Fibromyalgia
Fibromyalgia is a common long-term condition, affecting 2-4% of the population, more commonly women than men, that causes pain all over the body along with many other symptoms.  People with fibromyalgia often have:

• Tenderness to touch or pressure affecting the skin or soft-tissues – this is the most obvious complaint and often is misdiagnosed as tendonitis, tennis elbow, or arthritis.   This tenderness is generally in a fairly symmetrical pattern over the shoulders, neck, base of the skull, upper chest, arms, legs, lower back, buttocks, hips, thighs, and lower legs - in short, all over. 
• Severe fatigue – fibromyalgia is often thought to be related to chronic fatigue syndrome – there is debate about whether they are different conditions or both on the same spectrum of illnesses
• Sleep problems (waking up unrefreshed) – called non-restorative sleep
• Problems with memory, concentration, or thinking clearly (cognitive symptoms, often referred to as “fibro-fog”)
• Depression or anxiety
• Migraine or tension headaches
• Irritable bowel syndrome (commonly called IBS) with cramps, bloating, constipation or diarrhea
• Gastroesophageal reflux disease (often referred to as GERD) or heartburn
• Irritable or overactive bladder, often labelled as interstitial cystitis
• Pelvic pain
• Temporomandibular disorder - often called TMJD that may include face or jaw pain, jaw clicking, and ringing in the ears. 

While not part of fibromyalgia itself, it is not unusual for patients to also complain of multiple chemical sensitivities. They may be told they have costochondritis because the upper chest is tender.They may also have numbness or tingling in the hands and feet suggestive of a nerve disorder. 

Books and articles often say that the causes of fibromyalgia are unknown. It may be that it is the final destination arrived at from a variety of different starting points. For some people it occurs after an illness such as influenza; for others after an accident or other traumatic event. For many it develops gradually after an overwhelming incident or as the culmination of years of accumulated stressful events, often dating back to childhood. Numerous studies have found that between 50 and 63% of patients with fibromyalgia also meet the criteria for post-traumatic stress disorder, frequently reporting adverse childhood events or subsequent physical or emotional trauma. Adverse childhood events (such as the loss of a parent, abusive or chaotic households, early hospitalizations, accidents, neglect etc), and later traumas all can prime the nervous system's fight/flight/freeze response, giving rise to a sense of being unsafe in the world, and cause the body to respond with physical symptoms. Chronically elevated stress hormones change the way our glucose metabolism and digestive function work, cause increased muscular tone (tight muscles), and affect our immune system function. 

There is a complex inter-relationship between our nervous systems, our hormones, immune systems, gastrointestinal system, and our muscular function, including how the energy powerhouses (mitochondria) in our cells function. In other words, although it is a very real physical condition, the pain is being produced in the nervous system in response to (usually prolonged and cumulative) internal (such as the demands or expectations we place on ourselves) and external sources of stress. It can also be triggered by sleep deprivation in some people.  

For this reason, it is possible to turn the pain down or even off, by means of techniques that address past trauma, anxiety, stress, beliefs and expectations, as well as by optimizing nutrition, sleep and general well-being through regular exercise (while avoiding extreme of activity).  Coming to an understanding of the condition reduces fear, which in turn can substantially reduce pain intensity.

Fibromyalgia can be best thought of as a central nervous system condition in which the brain and spinal cord are sensitized and therefore respond to sensations which are perceived as much more painful than the same sensation would be experienced by someone without fibromyalgia. It is sometimes referred to as a Central Pain Amplification Disorder. Similarly, people with irritable bowel syndrome will perceive the same degree of gaseous intestinal distension as being much more painful than someone without IBS would do. It is as though the pain ‘thermostat’ or dial has been turned up to a very high level. 

Unlike rheumatoid arthritis or lupus, fibromyalgia is not an autoimmune or inflammatory condition. It can co-exist with arthritis but it is not primarily a joint condition. It does not lead to any ilife-threatening disease.

Fibromyalgia may run in families to some extent but whether this is genetic or due to a common environment (similar stresses) or a learned response to adverse circumstances is not clear. A small subset of people with symptoms suggestive of fibromyalgia have been found on skin biopsy to have an abnormality of small nerve fibres. Genetics alone cannot explain fibromyalgia. Symptoms tend to be worse with stress, over-work, excessive exercise, or sleep deprivation. 

Diagnosing Fibromyalgia

1. symptoms as mentioned above, present for more than 3 months with no other explanation
2. pressure at certain common soft tissue points on physical exam can be helpful to detect tenderness and to exclude other causes of muscle pain.

There is no specific blood test or X-ray that can diagnose fibromyalgia. Commonly tests will be ordered to exclude other conditions, for example, sleep apnea, an underactive thyroid, or polymyalgia rheumatica, anemia, iron-deficiency, rheumatoid arthritis or lupus. 

Treating fibromyalgia

While there is no one specific cure for fibromyalgia, approaching it from a number of different angles – certain medications, carefully structured aerobic exercise within one’s capabilities, and mind-body approaches such as relaxation, stress-reduction, Cognitive Behavioural Therapy, mindfulness, Tai Chi, and clinical hypnosis or guided imagery, can be helpful. Ensuring adequate sleep is essential. Some people have co-existent anxiety, depression, PTSD, panic disorder, all of which can also be treated.  Proper nutrition is also important. Anecdotally, some patients report a correlation between pain intensity and diet, such as refined carbohydrates, gluten, nightshades, or meat. This may be an individual response. 

A number of medications are often tried to reduce symptoms. Most of these are “off-label”. 

Low doses of an antidepressant called amitriptyline (Elavil) or related medications (such as nortriptyline or trazodone) can often be very helpful for pain, sleep, and to reduce migraines. 
A muscle relaxant such as cyclobenzaprine (Flexeril) can be helpful.  This is structurally similar to tricyclic antidepressants (TCAs) such as amitriptyline. 
A newer SNRI medication, duloxetine (Cymbalta) can sometimes help. 
Additional medications include pregabalin (Lyrica) and gabapentin (Neurontin) can be used. 
Another off-label medication is low dose naltrexone. 

Opioid narcotic medications are best avoided as they have significant side-effects, are largely ineffective, addictive and can lead to a conditions known as opiate-induced hyperalgesia, a parodoxical increase in pain the more opiates one cosumes. Of the opiates Tramadol may be better than the others but shares all the same risks as other opiates and interacts with other medications. 

Acetaminophen and anti-inflammatories (such as ibuprofen) are generally not effective for fibromyalgia but may help other co-existing pain. Sleeping tablets such as Zopiclone and benzodiazepines are not recommended. 

One small study published in December 2018 suggested that some patients with fibromyalgia may respond to treatment with a diabetes drug called metformin if their average sugar level (HBA1C) was in the high normal or elevated range. 

Gaining an understanding of fibromyalgia, engaging in self-care, ensuring good sleep, reducing stress, modifying behaviour, counselling, dietary modifications and supplements, and a judicious exercise regimen can all be helpful. 

In my own practice a combination of tender point injections, counselling, relaxation techniques, clinical hypnosis, medication and nutritional advice, and patient-education (which may include recommended reading and journalling) can lead to a significant reduction in symptoms, periods of remission, or even resolution. 

Experts in managing stress-induced illness and pain have produced a new book titled Psychophysiologic Disorders. It is available from Amazon in paperback and Kindle formats and free to subscribers of Kindle Unlimited. It is a comprehensive, in-depth, and up to date approach, reflecting the latest in neuroscience. 

​It describes a host of different stress-induced conditions and how they can be managed. 

Psychophysiologic Disorders: Trauma Informed, Interprofessional Diagnosis and Treatment Paperback – Nov. 13 2019 by David Clarke MD, Howard Schubiner MD, et al.

Physicians and allied mental health professionals have created an App that you can use gradually over time to help both educate yourself and manage the symptoms you have, once your condition has been properly evaluated medically. The Curable App can be downloaded from the appropriate App Store for your device and requires an annual subscription. 

Steven Blake, a therapist in the UK, has skillfully woven together a number of therapeutic techniques by which it is possible for one to persuade the unconscious or subconscious mind to reduce or eliminate chronic pain which has outlived its usefulness. 

This technique has a number of premises including the understanding that acute (new) pain is helpful and protective, even though unpleasant, inasmuch as it is a warning that something is amiss (like an alarm signal) and needs to be sorted out, whereas, chronic (old) pain in general no longer serves a purpose, rather like something that is past its "sell-by date", or like an alarm which has malfunctioned and continued to ring long after the cause has been dealt with. Once chronic pain has been appropriately and thoroughly investigated medically and it has been determined that conventional medical therapy is either not available, effective or needed, then alternative means of relieving the suffering are appropriate, provided they are safe and effective.

Steven describes this process on his website.  This technique does not require a formal trance or hypnotic induction though it does require deep relaxation and can be combined with other therapies. 

It goes without saying that cause of a pain needs to be appropriately investigated before using these kinds of techniques to relieve the pain. The advantages of this technique include its safety, speed of onset, and remarkable effectiveness, not to mention that no drugs are involved. This technique has been effectively used in my office for a number of patients with chronic pain. Not everyone responds but there is nothing to lose but your pain. 



​

Anyone who has studied introductory  psychology has heard about Pavlov's dogs and the concept of conditioning. Pavlov observed that dogs salivate when presented with food. This is an unconditioned (or innate, instinctual) response to the stimulus of food. He noted that over time his dogs would salivate when approached by his assistant (not that the assistant was a tasty morsel but that they associated the assistant with dinnertime). He then performed some experiments. He would ring a bell (a neutral stimulus) and the dogs would not salivate. Then he rang the bell while presenting the dogs with food and they would salivate. After some repetitions of this, the dogs would salivate when hearing the bell rung, even when no food was on offer, a conditioned response. This type of classical conditioning is one mechanism whereby physical pain can be produced in response to a stimulus which the unconscious mind associates with a painful experience. 

If you read some of the stories in the books and websites listed under resources in Part 1 you might come across some anecdotes which illustrate this process. I paraphrase:

A Viet Nam veteran who was injured in the leg during an incident involving a helicopter recovered fully from the injury. However, periodically over the years he would suddenly experience intense pain in the previously-injured leg which would last for several days before dissipating. One day his wife commented on the helicopter flying overhead and it dawned on him that every time he heard a helicopter's engine his leg hurt. 

One lady experienced intense pain whenever she drove through a particular town. She eventually realized that the town was en route to the in-laws' home where she often felt the same pain because of the stressful atmosphere. In time she experienced the pain when travelling that route even when not visiting the family. 

Have you every taken an instant dislike to someone whom you have never met before and wondered why? Perhaps he or she reminds you of someone with whom you have previously had a bad experience. Have you ever had memories flood back instantly transporting you in your mind's eye to someplace else in response to a song, fragrance, or scenery? This is because the parts of the brain involved with memory, pleasure and emotion are  very closely associated, and are also connected to the parts of the brain which process the flight and fight response. The limbic system is also closely connected to the thalamus which is the clearing house for the processing of painful stimuli. 

One of the questions I have learned to ask patients with unexplained pain is: "What was going on in your life when it first happened?" This sometimes gives a clue as to the meaning of the pain and how to approach it. 

Here is some info from the TMS Wiki. Please note: Myositis is not a good term for this condition as there is no inflammation present. 

An Introduction to Tension Myositis Syndrome (TMS)(Redirected from An Introduction to TMS)

Have you struggled with chronic pain or another medically unexplained symptom for a long time? Have you tried everything to alleviate your pain, but nothing worked? Have you had doctors tell you they "just can’t find anything wrong?"

Then you may have Tension Myositis Syndrome (TMS). TMS is a condition that causes real physical symptoms that are not due to pathological or structural abnormalities and are not explained by diagnostic tests. In TMS, symptoms are caused by psychological stress. 

You may be at your wits end. However, there is hope. We know this because the authors of this wiki struggled with chronic pain for many years, and that is exactly how we felt: hopeless. We're not doctors so, of course, we can't diagnose you, and everyone is different, but we are here to tell you what worked for us and how it did so without surgery, needles, or drugs. We found relief from pain through TMS.

Contents [hide] 

• 1 What is TMS?
• 2 How TMS Develops
• 3 Treatment
• 4 Medical Evidence
• 5 More Resources

What is TMS?
Tension Myositis Syndrome (TMS), also known as Tension Myoneural Syndrome, is a condition originally described by John E. Sarno, MD, a retired professor of Clinical Rehabilitation Medicine at New York University School of Medicine, and attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine at New York University Medical Center. TMS is a condition that causes real physical symptoms, such as chronic pain, gastrointenstinal issues, and fibromyalgia, that are not due to pathological or structural abnormalities and are not explained by diagnostic tests. In TMS, pain symptoms are caused by mild oxygen deprivation via the autonomic nervous system, as a result of repressed emotions and psycho-social stress. This is not to say that the pain is “all in your head” or that it is not real. TMS symptoms are very much real, and we should know. All of the people who wrote and developed this website had debilitating chronic pain and other symptoms. We know, first hand, what it is like to have back pain, sciatica pain, RSI, fibromyalgia, chronic fatigue syndrome, migraines, irritable bowel syndrome, and a wide array of other symptoms. We visited doctors and were told the same things you probably heard: "you have a degenerative disc disease, a herniated disc, you type too much, it is due to overuse, or that you are just aging." Even though we were told this, when we applied the ideas first promoted by Dr. Sarno we became pain free and regained our lives.

For more info on TMS watch The 20/20 segment on John Sarno and TMS.

How TMS Develops: At the heart of the development of TMS is our desire to be good people, loved by those we care about. This desire leads us to strive for perfection, and to put the needs of others above our own. We will cook a three course family meal after working a 10 hour day, because that is what a good mother would do. We will be the first person to volunteer to work on the weekend, because that is what a good employee would do. We will stay up all night making sure our homework is perfect, because if we don't, we won't get a good job. Our beliefs of what a good and perfect person will do directly influence our behavior on a day-to-day basis. 

But sometimes, as more and more external stress is added and our desire for perfection increases, we develop a very deep seated resentment toward these tasks. There are some nights when you come home from working a double shift and are angry that you have to cook a meal for your family, while your husband has been watching TV all night. Part of us hates telling our friends that we can't go out on Friday night, because we have to read and study for a class the next day. When our newborn baby wakes us up at 3 am for the fourth night in a row, some part of us has rage at the child, for waking us up yet again. These are all normal feelings and emotions to have. However, when a person has an emotion that goes against their belief of what a good and perfect person would do, the only option available to them is to repress that emotion. If we admit that we are angry at our family, our boss, or at doing homework, we fear that we would be considered a bad person and will be rejected by those we love or who we want to respect us. If we are not perfect, we will be unworthy of being loved. So instead of admitting that we are angry at our spouse for never cleaning up or doing the dishes, we repress it deep in our unconscious. 

Another repressed emotion might be guilt. Some of us have to care for a loved one who is injured or aging. Being a caretaker is not an easy task. If we aren't able to provide the necessary care, or the care the person not only desires but may demand of us, we may feel guilt. If we repress that feeling, especially if we are the type of person who wants to please very much, it can cause us TMS pain.

As we continue to repress these emotions, we create an immense amount of emotional tension which only increases as more and more stress is added to our lives. In order to keep you from recognizing that you have these powerful emotions of anger and rage or guilt, your unconscious creates physical symptoms, such as back pain, neck pain, plantar fasciitis, acid reflux, anxiety, depression, Dizziness, and irritable bowel syndrome. These symptoms serve as a way to distract you from the unwanted emotions by having you focus on your back hurting instead of your anger, rage, or guilt. We develop TMS because we are unable to accept and/or process these emotions.

 A few years ago a lady came to the office and said: “Remember that chronic pain I had? It’s gone.”
“What happened? “ she was asked.
“ I read a book.”

The book she had read was Dr. Scott Brady’s Painfree for Life which describes how the unconscious mind can aggravate, perpetuate, or even produce physical pain through the action of the autonomic nervous system, that part of the nervous system which is involved in the ‘fight, flight or freeze’ response to perceived danger.

When we heard her story we read Brady’s book and over a short period of time acquired a number of other books based on the work of Dr. John Sarno, a rehabilitation specialist, who discovered the role of stress or tension in causing back pain, and later extended this concept to a much larger group of functional conditions.  We had known that pain always seems worse when one is frightened and that a lot of chronic pain sufferers had emotional trauma in their backgrounds, but we were not aware that the brain could reproduce or initiate physical pain in the absence of any actual disease process.

 Since then we have had several patients whose pain disappeared or substantially diminished once they became aware of aspects of their personality, past experience, present circumstances, or psychological issues which triggered their pain.

 Please note, I am not speaking here of malingering (faking the pain when you know that nothing is wrong), or of secondary gain (remaining in the sick role when it is to your advantage to do so because you can avoid work or something else unpleasant or obtain sympathy). Even secondary gain can be subconscious – it is well known, for instance, that the best predictor of a swift return to work after a back injury is whether or not the worker enjoys the job.

 We are talking of an entirely subconscious process of real physical pain being produced (or reproduced) by the brain as a distraction, which allows the conscious mind to avoid dealing with intolerable memories or feelings by focusing on the pain instead of those other experiences. We are also talking about physical pain being produced by alterations in muscle tension, posture and blood flow brought on by emotional stress. Of course, we all recognize that stress can produce physical symptoms: sweating, nausea and diarrhea from “nerves” prior to giving a speech or writing an exam, for instance, or a tight jaw or shoulder knots when we are angry or frustrated. The same applies to musculoskeletal pain. Consider for a moment the metaphors we use in every day language: he’s a pain in the neck, she gives me heartburn, this job is full of headaches etc.

 Causes:

 ·      Personality:  you don’t have to have a dreadful trauma in your background or a psychiatric illness for the subconscious mind to produce pain. If you are a perfectionist, a people-pleaser (always trying to please other people and never feeling you completely satisfy them), or having impossibly high standards for yourself, you can set the stage for pain.

·      Past: a past history of abuse, or severe emotional trauma or intolerable memories can be triggers for pain. 50% of people with fibromyalgia, for instance, have post-traumatic stress disorder (PTSD) and victims of assault or childhood abuse frequently develop a variety of chronic pain syndromes.  Old pains long cured can suddenly recur when a subconscious memory is triggered by a sound, sight, aroma, or similar experience.

·      Present: feeling trapped, vulnerable or powerless in the job from hell or an unhappy relationship or other circumstance can produce physiological changes, postures and muscular tension, leading to pain.

·      Psychiatric illness such as depression or anxiety can also produce physical symptoms.

 
Examples from our clinical practice:

 ·      One patient underwent counseling including EMDR by a skilled psychologist. When this was completed not only were her traumatic memories dealt with and her depression lifted, but her fibromyalgia was also gone. 

·      One young lady volunteered that her fibromyalgia resolved when she forgave her mother.

·      Another found that journaling controlled her neck pain which functioned as a barometer for stress.

·      An accomplished student athlete with a two-year history of incapacitating back pain despite multiple investigations, treatments and specialist consults, read up online about the personality traits that contribute to stress-related pain. After viewing some of the websites listed below the pain was gone.

We don’t suggest for a moment that all chronic pain fits into this category but simply that it is worth keeping an open mind about the possibility that stress may pay a large role in chronic pain.

 Over the next few blog entries I hope to outline in simple terms how pain is processed and modified by the nervous system.

 
Stress Illness (Mindbody Syndrome or Psychophysiological Disorder) Resources:

(Disclaimer: we do not have any proprietary interest in any of these resources). 

Books by John Sarno:

“Mind Over Back Pain”

“Healing Back Pain: the Mind-body Connection”

“The Mindbody Prescription: Healing the Body, Healing the Pain “ (also on video)

“The Divided Mind”  this one is the most comprehensive but is quite academic.

 Book and Video Course by Scott Brady: “Pain-free for Life”

 Book by Marc Sopher: “To Be or not to Be – Pain-free”: the simplest and shortest of these books. 

 Book and Online Course by Howard Schubiner:  “Unlearn Your Pain.”             

 Book by David D. Clark “They Can’t Find Anything Wrong.”

 Book by Steven Ray Ozanich “The Great Pain Deception”

 Workbook by David Schecter  “Mindbody Workbook.”

 Book by Nancy Selfridge and Franklynn Petersen  “Freedom from Fibromyalgia”

 Internet resource: www.tmswiki.org : multiple articles and links on this subject. 

 Journal article:

 Abbass, A.   Somatisation : diagnosing it sooner through emotion-focused interviewing   MARCH 2005 / VOL 54, NO 3 · The Journal” of Family Practice


Additional resources:

 Psychotherapy:

Fosha, D, et al “The Healing Power of Emotion”

EFT, Faster EFT, EMDR can all be researched online.

Pain: Management textbook:

Steven Waldman  (editor)  “Pain Management”

Understanding some of the chemistry:

A book by Candace Pert: “Molecules of Emotion “ explains the biochemical process behind emotion and pain.