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This is an interesting question, and one I've thought a lot about. I recently spoke with Dr. Schechter and Dr. Schubiner about this, and I have a theory which is by no means conclusive.

There's a lot of evidence that TMS pain is a function of learned neural pathways in the brain. This is not new, TMS physicians have been talking about this for years.

So the pain is in the brain, we get that. But how does that account for the physical tension that some TMSers have - physical tension that can be so profound, other people, such as massage therapists, can even feel it? This physical tension seems to indicate that in some cases the pain is more than just an interpretation of neurons in the brain.

I believe that neural pathways in the brain can flip a switch, generating physical tension in the body. The way one responds at the onset of the pain determines whether the tension perpetuates, or whether the switch flips off.

This is where the idea of outcome independence comes in.

If you buy in to the pain and generate fear, it sends signals to the brain and the switch stays flipped. You're in a fight or flight state, the tension and pain remain, as their psychological purpose is being fulfilled.

If on the other hand, you don't buy in to the fear, the switch eventually flips off. The pain and tension subside, as their psychological purpose (fear, preoccupation) is not being served.

An example: One of the many manifestations of TMS I had was heel pain. It came on one day out of nowhere. I don't remember banging it or anything, but even the slightest pressure was enormously painful. It felt like what it feels like when you have a bruise. There was clearly a lot of physical tension in that area.

For two days I limped, trying to figure out whether it was TMS or an actual injury. Then, I got a magical piece of evidence that changed everything. I woke up at 4 AM and had to go to the bathroom. Groggily, (is that a word?) I walked to the bathroom and back to bed. I was so out of it that I forgot to limp. But I didn't have any pain!

That was all I needed to know that for sure, definitively, it was TMS. The next day I forced myself to walk without a limp, reaffirming my evidence, standing up to the fear, and not caring whether or not it hurt. My goal was not to get rid of the pain, rather it was to hone a level of authentic indifference about whether or not I had pain.

It was hard. All those websites that I looked up days before saying you can develop long-term heel pain if you don't rest a bruise flashed through my mind. But I kept on repeating the evidence:

"It didn't hurt at all when I mindlessly walked on it barefoot at 4 AM."

Of course my fear brain would counter:

"What if it hurt but you were just too groggy to realize it?"

Me: That doesn't make any sense.

Fear brain: What if it didn't hurt because you'd been sleeping beforehand and it was rested a little?

Me: No, Schubiner said if it was a real bruise, it'd hurt even more after inactivity, not less...

I knew it was TMS.

By the end of the day, the pain and the physical tension were gone. I'm sure that if I had bought in to the fear and continued treating it like a structural injury, the pain and tension would have persisted. I believe that by interrupting the fear cycle, the neural pathways that were sending signals to generate tension in my heel were effectively switched off.

The muscular tension is real, but the source of the tension is the brain, and the way to ultimately relieve it is not through a physical intervention, but a psychological one.

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