Friday, September 4, 2009

Tension Myositis Syndrome & Chronic Pain Myths

Chronic pain, especially nonspecific pain that is unexplained by structural or organic pathology, is a frustrating challenge for healthcare providers and patients alike. Tension Myositis Syndrome (TMS) — focusing on mind-body, psychosomatic pain related to unresolved emotional distress — has been proposed as a primary cause. However, whether TMS is more myth than reality and its clinical validity need careful consideration.

A New Paradigm of Chronic Pain Needed?
This subject came to our attention in a recent article titled “Treating Chronic Pain – There is a Better Way!” by Colleen Perry at the popular Huffington Post website [see article]. Perry, a marriage and family therapist in California, claims a new paradigm is needed when it comes to chronic pain and its treatment. She contends that many conditions are often mistakenly treated with drugs and/or surgery, including back pain, neck and shoulder pain, migraine headaches, fibromyalgia, carpal tunnel syndrome, repetitive strain injury, pelvic pain, irritable bowel syndrome, and others. For a better solution, she recommends a concept called Tension Myositis Syndrome, or TMS, which was originally proposed by John Sarno, MD, in the 1970s to describe disorders that appear to be purely physical but actually originate from distressful emotions. Perry asserts that “we cannot talk about reforming our healthcare system without taking into account the billions of dollars that are wasted by the American Medical Association's widespread refusal to recognize chronic pain as a mind-body disorder [which is the essence of TMS].”

Indeed, it does appear that TMS has not received serious recognition or study from mainstream medicine, even though Sarno — professor of Clinical Rehabilitation Medicine, New York University School of Medicine, and attending physician at the Rusk Institute of Rehabilitation Medicine — claims to have successfully treated thousands of patients merely by educating them on his beliefs of an emotional basis for their pain symptoms. His approach hinges on mind-body connections whereby pain arises from unresolved emotional issues; in effect, the brain causes the pain as a diversion or distraction from emotions that are threatening to the patient.

The phrase “Tension Myositis Syndrome” refers to the emotional disturbances behind the condition (tension), the involvement of skeletal muscles (myositis), and the multitude of symptoms (syndrome). Most recently, Sarno says the condition should be called “Tension Myoneural Syndrome” to include nervous system involvement, and others have suggested “The Mindbody Syndrome” as easier for the lay public to remember. TMS most clearly seems applicable to chronic pain without evidence of structural or organic pathology — nonspecific in nature; however, Sarno believes TMS should be considered even in cases where there is evident pathology, at least as a contributing factor.

Where is the evidence to support TMS?
Advocates claim there are inherent difficulties in performing clinical trials to validate psychosomatic characteristics of TMS, consequently there is very little supportive research literature. However, there is extensive popular literature on the subject (eg, see document here, or website here), and Sarno’s most recent book, The Divided Mind: The Epidemic of Mind Body Disorders (2006), and earlier works have sold very well. The “cure” for TMS requires identifying and managing underlying psychological stressors; in some persons, merely acknowledging the existence of threatening unconscious emotions allegedly has relieved all pain. Specific treatment modalities have included, reading books on the subject, cognitive behavioral therapy, hypnotic suggestion, and guided imagery. In one case-series report of 51 patients with chronic back pain diagnosed as TMS, treatment consisted of office visits, written and audio educational materials, guided journaling, and psychotherapy for select patients [Schecter et al. 2007]. During 3 to 12 months of followup there were significant decreases in pain scores and medication use, while physical health and activity scores increased significantly; however, reports such as these must be considered anecdotal.

In an interesting controlled clinical trial published several months ago in JAMA [Kroenke et al. 2009], researchers randomly assigned patients diagnosed with depression and chronic pain (back, hip, or knee) to either usual care (n=127; standard antidepressants and analgesics) or an experimental intervention (n=123; including the usual analgesics plus optimized antidepressant medication regimens and a multi-session pain self-management program consisting of an examination of negative emotions, relaxation techniques, behavioral modification, and other approaches for increasing self-efficacy). Compared with usual care, the intervention group experienced significantly greater reductions in both depression and pain. Unfortunately, there was no third group receiving usual care plus the self-management program; that is, to separate out effects of enhanced antidepressant therapies that could have, themselves, manifested pain relief. Still, in a sense, the intervention might be considered a form of “medication-assisted TMS-management therapy,” and it seems to support the value of attending to possible psychosomatic influences as a component of chronic pain management.

Inherent Dangers & Caveats
Other research seems to contradict TMS interpretations of chronic pain. An extensive systematic review examining the influence of psychological factors on the onset and continuation of complex regional pain syndrome (CRPS, also known as reflex sympathetic dystrophy, or RSD) found that, while many patients with CRPS are stigmatized as being psychologically different, there was no evidence of psychosomatic effects [Beerthuizen et al. 2009]. European investigators have recently expressed concerns about inappropriately attributing somatic pain complaints having no evident clinical pathology to purely psychological origins, or “psychologization,” which could serve as a barrier to effective pain management [Crombez et al. 2009].

Some researchers, such as Norton M. Hadler, MD, have for many years described psychosomatic aspects of chronic pain disorders in pejorative terms [eg, Hadler 1978; Hadler et al. 2007]. For example, Hadler and colleagues consider work-related cumulative strain disorders and backache as mere “surrogate complaints” reflecting psychological distress over poor working conditions and unrewarding work rather than as bona fide maladies. They write: “No physician, employer, human resource professional, claims adjuster, or worker is likely to realize that the backache is intolerable and disabling because the job is intolerable, unsatisfying, or insecure” [Hadler et al. 2007]. The implication in Hadler’s publications through the years is that many persons with pain complaints are psychologically unfit malingerers hoping to take advantage of workers’ compensation or other assistance for bogus conditions having no basis in structural or organic pathology. And, while he does not specifically name tension myositis syndrome, concepts of TMS used inappropriately would appear to bolster Hadler’s arguments opposing physical origins of the complaints.

Therefore, a final concern is whether treatment of TMS would be covered by health insurance and/or other compensation systems. Especially, since it appears that the psychological basis of the disorder opens the door for a variety of alternative therapies, often delivered by nonmedical practitioners. So, there may be dangers in broadly accepting TMS unless its scientific validity can be confirmed. Even if TMS is more myth than reality, as with all myths there still may be some innate truth behind it since pain is a subjective experience and emotional discord may exacerbate pain perception. However, whether or not mind-body connections play a central or peripheral role in chronic pain, and the extent to which discovering and managing emotional underpinnings can have remedial effects, requires more investigation. Any opinions? Post your comments below.

> Beerthuizen A, van’t Spijker A, Huygen F, Klein J, de Wit R. Is there an association between psychological factors and the complex regional pain syndrome type 1 (CRPS1) in adults? A systematic review. Pain. 2009;145(1-2):52-59.
> Crombez G, Beirens K, Van Damme S, et al. The unbearable lightness of somatization: a systematic review of the concept of somatization in empirical studies of pain. Pain. 2009;145(1-2):31-35.
> Hadler NM. Legal ramifications of the medical definition of back disease. Ann Intern Med. 1978;89(6):992-999.
> Hadler, NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA. 2007;297(14):1594-1596.
> Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA. 2009;301(20):2099-2110.
> Schechter D, Smith AP, Beck J, et al. Outcomes of a mind-body treatment program for chronic back pain with no distinct structural pathology – a case series of patients diagnosed and treated as tension myositis syndrome. Altern Ther Health Med. 2007;13(5):26-35.


David Schechter, MD said...

Dr. Leavitt,
I commend you for discussing this subject citing some research data, including my own (Schechter, et al 2007). Especially so with the website being supported by "Purdue Pharma LP". As with so much in medicine, the pharmaceutical industries and their research funding drive "scientific" progress. But the TMS diagnosis and treatment has helped thousands and over 40 doctors and therapists attended a National Conference on this subject in Ann Arbor in the spring.
I look forward to other comments from those helped and practitioners in this emerging area of treatment.

SB. Leavitt, MA, PhD said...

We thank Dr. Schechter for his kind words, and we would encourage him to get together with the Kroenke team (see JAMA reference) in doing further clinical research to validate the importance of attending to mind-body, psychosomatic factors in the treatment of chronic pain conditions.

For the record, by mutual agreement, Pain Treatment Topics is developed completely independently of any influence or direction coming from our sponsors.

Ann Gourieux said...

As a chronic intractable pain patient of 18 yrs., I am open to all new research as to the aspects of what exasperates chronic pain. I had a very stressful job. I can say that getting tense caused my pain to get worse.

I don't really like adding another syndrome to the mix. Look how long it took the medical community, to accept fibromylagia.

Colleen Perry said...

Dr. Leavitt,
I thank you for your article on TMS. The more people who are suffering with chronic pain know about their options, the better! I think we can all agree on that.

It may be of interest to you and your readers to note that although I support the diagnosis of tms to explain many cases of chronic pain, I'm not in agreement that all pain caused by our emotions is due to "repressed" or supressed emotions as Dr. Saro originally believed.

In my work as a psychotherapist I have been introduced to publications and research that indicates unresolved trauma can result in chronic pain due to it's effect on the autonomic nervous system. This provides more of an accurate physiological explanation for chronic pain.

As an aside, I have real sympathy for Ann. The above comment she makes about the medical community finally accepting fibromyalgia is sad in that it has taken this long to accept that women's pain complaints were legitimate, but unfortunately "labeling" the issue without providing effective treatment is merely applying a band aid over a significant wound.

I look forward to more conversations AND research about this very important topic.
Colleen Perry MFT

SB. Leavitt, MA, PhD said...

I appreciate Ms. Perry sharing her further insights above. I’m not certain of what she means by “unresolved trauma” but it reminds me that there is important research literature on the interface of posttraumatic stress disorder (PTSD) and pain syndromes. This may be applicable to concepts of TMS; however, it would be a topic for a separate discussion -- I do try to keep the blogposts brief.

Ann Gourieux said...

Ms. Perry,

Women are not the only people who suffer from fibromyalgia. It has been said that "some" patients diagnosed with fibro have had a traumatic experience in their past which "could" be "one" of the reasons for their diagnosis.

Anonymous said...

Knowing that Howard Stern and John Stossel were "cured" by Dr. Sarno was all the evidence I needed to further explore TMS. Two bigger cynics could not be found on this planet.

Anonymous said...

Having suffered from the pains of Dermatomyositis and Rheumatoid arthritis for over 20 years, I can say without doubt that this type of pain is NOT "psychosomatic". I do suspect that there is a "mind-body connection" that is PROBABLY related to that portion of the brain which is sometimes referred to as the "reptilian brain" (that part of the brain-stem that is below "conscious" AND below "sub-conscious").
There should be some serious investigation into the afore-mentioned "mind-body connection" and the "reptilian brain" particularly as it may apply to Auto-Immune Diseases.
But the "Medical Community" has closed its ears to their layman patient's insights.
Perhaps Witch Doctors are the answer!

Anonymous said...


Anonymous said...

I am a Cognitive Behavioural Hypno-Psychotherapist and receive extremely good results with pain patients except it seems when they are taking high doses of morphine which I fully acknowledge suppress emotions. Can anyone medical comment on TMS and patients taking Morphine?