For Doctors... (initially written while working on SMI research projects for the Seligman Medical Institute Foundation 2006) ..edited 2018 and August 2020.
...A Letter from Our Principal Investigator Explaining the Diagnosis and Treatment
Among the diagnoses and treatment approaches I use in my office is Tension Myositis/Myoneural Syndrome (TMS). This diagnosis was developed by John, Sarno, MD Professor of Rehabilitation Medicine at NYU’s Rusk Institute over 40 years ago.
He had published several articles on the subject and popularized the concept by writing four books for the lay public—most notably Healing Back Pain. The diagnosis is not widely known in the medical community and there are several reasons for this, including a lack of published data. Also, medicine has a pronounced reductionist focus that has historically developed and been quite successful, especially for acute disease processes.
At its essence, the diagnosis of TMS is a description of the cause of persistent/chronic back pain (and/or neck pain, tension headaches, TMJ) and logically leads to a specific treatment approach. The diagnosis implies that the physical pain experienced by the patient is in fact a manifestation of psychological tension and is therefore most effectively treated with a psychological focus.
In more contemporary neurobiological terms, the pain is centrally based and enhanced by amplifying descending pathways, and the treatment is to focus on the individual’s perception of pain to modify the inhibitory descending pathways to reduce/eliminate pain. The brain is the focus and chronification of pain has occurred rendering it a different phenomenon than acute pain.
The pain may manifest physically as muscular spasm, soft tissue pain, or even involve a minor neural component (such as tingling) but is NOT primarily due to a structural process in the spine or elsewhere. For this reason, it is essential to exclude structural lesions such as large disc herniations, nerve compression, severe stenosis, tumors, etc. before making this diagnosis and to do a careful neurological examination.
The diagnosis is typically made in patients for whom multiple attempts at physically-based treatment have failed (e.g. physical therapy, chiropractic, acupuncture, even epidurals and facet blocks). There are two reasons for this. First, patients rarely will consider a psychologically oriented diagnosis for physical symptoms until they have first tried conventional (and alternative) approaches that treat pain physically. Second, patients typically find their way to a TMS-oriented doctor in "desperation" or after failure of other approaches.
Diagnostic criteria for this condition include:
Excluding structural pathology (NB: minor disc bulges do not rule out TMS as the actual cause of pain; MRI’s are often over-read and must be interpreted with care to ensure an accurate diagnosis is made)
Characteristic personality types (self-critical, highly responsible, perfectionist, often meticulous/thorough)
Other "psychosomatic conditions" in history — e.g. IBS, tension headaches, stress-induced rashes, etc.
Patterns of psychological crises before/during attacks (e.g. anger, grief, fear, anxiety)
A tendency to over-restrict activity based upon pain or faulty advice from prior practitioners
Characteristic tender points
Making the diagnosis and having the patient accept and believe in the diagnosis
Teaching the patient to "think psychologically" about the pain—and hence not to focus physically on perceived exacerbating factors and therefore fear physical activity
Educational materials and workbook for home study/use are available
Cognitive/analytic psychotherapy where indicated (More severe, long-standing cases and people with troubled childhood (e.g. molestation) are often referred.)
Follow-up visits with practitioner to assess response, fine-tune program
Gradual increase in activity level to normal is important.
We find that belief in the diagnosis is crucial to success with this model. The patient is undergoing a change in belief system about the pain that causes dramatic physiological changes leading to interruption of the pain-fear-spasm cycle. This doesn’t occur until the patient accepts the diagnosis, reduces fear/worry, and begins to re-focus psychologically.
The success rate among patients who are diagnosed with TMS and follow through with treatment is quite high (follow-up studies have demonstrated 60-70% success or higher without medications or physically based treatments). The cost to the patient is quite reasonable, and the program is safe and non-invasive.
Note that this program is not "behavioral management" of pain. The diagnosis and treatment is predicated on the likelihood of elimination of pain by interruption of the psycho-physiological pathways that have become the pain problem itself (whether initially the cause or merely the perpetuating factor).
We had a non-profit foundation, Seligman Medical Institute (SMI) that is supporting research and educational programs in this area and look forward to publishing more data on this subject in the near future.
For now, the Web site, books, and other materials explain the program quite well.
David Schechter, MD
Family/Sports Medicine, Board-Certified
Author, The MindBody Workbook, Think Away Your Pain and The MindBody Workbook for Teens