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

Emotions, particularly those that are subconscious, were not seriously studied by the scientific community until relatively recently.  For much of the 20^th century, psychologists were more interested in studying our conscious awareness and didn’t think that it really mattered what might be going on beneath the surface of consciousness. 

Paul Ekman has gained a great deal of notoriety recently (the new TV show “Lie to Me” is based on his work) and his pioneering work demonstrated that people from all of the different cultures of the world experience and show the same emotions via their facial expressions.  His work is detailed in his book, Emotions Revealed, and is fascinating reading.  Dr. Ekman and others have also conducted research that shows that emotions cause very specific reactions in the body that are distinct.  In other words, emotions are universal and they are indelibly attached to specific physical reactions.  This work has helped to explain why someone may develop back pain when angry and another person may develop headaches.

Another giant in the study of emotions has been Joseph LeDoux, a neuroscientist at New York University.  Dr. LeDoux has done studies to help us understand how emotions are generated and processed in the brain.  His excellent book, The Emotional Brain, details what we know about how the brain handles emotions and we have learned a lot!

We now know that emotions are part of our survival mechanism and are part of the brains of all creatures.  We are hard wired to constantly scan the world around us for danger.  We do this as part of being alive by subconscious brain mechanisms.  When we encounter something that might be dangerous, such as a snake, a menacing look, or a car heading towards us, we instantly react (even before we are truly aware of the danger) in order to avert the danger and save our life.  These reactions are controlled by the amygdala and the autonomic nervous system.  We pick up cues to potential dangers and these nerve signals are instantly transferred to these centers; the amygdala is the center that processes emotions such as fear and anger and the autonomic nervous system (ANS) controls our heart, lungs, bowels, bladder, blood vessels and muscles.  The ANS acts to generate the fight or flight reaction (actually the fight, flight or freeze reaction), which causes our bodies to react to danger.  These systems operate in all creatures on a subconscious basis, meaning we are not consciously aware of these systems.    

Humans have a very well developed consciousness and we can be aware of our emotions.  The great psychologist, William James, pointed out many years ago that we actually become aware of our emotions after they occur in our bodies.  Most psychologists of the time thought that we would “see a bear, feel afraid and then run.”  However, James realized that it is actually that we “see a bear, run, and then feel afraid.”  In other words, we react in our bodies (via the ANS) before we are even aware of the danger and before we actually feel afraid.  

Humans are also capable of worry.  We can worry about dying, about having enough money, about something someone said about us, about being able to carry out some act.  We can carry grudges and harbor anger and guilt.  In other words, we can generate feelings even when there is no current danger and therefore we can activate the ANS many times during a day or even constantly, when something is really bothering us.  When we become aware that something is bothering us, we can usually act to do something about it.  When we notice that we are upset or angry or worried about something, we can try to put it into perspective, we can talk about it with others, we can change our actions to alter our situation. 

What happens when we are in a state of worry, fear, anger, or guilt, yet we haven’t noticed it?  In other words, we are activating our ANS, yet we are unaware of the feelings.  This happens frequently to most people because we are often too busy to notice some feelings, or we don’t want to feel them or are afraid of them, or we haven’t learned to recognize them.  When we don’t notice feelings or actively suppress them due to subconscious mechanisms, we are more likely to have those feelings affect our bodies in some way.  This is how Mind Body Syndrome (MBS) begins.  The three major factors in the development of MBS are:  1) External stress, 2) Internal pressures that we put on ourselves and 3) Suppression of emotion or feeling trapped in the difficult situation. 

I have recently become aware of the issue of MBS in U.S. veterans.  Up to 50% of veterans have some sort of chronic pain and up to 20% have post-traumatic stress disorder (PTSD).  Several studies have shown that MBS syndromes such as back pain, headaches, irritable bowel syndrome and others are closely linked to PTSD.  In fact, I consider MBS to be a form of “PTSD that occurs in the body.”  Consider the young people we send off to war.  They want to serve their country and do a good job.  They take pride in their work and put high expectations upon themselves.  These, of course, are the internal pressures.  They get sent to dangerous areas where they are shot at, they may not know whom they can trust, and some of their friends get injured or killed.  Therefore encountering severe external pressures.  Finally, they are trained to suppress their emotions in order to be an effective soldier and they are basically trapped in their situation, unable to return to the U.S. for months to years.  We shouldn’t be surprised that so many soldiers return with PTSD and/or MBS. 

When people train themselves to notice their emotions and accept them as normal.  When we learn not to fear emotions or suppress them. When we learn to do what we can to accept what we must accept and change what we can change (the Serenity Prayer), we will not need our bodies to alert us (by creating some symptom) that we are in danger.  We will not develop MBS or we will be able to overcome it relatively quickly.  What we don’t notice, can hurt us. 

To your health,

Howard Schubiner, MD