Professional Documents
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by Michael Hutchinson, author of "The Book of Floating" There's no doubt that floating works - as a therapeutic, educational and entertainment tool it has powerful effects on a number of levels, including the physical, emotional, intellectual and spiritual. But why is the floatation environment so effective? What can be so actively beneficial in an essentially passive device? This is a question that has intrigued scientists, and today there is floatation research going on in laboratories around the world. The evidence accumulated so far falls into a number of distinct, though interrelated explanations. Among the most important are as follows:
stars, so are the subtle contents of the right hemisphere usually drowned out by the noisy chattering of the dominant verbal/analytical left brain, whose qualities are the more cultivated and valued in our culture. But recent research indicates that floating increases right-brain (or minor hemisphere) function. Floating turns off the external stimuli, plunges us into literal and figurative darkness - then suddenly the entire universe of stars and galaxies is spread out before our eyes. Or as brain researcher Dr. Thomas Budzynski of the University of Colorado put it, "In a floatation environment, the right hemisphere comes out and says, 'Whoopee".
"These are individuals who often have tried many different forms of treatment before. They are individuals who are in the greatest possible need of relaxation but who have the hardest time adopting methods of relaxation. They are so tightly wound up that the methods don't work," says Professor Torsten Norlander. What happens, then, when these patients are allowed to float? It appears that floating is an effective way to trigger the body's relaxation response. The level of stress hormones goes down during and after floating. Moreover, it seems as if the treatment has an even greater effect since prolactin, a kind of 'life-force hormone,' is released in larger amounts. After a period of treatment totaling seven weeks, 22 percent of the participants in the floating group were entirely free of pain, and 56 percent experience a clear improvement; 19 percent noticed no difference, and 3 percent grew worse. In terms of symptoms, the findings were as follows: 23 percent slept better; 31 percent experienced less stress; 27 percent felt less anxiety; and 24 percent were less depressed or came out of their depression completely. What the researchers find particularly gratifying is that the positive effects were still in evidence four months after the floating treatment ended. To ensure that the good results can be ascribed to floating as such, the researchers set up, on the one hand, a control group that did not take part in floating and, on the other hand, a subdivision within the floating group. One of these subgroups received normal attention and encouragement, while the other subgroup was given extra attention and encouragement. "It might be suspected that it was the attention and encouragement that yielded results, so we wanted to try treating the two floating groups differently. But it turned out that there was no difference between the two subgroups of floaters: their results were equally good. On the other hand, the control group, which did not take part in floating, registered no improvement whatsoever," says Sven-Oke Bood, a doctoral student in psychology and a registered nurse. This research on floating is part of his coming doctoral dissertation. Stress is largely about how we worry about things that have happened and are going to happen. When an individual, instead, manages to reach a sort of 'here-and-now' state, the brain can rest. These researchers believe that floating is a way of achieving just such a state. In a dark and silent floating tank, the patient is cut off from many sense impressions. Besides the rest the brain gets, the muscles also become relaxed. In one study the researchers found that about 12 floating treatments are sufficient to achieve results. The group that received 33 floating treatments attained only slightly better pain relief and blood pressure levels. It seems as if 12 treatments are enough to alleviate anxiety, depression, and other stress-related symptoms.
In another study the researchers examined whether floating can be combined with conversational therapy. Thus far it seems that patients who float achieve positive results more quickly during conversational therapy. Floating enhances the effect.
The research project, which has been underway since 2003, is being funded by the Vormland County Council and the Center for Clinical Research. These research findings are being presented in the prestigious American scientific journal International Journal of Stress Management in May and in a specialist journal for pain research. Peer reviewed publication and references International Journal of Stress Management, May issue
Vetenskapsrodet (The Swedish Research Council) The Swedish Research Council bears national responsibility for developing the country's basic research towards attainment of a strong international position. The Council has three main tasks: research funding, science communication and research policy. Research is the foundation for the development of knowledge in society, and the basis of high-quality education. Research is also crucial as a means of enhancing welfare through economic, social and cultural development.
A BRIEF OVERVIEW OF RESEARCH REGARDING THE EFFECTIVENESS OF RESTRICTED ENVIRONMENTAL STIMULATION THERAPY AS A COMPLEMENTARY TREATMENT FOR A RANGE OF BEHAVIORAL DISORDERS
Baylah David, Ph.D. Neurobehavioral Health Services, 5363 E. Pima, Suite 100, Tucson, Arizona 85712, (520) 321-0373
Introduction
The use of sensory restriction as an intervention which alters human consciousness began in 1951 with the opening of the McGill University Perceptual Isolation Laboratory, mandated, primarily, to study the mind-altering effects of monotonous environments. By 1960 or 1961 systematic exploration of sensory restriction as a therapeutic modality in the treatment of psychological disorders began, with the study of its effect on various types of mental illness among people inpatient in psychiatric hospitals. Research into the use of such an environment as a therapeutic
intervention has evolved considerably in the intervening forty years, and has focused primarily on its use in the treatment of addictive disorders. This paper reviews the research bases and effectiveness of Restricted Environmental Stimulation Therapy (REST). REST is a psychotherapeutic practice that places the client in an environment with a drastically reduced level of external stimulation. Research evidence indicates that REST consistently has beneficial effects on medical, psychological, and behavioral health outcomes, particularly when used in conjunction with other therapies.
Smoking cessation
For thirty years research has been conducted on the use of "sensory restriction" as a smoking cessation intervention. About twenty research studies have been conducted. The findings have been consistent: when used by itself, in studies with follow-up periods ranging from 12 months to 5 years, 25% of REST subjects achieved long term abstinence . When REST was combined with other effective smoking cessation treatments (e.g. behavior modification , hypnotherapy ) in studies with follow-up periods ranging from 18 months to 5 years, 50% achieved long term abstinence. In a few clinical studies, one to two years in duration, REST has been combined with weekly support groups. In those instances 75-80% have maintained abstinence for the length of the study . Success rates for REST as an adjunct or complementary therapy are dramatically better than most other available treatments. For example, at the end of one year the success rate of the nicotine patch alone is 5% and combined with behavior modification 20%. Studies of the use of anti-depressants such as Zyban/Wellbutrin for smoking cessation, which show a 40-50% success rate, have not included follow-up data longer than one year and are contra-indicated for a large segment of the crossaddicted population, specifically those with eating disorders. In addition to the non-invasive and brief nature of the REST treatment, two factors distinguish it from others with regard to smoking cessation: its notably low relapse rate and the remarkable characteristic that it lifts physical craving for nicotine, thereby removing the aversive factor of physical withdrawal.
Drug abuse
A University of Arizona study examined chamber REST as a complementary relapse prevention technique with substance abusers enrolled in traditional outpatient substance abuse treatment programs. At the end of 4 years of follow-up 43% remain continuously sober and drug free. None of the control group did so for eight months of follow-up .
Summary
Addiction in its various manifestations, and smoking cessation in particular, have been the focus of the largest body of chamber REST research; about three-fourths of all subjects were exposed to REST as treatment for an addiction/"behavioral disorder". In addition, however, a meaningful body of research has been conducted, over several decades, on the effect of chamber REST in treating a variety of more traditional psychiatric and psychological disorders (e.g., phobias, obsessive compulsive behaviors, anxiety, depression, autism and schizophrenia), as well as chronic pain, stuttering and hypertension. (references available) The "side effects" of REST treatment are often even more dramatic than its effectiveness in achieving explicit behavioral goals. In a group of patients undergoing REST as part of a smoking cessation program, several of the participants reported that their time in the chamber was used to think more deeply than usual about other life problems, and that solutions found as a result of this experience were applied successfully afterward. The list of benefits included an increase in exercise and/or a decrease in caffeine or "fattening food" consumption, and a solution of interpersonal problems, with family members (constant arguments, withdrawal, perceived rejection) and at work (insufficient recognition, failure to assert oneself). A British psychiatrist published a case of unexplained muscular tension, hypertension, neck pain, and generalized anxiety which was positively impacted by a 24-hour chamber REST session. Not only did the patient achieve normal blood pressure and a relief from the somatic symptoms that made medication no longer necessary, he also reported a significant change in his outlook on life. The history of REST research seems to have revealed what traditional cultures knew for thousands of years that solitude and sensory reduction facilitate healing of many disorders. Because REST requires a minimal investment of time, has a paucity of contra-indications, augments the effectiveness of existing treatments and potentiates the effectiveness of other therapeutic interventions, we owe it to those we serve to utilize it as a tool.
In the past decade relaxation training has been one of a number of behavioral approaches to the treatment of chronic pain. Recently, flotation REST (Restricted Environmental Stimulation Therapy), which consists of floating in buoyant liquid kept at skin surface temperature in a soundproof, light-free enclosure, has been used to induce deep states of relaxation and assist in the relaxation training process. This report presents data on patients receiving multimodal treatment for chronic pain, including REST-assisted relaxation training. The patients received individual stressoriented psychotherapy, biofeedback-assisted relaxation training and REST-assisted relaxation training. The use of flotation REST will be discussed through a comparison of the subjective effects of REST relaxation of biofeedback assisted relaxation specifically regarding the perception of pain.
Introduction
Treatment of pain disorders has undergone a refocusing of efforts in recent years. The movement has generally been away from the external management of pain perception through medication or surgery; towards the internal regulation of pain experience through behavioral management,
(Fordyce & Steger, 1979) relaxation training (Turk, Meichenbaum and Genest, 1983) and cognitivebehavioral approaches (Turk, et.el., 1983). These approaches have been used extensively with various pain disorders including chronic, recurrent pain and chronic intractable, benign pain (Turk, et.al., 1983). As mentioned, one component of this treatment approach has been relaxation training. Often the relaxation training is assisted through the use of EMG or thermal biofeedback. The rationale for this is simply that biofeedback provides specific training for physiological processes enhancing the generalized relaxation instructions. In addition biofeedback may provide motivational factors not available in relaxation training alone. The goal of relaxation training is for an individual to be able, through the use of an internalized set of cues, commands, images, phrases or kinesthetic sensations, to alter his or her physiology to a state of reduced output. Any process that assists an individual in experiencing that state may prove useful in a behaviorally oriented chronic pain therapy. Flotation Restricted Environmental Stimulation Therapy (Flotation REST) has been shown to create powerful physiological and subjective relaxation states (Turner & Fine, 1983, Suedfeld, 1983, Jacobs, Heilbronner & Stanley, 1984). This technique involves flotation in a lightproof, sound attenuated chamber containing a thermally constant (94.5 degrees) buoyant (1.28 s.g.) solution of epsom salts and water. Flotation REST in combination with relaxation training, stress management and biofeedback has been used experimentally and clinically for stress related disorders (Jacobs, Kemp, Belden, 1983, Fine & Turner, 1983). This report describes the use of flotation REST as part of a multimodal program for chronic pain.
Methods
Fifteen patients (ten males and five females) were referred to the Behavioral Medicine Clinic of the Medical College of Ohio for a chronic pain disorder by their current attending physician. Eight patients were treated in an outpatient program, seven patients were treated on an inpatient unit. Ten patients had daily, chronic low back pain, three patients had daily chronic shoulder pain, and two patients had chronic headaches at least once per week. The number of years with pain ranged from . 25 to 16 with a mean of 7.3. Patients were treated on the inpatient unit if a) a psychiatric condition (i.e. depression) was considered significant to warrant admission or b) environmental conditions made outpatient treatment unfeasible (length of drive for treatment). Each patient's treatment began with a thorough interview. This interview covers the patient's pain disorder and psychosocial information about the patient. Throughout the treatment process the therapist worked with the patient on significant psychosocial factors as well as relaxation oriented interventions. Treatment consisted of relaxation training (autogenic phrases and/or progressive relaxation) EMG and/or thermal biofeedback, stress oriented psychotherapy and flotation REST. In addition inpatients participated in a milieu therapy program including occupational therapy, group therapy and exercise therapy. After the initial interview session, each patient's psychophysiological baseline was recorded using frontal and/or neck EMG and peripheral temperature measurements. The therapist then instructed the patients how to use a modified autogenic training relaxation exercise for regular home use. Patients then use EMG frontal and/or neck biofeedback during one hour sessions in the clinic. The number of feedback sessions ranged from 6 to 36 with a mean of 13. Actual feedback training is for 25 minutes and the other time is used for psychotherapy. REST was introduced to the patient after the patient maximized the effects of the biofeedback training. REST was introduced to a) increase the depth of the subjective experience of relaxation and b) increase the subjective sense of reduction of pain during relaxation. Procedures for flotation REST involved flotation in the REST chamber either nude or in a bathing suit. During flotation, and after an initial period of silence ranging from 10-25 minutes, a tape recording of the autogenic phrases was played. As treatment sessions progressed some patients were asked to use the phrases without the tape, and some were also given imagery suggestions specific to
their situation. REST sessions were between 40 and 60 minutes long, the length chosen by the patient. The number of REST sessions varied from 2 to 18 with a mean of 7. Patients rated their pain experience using a scale of 0-6 on pain log sheets. Patients rated the depth of relaxation achieved on a scale of 0-10 in a follow-up interview.
Results
The results presented here are taken from the patients' clinical records at the end of treatment and a follow-up conducted at least three months post treatment except for two patients still in long term treatment. For the 13 patients with chronic intractable benign pain there was a difference in intensity but no differences in frequency or duration of pain after treatment. For the two patients with chronic recurrent pain, all three subjective pain rating measures changes. (See Table 1). Twelve patients stated that they regularly used relaxation to affect their pain, and were able to reduce it. Patients subjectively rated the REST relaxation as more relaxing and more pain relieving than the Biofeedback Assisted Relaxation (Fig. 1). Patients were asked to rate whether or not they became pain free during biofeedback or REST. Eight patients rated themselves as pain free after REST, one patient rated himself as pain free after biofeedback and 2 patients did not become pain free (Table 2). Twelve patients were not able to work because of their pain. Three of these patients are now working and one is being retrained for a less physically stressful career. Table 1: Subjective Reports of Pain Pre/Post Treatment Intensity Pre 1 Post 1 CIBP + CRP* N = 15 4.3 3.57 P<.10 SIG (F=4.15,dF1,14) Frequency CIBP N = 13 Daily Daily CRP N = 2 3/Week 2/Month Duration CIBP N = 13 Constant Constant CRP N = 2 18 Hours 6 Hours *Chronic Intractable Benign Pain & Chronic Recurrent Pain Table 2: Patients Experiencing Total Remission of Pain During Relaxation REST Biofeedback Both 812
Discussion
This clinical, preliminary report examined the efficacy of REST in a multimodal program for chronic pain. Numerous reports have already established the use of relaxation training as an appropriate component of this treatment (reviewed Turk, et. al., 1983). Previous reports have show REST to be more physiologically and subjectively relaxing than relaxation training alone (Turner and Fine, 1983, Jacobs, et.al., 1984). In this report relaxation was assisted by both EMG biofeedback and flotation REST. Both were reported as effective in assisting the patients in relaxation, with patients reporting that REST was significantly more relaxing than Biofeedback. In addition, more patients were able to experience periods of complete remission of pain with REST than with biofeedback. Patients in this treatment program reported a small but significant decrease in average subjective pain experience during follow-up. Although the chronic intractable benign pain patients did not report a decrease in the frequency or duration of pain, they did regularly use relaxation as an intervention of the pain. The patients stated that they felt that their relaxation skill was important in their ability to live with their pain.
The mechanism through which flotation REST reduces pain experience is unknown. The buoyancy of the solution may provide a more supportive environment than the typical relaxation chair, allowing deeper muscle relaxation. The reduction of environmental stimulation may allow the person to better attent to previously ignored tension in the muscles, further enhancing relaxation. The lack of environmental stimulation may disrupt a cognitive component of pain by eliminating environmental cues normally associated with pain. A recent preliminary report (Turner & Fine, 1984) has indicated that the subjective effects of flotation REST can be affected by the narcotic antagonist Naloxone. This suggests that REST either increases endogenous opiod production or heightens sensitivity to existing opiod levels. This may be biochemical aspect of the subjective pain reduction. Many of the pain patients treated expressed a desire to have a flotation REST chamber at home. For patients with chronic intractable benign pain secondary to injury, this may be a cost effective alternative that would increase their overall level of functioning, and help reduce or eliminate pain medication. In summary, this report demonstrates that relaxation training was an effective tool for reducing the subjective intensity of pain for all of the patients studied. Both Biofeedback and REST were perceived as helpful in the relaxation process, although REST was seen as significantly more powerful in affecting relaxation than Biofeedback. More pain free periods followed REST relaxation than Biofeedback assisted relaxation. Despite some methodological weakness, this report is strongly suggestive of an important role for REST in the treatment of chronic pain. Jacobs, G., Heilbronner, R., and Stanley, J. The Effects of Short-Term Flotation REST on Relaxation: A Controlled Study. Health Psychology, 1984, 3, 99-112. Jacobs, G., Kemp, J., and Belden, A. A Preliminary Clinical Outcome Study On A Hospital-Based Stress Management Program Utilizing Flotation REST and Biofeedback. Unpublished manuscript. Fine, T.H. and Turner, J.W., Jr. The Effects of Brief Restricted Environmental Stimulation Therapy in the Treatment of Essential Hypertension. Behavior Research and Therapy, 20, 567-70, 1982. Fordyce, W. and Steger, J. Chronic Pain in Pomerleau, O.F., and Brady, J.P. Behavioral Medicine: Theory and Practice, Baltimore: Williams and Wilkins, 1980. Turk, D., Meichenbaum, D., Genest, M. Pain and Behavioral Medicine. New York, Guilford, 1983. Turner, J.W., Jr. and Fine, T.H. Effects of Relaxation Associated with Brief Restricted Environmental Stimulation Therapy (REST) on Plasma Cortisol, ACTH, and LH. Biofeedback and Self-Regulation, 1983, 8, 115-126. Turner, J.W. and Fine, T.H. Naloxone and Restricted Environmental Stimulation Therapy. Presented at the 15th Annual Meeting of the Biofeedback Society of America, Albuquerque, 1984.
Epsom Salt
Many years ago Epsom Salt was the most popular medical drug in England. The people who used it didn't know exactly why it was so beneficial. They knew nothing of its antiseptic and restorative qualities, but they did understand that in some way it was good for health and promoted longevity. They found by experience that not only did it keep away sclerosis, kidney diseases and rheumatism, but that it was also very useful in correcting any tendency to put on too much weight. Epsom Salt is now made from a rock substance called Dolomite, which is found abundantly in, and derives its name from, a mountainous district in the South Tyrolean Alps called "The Dolomites". This Dolomite rock belongs to a very large group of substances known as 'salts', in which an alkaline base is combined with an acid radical to form a neutral substance (the 'salt'). It consists of two metals, calcium and magnesium, combined with two non-metallic elements, carbon and oxygen, and takes the form of a neutral double salt known as carbonate of calcium and magnesium. Epsom Salt is also a 'salt' but instead of being made of magnesium, oxygen and carbon, as is the case with the carbon salt, its constituents are magnesium, oxygen and sulphur. Chemically it is known as magnesium sulphate. Magnesium sulphate is not found in a natural state, so it has to be made artificially from some suitable magnesium containing substance. The substance best suited for
Summary
Restricting stimulation from the environment has been shown to alter psychological and physiological states. The present study of 27 healthy subjects examines the effects of restricted environmental stimulation technique (REST) on plasma levels of cortisol and variability in plasma cortisol levels across repeated REST sessions.
The REST environment consisted of a 1.2 X 1.2 X 2.4-m ovoid chamber containing 25 cm of saturated MgSO, solution (sp gr 1.28) maintained at 34.5OF. The buoyant supinely floating subject experienced a minimum of light, sound, and temperature awareness and spatial orientation. The non-REST environment was a cushioned reclining chair in a quiet dimly lit room. The 5wk protocol consisted of four visits for blood sampling during a 2-wk baseline followed by eight REST or non-REST sessions, 40 min each, with blood samples taken on four nonsession days between sessions 5 and 8. Variability in plasma cortisol was expressed in terms of standard deviation. REST was associated with across-session decreases of 21.6% in plasma cortisol and 50.5% in plasma cortisol variability, whereas no changes in these measures occurred in non-REST. It is concluded that REST influences both static and dynamic aspects of adrenocortical function, possibly altering the feedback monitoring of plasma cortisol.
Introduction
Increased levels of plasma cortisol in humans have been reported in association with a variety of psychological and physiological stress conditions (13, 16). Conversely, decreases in blood pressure (BP) (3, 7) and plasma levels of several hormones, including cortisol(22) and aldosterone and renin activity (12), have been reported in association with repeated brief exposure to a sensorily restricted environment. One version of this condition is flotation REST (restricted environmental stimulation technique), in which the individual lies supinely in thermoneutral buoyant fluid with minimized photic, auditory, and tactile stimulation (9, 19).
To date, studies of the relationship of restricted sensory input to physiological activity have been limited to point-in-time measurements of given parameters, which give little information on the dynamics of the system. One possible dynamic measure of a system is the variability of its measured parameters (6, 15), and standard deviation (SD) around mean values for a given parameter is a statistic that describes such variability. The involvement of central nervous mechanisms in the dynamic regulation of physiological systems has been evidenced in several studies of BP regulation. Increased variability in mean arterial BP has been demonstrated in several species after disconnection of baroreceptor input to BP regulation (2, 11, 21). Because flotation REST (henceforth, REST) greatly attenuates the input of sensory information about light, sound, kinesthetics, and temperature, it was of interest to assess the possible impact of REST on dynamic aspects of physiological regulation. Plasma cortisol was chosen as the monitored parameter for the present study on the bases that REST effects on the activity of this hormone have been previously demonstrated (8,15) and feedback regulation of plasma cortisol has been well researched. In this study the effect of brief repeated REST on plasma levels of cortisol and their variability is examined. The study is designed to minimize the amount of protocol-related disruption that subjects experienced in their normal daily life.
plasma cortisol over 20 min were unlikely under these conditions (1,27). The overall difference between a and b samples was 7.8%, and a and b samples for each session were pooled. Because of potential effects of meals on cortisol release, all subjects were instructed to eat their regular breakfast and not to eat lunch until after the blood sampling session on sampling days. For each treatment session the subject undressed, showered briefly, experienced REST or non-REST for 40 min, showered again (REST only), dressed, and departed. Average total session time was 70 min. Subjects were encouraged to discuss a given session when it was over and were requested to report any unusually stressful experience during the study. A brief subjective report questionnaire was completed by each subject after each treatment phase session.
RESULTS
Plasma cortisol data are presented in Fig. 1. These data were subjected to two-way repeatedmeasures analysis of variance. Hypothesis testing for cortisol data was accomplished with the parametric Tukeys test and F test (18). There were no differences among sessions within baseline or among monitored sessions within treatment in either the REST or non-REST groups. In other words, plasma cortisol levels did not change significantly during baseline or during the portion of treatment that was monitored in either REST or non-REST. Plasma cortisol values in REST treatment were lower (P < 0.05, Tukeys test) than in REST baseline, non- REST baseline, and nonREST treatment. Cortisol values in the latter three were not different. The mean cortisol level (across sessions and subjects) was 11.29 t 0.37 (SE) pgldl in REST treatment and 14.21 t 0.82 in REST baseline. As a dependent variable in this study, variability refers to the classical statistical definition of measures of dispersion and is reported as SD, which is the square root of the variance iN SD= \/C (Xi-X)2/N-i V i=l For each subject, SD was calculated across samples for baseline (4 cortisol values) and treatment (4 cortisol values). These individual SD values were then averaged across subjects in baseline or in treatment to yield SD values as follows: REST baseline, REST treatment, non- REST baseline, and non-REST treatment. To account for the possibility that lower SD values in a given condition were simply the consequence of plasma cortisol values being lower, the coefficient of variation (SD/Z 100) was determined for each SD. Plasma cortisol variability, reported as SD and as coefficient of variation (Table l), was subjected to statistical analysis. Although parametric statistics are normally more robust than nonparametric statistics, the latter do not require normalcy of distribution and equal variances in the sample populations to be compared. Because it was hypothesized that variability could be influenced by TABLE 1. Effect of repeated brief REST on variability of plasma cortisol values REST (n = 15) Non-REST (n = 12) Baseline Treatment Baseline Treatment Plasma cortisol, cLg/dl SD CV 14.21 11.29 13.77 14.14 3.86 1.91* 3.51 3.77 29.86 18.56* 26.85 30.06 n, No. of subjs. Values were calculated for 4 samples from each subject and then averaged across subjects in each group. REST, restricted environmental stimulation technique; SD, standard deviation; CV, coeff of variation [(SD of cortisol value/cortisol value) X 1001. * Different from Baseline (P < 0.005, Wilcoxon matched pairs test). 2012 RESTRICTED ENVIRONMENTAL STIMULI AND PLASMA CORTISOL treatment in this study, data were tested for significant differences by a nonparametric test. The SD and coefficient of variation were 50.5 and 37.9%, respectively, lower in REST treatment than in REST baseline, and the changes in both parameters were significant (P < 0.005, Wilcoxon matched pairs test). In the non-REST group there was no difference in either SD or coefficient of variation between baseline and treatment. Eighty-seven percent of the REST subjects showed decreased plasma cortisol across sessions, and 93% showed decreased SD for cortisol. A Pearson correlation was performed on REST group data, comparing acrosssession percent change in plasma cortisol with acrosssession percent change in the SD of plasma cortisol. These changes were not correlated (r = 0.12; NS, P > 0.05, df = 13). DISCUSSION Both the concentration and the variability in concentration of cortisol in plasma were decreased across sessions in the REST group, whereas no changes occurred in the non-REST group. These data suggest a RESTspecific effect on the activity of the adrenal cortex or the clearance of cortisol or both. The present study does not differentiate between these possibilities. Although the
metabolic clearance rate (MCR) for cortisol has been shown to increase 19-30% after exogenous pharmacological- dose ACTH administration (27), it appears unlikely that cortisol clearance changes significantly in unstressed individuals (1, 20). In the present study of unstressed healthy subjects, mean plasma cortisol decreased 21.6%. The decrease in plasma cortisol levels was not surprising, because previous studies have demonstrated decreased plasma cortisol across REST sessions in normal subjects (22). The decrease in variability around the mean value of plasma cortisol from baseline to treatment in the REST group, but not in the non-REST controls, suggests that the conditions of REST can influence the dynamic state of cortisol regulation. The coefficient of variation data demonstrate that the decrease in variability is not due simply to smaller SD values accompanying smaller absolute cortisol values. In fact, the results of the Pearson correlation show that changes in plasma cortisol and changes in the SD of mean plasma cortisol were not significantly correlated. This suggests that the effects of REST on absolute cortisol levels can occur independently of the REST effects on the variability of cortisol levels. It is known that cortisol exhibits episodic pulsatile release (8), with considerable variation occurring within and between individuals (10,25). Also, it has been shown that there is a cortisol peak associated with mealtimes (4). These factors may have contributed a significant noise component to the variance data. However, it appears that the REST effect was robust enough to have a discernible impact on variability, because SD values were decreased across treatment in REST but not in non- REST. Sampling was too infrequent in the present study to determine whether changes in pulse frequency or pulse height were associated with REST. A large number of blood samples taken 15-20 min apart would be necessary for analysis of pulsatile release characteristics (23, 24). Such analysis would require the use of an in-line venous catheter. This approach was not chosen for this study, because it precluded assessment of the effect under normal circumstances. The present study was designed to minimize the amount of disruption that subjects experienced in their normal daily life. This was done to monitor the dynamic physiological system across time under natural everyday conditions. A more radical monitoring such as in-line blood sampling over many hours might confound the interpretation of the treatment effect. Although the control condition could potentially obviate this problem, there is the possibility that the stress associated with extended intravenous monitoring would wash out the REST effect. The present study is, to our knowledge, the first report of external environmental conditions influencing the variability of plasma cortisol levels. In the conceptual framework of cybernetic theory, variability is one measure of the dynamic state of a negative feedback loop (15, 26). Plasma cortisol is one component of an integrated negative feedback loop. Thus plasma cortisol variability is one reflective measure of the dynamics of physiological regulation. In the present controlled study, the intervention (REST) was associated with a change in plasma cortisol levels and variability over time; i.e., REST influenced both the total output and the dynamics of the physiological system. This result is consistent with other studies in which variability in a measured parameter was influenced by a central nervous systemmediatedintervention. For example, Cowley et al. (2) observed increased variability in mean arterial pressure after BP baroreceptor disconnection in dogs, various mental and physical stressors have been shown to influence BP variability in humans (5,17), and Porges (14) reported decreased variability in heart rate in association with increased attention to a reactiontime task. It should be noted that these studies examined immediate response dynamics, whereas the present study examined longer-term dynamics. It has previously been reported that repeated REST can be associated with cortisol changes that persist for days beyond the REST sessions (22). Likewise, REST effectiveness in BP reduction in essential hypertensives may continue for weeks to months beyond cessation of treatment (3, 12). This raises the possibility that REST may contribute to reorganization of set points for the operation of physiological feedback loops. The cortisol variability data in the present study are consistent with such a hypothesis, although they do not address either the mechanism by which REST affects plasma cortisol levels or whether REST specifically facilitates or improves feedback regulation of plasma cortisol levels. Address for reprint requests: J. W. Turner, Jr., Dept. of Physiology and Biophysics, Medical College of Ohio, 3000 Arlington Ave., Toledo, OH 43699-0008. Received 21 February 1990; accepted in
final form 20 December 1990. REFERENCES 1. BAILEY, E., AND H. F. WEST. The secretion, interconversion and catabolism of cortisol, cortisone and some of their metabolites in man. Acta Endocrinol. 62: 339-359, 1969. 2. COWLEY, A. W., JR., J. F. LIARD, AND A. C. GUYTON. Role of the RESTRICTED ENVIRONMENTAL STIMULI AND PLASMA CORTISOL 2013 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. baroreceptor reflex in daily control of arterial blood pressure and other variables in dogs. Circ. Res. 32: 564-576, 1973. FINE, T. H., AND J. W. TURNER, JR. The effect of brief restricted environmental stimulation therapy in the treatment of essential hypertension. Behau. Res. Ther. 20: 567-570, 1982. FOLLENIUS, M., G. GRANDENBERGER, B. HIETTER, M. SIMEONI, AND B. REINHARDT. Diurnal cortisol peaks and their relationship to meals. J. CZin. Endocrinot. 55: 757-761, 1982. HATCH, J. P., K. KLATT, S. W. PORGES, L. SCHROEDER-JASHEWAY, AND J. D. SUPIK. The relationship between rhythmic cardiovascular variability and reactivity to orthostatic, cognitive, and cold pressor stress. PsychophysioLogy 23: 48-56, 1986. HOUK, J. C. Control strategies in physiological stems. FASEB J. 2: 97-107,1988. JACOBS, G., R. HEILBRONNER, AND J. STANLEY. The effects of short term flotation REST on relaxation: a controlled study. HeaZth Psychol. 3: 99-111, 1984. KRIEGER, D. T. Rhythms in CRF, ACTH and corticosteroids. In: Endocrine Rhythms, edited by D. T. Kreiger. New York: Raven, 1979. LILLY, J. The Deep Self. New York: Simon & Schuster, 1977. LINKOWSKI, P., J. MENDLEWICZ, M. KERKHOFS, R. LECTERCZ, J. GOLDSTEIN, M. BRASSEUR, G. COPINSCHI, AND E. VANCAUTER. 24 Hour profiles of adrenocorticotropin, cortisol and growth hormone in major depressive illness: effect of antidepressive treatment. J. Clin. Endocrinol. Metab. 65: 141-152, 1987. MANCIA, G., A. FERRARI, L. GREGORINI, G. PARATI, G. POMIDOSSI, G. BERTINIERI, G. GRASSI, M. DIRIENZO, A. PEDOTTI, AND A. ZANCHETTI. Blood pressure and heart rate variabilities in normotensive and hypertensive human beings. Circ. Res. 53: 96-104, 1983. MCGF~ADY, A., J. W. TURNER, JR., T. H. FINE, AND J. T. HIGGINS. Effects of biobehaviorally-assisted relaxation training on blood pressure, plasma renin, cortisol, and aldosterone levels in borderline essential hypertension. CZin. Biofeedback Health 10: 16-25, 1987. MUNCK, A., P. M. GUYRE, AND N. J. HOLBROOK. Physiological functions of glucocorticoids in stress and their relation to pharmacological actions. Endocr. Rev. 5: 25-44, 1984. PORGES, S. W. Heart rate variability and deceleration as indexes of reaction time. J. EXD. PsvchoZ. 92: 103-110. 1972. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. SCHWARTZ, G. Disregulation theory and disease: applications to the repression/cerebral disconnection/cardiovascular disorder hypothesis. Int. Rev. AppZ. Psychol. 32: 95-118, 1983. SELYE, H. Stress in Health and Disease. Boston, MA: Butterworths, 1976, p. 1256. SLEIGHT, P. The influence of arterial baroreceptors in man on the variability of blood pressure and plasma catecholamines in man. Chest 83: 320-322, 1983. SNODGRASS, J. The Numbers Game: Statistics for Psychology. New York: Oxford University Press, 1977. SUEDFELD, P. Restricted Environmental StimuZation: Research and CZinicaZ Applications. New York: Wiley, 1980. TAIT, J. F., AND S. BURSTEIN. In: The Hormones. edited by G. Pincus, K. V. Thimann, and E. B. Astwood. New York: Academic, 1964, p. 441. TRAPANI, A. J., K. W. BARRON, AND M. J. BRODY. Analysis of hemodynamic variability after sinoaortic denervation in the conscious rat. Am. J. Physiol. 251 (Regulatory Integrative Comp. Physiol. 20): Rll63-Rl169, 1986. TURNER, J. W., JR., AND T. H. FINE. Effects of relaxation associated with brief restricted environmental stimulation therapy (REST) on plasma cortisol, ACTH, and LH. Biofeedback SeZf-Regul. 8: 115-126, 1983. VANCAUTER, J. E. Method for characterization of 24hr temporal variations of blood components. Am. J. Physiol. 237 (Endoqrinol. Metab. Gastrointest. Physiol. 6): E255-E264, 1979. VANCAUTER, J. E. Estimating false-positive and false-negative errors in analysis of hormonal pulsatility. Am. J. Physiol. 254 (Endocrinol. Metab. 17): E786-E794, 1988. WEITZMAN, E. D., D. FUKUSHIMA, C. NAGEIRE, H. ROFFWARG, T. F. GALLAGER, AND L. HELMAN. Twenty-four hour pattern of the episodic secretion of cortisol in normal
subjects. J. CZin. Endocrinol. Metab. 33: 14-22, 1971. WIENER, N. Cybernetics or Control and Communication in the Animal and Machine. Cambridge, MA: MIT Press, 1948. ZIPSER, R. D., P. F. SPECKART, P. K. ZIA, W. A. EDMISTON, F. Y. K. LAU, AND R. HORTON. The effect of ACTH and cortisol on aldosterone and cortisol clearance and distribution in plasma and whole blood. J. CZin. Endocrinol. Metab. 43: 1101-1109, 1976.
Thomas H. Fine is an Associate Professor in the Department of Psychiatry of the Medical College of Ohio. He began his research and clinical work with Biofeedback in 1975, and, with John Turner, initiated the Restricted Environmental Stimulation Therapy research program at MCO in 1978. Roderick A Borrie, Ph.D. is a Clinical Psychologist at South Oaks Hospital, Amityville, New York. He began his exploration of therapeutic uses of Restricted Environmental Stimulation Therapy at the University of British Columbia with Dr. Peter Suedfeld, and continues to use it in current work with patients suffering chronic pain and illness.
Introduction
Restricted Environmental Stimulation Therapy (REST) has fascinated many researchers, clinicians, and explorers of consciousness, promising something special - a powerful transformation, a mystical peak experience, an intense change in biochemicals, improved performance, or a healing of our ills. Beyond the fascination, Flotation REST has established itself as a unique method in the field of applied psychophysiology. Flotation REST has proven to be a technique with predictable psychophysiological effects and powerful clinical and performance applications. This article will provide the reader with an introduction to the basic research into Flotation REST's psychophysiological effects, and a brief overview of the clinical and performance applications currently in use by REST clinicians and researchers. The article will examine in greater detail the use of Flotation REST as an intervention for chronic pain. REST is an acronym for Restricted Environmental Stimulation Technique, a name developed in the late 1970s by Peter Suedfeld and Roderick Borrie for a technique that had previously been called Sensory Deprivation (SD) or Sensory Isolation. Since much of the early SD research had been misinterpreted, especially by writers of introductory psychology texts, a widely accepted myth developed that SD environments were highly stressful, even models for producing psychotic like experiences. This led to difficulties with the Sensory Deprivation concept. Ultimately Suedfeld and Borrie proposed that, since the process involves restricting the environmental stimulation that the patient or subject experiences, REST would be a more accurate and less provocative acronym. Flotation REST is a special type of REST popularized by John C. Lilly, M.D. Lilly developed an immersion system in the late 1950s at that was used in early SD experiments. In the 1960s he developed a flotation system in which a person floats in a light free, sound reduced chamber in a highly concentrated solution of Epsom Salt and water maintained at a constant temperature of 9,4.5 F (Lilly, 1977, p. 118). Both Wet and Dry REST systems have been utilized in research and practice. Wet-REST systems utilize flotation in salt water, and Dry-REST systems utilize a modified REST environment in which a pliable 15 mm. polymer membrane separated the floater from the fluid (Turner, Gerard, Hyland, Neilands, & Fine, 1993). At the Medical College of Ohio, John Turner and I conducted a series of studies investigating the psychophysiological effects of brief sessions of Flotation REST. The REST environment used in all of these studies was a plastic or fiberglass chamber, approximately 1.1 m. x 1.3 m. x 2.5 m. filled to a 25 cm. depth with saturated epsom salts (Mg SO) solution having a specific gravity of 1.28 and
temperature maintained at 34.5 C. The chamber was light-free and the sound level was less than 10 decibels, with further attenuation due to submersion of the ears in the solution. The general protocol consisted of 30-40 minute sessions repeated approximately every third day with a total number ranging from 4 to 20 sessions per study. The first parameter we addressed was the subjective report of the REST experience. We utilized several indices of subjective reports including the Spielberger state anxiety scale, Zuckerman multiple affect adjective checklist (Turner & Fine, 1990a), profile of mood states (POMS) (Turner, Fine, Ewy, Sershon, & Frelich, 1989), and subjective rating scales of emotion and relaxation. All of the initial studies found marked pre-post and across-session changes indicating relaxation, an increase in positive emotion and a decrease in negative emotions. In addition, an analysis of well over 1,000 descriptions of the REST experience indicated that more than 90% of subjects found REST deeply relaxing.
all pain during flotation, and that this spontaneous anesthesia could remain for up to several hours after the session. Unfortunately, as with many bio-behavioral treatment approaches, the large scale controlled trials have yet to be undertaken.
the overall mean of 31%, except the upper back, which showed a 63.6% pain reduction, the arms which showed a 48.2% reduction, and the legs, which showed a 15.3% pain reduction. The duration of relief varied from two hours to seven days. A second set of data came from a survey mailed to patients who had completed the program. The questionnaire asked patients to assess how much pain relief they received from the various components of the pain program (Flotation, relaxation training, and counseling) and from other treatments they had received medication (pills and shots), physical therapy, chiropractic, and surgery. Short-term pain relief, long-term pain relief, relief from anxiety or stress, and relief from depression were indicated separately. Additionally, they were asked whether each treatment improved their outlook and/or helped them cope with their pain. All 27 respondents had received treatments other than those from this pain program: 81% had used pain medications; 56% had had some form of pain injections; 70% had received physical therapy; 59% had received chiropractic treatment; 22% had undergone surgery. These patients reported more short-term and long-term pain relief from flotation than from the other therapeutic modalities. For non-pain symptoms, the comparisons were even more striking. Patients reported far more relief from anxiety and stress from flotation than any other modality. For depression, flotation was equal to counseling at near 70%, with relaxation training at 53% and physical therapy and medication at 20%. Patients also claimed to have reaped a variety of other benefits from flotation, reporting improvements in sleep (65%), mental concentration (77%), energy (46%), interpersonal relationships (54%), ability to work (35%), ability to cope with pain (88%), ability to cope with stress (92%), and feelings of well-being (65%) resulting from flotation REST. In answering the question, "Did this treatment improve your outlook toward your pain?" 96% responded positively for flotation, 100% for counseling, 100% for relaxation training, 50% for physical therapy, 24% for pain pills, 17% for pain shots, 15% for chiropractic. To the question, "Did this treatment help you cope effectively with your pain?" 96% responded positively for flotation, 92% for both relaxation training and counseling, 50% for pain shots, 44% for pain injections, 38% for physical therapy, and 17% for chiropractic. It is clear that flotation was rated on average as more effective than other treatments with respect to pain, anxiety and depression relief.
can produce an immediate elevation in mood, probably due to the mood enhancing effects of deep relaxation as well as the optimism that occurs with the experience of physical relief. When depression is the primary diagnosis, flotation is best used as an adjunct to counseling and then only after the patient has gained a modicum of feeling in control. Caution is necessary in administering REST with depressed patients due to the often obsessive nature of negative thinking that will continue during the REST session. Once these patients have developed a better understanding of their disorder, flotation REST can be a mood elevator that speeds the course of therapy, especially when combined with positive guided imagery during the sessions.
References
Fine, T.H., & Turner, J.W., Jr. (1983). The Use of Restricted Environmental Stimulation Therapy (REST) in the Treatment of Essential Hypertension, First International Conference on REST and Self-Regulation, 136-143. Fine, T.H. & Turner, J.W., Jr. (1985). Rest-assisted relaxation and chronic pain. Health and Clinical Psychology, 4, 511-518. Goldstein, D.D. & Jessen, W.E. (1987). Flotation Effect on Premenstrual Syndrome. Restricted Environmenntal Stimulation: Research and Commentary, 260-273. Lilly, J.C. (1977). The deep self. New York: Simon & Schuster. McGrady, A.V. Turner, J.W. Jr. Fine, T.H. & Higgins, J.T. (1987). Effects of biobehaviorallyassisted relaxation training on blood pressure, plasma renin, cortisol, and aldosterone levels in borderline essential hypertension. Clinical Biofeedback & Health, 10(1), 16-25. Rzewnicki, R. Alistair, B.C. Wallbaum, Steel, H. & Suedfeld, P, (1990). REST for muscle contraction headaches: A comparison of two REST environments combined with progressive muscle relaxation training. Restricted Environmental Stimulation: Research and Commentary, 245254. Turner, J.W. Jr. DeLeon, A. Gibson, C. & Fine, T. (1993). Effects of Flotation REST on range of motion, grip strength and pain in rheumatoid arthritics. In A. Barabasz & M, Barabasz (Ed.), Clinical and experimental restricted environmental stimulation (pp. 297- 336). New York: SpringerVerlag. Turner, J.W. Jr. Fine, T.H. (1983). Effects of relaxation associated with brief restricted environmental stimulation therapy (REST) on plasma cortisol, ACTH, and LH. Biofeedback and Self-Regulation, 9, 115-126.
Turner, J.W. Jr. & Fine, T.H. (1990a). Hormonal changes associated with restricted environmental stimulation therapy. In P. Suedfeld, J. Turner, & T. Fine (Eds.), Restricted environmental stimulation theoretical and empirical development in flotation REST (pp. 71-92). New York, NY: SpringerVerlag. Turner, J.W. Jr. & Fine, T.H. (1991). Restricting environmental stimulation influences variability and levels of plasma cortisol. Journal of Applied Physiology, 70(5), 2010-2013. Turner, J.W. Jr. Fine, T. Ewy, G. Sershon, P. & Frelich, T. (1989). The presence or absence of light during flotation restricted environmental stimulation: Effects on plasma cortisol, blood pressure and mood. Biofeedback and Self-Regulation, 14, 291-300. Turner, J.W. Jr. Gerard, W. Hyland, J. Neilands, P. & Fine, T.H. (1993). Effects of wet and dry flotation REST on blood pressure and plasma cortisol, In A. Barabasz & M. Barabasz (Ed,), Clinical and experimental restricted environmental stimulation (pp. 239-248). New York: Springer-Verlag.
Digestive system
It's common to have a stomachache or diarrhea when you're stressed. This happens because stress hormones slow the release of stomach acid and the emptying of the stomach. The same hormones also stimulate the colon, which speeds the passage of its contents. Chronic hormone-induced changes can increase your appetite and put you at risk of weight gain.
Immune system
Your immune system is a complex balancing act between components that operate as an all-purpose emergency crew and more specialized components that deal with specific disease agents. The immune system, like the hormone system, evolved so that it could quickly deal with physical threats. Indeed, cortisol is one factor that prompts the system to reprioritize its tasks. These shifting priorities are essential for priming the immune system to respond quickly to injuries, like creating inflammation around a bite or puncture wound, but these changes are not beneficial in the long run. When you experience chronic stress, some features of your immune system may remain suppressed, making you susceptible to infections. Other features of the immune system may be permitted to run unchecked, increasing your risk of autoimmune diseases, in which your immune system attacks your body's own healthy cells. Stress may also worsen the symptoms of an autoimmune disease. For example, stress can trigger lupus flare-ups.
Nervous system
Certain byproducts of cortisol act as sedatives, which can contribute to an overall feeling of depression. If your fight-or-flight response never shuts off, the stress hormones may contribute to persistent and severe depression, as well as feelings of anxiety, helplessness and impending doom. Such stress-induced depression often results in sleep disturbances, loss of sex drive and loss of appetite. It also may make you more vulnerable to developing certain personality or behavioral disorders. Studies also suggest that chronic activation of stress hormones may alter the operation and structure of brain cells that are critical for memory formation and function.
Cardiovascular system
Chronic activation of stress hormones can raise your heart rate and increase your blood pressure and blood lipid (cholesterol and triglyceride) levels. These are risk factors for both heart disease and stroke. Cortisol levels also appear to play a role in the accumulation of abdominal fat, which gives some people an "apple" shape. People with apple body shapes have a higher risk of heart disease and diabetes than do people with "pear" body shapes, in which weight is more concentrated in the hips.
Other systems
Stress worsens many skin conditions such as psoriasis, eczema, hives and acne and can trigger asthma attacks.
Life experiences may increase your sensitivity to stress as well. Strong stress reactions sometimes can be traced to early environmental factors. People who were exposed to extremely stressful events as children, such as neglect or abuse, tend to be particularly vulnerable to stress as adults.
Managing stress
Stressful events are a fact of life, but you can take steps to manage the impact these events have on you. You can learn to identify what stresses you out, how to take control of some stress-inducing circumstances, and how to take care of yourself physically and emotionally when you face events you can't control. These strategies can include exercise, relaxation techniques, healthy nutritional choices, social support networks and professional psychotherapy. The payoff of managing stress is peace of mind and perhaps a longer, healthier life. www.mayoclinic.com