Illustration by Maya Chastain
Pain is, unmistakably, an unpleasant, undesired experience. Physical discomfort and suffering can be disabling and lead many people to seek medical care to alleviate their symptoms. Physical therapists like myself can play a crucial role in helping patients improve their pain levels when their pain results from musculoskeletal abnormalities. However, physical pain is not always an indicator of injury, weakness, or dysfunction. Sometimes, physical pain has nothing at all to do with structural damage, but instead, stems from the mind-body connection.
The mind-body connection has always been an integral component in Eastern medicine, though the Western medical paradigm overlooked this connection up until the late 20th century. One of the earliest American physicians to recognize the physical manifestations of psychological pain was Dr. John E. Sarno, MD at NYU, who has influenced Western medical professionals to study this connection increasingly in years since. Sarno noticed a pattern with several of his patients that presented to him with real physical pain but did not improve as expected with mainstream medical interventions. He took a revolutionary approach by considering these patients from a holistic perspective, and realized that their emotions were playing a role in the pain that they experienced. Through his recognition of the mind-body connection, Sarno was able to permanently cure pain that many patients had been experiencing chronically for years despite pursuing countless healthcare services.
The phenomenon starts with the generation of an emotion within the subconscious mind. If your conscious mind labels an emotion "bad," does not want to experience it, and/or does not want to reveal it to the outside world, the emotion may be immediately and automatically repressed and stay in your subconscious mind. This prevents the emotion from moving into your conscious mind and being revealed to yourself and others around you. These psychological “pains” can then manifest in real physical symptoms, a process which Sarno called Tension Myoneural Syndrome (TMS), and has also been referred to as Psychophysiologic Disorder (PPD). In Sarno’s words, “it is as though the mind has decided a physical pain is preferable to an emotional one.”
The physiology of this syndrome begins in the brain. Sarno posited that repressed emotions can trigger a stress response by the autonomic nervous system, leading to restriction in blood flow, thus depriving certain muscles, nerves, tendons, or ligaments of oxygen, eventually resulting in pain and other kinds of dysfunction in these tissues. Scientists following in Sarno’s footsteps in recent years have been able to study brain function through functional Magnetic Resonance Imaging tests. FMRI tests have revealed that repressed emotions cause alterations in the brain's anatomy in the form of learned neural pathways, which send signals to other parts of the body and create real pain, despite the absence of tissue damage. The brain can tend to choose sites of abnormality within the body for the systems to manifest in, which is why the pain may be in the same location in the body as a herniated disc for example, even though the aberration may not be pathological. The good news is that these learned neural pathways can be unlearned and reversed through neuroplasticity - the brain’s ability to adapt through growth and reorganization.
Some of the most common emotions and mental states that are repressed include: anxiety, anger, stress, inferiority, narcissism, dependency, loss of control, and the need to be loved, admired, and respected. You may be more likely to develop TMS if you tend to be: ambitious, hardworking, recognition-seeking, competitive, aggressive, and/or you put yourself under a great deal of pressure. The most common physical manifestations of TMS are in postural muscles such as the back and the buttocks, and/or in the neck and shoulders, but it can also occur in other areas all throughout the body or as headaches.
The mind-body connection can also perpetuate a fear avoidance cycle. The brain creates a connection between repressed emotions and your physical positions or movements. For example - you may feel stress while sitting in your chair working from home. Repressing this emotion can cause pain to manifest in your body. The brain begins to associate the position of sitting with the painful experience, thus your body learns to be fearful of sitting. This perpetuates a cycle of anxiety, fear avoidance, and pain. Often, the fear is more disabling than the pain itself.
To change the neural pathways and heal the pain, you must change your perception that your body is weak, damaged, fragile, or vulnerable, and instead accept that the pain is caused by repressed emotions. Complete resolution of the pain will come with the knowledge that the pain is a defense created in order to distract from what is going on in the emotional sphere. If the purpose of the pain is to make you focus on the body, but you ignore the bodily symptoms and acknowledge the psychological things instead, haven't we made the pain syndrome useless?
For permanent resolution of the pain, recovery depends on information, awareness, active participation in the recovery process, and confidence in the power of the mind to heal the body. According to Sarno, to heal the pain, follow these 5 steps:
1. Think psychological
Determine what things or factors in your emotional life are contributing to the pain; acknowledge and express what emotions your mind is trying to avoid experiencing
2. Talk to your brain
Convince the conscious mind that TMS is not serious and not worthy of its attention, better yet that it is a phony, a charade, and that rather than fear it you should ridicule it and develop an attitude of disdain toward the pain
3. Resume all physical activity
Since the source of the pain is a harmless process, there is no risk or danger in even the most strenuous, vigorous movement
4. Discontinue physical treatment, including physical therapy
Any relief from this pain following physical treatment is due to a placebo cure, it is almost always temporary. As long as you are in any way preoccupied with what the body is doing, the pain will continue
5. Set aside time every day to review the 12 daily reminders:
The pain is due to TMS, not to a structural abnormality
The direct reason for the pain is mild oxygen deprivation [or learned neural pathways]
TMS is a harmless condition caused by my repressed emotions
The principal emotion is my repressed anger (or other emotion)
TMS exists only to distract my attentions from the emotions
Since my back (replace with other painful body area) is basically normal there is nothing to fear
Therefore, physical activity is not dangerous
And I MUST resume all normal physical activity
I will not be concerned or intimidated by the pain
I will shift my attention from pain to the emotional issues
I intend to be in control-NOT my subconscious mind
I must think Psychological at all times, NOT physical.
The secret to getting over TMS is not changing yourself or your emotions, but simply recognizing that they exist and that your brain is trying to mask, disguise, and hide their existence through the mechanism of the pain syndrome. Harboring repressed feelings has nothing to do with strength of character or mental competence, and having TMS does not make you emotionally defective. If you have TMS, you are not to blame or responsible for creating the pain syndrome, but you can be responsible in healing it.
As a medical practitioner, I accept responsibility to encourage patients who I suspect are experiencing TMS to stop seeking my care, even if patients report some temporary relief of pain after my treatment. It is practicing poor medicine to only address symptoms and not the root of the problem. I vow to play a role in educating patients not to be fearful of certain movements and not to be reluctant to exercise. I vow to encourage patients to acknowledge the root of the problem and to empower them to act on it, in pursuit of a cure - a complete and permanent resolution of the patients’ pain.
