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“One report that particularly impressed me appeared in the prestigious journal Science in April 1982 by authors Visintainer, Volpicelli, and Seligman. They described a group of rats, all suffering from the same cancer, that were exposed to annoying electric shock under two different experimental conditions; one group could escape from it, and the other had to take it until it stopped. Both groups got exactly the same dose of shock; the ability to escape from it was the only difference between the two groups. According to the authors, "Rats receiving inescapable shock were only half as likely to reject the tumor and twice as likely to die as rats receiving escapable shock or no shock. Only 27 percent of the rats given inescapable shock rejected the tumor, compared to 63 percent of the rats given escapable shock and 54 percent of the rats given no shock." The clear implication of the study was that the immune systems of the rats that were more emotionally stressed were less efficient, since it is the effectiveness of the immune system that determines whether a cancer will be thrown off or not. If this is the case with rats, imagine how much more important the emotions must be in humans. (page 185)”

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“There appears to be a close connection between these skin disorders (acne and warts) and the emotions. As with virtually all of these mind-body processes, there is no laboratory proof of the causative role of emotions, but there is certainly a mountain of clinical evidence. Acne is one of the common "other things" that people with TMS have had or continue to have even while they're having back trouble. And then there's the story of the man who developed an itchy rash under his wedding band that disappeared as soon as he separated from his wife. Other gold rings did not produce a similar rash. It has been suggested that other skin disorders like eczema and psoriasis are related to the emotions. I am inclined to agree but have no evidence one way or the other. (page 195)”

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“Since the subject of the emotions and cancer has been introduced, let's pursue it further. Though it is not yet under intensive research by mainstream medicine, there have been many observations through the years that psychological and social factors may play a role in the cause and cure of cancer. One of these was reported by Kenneth Pelletier, a member of the faculty of the School of Medicine, University of California, at the time. He was interested in "miracle cancer cures" that had occurred in seven people in the San Francisco area and wondered if they had anything in common. He found, in fact, that all seven people became more outgoing, more community oriented, interested in things outside of themselves; they all tried to change their lives so that there was more time for pleasurable activities; all seven became religious, in different ways, but all looked to something bigger than themselves; each spent a period of time each day meditating, sitting quietly, and contemplating or praying; they all started a physical exercise program, and they all changed their diets to include less red meat and more vegetables. It certainly looks as though social and emotional factors played a role in these "miracle cures." (page 186)”

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“Anxiety arises in response to the perception of danger and is logical unless the perception is illogical, as is often the case. The anxious person tends to anticipate danger, often where there is little or none. This is the nature of the human animal. However, he or she is often not aware of this anxiety, for it is generated in the unconscious out of feelings that are largely unconscious and are kept in the unconscious through the well-known mechanism of repression. Because of the unpleasant, embarrassing, often painful nature of these feelings and the anxiety they generate, there is a strong need to keep them out of consciousness, which is the purpose of repression. As will be seen later, the purpose of TMS is to assist in the process of repression. (page 43)”

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“The term trigger points, which has been around for many years, refers to the pain elicited when pressure is applied over various muscles in the neck, shoulders, back, and buttocks. There is some controversy over what precisely is painful, but most would agree that it is something in the muscle. Rheumatologists, who have taken the lead in studying fibromyalgia (TMS), appear to avoid using the term, probably because of its association with other diagnoses through the years. I neither use it nor avoid it, for I have concluded that these points of tenderness are merely the central zones of oxygen deprivation. Further, there is evidence that some of these points of tenderness may persist for life in TMS-susceptible people, like me, though there may be no pain. In the first chapter, the point was made that most patients with TMS will have tenderness at six key points: the outer aspect of both buttocks, both sides of the small of the back (lumbar area), and the top of both shoulders. These tender points, trigger points, call them what you will, are the hallmark findings in TMS, and they are the ones that tend to persist after the pain is gone. It is an important part of the physiology of TMS to know that the brain has chosen to implicate these muscles in creating the syndrome we know as TMS. Patients sometimes ask if breathing pure oxygen will relieve the pain. This has been tried and, unfortunately, does not help. If the brain intends to create a state of oxygen deprivation, it will do so regardless of how oxygen rich the blood is. (page 77)”

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“The work of Dr. Hans Selye is credited with first drawing attention to how stress affects the body; his research and writing were prolific and stand as one of the major accomplishments of medicine in the twentieth century. Dr. Selye's definition of biological stress is "the nonspecific response of the body to any demand made upon it." Stress can be either external or internal to the individual. Examples of external stress are your job, financial problems, illness, change of job or home, caring for children or parents. However, the internal stressors appear to be more important in the production of tension. These are one's own personality attributes, like conscientiousness, perfectionism, the need to excel, and so forth. People often say that they have a very stressful job and that's why they're tense. But if they weren't conscientious about doing a good job, if they weren't trying to succeed, achieve, and excel, they wouldn't generate tension. Often such people are highly competitive and determined to get ahead. Typically, they are more critical of themselves than others are of them. (page 36)”

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“For many years I was under the impression that TMS was a kind of physical expression or discharge of the repressed emotions just described. In fact, this is what I suggested in the first edition of this book. I had been aware since the early 1970s that these common back and neck pain syndromes were due to repressed emotions. Eighty-eight percent of a large group of patients with TMS had a history of other tension-related disorders, like stomach ulcers, colitis, tension headache, and migraine headache. But the idea of TMS as a physical manifestation of nervous tension was somehow unsatisfactory and incomplete. Most important, it did not explain the repeated observation that making a patient aware of the role of the pain as participant in a psychological process would lead to cessation of pain, to a "cure." (page 56)”

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“It was a psychoanalyst colleague, Dr. Stanley Coen, who suggested in the course of our working on a medical paper together that the role of the pain syndrome was not to express the hidden emotions but to prevent them from becoming conscious. This, he explained, is what is referred to as a defense. In other words, the pain of TMS (or the discomfort of a peptic ulcer, of colitis, of tension headache, or the terror of an asthmatic attack) is created in order to distract the attention of the sufferer from what is going on in the emotional sphere. It is intended to focus one's attention on the body instead of the mind. It is a response to the need to keep those terrible, antisocial, unkind, childish, angry, selfish feelings (the prisoners) from becoming conscious. It follows from this that far from being a physical disorder in the usual sense, TMS is really part of a psychological process.”

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“The physiology of TMS begins in the brain. Here repressed emotions like anxiety and anger set in motion a process in which the autonomic nervous system causes a reduction in blood flow to certain muscles, nerves, tendons, or ligaments, resulting in pain and other kinds of dysfunction in these tissues. The autonomic nervous system is a subsystem of the brain that has the responsibility for controlling all of the body's involuntary functions. It determines how fast the heart beats, how much acid is secreted into the stomach for digestive purposes, how rapidly one breathes, and a host of other moment-to-moment physiologic processes that keep our bodies functioning optimally under everyday circumstances or in emergencies. The so-called fight or flight reaction that all animals share, particularly important in lower animals, is directed by the autonomic system. In order to meet the emergency, every organ and system in the body is properly prepared. For some systems it means total cessation of activity so that the body's resources can be mobilized to deal with the danger more effectively. Typically, most of the body's nutritive and excretory activities are shut down, the heart beats more rapidly, and blood is shunted away from less important functions so as to be available in larger quantities for systems that are crucial to escape or fight, like the muscles. The critical importance of the autonomic system of nerves is obvious. (page: 71)”

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“The term trigger points, which has been around for many years, refers to the pain elicited when pressure is applied over various muscles in the neck, shoulders, back, and buttocks. There is some controversy over what precisely is painful, but most would agree that it is something in the muscle. Rheumatologists, who have taken the lead in studying fibromyalgia (TMS), appear to avoid using the term, probably because of its association with other diagnoses through the years. I neither use it nor avoid it, for I have concluded that these points of tenderness are merely the central zones of oxygen deprivation. Further, there is evidence that some of these points of tenderness may persist for life in TMS-susceptible people, like me, though there may be no pain. In the first chapter, the point was made that most patients with TMS will have tenderness at six key points: the outer aspect of both buttocks, both sides of the small of the back (lumbar area), and the top of both shoulders. These tender points, trigger points, call them what you will, are the hallmark findings in TMS, and they are the ones that tend to persist after the pain is gone. It is an important part of the physiology of TMS to know that the brain has chosen to implicate these muscles in creating the syndrome we know as TMS. Patients sometimes ask if breathing pure oxygen will relieve the pain. This has been tried and, unfortunately, does not help. If the brain intends to create a state of oxygen deprivation, it will do so regardless of how oxygen rich the blood is.”

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“The work of Dr. Hans Selye is credited with first drawing attention to how stress affects the body; his research and writing were prolific and stand as one of the major ac complishments of medicine in the twentieth century. Dr. Selye's definition of biological stress is "the nonspecific response of the body to any demand made upon it." Stress can be either external or internal to the individual. Examples of external stress are your job, financial problems, illness, change of job or home, caring for children or parents. However, the internal stressors appear to be more important in the production of tension. These are one's own personality attributes, like conscientiousness, perfectionism, the need to excel, and so forth. People often say that they have a very stressful job and that's why they're tense. But if they weren't conscientious about doing a good job, if they weren't trying to succeed, achieve, and excel, they wouldn't generate tension. Often such people are highly competitive and determined to get ahead. Typically, they are more critical of themselves than others are of them. (page 36)”

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“Often people are programmed to have pain because of things they have heard or been told a practitioner. "Never bend at the waist" means the onset of pain is a sure thing when they bend from then on, although it may never have caused pain before. Someone says that sitting compresses the lower end of the spine-so, of course, it's got to hurt when you sit. Standing in one place, lifting, carrying all have a bad reputation and will quickly be conditioned into a patient's pattern. (page 28)”

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“Anxiety arises in response to the perception of danger and is logical unless the perception is illogical, as is often the case. The anxious person tends to anticipate danger, often where there is little or none. This is the nature of the human animal. However, he or she is often not aware of this anxiety, for it is generated in the unconscious out of feelings that are largely unconscious and are kept in the unconscious through the well-known mechanism of repression. Because of the unpleasant, embarrassing, often painful nature of these feelings and the anxiety they generate, there is a strong need to keep them out of consciousness, which is the purpose of repression. As will be seen later, the purpose of TMS is to assist in the process of repression.”

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“Another useful strategy sounds silly at first but has great merit. Patients are encouraged to talk to their brains. So many patients reported having done this on their own with good results that I now routinely suggest it, despite lingering feelings of foolishness. What one is doing is consciously taking charge instead of feeling the helpless, intimidated victim, which is so common in people with this syndrome. The person is asserting himself, telling the brain that he is not going to put up with this state of affairs-and it works. Patients report that they can actually abort an episode of pain by doing this. (page 93)”

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“This is an important strategy, but one must be careful that it does not become a ritual. Patients are given a list of twelve key thoughts, and it is suggested that at least once a day they set aside fifteen minutes or so when they can relax and quietly review them. They are called daily reminders. * The pain is due to TMS, not to a structural abnormality. * The direct reason for the pain is mild oxygen deprivation. * TMS is a harmless condition, caused by my repressed emotions. *The principal emotion is my repressed anger. * TMS exists only to distract my attention from the emotions. * Since my back 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 the pain to emotional issues. * I intend to be in control-not my subconscious mind. * I must think psychological at all times, not physical. (page 97)”

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“In my experience, structural abnormalities of the spine rarely cause back pain. That ought not surprise us, for this epidemic of back pain is very new. Somehow the human race managed to get through the first million years or so of its evolution without a problem, but if the structural diagnoses are correct, something happened to the spine during the last evolutionary eyeblink, and it has begun to fall apart. This idea is untenable. One suspects that these spine abnormalities have always been there but were never blamed for pain, because there was no pain to blame them for. Fifty years ago, back pain was not very common, but, more importantly, nobody took it seriously. The epidemic of back pain is due to the enormous increase in the incidence of TMS during the past thirty years, and, ironically, the failure of medicine recognize and diagnose it has been a major factor in that increase. Instead of TMS, the pain has been attributed primarily to a variety of structural defects of the spine. It's essential to know that almost all of the structural abnormalities of the spine are harmless. (page 117)”

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“Though the back sufferer isn't aware of it, it is generally known by students of the spine that the last intervertebral disc, between the fifth lumbar vertebra and the sacrum, is more or less degenerated in most people by the age of twenty. Discs are structures located between the bodies of spinal bones to take up the shock. They are firmly attached to the vertebral bodies above and below, and in no way can they "slip." Enclosed by a tough, fibrous outer shell, there is a thick fluid inside, which is what absorbs the shock. The discs at the lower end and in the neck, because of all the activity in those locations, begin to wear out at an early age, some by the age of twenty, as stated. (page 118)”

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“For example, the diagnostic study (CT scan or MRI) might show a herniated disc at the interspace L4-L5, one of the possible consequences of which might be weakness in the muscles that elevate the foot and the toes. The examination, however, revealed that not only those muscles were weak but so were the ones in the back of the leg, muscles that are not energized by the spinal nerve passing by interspace L4-L5. Then when I found on examination that the buttock muscles in the vicinity of the sciatic nerve were painful to pressure, it was apparent that the nerve disturbance was not coming from the region of the herniated disc but from the sciatic nerve that serves both sets of muscles. (page 120)”

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“It may be tempting but is inadvisable to attribute symptoms to normal aging phenomena. In my experience, disc degeneration is no more pathological than graying hair or wrinkling skin. In recent years, there have been numerous reports the medical literature of herniated discs in patients with no history of back pain. They were discovered inadvertently on CT or MRI studies done to investigate other parts of the body. (page 122)”

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“In the group of disorders referred to as tendonitis, the tendon is correctly identified as the offending part, but the reason given for the pain is incorrect. The anatomy is right, but the diagnosis is wrong. It is generally assumed that the painful tendon is inflamed because of overuse. So the treatment is to immobilize and rest the part and/or inject the tendon with a steroid (cortisone). Relief is often only temporary. Many years ago, the suspicion dawned on me that tendonitis (more properly called tendonalgia) might be part of TMS when a patient reported that not only had his back pain resolved with treatment but also his elbow had ceased to hurt. I put this to the test and, indeed, found that I could get resolution of most tendonalgias. I now consider tendon/ ligament to be the third type of tissue involved in TMS. Common sites of tendonalgia are the shoulder, elbow, wrist, hip, knee, ankle, and foot. (page 138)”

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“Inflammation must be discussed, for it is the explanation presented for many cases of upper and lower back pain and is the basis for the prescription of both steroidal (cortisone) and nonsteroidal (such as ibuprofen) anti-inflammatory drugs. Because of the magnitude of the back pain problem, these medications are widely used. Experience with the diagnosis and treatment of TMS makes it clear that the source of the pain is neither spinal structures nor inflammation. An inflammatory process is an automatic reaction to disease or injury; it is basically a protective, healing process. The response to an invading bacteria or virus is an inflammation. (page 140)”

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“Pain relief is the goal of all treatments, but treatments to relieve pain are designed to take away pain per se. Generally, this is symptomatic treatment and, therefore, poor medicine unless it is administered for humanitarian purposes. The use of morphine, Demerol, or other strong analgesics is certainly justified when there is excruciating pain but not as a definitive treatment. Acupuncture appears to work as a local anesthetic. In other words, it blocks the transmission of pain nerve impulses to the brain. If one is dealing with a chronic disease for which no relief of pain can be expected, this is a good treatment. For the typical back patient, it can give temporary relief but it does nothing about the underlying process, the cause of the pain. (page 145)”

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“Robert Ader, a research psychologist at the University of Rochester, was engaged in an experiment in which he was trying to condition rats to dislike saccharin-sweetened water. This was similar to the classic experiment of Pavlov in which he conditioned dogs to salivate at the sound of a bell. In order to develop an aversion to the saccharin, Dr. Ader injected the rats with a chemical that made them nauseated so that they associated the sweet water with nausea. What he didn't realize until later was that the chemical be injected, cyclophosphamide, also suppressed the rats immune systems, so that they were dying mysteriously. But the striking thing was that now all he had to do was feed the rats saccharin-sweetened water and their immune systems would be suppressed, even though they had not been injected with the chemical, because they had learned (been conditioned) to associate the sweet water with the nausea-producing chemical. Now, simply feeding saccharin could produce suppression of the immune system. This was a landmark discovery, for it demonstrated that a brain phenomenon, in this case aversion to a taste, could control the immune system. (page 183)”

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“One report that particularly impressed me appeared in the prestigious journal Science in April 1982 by authors Visintainer, Volpicelli, and Seligman. They described a group of rats, all suffering from the same cancer, that were exposed to annoying electric shock under two different ex- perimental conditions; one group could escape from it, and the other had to take it until it stopped. Both groups got exactly the same dose of shock; the ability to escape from it was the only difference between the two groups. Accord- ing to the authors, "Rats receiving inescapable shock were only half as likely to reject the tumor and twice as likely to die as rats receiving escapable shock or no shock. Only 27 percent of the rats given inescapable shock rejected the tumor, compared to 63 percent of the rats given escapable shock and 54 percent of the rats given no shock." The clear implication of the study was that the im- mune systems of the rats that were more emotionally stressed were less efficient, since it is the effectiveness of the immune system that determines whether a cancer will be thrown off or not. If this is the case with rats, imag- ine how much more important the emotions must be in humans. (page 185)”

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“It was a psychoanalyst colleague, Dr. Stanley Coen, who suggested in the course of our working on a medical paper together that the role of the pain syndrome was not to express the hidden emotions but to prevent them from becoming conscious. This, he explained, is what is referred to as a defense. In other words, the pain of TMS (or the discomfort of a peptic ulcer, of colitis, of tension headache, or the terror of an asthmatic attack) is created in order to distract the attention of the sufferer from what is going on in the emotional sphere. It is intended to focus one's attention on the body instead of the mind. It is a response to the need to keep those terrible, antisocial, unkind, childish, angry, selfish feelings (the prisoners) from becoming conscious. It follows from this that far from being a physical disorder in the usual sense, TMS is really part of a psychological process. (page 56)”

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“If I can 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 one should ridicule it, that most of the structural diagnoses are not valid and that the only things worthy of one's attention are the repressed feelings, what has been accomplished? We will have made the TMS useless; it will no longer have the ability to attract the attention of the conscious mind; the defense is a failure (the cover is blown, the camouflage is removed), which means the pain ceases. If that all sounds like something out of science fiction or Grimm's fairy tales, one can only say that it works and has worked in a few thousand people over the last seventeen years. (page 87)”

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“Unfortunately, society is still backward about the need for and the place of psychotherapy, and there is a common feeling that anyone who needs psychotherapy is weak or incompetent. To harbor repressed feelings has nothing to do with strength of character or mental competence. And yet we are so unenlightened about this matter in the United States that one is virtually ruled out of seeking public office if he or she has ever been in psychotherapy. (page 102)”

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“We're going to try to stop the body from reacting physically to your emotions." "We want you to learn to send messages to the subconscious mind." "Information is the penicillin that cures this disorder." "The cure is knowledge." "Until now, your subconscious mind has been in charge; I'm going to teach you how to have your conscious mind take over." "Get mad at your brain; talk to it; give it hell." "TMS is a trick your mind is playing on you - don't fall for it." "TMS is a sideshow designed to distract you from what is going on emotionally." "The symptoms are an act to mask what's going on in the psyche." "Most of the structural changes in your spine are natural occurrences." "The brain doesn't want to face up to the repressed anger, so it is running away from it." "By laughing at or ignoring the pain, you are teaching the brain to send new messages to the muscles." (page 106)”

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“A placebo cure is almost always temporary, and we are looking for permanent resolution of the pain. Therefore, we would not be satisfied with a placebo cure. This is all too common. People are administered a large variety of physical treatments, feel better for a few days, and then need another treatment. (And, of course, they never overcome their fear of physical activity.) One of the reasons I know the TMS program does not induce a placebo reaction is the fact that almost all patients have permanent resolution of symptoms. A second reason is that the placebo effect is based on blind faith; patients know little or nothing about the disorder they have and the rationale for treatment. They simply trust the treating practitioner. The educational program employed in the treatment of TMS is the very opposite. I teach patients literally all I know about the disorder; they are encouraged to ask questions, and they are warned that they must find the diagnosis logical and consistent. Their recovery depends on information, on awareness. They are active participants in the recovery process. This is anything but a placebo process. Perhaps the most compelling argument that what we do is not a placebo is the fact that on numerous occasions since the publication of the book Mind Over Back Pain, the predecessor of this one, people have reported complete and permanent resolution of pain simply by reading the book. There is no personality influence here, no bedside manner; just plain, solid information. And we have learned that that's what it takes to banish TMS. (page 109)”

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“Patients are taught that there is no correct way to bend or lift, one doesn't need to avoid soft chairs or mattresses, corsets and collars are unnecessary, and in general the great number of admonitions and prohibitions that have become part of back pain folklore are simply without foundation, because TMS is a harmless condition, and there is nothing structurally wrong with the back. Running is not bad for the spine; weak abdominal muscles do not cause back pain; strong back muscles do not prevent back pain; it is perfectly all right to arch the back, swim the crawl or breast stroke; man was meant to walk upright (Homo sapiens and his ancestors have been doing so for somewhere between 3 and 4 million years); a short leg does not cause back pain. One could go on and on. (page 110)”

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“I remind them (patients) that the musculoskeletal system is not the only one where the brain can set up a diversion. It can do the same thing in the gastrointestinal tract; the head, with tension or migraine headache; the skin; the genitourinary tract. The brain can cause mischief in any organ or system in the body, so one must be on guard. I advise my patients to consult their regular physicians if a new symptom occurs but to let me know about it since it may be serving the same purpose as TMS. For example, stomach ulcers should be treated with proper medication, but it is almost more important to recognize that they are coming from tension factors. (page 112)”

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