Chronic Pain Relief

MBS #16–Why does MBS occur more commonly in women?

Thu, 06 Nov 2008 02:49:50 +0000

Gender issues and MBS—Why does MBS occur more commonly in women?–MBS Blog #16

Scientists have known for many years that women are more likely to develop certain illnesses, which we now understand to be caused by Mind Body Syndrome. These disorders are irritable bowel syndrome and migraine headaches, which are seen about three times more frequently in women than in men. Irritable bladder syndrome (christened Interstitial cystitis by modern medicine), TMJ disorder and fibromyalgia are diagnosed in women about 4 to 6 times more commonly than in men. An interesting comparison is back pain, which is seen equally between women and men (actually woman even have slightly higher rates of low back pain than do men; approximately 29% in women versus 25% in men). Researchers have been silent for the most part on why these differences occur. The usual fall back position is that it must be genetic. But these are not primarily genetic disorders (see MBS blog #8 for details on the genetic aspects of MBS). They are learned and they develop due to stress and emotional reactions to stress over a lifetime.

I have been pondering the discrepancy between women and men in the MBS set of disorders and I have some thoughts that might help to explain the differences. I must state at the outset that no one really knows the answer and my thoughts are just that; thoughts to get the field started, so that hopefully we can learn enough to make some definitive conclusions at some point.

First of all, we know that certain factors lead to the development of MBS. Those are who are exposed to childhood traumas, such as emotional, physical and/or sexual abuse, fear, shame and guilt are particularly susceptible to MBS later in life. The reason for that appears to be a resetting of the autonomic nervous system to become over-reactive. When stresses occur in our lives during situations in which we are powerless and vulnerable, they are more likely to create MBS. It is not only the life stresses that create MBS, but it is also the pressures that people put upon themselves; these internal pressures are extremely important as they magnify the life stresses greatly and are difficult to get away from since they are self-imposed. Finally, there are certain societal expectations and learned “sickness roles” that can play a part in the development of MBS.

Given this background in the features leading to MBS, how might these factors affect women and men differently? Childhood trauma affects both genders of course, but females are more likely to be victims of sexual abuse and they are often more likely to feel powerless in family situations of violence and abuse. Girls may grow up close to their mothers and therefore may have inadvertently “learned” that headaches or abdominal pains are common medical conditions in their family. Vulnerability and lack of power are often seen in women who are in work situations. Sexual harassment on the job, lower pay for the same work, and decreased ability to obtain promotions are common occurrences for women and can contribute to MBS. Society expectations of women should be capable of doing are increased and this can lead to increased pressure on women to be excellent at their jobs, at being a mother, a daughter, a sister, a wife, a student, a homemaker, a cook, a chauffeur, and all of the activities and responsibilities of modern life.

Note the situation one of my patients described at the time she developed MBS. “I was thirty-three years old and pregnant with my second child. We were living in the inner city as part of a church that was called to seek racial reconciliation. I was deeply committed to doing all I could to address the injustice that surrounded me. I was being encouraged to accept more and more leadership in the church, and did so as I longed to be a role model for the younger women in our midst. So not only was I trying to work part-time outside the home addressing gross injustice, I was also trying to carve out enough space to be a great ‘stay-at-home-mom’ like my mother. And the same time, there was the longing within to create a beautiful home, cook great healthy meals, be the perfect wife, and then on top of that, be a gorgeous sexy woman that a man likes to come home to.” This perfectly describes the tremendous pressures put upon modern women by society and by themselves.

When we consider self-imposed pressures, there are some research studies that have looked at the personalities of women as compared to men in societies all over the world. In one study of over 17,000 people from 55 different countries, women reported higher levels of being extroverted, agreeable, conscientious and worrying. In another study of over 23,000 people from 26 countries, women reported being more warm, open to feelings, agreeable and worrying, while men were more assertive and open to new ideas. These studies support the concept that women are more likely to put more pressure on themselves. They appear to have a higher level of conscience, of obligation, of duty, of “the shoulds” (as Dr. Sarno calls it) or of the super-ego (as Freud called it). Higher levels of self-imposed pressures are critical factors in the development of MBS. In addition, in these studies, the women who had higher levels of these traits were those from modern urban societies, rather than those from more traditional rural societies.

I have often noted that women with MBS are more likely to be more self-critical, self-blaming, feel more obligation, have a stronger sense of duty, worry excessively, take responsibility for external problems, be more caring about others, and be less likely to do things for themselves. I have found that when women take more time for themselves and begin to do more things for themselves and learn to “say no” sometimes to the needs or demands of others, their MBS symptoms rapidly improve.

Here is a quote from a woman who completed my MBS program. “In order to heal yourself from fibromyalgia and other TMS symptoms, you have to look at the truth in your life, no matter what it is. If you live an illusion, you will never reach the end you seek. In this program, I have learned the truth about my life and myself. I have learned things that I needed to learn and have made difficult, yet important, decisions about my life and my relationships. To have health in our bodies, our minds need to be at peace. As I have found peace, I find I like myself more and I find that my body is healthy again. Thanks to this program, my bodily pain, my headaches, and my fatigue are so much better.” She learned that she was important and that she had to make decisions for herself and take control of her life. She had to do things that might have been difficult, but that were for herself, even if they made some other people upset. She needed to free herself from some of the self-imposed pressures.

In my opinion, these are the reasons that women have higher rates of MBS than men. It is not because they are weak or “crazy,” it is because they are often kinder and more caring, and are more likely to have both external and internal pressures.

To your health,

Howard Schubiner, MD

Mind Body Syndrome in Musicians–MBS Blog #15

Wed, 15 Oct 2008 06:04:56 +0000

Have you ever noticed that musicians are more likely to have repetitive stress injuries? Of course you have. But are you sure that the cause is actually overuse?

What about headaches, back aches, neck aches, abdominal pain, fibromyalgia and TMJ pain? Do musicians have more than their share of these as well?

Consider the situation of Jill, a 35 year old cellist who suffered from chronic and recurring wrist pain that for year she attributed to overuse. Here is her story in her own words:

”I have been an active freelancer in a major city for years. Since graduate school days, I have played in many orchestras and chamber groups, driven long distances, taught in various schools, and presented at conferences.Like many of us, I had lived with various aches and pains for years. One fall, preparing for some particularly demanding concerts, my whole upper body seemed to just shut down. I experienced overwhelming fatigue, pain, and various other symptoms. Somehow I kept performing through the 3 month wait for appointments, tests, and results. I was horrified when the specialist told me in all of 5 minutes that I needed 3 surgeries.

I was incensed at his bluntness and his unwillingness to come up with anything more than that. I made up my mind then and there that I would find my own way out of this, and consider surgery the absolute last resort.

For the next several years I went from one medical professional to the next, with discouraging results. I did exactly as I was told, paying large sums of money to see people not covered on my insurance, and yet nothing was improving. Playing caused symptoms - sometimes predictably and other times with no recognizable cause. I was also unable to do many other things I loved to do. I became very discouraged and ready to give up.

What kept me going throughout this dismal period was a deep sense that I was missing a vital piece of this puzzle. Why did the symptoms seem so erratic? Were they really?

Why did they bother me more on the day I had to give a badly paid workshop? Why did they diminish to nothing when the workshop turned out to be enjoyable? Why did I feel so much better after being encouraged by a physical therapist? Why was it that my worst flareup began when I saw the most discouraging doctor?

Obviously, there was an emotional component to this whole thing – when I calmed down, it calmed down - but when I mentioned this to medical professionals, they responded with shrugged shoulders or polite silence. Sometimes they even laughed at me.

I decided to observe myself closely and find my own answers. Soon I found that the onset of pain often came seconds after a painful thought or feeling, usually frustration or fear. Gradually a pattern began to emerge. At one point I spent a long weekend alone, walking in nature, doing yoga, meditating. My symptoms diminished to almost nothing. Yet on all 3 days, when I had to call a difficult coworker, the pain in a particular spot on my arm returned with a vengeance.

Finally I discovered Dr. Schubiner’s website, yourpainisreal.com, and participated in his fascinating teleconferences. I instantly recognized Mind Body Syndrome in myself and knew I had finally found help. After registering for his online Mind Body Program, I learned to not just relax my body, but to establish an ongoing dialogue with it, or with my instrument, or with the pain, or my frustration, or my deeper self, or whatever needed exploring.

I learned to listen for valuable messages from my inner mind - I saw that I had been driving myself ridiculously hard, both physically and emotionally, for years. Perhaps the memory of that strain was an inner barrier to my going back to frequent performing. I also learned to recognize pain that was a conditioned response to certain life situations. The program taught my to take control and stop that pain from escalating.

This process, though long and at times frustrating, became a fascinating series of valuable life lessons, with profound rewards. I am now able to play longer and am taking more work. With my body’s feedback, I am learning to play in a more relaxed way. I have much to learn in that area, but the things I am learning are equally valuable for my students. Dr. Schubiner’s warm and encouraging responses to my emailed questions have given me comfort, strength, and valuable insight. I have an array of skills and tools to use if things get stressful. And best of all - no drugs and no surgery!

Today I am playing virtually pain free, with more joy than ever. I am deeply grateful every day for these valuable lessons, for the gift and privilege of music making, and to Dr. Schubiner for his exceptional help.”

There have been a tremendous amount of advances in understanding chronic pain in the past two decades. It is important to realize that an injury or an overuse situation can cause acute pain. But with a bit of rest, ice and Motrin, this pain will typically resolve within a week or so. But when the pain doesn’t resolve, it is usually NOT because there is an ongoing injury, but because a series of nerve connections have become sensitized and have created a vicious cycle of nerve pathways which are continuing to cause pain, even though the original injury has actually healed. Can this really occur?

The answer is clearly “yes.” We now understand that this situation is common and it is similar to what occurs in people with phantom limb syndrome. In this syndrome, people who have had an amputation often feel pain, which can be severe, in the area that was amputated; they feel pain in the foot or arm, which is missing. Obviously, there is no ongoing injury or tissue breakdown in that area; it is gone. Medical researchers have figured out that an alteration of the brain and nerve pathways are the actual cause of this pain. And we now are beginning to realize that this situation also occurs in people with pain in areas which have also healed, such as was the situation with the types of pain seen in chronic tendonitis, so called repetitive stress injury and the other syndromes listed above. The name given to this syndrome varies. It is called central sensitization syndrome by researchers, but I call it the Mind Body Syndrome because it is caused simply by connections between the mind and the body.

The next important question to consider is this: What triggers the nerve to get sensitized and produce the vicious cycle of pain? To answer this question, we must look at what factors in the brain cause pain to become exacerbated or attenuated. The anterior cingulated cortex (ACC) area of the lower part of the brain causes pain to be increased and the things that cause the ACC to be activated are thoughts and feelings of being afraid, guilty, worried, trapped, overwhelmed or angry. Of course, these thoughts and emotions happen to everyone. In addition, certain types of individuals tend to put extra pressure on themselves, have a tendency to be perfectionists and are often sensitive to criticism. It isn’t difficult to see that musicians tend to fit this personality profile.

The area of the brain that reduces pain is the dorsolateral prefrontal cortex (DLPFC) and this part of the brain is activated by clear thinking, understanding, being in control, processing thoughts to avoid worrying or guilt, and dealing with emotions by rationalizing, reappraising and letting go.

So what does all this mean for musicians with chronic pain that hasn’t been helped by rest, ice, massage, pain medications, and other remedies? Can this syndrome be cured? What can be done?

The answer is surprising easy. Once you understand what is actually going on, once you realize that the body is not diseased, injured or damaged, you can quickly get better. You can learn to activate the DLPFC by changing your thinking about the pain, about your situation, about your stresses, about your life situation. You can actually change the brain and the nerve pathways by thinking differently, by coping with difficult situations, and by doing things like self-affirmations and meditation. Taking good care of yourself, facing situations that you may have avoided, doing things that nourish you and that are fun. All of these things will activate the DLPFC and diminish activity in the ACC.

For those who need more information, read the Mindbody Prescription by Dr. John Sarno or see the web site: www.yourpainisreal.com

This approach worked for Jill and it has worked for thousands of people over the past 30 years since this syndrome was described by Dr. Sarno. And it can work for you. If you have tried many other treatments for chronic pain, you may have been looking in the wrong place.

Dealing with doubt, thoughts and emotions — MBS Blog #14

Thu, 02 Oct 2008 11:53:20 +0000

Several people have asked me how they can deal with troublesome thoughts and emotions that arise. These thoughts and emotions, such as doubts about really having TMS/MBS or worry if you’ll ever get better or fear about developing pain, are extremely common. Everyone has those from time to time or even very frequently.

So, how can you deal with doubts, fear and worry? You may worry about having some medical/physical problems instead of MBS/TMS and how do you deal with others when they challenge your view of MBS/TMS and suggest that there is some medical/physical problem going on. These questions boil down to two main issues, I think. The first has to do with doubt about the diagnosis of MBS/TMS. The second has to do with the issue of the power of thoughts and emotions.

Dr. Sarno always (correctly) says that we need to “erase doubt.” People always do better in the MBS/TMS program when they are convinced that their physical and psychological problems are due to emotions, stress and reactions to stress, both conscious and unconscious. However, we are in this boat because we are human, i.e. we have minds and bodies and they constantly interact. Because we have minds, we will frequently have thoughts that make us wonder if we’re on the right track. I spoke to a lady today who told me that she must have something physically wrong because her pain was so severe, despite the fact that her pain had gotten much better after one week of working with the MBS/TMS program. So, it is important to erase doubt, but some doubts will undoubtedly creep in. Severe pain can definitely impair your ability to think and process emotions. It can lead to depression and more emotions, which can further impair your ability to cope with pain and which can itself lead to more pain. Some doctors also suggest that severe pain can lead to decreases in efficacy of anti-depressant medications, thus compounding the problem further. The more pain, the more doubt and then things can get spiraling out of control. In those cases, you really need to stop and go back to the beginning. You may need to seek medical advice for reassurance that there is in fact nothing more serious going on and you may even need some more testing to confirm this.

This leads to the second issue: the power of thoughts and emotions. It is critical to realize that thoughts are uncontrollable, i.e. one can never choose what thoughts will come into their heads. The mind will continually come up with a huge variety of thoughts, many of which are unproductive, weird, wild, inane, or beautiful. If we can’t control out own thoughts, one certainly cannot control other people’s thoughts, and therefore we must learn ways of dealing with thoughts and reacting to thoughts or else we will be at the mercy of every stray thought that we (or someone else) comes up with. And, of course, it is not only thoughts that we need to deal with, but emotions as well, which are basically thoughts that are connected to important material from our past.

After doing a lot of research on how the brain works, I have developed a model to explain how MBS develops in the brain. You can watch a video about this on my web site, www.yourpainisreal.com. When pain occurs, it activates nerve pathways which send those pain signals to the brain and particularly to the amygdala, which is the emotional center of the brain and the area that can immediately activate the autonomic nerve system (ANS), which is the unconscious connection to the body to create the fight, flight or freeze reaction. These reactions are immediate, so that if you feel the pain of a burning match, you will immediately pull your hand away before you can even think about what is happening. This reaction occurs within 12 milliseconds, much faster than could occur if you had to send those signals up to the frontal cortex where you would become aware of them consciously. This reaction protects us from danger and happens without our conscious awareness.

How do troublesome thoughts, fear and worry affect this reaction? Research studies by Dr. John Burns in Chicago have shown that fear decreases the pain threshold, i.e. when we are worried or anxious, we cannot tolerate as much pain. Many brain MRI studies have shown that the anterior cingulated cortex (ACC) is activated when we are in pain. This part of the brain is higher than the amygdala and ANS and processes these emotions. Fear, worry, anxiety all activate the ACC, which in turn activates the amygdala and the ANS to produce physical reactions in the body, such as pain and other symptoms (including symptoms in the GI tract and urinary system). When the ACC is activated, the dorsolateral prefrontal cortex area (DLPFC) is inactivated and vice versa. The DLPFC is even higher up in the brain and the area in which we can consciously process emotions. When we process emotions and calm ourselves down, talk to ourselves to help us relax, remind ourself that we are OK, that there is no real danger, then the DLPFC is activated and then the ACC will automatically become inactivated. This will turn off the ANS and amygdala responses which activate pain. As I often say, my whole program is designed to activate the DLPFC!!

Ways to activate the DLPFC are my meditation, by writing, by processing emotions, by coping with the stresses in our lives, by confronting the issues that hold us back and keep us in a state of worry, fear, anger or guilt. In other words, all the activities and exercises in the program are designed to decrease the ACC and increase the DLPFC.

An important method that is often a great first step comes from the practice of mindfulness. The first reflection/meditation in the MBS/TMS program gives you a crash course in mindfulness. The essence of mindfulness is to be aware of the present, accept the present moment without having to react to it or respond to it, and then choose to let that moment go in order to pay attention to the next moment. Or, of course, we can choose to act and do something about the thought or emotion we have just noticed. This practice teaches us to be aware of thoughts and emotions without having to react to them, without having our bodies react to them, without allowing the mind to cause pain or other physical symptoms as it has done in the past.

So, listen carefully to the first meditation and practice paying attention to all thoughts that arise, no matter if they are silly, happy, sad, scary, or divine. As you listen to the reflection, practice this: Notice each thought, accept each thought as “just a thought,” and let it go. Then do the same thing as you go through your day: Notice thoughts and emotions, accept them as just thoughts and emotions, and choose to let them go.

As you practice paying attention without reacting to thoughts and emotions, you will learn to free yourself from the tyranny that your thoughts (and other people’s thoughts) can have.

One important point: If thoughts (such as doubts) and emotions such as worry and fear can cause you to have pain or other physical symptoms, it is highly likely that those symptoms are due to MBS/TMS. Makes sense, doesn’t it? That, in itself, should help you erase doubt. Then you can see that you really have to deal directly with the thoughts and emotions. These are what drives pain and other MBS symptoms.

Emotions are usually seen as scary and our usual response to emotions is to try to push them away and get rid of them. It doesn’t feel good to live with fear and worry. Unfortunately, the more we try to push them away, the more they tend to have power over us. The mindful approach is not to fight them or be afraid of them, but to notice them, accept that they are here and learn from them. We can treat them as something important coming up from our minds (both conscious and unconscious) that we can learn from and need to learn from in order to get better.

See the poem from Rumi below to get a totally different perspective on emotions. Write me if you want to learn more about this critical topic.

To your health,

Howard Schubiner, MD

The Guest House

By Rumi

This being human is a guest house

Every morning a new arrival. 

A joy, a depression, a meanness, 

some momentary awareness

comes as an unexpected visitor. 

Welcome and entertain them all! 

Even if they are a crowd of sorrows, 

who violently sweep your house 

empty of its furniture. 

Still treat each guest honorably. 

He may be clearing you out for some new delight. 

The dark thought, the shame, the malice, 

meet them at the door laughing, 

and invite them in. 

Be grateful for whoever comes, 

because each has been sent 

as a guide from beyond.

MBS Blog #13: How deep have you gotten? Layers of health in coping with TMS/MBS

Wed, 17 Sep 2008 02:20:40 +0000

MBS Blog 13

The layers of wellness: levels of coping with TMS/MBS

I have spoken to so many people who are frustrated that their TMS symptoms have not gotten better yet. They have read so many accounts of people who have read Dr. Sarno’s books and immediately gotten better. They wonder why they haven’t had the same response. This can lead to increased worrying: worrying about what’s wrong with them, if they really have TMS or not, if they are making themselves sicker by worrying, and this vicious cycle can go on and on.

On the TMS Help Forum and other web sites, there are many excellent suggestions about methods of self-help and books that people have used to vanquish their TMS symptoms. Most of these are great resources and can be helpful to many.

I was talking about this the other day with a good friend and excellent psychologist, Mark Lumley from Wayne State University. He and I actually ended up writing a little poem about the layers of work that many people may need to do to get better. I must warn you, neither of us are poets, so the so-called poem isn’t very poetic. But we like it because it means something important to us. Here it is.

Things to do:

Notice what has been hidden;

Understand what has been a mystery.

Speak what has been unspoken;

Confront what has been avoided.

Accept what needs to be accepted;

Forgive what needs to be forgiven.

Change what needs to be changed.

Howard Schubiner, MD and Mark Lumley, Ph.D.

It is truly amazing that some people can simply read The Mindbody Prescription and get better. I had a patient who only read the first 20 pages and his fibromyalgia symptoms disappeared. However, when the source of a great deal of tension in his life, his college aged son, came home for the holidays, his pain returned immediately.

For most of us though, it takes more, often much more. There can be several levels of ways of coping with our emotional issues. I have designed my TMS/MBS program to gradually urge people to understand and address any issues in their life more deeply and begin to cope with them more actively. In fact, I am adding some new material to the fourth week of the course soon.

Here are some of the levels (as I currently see them):

1. Learning that TMS 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

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

5. 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?

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

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

8. 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

9. 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 Bryon Katie in week 4 of the program)

10. 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

There are many steps and each person may need more of one or more of another. It’s your job to figure out what you need to do. Fortunately, you have a great teacher in this process: yourself, i.e. your mind and your body. It will very clearly tell you when you are doing what you need to do and it will tell you when you still have more work to do. Our bodies talk to us in their language. It’s up to us to decode it. Unfortunately, it’s language is the only one it knows and it if often the language of pain. But pain is nature’s way of alerting us to the fact that there is something wrong. It may be that we just stubbed our toe or placed a finger on a hot frying pan, or it may be that we are stuck in a difficult situation at work or in a relationship. There is a recent research study done by Naomi Eisenberger at UCLA in which they showed that the pathways in the brain that are activated by emotional distress (in this case, a game where the person is excluded; i.e. social exclusion) are the same pathways that are activated by physical pain (i.e. the anterior cingulated cortex). This shows clearly that there is really no difference between emotional pain and physical pain. They are one and the same and the mindbody (as Dr. Sarno calls it) will decide which one (or both) we feel.

Our job is to listen. Our job is to pay attention to our bodies. They are trying to help us by being our teacher. Learn to see what events, emotions, and thoughts occur with increased and decreased pain. Be kind to yourself and to your mind and to your body. Start doing the work of healing yourself. There can be several steps as outlined above. And there is much work to be done for most of us, but this is the essence of being human. Our highest level of accomplishment is in seeing ourselves clearly, in taking control and making changes that need to be made with honesty and with kindness. It’s a fantastic journey that most people never approach. We are fortunate to be making this journey and we are doing it together. It isn’t an easy or simple journey, but the rewards are great.

In truth and kindness,

Howard.

#12 Back pain: the truth and the science to prove it

Dr. Schubiner — Wed, 27 Aug 2008 02:00:20 +0000

This is the second part of a blog about back pain. This blog deals with the MBS approach to understanding back pain.

How can back pain occur in the absence of something wrong with the back?

There is a way to explain this based on new research into how the brain changes over time (neuroplasticity). One way is to consider what happens in phantom limb syndrome. In this situation, there is pain in the area of the body that is missing; that has been amputated. Clearly, there is nothing wrong with the area where the pain is felt, yet there can be severe pain. In this case, the pain appears to be due to sensitization of nerve fibers that go back to the brain, amplification of pain in the brain and a conditioned response of nerve fibers going back to the body. The brain and body have in essence learned to have this pain. The nerve connections have gotten fired after the amputation, but then have gotten “wired” and keep sending pain signals, which are felt to be in the amputated limb. It is likely that back pain (and other pain syndromes, including headaches, abdominal and pelvic pain, whiplash, fibromyalgia and TMJ pain) is caused in many people by similar nerve pathways.

What triggers this type of back pain to start and become chronic?

The answer is surprising and even offensive to some people and that is stress and emotional reactions to stressful events. A classic study showed the Boeing employees over four years and found that psychological stress predicted back pain much more than any other variable, including how much they used their back on their job. Other studies in Sweden, Holland, and England showed similar findings. In fact, job satisfaction is the most important factor that appears to determine if someone will develop chronic back pain or return to work after back surgery.

How can stress cause back pain?

Simply put, the brain and the body are one; they are intimately connected and it is impossible to have anything occur to one that won’t affect the other. If you stub your toe, the nerves send signals to the brain, which are interpreted in the brain as pain. If you get embarrassed, your brain sends signals to your face to cause blushing. The fascinating thing about the relationship between the mind and the body is that it is not a one way street, it is a broad highway of nerve signals that go in both directions at the same time and any changes in the body will affect the brain and any changes in the brain will affect the body.

Most people would consider that we are aware of our emotions and that these emotions can cause reactions in the body, such as the stomach tightness that occurs with a sudden stressful event. However, we now realize that emotions cause reactions in the body before we can become aware of even having that emotion. This occurs because we need to survive and the best way to survive is to react before thinking. William James, the great psychologist, explained that it is not correct that we “see the bear, get afraid, and then run” but rather that we “see the bear, run, and then feel afraid.”

When stressful events occur, it is known that the muscles of the body can tense up. In fact, the body is capable of tensing very specific muscles during a stressful event. It is not necessary to be aware of any emotions at all. The body may react to stressful events while we may not be aware that we are troubled by something. This occurs because the centers in the brain that cause reactions in the body are in the sub-conscious part of the brain, particularly the hypothalamus, which controls the fight, flight or freeze reactions.

There are two typical ways that back pain can start. One is with an accident, an injury, or with back movement. In this case, there is usually some degree to tissue damage due to the injury. The pain associated with the injury will usually decrease over time and go away once the injury has healed. If there is no serious medical damage, such as a fracture or an injury that damages the spinal column or nerves (doctors can diagnose these conditions with X-rays, MRI’s and by a neurologic exam, of course recognizing what we discussed above that an MRI abnormality is often not diagnostic of a medical condition if the neurologic exam is normal), then the pain should improve within a few days or weeks. However, the pain signals that start in the back and go to the brain can get “learned” as mentioned above and a vicious cycle can get started. Who is more likely to have this vicious cycle begin? The development of chronic pain is most likely in those who are the most stressed or distressed at the time of the accident. The brain has an area called the anterior cingulated cortex (ACC). This part of the brain amplifies pain signals and is activated by stress and emotions. Therefore, once the vicious cycle gets learned by the nerves, and this signal gets amplified in the brain and then muscle spasm and tension increases which increases pain.

Back pain can also start without any injury or accident. In this case, the muscle tension is started by the nerves coming from the brain in response to emotions (whether these emotions are recognized or not) and pain ensues. Once the pain occurs, the vicious cycle can become learned just as in the example above.

Over time, if the back pain doesn’t go away, the individual is likely to become less active and begin to worry and develop fear. These things exacerbate the pain by causing more muscle tension. The longer the pain lasts, the more likely that the individual will develop frustration, exhaustion and depression. The patients that I see in the Mind Body program are usually desperate and view this program as their last chance because they have tried everything else and nothing has helped.

The only way to cure most people with back pain, i.e. those people who do not have cancer, a fracture, or an infection causing the pain, is to get to the underlying cause of it. An MRI will not give accurate information on the cause of the pain. If the neurologic exam is normal, the pain is most likely coming from the Mind Body syndrome, i.e. this vicious cycle of nerve connections that can create and perpetuate pain despite the absence of a serious medical tissue disorder. The purpose of the Mind Body educational program is to identify the causes of the vicious cycle and to interrupt these connections. That is the best way to eliminate the pain. In addition, people who take this program learn to understand themselves better and gain more control over their lives.

To your health,

Howard Schubiner, MD

#11–Back pain 101–How modern medicine gets it wrong…

Dr. Schubiner — Thu, 14 Aug 2008 02:18:44 +0000

Conventional “knowledge” tells us that we were not meant to walk upright and that backs typically degenerate over time which leads to chronic back pain. If back pain was caused by degeneration of the back and the discs between the vertebrae, then it would make sense that back pain would increase with age. This is not the case however. Back pain actually drops a bit after age 65. We have been told that back pain will occur more often in people who use their backs more often. However, in studies from around the world, more people have back pain in industrialized, modern societies than in rural, agrarian societies.

What is the cause of back pain? There are several serious medical conditions that can cause back pain, such as a vertebral fracture (usually a compression fracture seen in the elderly or those with osteopenia), cancer of the vertebrae (seen in those with metastatic breast, lung or prostate cancer), serious abdominal conditions such as rupture of an abdominal aortic aneurysm, pancreatic cancer, rupture of a duodenal ulcer, or infections such as osteomyelitis, epidural abscess or diskitis. Fortunately, these conditons are relatively rare and easy to diagnose with modern imaging techniques (X-ray, CT or MRI).

What about sciatica and disc herniations? Severe disc herniations can cause sciatic pain (pain radiating down the back or side of the leg), but these are usually associated with some clear neurologic evidence of compression of the nerve root as it exits the spinal canal. These would include weakness of certain muscle groups in the leg compared to the other side, an abnormal deep tendon reflex, or a reduction in sensation in certain areas of the affected leg. If any of these findings are present, that indicates pressure on the nerve root and if these findings progress or do not resolve over time, these people are candidates for back surgery to relieve that pressure on the nerve roots. If these findings are not present, i.e. the leg is neurologically normal, then it is likely that there is no significant pressure on the nerve roots and therefore no significant disc herniation. Many people have sciatic type pain, yet have no evidence of neurologic findings and therefore do not need surgery and fall into the category of back pain discussed below.

What about back pain that does not radiate down the leg? This is known as axial back pain and is best considered to be due to a combination of factors that is usually misunderstood by most medical doctors. See below.

Most back pain cannot be diagnosed by any doctor, using our current methods, including examinations, X-rays, CT and MRI scans. This is shocking to most people because if you have back pain and go to a back specialist of some kind, they will invariably tell you exactly why (in their opinion) you have back pain. Unfortunately, the data tells us that they will be wrong; they will unintentionally be misleading you and misleading themselves. How can this be the case?

MRI’s are inaccurate in diagnosing back pain, unless there is one of the serious conditions mentioned above or a disc herniation has lead to neurologic findings. Most people without back pain will have “evidence” of an abnormal back on an MRI study. Most people will show disc herniations or bulges, stenosis, disc degeneration and other findings. And when people with and without back pain are given MRI’s each year, there is no correlation between MRI findings and back pain. In some people the MRI improves and the back pain gets worse, in others, the MRI gets worse and back pain gets better. It is virtually impossible for a doctor to tell if someone has back pain based upon an MRI. Yet, in people with back pain, doctors are quick to point out the abnormalities seen on an X-ray or MRI and to presume that theses abnormalities are the cause of the pain. As mentioned above, they will be wrong in making such an assumption. Conversely, many people with chronic and severe low back pain show no abnormalities on an MRI.

What about surgical treatment?

The SPORT trial published in JAMA in 2006 showed that there were no clear differences between those with sciatic pain who received surgery compared to those who had physical therapy after two years. Surgery for sciatic pain is more likely to be effective than that for axial back pain. There have been no studies to determine if surgery is actually effective for axial back pain. In fact, one of the investigators for the SPORT trial stated in an interview that it would be appropriate to conduct a research study comparing surgery for axial back pain with a sham surgical procedure. A similar study for arthroscopic surgery for knee arthritis showed no difference between the real surgery and the sham surgery. It is possible that some (or even a great deal) of the response to back surgery is due to the placebo effect. Studies have also shown that the rates of back surgeries in different communities varies up to five fold, depending on the number and type of surgeons in those communities.

The next blog will focus on how back pain can be caused by MBS/TMS. Stayed tuned.

To your health,

Howard Schubiner, MD

Letter from D.R.–”Saving the only life I could save”

Dr. Schubiner — Tue, 29 Jul 2008 02:37:53 +0000

Dear Dr. Schubiner,

For so many years, I have been taught and “programmed” to please others and basically ignore what I was feeling; because I didn’t matter. I denied myself things such as food (anorexia), pain medications and even rest. I even felt that I didn’t deserve to have feelings and lived with tremendous guilt.

I started to have pain at the age of 13 and I am now 49 years old. I had a very difficult childhood with severe abuse and neglect and it has been reflected in pain for all these years. I now understand that my subconscious mind caused me to have severe headaches. They began gradually and occurred about twice a month. But they were severe and forced me to lie in bed and cry. The headaches started to occur more often, until they came daily and lasted for the next 20 years! I forged on with my life; marrying, working and starting a family. The pain finally got so horrible that I had to quit a job that I loved and held for 21 years.

I was devastated, but I decided to become the best wife possible. I was determined to be the best coupon shopper to find sales on all items, sometimes dragging two toddlers with me across town just to save 50 cents. I tried to be the best housekeeper and stay at home Mom. I was obsessive about everything, to the point of exhaustion. Finally, I had a nervous breakdown and was hospitalized for three weeks.

Since taking your workshop and beginning therapy, I have come to an amazing revelation. My internal child was telling me, “Hey, I matter and if you won’t listen to me, then I’ll just have to force you to pay attention. I want some nurturing too. Quit trying to please everyone else and be kind to me. I deserve it.”

For all those years, I was very stubborn. I refused to pay attention to my wants and needs. My subconscious was more stubborn. Since the daily migraine headaches were not enough to wake me up, it decided to throw in pain in every muscle in my body for days at a time. I was diagnosed with Fibromyalgia, ended up applying for disability, and began taking narcotics for pain.

Did I listen to my subconscious then? No. I had stopped virtually all of my activities but I still felt undeserving, so I started to deny myself the pain medications and accept the pain as punishment for not being able to do all, for all. I came very close to suicide many times, feeling that I didn’t deserve to live. I could not get any lower than this. It was finally time for me to listen. Fortunately, miraculously, I came upon your Mind Body program.

After starting your program, I realized that I had Mind Body Syndrome (or TMS). But I wasn’t getting better. I couldn’t get to the root of my low self-esteem, anger, shame, and guilt. Your simple words, “Be kind to yourself” kept creeping into my thoughts. I did the affirmations on an hourly basis. I did all the writing assignments with a passion and truly believed that somehow this program was going to work. The writing brought up a lot of painful memories, and now instead of denying them, I sought out a therapist. I discussed the Mind Body program with her and she began to help me sort things out.

After one therapy session, I got into my car and the song on the radio was one of Billy Joel’s that I had heard thousands of times before. But this time, the words rang so true for me: “This is my life, go on with your life, leave me alone.” It hit me that this is what my subconscious has been telling me for the last 36 years. I don’t have to react to those voices from the past. This was my life and now I could choose how to live it. I told my inner child, “I understand, I am deserving, I matter and that everything was going to be OK.”

I was still in a lot of pain that day, in bed with a severe headache, when my daughter came in to ask if we going to the mall. When she saw me in so much pain, she quickly said, “That’s OK, Mom, we’ll go some other day.” But I looked at her and said, “Just give me a couple minutes and we’re going.” I began to breathe deeply, relax as best I could and started repeating over and over, “I understand, it’s OK. I no longer need the pain. Leave me alone. I’m going to do what I want and what I need. I no longer need the pain.” I got up and forced myself to go to the mall. That is what I really wanted to do. My other daughter called me and said, “Mom, you should be in bed. Go home.” But I wasn’t giving in this time.

The next day, I woke up full of energy. The pain was way down. I felt as if I could start living, instead of just existing. I worked on letting go of the past. A girlfriend had hurt me terribly and wrote me a letter full of hateful and spiteful words. I instantly wrote back trying to redeem myself, but the letter came back undeliverable. I kept both letters and have been trying to track her down for the last 17 years. I found those old letters, tossed them into the garbage and let go of my anger and guilt. I felt exhilarating.

I know I have a ways to go. My subconscious has been shouting to a brick wall for 36 years, but I am listening now and deep down I know that I will not give up on myself. Your kind words to me, “I will never give up on you,” will stay with me and keep me strong. I am not a once-in-a lifetime patient. I’m an average, everyday person who believed these words, “I have TMS.” Thank you for giving me my life back. You will always be in my heart.

D.R.

Comment: This is an amazing story, of course, but there are so many people who have suffered in a similar way and this woman had the courage and the perseverance to get better. It is such a common situation for my patients with TMS/MBS to have been so self-sacrificing that they truly never take time for themselves or they never stand up for themselves. People who have a very strong case of the “shoulds,” as Dr. Sarno tends to call it (what of course Freud called the Super-Ego, or the conscience, or a strong sense of obligation) appear to be at particularly high risk of developing TMS/MBS. They tend to feel trapped in difficult situations, as they often don’t seem to be able to find a way out that allows them to remain “nice.” They also tend to put extra pressure on themselves and to feel guilty about things they didn’t do or should have done. Their bodies will react to the situations where they feel trapped, or they feel guilty or highly self-critical. The symptoms of pain (or other symptoms) can often persist for a long time. In the story told by D.R., her symptoms did not abate until she began to change. She needed to take control and do some things for herself; she needed to act (not just read or write about her stress). She needed to change some things that needed changing. This is one lesson I have learned. When people truly see themselves and their truth, they can make changes that free them. We are good at building prisons for ourselves. Some times, we need to break down the walls.

To your health,

Howard Schubiner, MD

Mindfulness and the Mind Body syndrome

Dr. Schubiner — Tue, 15 Jul 2008 02:31:55 +0000

MBS Blog – #9 Mindfulness Meditation

I have been a devoted and passionate teacher of mindfulness meditation for about 15 years. Many people have misconceptions about meditation. The most common misperception is that meditation is about relaxing. Of course, meditation may be relaxing at times, but not always and the intent is not relaxation, but obtaining a better understanding of yourself, and learning to respond to body sensations and thoughts/emotions more deliberately, and learning to live fully in the moments of our lives. Mindfulness meditation is a form of meditation that asks people to simply pay very close attention to the here and now, to the present moment, to what is happening right now, whatever that may be. One of the great things about mindfulness is that one can practice it at any moment, no mater what you are doing or what is going on. That makes it quite useful as a way to cope with the ups and downs of life.

The reason to learn mindfulness meditation techniques for people with Mind Body syndrome is that it can help a great deal in learning to live fully in the present and to learn to let go of some of the things that tend to perpetuate MBS, such as fear, anxiety, sadness, issues from the past, or worries about the future.

The techniques taught in mindfulness practice are the following. You are invited to pay attention to your breath, simply noticing the breath without trying to change it, and without judging it in any way. Simply noticing the breath moment by moment, breath by breath. Try to stay awake and alert. Practice being kind to yourself as you practice mindfulness. Choose to pay attention to the breath. However, you will also notice that the mind will wander from the breath, sometimes frequently. Then simply notice that the mind has wandered and choose to pay attention to the breath once again. The essence of mindfulness is to notice what is happening, so if you are paying attention to the breath or if your mind is wandering, you can notice either of those and still be practicing mindfulness. You will be practicing noticing, accepting and letting go, moment by moment. Noticing without judgment, accepting the moment as it is, and letting go of the last moment in order to pay attention to the next moment.

The fantastic thing about mindfulness practice is that once you learn this approach, you can apply mindfulness (noticing, accepting, letting go) to anything in life, including your body, your thoughts, your emotions, your situations, your stressors, your walking, your eating, your driving, etc. It is a powerful practice that has been shown to help reduce pain, lower blood pressure, alleviate anxiety, and increase contentment. In fact, one study showed that people who took a mindfulness class had changes in their brainwaves that indicated an improvement in a biologic measure of happiness/contentment. Pretty amazing.

Of course, part of the program to help people with Mind Body Syndrome is to help them be happier and more content. It is also to help them to better cope with the stresses of their lives. It is to help them let go of past issues and be able to focus on the present. It is also to help them to be more kind to themselves. Mindfulness helps in all of these ways.

There are several excellent books on mindfulness meditation, including those by Jon Kabat-Zinn, Joseph Goldstein, Sylvia Boorstein, Thich Nhat Hahn and others. The Mind Body Educational program that I teach on this web site includes instruction in mindfulness meditation. There are mindfulness meditation teachers all over the world. One web site to find such teachers is: http://www.umassmed.edu/cfm/mbsr

To your health,

Howard Schubiner, MD

Genetics and Mind Body Syndrome

Dr. Schubiner — Wed, 09 Jul 2008 10:44:01 +0000

MBS BLOG # 8

Genetics and Mind Body Syndrome

Everyone knows that genes “controls” our lives. But how powerful an influence do our genes play in our lives? Of course, these issues have been debated for many years since the discovery of genes and the classic experiments of Gregor Mendel in 1865 on pea plants genetics. We wonder not only at the similarities of facial features of children and their parents, but also at their personality quirks that seem to be passed down through genes. There have been many books that purported to show that genes control everything. So, when we are told that a certain disease is genetic. We often assume that we are destined to be affected and that treatment may have little effect.

First, you must realize that there are certain genes that do have powerful effects that will produce diseases if those genes are present. For example, cystic fibrosis and sickle cell anemia are diseases produced by inherited genes. If you have those genes, you will get the disease. However, it is also clear that different people with the same genes can have differing levels of that disease, even in CF and sickle cell.

Other diseases have some contributions from genes, but these contributions are either minor or variable. For example, breast cancer has been found to have genetic components, but most people with breast cancer do not have the breast cancer gene. There are genetic contributions to asthma and migraine headaches, but these are relatively small contributions in comparison to the effects of genes on height, ADHD and schizophrenia, which have heritability factors of 0.8-0.9. The heritability factors of asthma and migraine headaches are in the range of 0.4-0.5, i.e. much smaller effects.

Fibromyalgia has been linked to certain genes as well, but this relationship is probably even smaller than in migraine headaches. For example, a twin study conducted in Finland did not show any genetic link, while a similar study in Sweden showed a 29% concordance rate for identical twins versus a 16% concordance rate for fraternal twins. Compare this to the 79% concordance rate for identical twins for ADHD versus a 32% concordance rate for fraternal twins for ADHD. To my knowledge, there is no evidence that back pain or neck pain has any genetic component.

So, what is the relationship between genes and disorders like migraine headaches or fibromyalgia? The best way to understand this issue is by understanding epigenetics. This is the field that looks at the role that environment plays on how our genes are affected. In other words, genes can be “turned on” or “turned off” and this is done by a huge number of regulatory proteins that are affected by what happens in our lives, i.e. what we are exposed to in our environment, everything from dust to chemicals to stress and emotions.

There is a water flea, the spiny helmet Daphnia, which can be born with or without its protective helmet. And it can grow a helmet if needed. If this flea is born without the helmet and there is a predator in the area (or even if the scent of a predator is dropped into the water), the flea will grow its helmet. In other words, the environment can send signals that create proteins that affect how the genes for growing the helmet are turned on. Recently, it has been shown that if a mother Daphnia flea is living in an area without predators, the offspring will be born without their helmets, however if the mother is exposed to the predators (or their scent), the baby fleas will be born with helmets. This is a clear example of how the environment can alter the way that genes are expressed, i.e. how the genes actually affect an organism.

What does this suggest for Mind Body Syndrome? The most important thing to realize is that genes are NOT destiny in relation to migraine, fibromyalgia, and other syndromes that make up this disorder. While scientists can identify certain genes that are found in association with these syndromes, they will not necessarily be expressed, i.e. they can be “turned on” by what happens in our lives, e.g. stress, emotions, life circumstances, but they can also be “turned off” by changes in our lives, e.g. control, understanding, acceptance, happiness, love.

Certain MBS disorders are commonly seen to “run in families” such as neck pain, headaches, stomach pains. However, we must realize that MBS is contagious (see Blog #6) and that it is very easy for certain MBS symptoms to be produced by the mind when stressful events occur in our lives. Which MBS symptoms are “chosen” by the mind depends on a lot of things, but one of those things is what might be reasonably expected. And it makes sense that our minds might expect to have a symptom that “runs in the family”, i.e. that others have.

In conclusion, be careful of how scientific information is presented with regard to genetics. Mild associations do not mean that these genes will necessarily produce a syndrome. Do not be swayed by these studies into thinking that MBS is primarily genetic. It is not.

To your health,

Howard Schubiner, MD

Letter to Dr. Schubiner from Paul Mazzafero

Dr. Schubiner — Sat, 28 Jun 2008 17:25:03 +0000

June 21, 2008

Letter to Dr. Schubiner from Paul Mazzafero, Davie, Florida

I first suffered excruciating back pain in 1984 as a 20-year-old young man. I had searing back and calf pain. I eventually had surgery in 1988 to remove a synovial cyst off my sciatic nerve. However, post surgery the pain was still there. I was scared I would be like this for life and was in pain management. I eventually picked up a book by Dr. Sarno and read it. I went to the Dr. and he assured me my back was fine. I was so emotionally damaged at this point I did not know what to do since I had already been to 21 doctors and had every test, steroid, epidural, etc. I eventually said, “I am fine and this is psychological”. I proceeded to workout like a madman and eventually the pain left me for 16 years. In fact I went on to compete as a boxer and was very active.

Fast forward to 2004, when I was throwing 100 pound logs and felt the dreaded pop and searing calf pain. “Uh oh,” I said and went to my GP and he ordered an MRI which was negative. However, I still had the calf pain. P.T. did not work…..Epidurals did not work……Massage did not work….Chiropractic did not work….Books, exercises, you name it and nothing worked. I was on prednisone and gained weight. I stopped working and contemplated ending it all. I am a vociferous reader and came across your program and within doing the 1st night of journaling I felt relief, not 100% but I felt like a layer was being peeled off an onion. I realized I was in a miserable job when this happened and that I am a perfectionist and I could understand how these factors played an important role in my back pain. Anyways, long story short: within 3 weeks of doing the online program, I was feeling 90% better but still skeptical a little. However, after 6 weeks, I have been pain free 100%. Dr. Schubiner’s course was an introspective look at what makes me tick. I do not think the pain will come back. In fact the 1st week when I started to feel better, an old neck injury and pain mysteriously returned…..I laughed out loud. When I am stressed, I pull out my notebook and read my journal and sometimes re-watch the videos.

I feel very light after journaling. Unburdened if you will. Explored things that have never been addressed my whole life. I also have learned to be nicer to myself where before I was a hard charger and a no excuse type guy. I have loosened the grip on life and live in the now. I also have gone from being a power athlete 5′10″ 215 pounds to being a lean athlete 185 lbs. I believe there is a huge connection between the body and the mind. Your course was an eye opener for sure. I was in chronic pain for 4 years and am pain free as we speak.

Having this kind of severe pain is a helluva a cross to bear. You can use my name. I have nothing to hide. In fact I am almost thankful for my pain. If not for it I would never be able to know me……continuing to hide layer upon layer. It has also led me to places I never knew I could go or dare to go. I am a much better person for it. I am probably simpler than most I have seen on the forums. I certainly have issues as we all do, but I take things as they come and do not over analyze things too much, which I think can make you paralyzed in living. I have a friend who is that way. Instead of just enjoying or letting things happen sometimes people always need to know the why. I think we become hypersensitive to issues and to our pain and it sets the TMS into over-drive.

Thanks Dr. Schubiner. You are a godsend. You are truly a blessing for many of us who thought life was over. I really mean that. Your course is worth every penny.

Sincerely,

Paul A. Mazzaferro

Comment:
It can be incredibly frustrating for people who have had excellent results in the past to Dr. Sarno’s approach, when they find themselves suffering again, but not able to break the cycle using the tools that they used the first time around. This story attests to the importance of being persistent, of continuing to examine oneself, and of using new and different techniques. Simply “journaling” may not be enough for many people, which is why I attempted to include a variety of specific and targeted writing techniques into this online program. These techniques are designed to give one more insight and understanding about one’s life, experiences and emotional reactions. Paul was able to do this and therefore began to break through the layers that kept him from his true self. He was also able to take a somewhat “lighthearted” approach to this work. This is difficult to do for many, because of the severe pain and uncomfortable symptoms. However, being able to laugh at certain symptoms, see the irony of certain reactions we have, and realize that the mind can produce such a strange set of symptoms can only help us to let go. I have seen many people “over-analyze” their symptoms and their emotions. It is great to see Paul be able to simply realize that he has TMS, learn to understand why, and then most importantly move on with living. Thanks for the courage to tell your story and the courage to look at your life and to heal.