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    The Psychology of Tension Myositis Syndrome (TMS)

All the passages below are taken from the book “Healing Back Pain: The Mind-Body Connection” by John E. Sarno, M.D. It was published in 1991.

The Psychology of TMS

Neck, shoulder and back pain syndromes are not mechanical problems to be cured by mechanical means. They have to do with people’s feelings, their personalities and the vicissitudes of life. If this is true, the conventional management of these pain syndromes is a medical travesty. Traditional medical diagnoses focus on the machine, the body, while the real problem seems to relate to what makes the machine work—-the mind. TMS is characterized by physical pain but that acute discomfort is induced by psychological phenomena rather than structural abnormalities or muscle deficiency. This is an exceedingly important point; and just how this works will be clarified in the pages to follow. But first a few definitions to be sure that the terms are clear.

TENSION

Tension is a word that is widely used and means different things to different people; in my work and in this book the disorder is called the Tension Myositis Syndrome. The word tension is used here to refer to emotions that are generated in the unconscious mind and that, to a large extent, remain there. These feelings are the result of a complicated interaction between different parts of our minds and between the mind and the outside world. Many of them are either: unpleasant, painful or embarrassing, in some way unacceptable to us and/or society, and so we repress them. The kinds of feelings referred to are anxiety, anger and low self-esteem (feelings of inferiority). They are repressed because the mind doesn’t want us to experience them, nor does it want them to be seen by the outside world. It is likely that, if given a conscious choice, most of us would decide to deal with the bad feelings; but as the human mind is presently constituted, they are immediately and automatically repressed—-one has no choice.

To sum up, the word tension will be used here to refer to repressed, unacceptable emotions.

STRESS

The word stress is often confused with tension and seems to stand for anything that is emotionally negative. I like to use it to refer to any factor, influence or condition that tests, strains or in any way puts pressure on the individual. We can be stressed physically or emotionally. Excessive heat or cold are physical stressors; a demanding job or family problems are emotional ones. The stress involved in TMS leads to emotional reactions that are repressed.

The work of Dr. Hans Selye is credited with first drawing attention to how stress affects the body; his research and writing were prolific and stand as one of the major accomplishments of medicine in the twentieth century. Dr. Selye’s definition of biological stress is: “the nonspecific response of the body to any demand made upon it.”

Stress can be either external or internal to the individual.

Examples of external stress are your job, financial problems, illness, change of job or home, caring for children or parents. However, the internal stressors appear to be more important in the production of tension. These are one’s own personality attributes, like conscientiousness, perfectionism, the need to excel, and so forth. People often say that they have a very stressful job and that’s why they’re tense. But if they weren’t conscientious about doing a good job, if they weren’t trying to succeed, achieve and excel, they wouldn’t generate tension. Often such people are highly competitive and determined to get ahead. Typically, they are more critical of themselves than others are of them.

A homemaker and mother with a similar personality stresses herself in the same way as someone in the work world, but the focus of her concerns is the family. She worries about her children, her husband, her parents. She wants the best for everyone and will do everything in her power to bring it about. She may also tell you that it is important to her that everyone like her, that she gets very upset if she feels that anyone is displeased with her. (This compulsion to please is, of course, not limited to women; a middle-aged man expressed identical sentiments in my office recently.)

Stress, then, is outside what one might call the inner core of the emotional structure and is composed of the stresses and strains of daily life and, more importantly, aspects of one’s own personality. And stress leads to tension (repressed, unacceptable feelings). Now let’s take a closer look at the personality.

THE CONSCIOUS MIND

The part of your personality that you’re aware of resides in the conscious mind; it is the realm of emotions you can feel. You feel sad, glad, exhilarated, depressed; you also know that you are conscientious, hardworking, a worrier, perhaps compulsive and perfectionistic. You may realize that you are often irritable or you’re aware of having a need to assert yourself. A man may have strong feelings of masculine superiority and be aware of it, indeed proud of it. These make up the conscious you and they seem to determine what we do in life and how we conduct ourselves. But do they? Often these outward characteristics reflect inner drives of which we may be totally unaware, so it is important to look at the subconscious mind, as we shall do in a moment.

Many people with TMS are aware of possessing conscientious personality characteristics. They often refer to themselves as Type A people, after the work of Dr. Meyer Friedman and Dr. Ray Rosenman, who described the type of person prone to coronary artery disease in their book Type A Behavior and Your Heart (New York: Alfred A. Knopf, 1974). What they described is someone who is hard-driving, obsessed with work to the extreme. Such a person might claim to work eighteen hours a day and never feel tired.

This is not characteristic of someone who gets TMS. Though hardworking, there is awareness of one’s limitations and certainly some awareness of oneself as an emotional being. I have the impression that the true Type A person is not at all in touch with himself emotionally. He or she tends to deny feelings as though they are a sign of weakness. That there is an important difference between the patient who gets TMS and the Type A person is based on the observation that it is rare for TMS patients to have a history of coronary artery disease or to develop it later. There have been a few, of course, but nothing like the numbers of patients who have other things, like stomach trouble, colitis, hay fever, tension headache, migraine headache, acne, hives and many other conditions that seem to be related to tension. These appear to be equivalents to TMS and reflect a lower level of compulsivity than that of the Type A person.

The personality characteristics of which we are aware represent only a part of our emotional makeup and may be less important than that which is unconscious.

THE UNCONSCIOUS MIND

The word unconscious has an unfortunate other use, that is, to be out of contact as in sleep or when brain damaged. However, it is firmly entrenched in the psychological literature as referring to that part of emotional activity of which we are usually unaware, and we should, therefore, use the word when discussing emotions. We would probably be more comfortable with the word subconscious, and will use it when talking about things below the level of awareness other than the emotions.

The unconscious is subterranean, the realm of the hidden and mysterious and the place where all sorts of feelings may reside, not all logical, not all nice and some of them downright scary. We get some hint of the kind of things that inhabit the unconscious from our dreams. Someone said that every night when we go to sleep we all go quietly and safely insane because that’s when the remnants of childish, primitive, wild behavior that are a part of everyone’s emotional repertoire can show themselves without being monitored by the waking, conscious mind. The unconscious is the repository of all of our feelings, regardless of their social or personal acceptability. To know about the unconscious is extremely important, for what goes on down there may be responsible for those personality characteristics that drive us to behave as we do when we’re awake—-and the unconscious is where TMS and other disorders like it originate.

It is an interesting fact that the overwhelming majority of emotional and mental activity occurs below the level of consciousness. The human mind is something like an iceberg—-the part that we are aware of, the conscious mind, represents a very small part of the total. It is in the subconscious mind that all of the complicated processing goes on that allows us, for example, to generate written and oral language; to think, to reason, to remember; in short, to do most of the things that identify us as human beings. Our ability to make sense of the things we see, to recognize faces, and dozens of other mental activities we take for granted are the result of brain activity of which we are unaware.

It is likely that the majority of emotional reactions occur in the unconscious. Feelings that remain there do so because they are repressed and it is these that are responsible for the sequence of events that causes TMS. This condition begins and ends in the unconscious.

Incidentally, one should make a distinction, as Freud did a long time ago, between mental items that are not conscious but which can be brought to consciousness with effort, like the things in our memories—-Freud called that mental domain the preconscious-—and things in the unconscious that are unavailable and cannot be recalled. We simply don’t know they are there.

To better understand how and why TMS gets started, it’s essential to look at some of these unconscious emotional processes.

Low Self-Esteem

I find it almost shocking to realize how common it is for people to have feelings of inferiority deep inside. There must be a cultural reason for this that is reflected in the way we are managed as children and, therefore, the way we develop. This is a subject that should be studied intensively and no doubt will be someday. These feelings of inferiority are deep and hidden but reveal themselves through our behaviour. We generally overcompensate for bad feelings, so if we feel weak, we act strong. This is beautifully illustrated many years ago when a self-proclaimed “tough guy” came under my care for crippling back pain. The staff reported that he was constantly bragging about his prowess in hand-to-hand combat, in financial matters and with women. In my office he wept inconsolably about his inability to cope with his back pain. Emotionally, he was a very little boy trying desperately to prove to himself and the world how tough he was.

It is likely that for most of us the compulsive need to do well, succeed and achieve is a reflection of deep-seated feelings of inferiority. Wherever it comes from, the need to accomplish or live up to some ideal role, such as being the best parent, student or worker, is very common in people who get TMS.

A typical example was a patient who through compulsive hard work established a very successful business and became the patriarch and benefactor of his large family. He enjoyed the role but felt the responsibility deeply. Throughout his entire adult life he had low back pain, which resisted all attempts at treatment. By the time I saw him the pain patterns were deeply ingrained and part of his everyday life. He understood the concept of tension-induced pain but was unable to erase the patterns of a lifetime. He felt that he was too old to engage in psychotherapy, which is often required for patients like this. The primary benefit he derived from treatment was the reassurance that there was nothing structurally wrong with his back.

Another patient was a young man in his twenties who had his first child shortly before he opened a new branch of the family business. The simultaneous imposition of these new responsibilities in this very conscientious young man induced severe low back pain due to TMS. As soon as he became aware that the source of his symptoms was inner tension, the pain disappeared. As will be seen later, awareness is the key to recovery from TMS.

What these two people had in common was a great sense of responsibility and a strong inner drive to succeed in both business and family matters. Such people don’t need to be monitored; they are self-motivated, self-disciplined, their own severest critics.

People who get TMS are often intensely competitive, success oriented, achieving and usually very accomplished. In our culture success often requires the ability to compete effectively, and they do. They are accustomed to putting a great deal of pressure on themselves and often feel as though they have not done enough.

Sometimes the perfectionism manifests itself in unusual ways. I remember seeing a young man once who had grown up on a farm. He said that when he had read my first book he didn’t see how this perfectionism applied to him until he realized that at haying time he had a powerful compulsion to stack the bales of hay perfectly.

At this point if you’re mentally scratching your head and wondering why being hardworking, conscientious or compulsive and perfectionistic should bring on TMS, you’re right. It is clear that there is a relationship between these personality characteristics and this pain syndrome, but what is it? To understand this we need to think about anxiety and anger.

Anxiety and Anger

Not being trained in psychology or psychiatry I am aware that my concepts and explanations of what goes on in this psycho physiologic process may sound naive to professionals in these fields. However, this is a book for the general public, and the lack of jargon and complex concepts will probably be welcome. My lack of training in these fields notwithstanding, what I have observed about the nature of this pain syndrome and its causes should be taken seriously by psychology professionals. We are dealing here with the almost totally unexplored territory between what is purely mental-emotional and what is physical. There is a powerful and important link which, sadly, contemporary medical science (with a few notable exceptions) is unwilling to explore. The reason for that reluctance is discussed in chapter 7, “Mind and Body.” My experience in the diagnosis and treatment of TMS throws some light on what is going in that mysterious domain where the emotional and the physical connect.

Anger and anxiety are discussed together for I think they are closely related and are the primary repressed feelings behind TMS and other disorders like it.

It was obvious from the beginning of my experience with TMS that most patients shared the personality characteristics described above. Those who denied possessing any of those characteristics eventually admitted that they had many emotional concerns but they tended to deny them and instead would “put them out of my mind.”

With this repertoire of personality traits it was not difficult to postulate that anxiety was responsible for TMS, since such an individual would be anxious about how things would turn out. Anxiety is a uniquely human phenomenon, closely related to fear but much more sophisticated, for it is rooted in a capacity animals do not possess—-the ability to anticipate. Anxiety arises in response to the perception of danger and is logical unless the perception is illogical, as is often the case. The anxious person tends to anticipate danger, often where there is little or none. This is the nature of the human animal. However, he or she is often not aware of this anxiety, for it is generated in the unconscious out of feelings that are largely unconscious and are kept in the unconscious through the well-known mechanism of repression. Because of the unpleasant, embarrassing, often painful nature of these feelings and the anxiety they generate, there is a strong need to keep them out of consciousness, which is the purpose of repression. As will be seen later, the purpose of TMS is to assist in the process of repression.

Narcissism

The role of low self-esteem was described above. Standing right beside this deeply buried feeling is another of equal importance, called narcissism. It refers to the human tendency to love oneself, that is, to be self-centered to an excessive degree. The evolution of culture in the United States seems to have produced people who are much more “I” than “we” oriented. I have heard it said that many of the American Indian languages had no pronouns for I and me because of a powerful sense of community and of being part of something larger than themselves. By contrast, contemporary North Americans believe in individualism and have great admiration for the person who “goes it alone.” But the other side of that coin is that the individual may become overly focused on himself and, if he is not motivated by lofty ideals, tend to greediness and avarice. It is shocking and revealing to contemplate respected members of the business community or government engaged in felonious acts, but it is not surprising when one considers that this is a logical extension of today’s narcissistic trends.

Anger

Narcissism exists in all human beings to some degree. When it is strong it can make trouble since it means that the person is easily irritated, often frustrated by contact with others who do not do his bidding, or do it badly. The result is anger, and if the person is very narcissistic he or she may be angry all the time but never know it because, like anxiety, it has been repressed. It’s all there in the unconscious mind.

Here’s a seeming paradox. On the one hand we have poor self-esteem but then our narcissism leads us to behave emotionally like reigning monarchs. It is the story of the prince and the pauper-— they are one and the same person. These diametrically different feelings are opposite sides of the same coin, though it may strike us as strange that they generally exist simultaneously.

How typical of the human mind. It appears to be a storehouse of often conflicting feelings and tendencies, most of which we are totally unaware of.

We are angry for other reasons. In fact, anything that makes us anxious (all unconscious) will tend to make us angry as well. You’re trying to do a good job; you hope it turns out well (anxious), but you’re also resentful of the problems with which you must content, like other people and their needs (angry).

Although the production of anxiety and anger is often work related, personal relationships are an equally common source of repressed emotions. Family dynamics often produce serious problems that may be unrecognized because of their subtlety.

One of my patients was a woman in her late forties who had had a sheltered adolescence, an early marriage and, as dictated by her culture, thereafter had devoted herself exclusively to home and family. She did an excellent job since she was an intelligent, competent and compassionate woman. However, there came a time when she began to resent the fact that she had not been allowed to go to school as a child and could not read and write, could not drive a car and had been denied many experiences because the needs of her family so dominated her life. She was totally unaware of the existence of this resentment and, as a consequence, developed a long, disabling history of back pain, including unsuccessful surgery. When she came to my attention she was in constant pain and was almost totally unable to function. Through the education program and psychotherapy she became aware of these repressed feelings and the pain gradually disappeared.

The process was not without psychological trauma, for now she was faced with the disapproval of her family and friends and her own deeply ingrained attitudes. She was in considerable conflict and now experienced emotional pain. But this was appropriate and vastly preferable to the physical pain, of which she had been a helpless victim.

An important source of anger and resentment, of which we are usually unaware, stems from our sense of responsibility to those who are close to us, like parents, spouses and children. Though we love them, they may burden us in many ways and the resultant anger is internalized. How can one be angry at elderly parents or a baby?

A good example: A man in his forties went to visit his elderly parents in another city. Before the weekend was over he had a recurrence of back pain, the first since successfully completing the TMS therapeutic program a year before. When I suggested that the return of pain meant that something was bothering him subconsciously, he said the weekend had been pleasant. But then he revealed that his mother was feeble, that he had spent most of the weekend ministering to her needs, and that both of his parents were a worry to him. To make matters worse, they lived a plane ride away. But he was a good man, and his parents couldn’t help it if they were getting old. So his natural (intrinsic, unconscious, narcissistically inspired) annoyance (anger, resentment) was completely repressed and, for reasons which shall be clarified shortly, gave rise to the recurrence of back pain.

Or take the case of the young father whose first-born turns out to be a non-sleeper. Not only does he lose sleep but his wife is pretty much tied up with baby around the clock. He has to pitch in during his free time, their social life is much curtailed and what was a long honeymoon before baby came is now a grind. He develops back pain because he’s mad at the baby (ridiculous), and angry at his wife because she can no longer minister to his emotional and physical needs as she had before (absurd). And to make matters worse he has become a part-time nursemaid and cook. But he doesn’t know about any of these feelings—-they are deeply buried in his unconscious; and to make sure they stay there he gets back pain—-TMS.

There is a large group of psychologists and doctors who would put a different interpretation on the young father’s plight. They would say his back hurts from lifting the baby and not getting enough sleep; and that the pain is very bad because he’s trying to get out of doing his part with the baby-—now he has a good excuse. Of course, they say, this is subconscious.

This is the so-called secondary gain theory of chronic pain. The trouble with it is that it presupposes a structural reason for the pain, which is usually untenable (this baby’s father played high school and college football); and, secondly, it elevates to pre-eminence a feeling that is either minor of non-existent, that the person is deriving some benefit from the pain. Behavioural psychologists like it, however, because it’s simple and all you have to do is reward “non-pain behaviour” and punish its opposite. There is no getting involved with messy unconscious feelings like anxiety and anger. Years ago, before I knew about TMS, I tried this approach and found it singularly ineffective. Little wonder-—it was wrong diagnosis.

All family relationships are emotionally loaded. It is one of the first things to be considered when someone has an attack of TMS that seems to come out of nowhere. The combination of real concern and love for the family member and inner resentment of the duties and responsibilities associated with the relationship are a source of deep conflict, the stuff of which TMS is made.

Here is a classic story with some interesting sidelights about the natural history of TMS. The patient was a thirty-nine-year-old married man who ran a family business originally started by his father. He told me that his father was still active in the business but that he had become a hindrance rather than a help. He admitted to conflict with his father over this and to feeling guilty about the whole thing. The pain syndrome had begun about two and a half years before, and about four months into the experience he read my first book. He decided it was hogwash and proceeded to make his way through the medical system, determined to get rid of the pain. He said he saw many doctors and tried virtually every available treatment, with no success. Two years later he was still in pain, was rapidly becoming obsessed with it, and was extremely limited physically. He was afraid of any physical activity and could not even bend. At that point he read the book again and reported with incredulity, “It had a totally different effect on me.” He said he saw himself on every page. His explanation was that he had to go through all the tests and doctors before he was ready to acknowledge a psychological basis for the pain.

Needless to say, he did very well on the program and was soon free of pain. During the consultation I found him to be so perceptive and psychologically attuned I could not imagine that he had originally rejected the diagnosis. It was a lesson to me: One of the unfortunate realities about working with a disorder like TMS is that most people will reject the idea until they are desperate for a solution.

The reason for the pain syndrome, the man’s conflict over his relationship with his father, was very clear.

Here is another good example of the role of family dynamics in producing symptoms. A woman who had been successfully treated for low back pain two years prior called one day to tell me that she had now developed neck, shoulder and arm pain but was certain it was due to a painful psychological situation involving her husband and teenage stepdaughter. I encouraged her to carry on without formal treatment but the situation remained unresolved and the pain became increasingly severe; she also lost considerable motion in both shoulders, a common consequence of TMS in the neck and shoulders. Then one day she decided to face the problem squarely and confront her husband. The result was a surprisingly easy solution that defused the entire situation, and with resolution of her personal problems the pain disappeared. She had undoubtedly harbored great resentment, and as long as she did the pain persisted. I shall have more to say about how one deals with this kind of situation in the treatment chapter, but this case clearly illustrates the relationship between repressed anger and TMS.

One of the great sources of conflict in the unconscious is the battle which rages between those feelings and needs that stem from the narcissistic impulses described above and another very real part of the mind that is concerned with what is appropriate, reasonable and mature or, even more demanding, what you should be doing. The well-known psychoanalyst, writer and teacher Karen Horney described what she called “the tyranny of the should,” which may dominate someone’s life. Patients often describe in detail how their lives are governed by these behavioral imperatives. One woman told me, after denying that she was compulsive or perfectionistic, that she came from a family that prided itself on its strength of character and rigidity, “stiff upper lip’ and that stuff. It was clear that there were other parts of her personality that were softer and more pliable, so the conflict in her unconscious must haven considerable.

Sometimes the pressure to behave in a certain way comes from one’s culture. I recall a strikingly attractive woman who was part of a religious group that believed in very large families; six or eight children were not unusual. Though she acknowledged that her pain was due to “tension” it persisted and she couldn’t understand why. I suggested that she might be resentful of the work and responsibility for a large family. For a long time she denied this, insisting that she felt no such resentment, and the pain continued, sometimes very severely. I pointed out that she would not be aware of the feeling since it was unconscious and repressed. Perseverance, both hers and mine, paid off. She began to get inklings of her deeply repressed resentment, and then had a dramatic resolution of her symptoms.

The longer I work with TMS the more impressed I am with the role of anger. We have all learned to repress it so completely that we are totally unaware of its existence in many situations. In fact, I have begun to wonder if anger is not more fundamental to the development of symptoms than anxiety and, indeed, whether anxiety itself may be a reaction to repressed anger.

The following story made a deep impression on me. The man was in his midforties and, among other things, had a history of having occasional panic attacks. These represent acute anxiety. After having examined him and established that he had TMS, we discussed the psychology of the disorder and I told him that I was beginning to suspect that anger might be more important than anxiety. He said that something had just happened to him that supported that supposition. He had become extremely angry at someone and was on the point of starting an altercation when he decided that it would not be appropriate, that he had better swallow it. Within moments he had a panic attack! He was probably more than angry—-he was in a rage, and the need to repress it, both unconsciously and consciously, necessitated some kind of reaction, hence the panic attack. As we shall see in a moment this is precisely the kind of situation that brings on TMS and other physical reactions. But first let’s consider the phenomenon of repression. Where does it come from?

Repression

I remember a mother telling me proudly how she had stopped the temper tantrums in her little fifteen months old. The “wise” family doctor suggested that she splash ice water in the child’s face when he started to have a tantrum. It worked beautifully—-he never had another tantrum. At the ripe age of fifteen months he had learned the technique of repression. He had been programmed to repress anger because it produced very unpleasant consequences, and he would carry that dubious talent with him throughout his life. Now when confronted with the multitude of frustrating, annoying, sometimes enraging things that happen to people every day, this man automatically internalizes his natural anger, and when that anger collects and builds up, he will have TMS or some such physical reaction in response to it.

The story illustrates one of the sources of the need to repress: innocent parental influence. This may be the most common reason for learning to repress. In an attempt to make good people of their children, parents may inadvertently induce the conditions for psychological difficulty later in life.

When you think about it, there are many reasons why we repress anger, all logical and mostly unconscious. Everyone wants to be liked or loved; no one enjoys disapproval, so we repress unlovable behavior. We would hate to admit it, but unconsciously we fear reprisal. The cultural imperatives of family and society provide strong motivation not to show anger; this becomes deeply imbedded, starting as it does in early childhood. We realize, all unconsciously, that anger is often inappropriate, springing from irritants which ought not make us angry, and so we repress. Instinctively we feel that anger is demeaning, and perhaps even more powerful, we feel a loss of control when we are angry, and that is something the TMS personality finds hard to take. All of this is unconscious and thus we are unaware of our need to repress the anger. Instead we may experience a physical symptom, TMS or something gastrointestinal, for example.

I do that a lot. I have learned that heartburn means that I’m angry about something and don’t know it. So I think about what might be causing the condition, and when I come up with the answer the heartburn disappears. It is remarkable how well buried the anger usually is. Generally for me it is something about which I am annoyed but have no idea how much it has angered me. Sometimes it is something that is so loaded emotionally, I don’t come up with the answer for a long time.

     After a seventeen-year experience working with TMS it seems clear that, in our culture at least, we all generate anxiety and anger and that, in any culture, human beings repress potentially problematic emotions. Put another way, the psychological conditions that lead to psycho physiologic reactions like TMS, stomach ulcers and colitis are universal; they only vary in degree. Those at the upper end of the severity spectrum, with more intense symptoms, we call neurotic, but in fact we are all more or less neurotic, making the term meaningless.

     The concepts of repression and the unconscious are closely bound together. They were first put on a sound, scientific basis by Freud. There is a wonderful metaphor of the unconscious in Peter Gay’s excellent biography of Freud, Freud: A Life for Our Time (New York: Norton, 1988), p. 128: “Rather, the unconscious proper resembles a maximum-security prison holding anti-social inmates languishing for years or recently arrived, inmates harshly treated and heavily guarded, but barely kept under control and forever attempting to escape” (italics added).

The emotional phenomena that have been described in this chapter are the “anti-social inmates” of the unconscious. We seem to have a built-in mechanism for avoiding what is emotionally unpleasant, which is the reason for repression. But there appears to be an equally strong force in the mind working to bring those feelings to consciousness (“ forever attempting to escape”) and that is the reason for reinforcements, for what psychoanalysts call a defense.

A short time ago I saw a woman who told the most interesting story. After I had examined her and told her she had TMS and what it meant, she said that the pain had begun after she invited an older sister to take a trip to Europe, at her expense. She began to worry about whether the sister would have a good time, felt that it was her responsibility to see that she did, and then got angry and resentful about having to feel that way. She further reported that she began to dream about her mother and sister and to recall her teenage resentments against them, based on the feeling (no doubt unjustified) that they “ganged up on her—-to be good,” and that she was excluded from their close relationship. All of this was enhanced by the fact that she felt her father, with whom she had been very close, had abandoned her—-he died when she was eleven.

This is the kind of thing from which TMS often arises: anxiety, anger, resentment, with roots that go all the way back to childhood. I thought it remarkable of her to have come up with all that important psychological material with just a hint from me.

The universality of these psychological phenomena is supported by the strangely ignored fact that over 80 percent of the U.S. population has a history of these pain syndromes and that their incidence has increased geometrically over the last thirty years. Back and neck pain syndromes are the first cause of worker absenteeism in this country. It is estimated that somewhere around $56 billion are expended annually in the United States on the ravages of back pain. This virtual epidemic of pain syndromes can only be properly explained on the basis of a universal psycho physiological process.

PHYSICAL DEFENSES AGAINST REPRESSED EMOTIONS

For many years I was under the impression that TMS was a kind of physical expression or discharge of the repressed emotions just described. In fact, this is what I suggested in the first edition of this book. I had been aware since the early 1970s that these common back and neck pain syndromes were due to repressed emotions. Eighty-eight percent of a large group of patients with TMS had a history of other tension-related disorders, like stomach ulcers, colitis, tension headache and migraine headache. But the idea of TMS as a physical manifestation of nervous tension was somehow unsatisfactory and incomplete. Most important, it did not explain the repeated observation that making a patient aware of the role of the pain as participant in a psychological process would lead to cessation of pain, to a “cure.”

It was a psychoanalyst colleague, Dr. Stanley Coen, who suggested in the course of our working on a medical paper together that the role of the pain syndrome was not to express the hidden emotions but to prevent them from becoming conscious. This, he explained, is what is referred to as a defense. In other words, the pain of TMS (or the discomfort of a peptic ulcer, of colitis, of ten headache, or the terror of an asthmatic attack) is created in order to distract the attention of the sufferer from what is going on in the emotional sphere. It is intended to focus one’s attention on the body instead of the mind. It is a response to the need to keep those terrible, antisocial, unkind, childish, angry, selfish feelings (the prisoners) from becoming conscious. It follows from this that far from being a physical disorder in the usual sense, TMS is really part of a psychological process.

     Defenses against pressed emotions work by diverting one’s attention to something other than the emotions that are being kept hidden in the unconscious. Patients have different metaphors to describe the process; that the defense acts as camouflage; that it is a diversion or distraction. To be successful it must occupy one’s attention and it works even better if you are totally preoccupied or obsessed by whatever it is. That is why physical defenses are so good: they have the ability to really grab one’s attention, particularly if they are painful, frightening and disabling. This is exactly what happens with TMS.

     The common back, neck and shoulder pain syndromes have reached epidemic proportions in the United States over the past thirty years because they have become the preferred defense against the repressed emotions described above. The mark of a good camouflage is that it will not be recognized for what it is, that no one will know that something is being hidden. Virtually no one suffering from them thinks that these pain syndromes are related to emotional factors. On the contrary, almost everyone thinks they are due to injury or a variety of congenital and degenerative abnormalities of the spine. There is another group of disorders that are part of the TMS repertoire and are thought to be due to soft tissue pathology (fibromyalgia, fibrositis, myofasciitis, among others), but these too are attributed to injury, muscle incompetence and the like—-the perfect camouflage. As long as the person’s attention remains focused on the pain syndrome, there is no danger that the emotions will be revealed.

It has been a recurrent observation of mine that the more painful the repressed emotion, the more severe the pain of TMS has been. The patient who is found to be harboring enormous anger as a result of childhood abuses, for example, usually has severe, disabling pain, and the pain disappears only when that person has an opportunity to express the terrible, festering rage that has occupied his or her unconscious for years—-another example of the potential of anger to initiate the pain of TMS.

EQUIVALENTS OF TMS

As has been suggested, other physical disorders may serve the same purpose as TMS. Here is a list of some of the most common ones:

Pre-ulcer states             Tension headache

Peptic ulcer                 Migraine headache

Hiatus hernia                Eczema

Spastic colon                Psoriasis

Irritable bowel syndrome     Acne, hives

Hay fever Dizziness          Dizziness

Asthma                       Ringing in the ears

Prostatitis                  Frequent urination

All of these disorders should be treated by one’s regular physician. Though they may be serving a psychological purpose they must be investigated and treated medically. Hopefully, the patient will also receive some counseling.

Each of these physical conditions serves equally to assist repression. The more that practitioners identify them as “purely physical” the more they assist in the defense mechanism, which means the continuation of the pain, ulcer, headache or whatever is going on. As long as the defense works it will continue.

Physical (as opposed to psychological) defenses against repressed emotions are undoubtedly the most common because they are undoubtedly the most common because they are so successful. They are also very effective since a patient can transfer from one to another. For example, excellent drugs have been found to reverse the pathology of peptic ulcer. As a result, the mind simply shifts to another physical disorder.

One man in his mid-forties told me that ten years before he had started to have trouble with his low back; after many years it was relieved by surgery. A few months after the operation he began to have stomach ulcer problems, and that went on for almost two years. The doctor tried a number of medications but just couldn’t get rid of the ulcer. Finally it stopped and shortly thereafter the patient began to have neck and shoulder pain; it had been going on for almost two years and so he had come to see me.

The back surgery and ulcer treatment didn’t alleviate his basic problem; they merely acted as placebos and mandated a shift in the location of his physical symptoms.

The Peptic Ulcer Story

The ulcer story is interesting. There has been a decline in the incidence of peptic ulcer in the United States and Canada over the past twenty to thirty years, due in part to the effective drugs that have been developed.

For a better explanation, however, I am indebted to columnist Russell Baker, who asked in one of his Sunday columns in the New York Times Magazine (August 16, 1981), “Where Have All the Ulcers Gone?” Mr. Baker pointed out that people seemed to be getting fewer ulcers. The article set me to speculating that since everyone, doctors and laymen alike, had come to realize that ulcers really meant tension, they no longer served the purpose of hiding tension, so fewer people developed them. Could this be the reason why neck, shoulder and back pains have become so common in recent years? Is it possible that these are now much better hiding places for tension than the stomach?

MIND AND BODY

It is my impression that virtually any organ or system in the body can be used by the mind as a defense against repressed emotionality. These include disorders of the immune system, such as hay fever, or frequent respiratory or genitourinary infections. An academic urologist of my acquaintance has said that over 90 percent of his cases of prostatitis are due to tension. I have a patient who suffers from constant dry mouth, the result of tension-induced constriction of his salivary ducts. Laryngitis may be of emotional origin; ophthalmologists tell us that tension-induced visual difficulties are common, and on and on. To repeat, all symptoms should be thoroughly investigated to rule out structural, infectious or neoplastic processes. This subject is reviewed in more detail in the chapter on mind and body.

While it is wise to rule out so-called organic disorders, the diagnosis of psycho physiologic conditions should be made positively and not by exclusion. A diagnosis by exclusion is not a diagnosis. It says, “I don’t know what this is and therefore it’s probably tension induced.” Rather the diagnostician should say, “Now that I have eliminated the possibility that there is a tumor or cancer I can proceed with confidence since this physical condition I am looking at has all the signs and symptoms of an emotionally induced process.” That is rarely done, however, for most practicing physicians either do not recognize the disorder as psycho physiologic, or if they do, treat it symptomatically as though it were organic.

The Role of Fear in TMS

Severity of TMS is measured not only by the intensity of the pain but by the degree of physical disability that exists. What things is the person afraid of or unable to do? Disability may be more important than pain because it defines the individual’s ability to function personally, professionally, socially and athletically.

In the long run fear and preoccupation with physical restrictions are more effective as a psychological defense than pain. A severe attack of pain may be over in a few days, but if the person is afraid to do things for fear of inducing another attack or because he or she has found that the activity will invariably bring on pain, even if it is not an acute attack, then the preoccupation with the body is continuous and the defense is working all the time. In the majority of patients with whom I work this is the most important factor. Occasionally I have a patient who says that he or she has no physical restrictions, that pain is the only problem. But such patients are rare; most patients are afraid of physical activity, which tends to perpetuate the problem by inducing further anxiety and often leads to depression as well. What one sees is truly a physicophobia, a fear of physical activity.

The degree of preoccupation with symptoms is a measure of the severity of the problem. Many patients report that the syndrome dominates their lives while others are clearly obsessed by the disorder. It is the first thing they think of when they awaken in the morning and the last at night before sleep comes.

A young woman with whom I was working said one day that she was “terrified of the physical pain.” It was clear as we talked, however, that she was really terrified about emotional things and the pain syndrome had allowed her to avoid them.

It has been my experience that the overall severity of the pain syndrome, including obsessional components, is a good guide to the importance of the underlying emotional state of the patient. By importance I mean how much anger and anxiety there are, and how severe the traumas of early life are that have contributed to that person’s current psychological state. People who were abused as children, emotionally or physically, but especially sexually, tend to have enormous reservoirs of anxiety and anger. This is one of the first things I think of when I see someone who has a particularly severe TMS. The physical symptoms are the means by which they remain out of contact with some terrible, frightening, deeply buried feelings. Those words are not exaggerations­ there is great fear and probably enormous rage festering in their minds that they dare not acknowledge. Such patients will tell you that they understand why the pain will not leave, for when they begin to get close to those buried feelings they are panic stricken and can proceed no further. They invariably require psychotherapy as part of the therapeutic program.

On the other hand, in the great majority of people with TMS, about 95 percent, the anxiety level and the reasons for it are much milder and they experience no emotional reaction when the pain disappears. One has the impression in these cases that the mind has overreacted to the anger and anxiety and the defense wasn’t necessary in the first place.

What has been described is universal in our culture; only the degree of repressed emotionality varies. And in our culture, nature has created a mechanism whereby we can avoid being aware of those bad feelings­ it gives us physical symptoms.

Fortunately there is a way of stopping what is clearly a maladaptive response for most of us. Logic tells us that the brain is reacting in an infantile fashion. However, my work with TMS has demonstrated that the brain has other attributes and can reverse the process that leads to physical symptoms.

Fear is pervasive. Anything that heightens anxiety will increase the severity of symptoms. One of my patients reported that she left the doctor’s office in a state of shock after having been told that the lower end of her spine was degenerating. She said she almost fainted in the street and that her pain was much worse after the visit to the doctor.

A young man in his twenties, with the physique of a football player, told of how he was the strong one in the family business. One day he decided to accompany his father on a visit to a back practitioner since he had experienced some mild low back pain while brushing his teeth. X rays were taken and he was told that there was a malalignment of the lower end of the spine, whereupon his mild symptoms got worse. When the pain persisted he was advised to see a medical specialist, a CT scan (see “Common Patterns of TMS”) was done that showed a herniated disc, and he was now advised that he had a serious problem and that he must do no more heavy lifting, never play basketball again (one of his great loves) and generally be very careful. He was devastated. Though he had started out with mild low back pain, he now had severe pain every day and was greatly limited in his work and life. He had become disabled, thanks to the structural diagnoses that had been made and all that they implied. He now believed there was something seriously wrong with his spine and that he would never again be able to lift a heavy weight or play sports. When I saw him in consultation he was profoundly depressed.

Fortunately, he had TMS. He responded well to treatment and has been living a normal life again (including playing basketball).

There are many things about having back pain that stimulate fear. The American public is now convinced that the back is a fragile, delicate structure, easily injured and perpetually vulnerable. There are dozens of dos and don’ts: don’t bend, don’t lift, lift with a straight back, don’t sit on a soft chair or couch, don’t swim the crawl or breast stroke, don’t wear high heels, don’t arch your back (which is what the crawl, the breast stroke and high heels do), sleep on a hard mattress, don’t run, no vigorous sports, etc. ad nauseam. A large group of my successfully treated patients (a few thousand) have demonstrated that these are not valid instructions. All they succeed in doing is help perpetuate the pain syndrome and make life hell.

There is fear of recurrent attacks. Anyone who has had a severe back attack cannot help but live in terror of the next one. Ironically, by contributing to a high level of anxiety this fear almost guarantees that another attack will come sooner or later.

Anxiety and anger are enhanced by the perception that one is an inadequate parent, spouse, sexual partner, worker, homemaker or whatever else you do in life. You can’t go to the movies, theater, concert or restaurant because you can’t sit for long. Your woe is double if you are self-employed.

The sad reality is that the patient with back pain is a prisoner of pervasive fear—-and fear is a prime perpetuator of the pain syndrome.

Coping

I have heard it said that people get stress-induced pain because they can’t cope. It is quite the opposite; TMS occurs because they cope too well. Coping requires that we repress emotions that might interfere with whatever we are trying to do and TMS exists in order to maintain repression of those emotions.

Someone I saw recently, a high-powered businessman, told me that he can never say no to friends and family who ask him to do things for them because saying no to him means defeat. Saying yes, and going ahead and accomplishing what he was asked to do, is like winning, no matter what it may cost him emotionally. He is a cooper par excellence and a prime candidate for TMS. This also illustrates some of the other characteristics of the TMS personality: the need to be loved, admired, respected; the drive to achieve; and the intense competitiveness. We pay a price for coping­---we’re great on the outside and we suffer on the inside.

Rejecting the Diagnosis

It is an unfortunate fact that most people would reject the diagnosis of TMS if it were presented to them. This is not surprising, for there remains a strong prejudice in our society regarding anything having to do with psychological problems and psychotherapy. It doesn’t matter that the overwhelming majority of such “problems” are minor or that millions of people have psychotherapy every year. Emotional difficulties appear to fall into the same category as racial and religious prejudice.

Judging from the politics of running for public office, the events of recent years suggest that society has done better in overcoming its racial and religious phobias than it has with psychology. We elected John Kennedy. But we have learned from the electoral process in recent years that any hint of a psychological history is still the kiss of death for someone running for high public office. Cruel paradox, for the contemporary political scene suggests that many politicians would profit greatly from psychotherapy. Under the circumstances it is very unlikely that a politician would acknowledge having TMS.

Similarly, most athletes would reject the diagnosis since psychological syndromes are equated with weakness, and athletes have an image of strength and indomitability to preserve. I know of a few who have been referred to me but have never come.

Of course, the same prejudice is strong in medicine. Doctors prefer to treat physical disorders; they feel insecure when confronted with patients who have emotional symptoms. Their usual response is to prescribe a medication and hope that the patients will feel better. Even the field of psychiatry now has a large segment of practitioners who prefer to treat primarily with drugs. And I know of a number of psychiatrists who rejected the concept of TMS when it was suggested as a possible explanation for their back pain.

On the other hand, people with physical symptoms rarely encounter such prejudices. Medical insurance will pay for the most elaborate diagnostic and therapeutic procedures but most policies exclude or sharply limit payment for psychotherapy. Thousands of dollars will be given for an organ transplant to preserve life but peanuts assigned for therapy that will improve the quality of life.

Little wonder that the mind develops strategies to avoid the experience and appearance of emotional difficulty. Unconsciously, we would rather have a physical pain than acknowledge any kind of emotional turmoil.
     I discussed this with a patient of mine, who made a cogent observation. She said, “If you ask people to ease up on you because you’re emotionally overloaded, don’t look for a sympathetic response; but tell them you’ve pain or some other physical symptom and they immediately become responsive and solicitous.” How right she is. It is perfectly acceptable to have a physical problem in our culture, but people tend to shy away from anything that has to do with the emotions. It is one more reason why the mind will choose a physical rather than an emotional manifestation when confronted with unpleasant emotional phenomena.

 
IS TMS WORLDWIDE?

From time to time I have been asked if there are people anywhere in the world who don’t get TMS. Dr. Kirkaldy-Wallis, a British-trained physician who worked in Kenya for twenty-two years, provided the answer. He reported at a medical meeting in 1988 that back pain was very rare in indigenous Africans but was just as common in Caucasians and Asians as it is in the United States and Canada. He attributed this partly to cultural differences, positing that Africans didn’t seem to generate anxiety as we do. Entirely logical.
 
THERE’S NOTHING NEW

As the details of this disorder were emerging many years ago I found it hard to believe that no one had ever seen this problem before. A search of the medical literature turned up an article in a 1946 issue of the New England Journal of Medicine by a Major Morgan Sargent describing a large population of returning Air Force personnel who had backache. Dr. Sargent, not a psychiatrist, reported that 96 percent of a large group had psychologically induced pain, and then he went on to describe what was clearly TMS. It was a sign of the times that Dr. Sargent’s paper was accepted for publication in the journal. It would probably now be rejected as “unscientific.” (I shall elaborate on changing attitudes about mind-body interactions in chapter 7.)
 
THE SOLUTION
     It is at this point that the patient will say, “All right, you’ve convinced me. I understand why I’ve got this pain. Now how in the world do I change my personality, solve my problems (especially the insoluble ones, like my ninety-year-old mother), stop generating anger and anxiety, and stop repressing my feelings?”

In fact, Mother Nature has been extremely kind in this instance, for the solution doesn’t require any of those difficult transformations in the majority of cases. To be sure, a small number of patients will have to be in psychotherapy to recover, but they represent less than 5 percent of the total. The rest will get better simply by learning all about TMS and changing their perceptions about their backs. Does it sound simple? It is and it isn’t, as the treatment chapter will detail.
 
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