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TMS v. RCTs: A Conversation

It’s Tension Myoneural Syndrome versus the necessity of Radomized Controlled Trials in this back-and-forth between Frances Sommer Anderson and Bronwyn Thompson of HealthSkills.  Here it is:

The Where the Client Is interview with Dr. Anderson that got things rolling:

As a psychologist, I am not qualified to make a medical diagnosis, even a psychosomatic diagnosis such as TMS. A physician distinguishes the TMS pain through an interview and examination initially, thereby linking mind and body with a diagnosis of TMS. Teamwork with that physician is a requisite. Let me elaborate by illustrating why the teamwork is necessary. When I’m treating a patient who has been given a TMS pain diagnosis by a physician, I obtain written consent to collaborate with the physician, explaining the “rehabilitation team” approach, learned at Rusk Institute, which I have used effectively with Dr. John E. Sarno for more than 30 years…[continued]

Thompson’s response to the interview is here.

[U]nfortunately there is not a lot of good evidence for Dr Sarno’s hypothesis, particularly the second part (that people need to ‘heal’ their repressed emotions).  Having said that, some of the mindfulness and acceptance material I’ve been reading suggests that, instead of repressing, controlling or focusing on negative emotions, we may find it more helpful and less distressing to experience these ‘lightly’ or nonjudgementally, and in doing so, release ourselves from their influence and choose to act according to our values…[continued]

Dr. Anderson’s response to Thompson (here in full; posted as a Word document on HealthSkills):

Thank you for your careful reading of my interview and for posting your commentary.  I respond in the spirit of dialogue that opens up the very important topic of integrating domains of knowledge about mental, emotional, and neurobiological processing.

First, I want to clarify that Dr. Sarno and the clinicans who work with him do not do “chronic pain management.” We aim for pain relief in treating a mindbody pain condition that Dr. Sarno has delineated in his peer-reviewed publications and in his books directed at a broader audience.  Dr. Sarno initiated his treatment approach 40 years ago, when he was trying to treat people for whom ALL approaches to pain relief and management had failed, e.g., surgery, hypnosis, CBT.  I was fortunate to join his pain service 30 years ago, while it was still in the pioneering phase.  Dr. Sarno discovered, in collaboration with the psychotherapists who were on his rehabilitation team, that his patients had difficulty acknowledging their emotions, or affects–I will use this term interchangeably with emotions going forward.  It was common that these people could not feel positive or negative emotions.

While Dr. Sarno did not collect data via randomized clinical trials to document that his approach to pain relief works, his clinical success can be indirectly assessed by noting the volume of sales of his books and the vast number of testimonials on the internet attesting to complete recovery from pain, such as http://www.tmswiki.wetpaint.com. In addition, physicians from around the country, indeed from around the world, have been inspired by Sarno’s theory and treatment approach and have begun offering their own elaborations of it, e.g, David D. Clarke (www.stressillness.com), David Schechter  (www.schechtermd.com), and Howard Schubiner (www.unlearnyourpain.com).  The impetus for the upcoming Los Angeles Mindbody Conference on stress-related pain (www.lamindbodyconference.org) has come from patients who have been successfully treated by this approach, as well as from physicians and mental health clinicians who have worked with Sarno.  My colleague, Eric Sherman, PsyD, and I have been inspired to publish a book of cases studies in 2010, Pathways to Pain Relief (www.pathwaystopainrelief.com), to illustrate how we treat people who have been diagnosed by Dr. Sarno with Tension Myoneural Syndrome (TMS).

Like the author of this post, all of us who have been influenced by Dr. Sarno’s theory and treatment have an interest in “emotional regulation and self regulatory systems,” although we may be using different terminology.  I recommend reading about the theoretical and empirical foundation for my treatment technique in my chapter in Relational Perspectives on the Body (www.francessommeranderson.com).  I provide a detailed case presentation of my treatment of a patient with TMS pain, illustrating how overwhelming emotions were related to her long history of back pain and how she was relieved of this pain as she worked with disavowed affects.  I ground my “technique” in the publications of psychoanalyst researchers such as Henry Krystal (Michigan State University), his son John Krystal (Yale University), and Graeme Taylor (University of Toronto) and his colleagues in Canada.  These clinician-researchers have focused on the role of emotions/affects in health and illness.  In particular, their findings document the value of recognizing what we’re feeling, and developing the capacity to tolerate and regulate both positive and negative emotions.  Feelings/emotions/affects become problematic when we need to avoid experiencing them because they may be overwhelming.  Intolerance and avoidance of emotions can be associated with physical as well as psychological illness, as documented by these and other researchers.  Researchers are increasingly focusing on the significant role of emotions, e.g., in the neurobiology of fear (Joseph LeDoux) and the neurobiology of trauma, e.g., Bessel van der Kolk and his colleagues.  How these dysregulated emotions are related to health and illness should concern all practitioners.

My treatment approach is also influenced by the field of contemporary neuroscience, which the author values as a model in explaining chronic pain syndromes.  I want to emphasize that I am not at odds with the identification of a neurobiological substrate for pain and other disorders. I am in favor, however, of an integrative approach rather than one that values biology or psychology over the other:  Unfortunately, valuing neurobiology over psychology is once again a manifestation of the dichotomous mind vs. body philosophy that still informs much of Western medicine.  My point is made most convincingly by a number of current clinicians and researchers.  Allan Schore’s (http://www.allanschore.com/) integration of data from the psychoanalytic theory of development, neurobiology of attachment, and the neuroscience of emotional regulation demonstrates the value of an integrative synthesis of knowledge from the domains of psychoanalysis, psychology, and neurobiology.  Daniel J. Siegel (http://drdansiegel.com), a psychiatrist who has studied mindfulness meditation and neuroscience, uses the term “interpersonal neurobiology” to capture the complexity of the interpenetration of the psychological and the neurobiological realms of theorizing (The Mindful Brain).  A psychologist, Wilma Bucci (http://www.referentialprocess.org/), is a cognitive science researcher (Chapter in Bodies in Treatment, FSA Editor; www.referentialprocess.org) who has developed a “multiple code theory,” arguing for a “congruence” between psychological and neurobiological models of emotional and cognitive processing.  Candace Pert’s substantive research (http://www.candacepert.com/), offered for a general audience in Molecules of Emotion, demonstrates how “emotions” are stored in every area of the body, including in the molecules.

Thompson responds with How to Judge a Treatment:

Pain, like many other conditions, is complicated by the fact that it’s invisible – we don’t have any objective measures of pain itself, and we have to rely on behaviours (including verbal self report and movements) to determine whether treatment has done any good.  Behaviours are strongly influenced by external factors such as other people’s responses, along with internal factors such as beliefs and expectations…[continued]

Thompson’s response to this post:

Thanks for posting this discussion in full. I’d like to just correct a couple of points – ‘tension myoneural syndrome’ is not a term used commonly in New Zealand (and it also doesn’t appear in the International Association for the Study of Pain Taxonomy and Classification of Chronic Pain). I also note that it’s not a term used in DSM iv, nor indeed in any of the formal classification systems used in health care.
Now I’m not saying having pain that is associated with increased anxiety/stress or low mood (or even ‘trauma’ associated with a diagnosis of something like PTSD) do not exist. That’s silly because they do. What is arguable is their aetiology, and their ongoing management.

The terms more commonly used to describe widespread body pain (or regional pains) is central sensitisation conditions, and can include such things as fibromyalgia and regional pain syndromes. These are recognised as influencing the sensitivity of the nervous system and increase the sympathetic nervous system responses to change.

I did laugh a bit at the suggestion that what I’m saying returns to the great ‘mind and body’ divide – because that’s usually what I’m accusing the medical professionals I sometimes work with of doing! In fact it’s very clear that the whole experience of having pain is a psychological one with underlying neurobiological systems underpinning it.

I don’t see this as mutually exclusive, simply that we have much to learn about the ways the psychological and social processes work. It certainly doesn’t take away from the influence of attitudes, beliefs, biases and learning – but it does mean that we may not be in the best place to describe how they influence us. I’m really excited about neurobiological processes, because they do start to give us some idea of how our fabulous brains (and nervous systems) go about influencing things that have until now been a mystery.

I am personally not comfortable with using approaches that need special assumptions, and that can’t be tested. That’s why my response was around the need to use an evidence base in the peer reviewed literature. And I can’t find outcome studies of Dr Sarno’s approach – which is, in the end, the best way to determine what works and what doesn’t, irrespective of the mechanisms involved.

regards
Bronnie

The conversation continues here.

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