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        The Treatment 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.

 

EARLY HISTORY

My treatment of TMS has evolved over the past seventeen years in response to a clear-cut diagnostic concept­--that the pain syndromes are the result of the mind-body interaction. When it began to dawn on me that this was the case, my automatic reaction was to explain to the patient what I thought was going on. At the same time, I prescribed physical therapy for everybody, as I had always done. My reasoning was that such therapy could not hurt and, since I believed that oxygen deprivation was responsible for the symptoms, it might actually be beneficial since all the modalities I prescribed tended to increase the local circulation of blood.

As time went on something interesting emerged. I found that most of the patients who got better were those who accepted the idea that their pain was the result of emotional factors. Some who improved remained skeptical of the diagnosis but responded well to the physical therapy. It was also apparent that some physical therapists were more successful than others. Based on these observations, two therapeutic conclusions were reached:

 

1. The most important factor in recovery is that the person must be made aware of what is going on; in other words, that the information provided is the “penicillin” for this disorder.

2. Some patients will respond to physical therapy and/or the physical therapist with a placebo reaction. As has been said earlier a placebo reaction is fine, but it is usually temporary. Our goal was to effect a complete and permanent cure.

 

The effectiveness of the placebo reaction was easy to understand but I was mystified by the obvious importance of informing the patient of what was going on. This was knowledge therapy, and it appeared to make no sense at all. However, I was delighted with its effectiveness, and my cure rate was distinctly better. In addition I finally had the feeling that I knew what was going on despite my inability to explain all the details. That wasn’t too upsetting, for after all we were dealing with a process of the brain and it is common knowledge that little is known about how the brain works.

During this period I worked closely with a group of talented physical therapists who had learned all about the Tension Myositis Syndrome and combined their physical treatment with discussion of the psychological factors involved. They functioned as surrogates for me as well as physical therapists. It was a painful decision to stop using physical therapy later on because I so appreciated the work of these dedicated professionals.

Also during those early years I developed a close working relationship with a small group of psychologists on the staff of the Howard A. Rusk Institute of Rehabilitation Medicine, an association that has continued to this day. I learned a lot of psychology from them and they have played an important role in the treatment of those patients who needed psychotherapy in order to get better. In essence we function as a team.

In 1979, perhaps later than I should have, I began to bring groups of patients together for what one might call lecture-discussions. With each passing year it became increasingly obvious that educating the patient about TMS was the crucial therapeutic factor. Occasionally, I would see a patient who had been psychoanalyzed or had been in psychotherapy for a long time but had a pain syndrome nevertheless. So it was clear that psychological insight was not sufficient to prevent TMS. It wasn’t until patients learned the facts about TMS that the pain went away. Starting with four one-hour lectures, we evolved to two two-hour sessions, the first of which is devoted to the physiology and diagnosis of TMS and the second to the psychology of TMS and its treatment. The reason for the lectures was clear­ if the information was so important to patients’ recovery, then they had to be well educated about TMS. More specifically, it was essential that patients knew exactly what they didn’t have (all the structural diagnoses) and what they did have (TMS). From a strictly physical point of view, TMS is harmless; therefore, they had nothing to worry about physically. All the prohibitions and admonitions were unnecessary. Indeed, they actually contributed to the problem by creating fear where none was appropriate.

 

CURRENT THERAPEUTIC CONCEPTS

If the purpose of the pain is to make one focus on the body, and through these lectures the patient can be convinced to ignore the bodily symptoms and think about psychological things instead, haven’t we made the pain syndrome useless?

It’s a bit like blowing the cover on a covert operation. As long as the person remains unaware that the pain is serving as a distraction, it will continue to do so, undisturbed. But the moment the realization sinks in (and it must sink in, for mere intellectual appreciation of the process is not enough), then the deception doesn’t work anymore; pain stops, for there is no further need for the pain. And it’s the information that gets the job done.

The illustration of “The Conscious Mind” should make the point clear. It is in the brain, the organ of the mind, where the unacceptable emotions described in the psychology chapter are generated, hence the arrow up to the right. Straight above, the conscious mind, or what might be called the “mind’s eye,” is represented. It is in order to prevent the conscious mind from becoming aware of the unpleasant emotions that they are repressed, that is, kept in the unconscious. It must be that something in the mind is fearful that they will not remain repressed, that they are trying to come to consciousness, for it is decided that a defense mechanism is necessary and, psychologically speaking, a defense is anything that will distract the conscious mind (the “mind’s eye”) from what is being repressed. So the brain creates TMS­--the arrow to the left. Now the person must pay attention to all the various manifestations of TMS and can avoid the unpleasantness of experiencing those bad feelings on the right.

This illustration is particularly useful in understanding why one gets rid of TMS by learning about it. If I can convince the conscious mind that TMS is not serious and not worthy of its attention, better yet that it is a phony, a charade, and that rather than fear it one should ridicule it, that most of the structural diagnoses are not valid and that the only things worthy of one’s attention are the repressed feelings, what has been accomplished? We will have made the TMS useless; it will no longer have the ability to attract the attention of the conscious mind; the defense is a failure (the cover is blown, the camouflage is removed), which means the pain ceases.

If that all sounds like something out of science fiction or Grimm’s fairy tales, one can only say that it works and has worked in a few thousand people over the last seventeen years.

Here’s a striking story to illustrate the point. A woman from out of town went through the program and had a good result. Within a few weeks after the lectures her pain was gone and she resumed all her old activities, including tennis and running. One day about
nine months after completing the program she was out running and developed a pain in a new location, the outer aspect of one of her hips, another manifestation of TMS. Later, she told me the details of the episode.

 

She saw her local doctor, who said she had bursitis in the hip and put her through X rays, injections and medication. She admitted that she was in a lot of pain­ and had been for three weeks­ while talking on the phone, and that I was right to scold her for following her doctor’s regimen. After talking to me, she said she stood for several minutes reflecting and she got mad­ really angry at herself and especially her brain for having pulled that stunt­ and she ended up having quite a talk with her brain. Within two minutes the pain was totally gone and had not recurred. Amazed at how quickly her pain disappeared, she began to jog again, concentrating on the real problem, unconscious anxiety about hurting herself during exercise.

The point of this story is that the information was the crucial factor and that it worked so quickly because she had already been through our program and had integrated (meaning she had accepted at a deeper level) the concepts of TMS. The pain would not have disappeared instantly if she had not already known about TMS. But because she did know about it, because she had been through the lecture program, the moment she realized that the hip pain was another manifestation of TMS, it disappeared because it could no longer successfully hold her attention as a legitimate physical disorder and could no longer distract her from the world of her emotions.

But then you might ask: “Why did she have a recurrence of pain at all?”

The occurrence of pain in TMS always signifies the presence of repressed bad feelings, like anger and anxiety.

“But your program is supposed to prevent this sort of thing from happening; what happened here?”

The fact that this lady developed pain in a new place tells us that her brain was still trying to use the TMS to hide repressed feelings. I discussed this with her and we agreed that if it happened again it might be wise to consider psychotherapy. (See “Psychotherapy” for a discussion of who needs psychotherapy and who doesn’t.)

Though this subject has already been discussed in the psychology chapter, it would not be amiss to repeat that there are clearly opposing forces in the mind as to what will be the ultimate fate of these repressed emotions. There must be a force (I can’t find a better word) which is trying to bring these feelings to consciousness, despite their unpleasant content. If they were subconscious and destined to remain so there would be no need for a diversionary process like TMS. The existence of TMS suggests that something is trying to bring these bad feelings to light. One might call this circular reasoning, except that there is well-documented evidence in the psychology literature that people exhibit a wide variety of behaviors that are designed to allow them to avoid unpleasant or painful emotional experiences. A classic example is the germ phobia. The person is obsessed with germs and washes his hands a hundred times a day. (Some might call this a compulsion neurosis but it is the fear of germs which produces the hand-washing compulsion.) Illogical behavior like this has long been recognized as a kind of substitute or displacement for strong, unconscious feelings that the person cannot deal with, hence the preoccupation with germs.

TMS serves the same purpose by keeping one’s attention focused on the body, as do a variety of other physical disorders like tension headache, migraine, hay fever, eczema and heart palpitation, to name a few.
 
TREATMENT STRATEGIES

The treatment program rests on two pillars:

 

1.      The acquisition of knowledge, of insight into the nature of the disorder.

2.      The ability to act on that knowledge and thereby change the brain’s behavior.

 

Think Psychological

So one must learn all about TMS, what actually causes the pain, and what part of the brain is responsible--all the things covered in the physiology and manifestation chapters. Then one reviews the psychology of the disorder, the fact that we all tend to generate anger and anxiety in this culture, and that the more compulsive and perfectionistic of us generate a lot. What one must then do is develop the habit of “thinking psychological” instead of physical. In other words, I suggest to patients that when they find themselves being aware of the pain they must consciously and forcefully shift their attention to something psychological, like something they are worried about, a chronic family or financial problem, a recurrent source of irritation, anything in the psychological realm, for that sends a message to the brain that they’re no longer deceived by the pain. When that message reaches the depths of the mind, the subconscious, the pain ceases.

That brings up an important point. Of course, everyone wants the pain to go away immediately. Patients often say, “All right, I understand very clearly what you’re saying­--why doesn’t the pain stop?”

The last lines of a poem by Edna St. Vincent Millay illustrate the reason why the pain doesn’t disappear quickly:

 

Pity me that the heart is slow to learn

What the swift mind beholds at every turn.

 

If we substitute the words “subconscious mind” for “heart” the point will be clear. The conscious mind is swift; it can grasp and accept things quickly. The subconscious is slow, deliberate, not quick to accept new ideas and change, which is no doubt a very good thing. Were it not so, humans would be very unstable animals. However, at times like these, when we want things to change quickly, we are impatient with the lumbering subconscious.

Well, how long does it take for the pain to go? Though I am reluctant to talk about numbers, experience has shown that the majority will have resolution of most of their symptoms in two to six weeks after the lectures. Patients are warned, however, that the time may be prolonged if they count the days or weeks or become discouraged if the pain isn’t gone when they think it should be gone. Human beings are not machines and there are many factors tending to vary the time of resolution. How strong are the repressed emotions? How much fear has the person built up over the years? How readily can he or she repudiate the structural diagnoses with which they came?

 

Talk to Your Brain

Another useful strategy sounds silly at first, but has great merit. Patients are encouraged to talk to their brains. So many patients reported having done this on their own with good results that I now routinely suggest it, despite lingering feelings of foolishness. What one is doing is consciously taking charge instead of feeling the helpless, intimidated victim, which is so common in people with this syndrome. The person is asserting himself, telling the brain that he is not going to put up with this state of affairs­ and it works. Patients report that they can actually abort an episode of pain by doing this.
 
Resume Physical Activity

Perhaps the most important (but most difficult) thing that patients must do is to resume all physical activity, including the most vigorous. This means overcoming the fear of bending, lifting, jogging, playing tennis or any other sport, and a hundred other common physical things. It means unlearning all the nonsense about the correct way you are supposed to bend, lift, sit, stand, lie in bed, which swimming strokes are good and bad, what kind of chair or mattress you must use, shoes or corset or brace you must wear, and many other bits of medical mythology.

The various health disciplines interested in the back have succeeded in creating an army of the partially disabled in this country with their medieval concepts of structural damage and injury as the basis of back pain. Though it is often difficult, every patient has to work through his or her fear and return to full normal physical activity. One must do this not simply for the sake of becoming a normal human being again (though that is a good enough reason physically and psychologically by itself) but to liberate oneself from the fear of physical activity, which is often more effective than pain in keeping one’s mind focused on the body. That is the purpose of TMS, to keep the mind from attending to emotional things. As Snoopy, that great contemporary philosopher, once said, “There’s nothing like a little physical pain to keep your mind off your emotional problems.” Charles M. Schultz, the creator of Peanuts, is clearly a perceptive man.

I now believe that the physical restrictions imposed by TMS are much more important than the pain, thus making it imperative that the patient gradually overcome them. If patients cannot do this they are doomed to have recurrences of pain. A few pages back phobias were mentioned. The pervasive, universal fear of physical activity in people with these pain syndromes, especially of the low back, has prompted me to suggest a new word­--physicophobia. It is a powerful factor in perpetuating low back pain syndromes.

It should be noted, parenthetically, that the advice to resume normal physical activity, including the most vigorous, has been given to a very large number of patients over the past seventeen years. I cannot recall one person who has subsequently said that this advice caused him or her to have further back trouble.

I suggest to patients that they begin the process of resuming physical activity when they experience a significant reduction in pain and when they are feeling confident about the diagnosis. To start prematurely only means that they will probably induce pain, frighten themselves and retard the recovery process. Patients are usually conditioned to expect pain with physical activity and so must not challenge the established programmed patterns until they have developed a fair degree of confidence in the diagnosis.

One of my patients, an attorney in his mid-thirties, had an interesting experience in this regard. He went through the program uneventfully and in a few weeks was free of pain and doing everything­ except one thing. He was afraid to run. He explained to me later that it had been drummed into his head for so many years that running was bad for your back that he simply couldn’t get up the courage to try, though he could do many things more strenuous than running. After almost a year he decided that this was silly and he was going to run. He did, and his pain returned. Now he was at a crossroad; should he continue to run or back off? He called for my advice but unfortunately I was on vacation and he had to make his own decision. Wisely, he decided to bull it through. He continued to run and he continued to hurt. Then one night he was awakened from sleep with a very sharp pain in the upper back, but his low back pain was gone. Knowing that TMS often moves to different places during the process of recovery, he decided that he had probably won, and he had. Within a couple of days the upper back pain was gone too and he has not had a recurrence of either upper or lower back pain since that time.

One has to confront TMS, fight it, or the symptoms will continue. Losing one’s fear and resuming normal physical activity is possibly the most important part of the therapeutic process.

 

Discontinue All Physical Treatment

Another essential for full recovery is that all forms of physical treatment or therapy must be abandoned. It is instructive to consider that I did not stop prescribing physical therapy until twelve or thirteen years after I began to make the diagnosis. It took that long for me to fully break with all the old traditions in which I had been schooled. Conceptually, prescribing physical therapy contradicts what we have found to be the only rational way to treat the problem; that is, by teaching, and thereby invalidating, the process where it begins­ in the mind. Further, it had become obvious that some patients had put all their confidence in the physical therapy (or therapist) and were having placebo cures (see “The Placebo Effect”), which meant that sooner or later they would be in pain again. The principle is that one must renounce any structural explanation either for the pain or its cure, or the symptoms will continue. Manipulation, heat, massage, exercise and acupuncture all presuppose a physical disorder that can be treated by some physical means. Unless that whole concept is repudiated, the pain and other symptoms continue.

Patients are usually shocked when it is suggested that they stop the exercises and stretching they have been taught to do for their backs. But it is essential in order to establish firmly in the mind what is important. Exercise for the sake of good health is of course something else, and it is strongly encouraged.

 

Review the Daily Reminders

This is an important strategy but one must be careful that it does not become a ritual. Patients are given a list of twelve key thoughts, and it is suggested that at least once a day they set aside fifteen minutes or so when they can relax and quietly review them. They are called daily reminders.

 

·     The pain is due to TMS, not to a structural abnormality.

·     The direct reason for the pain is mild oxygen deprivation.

·     TMS is a harmless condition, caused by my repressed emotions.

·     The principal emotion is my repressed anger.

·     TMS exists only to distract my attention from the emotions.

·     Since my back is basically normal there is nothing to fear.

·     Therefore, physical activity is not dangerous.

·     And I must resume all normal physical activity.

·     I will not be concerned or intimidated by the pain.

·     I will shift my attention from the pain to emotional issues.

·     I intend to be in control­ not my subconscious mind.

·     I must think psychological at all times, not physical.

 

By the end of the second lecture-discussion it is assumed that the information about TMS has been intellectually processed. Patients are then urged to give this information an opportunity to “sink in,” to be integrated, to be accepted at a subconscious level, for conscious acceptance, though essential as a first step, is not sufficient to reverse the TMS. Patients are instructed to give it two to four weeks and then call me if they have not made sufficient progress. If they have not, I arrange either to see them in my office or, more commonly, attend a small group meeting composed of patients like themselves (who have made little or no progress) or those having recurrences after having been free of pain for months or years. It is the purpose of these sessions to uncover the reason for the recurrence or lack of progress.

 

SMALL GROUP FOLLOW-UP MEETINGS

 

The first thing to ascertain is that the patient understands and accepts the diagnosis. Let’s take a theoretical patient, a fifty-year-old businessman. He comes to the meeting because he hasn’t improved after attending the lectures. Some of the possible reasons are:

 

1.  He accepts 90 percent of the diagnosis but still has some concerns that the herniated disc demonstrated on the CT scan or MRI has something to do with the pain.

2.  He finds it hard to believe that this thing can go away with just an education program.

3.  He accepts the diagnosis but can’t get up the courage to begin physical activity.

 

Mental impediments such as these allow the brain to continue the TMS since the man is still engaged with his symptoms as a physical disorder. As long as he is in any way preoccupied with what his body is doing, the pain will continue. His confidence in the diagnosis needs to be built up so that he can accept the fact that he has TMS.

The person sitting next to him is a thirty-year-old homemaker, wife and mother. She tells us she is no better since the lectures but she is not surprised because her life remains as hectic as ever, she is perpetually tired and harassed, and she never feels as though she has done as well as she should.

It is pointed out to her that she will never cease being a perfectionist, that she will always have too much to do, but that the secret of getting over TMS is not changing oneself but simply recognizing that the combination of the realities of her life and personality cause her to generate an enormous amount of anxiety and anger.

Yes, anger too. She has probably never acknowledged the fact that although she adores her three little girls, she is simultaneously angry at them for what they require of her. The idea that she could be subconsciously angry at her children is outside of her experience. When she grasps the idea that the cure is in the acknowledgment of such unacceptable subconscious feelings the pain will cease.

The man in the back row who next raises his hand is a forty-five-year-old construction foreman who came through the program three years ago and had been doing fine until last week­ no pain, no physical restrictions, no problems. Then, out of the blue, he developed an acute low back spasm and now is having severe pain. If he hadn’t been through the program he would really be scared. But he can’t understand why this happened.

“What’s going on in your life?” I ask him. “Nothing in particular,” he says. “My wife is fine, the children are doing well, we don’t have any health or financial problems.” But the occurrence of an acute spasm means that there has to be something psychological going on because TMS is an emotional barometer. So I continue to question him and finally it comes out there have been problems on the job, difficulties with some of the men he supervises and criticism from his superior.

“Nothing I can’t handle,” he says, but he doesn’t realize that though he’s “handling” it he’s generating large quantities of anxiety and anger in the process. There is always important emotional activity going on below the level of consciousness and we have no way of knowing about it, unless from experience we learn to suspect it and anticipate it.

He leaves the meeting a little wiser about how his emotional insides work. The back pain will subside and hopefully he will think about his inner reactions the next time he is confronted with a stressful situation.

The small group meetings have proven to be a valuable therapeutic tool. Patients not only gain understanding about their own situations but profit from the experiences of others. It’s always reassuring to know that there are others going through the same thing you are. These meetings also give me an opportunity to decide which patients may need the assistance of a psychotherapist.

 

Psychotherapy

Although about 95 percent of our patients go through the program without psychotherapy, some will need such help. This means simply that they have higher levels of anxiety, anger and other repressed feelings and that their brains are not going to give up this convenient strategy of hiding these feelings without a struggle. When someone tells me he is having trouble accepting the diagnosis, I suspect that there is resistance in the subconscious to giving up the TMS.

I recall a patient who reported that when he began to become aware of these long-repressed feelings (through psychotherapy) they were so painful and frightening that he was reluctant to deal with them.

These are not people suffering mental illness; these are people who are leading normal, productive lives but who have subconscious emotional baggage that they have never been aware of. Sometimes things happen in childhood that leave one with a large reservoir of resentment and anger but the feelings are kept deeply buried because they are too scary or socially unacceptable to be allowed to reach consciousness. As has been said before, this tendency to repress bad feelings is universal; it is something we all do to a greater or lesser extent. It is not neurotic--or we are all neurotic.

But in some, as in a person who was abused as a child, the repressed feelings may be strong and it is necessary for them to have helped in recognizing that those feelings are there and in learning how to deal with them. That is the role of psychotherapy.

Unfortunately, society is still backward about the need for and the place of psychotherapy and there is a common feeling that anyone who needs psychotherapy is weak or incompetent. To harbor repressed feelings has nothing to do with strength of character or mental competence. And yet we are so unenlightened about this matter in the United States that one is virtually ruled out of seeking public office if he or she has ever been in psychotherapy.

It is my own bias that we would be better governed if everyone running for an elective office were required to have some psychotherapy. I suspect we might be spared some of the scandals in high places that occur with distressing regularity in our nation.

Two things are emphasized about the need for psychotherapy in our program: only about 5 percent of the patients will require it; it is no disgrace to be one of the 5 percent.

I have great admiration for the people who go through our program. They must overcome some not inconsiderable impediments before they can get better.

One of these is the skepticism and sometimes ridicule they encounter. Another is the constant admonition, usually from family members, to be careful (“ Don’t lift that,” “Don’t bend over,” “Be sure to put on your corset”). For this reason, I encourage the full participation of close family members so that they will not undermine the therapeutic process.

One of the biggest problems for patients is developing confidence that they can banish this physical disorder with a learning program. That kind of thing is completely outside of people’s medical experience. It is my job to convince them that it can be done.

 

FOLLOW-UP SURVEYS

An important confidence builder is the fact that most people who have gone through the program have been successful. In 1982 we did a follow-up survey on 177 patients who had been treated between 1978 and 1981. Seventy-six percent were leading normal lives with little or no pain, 8 percent were improved and 16 percent were unchanged. Some of those patients had not had the benefit of lectures and in many other ways the program was not as sophisticated as it is now.
     In 1987 a similar follow-up study was done, this time on a group of patients who all had CT scan-documented herniated discs and had the TMS program between 1983 and 1986. This time 88 percent (ninety-six people) were successful, 10 percent were improved and only 2 percent were unchanged.

Still more recently the well-known journalist-writer Tony Schwartz, who was successfully treated in 1986, mentioned in an article he wrote for New York magazine on Dr. Bernie Siegel that he had referred the program to forty patients for treatment and thirty-nine of them were free of pain. I call this Tony Schwartz’s ministries.

A young colleague, Dr. Michael Sinel, at present assistant director of Outpatient Physical Medicine at Cedars-Sinai Medical Center, Los Angeles, has made the diagnosis and treated about fifty patients. His work is noteworthy because included in his patient population are some who were not necessarily receptive to the idea of a tension-induced disorder, making his job much more difficult. Nevertheless, following the basic concepts enunciated in this book, his preliminary data indicate that 75 percent of the group have had good to excellent pain resolution and better than 90 percent have experienced significant functional improvement.

I have invited my colleagues at medical meetings to observe the program and would welcome a survey conducted by an outside organization. Statistics as impressive as mine are bound to evoke skepticism in the medical community.

There is reason to believe the statistics will remain favorable, since I now interview patients prior to consultation in order to discourage those from coming who would not be receptive to the diagnosis. The reality is that only a small proportion of the back pain population would be open to the diagnosis and it is a waste of time and effort to try to treat someone who could not accept the TMS diagnosis.

Some critics have said that I get such good results because I only accept patients who believe in my concepts. But I can only work with patients who are reasonably receptive to the idea that their emotions are responsible for their pain. Even so, most of my patients are still skeptical when I first see them. It is my job to convince them of the logic of the diagnosis, because only by acknowledging the role of emotions can we get the brain to stop doing what it is doing. That is not believing­--it is learning.

Would a surgeon operate on a patient who was not a good surgical risk? Should I be less selective than a surgeon?

Another common criticism by my peers, since we are talking about critics, is that I go too far in claiming that the majority of pain syndromes of the neck, shoulders and back are due to TMS. “He may be right in 30 percent to 40 percent of the cases,” they say.

If 30 percent to 40 percent of back pain patients have TMS, why then do these critics never make the diagnosis themselves?

The sad fact is that they cannot because it means repudiating long-held diagnostic biases and acknowledging the role of the emotions in these pain syndromes--something for which they have a “visceral incapacity,” to borrow a phrase from Senator Byrd of West Virginia.

These treatment results are the only solid proof of the accuracy of the diagnosis and the efficacy of the therapeutic program. Indeed, many of the people who come know one or more successfully treated patients. But that’s not new in medicine. The best referral source is still a successfully treated patient.

It should be emphasized I don’t consider someone to have been successfully treated unless he or she is free of significant pain (everybody is entitled to a little bit of pain from time to time) and is able to engage in unrestricted physical activity without fear. As said before, the fear of physical activity may be more disabling than the pain for someone with a chronic pain problem. Virtually everyone I have seen has been a prisoner of fear (of hurting himself, of bringing on an attack) and that works even better than the pain to keep the attention focused on the body instead of the emotions. It is our job to liberate them from this pervasive fear.

I find myself searching endlessly for ways of getting the message across. Certain phrases may reach some people but not others­ so I use them all:

 

“We’re going to try to stop the body from reacting physically to your emotions.”

“We want you to learn to send messages to the subconscious mind.”

“Information is the penicillin that cures this disorder.”

“The cure is wisdom.”

“The cure is knowledge.”

“Until now your subconscious mind has been in charge; I’m going to teach you how to have your conscious mind take over.”

“Get mad at your brain; talk to it; give it hell.”

“TMS is a trick your mind is playing on you-—don’t fall for it.”

“TMS is a sideshow designed to distract you from what is going on emotionally.”

“The symptoms are an act to mask what’s going on in the psyche.”

“Most of the structural changes in your spine are natural occurrences.”

“The brain doesn’t want to face up to the repressed anger, so it is running away from it.”

“By laughing at or ignoring the pain you are teaching the brain to send new messages to the muscles.”

“We’re going to help you take the Sword of Damocles into your hands instead of having it hang over your head.”

 

I am particularly grateful to a patient, Ms. Norma Puziss, who presented me with the following verse at the completion of her treatment program. It is now a regular part of the lecture-discussion.

 

Think psychological, not physical,

An idea that is most quizzical.

No one would have guessed

Emotions deeply repressed

Could produce such tension

Not even to mention

TMS.

There is nothing to fear!

Subconscious, do you hear?

You concentrate on pain,

A back sufferer’s bane,

To divert one’s attention

From underlying tension.

Your secret is out;

You have lost your clout.

So give it up, resign---

TMS is benign!

I am in control, not you.

I have learned that I’ve got to­---

Think psychological, not physical.

 

I am sure that this wonderful bit of verse has been helpful to many of my patients, since it captures one of the basic ideas so beautifully.

Since it is characteristic of people with TMS to feel victimized and not in control, the treatment program must help them regain their sense of power by pointing out that the source of the pain is a harmless process. I encourage patients to develop an attitude of disdain toward the pain to replace their strong feelings of intimidation. This sends a message to the subconscious that the strategy of keeping attention focused on the body is about to fail­ which means the cessation of pain.

QUESTIONS PEOPLE ASK

One of the more difficult concepts to grasp is the fact that one does not have to eliminate tension from one’s life.

 

People ask, “How do I change my personality and how do I stop generating anxiety and anger?”

 

If these were prerequisites for recovery my cure rate would be zero. It is not changing one’s emotions; it is recognizing that they exist and that the brain is trying to keep one from being aware of their existence through the mechanism of the pain syndrome. That is the key point in understanding why the knowledge is the effective cure.

 

“How do you know that what you’re doing is not a placebo?”

 

An excellent question and one that has always concerned me because a placebo reaction is to be assiduously avoided. A placebo cure is almost always temporary and we are looking for permanent resolution of the pain. Therefore, we would not be satisfied with a placebo cure. This is all too common. People are administered a large variety of physical treatments, feel better for a few days, and then need another treatment. (And, of course, they never overcome their fear of physical activity.) One of the reasons I know the TMS program does not induce a placebo reaction is the fact that almost all patients have permanent resolution of symptoms.

A second reason is that the placebo effect is based on blind faith; patients know little or nothing about the disorder they have and the rationale for treatment. They simply trust the treating practitioner. The educational program employed in the treatment of TMS is the very opposite. I teach patients literally all I know about the disorder; they are encouraged to ask questions and they are warned that they must find the diagnosis logical and consistent. Their recovery depends on information, on awareness. They are active participants in the recovery process. This is anything but a placebo process.

Perhaps the most compelling argument that what we do is not a placebo is the fact that on numerous occasions since the publication of the book Mind Over Back Pain, the predecessor of this one, people have reported complete and permanent resolution of pain simply by reading the book. There is no personality influence here, no bedside manner; just plain, solid information. And we have learned that that’s what it takes to banish TMS.

 

“Why have you stopped using physical therapy as part of your treatment program?”

 

This was touched on before but it bears repeating. As has just been said, any physical treatment can be a placebo, including physical therapy, and we strive to avoid this because the result is temporary. But there is another, more subtle reason. If I am trying to get people to stop paying attention to their bodies and start thinking psychologically about their pain, am I not contradicting my own therapeutic strategy if I prescribe physical therapy? It took me a long time to realize this and get up the courage to stop prescribing it, for after all I was taught to depend on physical treatments like everyone else. I only remember with some effort now how difficult it was to start “going pure,” that is, to depend on the education program exclusively. In fact, to emphasize the point, I recommend to patients that they stop doing all exercises that are designed to protect or help the back, for the same reason. They must do nothing to focus attention on the painful area.
     In this same vein, patients are taught that there is no correct way to bend or lift, one doesn’t need to avoid soft chairs or mattresses, corsets and collars are unnecessary, and in general the great number of admonitions and prohibitions that have become part of back pain folklores are simply without foundation because TMS is a harmless condition and there is nothing structurally wrong with the back. Running is not bad for the spine; weak abdominal muscles do not cause back pain; strong back muscles do not prevent back pain; it is perfectly all right to arch the back, swim the crawl or breast stroke; man was meant to walk upright (Homo sapiens and his ancestors have been doing so for somewhere between 3 and 4 million years); a short leg does not cause back pain. One could go on and on.

 

“How can I tell the difference between TMS and pain from overworking unused muscles?”

 

That’s easy. When you’ve done some unaccustomed physical activity and wake up the next morning with aches in your arms or legs, it’s a good kind of ache and it’s usually gone by the following day. The pain of TMS is always nasty and it doesn’t go away very quickly, if at all.

 

“What kind of exercise can I do?”

 

When the pain has subsided one can do anything and everything, the more strenuous the better. Obviously one should follow a strenuous routine only after consulting with one’s doctor. But the point is that exercise should be done for general health reasons, not for the back.

 

“Suppose the pain goes away in my low back and starts up in the neck and shoulders. What do I do?”

 

My routine advice to patients is to call me up so that we can discuss the meaning of the switch. During the early phases of the treatment program the brain may try to locate the TMS somewhere else in the neck, shoulders, back or buttocks. It is reluctant to give up this convenient strategy for diverting attention away from the emotions. Patients must be warned that this may occur, that they must not panic or get discouraged, but merely apply the same principles to the new location. I remind them that the musculoskeletal system is not the only one where the brain can set up a diversion. It can do the same thing in the gastrointestinal tract, the head, with tension or migraine headache, the skin, the genitourinary tract. The brain can cause mischief in any organ or system in the body, so one must be on guard. I advise my patients to consult their regular physicians if a new symptom occurs but to let me know about it since it may be serving the same purpose as TMS. For example, stomach ulcers should be treated with proper medication but it is almost more important to recognize that they are coming from tension factors.

 

“What do I do if I get a recurrence six months or a year from now?”

 

I advise patients to call me immediately so that we can promptly start looking for the psychological reason for it. This usually means attendance at one of the small group meetings or a visit to my office.

 

“What about hypnosis? Isn’t that a good way to get your mind to do what you want it to do?”

 

On a temporary basis, yes, but we are looking for a permanent cure. Just recently a study done at Stanford Medical School and reported in The American Journal of Psychiatry demonstrated very nicely that with hypnosis pain could be markedly diminished in some patients. That is desirable if you are treating pain, as in patients with cancer. But I tell my patients, with considerable agitation, that I don’t treat pain! That would be symptomatic treatment and it’s poor medicine. I treat the disorder that is the root cause of the pain. To the best of my knowledge, hypnosis would not contribute to that process.

Which leads to a subject I would rather not discuss, it pains me so. But discuss it we must for it is of great importance. It has to do with how “chronic pain” is treated in the hundreds of pain clinics established in the last twenty years across the country.

The basic principle, first enunciated by a nonphysician, is that chronic pain is a separate disease entity, an exaggeration of the pain of some persistent structural abnormality that develops because patients derive what psychologists call “secondary gain” from the pain. That is, the pain brings them some psychological benefit, like attention, money or escape from the world. It is theorized that patients learn this behavior because it is encouraged by the medical system, family and friends. Treatment is designed to discourage this by rewarding nonpain behavior and “punishing” its opposite. Students of psychology will recognize these ideas as deriving from the work of B. F. Skinner, who became widely known for his work in demonstrating this kind of conditioning.

While it is well known that human beings can be conditioned in the classic Pavlovian sense, one must be very careful about applying Skinnerian principles to human beings. Elements of secondary gain are often identified in my patients but they are by no means the primary psychological factors at work. To attribute to secondary gain such importance is to ignore the real problem­ repressed feelings of all kinds­--and make the equally egregious mistake of failing to recognize the true physiology of the pain, that it is not due to a persistent structural abnormality but to a psychophysiologic process, as described in this book.

It is for this reason that these pain clinics sometimes help but rarely cure their patients.

 

“Is the TMS treatment program an example of vis medicatrix naturae, or the body’s ability to heal itself?”

 

In one sense it certainly is. But in another, it goes beyond the usual process of self-healing which is always at work when we are injured or invaded by poisons or infectious agents. This is an example of how a particular kind of physical disorder, a psychophysiological process, can be reversed. In the last chapter we shall discuss this and other mind-body interactions, a subject that is finally beginning to command the attention of research medicine. 

 

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