New Program Day 18: Conditioned Responses

Day 18: Conditioned Responses

In the late 1960s, comedian Steve Martin was on top of the world. His career was taking off, he was making good money, and he was dating up a storm. But then one night, it all came crashing down. He was out with his friends, when out of nowhere he had a crippling panic attack.

“My heart began to race above two hundred beats per minute,” he said. “The saliva drained from my mouth so completely that I could not move my tongue.”

The next day he was feeling better, but that very evening, he had another panic attack!

His brain had developed an unfortunate connection - he came to associate nighttime with anxiety. And this association lasted for months. During the days he was fine, but as soon as the sun would set, he was a mess.

Steve Martin developed a conditioned response - his brain connected a physical symptom with a neutral stimulus. Conditioned responses are very common with people in pain as well. This occurs when pain becomes linked with a physical position or activity.

For example:
Sitting Back pain
Typing Wrist pain
Eating Stomach pain

But in the case of neural pathway pain, it isn’t the position or activity that’s causing the pain, rather it’s the belief that the position or activity is dangerous that’s causing the pain.

Learned Behavior

Evolutionarily speaking, conditioned responses are actually helpful. If you eat a poisonous berry and get sick, you brain creates an association. It puts a “DANGER” sign up, and after that, even the smell of that berry can make you nauseous. Conditioned responses can protects us from repeating dangerous behaviors.

But what if that berry wasn’t poisonous? What if you just happened to get sick shortly after eating it? Your brain – not taking any chances – might create an association anyway, and put a “DANGER” sign up on a food that’s actually safe.

Assuming you have neural pathway pain, this is how conditioned responses develop. Your brain interprets a safe behavior (sitting, walking, typing, etc.) as if it’s dangerous.

In the following clip, a 17-year-old named Mya developed a conditioned response to eating. Her brain learned that food = danger, and it’s responding accordingly.

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Thankfully, Mya’s currently working with a specialist to help her unlearn this association.

Unlearning What We’ve Learned

The way to overcome conditioned responses is to teach your brain that the position or activity it's interpreting as dangerous, is actually safe.

The first step in this process is acknowledging the obstacles. Often we're able to accept intellectually that we have neural pathway pain, but on a gut level we still have a tendency to think physically.

And this makes sense.

If you sit and you have pain, or you walk and you have pain, it’s a logical conclusion to think that it’s the sitting or the walking that’s causing your pain. Everything you've ever learned about cause and effect is telling you that's what it is.

So to overcome conditioned responses, we actually have to embrace a perspective that's inherently counterintuitive: “It isn’t the sitting that’s causing me pain even though it hurts every time I sit?”

Searching for Exceptions

It’s hard to embrace a reality where our senses are essentially lying to us. Gathering evidence to support this perspective can make it lot easier.

The most compelling evidence that there’s nothing physically wrong with us comes in the form of exceptions.

The Exception

By 2006, I’d been suffering from chronic back pain for several years. It was pretty consistent – the longer I sat, the worse the pain was. Even though it hurt to sit, I tried not to let that stop me from living my life, and in April of that year, I went to a Lakers-Suns playoff game. In the fourth quarter of the game, the Lakers made a huge comeback, and Kobe Bryant made a last second shot to push it into overtime. Overtime was even more exciting, and he made another last second shot to win the game!

It was pandemonium!

But nobody in the stadium was more excited than me, because for the first time in two years, I was sitting without pain.

Sometimes when we’re deeply distracted, we’re unconsciously depriving our pain of its one fuel source: fear.

When this happens, we can develop exceptions – instances where the pain isn’t what we would expect it to be, given our physical position or activity.

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Finding exceptions can help us more easily believe that it isn’t the position or activity that’s causing our pain.

While finding these past exceptions can be helpful, if you don’t have any of these instances, it’s okay. As you continue teaching your brain that it’s safe, you increase your likelihood of getting these exceptions.

Compiling the Evidence

There are other ways to gather evidence that your pain isn’t physically caused as well.

Have physicians been unable to find any cause for you pain?
Did the symptoms come on without any preceding physical trauma?
Does the pain seem to ebb and flow based on your stress level?

None of these are definitive proof, but we’re trying to build a case.

As you continue to gather evidence, it’s a good idea to put together an evidence sheet: a list of all the reasons to support that your pain is psychogenic.

One of our former patients has offered her evidence sheet for us to share:

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Reinforcing the Evidence

The night of my magical Lakers experience, I remember thinking, “It’s psychogenic for sure! I’m free!” Then the next night I was out to dinner and my back started hurting, and all that went out the window.

No matter how much evidence we have that our pain is psychogenic, it can be hard to hold on to that when we’re in a pain state.

It can help to reinforce the evidence that you’ve gathered throughout the day, especially when you’re in a pain state. “Right now, I’m thinking it hurts because I’m sitting, but because of this piece of evidence and that piece of evidence, I know that it isn’t the sitting that’s causing the pain, it’s the belief that sitting is dangerous that’s causing the pain.”

The more you’re able to internalize this message, the more likely you are to gather even more evidence. It can become a positive feedback loop.

Ultimately, when you’re able to teach your brain that these physical sensations are non-dangerous, the pain begins to fade.

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The story of Maya is very compelling evidence for the Mindbody connection and how inextricably linked and incredibly powerful it can be. I'm still vascillating back and forth in my own belief, between the structural and psychogenic possibilities... But this post is difficult, even for the most hardened skeptic to dismiss.
Thank you again to Alan Gordon for being the rescuer and possibly the final hope for many of us. If gratitude cured TMS, I'd be out doing all the things physical that so defined me just three short years ago.

 

before i had ever even heard of TMS, it was the "exceptions" that always confused me. Back before pudendal neuralgia struck (started after a medical procedure) I mostly had bladder pain only. I was an avid mountainbiker, and for some reason, my pain would go from doubled over, to nearly gone while riding, then back to terrible after i was off the bike. Also, i rarely had pain upon waking (it would normally kick in about .5-1hr after waking up). That's pretty common with PN, but not with interstitial cystitis. Another time, my dog was in the animal ER and she was nearly dying. i sat for many hours in a hard chair, full of anxiety in my gut, but suddenly realized i had no sitting PN pain, not only that, i had forgotten to take my meds. I always chalked this up to "being distracted", which i guess, is partially true, but i was curious as to why certain activities could be "so" distracting as to clear my pain? Vigorous housework also clears my PN pain, but the moment i lay down to play on my phone, the pain comes back like a tidal wave.

There were the exceptions, and then there were the opposite effects. For instance, most PN patients feel better when laying down, but when i laid down to rest, and play with my phone, the pain would go thru the roof. What was it about that activity that gave me such an increase, that pain meds wouldnt touch it? Deep down when i was playing with my phone, i had this background anxiety and negative feelings, like "you're doing this because you're hopelessly bored. You have no life. Your friends are living life without you. They'll all abandon you, etc"

Now that i know of TMS, it all makes sense.

 

Thanks Alan, this makes a lot of sense, but I'm having trouble believing that sitting, standing and walking don't in themselves cause pain, as I'm afraid I don't have any exceptions, as for me the amount of physical activity always correlates to my pain levels, and these are never worse when stressed (or better when not). I'm not saying there isn't a TMS component to my pain, as the pain is definitely more extreme than it should be, given the cause - which is basically oversensitised tissues, from having too many operations and procedures in one area. Alan, do you have any advice for me, when I know that every time I sit, stand or walk more than a specified time, I get a flare-up of symptoms that leaves me even more incapacitated? I am not afraid of tissue damage, just of having more pain than I can cope with.

 

This is a great post today! I am going to focus more on the exceptions and try to build some momentum! Thanks Alan.

 

This is an extrem important post for me. The clip of Maya shows very compelling the conditioned response to eating.
Now I can grasp my conditioned response to eating too. Even though my response is not the same as Mayas, it is the first time, I can really imagine, my pain is not structurally caused.
So far I had some doubts.
Alan, thank you very much!!!

 

Thank you Alan! Do you have anything additional you could add in relation to repetitive stress? I was/am experiencing forearm pain when using my mouse or my phone. I'm convinced this is TMS as it arose during a particularly stressful period after years and years of using a mouse. PT said, "your body adjusted and adjusted (I had "bad" posture and desk ergonomics) until it couldn't adjust anymore, and then you began experiencing pain". This makes sense to me, but lots of other things have led me to believe in TMS. That said, I'm questioning how repetitive actions do genuinely affect the body. It can't be great to sit all day, or have a slumped forward posture, or repeat the same arm movements for hours upon hours, or not take breaks to stretch. Do these things matter or not? If you or anyone else has any thoughts I would appreciate it!

 

That's a great question. I do know that there have been two large studies on this: one was at the Mayo Clinic and one was conducted in Denmark. Both studies found no correlation between the amount of time typing and the development of carpal tunnel syndrome.

That being said, obviously the things we do to our body can cause pain. I have a friend who several years ago developed shoulder pain. It turned out that she recently started carrying a heavy backpack around over just one shoulder whenever she on the move. When she switched to two-shouldering it, the pain went away. Perhaps it was a placebo, perhaps it wasn't.

I don't like to make global statements like, "posture doesn't matter" or "incessant repetitive activities can't cause pain." I think we need to be open-minded and thoroughly determine each situation on a case by case basis.

As you assess your evidence, and continue to gather more evidence, hopefully that determination will become clearer. I generally recommend first and foremost to consult with a TMS physician. This can often help reduce the level of uncertainty around our symptoms.

 

In my case there don't seem to be many conditioned responses. Pretty much pain and fatigue whatever I do. I just lie in bed a lot. Could the conditioned response for fibromyalgia sufferers be: life = danger/pain? Is the approach to heal different when facing whole body pain, for example regarding somatic tracking?

 

I'm a singer/songwriter who was diagnosed with spasmodic dysphonia (SD), which in my case involves a tightening of the vocal cord muscles resulting in a sort of strangled voice. It requires a lot of effort to speak and the speech comes out sounding very strained. Dr. Sarno lists SD as a probable TMS equivalent. My own evidence strongly supports that. I have had several incidents that I call "miracle moments" when my voice returned to normal or near-normal. There were some common elements to these moments. I am extremely prone to worry and anxiety, but these "miracle moments" were times when I was unusually free of that anxiety. One of the times was on a Christmas night. Like many, I find the hustle and bustle of the Christmas season a peak time of anxiety. I had gotten through the family commitments and was finally alone and able to take a deep breath and totally relax. I decided to get out my guitar and attempt singing a song. To my amazement, I was able to sing in my old natural voice. What a blessing! And it was also evidence that my vocal problem was not structural but, rather, a result of tension caused by anxiety, stress, etc. Tension...
I've had several of these "miracle moments" and they all occurred when I was very anxiety-free, totally relaxed and focused happily on something other than my vocal problem. Getting out of our own way is a big part of making progress.

 

Alan
I have found this very helpful. I have tons of evidence and the pain actually went away for 10 days recently. Unfortunately, it has come back. Despite my evidence, I fear that the pain will reappear and it does!
This cycle has repeated itself many times. I am fine for 5-10 days with no symptoms and then something causes a reaction and I start thinking I have pain and the pain reappears ! Once I have pain I can't seem to convince myself despite all the evidence that I am not in danger. Any advice?

 

This is a wonderful question - thanks for asking it. I can't wait to read Alan's response. I've had the same thing, no pain, return of pain, no pain, return of pain. I am about two months into my healing journey, so I wonder if that is a normal thing? It would be nice to not keep repeating the pain, that's for sure.

 

When I was an intern, whenever I talked about how I overcame my symptoms, the pain would return! So I stopped talking about it. After a few months, I realized that I was just feeding into the fear. So I started talking about it again, and it came back, and I didn't care, and then it went away.

The only power the pain has over you is its ability to scare you.

You know there's nothing wrong you - you've proved that - now it's just a matter of changing your relationship with fear. When you have the thought, "Uh oh, what if the pain comes back?" Respond to that voice, "Let it come back. Bring it on. I'd rather be in pain than live my life in fear."

When you truly get to a place where you're not getting sucked in by the fear, the paid loses its power over you.

 

Yes Alan, I love that .... standing up to fear. I work for an airline and I notice that when I get to the airport for a trip I would go numb and tingly on one of my legs. I mean -- I used to start thinking catastrophe!!! I won't be able to work, who will take care of me, what if i collapse ... etc. etc... and when I was on the plane I would be fine. I'd get busy and think...where did it go? Still get numb sometimes, but I am able to say, so what. Even if I fall on the ground and can't work... oh well. I'd rather not be afraid. (At least this is my challenge, but I can honestly say one I am meeting more and more of these challenges thanks to this program.) Much gratitude!!!

 

Jdb49

I have been diagnosed with MTD, muscles tension dysphonia. I thought spasmodic dysphonia was random spasms of the muscles rather than tension as you describe.

It's interesting to hear from someone else with a voice/throat problem as it's rare!

I also suffered for most of my life with very high anxiety, panic attacks and insomnia. It seems all too common on these forums, which is surely no coincidence!

It's been a year and a half now. I'm only just starting to see the light at the end of the tunnel. I feel that now I will recover, and so I'm less desperate. I'm still in pain every day, but because it's only when I use my voice and otherwise I feel fine I know that it will change.

I have been having voice and breathing lessons with a very helpful teacher. The main thing it's shown me is how locked up my diaphragm is, and my breathing is just not free. I control it. Which for the voice is a recipe for disaster. I started to find that occasionally with her guidance o could sing scales with little or no pain. Then I get home and see family and it's instantly ten times worse. This was a big insight.

Thanks again Alan for this program, Its obviously really helping and inspiring everyone

 

I'm not sure how this applies to migraine, especially when you don't necessarily have any really consistent triggers. Anyone have any ideas on that? I can relate to a lot of this stuff, but my symptoms aren't nearly as cut and dried as most of the examples, so it's hard to apply it.

 

If you're not seeing any consistent triggers, it would seem like you either have an awful lot of conditioned responses or the seemingly random triggers actually have a cohesive theme or meaning.

 

When I had migraines I had many triggers due to conditioning--e.g. changes in barometric pressure, changes in my hormones due to my menstrual cycle, and social anxiety, as well as some emotional triggers. There were no structural reasons for these conditions to produce a migraine. Once I believed that, I was able to tell myself this whenever the very first indications that a migraine was coming on. I found "talking to my brain" very helpful. As soon as I felt those first twinges I'd say "Stop it brain! There is no logical reason for (x trigger) to be causing a headache. So just stop.You're fine. Nothing is wrong." Sounds too simple to work and I initially felt silly doing it. But it worked! And everytime! Eventually I stopped getting the twinges and have been migraine free for years now after having them since 4 years old. You can read my success story on my profile or in the success stories sub-forum.

Belief that the triggers are conditioned (learned, associative) response and not due to some structural process in the body is key in my opinion.

Journaling helped me find the triggers. It's a great tool for finding patterns and associations.

Best wishes.......

 

Alan,

I definitely got the mold of TMS and have been struggling with neck and back pain since age 13 and knee pain which has subsided. I have the neck pain under control but it is still painful. My biggest struggle is my current diagnosis of Intersitial Cystitis which causes me to have to urinate frequently and I constantly have discomfort in my bladder. It has made my life so difficult because I get no relief. I tried everything except really apply the TMS protocol which I have done in the past. However I do get recurring UTI and strep b bacteria because of this so it causes doubt in my mind that it is TMS because I have an actual infection sometimes. But when I don't have the infection I still feel discomfort and antibiotics don't help. Is it still possible to be TMS?

 

I had migraines from about age 14 into my late 40s. I see now that when I would get that first little visual disturbance, I would panic and just wait for the agony to take over. And it was truly awful. The migraines stopped happening for an unknown, but much appreciated, reason, although they were replaced with (I know now) different TMS symptoms. Still working on that but I'm loving this process.