FIBROMYALGIA AND THE SARNO CONNECTION

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.

http://www.tmswiki.org/ppd/An_Introduction_to_Tension_Myositis_Syndrome_(TMS)

Introduction

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).

http://mind-body-blog.blogspot.com.au/2008/02/mindbody-syndrome-tension-myositis.html

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.

Conclusion

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.

References:

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.

 

 

47 Comments

  1. In case this article gives the impression that psychological stressors may not be important in the pathophysiology of fibromyalgia, I refer readers to the summary article by Dr Pamela Lyon. She makes it clear that perceived physical and/or psychological stressors are equally capable of activating systems of stress response. The “stress response” hypothesis suggests that it is the inability of these self-regulating systems to switch themselves off when the stressor that evoked them is no longer present. Link: http://www.fmperplex.com/2013/02/12/evolution-stress-and-fibromyalgia/

    • Thanks Dr. Quintner. I used to be that patient reading Dr. Sarno, fighting so hardly for finding those thoughts and experiences to blame. I did fix some emotions about my past, but my pain endures and sometimes I feel anxiety even when I am asleep.
      This year, one month before my 30 birthday, I was diagnosed with Fibromyalgia. I think my story supports your explanation because I was living under chronic stress, suffering anxiety and personal frustrations, then came the pain. If I ‘ve understood well, my question is what can I do to switch the stress response off ? What is the possible solution? Is there something being researched?
      (Sorry for my english) Greetings from Colombia.
      Paola

        • Thanks a lot, Dr. Quintner. I read the article and it is so hopeful and exciting to know there are people working for understanding this topic! As a science lover and sufferer of this condition I will pay very close attention to the news around this area. I think I’ll be alive to do my epigenetic therapy. Kind Regards!

  2. Addendum: Where did Sarno go so wrong?

    It appears that John Sarno extrapolated the findings derived from a large group of hospitalized male air force personnel to members of the general population who were experiencing persistent idiopathic back pain.

    Roy Grinker and John Spiegel (1945) had undertaken a detailed and important study of this particular air force population. Grinker was a leading American neurologist & psychiatrist, and Professor of Psychiatry at the University of Chicago and Spiegel was an American psychiatrist who was an acknowledged expert on violence and combat stress.

    The inspiration for John Sarno’s work was an editorial in the New England Journal of Medicine by Major Morgan Sargent (1946), who was commenting upon the work of Grinker and Spiegel:

    “These patients are for the most part men who have returned from combat tours in all parts of the world, and who on admission are suffering from symptoms of nervousness, insomnia, tension, irritability, restlessness, depression, startle reactions and other neurotic complaints … Most of these patients are former members of air crews … Their symptoms have been brought on by long separation from home, privation, loneliness and difficult climatic conditions. No patients have been seen in whom backache was the only complaint.”

    In today’s parlance, most of these men would be diagnosed as suffering from Post Traumatic Stress Disorder (PTSD).

    However, Sarno (1998) broadly defined “stress” as “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.”
    He then made a huge leap of faith by announcing that “the stress involved in TMS leads to emotional reactions that are repressed.”

    Sarno (1998) saw the clinical phenomena observed in the male air force personnel by Grinker and Seigel (1945) as being typical of fibromyalgia. Moreover, they were now mostly to be found affecting women:

    “Muscular rheumatism, chronic aches and pains, disturbed sleep and morning stiffness affect a few million people in the United States, most of them women between the ages of twenty and fifty, and may be diagnosed as fibromyalgia.”

    The contribution made by Grinker and Spiegel was without any doubt highly important the history of PTSD.

    Finally, the clinical and biochemical overlap between PTSD and fibromyalgia is well recognised and accords with the evolutionary stress hypothesis for fibromyalgia (Lyon et al. 2011) and with current understanding of the biology of PTSD (Baldwin 2013).

    References:

    Baldwin DV. Primitive mechanisms of trauma response: an evolutionary perspective on trauma-related disorders. Neurosci Biobehav Rev. 2013; 37(8): 1549-1566.

    Grinker RR, Spiegel JP. Men Under Stress. New York: Blakiston, 1945.

    Lyon P, Cohen ML, Quintner JL. An evolutionary stress-response hypothesis for chronic widespread pain (Fibromyalgia Syndrome). Pain Medicine 2011; 12: 1167-1178.

    Sargent M. Psychosomatic backache. NEJM 1946; 234: 427-430.

    Sarno JE. Psychogenic backache: the missing dimension. J Fam Practice 1974; 1: 8-12.

    Sarno JE. The mind-body prescription: healing the body, healing the pain. New York: Warner Books, 1998.

  3. Thank you for a very interesting perspective. I had sent this article to a couple of leading advocates for Dr. Sarno’s theories hoping they would engage you in further discussion, but I see that has not happened. I take it you are familiar with the many reported “success stories” using Dr. Sarno’s (or similar) methods in addition to his own claims of success, assuming their accuracy do you think they are just placebo responses?

  4. Peter, I am reminded of the great American physician Dr Silas Weir Mitchell [1829-1914] and his “rest cure” for neurasthenia (the clinical features of which bear some resemblance to those of modern day fibromyalgia). He was able to achieve remarkable results that unfortunately eluded the best efforts of his followers.

    My interest in the work of Dr John Sarno dates from February 2012 when he contributed evidence to a hearing of the US Senate Committee on Health, Education, Education, Labor and Pensions that was then considering “Pain in America: Exploring Challenges to Relief”.

    Link: http://www.help.senate.gov/imo/media/doc/Sarno.pdf

    To answer your question, on the evidence available to me I suspect there are elements of expectation and confirmation bias (i.e. post hoc ergo propter hoc) that will need to be addressed in future studies. Therefore, I look forward to publication of the important study signposted by Hsu et al. (2010).

    In the meantime, advocates for Dr Sarno’s theories and practice are welcome to contribute to this discussion.

    Reference: Mitchell SW. Fat and Blood: an Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria. Philadelphia: JB Lippincott & Co., 1884.

  5. Given the wide divergence of chronic pain symptoms, and perhaps more importantly the absence of any precise treatment regimen advocated by Dr. Sarno (how, for example, does one define “think psychological” or ensure that a group of patients are doing so?), I would think it would be quite hard to design and conduct a reliable scientific study in this area. So retrospective, anecdotal-type evidence, for all its weaknesses, may be all one has to go on. That said, there certainly is historical and common-sense appeal to the broad notion that the psyche (or whatever the right word is) can play a major role in causing physical symptoms.

  6. So what is your stance then? are Dr. Sarno’s theories “out-dated” and “insupportable” or not?
    I have been the close witness of people with severe back and leg pain, who had surgeries like laminectomy and also tried everything imaginable from physical therapy to Acupuncture and so on, and these people have diminished their back or leg pain completely with his “out-dated” theories.
    Granted, it’s not always a quick and easy fix, but I have seen great results from it.
    Even there are forums on the internet where you can read hundreds of success stories, no quotation marks, where people have been freed from years and years of pain, even from fibromyalgia ..
    are all these people under a false influence?

  7. My stance is that Dr Sarno’s theories are both outdated and insupportable. But those who still espouse his theories and follow his methods of practice have an obligation to present their outcome data in a scientifically credible forum. Is that fair comment?

    • I don’t know about the “outdated” and “insupportable” remarks.
      I agree that it is better to provide randomized clinical trials and share the results with people. BUT, you have to keep in mind that we are mostly talking about matters of the unconscious mind, these are pretty qualitative data and couldn’t be represented the best by numbers and values. If anything, the results would show that people “self-reported” , or “felt” better. For example, with something like fibromyalgia that the doctors can’t find a physiological reason for the pain, they can’t measure the amount of it either! it just relies on the patient and how he/she feels. So I think one of the problems facing the people who are working on TMS is that they can’t say that this physiological marker was improved,etc.. Also, Regardless of his “outdated” theories, he still showed data that people who didn’t have any pain, had severe disc “issues” in the MRI scans and the ones who did have pain , had no “problems” in their spinal discs. this was consistent with a lot of other physical deformities that today are “treated” with surgery. don’t you think a lot of these surgeries are at best placebos? because again, I personally have witnessed a laminectomy which didn’t heal my sister in law’s pain, it persisted after 3 years of different kinds of therapy, but when she worked on her mind and let her fears go away like Sarno says, her pain vanished in like less than a month..
      Don’t get me wrong! I my self am a Master’s student in Clinical Exercise Physiology and am also thinking about going to Rehabilitation Sciences for my PhD, I try to look at EVERYTHING with a critical eye, but this just seems like something that AT THE VERY LEAST, couldn’t be flat out wrong.. maybe there are somethings that he didn’t completely understand, maybe there are other factors involved, but ALL THE SCIENCES have evolved this way. calling something like Dr. Sarno’s work “outdated” and “insupportable” makes the impression that it isn’t worth evolving and developing into something that is more complete and accurate.

      • Thanks for your response. I too look at these issues very critically. Let us see whether Dr Sarno and his followers wish to take up the challenge that has been thrown down to them. Others have extensively researched the field of the “unconscious mind” and published their findings. Mindfulness meditation is slowly gaining in acceptance as being a valuable tool in pain management. I wish you well in your academic career.

        By the way, you may have not seen our hypothesis paper on fibromyalgia. Here is the reference: Lyon P, Cohen ML, Quintner JL. An evolutionary stress-response hypothesis for chronic widespread pain (Fibromyalgia Syndrome). Pain Medicine 2011; 12: 1167-1178.

  8. I agree that it would be extraordinarily difficult if not impossible to validate Dr. Sarno’s theories, or more general psychological approaches to pain, in a controlled trial that would pass scientific muster. But what conclusion does one draw from that? That doesn’t necessarily invalidate the theory, does it? Must it be verifiable? After all, one can’t prove the existence of God either, but I have no doubt that among even the most rigorous scientists many believe. Sometimes anecdotal evidence plus plausibility is all one can go on. Dr. Quintner, if your position is that Dr. Sarno’s theories/methods are not plausible, perhaps you could elaborate?

    • A scientific theory is only useful if it can generate testable hypotheses. According to Dr Sarno’s theory, psychic (emotional) stressors can generate “aberrations of soft tissue” that act as foci of nociceptive input and thereby be the source of muscular pain. However, such “aberrations” have never been demonstrated, which puts his theory into the same category as that which postulated the existence of “myofascial trigger points”. In both these instances, the respective theories have been exposed as mere conjecture rather than established knowledge. In my opinion, as I have argued above, Dr Sarno’s theories are implausible. Anecdotal evidence supporting his treatment methods does not validate his theory. This type of fallacious argument is known by the name of “post hoc ergo propter hoc”.

      • As I understand it Dr. Sarno’s proposed mechanism of pain is that reduced blood flow to the affected muscle or other soft tissue causes mild oxygen deprivation.

        In any event, I get that neither he nor his followers have met their burden of proof. But to me, as a layperson, that doesn’t establish that the theory is wrong, only that it hasn’t been proven yet.

      • It is true, anecdotal evidence does not validate Dr. Sarno’s theory. Unless you are one of the fortunates who embraced Dr. Sarno’s theory, intuitively understand the validity of the theory, and feel the challenge of facing the self while discovering fear and pain melting away.
        In this case, post hoc ergo propter hoc is validated without question.

        • The fact that a psychological-based intervention has been found helpful by many patients with chronic widespread pain (aka fibromyalgia) cannot be used legitimately as evidence to validate a theory of its causation (as advanced so ably by the late Dr Sarno). For your interest, this recent publication (still in press) does indeed support what appears to me to have been your own experience: https://www.ncbi.nlm.nih.gov/pubmed/28796118

  9. Aren’t we just talking about viewpoint and semantics. Can’t we just agree that changes in the body cause structural (and other) changes in the brain and mind and changes in cognitions, emotions, and behaviors cause structural changes in the brain and body. That chronic disease is usually a result of many years of lifestyle both of the body and the mind and the body. Lifestyle incorporates stress psychoanalytic discrepancies and many other factors. To fix or improve you need a behavioral change, which includes a metal change, and this can be achieve psychoanalytically or behaviorally or other “alternative” means. The situations are very disparate , so one size does not fit all? Other times, a surgical intervention will provide the best result, but it is fixing a result or a symptom, and the cause is complicated.

    • Marc, I picked up your typos. I see that you have broadened the discussion to include chronic disease and lifestyle factors. But keeping to the topic (“Fibromyalgia and the Sarno connection”), I cannot agree with you that Dr Sarno has gone close to solving the problem of the mind/brain/body relationship.

  10. John, many advocates of Dr. Sarno’s approach no longer look at oxygen deprivation as the mechanism behind the condition, rather learned neural pathways in the brain (see Howard Schubiner’s “Unlearn Your Pain”).

    I agree with you that the idea that pain is serving as a defense mechanism against repressed emotions is not the whole story, and doesn’t provide an evolutionary explanation for the genesis of such a process. Dr. Schubiner has proposed an alternate explanation for the evolutionary purpose of psychogenic pain as well.

    But these two points simply address the how and the why, while it is the what – that many forms of chronic pain are caused by a process in the brain and can be sufficiently treated from a psychological perspective – that is the meat of the theory.

  11. Ed, with respect, the notion of pain as protection/distraction against repressed emotions is pretty fundamental to Dr. Sarno’s theories, at least as I read his books and books by his advocates such as Steve Ozanich. Sure, there is a broader notion of pain as a psychogenic phenomenon that doesn’t depend on his particular slant, but that notion long preceded Dr. Sarno.

  12. Peter, although Dr. Sarno believed that the purpose behind the pain was to serve as a distraction from one’s repressed emotions, it is actually quite inconsequential as far as the treatment goes.

    Dr. Sarno believed that in most cases psychoeducation was the key component of recovery; that simply learning the pain was not due to structural abnormalities was sufficient to reduce or eliminate symptoms. So it’s significantly more important to learn what isn’t causing the pain than what is.

    I believe that Dr. Sarno developed his theories regarding oxygen deprication and distraction against repressed emotions primarily to answer questions that he considered relatively irrelevant, namely, how does this happen and why does this happen. I think he did the best that he could with the information that was available, but given that he is neither a neuroscientist nor a psychologist, he was relying on information outside his scope of expertise.

    I consider myself a proponent of Dr. Sarno’s theory, though I don’t agree with either of the aforementioned explanations.

    John, that was a pretty awesome play on words. I was going to make an appendix joke but could think of neither a set-up nor a punch line.

    I totally understand your skepticism. There are a handful a retrospective studies but those are hardly scientifically sufficient. What’s needed are credible, valid, large sample-sized RCTs.

    And they’re coming, John. They’re coming.

  13. The areas where I agree with Dr. Sarno are that many forms of chronic pain are psychogenic, that the brain has the capacity to generate any physical symptom in any part of the body, that often learned associations are developed and symptoms become associated with certain physical positions or activities though it is not the positions or activities themselves which cause the pain, and finally that overcoming the fear associated with the pain (usually fear of a structural abnormality or fear causing additional physical damage) is the most important component of recovery.

    If you were to present a compelling case that my current stance on the psychogenic component of chronic pain deviates from Dr. Sarno’s to the point where I no longer officially fell in the “proponent” camp, I would probably say, “Kudos on your debating skills.”

    Regardless of the technical distinction, I think the primary emphasis for many in the TMS community are that a lot (but not all) of chronic pain is psychogenic, that independent of the origin, the pain is indeed real, and that the symptoms can be treated with a cognitive-behavioral and/or psychodynamic approach.

  14. These are Dr. Sarno’s own 12 daily reminders. 3-5 seem quite integral to me, especially if one reads his books. No, Ed?

    1. The pain is due to TMS, not to structural abnormalities
    2. The direct reason for the pain is mild oxygen deprivation
    3. TMS is a harmless condition, caused by my repressed emotions
    4. The principle emotion is my repressed anger
    5. TMS exists only to distract my attention from the emotions
    6. Since my back is basically normal there is nothing to fear
    7. Therefore physical activity is not dangerous
    8. And I must resume all physical activity
    9. I will not be concerned or intimidated by the pain
    10. I will shift my attention from the pain to emotional issues
    11. I intend to be in control – not my subconscious mind
    12. I must think psychological at all times, not physical.

  15. Ed, how do you know when the pain of another person is “psychogenic” or it has what you call a “psychogenic” component?

    By the way, I do not have to present a compelling case that your current stance is insupportable because clearly it is a relic of the Cartesian split that led to the separation between body and mind.

    The TMS community needs to be aware that such a separation is outdated!

  16. Apologies if I am confused, but Dr. Sarno rejected the Cartesian split, no?

    ““Franz Alexander quotes Einstein as having said that Aristotle’s ideas of motion retarded the development of mechanics for two thousand years (also in Psychosomatic Medicine). It would be a pity if Cartesian philosophy were to do the same thing to the study of the influence of the mind, particularly the emotions, on the body.” (from Healing Back Pain)

  17. That’s a great question, John. Like with any other diagnosis, it starts by assessing for certain criteria: ruling out a pathological process (autoimmunes, etc.), assessing for a history of other pain syndromes, looking for inconsistency of symptoms, etc. These are by no means definitive, but you generally continue gathering evidence one way or another throughout treatment to get as clear a picture as possible. (I.e. If a patient generally has increased back pain the longer they sit, but during one session their back pain decreases significantly despite sitting stationary, the fact that that decrease in pain was correlated with a psychological intervention helps contradict their current paradigm that sitting longer = more pain.)

    It is this gathering of evidence in a variety of areas that helps make that diagnostic determination clearer.

    Peter, if you look at Dr. Sarno’s 12 daily reminders, they seem to have one goal: neutralizing the fear associated with the pain, and two specific techniques: fostering empowerment and generating a sense of safety.

    I’m not on board with the specific instructions of 3-5 or 10, for example, I’d change 3 to “TMS is a harmless condition, caused by learned neural pathways in the brain,” and 5 to “TMS simply exists as the collateral damage of the brain’s interpretation of a perceived threat”, but generally speaking, I think both sets of these instructions subcommunicate “you’re okay, don’t freak out, this pain is not dangerous.”

    The words are different, the explanations are different, but the underlying message is the same.

  18. Ed, I think I have accurately represented the published views of Dr Sarno and his followers. If I have omitted some key points or erred in my interpretation please let me know. As I understand it, your fundamental position is that when you cannot find a bodily explanation for a person’s pain, ipso facto they must have a mental problem and require some type of “psychological” intervention.

  19. John, your article has very accurately represented the the published views of Dr. Sarno, and in doing so you shone a light on the lack of rigorous evidence as well as some scientifically liberal assumptions he and his colleagues made regarding the psychological and physiological cause of the symptoms.

    The only conclusion you drew that i don’t think accurately reflects his views is your final sentence: the idea of blame being put on the patient for their symptoms. A person can no more likely be blamed for psychogenic pain than they can for the dreams they have while sleeping. Psychogenic pain is a process that does not involve conscious choice; just because it originates from one’s brain, it doesn’t mean they’re at fault.

    With regard to your second point, if a reason cannot be found for one’s pain, there are one of three reasons:

    1. The physician was not thorough enough/skilled enough/broad enough to identify the cause.

    2. The technology does not yet exist to determine the cause.

    3. The symptoms are a function of learned neural pathways in the brain (my words, not Dr. Sarno’s.)

    Luckily there are ways to determine, through doing a thorough intake and gathering evidence, whether the source of one’s pain is likely to be a function of learned neural pathways. And in these cases, the pain can indeed be “unlearned”.

    • Ed, the concept of psychogenic pain has long ago been relegated to the dustbin of medicine.

      All of the experiences that we call “pain” emanate from our brain. The idea that there are “learned neural pathways” is far too simplistic an explanation for persistent pain.

      Dr Sarno was indeed a voice in the wilderness at a time when our colleagues were enthusiastically pursuing surgical solutions for spinal pain. He foresaw the disastrous consequences of this assault on people in pain.

      I know he did not intend to blame his patients for their pain but our enlightened society does not view favourably those who cannot produce a scientifically credible explanation for their ongoing complaints and disability.

  20. Ed, don’t you think at least some chronic pain is simply due to muscle tightness induced by stress/anxiety/fear, and if so how do “learned neural pathways” square with that? I am thinking of Ron Siegel’s book “Back Sense” which focuses more on muscle pain than brain pain although maybe it’s semantics because obviously all pain ultimately is processed by the CNS and brain. But to me anyhow learned neural pathways sounds a lot like central sensitization which, I think anyhow, is different from nociceptive pain caused by tight muscles. Hopefully this is at least a somewhat coherent question.

  21. John, I happen to think the idea that the brain can learn and remember pain, and the notion that certain pain pathways can become linked with specific physical positions or activities (neurons that fire together wire together…) is a rather elegant and complex explanation for persistent pain. But we’ll just have to agree to disagree.

    Happily, randomized controlled studies are in the works. Several years down the road there will be more evidence one way or the other and at that time we can have a less theoretical conversation.

    Peter, that is a great question. I don’t know. If I had to guess, I’d say that that the same process that generates pain generates muscular tension.

    Nocioception literally means danger reception. If the brain determines there is danger to the body, it sets off an alarm signal. That alarm signal is pain.

    Another physical response to the interpretation of danger is muscular tension. So tension and pain can exist concurrently, but it doesn’t mean there’s necessarily a cause and effect relationship.

    In fact, some pain patients are able to eliminate their pain, while the muscle tightness remains. And some patients are able to eliminate their muscle tension through physical therapy, but the pain remains.

    It’s a good question though, and ultimately more rigorous tests would be needed to make that determination.

    Happy Thanksgiving to you both! This has been an enlightening conversation.

    Your friendly neighborhood relic of the Cartesian split,
    Ed

  22. I think that brains do learn and change their structure while learn – neuro-plasticity. On the question of muscle tension, this is a component of both the autonomic fight or flight response and persistent or learned pain. However, the relationship varies greatly between individuals and type of pain i.e lower back pain patients on average show a much higher muscle tension that FM patients. Both can be learned and unlearned, but this requires behavioral change. The system works great for kids quite automatically, but in adults, many years of life stresses, stress and pain adaptations, genetic predispositions, environmental influences, attitudes and other factors lead to a well rehearsed system that takes effort to change. Fortunately, in most cases this can be done with resorting to surgery or pills, which fail more than they work. Not easy though.

  23. Marc, how do you clinically assess the physiological entity known as muscle tension? Once you have been able to help me understand this phenomenon, I will be better able to respond to your comment.

  24. It can be measured with EMG, Electromyogram. Just electrodes which capture measure the voltage difference, generally over time. Similar to what the EKG does with the heart. Actually the same electrodes capture both and signal processing is used to separate the inputs depending what you are looking for. It can just be a pair or many more and it can be surface or intra muscular with a probe (needle). In lower back patients, generally the muscle tension is high where it hurts and it becomes persistent. FM generally do not have high muscle tension.

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