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Book Review  |   November 2010
Unlearn Your Pain: A 28-Day Process to Reprogram Your Brain
Author Affiliations
  • John A. Jerome, PhD
    Clinical Associate Professor, Michigan State University College of Osteopathic Medicine; Pain Psychologist, Lansing Neurosurgery and The Spine Center, East Lansing, Michigan
Article Information
Book Review   |   November 2010
Unlearn Your Pain: A 28-Day Process to Reprogram Your Brain
The Journal of the American Osteopathic Association, November 2010, Vol. 110, 681-682. doi:10.7556/jaoa.2010.110.11.681
The Journal of the American Osteopathic Association, November 2010, Vol. 110, 681-682. doi:10.7556/jaoa.2010.110.11.681
Pain is an unpleasant sensory and emotional experience that indicates the possibility of tissue damage. It elicits a rapid defensive response at the spinal cord and brain stem levels, as well as slower, long-lasting, defensive stress responses involving musculoskeletal, neurologic, immune, and endocrine adaptations. Excessive activity in nociceptive pathways (ie, somatic dysfunctions) or in target regions of the forebrain can generate feelings of pain and distress when no peripheral generator exists. Continuous pain and stress reactions can lead to neuronal damage and changes that result in deepening and hardening of these aberrant synaptic patterns, such that an indelible chronic pain circuit (ie, pain matrix) can become ingrained in the patient's mind, body, and spirit. A combination of peripheral and central nervous system dysregulation can result in the pain system overresponding to noxious stimuli (ie, hyperalgesia), non-noxious stimuli (ie, allodynia), or—in some cases—generating spontaneous activity that the brain interprets as continuous chronic pain.1,2 
This abnormal nociceptive processing, or central sensitization, is the focus of Unlearn Your Pain: A 28-Day Process to Reprogram Your Brain, written by Howard Schubiner, MD, with Michael Betzold. Dr Schubiner is director of the Mind Body Medicine Center at Providence Hospital in Southfield, Michigan, and a clinical professor at Wayne State University School of Medicine in Detroit. After working as a pain psychologist for 35 years, I find it refreshing to see a physician produce an entire “psychology tool box,” and employ it in a thoughtfully organized, self-learning, 28-day program. A bonus to the 12-chapter text is a CD recording of “Meditations for Healing Mind Body Syndrome.” 
The text includes five sets of therapeutic writing exercises requiring 1 hour of “homework” each day of the 28-day program. These daily exercises are reflective and promote self-discovery by using mindfulness theory and practice, cognitive behavioral psychotherapy strategies, and therapeutic journaling. Specific psychological tools discussed by Dr Schubiner include breathing and muscle relaxation techniques, self-efficacy training, positive affirmations, fear/avoidance retraining, suggestions for reinterpreting pain sensations, systematic desensitization, reinforcing increased behavioral activity, and active problem solving. Dr Schubiner describes his model as “a process of writing, meditating, talking to your brain, and making changes in your life.” 
The author's implied goal is to educate the public and physicians about mind body syndrome (MBS), the term the author uses for pain stemming from “unresolved emotions.” His premise is that “MBS is caused by unresolved emotions, and it is usually necessary to resolve them to get better.” Unresolved emotions include depression, hopelessness, helplessness, fear, anxiety, and stress from unresolved conflicts, as well as childhood traumas and other problems. An individual's personality traits affect how he or she responds to stress. The author notes that “the mind has twisted your body into pain” to avoid unconscious conflicts, and the mind can be retrained to respond in adaptive ways to reduce suffering. The MBS model is squarely focused on emotionally induced pain disorders—an area that is not yet well understood. 
The MBS model assumes that “negative normal emotional reactions to stress have caused the pain, and that mental processes can reverse the pain”—and if an individual has not been helped by either traditional or alternative medical care, “the diagnosis may be MBS.” A physician arrives at an MBS diagnosis by first ruling out any pathologic “tissue breakdown disease,” such as infection, cancer, fracture, stroke, heart attack, or other serious intractable conditions. Dr Schubiner writes the following: 

If you have been suffering for some time, if your doctors haven't been able to adequately explain why you have so much pain, if your only options are injections or pain medicines, then you are likely to have MBS.

 
Among many medical diagnoses that the author lists as being commonly caused by MBS are back pain, chronic fatigue syndrome, fibromyalgia, headache, insomnia, irritable bowel syndrome, posttraumatic stress disorder, whiplash, and other chronic pain disorders and autonomic nervous system-related disorders. 
I believe that clinicians and researchers working in these areas will have difficulty collapsing their focus to a singular conceptual MBS model. The author points out that “it will be difficult to be cured if you don't believe that MBS explains why you have your pain.” A problem arises with the MBS model when structure-function factors and biomechanical issues explain the pain condition. This problem is highlighted by a question from a hypothetical patient in the book. The question asks if the patient should continue physical therapy as a way to stretch and strengthen the body. Dr Schubiner offers the following answer: 

Physical therapy is a form of exercise, so I have no problem with that. While you are exercising, make sure to tell yourself frequently that your body is strong, you are healthy, there is nothing wrong with your body, and that you are doing this to get stronger. If your physical therapist reinforces the idea that there is something wrong with your muscles or joints, this can delay your recovery from MBS.

 
For me, however, any solo chronic pain “cure” is problematic. The MBS model is weakened by its presentation of a solo “mind” treatment, without room for concurrent “body” treatment. According to Dr Schubiner, “If you believe a physical problem is causing your pain, this gives the subconscious mind an `out,' a way to continue producing pain.” In addition, the MBS model requires substantial self-determination and discipline by the patient and a strong belief in the unconscious mind. In the MBS model, the unconscious mind is a collection of jumbled bits of random emotions, memories, reactions, unresolved past and present stressors, and a “child mind” and “parent mind” feeding off each other—causing unconscious tension that triggers pain. 
The MBS model is not entirely at home in osteopathic medicine. Osteopathic physicians place special emphasis on factors originating in the neuromusculoskeletal system and on alleviating somatic dysfunction through osteopathic palpitory diagnoses, osteopathic manipulative treatment, medications, surgery, and education to restore normal motion and function.3 Osteopathic physicians assess and treat the whole person—including physical, psychological, social, cultural, behavioral, and spiritual aspects—in a collaborative partnership with individualized patients. Osteopathic physicians also urge patients to take self-responsibility for healthy lifestyle choices. Osteopathic assessment leads to a differential diagnosis with many comorbidities that often involve multimodal treatment plans. Chronic pain is conceptualized as a biopsychosocial process,4 with reciprocal musculoskeletal, neurologic, immune, and endrocine interactions.2 The goal of osteopathic medicine is to treat the person, not the pain. As Irvin M. Korr, PhD,5 wrote, “in short, the person is far more than the union of mind and body.” 
Dr Schubiner's MBS model uses sound evidence-based psychological tools, but I cannot see how an osteopathic physician could easily apply this model while knowing that the neuromusculoskeletal system can be treated directly to control pain symptoms. The connection between mind and body, and between body and mind, goes both ways. I wish that osteopathic philosophy and Dr Schubiner's MBS model could sit more comfortably side by side. 
Despite this concern, I believe that Unlearn Your Pain is clearly worthwhile reading for osteopathic physicians who want to learn more about psychological factors that drive chronic pain. The book's real strength is recognizing the role of mental processes in pain conditions and combining mindfulness practices6 and evidence-based cognitive behavioral strategies7 in a very easy read. 
 By Howard Schubiner, MD, with Michael Betzold. 271 pp. $25. ISBN: 978-0-9843367-0-8. Pleasant Ridge, MI: Mind Body Publishing; 2010.
 
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Elkiss ML, Jerome JA. Chronic pain management. In: Chila A, ed. Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:253-275.
Seffinger MA, King HH, Ward RC, Jones JM, Rogers FJ, Patterson MM. Osteopathic philosophy. In: Chila A, ed. Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010: 3-35.
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Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med. 2003;65(4):564-570.
Morley S, Eccleston C. Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80(1-2):1-13.