by: Dr. Arlen Ring
The term tension myositis syndrome (TMS) was coined by the sports doctor John Sarno to identify back and other musculoskeletal pain that was actually of psychological origin. In four books, he presented, in the most convincing terms, the limitations of the way standard medicine approaches chronic back pain. I wish to outline here the approach that I have developed for working with individuals suffering from TMS.
Chronic physical pain is not well understood by the medical profession. One reason is obvious. Pain is a subjective experience that cannot be defined exactly or communicated precisely. Like many people, you may live with chronic pain in your back or elsewhere in your musculoskeletal system. You may feel substantially limited in your life and likely are depressed and anxious about it.
The idea that back pain is due to structural abnormalities is highly ingrained in the medical profession. An orthopedist will be looking for a structural problem, such as a herniated disc or an impinged nerve. If imaging studies reveal anything at all, including wear and tear changes, you may be told that this is the cause of your back pain. Yet the correlation of pain with anatomical abnormalities is surprisingly low. One person can have substantial structural abnormality on diagnostic imaging and not experience much pain. Another can have diagnostic tests within normal limits and yet be suffering greatly.
If you have gone from one physically-based treatment to another and have not found relief from your back pain, you might find yourself opening up your thinking to the possibility that your pain has something to do with your emotions. This is not about your pain being imaginary. It is all too real. We’re talking about the possibility that hurt in your heart and mind has made its way into your body.
So where do you go from there? You could get yourself into psychotherapy. After all, psychologists are the health practitioners who deal the most directly with emotions. If you find a good one and stay with it, you will probably get substantial benefit of some sort. But will it relieve your back pain? The answer is maybe.
Why is the answer maybe instead of probably? I believe it is because a therapist’s training is to focus on the mind. The therapist is sorting through your ways of thinking and of handling your emotions looking for what is not serving you well. That is very good, but still leaves a gap from there to your body and specifically to your hurting back.
I want to draw on my 36 years of psychological practice and the experience I have had working with psychologically-generated pain to try to fill in the gap between the mind and the body. I call that gap, the squeeze leading to the clench.
The squeeze occurs when something in our life puts us into a conflict. Conflict in a person’s psyche can easily be understood. It is when we want or need different things that seem unattainable together. Here are some examples of inner conflicts that I frequently encounter working with chronic back pain sufferers.
You hate your job, but are afraid of being unemployed.
You are unhappy in your marriage, but are terrified of being alone.
You are angry at a parent, but can’t stand to see yourself as not being a loving child.
You want love and companionship, but see yourself as unworthy of being loved.
You wish someone would understand you, but you are too afraid to let anyone really get to know you.
You try endlessly to prove you’re OK, but underneath don’t really believe you are OK.
You have been abused and yet keep trying to go on as though you felt safe.
You long for love, but find yourself running away when it appears.
You keep selecting people who are not good for you.
You are certain that you are unacceptable.
You are trying so hard to be a good person, perhaps to the point of self-sacrifice, but are never sure you are good enough. This can be called goodism. The problem here is not the desire to be good. It is the driven compulsive nature.
You put tremendous pressure on yourself to be perfect. This is called perfectionism.
You suspect that you have been abused, but you don’t really want to think about it.
You are being abused in a current relationship, but the other person is telling you that it isn’t happening or that it is your fault.
The variety of these conflicts is endless. They create emotional pain and for some people they will result in physical pain. We tighten up against pain. I call this the clench. It is important to understand that we are not always conscious of what and when we are clenching.
When we are hurt, a natural tendency is to tighten up against it. This happens with emotional, as well as physical pain. Over time, this clenching has substantial negative effects, including the impairment of circulation, muscle spasm and loss of flexibility in connective tissue. Physical changes can evolve from the emotional. Trying to treat the pain and associated changes without addressing the conflict can be like trying to bail out a leaky boat without fixing the leak.
Traumatic experiences set us up for conflicts and for the possibility that the emotional will manifest as physical. When we get hurt emotionally, it gets encoded into our cellular memory. What this actually means is that patterns of activation in the emergency center of our brain become established as habits. The threshold for activation of re-experiencing the emotional pain becomes lower. We are easily triggered by events that by themselves would not be able to hurt us.
We have had the experience of fear and/or anger. Our bodies remember, even if we don’t, and circumstances keep retriggering the pain. Our body keeps remobilizing to protect us. Some settle into a state of chronic fear and anxiety or anger and irritability. Others experience the old trauma as physical pain now. We are conflicted as our cellular memory is trying to protect us from a repeat of the trauma and our conscious brain is trying to react effectively to our current situation. The signals we receive seem very physical. In our confusion as to where the pain is coming from, we may submit to ineffective and even harmful treatments. In our fear of hurting ourselves further, we may severely limit our activities.
We are not designed to be in a state of fear or anger on a continual basis. These emotions have as their purpose mobilizing our energies to fight, flee or freeze. Unaddressed, inner conflicts can put us in a state of chronic crisis level arousal. This is harmful for anyone and for some people will lead to the experience of physical pain. We are simply not meant to be in a state of frustrated partial emergency mobilization. We cannot handle it for long and yet we can find ourselves there. The less conscious we are of the pivotal role of conflict, the harder it is to free ourselves.
Distraction is an important element for some people suffering from psychologically-generated back pain. For some, it may be that the back pain is a more acceptable way to experience their suffering than to think of themselves as having emotional issues. For others, it is just confusing and it is easier to get their mind around a physical explanation for physical pain. Sometimes we just can’t see how to resolve a conflict and find it more tolerable to put it out of our mind. Putting unresolved conflicts out of our mind has consequences.
What often makes conflicts hard to decipher is that the emotional pain associated with them can cause us to banish certain awareness from our consciousness. This ability to repress painful awareness called dissociation is a mixed blessing.
Roseanne Barr called dissociation “God’s gift to abused children”.
We all have to put emotional pain away sometimes just to function. The problem is that banishing awareness of painful emotions doesn’t make the emotions go away; it just gives us relief from the immediate burden of our contradictions. The emotions are still psychoactive. They are still squeezing on you. You are still reacting to them, but with diminished awareness of why you are reacting.
It is essential to understand that your body remembers even if you don’t. If you feel intense anger towards your boss, but do not feel safe expressing it and do not feel able to leave your job, you are in trouble. This is the squeeze. You are stuck in a situation where your needs are not being met, and your body continually wants to mobilize to do something about it. You are constantly overriding your body’s need for fight or flight and this leads to an unstable and hard to bear situation. For some people it leads to the experience of physical pain.
I’m calling this a herniated psyche. Like a herniated disc, it is a part of you that is being squeezed too hard.
Brain imaging studies show that the part of the brain that activates when physical pain is being experienced is the anterior cingulate cortex. This area also lights up when we experience social rejection.
Social rejection is very loaded for the individual. We tend to react to being rejected with the feeling of shame. It is believed that we have this intense emotionally painful reaction because for both a child and for a member of a small social group, social rejection is an alarm signal for abandonment. Abandonment in many circumstances is a death sentence. Evolution has given us a loud alarm for this. It is the feeling of shame. Scientific speculation is that in our development as a species, the mechanism for registration of the possibility of being abandoned has piggybacked on the brain circuits that were already in place to register damage to our body. It can be difficult to distinguish pain signals that use the same brain hardware, but are actually of different origins. Socially, it just may seem more acceptable to think of your pain as physical then to bear the sense of shame that goes along with feeling socially rejected.
This connection between the emotional and the physical is expressed in many languages where the words that communicate physical pain are also used to describe emotional pain. We say:
My heart is broken
My feelings are hurt.
Under these circumstances, it shouldn’t be surprising if we can feel our pain as very physical, even when it has an emotional origin.
The systems in the brain for chronic and acute pain are different. Acute pain is generally a signal of something happening now in a local area. Chronic pain can mean that your brain has settled into a pattern of activation that substitutes the experience of physical pain for one of emotional pain. Dysfunctional patterns of activation can, over time, become autonomous. The threshold for activation of the sensation of pain can drop to where barely related events can set it off.
Over time, I have learned a number of ways of addressing the physical pain directly and working to create a more comfortable and functional pattern of brain activation. What makes me different from many other generally competent and effective psychotherapists is my focus on both the physical and emotional side of what you are experiencing. I am doing psychotherapy, but with a specific focus on the interface between what you are experiencing in your body and what is going on in your mind, gut and heart.
Obviously if you are in chronic pain, you want it to stop. Some of the things we can potentially do together are:
Resolve the conflicts that drive the pain.
Protect yourself from clenching and its consequences.
Reduce fear that might be causing you to shrink from living a full life.
Create new patterns of brain activation that don’t involve pain.
Find more comfort in both your body and your mind.