What is TMS? – An Interview with Eric Sherman, PsyD
In the run-up to the L.A. MindBody Conference later this month, Dr. Eric Sherman, a presenter at the conference, talked WTCI via email about the conference’s central topic: Tension Myoneural Syndrome (TMS) and treating chronic pain with psychotherapy.
Dr. Sherman is a psychologist practicing in New York City and author, with Dr. Frances Sommer Anderson, of the upcoming Pathways to Pain Relief.
What is TMS?
For the past thirty-five years, John Sarno, M.D., a physiatrist at The Rusk Institute of Rehabilitation Medicine and Professor of Rehabilitation Medicine at The New York University School of Medicine has pioneered the idea that a wide variety of pain disorders are psychophysiological in origin. A psychophysiological disorder is diagnosed when emotional factors partly or entirely contribute to the development of physical symptoms. Previously, psychophysiological disorders were more commonly referred to as psychosomatic disorders. Such conditions develop out of the physiological reactions which accompany all emotional or psychological experiences. Psychophysiological disorders are just one aspect of the recently energized field of Mind-Body medicine.
What is already well documented is that conventional treatments for back pain fail abysmally. If mainstream medicine effectively treated back pain, for example, desperate patients would seldom seek the help of Dr. Sarno and other Mindbody medicine experts. In his writing, Dr. Sarno identifies Tension Myoneural Syndrome (TMS) as a benign, psychophysiologic process in which mild ischemia or reduced blood flow to postural muscles, nerves, and a variety of tendons is initiated by dynamic psychological factors. What does that mean? Myoneural refers both to the functional and structural relationships between muscles (myo) and nerves (neural). Nerves transmit electrical signals to muscles, commanding them to contract or relax. Ischemia describes a condition of reduced blood flow or circulation to a particular area. Dynamic psychological factors are psychological forces that operate outside of an individual’s awareness yet still affect that individual’s behavior, just like an odorless and colorless gas causing baffling physical reactions. Therefore, TMS is a psychophysiological pain disorder where emotional experiences, which may be partially or completely out of a person’s awareness, produce ischemia or reduced blood flow to the postural muscles, resulting in mild oxygen deprivation and pain.
The overlapping relationships between blood flow, emotional experiences, and physiological reactions are immediately recognizable in the everyday phenomena of erections and blushing. Embarrassment is accompanied by increased circulation to the face and neck, and when a person is frightened, the blood drains from his face and he acquires a ghostly pallor. Sexual arousal redirects blood flow to the penis, which is actually a muscle, and an erection ensues. If that same person experiences fear or self-consciousness, blood flow to the penis is reduced and the man cannot sustain his erection. The interaction between emotional experiences, blood flow, and myoneural activity is the same psychophysiological process involved in TMS.
Dr. Sarno describes TMS as a physical disorder characterized by pain and/or other neural signs and symptoms affecting a variety of musculoskeletal locations. We use the term pathophysiology to refer to how a disease or malfunction arises from abnormalities in the structure or functioning of bodily systems. The pathophysiology of TMS involves the circulatory system.
Dr. Sarno emphasizes that the pain is real; it is not imaginary or “in the patient’s head” as sometimes misconstrued by physicians and mental health professionals. For example, few would misunderstand diarrhea as “fake,” imaginary, or “just in the patient’s head,” simply because it resulted from a “nervous stomach.” Because TMS is a physical disorder, the subjective experience of the pain is indistinguishable from pain originating from organic conditions such as injuries, tumors, and infections, even though the pathophysiology responsible for the syndrome is psychologically induced.
Dr. Sarno conceptualizes the pain symptomatology as a self-protective reaction or a defense against recognizing and experiencing intolerable affects, not the result of structural damage or disease. So when a herniated disc is diagnosed as the cause of the patient’s pain and disability, a psychophysiological disorder is misdiagnosed and physical treatments not only fail but serve to intensify the symptomatology. Appropriate treatment is delayed or denied, and iatrogenic, or physician-induced, debility develops.
If someone thinks they might have TMS, what should they do?
Often, individuals suspect accurately that they are suffering from TMS. However, it is essential that the diagnosis of TMS be confirmed by a physician, preferably one familiar with Mindbody disorders. Unfortunately, medical training promotes a collective professional blindness to Mindbody disorders. Conditions are inaccurately understood to be either physical in origin, or psychiatric in nature, ignoring the fact that in some instances the two may be related and that the whole can indeed be greater than the sum of the parts. Consequently, treatments based on a faulty diagnosis are doomed from the outset.
If an individual has access to a physician specializing in the diagnosis and treatment of Mindbody disorders, consulting with that physician is the logical first step to recovery. In the New York City area, individuals can consult with John Sarno, MD who first developed the concept of TMS and its first effective treatment. Ira Rashbaum, MD is another physician in the New York area who treats Mindbody disorders. In Detroit, individuals may consult with Howard Schubiner, MD, and in Chicago, John Stracks, MD. David Schechter, MD is a specialist in Mindbody medicine practicing in Los Angeles. David Clarke, MD writes and lectures extensively on Mindbody medicine. In New Hampshire, individuals can be evaluated by Marc Sopher, MD.
The preceding list of Mindbody practitioners is by no means definitive. If these physicians are geographically inaccessible, an individual should contact the nearest physician. Often these practitioners can refer prospective patients to someone closer to them.
If none of these resources represent viable options, then the patient should consult with a trusted physician, if for no other reason to rule out serious conditions such as fractures, tumors, infections, etc. If these diagnoses are excluded from the differential, the patient should certainly engage the physician in a discussion about whether symptoms could be explained on the basis of a Mindbody disorder.
Once a diagnosis of TMS is established, treatment may take several different forms. Of great interest is that large numbers of people have been permanently “cured” after reading one of Dr. Sarno’s books. This is important in theorizing on the nature of the psychophysiologic process and what is required to reverse it. Clearly, the acquisition of information about the process must be therapeutic. Therefore, merely explaining the diagnosis often results in symptomatic relief.
In addition to providing basic information about TMS, as part of the psychoeducational treatment model developed initially by Dr. Sarno, the physician may recommend any number of therapeutic modalities which help patients observe and monitor the relationship between their physical symptoms, and their emotional state. Physical symptoms are now enlisted as signals to guide introspection, rather than evaluate structural pathology.
Many patients do require individual and/or group psychotherapy. To avoid the same pitfalls patients face when they seek evaluation of their symptoms from physicians unfamiliar with mind body disorders, it is imperative that a prospective patient be referred to a psychotherapist experienced in treating TMS. The previously cited physicians can help with the referral process, as well as collaborate with the therapist and work together as a team to treat TMS and other Mindbody disorders.
Does treatment actually work?
Unfortunately, drug companies and medical device manufacturers have little incentive to fund research on Mindbody disorders. Furthermore, if mainstream medicine has a blind spot for Mindbody disorders, then it’s impossible to be curious about them and systematically investigate them. Although almost all of the evidence demonstrating the efficacy of treatment for TMS is anecdotal, it must be remembered that this body of anecdotal evidence has been collected by Dr. Sarno over nearly forty years from tens of thousands of patients. I have received photos from former patients in which they are break dancing, sky diving, or performing yoga contortions worthy of Cirque du Soleil. All of them had been advised to undergo surgery to correct disc herniations, the presumptive cause of their incapacitating pain. At the time of these photos, all of their scans would be unchanged, yet they are engaged in activities that are impossible for anyone who suffers from back pain. Psychotherapy cannot correct a herniated disc, however it can effectively treat TMS pain.
Dr. Arlene Feinblatt, formerly the Director of the Psychophysiological Pain Service at The Rusk Institute of New York University Langone Medical Center published data obtained from Dr. Sarno’s patients who participated in a time-limited, group psychotherapy treatment module. Her study demonstrated that patients who experienced the greatest relief in their pain symptomatology also significantly improved their tolerance for negative affect. Recently, Howard Schubiner, MD and his associates conducted a small scale, randomized controlled trial evaluating the effect of psychoeducational treatment on pain reduction in patients diagnosed with fibromyalgia (which is regarded by many as a TMS equivalent). The statistically significant results demonstrated sustained pain reduction in the patient group receiving an innovative psychoeducational treatment, compared to a wait-list control group. Obviously, similar studies need to be conducted, expanded, and replicated.
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