February 10, 2012
PPD/TMS Peer Network (formerly, the TMS Wiki) February Newsletter


Dear Friends and Colleagues, For any PPD/TMS activist, the end game that we work toward is having the PPD or TMS approach be the first line approach for certain diagnoses. If one accepts this goal, then an unavoidable first step will be to achieve professional legitimacy, and an unavoidable first step to this is to create an academic/professional literature of our own. In the economics literature, many people may think of an idea, but the first author to publish the idea, either in a journal (paper or electronic) or in a publicly available working paper, is considered to have priority, and is cited. I speak only for myself when I say this, but Alan’s essay in this newsletter is the first publication that I am aware of that focuses on preoccupation with pain as the “distractor” rather than the pain itself. I will let more learned minds than mine figure out whether Alan’s contribution is actually novel. However, along with previous articles published here, this raises the question of how articles within this newsletter should be cited. This will depend, of course, on the citation format you are using, but should you choose to cite anything in this periodical, going back to February 2010, I request that you refer to the publication as “The PPD/TMS Peer Network Practitioner Newsletter.” Through publishing articles such as the three part interview with Howard Schubiner, the review article about Allan Abbass’ investigations of using ISTDP to treat PPD, and Bob Evans’ article on Somatic Experiencing, this newsletter has attempted to facilitate the growth of an academic/professional literature with a distinctive PPD/TMS approach. Should anyone else wish to publish their own ideas, we welcome submissions. Please send them to practitionerinfo@tmswiki.org. Sincerely, Forest In This Edition Save the Date - PPDA Conference, October 6, 2012 TMS Wiki Version 2.0 March Peer Supervision with Guest Speaker Peter Zafirides, MD The Launch of Two New Mind Body and Chronic Pain Websites Breaking the Pain Cycle, by Alan Gordon LCSW Can Tics Be Contagious: An examinatin of the Le Roy, NY ailment mystery, by Howard Schubiner MD Q&A: When Should I stop taking my pain medications (Response by John Stracks, MD)

Save the Date - PPDA Conference, October 6, 2012: When Stress Causes Pain: Innovative Treatments for Psychophysiologic Disorders The Psychophysiologic Disorders Association, or PPDA, will be hosting a conference on Saturday October 6, 2012 at the New York Academy of Medicine. The day long conference will be held in New York City and will be co-sponsored by the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis. The keynote speaker will be senior Somatic Experiencing trainer and clinical psychologist, Raja Selvam, PhD, who is the developer of Integral Somatic Psychotherapy and Integral Trauma Resolution. Raja's approach draws from bodywork systems of Postural Integration and Biodynamic Cranio-Sacral Therapy, body-psychotherapy systems of Bioenergetics and Biodynamic Analysis, Jungian and Archetypal psychologies, psychoanalytic schools of Object Relations and Inter-Subjectivity, Somatic Experiencing, Affective Neuroscience, and Advaita Vedanta, a spiritual tradition from India. The psychoanalytic context for this conference will be provided by Lewis Aron, PhD, ABPP, Director of the NYU Postdoctoral Program. Spyros Orfanos, PhD, ABPP, Clinic Director of the Postdoctoral Program, will provide the closing summation. Other speakers include David Clarke MD, Howard Schubiner MD, Rob Munger MA, MS, Frances Sommer Anderson PhD SEP, Eric Sherman PsyD, Sharone Bergner PhD, Mary-Joan Gerson PhD ABPP, Evelyn Rappaport PhD SEP, Peter Zafirides MD and Alan Gordon LCSW. The PPDA is a 501(c)(3) non-profit organization created in 2011 in recognition of the need for multidisciplinary intervention to address this public health problem. More information regarding schedule and reservations will be made available in due time. Registration is set to open in early April. March Peer Supervision Teleconference The next Peer Supervision Teleconference will be held on Saturday, March 10th from 1:00 to 2:30 PM EST. The guest speaker will be PPD Psychitrist Peter Zafirides, MD. Dr. Zafirides has received the "Best Doctors in America" recognition for the last 7 consecutive years. He serves on the Board of Directors for the Psychophysiologic Disorders Association and is the host of "The Healthy Mind" online radio broadcast.	TMS Wiki Version 2.0 After many months of work the wiki's Executive Council has launched the new website. All of the approximately 600 wiki pages on the previous version have been brought over, and it is very similar to the old site. The only differences are that the new site has a slightly different feel and is much faster and more powerful. This new site will allow our organization to more effectively help individuals recover from chronic pain. If you have a moment I would love it if you would check out our new site located at: tmswiki.org. I want to thank all of the members of the PTPN's Executive Council and especially the members of the Web Site Transition Team including: JanAtheCPA served an important role in coordinating the transition and helping to field questions about the new software. She joined the wiki in the fall of 2011 and is a big fan of the Structured Education Program. Chuck made a number of instructional videos on how to edit pages and navigate the wiki. He has been developing our new forum software as well. Previously he helped out with the popular interview with Howard Schubiner. Enrique went from having chronic pain to running in triathlons. Along with helping out with the transition he also has helped coordinate the Q&A with an Expert program. Ollin is a very active member of the wiki's forum and was very active in helping organize the new wiki pages especially the Q&A with an expert pages. Pranav provided the transition with terrific technical advice and is also an anchor for our weekly Peer Support Drop-in Chats. Sienna joined the wiki in 2011 and has become a familiar presence on the forum and has been an active participant in the wiki's Executive Council. She initially came to the wiki to recover from low back pain. Sienna is from Spain and is one of our many international members. Rinkey has been a member of the wiki since May of 2010 and has been an active part of the wiki ever since. She has helped out on the Educational Program and has been a supportive voice on our forum for quite some time. Yb44 is one of the newer voices on the forum. She came to the wiki because of her migraines and Sciatica. She lent a great hand in cleaning up the pages and helped transition the educational program pages and the Q&A pages Zipity was very active during the transition by making instructiional videos on how to edit pages, as well as creating several templates that are now used on the site. Two New PPD-Related Websites In late fall Peter Zafirides, MD launched his brand new website called The Healthy Mind. The website consists of news about a wide range of Mind Body conditions and includes various essays, blog posts and podcasts. The site is located at http://www.thehealthymind.com/ Orthopedic surgion, David Hanscom, MD, has a website that is dedicated to improving how the surgical community treats patients and helping them become pain free. The site outlines his own approach which includes how to address the psychological causes of PPD symptoms. The site contians several articles and videos produced by Dr. Hanscom, and can be found at http://www.drdavidhanscom.com/
Breaking the Pain Cycle, by Alan Gordon LCSW The following article was written by Alan Gordon who has extensive experience treating clients with PPD. He is a member of the PPDA and played a vital role in organizing the 2010 Mind Body Conference in LA, where he also gave the presentation entitled "Cognitive-Behavioral Approaches in the Treatment of Mind-Body Disorders." Alan has also served as a guest lecturer at USC. This article can also be found on the wiki at http://tmswiki.org/ppd/Breaking_the_Pain_Cycle,_by_Alan_Gordon_LCSW. __________________________________________________________________________ This article is for those of you who have had the following thought: “I’ve tried to look at my pain psychologically, I’ve addressed some of the underlying emotions, why isn’t my pain going away?” There’s a short answer and a long answer. I’ll start with the short answer: PPD pain has an underlying purpose of preoccupation. The preoccupying behaviors serve to reinforce the pain, thus perpetuating the cycle. Unless you read behaviorism treatises in your spare time, this probably means nothing to you; but here’s the gist: the way to eliminate or significantly reduce your pain is to break this cycle of reinforcement. If you attempt this, I can tell you two things: 1.) There’s a good chance you’ll get rid of your symptoms, 2.) It’s really hard. I want to start off with a couple examples of the way reinforcement works. If you give a rat a food pellet whenever he runs on his wheel, you are reinforcing that behavior. His little rat mind will think, “Every time I run on the wheel, I get food. Food is good. I’m going to run on the wheel some more.” This works with people too. If you give candy to a toddler every time he throws a tantrum, you are reinforcing the tantrums. The kid learns, “If I throw a tantrum, I get candy,” and the behavior will continue. This is what’s going on with your pain. Though you’re likely unaware of it, your pain is being reinforced dozens of times per day. And like our tantrum-throwing toddler, if a behavior gets reinforced, it will continue. So the question is, how is the pain being reinforced? What is the reinforcing agent? Because (in most cases, at least) the purpose of the pain is to preoccupy or distract you from painful unconscious emotions, then anything that leads to preoccupation will serve as a reinforcer. There are two main vessels for preoccupation: fear and attention. Your mind originally introduced the pain in an attempt to preoccupy you. Every time you feel fear related to your physical symptom, and every time you pay attention to it, the pain is being reinforced. This is all unconscious, so please don’t take this to mean that you are responsible for perpetuating your pain. You are no more responsible for your unconscious processes than you are for your dreams about losing your teeth or showing up to school naked. Fear and attention. These two things are the fuel for your pain. Most of you have likely had the following thoughts at some point: “Will this pain ever go away?” “Remember how great life was before the pain started?” “Wait- is it better or worse than it was yesterday?” Each time you think about your pain, feel frustration over it, monitor it, rue its very existence, the part of your mind that created your pain is getting exactly what it wants. Preoccupation. You are fully, unequivocally preoccupied. Your mind goes to the pain 20 or 50 or 100 times per day. You monitor it, you fear it, you focus on it, you wonder if it’s going to hurt if you wear those shoes, you wonder if the party you’re going to is going to have comfortable chairs, you think, “How am I ever going to have kids if I can’t even lift them?” Your mind is a relentless machine, churning out thought after thought and fear after fear with one singular focus: the pain. And your mind has gone to the pain so many times for so many days or weeks or years, it has become a habit. And habits are hard to break. But you can break it. And when you do, when you take away its fuel source, the pain will lose its power. Like a car that runs out of gas, it will eventually peter out… In the movie “The Wizard of Oz,” Dorothy and the gang were terrified of the almighty powerful wizard. But as soon as Toto pulled the curtain back, and they saw it was just a man, he lost his power over them. I invite you to pull the curtain back. See what your mind is up to. See how desperate and persistent and clever it is at getting you to focus on your pain with this thought or that fear. Know that its goal, its ulterior motive is to terrify you or frustrate you or preoccupy you in some way; and make a conscious choice and a conscious effort not to buy into these thoughts. Take their power away. I’ve heard Buddhist monks make the following analogy: a thought is like a train pulling into the station. You can either jump on board the train and let it take you somewhere else, or you can watch the train as it passes you by. Watch these pain-themed thoughts as they come up. They are your mind’s way of trying to keep you fearful of and attending to the pain. Know that these thoughts are trying to get you to jump on board, and take a stand against them; even laugh at them and their cleverness. When you stop buying into these thoughts and fears, you’re cutting off the pain’s reinforcement. And when you stop reinforcing a behavior, the behavior loses its purpose. I mentioned earlier that this is hard to do. It actually goes against one's very nature because of the power that pain can have over you; it’s a relearning process that takes time and practice. I want to emphasize that I am not advocating that you attempt to ignore the pain. The pain itself is not the problem. It is the stories and emotions and fears and frustrations around the pain that is distracting you from painful unconscious emotions. The pain itself is simply a means to an end. I’ve had clients tell me that when they succeed at no longer indulging in these pain-themed thoughts, they actually become somewhat indifferent to the pain. Of course it still hurts, but without all the fear and frustration, the pain loses a lot of its meaning. When you reach this place of near-indifference, the pain is no longer serving its purpose, and will eventually fade. It is no easy task to attempt to become indifferent toward something that you care very much about, and is not something that can be achieved overnight. But by gradually taking away your pain’s power, you’ll likely see incremental changes, which will make continuing to do so even easier. I want to add two caveats. 1.) There’s a phenomenon in behaviorism known as an “extinction burst.” When you stop reinforcing a behavior, you’d think that the behavior would just immediately stop. But they’ve found that that isn’t the case. When you stop giving the rat food pellets for running on the wheel, it actually runs harder and faster at first, before it stops running altogether. When you stop giving the two-year-old candy, his tantrums actually get worse before they go away. No one likes to lose a behavior that’s working, so there’s a little resistance once the reinforcement is taken away. How is this relevant to the pain? Often when you take away the pain’s reinforcement (fear, attention, etc.) the pain gets worse before it goes away. The mind does not like to lose a defense mechanism any more than a toddler likes to lose hid candy-getting behavior. So just know that if you stop reinforcing the pain and it starts getting worse, don’t panic, that’s just an extinction burst; it means you’re on the right track. 2.) Although I focused primarily on how to respond to the pain, I don’t want to minimize the importance of working through the underlying emotions. Often if you don’t work through these emotions, a new symptom will pop up that will serve to preoccupy you all over again. One of the reasons breaking the pain cycle is so difficult is because the pain-related thoughts and fears are so persistent and relentless. So you must be too. There’s a great story I often tell my clients that captures the importance of this. In the late 70s, Bob Marley was scheduled to perform at a peace rally in Jamaica. Two days before the rally he was shot by an unknown gunman. Despite his injuries, he showed up at the rally and performed for 90 minutes. When asked afterward why he didn’t skip the rally to recover, he replied, “The people who are trying to make the world worse don’t take a day off. How can I?” Your thoughts and fears about the pain will not take a day off, how can you? Be disciplined, be persistent, commit yourself to pulling the curtain back on these thoughts, and break the pattern of reinforcement. When you take away the pain’s power, it is a behavior without purpose. And its days are numbered. Can Tics by Contagious, by Howard Schubiner, MD By now, many of you have probably heard about the mysterious mini-epidemic of tics and Tourett's syndrome that has developed in the small town of Le Roy, NY. Since the fall over 18 individuals have developed tic-like symptoms and the story has gained international attention. Highly renowned PPD physcian and author of the book Unlearn Your Pain, Howard Schubiner, has recently weighed in on this phenonemon in a recent article he wrote describing the connection between tics and PPD. The article also appears on Dr. Schubiner's blog and on the wiki at http://tmswiki.org/ppd/Can_Tics_be_Contagious,_by_Howard_Schubiner . Dr. Schubiner has recieved an multimillion dollar grant from the NIH to study PPD treatment methods in patients with fibromyalgia, and conducted the first randomized control trial on the effectiveness of the PPD approach in treating patients with fibromyalgia. __________________________________________________________________________________________ Can tics be contagious? The story from upstate New York doesn’t want to go away. There have been at least three national TV spots in the last few weeks about the 12 high school students who have developed tics. Neurologists consider tics and Tourette’s syndrome to be chronic neurologic disorders that are primarily inherited. The treatment consists of medications to attempt to control the abnormal movements and it is not generally believed that individuals can have any control over their tics. However, the mini-epidemic in LeRoy High School near Buffalo is believed by excellent neurologists to be caused by a conversion disorder, i.e. a physical symptom that is not a pathological or structural process, but is caused by stress and unresolved emotions. In other words, this is a manifestation of Mind Body Syndrome (MBS) or a Psychophysiologic Disorder (PPD). (I will use these terms interchangeably.) When one looks at the history of mini-epidemics of PPD, evidence abounds that PPD is a contagious disorder. There have been well-documented epidemics of repetitive stress injury, sick building syndrome, and psychogenic seizure-like activity (also known as pseudo-seizures). There is an interesting research article from Germany that demonstrates that back pain appeared to be contagious after the fall of the Berlin Wall. So, it isn’t really surprising that almost any symptom can be caused by MBS. Once a careful medical history, physical exam, and environmental evaluation rules out evidence for a pathological disorder, the diagnosis of MBS should be confirmed. In the LeRoy High School situation, experts have done this and have concluded that the girls are suffering from PPD. However, this apparently hasn’t gone over very well with the patients, their parents, or many members of the community. Today’s report showed angry parents filling a meeting of the school board asking them to prove that their buildings are safe. Of course, they have a clean bill of building health from the state of New York and the CDC. Yet, a psychological explanation for physical symptoms doesn’t seem to ring true or satisfy most people. Over the past few weeks, I have encountered several stories about tics and Tourette’s syndrome that suggest that it may not be as much of a neurological disease as we once thought. Story #1: A friend told me about a young man who suffered with Tourette’s for his whole childhood and adolescence. As an adult, he participated in an intensive psychological retreat during which he expressed and processed many emotional issues from his life. The tics resolved. Story #2: I met a psychologist who told me that he cured a teenager of Tourette’s “by accident.” The young man was sitting in the psychologist’s office and while waiting, he was throwing some balls into a box over and over. When the psychologist entered, the boy apologized for his behavior and stopped. But the psychologist suggested that it was fine to throw these balls and encouraged him to continue to do so, which he did. During the course of a single one hour session, the boy expressed many issues that were bothering him and threw the balls more forcefully. Following the session, he seemed relieved. The tics disappeared and never returned. Story #3: I was telling these stories to a friend. He immediately began to tell me his story. As a child, he was diagnosed with Tourette’s syndrome. The tics were incredibly embarrassing and humiliating to him. He hated them and vowed to stop them. He decided to resist them and spent many nights in bed holding his body against the urge to “tic.” After a few weeks of mental effort directed to stopping the tics, they went away and have not recurred. I am not suggesting that all tics or all Tourette’s syndrome is caused by PPD, but it wouldn’t surprise me if many cases are. It is interesting that over time, people with Tourette’s tend to grimace and even swear uncontrollably. Grimacing and swearing, of course, are signs of anger. Could it be that some people with Tourette’s syndrome have unresolved resentment, anger, or rage? It would certainly be wonderful if there were a relatively simple solution to these horrible disorders. We need to do some studies to determine if tics and Tourette’s may respond to our usual MBS approach and treatment It shouldn’t be too surprising that some neurological events are contagious. Patterns of speech are clearly neurological events. People who grow up in the south have different speech patterns and inflections than do those from the north. Phrases such as “like” and “you know” have become ubiquitous in the speech patterns of teenagers (and adults) in recent years. If these neurological events are contagious, why not tics? To your health, Howard Schubiner, MD Q&A with an Expert One common question that comes up quite often on the TMS Wiki regards when and how to stop taken pain medications. PPD physician, John Stracks, recently addressed this question for the wiki's Q&A with an Expert program. The question and Dr. Stracks' response is below. When should I stop taking pain medication during my recovery? Like many issues with TMS, the process is different for everyone but in general people gradually wean the medication as they become more confident of their ability to handle the pain using TMS techniques. I do NOT think that you need to stop the medication completely at the beginning of your TMS treatment (ie continuing to use some medication initially does not sabotage the TMS treatment process). If, as time goes along, you are not using less medication then you probably need to do more psychological work or re-read Dr. Sarno's book (or Dr. Clarke's or Dr. Schubiner's...) to figure out what's causing the pain. Many people have told me that in the end they keep medication handy for flare-ups even though they find they never actually need to take the medication because the flare-ups are so much more mild than they once were. Medications like NSAIDs (Aleve, Motrin, etc) can generally be stopped fairly quickly as there is not a significant danger of withdrawal symptoms. Narcotic pain medications (Vicodin, Norco) can be stopped quickly as there's no danger in doing so; in reality, though, withdrawal symptoms from stopping narcotics are strong and most people wean these gradually over the course of weeks or months. Anti-anxiety medications like benzodiazepines (Xanax, Valium) MUST be weaned off gradually as stopping them abruptly can cause seizures. Weaning narcotic and benzodiazepine medication should probably be done under the supervision of a health care professional.
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