This Might Hurt is a documentary describing the work of Dr Howard Schubiner. Viewers follow the moving stories of a group of chronic pain patients for whom conventional medicine had little to offer other than opiates and other drugs or potentially harmful unnecessary surgery. Most of them found significant relief using a structured program examining the underlying emotions contributing to their physical symptoms. 

This approach has been used at our office for many years. 

This Australian physiotherapist working in the UK was able to resolve her Raynaud's disease using a mind-body approach. You can read Part 1 of her story and then Part 2 here.  

Despite robust evidence for myriad ailments and sound
mechanistic data, hypnosis is underused by internists. Using
hypnosis fulfills our pledge to abide by evidence-based
treatments that alleviate suffering with the least collateral
harm, but there is a discrepancy between its benefits and
physicians who offer the treatment. Although hypnosis may
appear in the medical curricula at academic powerhouses
like Baylor, Harvard, Columbia, and Stanford, hypnosis
training is rare even at these institutions. Here is why a
modern resurrection of the oldest Western form of psychotherapy
should inspire internists to get trained and offer
medical hypnosis broadly.
Hypnosis, and its myths and misconceptions, have
evolved since the 18th century when Franz Mesmer inadvertently
led hypnosis into obscurity with his theory about
manipulating a force called “animal magnetism.” These
claims were dispelled by the French Royal Academy of Sciences,
and it took nearly 100 years for Scottish physician
James Braid to first describe a mental and suggestive theory
of hypnosis as a waking physiologic state. The 2014 definition
from the American Psychological Association’s Division
30 describes hypnosis as “a state of consciousness
involving focused attention and reduced peripheral awareness
characterized by an enhanced capacity for response to
suggestion.” Long-standing empirical evidence demonstrates
that hypnosis impacts perception, symptoms, and
habits, which have recently been explained by advanced
diagnostic modalities like functional magnetic resonance
imaging (fMRI). Changes during hypnosis include reduced
activity in the dorsal portion of the anterior cingulate cortex
(a key component of the salience network) and connectivity
between the prefrontal cortex and the insula (a pathway
for mind-body control).1 Augmented by data on neurotransmitter
metabolism and genetics, the neurophysiologic
basis of hypnosis is no longer mysterious. Though our
understanding of the mechanism of action of hypnosis is
more robust than that of even acetaminophen, this has not
sufficed to enhance its use.
Skeptics describe hypnosis in 1 of 3 ways: dangerous
mind control, an ineffective farce, or placebo. It is often
viewed as a loss of control and, therefore, dangerous, when
in fact it is a powerful means of teaching patients how to
control mind and body. The ability to enter into hypnosis,
termed hypnotizability, is a stable trait possessed by most
people, which can be entered into or terminated by the
patient. It is not effective in the presence of conditions such
as stroke or schizophrenia or impaired focused attention or
language processing. Hypnosis is more powerful than placebo
(though patient expectancy is a moderating factor),
and placebo effect is blocked by administration of naloxone,
while the hypnotic analgesia is not.2
Reviews on hypnosis for internal medicine topics are
impressive,3 with demonstrated efficacy for migraine headache,
4 irritable bowel syndrome,5 and anxiety.6 Hypnosis
improves procedural pain and emotional distress and
reduces medication consumption up to 40%7--in short, if
hypnosis were a drug, it would be standard of care. Internists
should prescribe hypnosis particularly when it outperforms
the current standard of care by safety and efficacy, as
in the case of opioids and sedatives.
Patients have a strong appetite for taking charge of their
symptoms; online hypnosis videos for anxiety and insomnia
boast 15-19 million views, and medical hypnosis is quite
acceptable by patients.8 But patients cannot be expected to
differentiate between legitimate and manipulative sources
of hypnosis online any more than if they bought pills off
the street. This treatment modality falls under the purview
of medicine, and our duty is to provide safe access. To do
this, we must improve the supply.
Formal training for medical providers is offered through
national societies, such as the American Society of Clinical
Hypnosis (ASCH) and Society for Clinical and Experimental
Hypnosis (SCEH). Trainings span 4 days and include
ethics and informed consent in addition to practical skills.
Hospital credentialing for the privilege of hypnosis may be
required: If none exists, designing one to include formal
training and mentorship requirement is advised. For
ARTICLE IN PRESS
Funding: None.
Conflicts of Interest: None.
Authorship: Both authors had access to the data and a role in writing
this manuscript.
Requests for reprints should be addressed to Jessie Kittle, MD, 300
Pasteur Dr MC 5210, Stanford, CA, 94305.
E-mail address: jkittle@stanford.edu
0002-9343/© 2020 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.amjmed.2020.10.010
COMMENTARY

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.