Have you struggled with chronic pain or another medically unexplained symptom for a long time? Have you tried everything to alleviate your pain, but nothing worked? Have you had doctors tell you they “just can’t find anything wrong?”
Then you may have Tension Myositis Syndrome (TMS). TMS is a condition that causes real physical symptoms that are not due to pathological or structural abnormalities and are not explained by diagnostic tests. In TMS, symptoms are caused by psychological stress.
People with fibromyalgia who are desperate for pain relief might well be tempted to read on to find out more about Tension Myositis Syndrome (TMS). At face value it does appear to be a genuine medical condition. But when they delve into its origins, there may be some unwelcome surprises.
Tension Myositis Syndrome, also known as Tension Myoneural Syndrome and Mind Body Syndrome, was originally described in 1981 by Dr John Sarno, a retired professor of Clinical Rehabilitation Medicine at New York University School of Medicine, and attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine at New York University Medical Center.
This article will trace the development of Dr Sarno’s ideas over the past four decades and will show how he and his followers have tackled the vexed problem of the relationship between mind and body by inventing a psychologically based condition (TMS) together with an imagined musculoskeletal lesion. As an aside, their strategy bears more than a passing resemblance to that of those who pioneered the now discredited concept of the “myofascial trigger point”.
What is TMS?
According to Sarno (1998) TMS is “a benign (though painful) physiologic aberration of soft tissue (not the spine) and it is caused by an emotional process.” He suggests that this process is the result of “specific, common emotional situations”. The various soft tissues that can be affected in this peculiar disorder include muscles, nerves, tendons and ligaments (Sarno, 1998).
As Coen and Sarno (1989) explained:
“Of approximately 4000 patients with neck, shoulder and back pain seen by physiatrist author (JES) over 15 years, over 95% were diagnosed as having TMS. What stands out most from our clinical material are the contributions of tension and chronic character defences to musculoskeletal symptoms, and then the uses made of pain (for dependency, defence of narcissistic preoccupation with the pain, for punishment, and to express anger against caretakers (internal and external).
We emphasise the relative ease of helping patients out of their back pain syndrome … Empathic explanation of the role of anxiety and defensive states in causing back pain, together with reassurance that this is a reversible self-limited process, usually leads to recovery.
The capacity to tolerate one’s affective life seems, in effect, to preclude the back pain syndrome. We believe that the more able patients are to tolerate what they feel, including their anxiety, vigilance, mistrust, anger and depressive feelings, the less troubled they will be by back pain.”
To further confuse the issue of nomenclature, Sarno proposed that TMS syndrome be relabelled “the mind body syndrome,” which includes the musculoskeletal disorder now referred to as “musculoskeletal mind-body syndrome (MMS), as well as a large variety of other psychophysiologic conditions involving other systems (Rashbaum & Sarno, 2003).
What is the postulated mechanism?
Physical symptoms are said to occur when the unconscious mind senses that repression of emotions may fail and an “emotional eruption” is imminent. The conflict is between “the reasonable, intelligent, moral, conscious mind and the childish, primitive archaic mind that continues to have a strong influence on the unconscious” (Rashbaum & Sarno, 2003).
Repressed unconscious emotions (e.g. rage) can trigger abnormal autonomic nervous system activity, apparently resulting in mild ischaemia (i.e. lack of blood supply) and mild oxygen deprivation that can adversely affect muscles, nerves & tendons. These changes in physiology are supposedly manifested by muscle pain, nerve pain, tendon pain, paraesthesias (“pins and needles”) and muscle weakness.
There is of course no scientific evidence whatsoever to support these wild guesses.
TMS & fibromyalgia
Sarno (1998) decided to characterize fibromyalgia as a severe form of “musculoskeletal mind-body syndrome” with multiple ischemic foci involving muscle, nerve, and tendon. Rashbaum and Sarno (2003) chided the American College of Rheumatology (ACR) because although the diagnosis required the identification of 11 of a potential 18 tender points in the trunk, arms, and legs, it did not make the connection between the emotions and clinical findings.”
Resorting to psychoanalytic theory, Sarno made the connection by proposing that fibromyalgia was caused by “the psychosomatic avoidance of psychic conflict.” He even gave the pain a purpose, which was “to distract attention from frightening, threatening emotions and to prevent their conscious expression.” Fibromyalgia therefore signified the person’s abject failure to resolve his or her own psychic conflict:
Physical symptoms occur when the mind senses that repression of emotions may fail and an emotional eruption is imminent. The conflict is between the reasonable, intelligent, moral, conscious mind and the childish, primitive archaic mind that continues to have a strong influence on the unconscious.
Current status of Sarno’s ideas
Schechter et al. (2007) published outcomes of a “mind-body” treatment offered to a convenience sample of 51 patients with persistent low back pain and a diagnosis of TMS (note that Sarno is referenced in relation to making this diagnosis). The primary goal of this program was “to raise patient awareness of how emotional issues, including repressed emotions, affect their physical pain” by counseling and educating patients on “how psychological factors can manifest as physical pain” and learn to begin “thinking psychologically,” instead of “structurally,” about their pain.
The authors conceded the many limitations of this study, with financial and logistical constraints forcing them to conduct a case series study instead of a randomized clinical trial. The authors’ lack of specific criteria for a diagnosis of TMS and their inability to precisely standardize the program for all patients makes interpretation of this paper impossible.
However, Dr Howard Schubiner and his co-workers are others who continue to advocate John Sarno’s ideas. As he informs those who visit his blog site:
Your body is producing pain because it’s manifesting unresolved stress, possibly from your childhood, or from stressful events in your adulthood, or from your present circumstances, and as a result of your personality traits (which affects how you respond to stress and how much pressure you tend to put upon yourself).
In a more recent publication, Lumley et al. (2015) have restated these views:
We view the key pathological process in both unresolved trauma and internal conflict to be the avoidance or suppression of one’s primary or adaptive emotions, which then activates neural pathways that trigger, augment, or maintain pain and other symptoms.
In the meantime, Hsu et al. (2010) reported the results of a randomized controlled trial of Dr Schubiner’s program of intervention – Affective Self-Awareness (ASA) – developed at Providence Hospital.
Without going into details, the 24 of the 45 participants who attended Dr Schubiner’s three 2 hour small group sessions over three weeks and had read one of Dr Sarno’s standardized texts (Sarno, 1998) reported less pain and improved physical functioning compared to those in the 21 wait-listed control group. Members of the latter group were “free to engage in any interventions on their own, as recommended by their providers …”
It comes as no surprise that the authors reported:
Individuals with fibromyalgia in this study appeared to accept the central message of the intervention: that the experience of pain in fibromyalgia is real, that fibromyalgia pain is processed in the central nervous system, that unrelated emotional experiences can initiate and perpetuate physical symptoms, and that the mind-body link can be tapped to empower individuals with fibromyalgia to more effectively diminish pain and associated symptoms.
The authors conceded that they had no idea as to the mechanisms responsible for the benefits of the ASA intervention. But at least they did acknowledge the possible contribution of various contextual factors.
The pivotal research question posed by Schubiner et al. (2012) is to “determine if targeting unresolved stress and emotions offers an advance in the treatment of chronic non-structural pain.”
Hsu et al (2010) do intend to conduct a larger study that will “not only assess the efficacy of this type of intervention in comparison to an active control group, but will allow for assessment of mediating and moderating variables to help determine mechanisms of action and subgroups of patients that respond best to this intervention.”
There can be no doubt that this formidable (and impossible?) task will continue to tantalize future generations of researchers who have embraced Dr Sarno’s ideas.
It is indeed unfortunate that Dr Sarno’s outdated theories, which were always highly speculative and heavily influenced by insupportable psychoanalytic theory, continue to influence some clinicians in their approach to patients with fibromyalgia. Their laudable aim may have been to close the mind-body split but in effect they have only succeeded in widening the gap and, in so doing, have inadvertently shifted the blame for their pain onto their patients.
Coen SJ, Sarno JE. Psychosomatic avoidance of conflict in back pain. J Am Acad Psychoanal 1989; 17(3): 359-376.
Hsu MC, Schubiner H, Lumley MA, et al. Sustained pain reduction through affective self-awareness in fibromyalgia: a randomized controlled trial. J Gen Intern Med 2010; 25 (10): 1064-1070.
Lumley MA, Schubiner H, Carty JN, Ziadni MS. Beyond traumatic events and chronic low back pain: assessment and treatment implications of avoided emotional experiences. Pain 2015; 156; 565–566.
Rashbaum IG, Sarno JE. Psychosomatic concepts in chronic pain. Arch Phys Med Rehabil 2003; 84 (Suppl. 1): S76-S80.
Sarno JE. The mind-body prescription: healing the body, healing the pain. New York: Warner Books, 1998.
Schechter D, Smith AP, Beck J, et al. Outcomes of a mind-body treatment program for chronic back pain with no distinct structural pathology – a case series of patients diagnosed and treated as tension myositis syndrome. Altern Ther Health Med. 2007; 13(5): 26-35.
Schubiner H, Burger A, Lumley M. P02.147. Emotions matter: sustained reductions in chronic non-structural pain after a brief, manualized emotional processing program. BMC Complement Alt Med 2012; 12 (Suppl 1): P203.