Autogenic Training: An Integrated Approach with ... Training: An Integrated Approach with Biofeedback forApproach with Biofeedback for Supppp gorting Health Erik Pepp,er, PhD San Francisco

Autogenic Training: An Integrated Approach with Biofeedback forApproach with Biofeedback for

Supporting Healthpp g

Erik Peper, PhDp ,San Francisco State University

anda dBiofeedback Health

[email protected]

©2013 Erik Peper

gwww.peperperspective.com

Autogenic Training (AT)Autogenic Training (AT)• T’//he techniques of autogenic training q g ghave been designed to support and facilitate the natural self-healing mechanisms that galready exist in our bodies.• The emphasis is to not to control these pnatural healing systems, but rather to use their intrinsic potentials more fullyy•AT develops a state that is the opposite of that which is elicited by stress

©2013 Erik Peper©2013 Erik Peper

y

Sympathetic Nervous System Parasympathetic Nervous System

Fight-or-Flight Response Rest-and-Digest

Energy Expenditure Promotes Healing and Growth

Increased Heart Rate Decreased Heart Rate

Increased Blood Press re Decreased Blood Press reIncreased Blood Pressure Decreased Blood Pressure

T M l R l M lTense Muscles Relax Muscles

Systems Shut Down Systems are Active

©2013 Erik PeperAdapted rom: ??????

My Background in ATMy Background in AT• Observed Elmer Green’s use of autogenic

h t f ilit t h d i f thphrases to facilitate hand warming for the very successful treatment of migraine

• Attended, organized and co-taught workshops with Wolfgang Luthe at the Biofeedback Society (AAPB) in the early and mid 1970s

• Impressed by the accumulated knowledge of p y gobserving thousands of patients who had practiced AT

©2013 Erik Peper

p

Useful Info from AT (1-2)• Offers guidelines about autonomic self-

regulation based upon thousands of patients who were follow-up (successful and unsuccessful). The Germanic compulsiveness showed when voluntary self-regulation could be helpful or harmful

• In most interventions, people who drop out are not follow-up (yoga, biofeedback)

• Biofeedback/neurofeedback has almost no data or follow-up on unsuccessful patients.

©2013 Erik Peper

p pJournals tend to only publish success.

Useful Info from AT (2-2)( )• The precision in teaching the basic postures

with facilitated mindfulness and directedwith facilitated mindfulness and directed participants to be in the “present”Using patient feedback to observe and• Using patient feedback to observe and support a passive attentive mindfulness state

• Developing somatic awareness (mind/body)• Successful outcomes clinical disorders and

optimizing health

©2013 Erik Peper

Two examplesTwo examples

• Pain in back during AT collapsePain in back during AT collapse• Terror and panic when neck relaxed

H d h ti t t ti t• Headache patient not wanting to say aggressive thoughts

• Warning when working with diabetes

©2013 Erik Peper

Autogenic Training: OverviewAutogenic Training: Overview

• BackgroundBackground• Components of Autogenic Training• Understand and psychological benefits• Understand and psychological benefits• Learn how to perform autogenics

G id li• Guidelines • Illustration of process with case example

©2013 Erik Peperhercules.gcsu.edu/bcooper/HLTH%204200/ppt_ch10.ppt

Autogenic Training: BackgroundAutogenic Training: Background• Grow out of the work in the late 19th century

(1894-1903) by Oskar Vogt and Korbininan( ) y gBrodmann in Berlin on the studies of sleep and hypnosis

• They observed that patients where able to put• They observed that patients where able to put themselves in an auto-hypnotic state which had positive recuperative effectsOb d th t h t t t l i h• Observed that short-term mental exercises when practices several times during the day reduced the stress of effects of fatigue and tension as well gas other disturbing symptoms such as headaches

• Johannes Schultz, a German psychiatrist and neurologist in 1905 was stimulated by their work

©2013 Erik Peper

neurologist, in 1905 was stimulated by their work and the therapeutic potential of hypnosis.

Origin of Autogenic TrainingOrigin of Autogenic Training• Johannes H., Schultz in 1932,

wrote his first book in whichwrote his first book in which he described Autogenic Therapy as a way to reduceTherapy as a way to reduce the dependency on the therapist

• Wolfgang Luthe in the 1960s consolidate AT and developed more advanced techniques

• Predominant research f G d

©2013 Erik Peper

sources from Germany and Japan

Derived from Self-hypnosisÉmile Coué (1857-1926) was a French psychologist and pharmacist and founder of self-hypnosis (autosuggestion) in Nancy, France. He explored the power of suggestions duringsuggestions during– By giving suggestions to the patients for whom

he filled their prescriptions I the pharmacyp p p y– He implemented the conscious autosuggstions,

Every day, in every way, I'm getting better and b tt d t d th ( titi f hbetter and suggested the (repetition of such expressions, according to a specified ritual, at the beginning and the ending of each day.

©2013 Erik PeperFrom: http://en.wikipedia.org/wiki/%C3%89mile_Cou%C3%A9

History of Self-RegulationYoga• Yoga

• Progressive relaxationA t i t i i• Autogenic training

• Autogenic biofeedback training• Transcendental meditation (TM)-Herbert

Benson’s Relaxation ResponseQ i ti• Quieting response

• EMG biofeedback• Temp biofeedback• Respiration biofeedback

©2013 Erik Peper

• Neurofeedback• Heart rate variability biofeedback

AT Use in the USA• Autogenic training is usually done with a few

phrases within relaxation/visualization approaches without teaching a type of mindfulness (much less success)

• AT as developed by Schulz and Luthe is totally different which leads to remarkable clinical outcome data

• Similar to Jacobson’s Progressive Relaxation gwhich consists of learning very specific control over sessions; instead, it is taught by an

©2013 Erik Peper

; , g yaudiofile as a general relaxation for a short time

Biofeedback and Autogenic Training in the USA

• Initially combined by Elmer and AliceInitially combined by Elmer and Alice Green at Menninger Foundation

• Wolfgang Luthe M D taught AT• Wolfgang Luthe, M.D. taught AT workshops at AAPB from about 1975-19791979

• Erik Peper initially learned AT from W lf L th d t ht AT dWolfgang Luthe and co-taught AT and presently teaches AT as part of the bi f db k l t SFSU

©2013 Erik Peper

biofeedback class at SFSU

Reason for studying AT• It is a means for self-regulation/regeneration

(reestablishes homeostasis) • It offers guideline and limitations in autonomic self• It offers guideline and limitations in autonomic self-

regulation (being Germanic, it followed both successful and unsuccessful patients)p )

• It is a reliable method of body/mind relaxation and way to achieve peace and calmness.

• Observe how others react• Western Mindfulness/training approach

U f l li i l d h l h li i• Useful clinical and health applications• Useful approach to integrate with biofeedback

Ph f lt i b d

©2013 Erik Peper

• Phrases are felt experiences can be used as conditioned cues warm hands, heaviness

AT Training is Skill MasteryAT Training is Skill Mastery

• AT is a psychophysiological skill masteryAT is a psychophysiological skill mastery• Learning passive attention

S ifi kill t• Specific skill mastery• Focuses upon being in the present• It is a minimum of three to six months

training-just like Progressive relaxationg j g• Practicing many, many times till the skill is

mastered and generalization into daily life

©2013 Erik Peper

mastered and generalization into daily life

Benefits of Autogenic TrainingBenefits of Autogenic Training• Has been shown to have physiological and p y g

psychological effects and reduces allostasis (promotes homeostasis),(p )

• Primary or adjunctive therapy for medical and psychiatric disorders. Applicationsand psychiatric disorders. Applications range from gastritis, diabetes, constipation, food allergies, asthma, sleepconstipation, food allergies, asthma, sleep disorders, time management, peak performance, child birth, hemophilia etc.

©2013 Erik Peper

performance, child birth, hemophilia etc.hercules.gcsu.edu/bcooper/HLTH%204200/ppt_ch10.ppt

Applications of A TApplications of A.T.•Psychological Physical:• Anxiety • Insomnia

• Asthma• Skin Conditions

• Depression• PTSD

• Hypertension• Arthritis PTSD

• Sports • Migraines• Irritable BowelIrritable Bowel

Syndrome• Pregnancy


Pregnancy• Sports

Application of A T in SportsApplication of A.T. in Sports• Better performance• Improved reactivity • Improved coordination • Better endurance• Faster recuperation • Reduction or

elimination of arousal before competitions


Common ThemesCommon Themes• Hierarchical skill mastery-each built upon

the other and trains attention (heavinessthe other and trains attention (heaviness, warmth, etc.)P i f f tt ti• Passive focus of attention

• Being in the present/mindfulness• Practicing at home and at work• Inhibiting the stress responseInhibiting the stress response• Global desensitization

I t ti h i d b h i©2013 Erik Peper

• Interrupting chained behavior

What is Autogenic TherapyWhat is Autogenic Therapy• Standard exercises (the six standard formulae)

f ll d b ti l f lfollowed by partial formulae• Autogenic modification

Organ specific formulae– Organ specific formulae– Intentional formulae

• Autogenic neutralizationAutogenic neutralization– Autogenic verbalization– Autogenic abreaction

• Autogenic meditation• Interdisciplinary techniques that include

biofeedback

©2013 Erik Peper

biofeedback

Autogenic methods: combinations and procedural interaction. In 10-20% of patients, a more intensive method called Autogenic Neutralization (AN) may be necessary. Meditative Exercises (ME), Autogenic Modification (AM), and Graduated Active Hypnosis (GAH) are less frequently employed Autogenic Feedback Training (AFT) and

©2013 Erik Peper

Hypnosis (GAH) are less frequently employed. Autogenic Feedback Training (AFT) and Autogenic Behavior Therapy (ABT) are relatively new techniques that are the result of interdisciplinary interaction.

Optimum Way to TeachIndividual Guidance / Web seminarIndividual Guidance / Web seminar

• Meet once a week• Assign one of the standard exercises to

practice at least three times a day as triplets• Record data• Next meeting share your observationsNext meeting share your observations• Practice next formula and report feedbackR d tiRecommendation• Teach a web seminar for 10 weeks practicing

©2013 Erik Peper

AT

Standard FormulaeStandard Physiological State PhraseStandardExercise

Physiological State Phrase

1 Heaviness in the My arms and legs are extremities

y gheavy

2 Warmth in the extremities My arms and legs are warm

3 Calm and regular function of the heart

My heart is calm and regularof the heart regular

4 Calm and regular respiration

My breath is calm and regular or It breaths me

5 Solar plexus warm My solar plexus is warm6 Forehead cool My forehead is cool

©2013 Erik Peper

7 I am at peace

Partial formula e.g., My neck and shoulders are heavy

Training LengthTraining Length

• Weekly individual or group sessionsWeekly individual or group sessions (group sessions preferred) for a minimum of 12-15 weeksof 12 15 weeks

• Daily practice at least 3 or four times a day practicing as tripletspracticing as triplets

• Recording of daily subjective experiences f i ifor session review

©2013 Erik Peper

Purpose of standard phrases and i ipositions

• Limits the degrees of freedom so that youLimits the degrees of freedom so that you can understand what is going on

• Minimizes distractions• Minimizes distractions• Understand what is happening (e.g., is an

autogenic discharge alright or anautogenic discharge alright or an indication to do further investigation)T i i df l /b i i h• Train mindfulness/being in the present

• Passive attention

©2013 Erik Peper

Main PrincipalsMain Principals

1. Mental repetition of specifically oriented verbal formulae for brief periods (e.g., 30 seconds)

2. Passive Concentration3. Reduction of exteroceptive and proprioceptive

ti l tistimulation 4. Training Postures5. Termination: flex the arms, take a deep breath,

and open eyes


Prepare for ATPrepare for AT• Practice in a quiet setting where you feel SAFE• Reduce external stimulation• Reduce external stimulation

– Bright lightsL d i– Loud noises

– Cold and breeze• Reduce somatic stimulation

– Loosen clothing (belt, bra, shoes– Take out hard contacts, dentures– Remove wallet, watch

©2013 Erik Peper

Main PrincipalsMain Principals1. Mental repetition of specifically oriented

verbal formulae for brief periods (e g 30verbal formulae for brief periods (e.g., 30 seconds)

2 Passive Concentration2. Passive Concentration3. Reduction of exteroceptive and

i ti ti l tiproprioceptive stimulation 4. Training Postures5. Termination: flex the arms, take a deep

breath, and open eyes


y

Body positionsBody positionsSitting in an upright chair is a position thatchair, is a position that can be used at work. It helps to relax the neck and shoulders, areasand shoulders, areas which often carry tension.

Lying down is the preferred position for practicing autogenic exercises when


ggoing to sleep. Pillows are sometimes placed under the head and knees.

Coachman PositionCoachman Position• Ideal position

Neutral joint positions– Neutral joint positions– Freedom of pelvic movement

O it f t tl iti– Opposite of startle position– Total letting go

• Problems– Neck does not let go– Arms are held tight– Legs are held contracted

©2013 Erik Peper

– Pelvic does not let go

Seated PositionSeated Position• A seated position in a

chair is recommended with your arms on lap

• Let your head hang comfortablyy

©2013 Erik Peper

Lying down positionLying down position

• The preferred position is lying on yourThe preferred position is lying on your back with arms at your sides, palms facing upup

• Heels resting evenly on surface

©2013 Erik Peper

Lying down positionLying down position

• The preferred position is lying on yourThe preferred position is lying on your back with arms at your sides, palms facing upup

• Heels resting evenly on surfaceB d i t l iti• Body in neutral position

©2013 Erik Peper

Are you really relaxing?Are you really relaxing?

©2013 Erik Peper

SU1 CP1 SU2 CP2 CP3SU3 SU4

Electrodermal Activity

Temperature

Left Cervical sEMG

Right Cervical sEMG

Ph i l i l di f i ht d l ft i l EMGPhysiological recording of right and left cervical sEMG, electrodermal activity and skin temperature. During the AT Coachman position (CP1, CP2 & CP3), the Right Cervicals EMG

©2013 Erik Peper

increased even though the person reported being totally relaxed.From: Doyle, J. & Peper, E. (2008). How to authenticate the effects of Autogenic Training. Psychophysiology Today. 3/4(1), 35-38. http://www.bfe.org/press/Psychophysiology%20Today%20vol%203-4-Issue%201.pdf

Use Webcam to illustrate how to do Coach position

©2013 Erik Peper

AT and BiofeedbackAT and BiofeedbackAT phrases are the subjective experience

d b bi d ithand can be combined with• EMG - My arm is heavy• Temp - My arm is warm• Respiration - It breathes meRespiration It breathes me• HRV - My heart beat is calm and regular

EEG M f h d i l I t• EEG - My forehead is cool; I am at peace

©2013 Erik Peper

Collapse versus Erect PostureDefeated versus Empowered

• The collapse position normally triggersThe collapse position normally triggers hopeless, helpless, powerless, defeated memories which encourages depressionmemories which encourages depression

• AT phrases focuses attention and inhibits the negative powerless thoughts andthe negative powerless thoughts and memoriesAt th d th t t h d• At the end the person stretches and moves into an expanded position (Cuddy)

©2013 Erik Peper

Tips & SuggestionsTips & Suggestions• Start a habit Practice 3-4 times a dayStart a habit. Practice 3-4 times a day.• Practice where you feel safe

A id ll di t ti• Avoid all distractions• Avoid AT after eating, drinking, or smoking (cigarettes)• Develop a ritualp• Experiment with the practices•Keep a journal


Keep a journal

Benefits of following formal procedure

• By controlling the body position andBy controlling the body position and cognitive activity, subjective discharges can be discriminated and may identifycan be discriminated and may identify problems.

Difficulty with breathing during collapse– Difficulty with breathing during collapse possibly linked to early drowning/sufficationexperiencep

– Discomfort in position possible discharge or indication of problems

©2013 Erik Peper

p

Reporting what you experienceReporting what you experience

• Only what you experience at this momentOnly what you experience at this moment of time without any judgments.

• It is training in being totally present• It is training in being totally present• Many people say:

– it is the same as before or previously– My hand did not warm as much as before

• These are all judgments, the key is to learn to only report “what is.”

©2013 Erik Peper

y p

Mental attitude during practiceMental attitude during practice• AT phrases are similar meditation with a word-it

k th i d i d d i l f dkeep the mind occupied and passively focused • Passively say the phrase and be present with

the area of the body without any judgments• If attention wanders such as a thought, When is g ,

it over, I am hungry, Distracted to the area of discomfort, bring the attention back to the , gphrase and passive attention to the body

• If attention keeps wandering do many short AT

©2013 Erik Peper

If attention keeps wandering, do many short AT sessions instead of forcing the attention

Increase Awareness of SomaIncrease Awareness of Soma

Many people are somatically disconnectedMany people are somatically disconnected and do not know or feel their body. Possible options to increase awarenessPossible options to increase awareness

• Stroke the arm or legs so that the person can feel the skin; ideally it is the interior ofcan feel the skin; ideally, it is the interior of the bodyD t t ti t th d• Do movement to activate the areas and then relax so it is easier to feel

©2013 Erik Peper

• Put hand in warm water

Generalize the Practice• Structured phrases at least three times a

day to develop awarenessday to develop awareness• Partial formula many times during the day

to interrupt chained behaviorto interrupt chained behavior

©2013 Erik Peper

Interrupting the Cascading Discomfort Process

P i / di f ts al

Pain/severe discomfort

mpt

oms

T

ota

First symptoms

and

sym

Initial awareness of discomfort such as stiffness

sign

s a

Thoughts and emotionsess

of s

Aw

aren

e

Non

e

Self- healing interventions

©2013 Erik Peper

A

Time

N

© 2013 Erik Peper

©2013 Erik Peper© 2013 Erik Peper

©2013 Erik Peper© 2013 Erik Peper

Autogenic modificationAutogenic modificationAllow specific changes to occur. This i l d dditi l h i dditi iincludes additional phrases in addition or in combination with standard exercises that focus on either physiologic change (organfocus on either physiologic change (organ-specific formulae) or on attitudinal or behavioral change (intentional formulae)behavioral change (intentional formulae)– Organ specific formulae (e.g. my lower abdomen

is warm to simulate peristalsis in the colon;– Intentional formulae (e.g., breath carries the

words for stuttering, or I am satiated for obesity)

©2013 Erik Peper

Autogenic neutralizationAutogenic neutralizationAutogenic neutralization is a structured

release of material in order to neutralize orrelease of material in order to neutralize or reduce its disturbing effect.

Autogenic verbalization in which the trainee is– Autogenic verbalization in which the trainee is encouraged to verbalize any materials related to a theme.to a theme.

– Autogenic abreaction in which the trainee just reports what is occurring –just reporting p g j p gwithout any judgments

• Clinical example of patient with headache

©2013 Erik Peper

Clinical example of patient with headache (aggression)

Autogenic Meditation (1-2)Autogenic Meditation (1 2)Autogenic Meditation is a series of sevenAutogenic Meditation is a series of seven

exercises begun only after the trainee has developed the ability to maintain passivedeveloped the ability to maintain passive concentration for at least 30 minutes (after at least 6 months of AT practice. at east 6 o t s o p act ce

©2013 Erik Peper

Autogenic Meditation (1-2)Autogenic Meditation (1 2)• Preparatory training (extending the time of

St d d f l t 30 50 i t )Standard formulas to 30-50 minutes)• Spontaneous experience of colors• Experience of selected colors• Visualization of concrete objectsVisualization of concrete objects• Visualization of abstract objects

E i f l t d t t f f li• Experience of selectred state of feeling• Visualization of other people

©2013 Erik Peper

• Answers from the unconscious

Themes Underlying AT (1-2)Themes Underlying AT (1 2)• It evokes the autogenic state diametrically g y

opposed to that elicited by stress It is self-generating thereby promotes healthC bi i d d b d ( i d d b d i h• Combines mind and body (mind and body is the same) (often if one is with the body it will warm up)up)

• Soma has an innate capacity for self-healing and this capacity is allowed to become operative in the autogenic state. Neither the trainer nor trainee has the wisdom necessary to direct the course of the self-balancing process hence the

©2013 Erik Peper

course of the self-balancing process, hence the capacity is allowed to occur and not be directed.

Themes Underlying AT (2-2)Themes Underlying AT (2 2)• Homeostatic self-regulation is encouraged.• The trainee does most of the learning at home, hence

responsibility for the training lies primarily with the t itrainee.

• The trainer must be self-experienced in the practiceTh ttit d f f l ti i f• The attitude necessary for successful practice is on of passive attention: active striving and concern with results impedes the learning process An attitude ofresults impedes the learning process. An attitude of acceptance is cultivated, letting be whatever comes up. This quality of attention is known as ‘mindfulness’

©2013 Erik Peper

p q yin meditative traditions.

Training Concepts (1-2)• Requires regular practice (brief mental exercise of

passive concentration upon the soma) of verbal stimuli (the basic six autogenic formulae)stimuli (the basic six autogenic formulae)

• Designed to promote an autogenic state which is a relaxed trophotropic state to facilitate homeostasisrelaxed trophotropic state to facilitate homeostasis and the self-normalizing process. (Trophotropic: the technical term used by W.R. Hess, having to do

ith th h i hi h h i l i llwith those mechanisms which physiologically belong to recuperation, protective mechanisms, unloading, restoration of achievement capacity, g, p y,normalization and healing. )

• It focuses upon doing it yourself

©2013 Erik Peper

• Process similar to Zen and Buddhist meditation.

Training concepts (1-2)Training concepts (1 2)• Specific postures

I t l t l tt ti t t f th b d• Internal mental attention to parts of the body• Inner repetition of the six phrases of the Standard

exercisesexercises.• Reporting upon experiences without judgment

(learning to be in the present without justification).( g p j )• Short exercises to learn mastery of mind (passive

attention) and learn to evoke the physiological ( ti ) It i b i ith th(somatic) response. It is being with the soma.

• 3-6 months for the standard formula (similar to Progressive Relaxation by Jacob Edmunson)

©2013 Erik Peper

Progressive Relaxation by Jacob Edmunson)

Non indications contraNon-indications, contra-indications and relative contra-

indications in Autogenic Training (AT)in Autogenic Training (AT),

Progressive Relaxation (PR) g ( )and biofeedback (BF)

©2013 Erik Peper

Non-indications: Not advisable to use AT PR BFto use AT, PR, BF

• Persons incapable of or unwilling to follow p ginstructions:– Mentally retarded– Under 5 years– Recalcitrant psychopath/-Acute schizophrenic

Different language– Different language• When careful and critical control of

person’s training symptoms is not possibleperson s training symptoms is not possible• When differential diagnostic evaluation

(e.g., autogenic discharges vs.

©2013 Erik Peper

( g g gunrecognized pathology) is not possible

Contra-indications: Potential for bl i h AT PR BFproblems with AT, PR, BF

• Persons in critical care state and where system is t f il di di d ( t ti l f h ttoo fragile, e.g., cardiac disorders (potential for heart attack, during/after heart attack or presence of related disorders such as arrhythmia embolism)related disorders such as arrhythmia, embolism)

• Persons taking medication, unless monitored closely e g in diabetes glaucoma hypoglycemiaclosely, e.g., in diabetes, glaucoma, hypoglycemia

• Persons showing significant paradoxical increases in blood pressure during ATblood pressure during AT

• Persons with psychoses (sub-acute and paranoid) and with dissociative (non-psychotic) reactions

©2013 Erik Peper

( p y )

Relative contra-indications: Particular caution modification of procedure required with AT, PR, BF

(1 2)(1-2)• Avoid area of concern to avoid:

– Heart command with cardiac disordersHeart command with cardiac disorders– Breath command with respiratory disorders– Solar plexus command during pregnancy

P ith i d i l ti• Persons with poor experience during relaxation• Persons with experience in min-altering drugs and /

or anesthesiaor anesthesia• When response is incongruous with instructions,

e.g., trainee reports pain during “letting go” instruction trainee becomes panicky when imagininginstruction, trainee becomes panicky when imagining a “relaxation” scene

• Excessive or unusual physiological response, e.g.,

©2013 Erik Peper

p y g p gflushing of face, sweating palms, heart palpitations, headache

Relative contra-indications: Particular caution modification of procedure required with AT, PR, BF

(2-2)• Excessive or unusual psychological response, e.g.,

disorientation in time and space discharge ofdisorientation in time and space, discharge of emotions such as crying, intense dynamic changing of image which is predominantly redWith bl ki th d t it• With persons blocking the need to cry or vomit

• No low frequency brainwave training with trainees who have epilepsywho have epilepsy

• No improper placement in muscle re-education• No unilateral training with bruxism• With persons who tend to “over tighten” during

tightening in PR• When person is insufficiently aroused before leaving

©2013 Erik Peper

• When person is insufficiently aroused before leaving a training session

Case Example: The use of Autogenic Training and BiofeedbackTraining and Biofeedback

for the Treatment of Plaque Psoriasis

Aaron Klein and Erik PeperSan Francisco State Universityy

©2013 Erik PeperKlein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

Subjective Experience• “I was helpless. I was scared. I was incurable. I

became self-healing. I became powerful. I accomplished what my doctors could not. I successfully treated my psoriasis with the power of my own mind.”

• “Through this journey I learned to understand g j ythe self as a process. Instead of emotionally punishing myself for who (what, where) I was p g y ( , )not, I began to accept myself as I was.”

• --a 23 year old college student

©2013 Erik Peper

a 23 year old college studentKlein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

What is Psoriasis?• Most common autoimmune disease in the US• Skin cell production is sped causing dead skin

cell patches to build up on the surface of the body

• These patches, known as scales, are mostThese patches, known as scales, are most often found on the elbows and knees but can appear on any and every part of the bodyappear on any and every part of the body

©2013 Erik Peper

(PubMed Health, 2011)Klein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

©2013 Erik PeperDermNet.comKlein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

Who does it affect?Who does it affect?• 7 5 million Americans suffer from7.5 million Americans suffer from

psoriasis• 125 illi l ld id• 125 million people world wide

• Most common between the ages 15-25

(National Psoriasis Foundation, 2012)


Costs?• Psychological Defeat

o doctor tell you your condition is lifelongo doctor tell you your condition is lifelong o your only hope is continuous symptom

suppressionsuppression• Treatment costs

o $11 25 billion annuallyo $11.25 billion annually• Missed work

t f 40% f l to accounts for 40% of annual costso 60% of patients miss on average 26 days

ll

©2013 Erik Peper

annually

Traditional TreatmentsTraditional Treatments• Cortisone creams

o causes thinning of the skino require vigilant applicationo require vigilant application

• Pharmaceuticalssuppress the immune systemo suppress the immune system

o Increase susceptible to other illness• Ph t th (t i )• Phototherapy (tanning)

o may cause skin cancer

©2013 Erik Peper

o regular treatment required(PubMed Health, 2011)

Background for Self-Regulation• Five adults studied over five weeks

o Had symptoms for five plus years• EMG i i d d f h i li• EMG training recorded from the anterior temporalis

with auditory feedback• T i i i i l i• Training in progressive relaxation• Significant reduction in stress and symptoms at five

weeks• Four patients were symptom free at the two month

ffollow upo Three were reachable two years later and were still

symptom free Research by McMenamy (1988)

©2013 Erik Peper

symptom free Research by McMenamy (1988)Klein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

Case ExampleCase Example• Twenty-three year old male student who hadTwenty three year old male student who had

been suffering from chronic psoriasis for the last five years with psoriatic plaques coveringlast five years with. psoriatic plaques covering his elbows, knees, ankles, and scalp, as well as smaller red irritations periodically appearing onsmaller red irritations periodically appearing on the entirety of his body.

• Diagnosed in 2008 and unsuccessfully• Diagnosed in 2008 and unsuccessfully treatment with standard medical approach


Previous treatments• Combination of topical corticosteroids daily since

diagnosis. g• Experimented with ultra violet light treatment for a

short period of time (stopped for fear of developing p ( pp p gskin cancer).

• Despite treatments his condition did not improve. If he even missed one day of topical corticosteroid application, his symptoms worsened dramatically.

• His failure to respond to treatment motivated him to explore an alternative approach.


Method (1-2)D il t i t i i (AT) f l ti• Daily autogenic training (AT) for relaxation, stress-reduction, and desensitization.

• Practice AT whenever he felt the urge to itch, touch his psoriatic plaques, or when thinking self-critical thoughts. He was to stop and conduct a quick five-step AT session in that moment. AT, utilizing a quick series of cues: “my right hand is heavy, my hands and feet are heavy and warm.” “My skin is cool, clear, and regenerative.” “I am worthy.”

©2013 Erik Peper•Klein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

Method (2-2)Perform self talk assessment from 0 10 (0• Perform self-talk assessment from 0-10 (0 being negative or low, 10 being positive or high)B h d l• Breathe deeply

• Post AT self-talk rating (0-10) • Change body posture from a powerless body

posture (collapsed and shrinking posture) to an p ( p g p )empowered body posture* (upright and expansive), while feeling happy to be working p ), g ppy gon empowering his health (Cuddy, ted video)

*http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you

©2013 Erik Peper

_are.html, Peper, E. & Lin, I-M. (2012). Increase or decrease depression-How body postures influence your energy level. Biofeedback, 40 (3), 126-130.

Results• The skin was smoother and less red. His

skin was the clearest and smoothest in theskin was the clearest and smoothest in the five years since his diagnosis.

• At a four month follow-up his improvement• At a four month follow-up his improvement was maintained. He transformed his body posture and• He transformed his body posture and expression from being collapsed and having a hoodie over his head to sittinghaving a hoodie over his head, to sitting and standing upright with an expression of confidence

©2013 Erik Peper

confidenceKlein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

©2013 Erik PeperKlein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback. © 2013 Erik Peper


Results

• Three weeks the• Three weeks the skin cleared for the first time inthe first time in five yearsO f ll• One year follow-up the skin sta ed clearstayed clear


ResultsTransformed his

Results

body posture and expression from being collapsed andbeing collapsed and having a hoodieover his head toover his head, to sitting and standing upright with an p gexpression of confidence


Implications 1-Implications 1• Biofeedback monitoring and training

changed the illness beliefs of the personchanged the illness beliefs of the person—“seeing is believing.” The initial temperature monitoring during autogenictemperature monitoring during autogenic training demonstrated that peripheral hand warming was possiblehand-warming was possible.

• Graphs and numbers made the changes b li bl d i d ti tibelievable and increased motivation. Detailed log keeping demonstrated that h d ti

©2013 Erik Peper

changes occurred over time.Klein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

Subjective Experience (1-2)Subjective Experience (1 2)• “Breaking this chain behavior was by far the

hardest things I’ve ever done It didn’t matterhardest things I ve ever done. It didn t matter what situation I found myself in, my AT practice took precedence The level of self control I hadtook precedence. The level of self- control I had to maintain was far beyond my norm. I b t ki I t li t• I remember taking an exam. I was struggling to recall the answer to the last essay question. All I t d t d fi i h th dI wanted to do was finish the exam and go home.


Subjective Experience (2-2)• I knew that I knew it, it was coming to me, I

began to write... Yet in that same moment I felt my right elbow start to tingle and my left hand started to drift towards it. Immediately I had to

f fswitch my focus. Despite my desire to finish I dropped my pen. I paused to breathe and ran h h AT M lik hi h dthought my AT. Moments like this happened daily, my normal functions were routinely i t t d b t t h S ti Iinterrupted by urges to scratch. Sometimes I would spend significantly more time doing AT th th t k t h d

©2013 Erik Peper

than the task at hand. Klein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

Implications 2-Implications 2• Self-monitoring of specific behaviors

(t hi b d ll i ti(touching, body collapsing, negative thoughts) and then substituting a new self-h li b h i i t t d th h i dhealing behavior interrupted the chained behavior and transferred the learning from th t i i i i t d lifthe training session into everyday life.


Adopting an attitude of passive attention and acceptance--the basis of mindfulness. p

• “I was able to attune myself to my body in such a way that I became aware of my body y y yfunctioning's without judgment. I began to notice small stressors before they became yoverwhelming. By being attentive to my body instead of reactive I was able to become aware of my plaques itching without going into a negative mindset. I was able to accept its g poccurrence as part of my journey. An itch was no longer a failure, it simply meant there was

©2013 Erik Peper

g , p ystill room for growth and improvement.”

Klein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

Evoking hope is critical for health (1-2)Evoking hope is critical for health (1 2)

“For years I had been under the impressionFor years I had been under the impression that I was hopeless in combating my psoriasis. It had been ingrained in me frompsoriasis. It had been ingrained in me from my first diagnosis. Every doctor from general care to dermatologists said ge e a ca e to de ato og sts sa dessentially the same thing, “this is a life-long condition without any cure, all we can o g co d o ou a y cu e, a e cado is help negate the symptoms.”



• “For years I had been under theFor years I had been under the impression that I was hopeless in combating my psoriasis. It had beencombating my psoriasis. It had been ingrained in me from my first diagnosis. Every doctor from general care to e y docto o ge e a ca e todermatologists said essentially the same thing, “this is a life-long condition without g, s s a e o g co d o ouany cure, all we can do is help negate the symptoms.”

©2013 Erik Peper

y pKlein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.


“Even going into the study I had feelings ofEven going into the study I had feelings of doubt. Reservations, not wanting to get my hopes up for nothing Yet less than onehopes up for nothing. Yet less than one week into the process I began to see objective improvement in his skin I foundobjective improvement in his skin. I found hope and comfort in knowing I was making progress The power to heal myself wasprogress. The power to heal myself was mine and no western medical professional could take it away again ”

©2013 Erik Peper

could take it away again.• . Klein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the

Treatment of Psoriasis. Biofeedback.

Healing as an ongoing journey (1-3)

“Through this journey I learned to understand the self as a process Insteadunderstand the self as a process. Instead of emotionally punishing myself for who (what where) I was not I began to accept(what, where) I was not, I began to accept myself as I was. This is not to say I became docile in fact quite the opposite Itbecame docile, in fact quite the opposite. It was as though a light went off in my head. My goals were still important even if theyMy goals were still important even if they were not the end of the journey.”


Healing as an ongoing journey (2-3)g g g j y ( )“I found peace in the understanding that personal

growth is not measured in external goalgrowth is not measured in external goal achievement but more so in ones commitment to evolve In other words achievement is ato evolve. In other words, achievement is a process and forward movement is progress to be celebrated This realization lifted anbe celebrated. This realization lifted an immense weight off of my shoulders. I was no longer failing to achieve because my goalslonger failing to achieve because my goals were still in the distant future.”


Healing as an ongoing journey (3-3)g g g j y ( )

“I was achieving every day as I committed g y yhimself to forward progress. I had become able to internalize and rejoice in my day by j y y yday devotion to life in the present moment. Being able to stay in the here and now, not g ycomparing myself to a hypothetical “what if- self” was an incalculably beneficial yrealization for me. My life will never be the same”.

©2013 Erik Peper

•Klein, A. & Peper, W. (submitted). There is Hope: Autogenic Biofeedback Training for the Treatment of Psoriasis. Biofeedback.

©2013 Erik Peperhttp://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are.html,

High testosteroneLow cortisol

©2013 Erik Peperhttp://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are.html,

Low TestosteroneHi h ti l

©2013 Erik Peper

High cortisolhttp://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are.html,

©2013 Erik Peper

http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are.html,

Body changes Mind/emotionsBody changes Mind/emotions

• Hold pencil between teeth you will becomeHold pencil between teeth you will become less depressed

• If you are powerful you can do more risk• If you are powerful you can do more risk action is modulated by cortexL ti t b k t• Low power actions revert back to overlearned patterns modulated by

d lamygdala

©2013 Erik Peper


Power /non-power posture• Power posture (take up

space/enlarge/open up)• Powerless posture (making yourself

smaller/defeated))

©2013 Erik Peper


Pose 2 minutesPose 2 minutes

+20%High power Low powerHigh power Low power

+20%

-10%

©2013 Erik Peper


High power Low power+15%

High power Low power

-25%

©2013 Erik Peper

25%http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are.html,

BooksBooks• Luthe, W. (ED).(1969). Autogenic Therapy (Vols. I,

II III IV V & VI ) N Y k S dII, III, IV, V & VI.). New York: Saunders.• Luthe, W. (1979). Introduction to the Methods of

A t i Th Wh t Rid CO A i tiAutogenic Therapy. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

• Kermani K (1996) Autogenic Training: The• Kermani, K. (1996).Autogenic Training: The Effective Holistic Way to Better Health. London, UK: Souvenir PressUK: Souvenir Press

• Linden, W. (1990). Autogenic Training. New York: Guilford Press

©2013 Erik Peper

A.T. Interview: Amelia Saetern


A.T. Interview: Sean Colin


Documents

Autogenic Training: An Integrated Approach with ... Training: An Integrated Approach with Biofeedback forApproach with Biofeedback for Supppp gorting Health Erik Pepp,er, PhD San Francisco