Understanding the depth and breadth of The Mindbody Syndrome (TMS)
It is clear to most people that emotions can cause physical reactions in the body. When someone gets embarrassed, their face will turn red. When standing up to speak before a large audience, many people would have physical reactions such as sweaty palms, churning stomach, a more rapid heart rate or a dry mouth. These are physiologic reactions obviously caused by activation of the autonomic nervous system that are reversible and do not indicate that there is a pathological or tissue breakdown condition in the body.
Most people also recognize that they can get a headache or a stomach ache after a stressful day. Therefore pain can also be caused by stress and emotions. These immediate reactions are relatively easy to discern as being connected to stress and emotions. Among people who are afflicted with TMS however, the time lapse between when the stress that is responsible for the symptoms may be years or decades. And the symptoms of TMS can be amazingly varied and severe. Common symptoms of TMS include back and neck pain, headaches, abdominal or pelvic pain, TMJ pain, or widespread pain now known as fibromyalgia. TMS symptoms can also be related to ANS activity such as is the case with IBS and IC. Neurologic symptoms of burning, tingling, itching, and other paresthesias may occur. Generalized symptoms such as fatigue are common. Psychological symptoms such as anxiety, OCD, PTSD, and depression are very common manifestations of TMS. And insomnia is very common as well. How can we understand the great depth and breath of these varied symptoms and how can we figure out what precise events and emotions are the causative factors in the life of an individual with TMS?
After conducting hundreds of detailed interviews with TMS sufferers, it is my firm belief that we can determine what has lead to TMS in the vast majority of patients. However, in order to truly understand these individuals with TMS, it is critical to learn to dig deeply in the history and the minds of our patients.
If we are patient and take the time to listen, patients will lead us to an understanding of the source of their pain and other TMS symptoms. We need to learn how to take these sensitive histories and learn what clues to attend to in order to help patients gain the insight into the key issues they will need to cope with in their lives. Certain patients have such overwhelming histories of childhood abuse or neglect, which when coupled with additional trauma in adulthood, gives an obvious explanation of the emotional sources of TMS. However, in other patients, it is necessary to listen for more subtle clues to explain how and why TMS developed.
I have compiled a number of examples to illustrate the thesis that childhood events create specific emotional memories that when triggered later in life cause the onset of TMS symptoms. Typically, there are two other psychological factors in the development of TMS: One is a strong sense of obligation, high expectations, perfectionism, desire to be good, guilt, low self-esteem, and self-blame. The other is a suppression of lack of awareness of the emotions that are reactions to life stressors or the internal pressures that patients put upon themselves.
Many patients have obvious childhood trauma and creates a tremendous reservoir of fear and anger, while in others, it is necessary to search carefully for milder forms of the sources of childhood and adult emotional experiences and reactions. Often the patient was unaware of the extent of the emotion or was actually unaware of the emotion itself at the time. This “suppression” of emotion is common and it has been stated by the highly esteemed neuroscientist, Joseph LeDoux, that the very emotions that are more likely to cause physical reactions in the body are precisely those emotions of which we are least aware.
A 45 year old woman was abused both physically and sexually for much of her childhood. She developed anxiety in childhood which was manifest by fear of being alone and the need to connect as much as possible to the people in her life, including her abusers. This is a common reaction to abuse; with the other common reaction being fear and inability to connect to anyone and the inability to feel emotions. She also blamed herself for the abuse and develop the belief that she was unworthy of love and self-esteem. As she grew up, she experienced other events which caused fear and anxiety, such as the loss of a boyfriend (who spread false rumors about her), the death of a parent, a divorce after her husband “cheated” on her and the loss of a job (after being harassed by a boss). Each of these stressors in later life caused the onset of a new symptom. Initially irritable bowel syndrome, then severe headaches, then TMJ pain, then pelvic pain, and finally widespread pain, diagnosed as fibromyalgia.
A 58 year old woman experienced the loss of a parent after her parents divorced when she was young. Growing up as a Catholic, she was taught that she had to be “good” or she would be punished by going to hell. As a young woman, her husband died of a severe heart condition. During the dying process, she participated in weaning him off the ventilator, which was his wish, but she felt extremely guilty about this as she thought it conflicted with her religious beliefs. He died in September and thereafter she began to develop abdominal pains each September. Over time, the pain worsened and began to occur every day and 3 separate GI evaluations did not reveal the source of the pain. In addition, she developed anxiety and started having panic attacks at approximately 3 pm each day. During the process of her treatment for TMS, she reviewed his death certificate and realized that the time of his death was 3 pm.
A 47 year old woman presented with head pain for 17 years. She had seen over 20 physicians, including several headache clinics and had even had facial surgery to try to alleviate the pain. She had also been on over 20 different medications without relief. Her mother was described as “being in her own world” and her father was described as being “bipolar.” When her father was in a bad mood, he would grab her by her collar and scream at her: “You idiot; you jerk; what’s wrong with you?; can’t you do anything right?” These events recurred on a regular basis during her childhood. She developed no symptoms of TMS until she was 30 years old. One day, she obtained a new pair of glasses and immediately upon putting them on, she developed pain on the left side of her head which lasted for 17 years. When asked about the stressors in her life when she got her new glasses, she realized that she has just gotten a new boss, who was a “mean and nasty woman” who used to yell and scream at her.
A 36 year old man was the oldest of three children and when his parents divorced, he was sent to live with his father, while his younger sisters stayed with their mother. His father never showed him that he was loved and when his father remarried, his step-mother decided to have him sent to a home for orphaned boys to be raised. He stayed in this home for about 6 years until he was 18. Once on his own, he made his way in the world and eventually had a good job, was married and had two small children. He had no TMS symptoms during all those years. His father had moved out of town, and one day when his father was visiting his sister, he asked his father to come and visit his children. The father came to their house, but was drunk, and only stayed for a few minutes, showing no affection for the children. Within minutes, the man developed abdominal and flank pain. The pain worsened over time. He found that when he tried to drink alcohol, he immediately developed nausea and vomiting. Multiple medical evaluations over several years revealed no cause for the pains and he was placed on narcotic analgesics.
A 42 year old woman grew up in a home with a kind father and a mother who was narcissistic. Her mother rarely showed love to the daughter and was usually off somewhere, often playing bridge or tennis. The patient grew up without any TMS symptoms, and married a successful businessman, worked part-time, was raising two small children, and working on building a new home. She put a great deal of pressure on herself to be a perfect mother, in contradistinction to her own mother. During this time of a number of stressful circumstances, her widespread pain developed and she was diagnosed was having fibromyalgia. When she was asked what her mother was doing during this time of stress, she started to weep and simply stated, “Playing bridge and tennis.”
A 64 year old woman grew up with loving parents and was raised to be very responsible. She took on this role seriously and became a good student, devoted daughter and excellent worker. Her younger sister was irresponsible and tried to get out of household chores and anything else she could “get out of.” The sister would lie to prevent getting caught and repeatedly asked the older sister to cover for her and/or do her work for her. When the patient was 32 years old, she was the head of a group at work assigned a difficult task requiring a great deal of work and teamwork. One of her subordinates did not complete her tasks, complained and tried to get others to do her work for her. Because of the importance of the assignment, the patient did a tremendous amount of extra work to cover for the lazy subordinate. At this time, she developed migraine headaches, which persisted for years. Several years later, she noted that she began to get headaches each time she drove to see her father, who was now in a nursing home. She drove to see him almost every day, but had to go across town. It turned out that her sister had been able to admit the father into a nursing home very close to her house, but a long way from the patient’s home.
A 20 year old young woman had a 3 year history of severe burning pain all over her body. The pain began in the vaginal area, but then gradually spread to her whole body. She was unable to work or go to school. She had a warm and close relationship with both of her parents. Her older sister was rebellious and was usually mean and condescending towards her. As her sister grew up, she began to lie, cheat, steal, drink alcohol and be promiscuous with boys. The patient saw how much pain her sister caused her parents and vowed never to act like her sister. At age 17, the patient met a wonderful young man and started to date him. He never pressured her and was kind and respectful. However, as their relationship developed, the patient became more upset and couldn’t stand to see him. She pushed him away and broke up with him to the amazement of her parents. During this time, she developed burning pain in the vaginal area, which gradually spread over her whole body. Multiple medical evaluations revealed no source for the pain and specialized testing showed evidence of a mild abnormality in the small nerve fibers, which could be explained by the fact that she has been scratching her skin or even a result of having the pain.
A 52 year old man developed back pain while on a plane from Michigan to California, where he was living. As a child, his father was his hero and well liked by everyone in the small town. His mother was critical and self-absorbed. She demeaned the young boy constantly and one day he replied to her in a disrespectful manner. Later that day, the mother called the local police and had him taken out of school in handcuffs and put into the town jail for the rest of the day. At age 50, his father was in a nursing home and when he returned to visit, he found that his mother was mistreating the father and he felt that his father was “imprisoned” in the home. On his return trip, his back pain began and lasted for 2 years.
A 34 year old man was raised by a dominant father and a submissive mother in a small, highly religious town. He was highly skilled in school and sports and admired by most. His father when drunk would often hit his mother, but this was accepted as “normal” in his community and no action was ever taken by anyone to alter these events. When asked how he felt about this, the patient replied that he often vowed that if he ever hit a woman, he would “cut off his hand.” When he was a Ph.D. student, he was under stress of preparing for his oral exams and was working feverishly on a big project. At this time, he began to have pain in both of his hands. The pain progressed to the point where he could not even turn a doorknob, could not work on a computer, and could not pick up his infant son. Despite multiple EMG’s and X-rays by several hand specialists, no one could explain his pain. When asked to recall any other events that occurred at the time of the onset of his pain, he noted that there was a conflict between two of his mentors. One mentor was a woman, who was angry with the other mentor and began to spread rumors that he was not fit to be a Ph.D. and he felt that she threatened his ability to complete his program. He was unaware of his strong feelings of anger towards her and his even stronger feelings of guilt at the prospect of his anger towards a woman. This internal and unconscious conflict was the trigger for his severe hand pain.
A 49 year old woman grew up in India in a home where the women are taught to be kind and submissive. Upon moving to the U.S., she married a physician and moved to the suburbs. By the age of 40, she had 3 teenagers and began to think that she might want to take some classes to improve her education and challenge her mind. However, at that time, her husband took a second part –time job and was less available. Her children continued to need her to drive them and care for them. Then, her mother-in-law moved into the house and began to tell the patient how to cook, clean and care for the children. Later, her brother moved into the house and expected that she would cook for him and ”wait on him.” The response from the patient: acquiesce to these demands and cancel the class she was going to take. At this time, she began to experience muscle aches which progressed over time until she was diagnosed with fibromyalgia.
A 57 year old man grew up in a relatively poor neighborhood. As a child, his family moved to a somewhat more upscale neighborhood and he began to be teased by the other kids for his clothes and lack of sophistication. As a young man, he and his wife switched from one church to another, which was wealthier and more conservative. He worked hard at the church, and volunteered for projects to show that he was capable and could fit in. Several years later, he developed ringing in his ears to a severe degree. When asked on what specific day it began, he recalled it starting one day prior to Thanksgiving. He usually spent the holiday at his mother-in-laws home, and she had never accepted him as being good enough for her daughter. She treated him with distain and he hated going there. In essence, he was tired of hearing her talk as if he wasn’t worthy and this triggered his long-standing self-doubts fueled by his childhood and adult experiences.
All of these stories have commonalities in terms of the psychological issues which create the underpinnings and then the triggers which create symptoms of TMS. The type of symptoms which occurs is quite variable. Often times, the symptoms that develop are metaphoric, such as the tinnitus when one doesn’t want to hear what is being said, the vaginal pain due to conflicts about sexuality, the hand pain related to a conflict about hitting a woman and a vow to “cut off one’s hand.” In any case, the key to an accurate diagnosis of these symptoms is a detailed history to elucidate the underlying emotional roots of the person and a careful search for the triggers which ignite the symptoms. As I mentioned to the man whose father had neglected him and later, neglected the patient’s children: “Your father and step-mother poured the gasoline in your childhood by sending you away, but he lit the spark when he showed a similar neglect for your children.”
It is my hope that by telling these stories that more people will see that TMS is very common and that normal, regular people have it. Just yesterday, after giving a lecture, a doctor came up to me and told me his TMS story. He grew up with supportive parents and went to Viet Nam in the sixties. He was wounded by shrapnel in action there, but came home with no other physical or mental injuries. His wife noticed that every now and then, he would suddenly start to limp for no apparent reason. When she pointed it out, he would start walking normally again. Eventually, they figured out that whenever there was a helicopter sound overhead, he immediately started to limp, even though when asked why he was limping, he had no idea that he even was limping. As soon, as they noticed the limping, and then he realized that there was a helicopter in the sky, his limping would stop.
The unconscious mind remembers all of our experiences and develops nerve pathways of memory. These nerve pathways can easily become attached to physical reactions in the body (or psychological reactions as well). When we encounter a trigger that reminds us of the earlier experience, a speed dial connection to the emotional memory occurs which can immediately activate the physical response.
To your health,
Howard Schubiner, MD