromyalgia population. The Journal of Alternative and Complementary Medicine, 20, A94-A95.

Sicras-Mainar, A., Rejas, J., Navarro, R., Blanca, M., Morcillo, A., Larios, R., … Villarroya, C. (2009). Treating patients with fibromyalgia in primary care settings under routine medical practice: a claim database cost and burden of illness study. Arthritis Research & Therapy, 11, R54. DOI:10.1186/ar2673.

Wolfe, F., Brähler, E., Hinz, A., & Häuser, W. (2013). Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care and Research, 65, 777-785.

Wolfe, F. (2009). Fibromyalgia wars. Journal of Rheumatology, 36, 671-678.

Wolfe, F., Anderson, J., Harkness, D., Bennett, R. M., Caro, X. J., Goldenberg, D. L., … Yunus, M. B. (1997a). A prospective, longitudinal, multicenter study of service utilization and costs in fibromyalgia. Arthritis and Rheumatology, 40, 1560-1570.

Wolfe, F., Anderson, J., Harkness, D., Bennett, R. M., Caro, X. J., Goldenberg, D. L., … Yunus, M. B. (1997b). Work and disability status of persons with fibromyalgia. The Journal of Rheumatology, 24, 1171-1178.

Shonin, E., & Van Gordon, W. (2013). Searching for the present moment, Mindfulness, 5, 105-107.

Shonin, E., Van Gordon, W., Compare, A., Zangeneh, M., & Griffiths, M. D. (2015). Buddhist-derived loving-kindness and compassion meditation for the treatment of psychopathology: A systematic review. Mindfulness, 6, 1161-1180.

Van Gordon, W., Shonin, E., & Griffiths, M. (2015). Towards a second-generation of mindfulness-based interventions. Australia and New Zealand Journal of Psychiatry, 49, 591-591.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2013). Meditation as medication: Are attitudes changing? British Journal of General Practice, 63, 654.

Shonin, E., & Van Gordon, W. (2015). The lineage of mindfulness. Mindfulness, 6, 141-145.

“Keeping Your Shit Together”: A Perspective on the Buddhist Middle-Way Approach

“Keeping Your Shit Together”:

A Perspective on the Buddhist Middle-Way Approach

Some people like fast cars, some people like fine dining, and some people like expensive clothes. Some people are partial towards liquor, some towards gambling, and some towards tobacco. Some people like men and some people like women. Some people have a penchant for extreme sports, some for hot climates, and some for partying. Some people are passionate about video games, some about film, and some about photography. Some people like technology, some like nature, and some like travelling.

Some people like some of the above, some like none of the above, and some people like all of the above. People like certain things when they are young, other things when they are middle-aged, and different things when they are older. Likewise, people like certain things in the morning, other things in the afternoon, and different things in the evening. Some people are comfortable with the fact they like some, all, or none of the above, some people are indifferent about this matter, and some people are uncomfortable or feel guilty about the things that they are partial towards.

As far as the Buddhist spiritual teachings are concerned, there are lots of different methods of relating to the various desires and partialities that we have in life. Some Buddhist paths advocate separation and renunciation from potentially desirous objects and situations. Other paths advocate being in the presence of our various desires but exercising advanced levels of mental discipline. There are also some (often misunderstood and incorrectly practised) esoteric Buddhist paths that advocate accepting and embracing one’s desires.

When correctly taught and practised, each of these approaches represent valid spiritual paths. They have their own rules, they lead to their own spiritual fruits (i.e., levels of awakening), and they are intended to suit the needs of individuals with differing degrees of spiritual capacity. Nevertheless, although the three paths referred to above appear to represent very different modes of spiritual practice, these paths often intersect and feed into each other. For example, an individual who chooses to renounce and completely separate themselves from potentially desirous objects and circumstances may reach a point in their spiritual development when they feel that in order to move forward, they need a greater level of interaction with people and phenomena (i.e., in order to ‘put their practice to the test’). Eventually, the same person might decide that in order to grow even further as a spiritual being, they have to embrace all phenomena and experiences, including those typically considered to be incompatible with a spiritual way of life.

Although there are points of intersection and convergence in the three spiritual paths outlined above, a person who embarks on a path that they are not suited for, or who switches from one path to another before they are ready, is likely to find that the path is of little benefit or that it actually does them more harm than good. In other words, there are many different ways of interacting with the objects, people, and situations that are a potential source of attraction, but in order to grow in spiritual realisation, it is vital to employ the method that is most suited to our particular stage of spiritual development.

Recently, we were giving a talk to a group of young adults from a socio-economically deprived inner-city suburb of a northern English city. The theme of the talk was the principle of the ‘middle-way’. The Buddhist teachings on the middle-way basically assert that the best way to relate to the various desires and partialities that we have in life is to do things in moderation. Too much of something is generally not good for us, and completely avoiding things can also be detrimental to our wellbeing. Following the approach of the middle-way means that we don’t take anything to extremes, but it also means that we are open to new experiences and aren’t afraid of responsibly enjoying our lives. We use the term ‘responsibly enjoying’ here because implicit within the Buddhist teachings of the middle-way, is the premise that however we decide to spend our time, nobody (including ourselves) should be hurt or taken advantage of as a result of our actions. If we keep this basic premise in mind, then the approach of the middle-way seems to provide us with a means of exploring, enjoying, and engaging with life, but without letting our mind be ‘over-run’ by the various objects and activities of our desire.

If we want to embrace spiritual living to a slightly greater extent, then in addition to ‘responsibly enjoying’ life (i.e., by making sure we don’t hurt or take advantage of anybody), we should try to undertake everything we do in a gentle and compassionate manner, and whilst maintaining meditative awareness. If we expand our understanding of the middle-way approach to embody these three basic spiritual principles (i.e., 1. Responsibly enjoying life, 2. Being gentle and compassionate, and 3. Cultivating meditative awareness), then the middle-way philosophy becomes a practical, effective, and expedient means of fostering spiritual growth.

In terms of where the middle-way approach fits within the schema of the three Buddhist paths referred to earlier (i.e., the paths of relating to potentially desirous objects and situations via: 1. Renunciation and separation, 2. Applying advanced mental discipline, or 3. Acceptance and embracing), it could be said that the middle-way teachings apply to each of these different paths. For example, if a person is practising the path of renunciation and separation, then there is a ‘middle-way’ philosophy that they can apply to that path (i.e., by moderating the degree to which they cut themselves off from the world around them). Likewise, if a person chooses to engage with potentially desirous objects by either applying advanced levels of mental discipline or by meditatively accepting and embracing them, then there is a corresponding middle-way approach towards relating to and following each these paths. Thus, whichever spiritual path we choose to adopt, the teachings and approach of the middle-way remain valid.

The above discussion concerning the middle-way teachings and how they relate to different types of spiritual path was basically the subject of the talk that we mentioned above, which was given to a group of approximately 35 young adults. At the end of the talk, the floor was opened to questions and comments. At this point, a young lady who was about 20-years-old stood up and commented as follows:

“What you are saying is that as far as Buddhism is concerned, life is basically about keeping your shit together. If you keep your shit together, then so long as you are not hurting anybody, you are free to thoroughly enjoy life. It’s when your shit falls apart and you take things too far that trouble starts. Based on what I’ve understood, it seems that you are also saying that if you manage to keep your shit together and be a kind person at the same time, then that’s even better. I think I can do that. It sounds like common sense to me.”

After the talk, we spoke briefly with the young lady and informed her that we liked her comment and thought she had provided some sound words of advice. We asked for her permission (which she kindly provided) to make use of her advice in some of our writing projects. We don’t really consider ourselves to be particularly up-to-date with modern phrases or expressions, but based on our understanding, it appears that an aspect of the meaning of the Buddhist middle-way teachings is captured by the expression ‘keep your shit together’.

In terms of giving some examples of what ‘keeping your shit together’ means in practice, we would say that if you like gambling or alcohol, then by all means enjoy placing a few bets or having a few drinks. However, if you bet to the point of bankruptcy or if you drink yourself into a state of severe inebriation on a daily basis, then it probably means that you are not ‘keeping your shit together’. The same applies to all of the other things mentioned at the start of this post. It is good to responsibly enjoy some of the things that we are partial towards, but if we take things too far (in either direction), then there are likely to be negative consequences.

In terms of the things in life that we are partial towards, people have different levels of tolerance. Therefore, it is up to us as individuals to work out what constitutes a middle-way between extremes, and what amounts to not keeping ourselves together. Similarly, in light of the fact that people have different tolerance levels, it is also important that we don’t judge people by projecting our own ideas of what is right and wrong onto them. What amounts to not keeping it together for one person, might constitute a middle-way approach for somebody else. In other words, if we try too hard not to ‘lose our shit’, and get all haughty and wound up when we deem that others have lost theirs, then this might actually mean that we have ‘allowed our shit to fly all over the place’.

Ven Edo Shonin & Ven William Van Gordon