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Howard Schubiner M.D.
Howard Schubiner M.D.
Chronic Pain

Four Questions Can Help Determine the Cause of Chronic Pain

Find out if you have tissue damage or a neural pathway underlying your pain.

Key points

  • With psychophysiological disorders (PPDs), symptoms are caused by stress and emotional reactions to traumatic life events.
  • Learned neural pathways, as opposed to tissue damage, cause physical pain when it comes to PPDs.
  • Doctors who don’t understand PPDs will usually tell patients there is something wrong in the body, such inflammation or scarring.

In my medical practice, I specialize in psychophysiological disorders (PPDs), i.e., disorders caused by stress and emotional reactions to traumatic life events. As I’ve written about in earlier blog posts, this is an important concept that everyone should understand about pain: learned neural pathways as opposed to tissue damage can cause physical pain. This pain is very real. In fibromyalgia and irritable bowel syndrome, there is no clear evidence of significant tissue damage, yet the symptoms are very real and often severe.

Over the last decade, I’ve paid very close attention to the symptoms my patients have and I try very hard to discern their cause. Every time a patient describes a new symptom, I investigate it to determine if tissue damage, a neural pathway, or a combination of the two causes it. It is critically important to make this determination, as the treatment is very different.

As a conscientious physician, the very last thing I want to do is tell someone that they have a neural pathway problem (i.e., a psychophysiological disorder), when in fact, they have a structural problem requiring specific medical treatment, such as surgery or medications. However, I have discovered by paying careful attention to histories and clinical evaluations that the majority of people that I see with chronic headaches and neck or back pains are actually suffering from a neural pathway problem.

However, many patients present with more unusual symptoms. After evaluating hundreds of patients with potential PPDs, I have realized that the symptoms of a PPD can be amazingly variable. It turns out the brain can be very “creative” in terms of producing a wide array of symptoms.

Since the brain is connected to every cell and fiber of the body via a vast neural network, any imaginable symptom can occur. The brain can produce pain or muscle spasms of the back, neck, eye, chest, abdomen, limbs, and pelvic and rectal muscles. I’ve seen patients with tingling, burning, or numbness sensations of the fingers, hands, ears, mouth (sometimes diagnosed as burning mouth syndrome), legs, feet, toes, or other areas. I’ve seen people with diarrhea, urinary frequency, and constipation. Symptoms such as dizziness, ringing in the ears, fainting, out-of-body experiences, and even hallucinations are common. I frequently see people with fatigue, insomnia, anxiety, depression, and PTSD that are caused by stress and emotional reactions. The brain is powerful enough to cause paralysis to the point of not being able to walk, move an arm, speak or swallow (these are examples of conversion disorders). It appears that the brain is even capable of causing death, from reports of death induced by curses or voodoo.

I frequently get emails from people with chronic pain or some of the other symptoms listed above. Chronic pain and other symptoms can be so devastating that they have been desperately searching for a cure for a long time. When their internet searches turn up references to Dr. John Sarno’s work, to whom I owe a great debt, they often intensify their search and find my site or other associated sites, such as the TMS wiki, the Pain Psychology Center in Los Angeles, The Psychophysiological Disorders Association, the websites of Dr. David Clarke and Dr. David Hanscom and others.

The main question they ask is this: “These are my symptoms. Can I be suffering from PPD or TMS?” (Tension Myoneural Syndrome and Tension Myositis Syndrome are terms Dr. Sarno used to describe this syndrome.)

Here are the four questions that I use to determine if a symptom is due to a PPD or not.

1. Is there a clearly defined medical disorder that explains the symptom?

As mentioned above, this is always the first step. Most patients I’ve seen have chronic symptoms and have had extensive medical testing, which has not found a significant medical problem. My colleague, Dr. David Clarke, titled his book, They Can’t Find Anything Wrong for these situations.

When this is the case, as often occurs with headaches, abdominal or pelvic pain, and many other conditions, you are be assured that there is nothing structurally amiss. When doctors make diagnoses that have no structural cause attached to them, you can assume the same thing. This occurs with IBS (irritable bowel syndrome), IC (interstitial cystitis), chronic fatigue syndrome, insomnia, anxiety, depression, fibromyalgia, myofascial pain syndrome, AMPS (amplified musculoskeletal pain syndrome), tinnitus, POTS (postural orthostatic tachycardia syndrome), burning mouth syndrome and many others.

Sometimes doctors will make diagnoses that give you the erroneous belief that there is a structural cause. The most common situation in this category is non-specific neck or back pain. As I described in an earlier blog post, MRIs typically show non-specific abnormalities, such as degenerated discs, bulging discs, scoliosis, and other “abnormalities” that are commonly seen in people who have no pain and should be interpreted as signs of “normal aging.” Patients with temporomandibular joint (TMJ) syndrome are often told that they have abnormalities in their bite, joint, or jaw, but again, these are common in people without pain. People who seek care from alternative doctors are often diagnosed with conditions such as adrenal fatigue, yeast overgrowth syndrome, food allergies, chronic Lyme disease, and other conditions that may not actually be tissue damage conditions.

2. Is there a history of other psychophysiological disorders?

Most adult patients I see have had several of these during the course of their lifetime. They may have had a “nervous stomach” as a child, headaches as a teenager, TMJ symptoms and anxiety in their 20’s, IBS or pelvic pain, depression, neck or back pain at other times. It can be very helpful to make a list of all of the potential PPD symptoms and note at what points in your life they began or recurred. The more of these that have been present, the higher the likelihood that the current symptoms are also PPD.

3. Is there a history of significant stressful events, particularly early in life?

The reason that the brain creates physical symptoms is to alert us to some kind of danger. The brain is designed to do this in order to protect us. When we touch a hot stove, the pain that ensues creates a painful memory so we don't repeat that mistake. Injuries create memorized neural pathways that can be activated by stressful events. A woman fell off a horse and injured her back as a teenager. The back pain from that fall lasted about two weeks, then resolved. Twelve years later, on the day before her wedding, her fiancé called it off and the exact same back pain recurred.

Stressful life events, such as physical, sexual, or emotional abuse, abandonment and loss, parental arguing, bullying, and many other similar events, create a sensitized “danger” pathway in the brain. The brain treats these exactly as it does physical injuries as shown in research on the effect of emotions on the brain. Stressful events later in life are much more likely to trigger physical pain or other PPD symptoms in someone with a sensitized “danger” signal. In other words, physical pain causes emotional pain and emotional pain causes physical pain. Not all people with PPD have had a major trauma in their lives. The normal stresses of life can create an exaggerated danger signal in people who are highly sensitive, i.e., people who are people-pleasers, have high expectations of themselves, are self-critical, tend to be overly responsible, and feel guilty for minor issues.

4. Were there significant life events occurring at the onset of the symptom(s)?

I always take the time necessary to review each patient’s life trajectory. This is the only way to identify the early life “priming” events and later life “triggering” ones. Often the triggering events are similar in emotional content to the priming ones.

For example, I recently saw a patient who was abandoned by her mother early in life. She developed significant abdominal pain when she returned to work after her children were born, as her subconscious brain interpreted this act as if she were abandoning them. A woman grew up with a strong, reliable father, and later developed neck pain when her husband had an affair. A man, whose mother frequently criticized him as not being smart enough, developed arm pain when he got a new boss who was micromanaging and overly critical.

I have found this approach very useful in separating structural problems from psychophysiological problems. At times, however, this distinction is not clear. In those circumstances, I rely on a careful physical examination and a review of all available lab and imaging studies. Sometimes, I am not sure and conclude that there may be elements of both structural issues and a PPD. I urge patients to go over their symptoms and test results with a physician who can help them sort this out if this is possible.

Unfortunately, many physicians are not aware of PPD and don’t consider it a possibility. Doctors who don’t understand that neural pathways can be the cause of symptoms will usually tell patients that there is something wrong in the body, such as some kind of inflammation, scarring, or dysfunction. Unfortunately, these erroneous explanations often exacerbate the problem by creating more fear. For neural pathway and PPD disorders, more fear actually creates more pain!

Thousands of people have recovered from chronic pain by changing how they think about pain. Check out these tributes to Dr. Sarno to see a sampling of these stories. As you read these, you will find that many of the people who recovered from chronic pain decided that their pain was due to a PPD and made the necessary changes in their beliefs, their thoughts, and their actions to heal.

If it is clear to you from answering the above questions, that you have a PPD, then you can begin to recover as well. The first step is to figure this out for yourself or in conjunction with your doctor or therapist. If you’re still not sure, you may need to consult with someone who is very familiar with these issues. Consult the directory of TMS practitioners on the TMS wiki to find someone who can help.

Once you have the correct diagnosis, you can begin to take steps towards recovery. Although millions suffer from PPDs, many are never told about this process. I recently saw a 55-year-old woman who had a very difficult and traumatic childhood, was diagnosed with over 20 different medical disorders, and could easily connect the onset of most of these disorders to significant stressful events in her life. However, no one had ever put the pieces together in a way that explained why she had so many symptoms and all of the tests never diagnosed a clear structural problem. When I explained that she actually only had one thing wrong with her (PPD) which is caused by learned neural pathways and that she can recover, she was incredibly grateful and began to experience hope for the first time in many years.

Everyone with chronic pain and other unexplained symptoms should take the time to look at these questions to begin to figure out if they have a PPD or not. It could be the turning point to saving a life.

To your health,

Howard Schubiner, MD

About the Author
Howard Schubiner M.D.

Howard Schubiner, M.D., is a clinical professor at Wayne State University School of Medicine

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