Fortunately for Mind Body Syndrome, we do know what is causing the symptoms: stress and emotional reactions that were typically primed in childhood and emerge later in life in response to new stressors which are linked to the earlier emotions (“emotional speed dial”), which is coupled with limited awareness or suppression of emotions and body reactions which alert us to a perceived danger.  I am currently finishing a book, entitled Unlearn Your Pain, which attempts to detail these processes from a psychological and neurological perspective.  It is axiomatic that the greater awareness and understanding of the cause of Mind Body Syndrome, the better we will be able to resolve the underlying emotional conflicts and eliminate the resulting physical or psychological symptoms.

For many people, the explanation above is sufficient to get them on the path towards healing.  However, for the more scientifically inclined, the question of “why is this happening?” goes deeper.  What is happening on a physical level in the body to create these symptoms?

There is clear scientific data to show that the pain and other symptoms experienced are real.  Studies by Dan Clauw, M.D. and colleagues at the University of Michigan clearly document that the pain of fibromyalgia (for which there is no evidence of physical tissue damage in the areas where the pain is being felt) activates the same brain structures as pain caused by tissue damage in the body.  However, a process known as central sensitization is present, which suggests that the nervous system and brain have developed pathways that create and activate pain.  These processes are learned and malleable since the pain often moves from place to place in the body and is greatly affected by stress and emotions. Dr. Clauw has also shown that people with chronic back pain also have central sensitization.  (This effect is demonstrated by increased amount of pain reported after pressure is exerted to the thumb.) Derbyshire and colleagues at the University of Pittsburgh have also shown that pain induced by hypnosis activates the same areas in the brain as does pain caused by heat applied to one’s hand. In short, the brain can create real pain.

Despite these data suggesting that the most important place to look for the cause of chronic pain in MBS is the brain, it is clear that effects in the body do occur.  When MBS causes diarrhea, the colon is activated to increased peristalsis (stool propelling motion); while when MBS causes constipation, the colon shows decreased activity.   When we get embarrassed, our face may turn red, obviously a sign of vaso-dilation of blood vessels; while stress can also cause our hands to get cold and clammy, which is caused by vaso-constriction of blood vessels.

There are scientific articles that document changes in tissues due to stress.  Studies of how quickly wounds heal in people with more or less stress show that healing is delayed and there is evidence of vaso-constriction and release of inflammatory cytokines, which cause slower return of these tissues to normal.  However, since this delay in healing is small (on the order of a few days) and the tissues do heal after wounds, I don’t think that these mechanisms of vaso-constriction and changes in the tissues persist long enough to explain pain that lasts for months, years, or decades.

In order to fully explain Mind Body Syndrome, it is necessary to explain symptoms that last for years and symptoms that are remarkably varied and complex.  Would vaso-constriction and tissue changes explain ringing in the ears, fatigue, anxiety, frequent urination, diarrhea, and constipation?  I don’t think so.  The only way to explain the varied manifestations of MBS is to understand that nervous system activation, probably of the autonomic nervous system (ANS), which becomes learned or wired into the brain is the likely culprit.  The ANS can cause increases or decreases in GI motility (for example, irritable bowel syndrome), urinary contractions (irritable bladder or interstitial cystitis), blood vessel constriction or dilation (migraine headaches, fainting, or flushing), rapid or slow heart beat, and activation (anxiety) or deactivation (fatigue and depression) of general nervous system activity.

It seems to me that attempts to explain MBS by focusing on what is going on in the peripheral tissues are misleading.  They tend to make people about a physical problem such as not getting enough oxygen to the body or persistence of soft tissue injuries that are not present.  Therefore, they may not be focusing on the real problem: learned pathways in the brain that need to be reprogrammed.  I believe that this concept better explains MBS in all of its manifestations and affirms that there is no significant physical problem that requires intervention.  When therapeutic energies are focused on changing the brain in order to change the symptoms, successful outcomes are more likely.

To your health,

Howard Schubiner, MD

I submitted a proposal to Kripalu, thinking that it would be a long shot. To my knowledge, no one has ever conducted such a seminar based upon the particular model initially proposed by Dr. Sarno. I didn’t hear from Kripalu for several months. One day, I mentioned the proposal to a close friend. Serendipitously, his sister, Annie Price, had just started working there and he called her to see if my proposal was being reviewed. She pulled it out of the pile and within a few weeks, I got an email asking if I could arrange to spend a week at Kripalu leading this retreat.

After working with people suffering with chronic pain and other syndromes caused by MBS for the past 6 years, it is becoming clear that there are a variety of paths to healing. For some, it only takes learning that emotions can cause pain and simply applying that revolutionary concept to their own life. These are the miraculous stories that most doctors (including me) love to tell. For others, it is necessary to look deeply into their life and work diligently and courageously at clearing the emotions that have been creating underlying mental conflict and tension. Others need to challenge the associations that have developed by pushing through pain that occurs with movement or exercise. In a blog I wrote on September, 2008, I described several steps that are often necessary to fully heal MBS (and heal one’s psyche at the same time).  I have listed them here as well.

1. Learning that MBS exists, that emotions can cause pain.

2. Understanding one’s own emotions, prior stressors, core issues that have lead to the physical and emotional symptoms.

3. Starting to uncover these core issues and emotions in writing and reflecting.

4. Speaking the truth to oneself, through writing, meditating, reprogramming the mind.

5. Reclaiming our bodies by doing the things which have triggered symptoms and using affirmations and self-talk to reprogram the brain so that these triggers (such as movements, exercise, certain foods, times, places, people) stop leading to MBS symptoms.

6. Recognizing hidden barriers in our own mind that may prevent us from getting better (see week 3 of the program); honestly asking ourselves the question: Why might my mind prefer to hang on to these symptoms?

7. Speaking the truth to others, telling others what you need, expressing anger or apology or forgiveness.

8. Accepting what needs to be accepted; forgiving what needs to be forgiven.

9. Doing things that we need to do, physical things (activities), but also things we want to do, and most importantly, figuring out what things need changing in our lives and actively working on those.

10. Letting go of past issues, recognizing that what has happened “should” have happened and that fighting reality is a horrible way to live (see the work of Byron Katie in week 4 of the program).

11. Creating our new self, deciding who we want to be and making that a reality, deciding how we will respond to issues and making that happen.

Because it can be complicated and difficult for many to overcome MBS (see some recent blogs of stories from brave people who have persevered to become symptom-free, for example, Joe’s story from October, 2009), we should be looking for innovative ways to help in the recovery process. The retreat at Kripalu was an attempt to create such a program.

From my perspective, the retreat went very well. I interviewed people separately to help them uncover the emotions that were creating their specific symptoms. Everyone was accepting of the MBS diagnosis and they all began to accomplish the first of the steps towards healing. There was enough time for people to bond together and share their stories. Kripalu is a healing environment, with healthy food, yoga classes, massage therapists, a great facility, and beautiful grounds. We had time for several directed meditations and mindfulness training. And they were away from their usual work and home lives, which allowed them to concentrate on their own healing and reflect on their lives. Everyone seemed thrilled with the retreat experience. I will solicit some of their stories in future blogs and get their input about this form of MBS work. Many of them began to see results in their attitude, mood, energy level, and pain within a few days. Time will tell if this experience worked to jump-start their recovery. They are now beginning the long, difficult work of going through the 4-week online program. I have tremendous faith in them and am grateful to them for attending this first MBS retreat. I’m not sure yet if this format will continue to be offered, but I think it holds great promise. There is clearly a need for new and different ways of doing this work.

I currently teach a 4-week class for healing MBS in the Detroit area. There is also the online program and now there may be a retreat format. I am coming out with a book in a couple of months. This will provide yet another option. I will write about that soon.

Send me your thoughts about the retreat format for healing MBS.  I’d be interested in your feedback.

To your health,

Howard Schubiner, MD

Here’s his story as told in an email to me:

“As far as my pain goes, I cannot report any miraculous change in symptoms; however, I continue to experience a very subtle phenomenon that I have dubbed an “erosion of tension.” Like the tide coming in and out, eroding the beach, it seems like my tight muscles are very, very slowly beginning to loosen. Then they contract again (or feel contracted), but when each time this happens (each time being like one back and forth of the tide), the tension in the muscles seems just the slightest bit less than before – so slight a difference, however, as to seem non-existent for the first few months that this was happening. Now, it has been long enough and steady enough that I believe it is happening, but doubt still lingers because of how subtle it all seems. Nonetheless, I am convinced of the MBS diagnosis. I do think that I am a particularly tough case, though. When I read about people who are totally healed by reading Dr. Sarno’s book one time through, I can get very envious, and also, sometimes, filled with doubt about whether I have MBS at all. But I am beginning to settle into the knowledge that I do.

Since first reading Dr. Sarno’s book (about nine years ago), I have forgiven my parents for an abusive childhood, begun to come to terms with a very rigid and intense Catholic upbringing, been able to sort through childhood traumas, been able to give up excessive drinking, gone through a whole year of psychotherapy, am finally done with the incessant belief that “there is something wrong with me” physically, and am at work on believing that there is nothing wrong with me mentally. I also went back to college and got a degree from an elite college, realized and admitted my deeply ingrained traits of perfectionism and self-hatred, rekindled a relationship with my wife and my daughter, my parents, and many other strangers. I have written literally thousands of pages of reflection, inquiry, and self-discovery, and have begun to remove from my shoulders the weight of the world, (and maybe, perhaps, if only for an instant, begun to rather like myself). I will say that most of the significant changes listed have come in the last year, with the help of your MBS website.

So, in one sense, yeah, I still have pain, and I’d love for it to be gone; but, in a weird sort of way, due to the incontrovertible changes for good that have transpired amidst the process of trying to “get healed”, I can now consider the pain a kind of benevolent guide. And while it was very difficult to trust this guide (it seemed so hostile and set against me) at first, I do trust it now; and if the pain is not totally gone yet, then I must choose to believe that it is because there is still more work that must be done.

The whole process has been like peeling an onion – one layer after another, after another – or, like unwrapping a gift, that gift being the unveiling of my long-covered-up True Self, which I hid so well for fear of it being destroyed by the hostile world surrounding. I think that this happened at such a young age that “undoing” it, at this adult age, seems semi-mystical. In actuality, perhaps it is just very natural. Or, yet again, perhaps the natural and the mystical are one in the same. I still don’t entirely understand any of this. The work of a Catholic monk by the name of Thomas Keating has helped exponentially. He writes much about the true/false self dichotomy; and has developed a form of Christian meditation that comes from ancient monastic practice. It is called Centering Prayer and I would highly recommend it to any other patients that you come across who, like me, struggle with a legacy of Christianity that might be suspicious of all things Eastern. You can learn more about his work here, if you have an interest: www.contemplativeoutreach.org

The greatest relief, thus far, has come in the instances where I’ve been able to throw up my hands and plead my ignorance. I don’t understand any of this! A favorite poet repeats the line: “I know nothing and I’m overjoyed. I know nothing and I’m overjoyed.” And I find myself resting in this, his mantra. This whole experience/journey/process has had a kind of supernatural aspect to it, and I find it very difficult to lay down my former ideas and just trust the leading, but this is what’s necessary. And that’s okay, I tell myself. I don’t have to be comfortable with it all the time. But, I’ve never been able to let my guard down like that before. I’ve always needed to concretely and intellectually “figure it out.” Be sure there were no surprises. And I have literally spent my whole life plagued by this vain attempt to make sense out of which religion was the true, right religion; what God wanted from me; whether or not the world was headed toward some kind of apocalyptic destruction; and on and on ad nauseam… But none of this has served me. It hasn’t allowed me the freedom to serve others either! It has only constructed a life lived in fear, isolation and self-hatred. Letting myself just be some guy who doesn’t have all the answers has been the greatest liberation of my life, and I know that it has been the catalyst to much of my own healing, both physical and otherwise.

Know that I am grateful for the opportunity to share these thoughts with you. And thank you for your continued interest and support. I feel confident that you are helping far more individuals with this work than you will ever get to know this side of the grave.”

Joe, thank you for those kind words.  You, also, are helping many people by your words, your example, and your wisdom. It is amazing how often the truth comes to us when we least expect it or when we aren’t really trying. Often we see the truth when we have surrendered to the realization that we are just who we are, and nothing more.  And that we are all that we need to be.

To your health,

Howard Schubiner, MD

Over the past couple of years, a new line of research has been developed which documents that certain disorders are socially contagious.  Nicholas Christakis and James Fowler have published articles in the New England Journal of Medicine and in the British Medical Journal documenting that smoking, obesity and happiness all share the ability to be affected by those around us.  The more people you know who are smokers, the more likely it is that you will be a smoker.  The same is true for having contacts who are overweight.  And if you have more friends and relatives who are happy, you are more likely to be happy!  It seems obvious that these issues can be affected by being in close contact because these issues are generally thought to be caused by our values, our thoughts and our behaviors.  That is, we can choose whether we smoke, how much we eat and exercise, and how to respond to the stresses in our lives.

Reading these articles made me think once again about the contagiousness of mind body syndrome.  I wrote a blog about this last year (Blog #6, June 20, 2008), but we now have some data and a way to measure this construct that we call social contagion.  Can physical symptoms be contagious?  We know that the flu or the common cold are contagious, i.e. you can catch it by being in close contact with someone who has it due to being exposed to the virus which causes it.  We would never think that you can catch cancer or heart disease because these are diseases caused by something that goes wrong inside your body, not something you catch from someone else.

If you read this blog, you are familiar with Mind Body syndrome, which is when one gets physical symptoms, such as back pain, headaches, fibromyalgia, irritable bowel syndrome or irritable bladder syndrome, due to stress and emotions that are either suppressed or unexpressed.  If these syndromes can be caused by stress and emotions, they may have many similarities with smoking, obesity and happiness, which are also related to stress and emotions.

Dr. Christakis referred me to one of his articles in which he suggests that headaches can be contagious.  He also indicated an article on back pain by Dr. Raspe and colleagues in Germany (Raspe, et. al. International Journal of Epidemiology 2008;37:69-74).

In this study, they gathered surveys on the amount of back pain reported by East Germans and West Germans, both before and after the fall of the Berlin Wall and the reunification of Germany.  Surprisingly, the prevalence of back pain was much lower in East Germany prior to reunification, however, after the two countries unified the amount of people with back pain in East Germany gradually increased to the level of that seen in West Germany, where it has remained.  The authors suggest that the cause of the rise in back pain in East Germans that back pain is socially contagious.  This is their explanation: “We hypothesize that back pain is a communicable disease and suggest a harmful influence of back-related beliefs and attitudes transmitted from West to East Germany via mass media and personal contacts.”

If headaches and back pain are shown to be socially contagious, this would be a huge advance in the understanding of what causes them.  The concept of Mind Body syndrome is not widely understood by physicians or by patients, even though everyone knows that you can get physical symptoms when under stress.  As I often say, your face turns red when you get embarrassed, your stomach tightens up when you have to give a speech, and you get a headache after a stressful day.  Doctors have recognized that stress and emotions can cause paralysis in the absence of a disease process such as a stroke or an infection, which is known as a conversion disorder.  However, most doctors do not realize that stress and emotions can cause chronic pain.

The work of Christakis and Raspe now offers the possibility of showing that certain disorders are related to stress and emotions, at least in part.  If we are able to use research methods similar to those used in these studies, we will hopefully be able to better understand the causes of common pain syndromes that are causing a tremendous amount of suffering in the world.  Let’s hope that this research goes forward.  The sooner these disorders are clearly understood, the sooner we will be able to help decrease suffering as well as medical testing and procedures which are unnecessary.

To your health,

Howard Schubiner, MD

I have learned so many things about the mind and the body over the past 5 years of working with patients with Mind Body syndrome.  One of the most interesting things is that disorders that we considered psychological, such as anxiety, depression, PTSD (post-traumatic stress disorder), and OCD (obsessive-compulsive disorder) actually are similar to (dare I say identical to?) Mind Body syndrome.  In other words, these disorders are caused by patterns of neurological response to stress and emotional reactions to stressful situations.  This leads to two conclusions: 1) that psychological disorders such as these occur as part of MBS and typically are exchanged (substituted) with pain and other typical MBS symptoms and 2) we can treat these disorders effectively using the same methods as we use for MBS. 

Read the story of Jacob, who had OCD, which morphed into chronic pain.  He learned that he had to deal with the OCD and the pain, but that they were connected by being components of Mind Body syndrome.

“About 10 years ago I had back pain for 2-3 years and read Dr Sarno’s book and also had a MRI which showed no problems and my back pain went away.  A couple years ago when having my second child I started getting high anxiety and really bad obsessive-compulsive disorder (OCD) about things like locking doors, chemicals around house and just about anything else.  Then about a year ago, I had surgery, and the pain after surgery started going away but lingered and then after taking numerous tests and seeing specialists and searching the internet about why the pain was not going away it started getting worse and worse.  Soon I was taking Vicodin for pain and searching for any cure I could find.  I even tried a pain clinic and had a nerve block which did not work and even made my back hurt for a few weeks (the doctor warned me that it was a possible side effect).  I was getting pretty desperate and depressed.  The pain was nearly unbearable.  I was taking sleeping pills at night to sleep and pain killers during the day. 

I saw Dr Schubiner during the middle of this and he tried to help me realize that the pain was caused by MBS and there was no physical problem.  However, I don’t think I really believed what he was saying.  I called him many many times desperately in pain.  One thing was weird and amazing:  when I was in really bad pain my OCD would subside, and then when the pain was a little better, the OCD would ramp back up.   I tried reading Dr. Sarno’s books and writing 1-2 hours every day.  Some days it seemed to work, other days it didn’t. 

I knew in the back of my mind that the pain was mostly mental, but it as so severe that it controlled me and my thoughts.  One day I was in my garage and I came to the realization that the pain had to be mental and I suddenly felt really confident.  The next day I woke up feeling a lot better.  But a couple of days later, the pain was back with a vengeance.  However, whenever I was able to be confident that I knew what was causing my pain (MBS), it would subside.  This happened a number of times, but I would always seem to slip back into pain.

Once when researching pain online (I do this much more often than I should), I stumbled across information about movements that can cause a hernia, which can cause pain in the lower abdominal area (my area of pain).  One of the things mentioned was lifting a heavy weight.  Well, that has become a big stumbling block in my recovery, as I would feel a little better and then I would lift something and sure enough I would start feeling more pain.  The pain wouldn’t necessarily occur right away, but it would start in a day or two, as I obsessed about it and got mad at myself for lifting whatever it was. 

I do feel better now.  I have a much better understanding of how my mind creates pain and how my obsessive thoughts are a big part of this problem.  I still have some pain every day.  It’s usually minor compared to what it was, but there is still some pain.  Every couple weeks it will get worse, usually after I obsess about lifting something.  But it gets better after a couple days.  Generally what’s worse than the ongoing pain is the fear in lifting anything over 15-20 pounds.  I know deep down that it is silly but the bombardment of thoughts about it is not worth putting my self through it.  Fortunately for me, my job does not require any lifting and I have become a pro at leaving the room to go to the bathroom when something heavy needs picked up.  I am definitely not cured but am holding on to the progress I have made. 

There are two things that I think are definitely true. The pain definitely takes my mind off of the obsessive thoughts/fears.  The second thing is that no one can help you but yourself.  It has to come from you.  I kept trying to look to somebody for an answer.  I think I started feeling better when I forced myself thru the agony to make it thru a day without taking any pain pills.  I always worried what if I would take the maximum amount of pain pills and still couldn’t make it through the day.  And I also worried that I would never start feeling better.  I do believe that when I was able to stop fearing the pain even a little (I still fear it to some degree as I was hesitant to even write this), that helped me feel better.  Now I just take a pain pill when it is really bad, but I know it will feel better in a couple days.

I am trying to take it day by day and not worry about tomorrow.  If I have some pain, I try not to worry about “what if it doesn’t go away.”  It is tough, but today I’m definitely better than I was a year ago.  The pain is sometimes better and sometimes worse, but it’s not near as bad as it was.  It’s the same with the OCD, sometimes better and sometimes worse, but again, it’s definitely not as bad as it was.  Unfortunately, I’m still terrified of lifting anything that might cause a hernia, but usually those thoughts go away after awhile.  But I can live with that.”

I am very impressed with Jacob’s story as it shows how difficult it can be to conquer MBS, especially when it is complicated by severe anxiety, in this case in the form of obsessive-compulsive disorder.  Jacob taught me that physical symptoms (typically pain) and psychological symptoms (typically anxiety or depression) are frequently exchanged for each other.  I have seen innumerable examples of symptom substitution over the years; pain moves from place to place, ringing in the ears replaces pain, pain replaces anxiety, insomnia replaces pain, diarrhea or constipation replaces OCD, depression replaces pain, fatigue replaces urinary symptoms.  Jacob had to cope with both pain and OCD; and as one improved the other one worsened.  It took great courage for him to face both of these symptoms at the same time in order to begin his recovery.  His story also teaches us that recovery isn’t always quick and immediate; it is often a prolonged and rocky journey.  Jacob isn’t totally free of pain or of OCD, but he understands himself better and has made tremendous strides in alleviating both of his MBS symptoms.  And, while he continues to work towards freedom, he can enjoy his life.

To your health,

Howard Schubiner, MD

The “disease” of TMS/MBS: Lori’s story

The last two blogs have dealt with the issue of fear and how fear can often derail the recovery process from TMS/MBS.  I thought it would be helpful to read the story of a brave woman who is confronting her fears head on.  Here is Lori’s story:

“Fear is a big issue for me right now, but I am making some progress in dealing with it. In the blog entry titled “A rose by any other name…” it says people can see themselves as having a disease called ”TMS” and see themselves as a victim of their life events, their stressors, or their mind. It goes on to say that people with TMS/MBS do not have a diseased autonomic nervous system (ANS). Until I read that, I hadn’t had the specific thought, “I have a diseased ANS”, at least not consciously. But when I thought about it, I realized that I really did fear that I had a disease or syndrome or chronic problem called “TMS” or “MBS”. I thought that since my physical symptoms were caused by emotional triggers, then those emotional triggers would always cause physical symptoms. I worried that whenever I was stressed, anxious, angry, guilty, or in a confrontation, I’d start to have physical symptoms. And since I often did have physical symptoms in those cases, that reinforced my fear of the emotional triggers.

“I read that blog entry over and over again, several times a day. I started to realize that when I did have physical symptoms, I had been thinking I had done something “wrong” to have caused them. I figured I shouldn’t have put myself in a stressful situation, or gotten angry and not calmed down quickly enough, or felt guilty and not figured out how to stop feeling guilty. Since I knew the physical symptom was due to an emotional trigger, I blamed myself for putting myself in the situation that caused the emotional trigger, or not controlling it well enough. Then I feared encountering future emotional triggers, thinking it was inevitable that they would lead to physical symptoms because I “had” MBS.

“I’ve started working on believing the thought “I don’t have a diseased ANS.” That means that it isn’t inevitable that I’ll have physical symptoms when I’m stressed. It isn’t inevitable that I’ll have physical symptoms when I feel guilty. It isn’t inevitable that I’ll have physical symptoms when I have a confrontation. I still do have physical symptoms with those emotions, since I haven’t gotten myself un-programmed yet. But now I don’t fear the physical symptoms so much. They aren’t part of a disease I have to have forever, or the result of a weak ANS, or the result of some flaw in my genetic code. They are just part of programming that it is possible to eventually resolve. I figured out that it’s OK to observe any physical symptom and any psychological symptom, no matter how painful or frightening, and not be afraid of it. It’s OK to let myself acknowledge the symptom and feel it without trying to push it away or get rid of it. It’s OK to feel strong emotions. It’s OK to be in stressful situations. It’s OK to take on challenges that might make me feel anxious.

“I haven’t yet been able to do this consistently, so the fear is still there sometimes. I find it’s easiest to just observe the physical symptom when the emotional trigger is obvious. When the emotional trigger is not obvious, or when it’s something I don’t seem to be able to resolve (for me that’s usually guilt), then it starts to get difficult to stay in the observer mode. I start to get swept up into feeling the physical symptom. I wonder why it’s not getting better yet. That quickly leads to worry that it’s never going to get better. Sometimes it helps to think, “What strong emotion might I be feeling right now unconsciously, even though I don’t feel it consciously or might feel the opposite consciously?” Or I think, “I must have a strong unconscious emotion that’s causing this physical symptom, even though I can’t identify it right now.” Other times it helps to think, “This physical symptom won’t last forever. It has always gone away, even if just for a short time, and it will again.” Sometimes nothing helps, and I just have to wait it out.

“One thing I still need to work on is that when I’ve identified the emotional trigger that’s causing a physical symptom, I often figure the physical symptom won’t resolve until the emotional trigger goes away. My logic is, “I figured out what’s causing this symptom, and that emotion hasn’t gone away, so of course my physical symptom won’t go away.” That is a fear that I need to change. I somehow need to reprogram my mind to learn that resolving the emotion or getting out of the trigger situation is not a requirement for getting rid of the physical symptom. Remembering I don’t have a diseased ANS is a step in the right direction.”

We can easily fall into the situation that was plaguing Lori, i.e. the notion that we have a disease called TMS/MBS, and that we will always develop symptoms of TMS/MBS whenever we are stressed or feel any kind of emotion.  This is a form of determinism, the idea that we are a victim of our past and can’t do anything about it.  In fact, the opposite is true when you think of it.  The traumas and stressors of our past have conditioned us to respond with pain because of our reaction to them, not because of the trauma itself.  Everyone has had traumas in their lives, of course some have been much worse than others, but the critical thing to understand is that we can control our reactions to the events in our lives, even though we cannot control the events that occur.   If you suffer from TMS/MBS, you do not have a disease, you have symptoms caused by stress and your emotional reactions.  Lori is a wonderful example of someone who is taking control of her reactions.  She is casting aside a victim mentality and asserting her ability to overcome her old patterns of reacting.  She is taking the journey towards freedom.  It is not an easy journey, but it is the only path that can lead to freedom from TMS/MBS symptoms and freedom from her past.

To your health,

Howard Schubiner, MD

It has become very clear to me over the last year or so that one of the biggest impediments to recovery from Mind Body syndrome (MBS) is fear.  It seems to be a part of the experience of so many people that it should be considered as a normal part of the MBS experience and therefore everyone will probably need to deal with fear at some point in their recovery.  In this blog, I will take a stab at identifying the sources of fear, the meaning of fear and offer some thoughts and methods on dealing with fear.

Where does fear come from?  We should recognize that fear is part of the normal experience of life.  We are born with a brain system that is built to protect us from danger and harm, i.e. to help us survive in a dangerous world where we may become stalked by a predator or endangered by one of our own species; another human being.  This system resides in the deeper parts of the brain (sometimes called the “reptilian brain”), it operates all of the time by constantly scanning the environment for danger, and it is clearly in the subconscious (or unconscious) part of the brain, i.e. we are not aware of its actions until after it has acted.  When we sense danger, the brain sends immediate signals from the amygdala (the emotional center of the brain) to the hypothalamus (where the autonomic nervous system resides) to cause some kind of action in our bodies.  Again, this occur without conscious awareness and our bodies are programmed to react to danger by activating the fight or flight reaction pathways.  After our body reacts (with muscle tension, gut or bladder tension, and many other reactions), we THEN become aware of the sensation of fear.  Interestingly, studies have shown that people who are paralyzed have lesser degrees of the sensation of fear (and other emotions). 

So, everyone will experience fear at some points in our lives.  In addition, studies have shown that scientists can develop rats which are more or less fearful, suggesting that there is also a component of fear which can be inherited.  Therefore, it is likely that some people are born with more or less predisposition to feeling fear.  Of course, we are also a product of our environment.  People who are brought up in homes or environments which create a sense of danger (of being hit, of being yelled at, of being abused, of being criticized or teased or taunted) learn to be afraid.  Once they learn fear, it is much more likely that they will experience higher levels of fear later in life when they are exposed to situations which create a sense of danger, especially situations which are similar to their early experiences, such as fear caused by a powerful authority figure, or by situations which remind them of early stressors.  This is the most important thing to understand about the development of MBS.  People who take a very careful look at their life experiences will almost always find these connections between early life experiences and situations which trigger the onset of MBS symptoms later in life.  When I conduct my clinical examinations (which take 90-120 minutes), I search carefully for these connections and most people (even those who are experiences in this area) are amazed at the simplicity and power of understanding the specific causes of their MBS symptoms. 

In addition to external dangers and early life experiences as sources of fear, human beings have the unique ability to think backwards and forwards.  We can have concerns about things we either did or didn’t do in the past and these can cause worry and fear (not to mention guilt, regret, resentment, and/or anger).  And obviously, we can think about the future and develop concerns that can cause worry and fear.  It is this part of fear that is most commonly evoked when dealing with MBS. 

During the recovery from MBS, several thoughts are likely to occur to everyone.  These are things such as:

“I am afraid that I’ll never get better and will be in pain forever.”

“I am afraid that I will re-injure myself and get the pain back again; and then it will be even harder to get rid of.”

“I am afraid that I won’t be able to relax enough to do the psychological work required.”
”I am afraid that I will have more stress in my life and that will cause a recurrence of pain (or other symptoms).”

”I am afraid that I will not be able to change my situation and therefore will never recover from MBS.”

Briefly stated, all fear arises from learned inbred and learned experiences of fear, which are compounded by the worry of some future uncomfortable mental or physical state.  When we are feeling better, fear tells us, “This will not last.  You will relapse and feel worse.”  When we are feeling poorly, fear tells us, “This is forever.  You will never recover.”  Listen to those statements.  How do they make you feel?  Even in me, writing this at a moment when I feel perfectly fine.  These statements create a sense of dread that is palpable and comes from deep within my mind.

Fear creates more fear.  The more we believe what fear tells us, the more fear we will have and the deeper we will learn the brain pathways that create the experience of fear in our bodies and in our minds.  As people go through the process of healing their MBS, they are often successful (at least to some degree) in reducing their MBS symptoms.  This is commonly when fear arises.  Fear is one of the main causes of MBS (along with anger and resentment, guilt and shame) and when we retrain our brains to reduce physical symptoms, fear often rears its head and begins speaking to us.  It is a good sign when this occurs, because the emotions are closer to the source of the pain and this means that we have peeled off a layer within our minds and therefore we are getting closer to full healing.  Of course, we are often not used to experiencing fear and it can be incredibly uncomfortable.  I have seen several people who began to feel fear as their pain began to resolve and their response to this was to retreat into pain (actually to welcome their pain back because they were “used to their pain and knew how to cope to some degree with the pain” while the fear was much too uncomfortable to bear. 

So, how can we deal with fear?  I will present a series of thoughts and methods that many have found useful.  It is often helpful to try many or all of these techniques and to be very resolute in your approach to dealing with fear.  Fear can be a vexing problem and it may take many weeks or months of thought and effort to overcome.  However, the battle is critical.  When you learn to deal with fear, you will become a much healthier and happier person.  You will learn a great deal about yourself and about the condition of being human.  You will be on a journey towards a higher level of cognitive, moral and spiritual awareness and growth.  So, dig in.  This is fantastic work that relatively few people undertake.  But it is well worth it.

#1:  Recognize fear for what it is.

Fear is universal; it is a part of everyone and is to be expected to occur.  So, don’t fear it; don’t fear fear.  As mentioned, fear feeds on itself.  Look for it to occur.  Be aware that when you feel fear, you are experiencing an emotion that is inbred and that has been learned.  You will never exist as a human being without the capacity to feel fear.  However, you can learn to co-exist with it and learn to cope with it when it arises to the point where it threatens to overwhelm you or make you feel uncomfortable.  Fear occurs for a reason.  Your mind is trying to protect you.  It is up to us to figure out what the situation is that has caused fear and to respond to our brain. 

#2:  Recognize the situation that is causing fear.

What is going on?  Is it fear of never getting better?  Fear of recurrence?  Fear of a situation in your life?  Fear of someone?  Fear of looking into yourself?  Fear just because you’ve always been afraid?  Fear of fear?  If your mind is trying to protect you, what is it trying to protect you from?  Is this a realistic fear; i.e. is there something to be afraid of right now at this very moment?  By that I mean, is there a grizzly bear in your room right now or is there someone trying to hurt you at this very moment?  You may have someone who is trying to hurt you in your life, but that is probably in the future.  Are you worried about the future?  If so, that is not what is happening in your life right now, this very second.  It is much easier to deal with fear if you recognize what is causing it and if you can realize that there is no IMMEDIATE danger to your body.

#3: Recognize what the fear is trying to teach you.

Fear is one of our teachers in life.  It is there to tell us something very important.  It is our minds way of talking to us.  Therefore, we can look at it as a way to understand ourselves better.  If we become aware of what are some of the underlying causes of the fear, we will begin to see what things we have to do in our lives to allay the fears.  If there is a particular person who causes fear, we need to learn ways of dealing with that person or ways of ignoring them.  If it is our own mind telling us that we will never get better or we will relapse, we need to learn how to quiet that voice, learn to ignore it, learn to let it pass on by, and even learn to laugh at it.

#4:  Learn to face your fears.

Albert Camus said that “travel is exciting in part because it is dangerous.”  Fear makes us realize we’re alive and a little fear is good for us.  If you’re having MBS symptoms or are fearful that they will recur, it is critical to tell yourself that you are OK, that you can tolerate MBS symptoms, that they won’t hurt you.  Pain due to MBS cannot hurt you.  It cannot damage your tissues or cause death.  You have had pain or other MBS symptoms before and if you have them again, you will be OK.  It’s not such a horrible outcome.  You are strong and healthy.  You must continue to tell yourself these things.  This is an antidote to the words of fear.  Talk to yourself and talk to your body and your mind.  You cannot be hurt by fear either.  Tell yourself that fear is just an emotion from your past.  It will arise from time to time, but it is not permanent.  It is a temporary response to thoughts and situations.  Just as it comes, it will go.  If you relax with fear and face it, it cannot hurt you.

#5:  Use meditation techniques.

As a mindfulness meditation teacher for many years, I have helped many people cope with fear and worry.  In the online educational program I have developed to help peole overcome MBS, there is some training in mindfulness techniques.  Mindfulness teaches us to listen to fear and other emotions and to learn to notice them without reacting, accepting what has occurred and letting go.  Learn to notice fear from a distance.  You can feel it without as much of a reaction; you can watch it arise in exactly the same way that you notice that your breath.  If you don’t react strongly to fear, you are breaking the cycle of fear feeding fear.  Accept that fear has occurred.  Look at it; listen to it; learn what it is trying to tell you.  Realize that it cannot hurt you if you don’t react to it.  Then learn to let it go.  Tell it that you are not going to be overcome by it.  It is not correct when it says you will not recover.  That is just a thought that can be rejected.  Pema Chodron’s book, The Places that Scare You, can help.  So can Tara Branch’s book, Radical Acceptance.  There are mindfulness meditation teachers all over the world who can help.  One resource for finding them is on the web sites of the University of Massachusetts Center for Mindfulness, founded by Jon Kabat-Zinn and currently directed by Saki Santorelli.

#6:  Use reasoning skills to reject the message of fear.

You are going to get better.  You are not going to relapse or if you do have some recurrences of pain or other MBS symptoms, you will be able to tolerate them and recover from them.  The messages you are getting from fear are WRONG.  The methods of Bryon Katie as described in week four of the online program and this approach will help you to recognize your incorrect thoughts and will help you learn how to dismiss such thoughts.  The videos on her website (www.thework.org) will help you see how to change thoughts which are incorrect and harmful if you continue to believe them. 

#7:  Express your fears/cope with your fears by writing and speaking.

The writing exercises that I have included in the online program are examples of therapeutic writing.  Therapeutic writing is an excellent to express emotions, to understand why you may have them, to learn to cope with them more effectively, to learn to accept certain situations, and to make decisions about courses of action.  Several books have been written on therapeutic journaling, such as Writing the Natural Way by Gabrielle Lusser, Writing Down the Bones by Natalie Goldberg, Writing Without Teachers by Peter Elbow, and The New Diary by Tristine Rainer.  Just as it can be helpful to write about physical symptoms, it can also be helpful to write about fear itself.  Some of the techniques that are included in the online program are fast writing, unsent letters and dialogues.  These are different methods which can be used to express and process emotions.  In addition, it can be very helpful to express your fears out loud and to deal with them by speaking to them and to your body.  These exercises are included in the online program under the heading, “Reprogramming the mind” and are also described in many of Dr. Sarno’s books and books by Nancy Selfridge, Fred Amir and Scott Brady.  An excellent workbook for healing MBS has also been developed by Dr. David Schechter. 

#8: Taking action to deal with sources of fear

For many people, there are some life situations that are causing fear and other emotions.  Often people feel trapped and helpless due to a situation in their family, at work or in their neighborhood.  In these situations, it is often necessary to take action of some kind, if possible.  Wisdom is always required to decide if there are actions that can be taken or if this is impossible.  The Serenity Prayer describes this situation and people often need courage to take action.  However, if you believe that action is necessary and possible in your situation, please find that courage and act.  You won’t regret it.  It can be freeing to act in ways that show your courage, your assertiveness, and your kindness to yourself.

Another critical thing to do is to confront the patterns your body has learned.  Many people have become afraid of physical activity and in particular of activities which have caused MBS symptoms in the past.  A wonderful example of someone who have taken this on is described in the last blog; a story by Brad.  It take courage and confidence to do this, but the more you are able to be active and confront old patterns of body pain, the more courage and confidence you will have.

#9:  Acting with purpose and gratitude; being kind to self and others, forgiving self and others

Finally, one can often allay fears by acting in ways which produce positive feelings.  There are several ways to do this. 

–Create a list of things for which you are grateful and writing about those things.

–Figure out what gives you purpose and meaning in your life and acting in ways to incorporate those things.

–Do things which are fun for you.  Take time each week to do things which make you happy and are enjoyable.  Many people with MBS have difficulty doing this, but it is precisely these people who need to take this time for themselves.

–Practice being kind to yourself in little and large ways each day and each week.

–Take time to be kind to others (but only do this if you are also taking time for yourself).  Kindness to others without kindness to self is not a prescription for health or healing.

–Decide on forgiveness.  If some life events call for forgiveness, consider granting that forgiveness, especially if it is for yourself.

A good web site for learning more about developing positive emotions is www.authentichappiness.sas.upenn.edu

I hope this blog has helped to clarify the role that fear plays in our lives.  We need not be afraid of having fear if we learn to recognize it, accept it and learn techniques of reducing fear when it arises.  Remember, it is normal to have fear and learning from fear is something that will further your recovery from MBS, enhance your confidence in yourself, and further your development as a healthy, aware, conscious human being. 

To your health,

Howard Schubiner, MD

Many people find that fear of not being able to recover from MBS and fear of pain are major factors preventing their recovery.  In order to address these issues, I offer the courageous story of Brad in his own words.  Following that (in the next blog), you will find my comments on dealing with fear and several methods that can help.

“In the late 1980s, I became totally crippled with back pain shortly after an incredibly stressful four-month period. I couldn’t do much besides lie around. I saw several doctors, who gave me a variety of diagnoses, and I realized they were just guessing, so I went to the library do some research. By chance (thank God!) I saw Dr. Sarno’s first book, Mind Over Back Pain, on the shelf. I took it out, and after reading it I knew that my pain had been caused by my recent psychological tensions. I also concluded that I had become literally phobic about many movements and decided that the only way to break the phobia was to challenge it with graduated exercise. So I began to exercise and lift weights.  However, I was very timid and therefore didn’t exercise as aggressively as I could have.Nonetheless, I improved enough in eight months that I was able to return to work. At the time, I had a very physically demanding job (landscape construction), and because I wasn’t entirely better, it was very frustrating: I wanted to work hard and lift heavy objects, but I couldn’t. Anyway, I made it through the summer. In the subsequent fall and winter, I went back to university and began lifting and stretching more aggressively. I did it gradually, but I persevered in always increasing the weights I was using and getting stronger. By the end of eight months I was at least 90 percent over my TMS. When I then returned to landscaping, I was overjoyed that I could physically work hard. By the end of the summer, the TMS had completely disappeared. For the next seven years, I never had the slightest back discomfort.

In 1997, I experienced a surreal conjuncture of stressors (my father had just died, my mother had just been diagnosed with terminal cancer, my wife landed in the intensive care unit of the hospital, and my sisters and I had some serious disagreements). That’s when the TMS returned — it came on gradually when I was walking down the street — but perhaps because I was distracted with all the stressors in my life the pain didn’t bother me; I knew it was TMS and had no doubt it would soon resolve itself. And it did — it was completely gone in a week or so. Then, two years later, when I was doing some yard work I had some pain. I didn’t really think I was that stressed out; anyway, I just “worked” the pain out, and it was gone in about five minutes. I was as good as new, and my back felt completely strong. 

Fast forward to the end of the year 2000, when my academic career appeared uncertain and I was feeling very insecure (and had become a workaholic): the pain returned. This time, I was inexplicably seized with fear about the pain. I was terrified it would become like it had been in the late 1980s and that I would have trouble getting rid of it. Fortunately, it never became as bad as it had been back then, but I did feel kind of disabled and afraid of lifting and moving naturally. So I started doing exercises again to weaken the fear, but in retrospect I was too cautious. I didn’t fully challenge the fears and therefore the soreness and tightness remained with me for years. Last summer I came upon Fred Amir’s book, and based on it I designed an exercise regime that I thought would break the phobia. Unfortunately, I kind of quit the “scarier” exercises (like dead lifts): I rationalized that I didn’t need to do them any more. Thus, I had been on the right track, but gave up too easily.
 
Finally, with your endorsement and encouragement, this past November I went back to a weightlifting regime to face my fears head on. Since then, I’ve been relentless in doing more and more movements and heavier lifting. (Of course, I’ve been very sensible and have avoided any injuries.) I’ve made slow but unmistakable progress with the TMS and have come to the point that I’ve overcome most of my fears. The little bit of residual muscle tension that remains is probably caused partly by lingering fear, or perhaps I should call it mental resistance: I get mental “flashes” when my mind tells me it doesn’t want me to bend to pick up a paper clip – even though I can effortlessly dead lift 50 lbs. for 30 consecutive repetitions! It’s bizarre! I also think some of the muscle tension is caused by my emotions about TMS; I still sometimes struggle with worry and frustration, especially. Today, when I really felt in control of my thought patterns and emotions and wasn’t worried or frustrated I had virtually no TMS symptoms at all.”
  

This powerful story describes in vivid detail the tension so many of us (those with TMS/MBS) feel in our lives.  We understand MBS very well, but it can be difficult to feel fully cured and fully healthy.  As Dr. Sarno often says, “You’re not fully healed until you’re free of pain and free of fear.”

I admire people like Brad who have been able to meet their fears head on.  I have seen so many people who have seen reductions or elimination of pain, but continue to struggle with fear of activity or of a return of MBS symptoms.  One option for dealing with the fear is to engage it and  work through it as Brad has done.  This component should always be part of healing because it directly confronts your fears and forces you to recognize that you can get better and that in fact you are better when you are able to do activities that used to cause pain.  However, there are many other methods to deal with fear and I will cover some of those in the next blog.

To your health,

Howard Schubiner, MD

It is clear to most people that emotions can cause physical reactions in the body. When someone gets embarrassed, their face will turn red. When standing up to speak before a large audience, many people would have physical reactions such as sweaty palms, churning stomach, a more rapid heart rate or a dry mouth. These are physiologic reactions obviously caused by activation of the autonomic nervous system that are reversible and do not indicate that there is a pathological or tissue breakdown condition in the body.

Most people also recognize that they can get a headache or a stomach ache after a stressful day. Therefore pain can also be caused by stress and emotions. These immediate reactions are relatively easy to discern as being connected to stress and emotions. Among people who are afflicted with TMS however, the time lapse between when the stress that is responsible for the symptoms may be years or decades. And the symptoms of TMS can be amazingly varied and severe. Common symptoms of TMS include back and neck pain, headaches, abdominal or pelvic pain, TMJ pain, or widespread pain now known as fibromyalgia. TMS symptoms can also be related to ANS activity such as is the case with IBS and IC. Neurologic symptoms of burning, tingling, itching, and other paresthesias may occur. Generalized symptoms such as fatigue are common. Psychological symptoms such as anxiety, OCD, PTSD, and depression are very common manifestations of TMS. And insomnia is very common as well. How can we understand the great depth and breath of these varied symptoms and how can we figure out what precise events and emotions are the causative factors in the life of an individual with TMS?

After conducting hundreds of detailed interviews with TMS sufferers, it is my firm belief that we can determine what has lead to TMS in the vast majority of patients. However, in order to truly understand these individuals with TMS, it is critical to learn to dig deeply in the history and the minds of our patients.

If we are patient and take the time to listen, patients will lead us to an understanding of the source of their pain and other TMS symptoms. We need to learn how to take these sensitive histories and learn what clues to attend to in order to help patients gain the insight into the key issues they will need to cope with in their lives. Certain patients have such overwhelming histories of childhood abuse or neglect, which when coupled with additional trauma in adulthood, gives an obvious explanation of the emotional sources of TMS. However, in other patients, it is necessary to listen for more subtle clues to explain how and why TMS developed.

I have compiled a number of examples to illustrate the thesis that childhood events create specific emotional memories that when triggered later in life cause the onset of TMS symptoms. Typically, there are two other psychological factors in the development of TMS: One is a strong sense of obligation, high expectations, perfectionism, desire to be good, guilt, low self-esteem, and self-blame. The other is a suppression of lack of awareness of the emotions that are reactions to life stressors or the internal pressures that patients put upon themselves.

Many patients have obvious childhood trauma and creates a tremendous reservoir of fear and anger, while in others, it is necessary to search carefully for milder forms of the sources of childhood and adult emotional experiences and reactions. Often the patient was unaware of the extent of the emotion or was actually unaware of the emotion itself at the time. This “suppression” of emotion is common and it has been stated by the highly esteemed neuroscientist, Joseph LeDoux, that the very emotions that are more likely to cause physical reactions in the body are precisely those emotions of which we are least aware.

A 45 year old woman was abused both physically and sexually for much of her childhood. She developed anxiety in childhood which was manifest by fear of being alone and the need to connect as much as possible to the people in her life, including her abusers. This is a common reaction to abuse; with the other common reaction being fear and inability to connect to anyone and the inability to feel emotions. She also blamed herself for the abuse and develop the belief that she was unworthy of love and self-esteem. As she grew up, she experienced other events which caused fear and anxiety, such as the loss of a boyfriend (who spread false rumors about her), the death of a parent, a divorce after her husband “cheated” on her and the loss of a job (after being harassed by a boss). Each of these stressors in later life caused the onset of a new symptom. Initially irritable bowel syndrome, then severe headaches, then TMJ pain, then pelvic pain, and finally widespread pain, diagnosed as fibromyalgia.

A 58 year old woman experienced the loss of a parent after her parents divorced when she was young. Growing up as a Catholic, she was taught that she had to be “good” or she would be punished by going to hell. As a young woman, her husband died of a severe heart condition. During the dying process, she participated in weaning him off the ventilator, which was his wish, but she felt extremely guilty about this as she thought it conflicted with her religious beliefs. He died in September and thereafter she began to develop abdominal pains each September. Over time, the pain worsened and began to occur every day and 3 separate GI evaluations did not reveal the source of the pain. In addition, she developed anxiety and started having panic attacks at approximately 3 pm each day. During the process of her treatment for TMS, she reviewed his death certificate and realized that the time of his death was 3 pm.

A 47 year old woman presented with head pain for 17 years. She had seen over 20 physicians, including several headache clinics and had even had facial surgery to try to alleviate the pain. She had also been on over 20 different medications without relief. Her mother was described as “being in her own world” and her father was described as being “bipolar.” When her father was in a bad mood, he would grab her by her collar and scream at her: “You idiot; you jerk; what’s wrong with you?; can’t you do anything right?” These events recurred on a regular basis during her childhood. She developed no symptoms of TMS until she was 30 years old. One day, she obtained a new pair of glasses and immediately upon putting them on, she developed pain on the left side of her head which lasted for 17 years. When asked about the stressors in her life when she got her new glasses, she realized that she has just gotten a new boss, who was a “mean and nasty woman” who used to yell and scream at her.

A 36 year old man was the oldest of three children and when his parents divorced, he was sent to live with his father, while his younger sisters stayed with their mother. His father never showed him that he was loved and when his father remarried, his step-mother decided to have him sent to a home for orphaned boys to be raised. He stayed in this home for about 6 years until he was 18. Once on his own, he made his way in the world and eventually had a good job, was married and had two small children. He had no TMS symptoms during all those years. His father had moved out of town, and one day when his father was visiting his sister, he asked his father to come and visit his children. The father came to their house, but was drunk, and only stayed for a few minutes, showing no affection for the children. Within minutes, the man developed abdominal and flank pain. The pain worsened over time. He found that when he tried to drink alcohol, he immediately developed nausea and vomiting. Multiple medical evaluations over several years revealed no cause for the pains and he was placed on narcotic analgesics.

A 42 year old woman grew up in a home with a kind father and a mother who was narcissistic. Her mother rarely showed love to the daughter and was usually off somewhere, often playing bridge or tennis. The patient grew up without any TMS symptoms, and married a successful businessman, worked part-time, was raising two small children, and working on building a new home. She put a great deal of pressure on herself to be a perfect mother, in contradistinction to her own mother. During this time of a number of stressful circumstances, her widespread pain developed and she was diagnosed was having fibromyalgia. When she was asked what her mother was doing during this time of stress, she started to weep and simply stated, “Playing bridge and tennis.”

A 64 year old woman grew up with loving parents and was raised to be very responsible. She took on this role seriously and became a good student, devoted daughter and excellent worker. Her younger sister was irresponsible and tried to get out of household chores and anything else she could “get out of.” The sister would lie to prevent getting caught and repeatedly asked the older sister to cover for her and/or do her work for her. When the patient was 32 years old, she was the head of a group at work assigned a difficult task requiring a great deal of work and teamwork. One of her subordinates did not complete her tasks, complained and tried to get others to do her work for her. Because of the importance of the assignment, the patient did a tremendous amount of extra work to cover for the lazy subordinate. At this time, she developed migraine headaches, which persisted for years. Several years later, she noted that she began to get headaches each time she drove to see her father, who was now in a nursing home. She drove to see him almost every day, but had to go across town. It turned out that her sister had been able to admit the father into a nursing home very close to her house, but a long way from the patient’s home.

A 20 year old young woman had a 3 year history of severe burning pain all over her body. The pain began in the vaginal area, but then gradually spread to her whole body. She was unable to work or go to school. She had a warm and close relationship with both of her parents. Her older sister was rebellious and was usually mean and condescending towards her. As her sister grew up, she began to lie, cheat, steal, drink alcohol and be promiscuous with boys. The patient saw how much pain her sister caused her parents and vowed never to act like her sister. At age 17, the patient met a wonderful young man and started to date him. He never pressured her and was kind and respectful. However, as their relationship developed, the patient became more upset and couldn’t stand to see him. She pushed him away and broke up with him to the amazement of her parents. During this time, she developed burning pain in the vaginal area, which gradually spread over her whole body. Multiple medical evaluations revealed no source for the pain and specialized testing showed evidence of a mild abnormality in the small nerve fibers, which could be explained by the fact that she has been scratching her skin or even a result of having the pain.

A 52 year old man developed back pain while on a plane from Michigan to California, where he was living. As a child, his father was his hero and well liked by everyone in the small town. His mother was critical and self-absorbed. She demeaned the young boy constantly and one day he replied to her in a disrespectful manner. Later that day, the mother called the local police and had him taken out of school in handcuffs and put into the town jail for the rest of the day. At age 50, his father was in a nursing home and when he returned to visit, he found that his mother was mistreating the father and he felt that his father was “imprisoned” in the home. On his return trip, his back pain began and lasted for 2 years.

A 34 year old man was raised by a dominant father and a submissive mother in a small, highly religious town. He was highly skilled in school and sports and admired by most. His father when drunk would often hit his mother, but this was accepted as “normal” in his community and no action was ever taken by anyone to alter these events. When asked how he felt about this, the patient replied that he often vowed that if he ever hit a woman, he would “cut off his hand.”  When he was a Ph.D. student, he was under stress of preparing for his oral exams and was working feverishly on a big project. At this time, he began to have pain in both of his hands. The pain progressed to the point where he could not even turn a doorknob, could not work on a computer, and could not pick up his infant son. Despite multiple EMG’s and X-rays by several hand specialists, no one could explain his pain. When asked to recall any other events that occurred at the time of the onset of his pain, he noted that there was a conflict between two of his mentors. One mentor was a woman, who was angry with the other mentor and began to spread rumors that he was not fit to be a Ph.D. and he felt that she threatened his ability to complete his program. He was unaware of his strong feelings of anger towards her and his even stronger feelings of guilt at the prospect of his anger towards a woman. This internal and unconscious conflict was the trigger for his severe hand pain.

A 49 year old woman grew up in India in a home where the women are taught to be kind and submissive. Upon moving to the U.S., she married a physician and moved to the suburbs. By the age of 40, she had 3 teenagers and began to think that she might want to take some classes to improve her education and challenge her mind. However, at that time, her husband took a second part –time job and was less available. Her children continued to need her to drive them and care for them. Then, her mother-in-law moved into the house and began to tell the patient how to cook, clean and care for the children. Later, her brother moved into the house and expected that she would cook for him and ”wait on him.” The response from the patient: acquiesce to these demands and cancel the class she was going to take. At this time, she began to experience muscle aches which progressed over time until she was diagnosed with fibromyalgia.

A 57 year old man grew up in a relatively poor neighborhood. As a child, his family moved to a somewhat more upscale neighborhood and he began to be teased by the other kids for his clothes and lack of sophistication. As a young man, he and his wife switched from one church to another, which was wealthier and more conservative. He worked hard at the church, and volunteered for projects to show that he was capable and could fit in. Several years later, he developed ringing in his ears to a severe degree. When asked on what specific day it began, he recalled it starting one day prior to Thanksgiving. He usually spent the holiday at his mother-in-laws home, and she had never accepted him as being good enough for her daughter. She treated him with distain and he hated going there. In essence, he was tired of hearing her talk as if he wasn’t worthy and this triggered his long-standing self-doubts fueled by his childhood and adult experiences.

All of these stories have commonalities in terms of the psychological issues which create the underpinnings and then the triggers which create symptoms of TMS. The type of symptoms which occurs is quite variable. Often times, the symptoms that develop are metaphoric, such as the tinnitus when one doesn’t want to hear what is being said, the vaginal pain due to conflicts about sexuality, the hand pain related to a conflict about hitting a woman and a vow to “cut off one’s hand.” In any case, the key to an accurate diagnosis of these symptoms is a detailed history to elucidate the underlying emotional roots of the person and a careful search for the triggers which ignite the symptoms. As I mentioned to the man whose father had neglected him and later, neglected the patient’s children: “Your father and step-mother poured the gasoline in your childhood by sending you away, but he lit the spark when he showed a similar neglect for your children.”

It is my hope that by telling these stories that more people will see that TMS is very common and that normal, regular people have it. Just yesterday, after giving a lecture, a doctor came up to me and told me his TMS story. He grew up with supportive parents and went to Viet Nam in the sixties. He was wounded by shrapnel in action there, but came home with no other physical or mental injuries. His wife noticed that every now and then, he would suddenly start to limp for no apparent reason. When she pointed it out, he would start walking normally again. Eventually, they figured out that whenever there was a helicopter sound overhead, he immediately started to limp, even though when asked why he was limping, he had no idea that he even was limping. As soon, as they noticed the limping, and then he realized that there was a helicopter in the sky, his limping would stop.

The unconscious mind remembers all of our experiences and develops nerve pathways of memory. These nerve pathways can easily become attached to physical reactions in the body (or psychological reactions as well). When we encounter a trigger that reminds us of the earlier experience, a speed dial connection to the emotional memory occurs which can immediately activate the physical response.

To your health,

Howard Schubiner, MD

For stress related illnesses, such as migraine and tension headaches, fibromyalgia, TMJ syndrome, irritable bowel and bladder syndromes, fatigue, and most people with chronic neck and back pain, it is absolutely critical to be able to name the illness correctly.  Doctors who are unfamiliar with the powerful role the mind has in being able to produce significant and sometimes severe physical symptoms will always label the illness as a purely physical one.  Hence, we see the proliferation of illnesses named as a syndrome or with a description that doesn’t help the person understand the true underlying cause of the illness.  Fibromyalgia is a good example of a severe syndrome who’s name literally means “pain in muscles and tendons.”  Unfortunately, people with this disorder already know that they have pain.  The name helps to legitimize the disorder, but it doesn’t help to solve the problem of helping them get rid of their pain.  In fact, the name can become a prison of sorts and can give them the impression that they will always be in pain, because the medication and physical therapies usually do not work. 

Therefore, for stress-related illnesses in which there is no tissue destruction in the body (e.g. not cancer, or stroke, or heart disease, or diabetes, or lupus, or rheumatoid arthritis), it can be extremely helpful to learn that one actually has a mind body issue, which Dr. Sarno terms Tension Myositis Syndrome, while I tend to use the term, Mind Body Syndrome.  These terms mean the same thing; that the symptoms are caused by reactions in the body to stress and emotions, which can be both conscious and/or subconscious.  The reason I don’t use TMS as often is that it implies some inflammation in the muscles (the definition of myositis), and there is no inflammation in the muscles in TMS/MBS.  Dr. Sarno has started to use the term, Tension Myoneural Syndrome more recently, which keeps the same letters of TMS, but takes out the inflammation reference.  

Other doctors use other terms as well.  Dr. Brady was written about Autonomic Overload syndrome and Dr. Schechter has written about Tension Distraction syndrome. 

It doesn’t matter too much to me what people call it, but what does matter very much to me is that people understand the nature of it.  There are some people who can become trapped in the diagnosis of TMS or MBS.  Just as they can begin to see themselves as being sick when given a diagnosis of IBS, or migraine, or fibromyalgia, or degenerating discs, some can develop the same relationship to TMS.  That is, they can see themselves as a victim of their life events, their stressors, or their mind.  If they have tried to cure themselves using TMS methods and have not succeeded right away, they may become worried that they won’t be able to get better or that they have a disease called “TMS.” 

I received a great question the other day.  Someone with MBS asked if they could drink caffeine, because caffeine can activate the autonomic nervous system and might this not aggravate MBS. 

Here was my answer to this question:

Your question about caffeine is a good one and an important one.  The short answer is that caffeine will not hurt you (unless you think it will, which means it could feed into MBS).  The more important answer is that many people have a significant misunderstanding about MBS/TMS and the autonomic nervous system (ANS). 

There is no doubt that the ANS is involved in causing the symptoms of MBS, but to understand this relationship, you need to think more carefully than just what things activate or deactivate the ANS.  People with MBS do not have an overly active ANS in general.  Dr. Brady calls it autonomic overload syndrome, which is somewhat misleading to my way of thinking.  There are aspects of ANS activity that are overly active, but they are typically very specific aspects and lead to very specific symptoms.  Even while having back pain or headache or irritable bowel syndrome, people with MBS have normal heart rates and blood pressures and bladder function; all of these are normal because of normal ANS function. 

John Burns studied the muscle activation of people with low back pain as well as their blood pressures and heart rates while they experienced certain emotions in the laboratory (sadness and anger).  He found that anger produced increased activation in low back muscles, but no activation in the shoulder muscles (trapezius) and no changes in blood pressure or heart rate. 

The point that I am trying to make is that your (our) ANS is fine.  It is not diseased.  We don’t have to treat it gently or worry if we are stressing it.  When you exercise, the ANS is really activated and this is a good thing.  Caffeine will not hurt you.  What will hurt you is thinking that you are sick or diseased.  What will hurt you is worrying about your ANS or your body.  What will hurt you is fear of hurting yourself.  When you stop worrying, you can start living.  That is what will set you free.  Then the small parts of the ANS that are acting up will calm down.

One thing that learned by doing mindfulness meditation for many years is this: “There is more right with you than there is wrong with you, by far.”  This is particularly true for those of us with Mind Body Syndrome, which includes just about everyone.

To your health,

Howard Schubiner, MD