What can I expect from my TMS visit with Dr. Gwozdz
I have been seeing TMS patients now for close to 15 years and have been pretty much following the same protocol for these patients over that time. It is the protocol that I learned from Dr. Sarno when I trained under him as a doctor in 2001.
During the initial TMS visit I really have two primary goals. One is to reassure myself that the patient does in fact have TMS and secondly to piece together the patient's history so that I can better understand all of the causes of the patients TMS. While doing so I often times have to determine what the patient's initial TMS presenting symptom was and not just what the current TMS symptom is. The reason is that I want and need to determine all of the underlying causes of the TMS. For instance if the patients back pain started about the time that their spouse announced that they were leaving the marriage that gives me a clue as to the underlying cause of their TMS but if I track their TMS symptoms back to when they were four and they were having a lot of abdominal pain that was causing them to miss school, then I may be able to determine an even more important cause of their TMS. I have found that I can be most effective if I spend 90 minutes in the initial encounter with each patient so that is what I schedule when the patient calls and requests a TMS appointment.
My belief is that TMS is actually a diagnosis of exclusion. I cannot just look at a patient and examine the patient to determine that they have TMS. I need to hear the history and also prefer to have the reassurance that they have pursued their symptoms with other physical doctors and therefore we have excluded any serious problems such as malignancy. Of course, this is not to say that I will trust the diagnosis provided by the other doctors as the cause of the patients pain but instead I will interpret the other doctor's diagnosis as Dr. Sarno taught me. Once I have reassured myself that the patient has had a thorough workup, and that they do not have any serious underlying problems, then I am able to provide the assurance that the patient needs in order to be cured of their TMS. This is important because lack of confidence by the TMS doctor would cause a lack of confidence in the TMS patient and therefore likely end in a poor result. I always try very hard to be sure in my own mind that the patient does in fact have TMS and I find that spending the extended period of time with the patient usually yields a much better result.
During the initial visit I start out by listening to the patient's history of their physical ailments and try to understand what was going on in the life when they developed their symptoms. Then I explore the past medical history, past surgical history, family history, childhood history and explore their relationships with spouse, family and friends and then I try to develop a timeline in my own mind linking their stressors to the development of their symptoms in order to determine all of the root causes of the TMS symptoms. A standard medical physical exam is completed while concentrating on some of the tender points that tend to be associated with TMS patients as Dr. Sarno always did. Although the physical exam is important, it really is the thorough psychosocial and medical history that is critical to the diagnosis of the TMS patient.
As I said, I feel more confident diagnosing a patient with TMS if they have had thorough medical work ups by other specialists such as neurologists or orthopedic surgeons. This allows me to be sure that I am not missing a medical/physical cause of the TMS. An MRI or CT of the affected area is also required before I see the patient in order to be sure that I am not missing anything else.
After the patient has completed the 90 minute initial exam with me and I have determined that they have TMS, I invite them back for my 2 to 3 hour lecture. The lecture is also an important part of the treatment of the patient. I model my lecture very much after the lecture that Dr. Sarno did except I have added some additional information, particularly regarding the "symptom imperative" and all of the different symptoms that TMS patients can have. I believe this is very important because I do not want the TMS patient to be relieved of their presenting symptom only to find out that because of the symptom imperative they now have some new symptom and do not realize that it too is just their TMS. In the first part of the lecture we talk about all the different symptoms that a TMS patient can have. We then discuss some specifics regarding back pain for those patients with back pain though many of my TMS patients have symptoms other than back pain. We then review the physiology of TMS. This is important because the TMS patient needs to understand how it is that the emotional brain can actually cause their symptom. Up until this point the patient most likely was led to believe that the abnormality found on x-ray or MRI was the cause of their symptom and not that their emotional mind was creating the symptom as a distraction to keep them from thinking about the things they don't want to think about. Understanding the physiology can help the patient to convince themselves that emotional issues can cause physical pain.
In part two of the lecture, we discuss the emotional mind. We discuss three primary areas of our emotions that lead to TMS: difficulties in our childhood, our personality traits, and current day stressors. We then are ready to launch into an approach to cure ourselves of TMS. It is my belief that there are many different approaches that can be useful for curing TMS. A number of TMS authors have put out very good books suggesting a number of different approaches. I believe that each of these approaches can work very well for select patients. Not every approach will work for every patient. I teach an approach that I used for myself and I've used for my patients over the years and that is just simply creating the list of sources of your TMS and then talking to your brain throughout the day reminding yourself that it is not physical causes that are the cause of your TMS but instead are the items on your list. The patient is then given a four-page homework assignment modeled after the one that Dr. Sarno used and the patient is sent home for one month to do their homework and eliminate all of their TMS symptoms. At the end of the month the patient is asked to come back to the office in order to review their progress and if the patient has not been successful, to determine why not. I do find it very important to do the monthly follow up as it often times results in an unsuccessful patient becoming successful. I help the patient to tweak what they are saying to their brains and how they are saying it. We compare the list that the patient developed as part of the homework with the list that I developed as part of the initial visit to be sure that all of the sources of TMS are covered.
If the patient is not cured after two or three months then the patient will be referred to one of the several TMS psychotherapists that I work with.
I should also mention here that in the lecture I frequently encourage patients to raise their questions and challenges. I want all the patients to completely understand what I'm talking about and not leave with any unresolved questions or concerns that might lead to them not being cured. If I don't know the answer, I will admit to that fact but in most cases I can eliminate their concern which should help to result in a more rapid cure. Patients are not required to speak; this is not a group therapy session but does occasionally change into one.
Some patients can cure themselves by reading while others need the additional help of a TMS doctor to provide the confidence that their pain is just TMS. I know that in 1987, I needed Dr. Sarno's reassurance when I was an engineering manager not a doctor, and now I am in a position to be able to provide that same care. I always credit Dr. Sarno for giving me back my life and wish to share the knowledge that we are healthy human beings who do not need to be in pain.