Survey Response: Arlen Ring, Ph.D.

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This survey was last updated in January 2009.

License Number: CA Psychologist Psy8070


Chronic physical pain is not well understood by the medical profession. One reason is obvious. Pain is a subjective experience that cannot be defined exactly or communicated precisely. Like many people, you may live with chronic pain in your back or elsewhere in your musculoskeletal system. You may feel substantially limited in your life and likely are depressed and anxious about it.

If you are having chronic back pain, I suggest starting with a medical evaluation. This would provide some examination of the structures of your back. You will likely be offered something on the order of physical therapy, pain killing anti-inflammatory drugs or surgery. If none of these give you adequate or lasting relief, or if you are not convinced that surgery is worth the risk, you might find yourself having to look further to resolve your pain.

The idea that back pain is due to structural abnormalities is highly ingrained in the medical profession. An orthopedist will be looking for a structural problem such as a herniated disc or an impinged nerve. If imaging studies reveal anything at all, including wear and tear changes, you may be told that this is the cause of your back pain. Yet the correlation of pain with anatomical abnormalities is surprisingly low. One person can have substantial structural abnormality on diagnostic imaging and not experience much pain. Another can have diagnostic tests within normal limits and yet be suffering greatly.

At a certain point when the physically oriented physician runs out of physical things to do and you are still hurting, he may suggest stress or pain management psychotherapy. He does not know what else to do for you. He may give you the implication that it is all in your mind.

Your problem then becomes this. Psychotherapy may be helpful in general, but not all psychotherapists will know how to focus their skills towards chronic back or other musculoskeletal pain. So even if you have come to agree that there may be a significant psychological component to your pain, how do you find a psychotherapist who knows how to work with it?

For that, I express my indebtedness to John Sarno, M.D.]], a professor of clinical rehabilitation medicine practicing in New York , for providing a foundation to understand and successfully treat chronic back pain. Dr. Sarno has written a series of books delineating the connection between chronic back pain and psychological factors, particularly repressed anger. He uses the diagnostic term Tension Myositis Syndrome (TMS) to describe how repressed conflicts end up being expressed in musculoskelatal pain for many people. He particularly focuses on the way anger finds it's way into the body. Being an anger specialist myself for many years, the anger - TMS connection is what brought me into focusing on how to help people with chronic pain.

I had been focusing on the mind body connection for a long time before I got exposed to Dr. Sarno. His thinking filled in some gaps for me. I have now spent several years specifically extending his diagnostic formulations into effective treatment for those people whose pain is caused by or worsened by emotions that have gotten directed into physical pain. I consider physical therapy, anti-inflammatory or pain deadening drugs and surgery to all have potential value. However, If you are not satisfied with the limitations of those approaches and believe that your pain has a significant emotional component, I can work with you on healing it.

A very consequential characteristic of we human beings is our ability to push things out of consciousness. Most people believe that if we can stop thinking about something, it will stop affecting us. We all have some ability to shift our focus away from something unpleasant.

You yourself may have the inclination to stop paying attention to something that causes you anger or fear. The problem with avoidance is that what you stop paying attention to, doesn't automatically stop paying attention to you. The analogy I would use is that you can close something down in your computer so that you no longer have to look at it on the screen. It's still there though hiding in memory. Similarly, emotions can hide in your back.

Chronic tension states find their way into the body in several different ways. These include:

1. Unconsciously clenching muscles to the point that spasm impairs circulation leading to oxygen deprived tissue (ischemia). This can include bracing against further pain.

2. Changes in the threshold of arousal in the limbic system (emergency center) of the mid-brain.

3. The generation and persistence of chemical transmitters in the brain that were only meant for short-term emergencies.

All of these conditions are potentially damaging. The first two can lead to chronic physical pain.

Some indications that you might be experiencing TMS include:

1. Moist heat relieves the pain for short periods of time

2. The pain Migrates from one place to another.

3. You are in a vicious cycle of fear and pain. (especially since you have become convinced that your back is fragile).

4. You would find it more acceptable to have a purely physical problem than an emotionally connected problem.

5. You have muscle tenderness on pressure (trigger points).

6. The pain mainly appears when you are upset or under pressure.

7. You feel trapped in a situation that could make you angry, but you do not feel able to express it directly.

8. Diagnostic testing has not identified a sufficient physical basis for your pain.

9. You have a sense of responsibility and conscientiousness that never quits.

10. Each doctor you visit gives you a different explanation of what the problem is.

11. You hate it when somebody does not like you.

I work in both directions with TMS sufferers. I go from the emotions to the physical pain. I go from the physical pain to the emotions. Over time, I have developed or adapted a number of effective approaches to treating TMS. Like all of my work, I vary my approach to treating chronic pain for the individual characteristics of each person.

Before I can work on a psychological level with a person who is experiencing chronic pain and who may suspect they have TMS, I would consider it essential that a good physical examination be done to define the medical situation. I believe that TMS can be sufficient cause itself for chronic pain or can be superimposed upon some degree of structural problem. At times however, the origin of chronic pain in an individual is not TMS at all.

A physician I can recommend to evaluate your musculoskeletal pain is David Schechter, M.D., a sports medicine doctor practicing locally. Dr. Schechter has trained with Dr. Sarno and has a deep understanding of TMS. 310-838-2225

Two other sections of my web-site that bare on this issue are Anger Management and Tension Is A Problem. It is likely that a number of other distressing physical problems are also TMS. I am currently using a hypnosis protocol for irritable bowel syndrome developed by Olafur Palsson, Ph.D. at the University of North Carolina . Experimental results are showing lasting improvement in 80%+ of people treated using this protocol.

Just one last thing to say about TMS. This is not an approach that blames you for your pain or claims that it is all in your head. The pain is real. You are hurting all right, but where you are feeling the pain, may not be where it originates. The issue is how to understand the origin of your pain well enough to return control to you.

I am a Licensed Psychologist with 35 years of practice. My office is in Woodland Hills , CA . My web-site is and I can be reached at or at 818 999-0581. I do not provide treatment by telephone or e-mail unless I have spent enough time with someone to have a sense of their relationship to their body.

DISCLAIMER: The TMS Wiki is for informational and support purposes only and does not provide medical advice, diagnosis, or treatment recommendations. See Full Disclaimer.