Written by on November 25, 2008 Everyone who has MBS/TMS or works with people who have this syndrome knows about symptom substitution, which Dr. Sarno calls the symptom imperative. Freud wrote about it many years ago. For the purposes of MBS/TMS, it basically means that the manifestations of MBS/TMS can vary over time. They can move, shift or completely change within minutes, days or weeks. I had a lady in one of my classes who came in with low back pain for seven years. After two weeks in the class, her low back pain was completely gone, but she had developed a pain in her neck. I had a 15 year old in one of my classes whose symptoms shifted over time from hip pain, to headaches, to chest pain, to loss of movement of his arm and leg (known as a conversion disorder in medical terminology, i.e. paralysis due to psychological, rather than physical, factors), to leg pain to fainting spells. I know someone who had groin pain, which morphed into back pain, then shifted into anxiety and OCD symptoms and then back again to the pain. It is amazing to watch MBS/TMS symptoms shift from day to day and week to week, even sometimes from minute to minute. This is especially interesting to see that the symptoms often involve both “physical” and “psychological” symptoms. This confirms that MBS/TMS can cause both sets of symptoms, such as pain and anxiety, diarrhea and OCD, urinary frequency and depression, rapid heart rate and fatigue. When we see this kind of symptom substitution, we can usually easily confirm that the cause of this is truly MBS/TMS. There are very few medical diseases that have this type of pattern and therefore when we see this we are confident that the correct diagnosis is MBS/TMS, once serious medical conditions are ruled out. The reason symptoms can come and go, alter and change, or transform into new symptoms is that they are all caused by the same underlying physiological issues. These pathways are described in earlier blogs and consist of activation of the amgydala (emotional memory center), the anterior portion of the cingulate cortex (amplifies pain due to fear, worry and frustration), and the autonomic nervous system (activates the fight, flight or freeze reaction). These cause a variety of changes in the brain and body such as increase in muscle tension or muscle spasm, alteration or spasm of muscles in the bowel or urinary tract, activating or inhibiting nerve signals that control our activity and feelings. Once these nerve pathways get activated, they tend to quickly become sensitized and then “wired” to produce learned connections that develop a life of their own and can persist for months, years or even decades unless they are stopped by MBS/TMS therapy. Note that these are physiological changes, i.e. temporary alterations that do not produce tissue destruction or damage, as opposed to pathological changes, such as cancer or heart disease. Whenever the mind produces new and different symptoms and allows the original symptoms to subside, we call this “symptom substitution.” Most people with MBS/TMS have this occur at some time. The critical aspect is to, as quickly as possible, recognize the cause of the new symptoms. Sometimes this requires going to a doctor to make sure, but often this is not necessary and it may cause more concern (and make the symptoms worse) if the doctor begins to do a lot of tests and suggest diagnoses that are not MBS/TMS. Of course, anyone may get a new medical disorder, but it is usually clear when a symptoms substitution has occurred by the timing of it, the lessening of the original symptoms, and the nature of the symptoms (i.e. typical MBS/TMS symptoms). The critical issue, of course, is how to deal with symptom substitution once you've recognized that this is what is occurring. One of the commonest and major obstacles to coping with symptom substitution is fear. Fear that something serious is going on, fear that this new symptom will not go away so easily, fear that it will morph into something larger and harder to control. I have had people in my program who were so distressed by the emergence of different symptoms, that they wished for their old symptoms to return, because they were used to them and knew how to cope with them. Don't let this happen. When symptoms shift, that is a good sign; you've got your symptoms moving, and as I always say, you've got them “on the run.” The brain will continue to produce “other” symptoms or substitute symptoms for a variety of reasons. One, it's not ready to give up yet (and you may need to continue to be firm with it). Two, you haven't yet integrated the changes that you need to make in your life or in your psyche (obviously you have to figure out what those changes are, and that's where therapy may help as well). Three, you haven't yet accepted yourself fully and completely, i.e. you are still fighting yourself, doubting yourself, being afraid of symptoms or of certain issues/events in your life. Four, you haven't yet learned what you need to learn from your symptoms. This may sound odd, but several people in the program have directly asked their symptoms (in meditation or in writing) this question, i.e. “what do I need to learn from you?” Increasingly I have seen that the body is basically trying to protect us by producing MBS/TMS symptoms. Once we recognize this, we can work with our mind and bodies to calm the fears, deal with the issues in our lives which are stressful and produce the danger signals that cause activation of the fight or flight reaction. The most important advice I can give you is to remain calm. Step back and look at how much progress you've made, how much better you understand yourself and how you've been able to make your original symptoms disappear. Have confidence that since you've come this far, you only need to go a little bit farther to gain control over the new symptoms. Realize that your brain/mind is getting desperate; it wants to hang on to some symptoms and since you've caught on to the original symptoms, it is trying something new. And it may be trying to gain control and scare you into retreating to your old patterns. This brings up the final point: dealing with fear. You have to face the fear so that it will lose it power over you. One thing to do is to go back and look at your life and examine when you had fears as a child, teenager or adult. What were the things that triggered fear, i.e. how did you and your brain/mind and body learn to create fear? Do some writing (use any of the three weeks of exercises, e.g. letters, dialogues, etc.) to help you understand these issues and better cope with them? What can you learn from your past and how can you understand your reactions today? Many people have been conditioned to respond to many situations with fear. Then use the meditations to help you cope with fear. Fear is a form of a thought that affects the body's response, or in other words, it's an emotion. In the meditation (particularly the first one on mindfulness), you can train yourself to notice your breath with less reaction and judging, let your breath go and focus on something else (e.g. the next breath). In the same way, you can notice thoughts, accept thoughts as “just thoughts” and let them go in order to focus on the next moment (e.g. the next breath). Then work with emotions, notice emotions, notice fear and practice being with it with less reaction, less judging. Breath with the fear when it arises, don't feel that you need to push the fear away, i.e. you don't have to be afraid of fear, it's just a thought that has been conditioned to occur within you. So, notice your fear, accept it as “just fear,” and let it go, and focus on your breath. Repeat these steps over and over and you will learn to cope better with the fear. This may be an amazing life lesson and provide you with the keys to unlocking your past and your future. The symptoms you are having are an opportunity to learn, to grow and cope better with life. Seize this opportunity and learn from it. As Dr. Sarno says, “You are not free from TMS until you are free from your symptoms and you are free from fear.” Of course, new symptoms may arise in the future because we're human. But being human, we are able to learn from our past, and to develop new ways of understanding and coping with what life has in store for us. To your health, Howard Schubiner, MD Disclaimer: It is important to recognize that the information contained in this blog, whether posted by me or anyone else, cannot be considered to be specific medical diagnoses, medical treatment, or medical advice. General information about MBS/TMS will be posted in response to questions, but you will need to decide if this information is relevant to your situation and, as always, you should consult with your physicians and counselors regarding new symptoms and any changes that you might make in medications or activities.