John E. Sarno, MD, is a pivotal figure in the arena of pain management because of his hotly debated approach to the diagnosis and management of back pain.
Dr. Sarno, Professor of Clinical Rehabilitation Medicine at New York University School of Medicine, and Attending Physician at The Rusk Institute of Rehabilitation Medicine at New York University Medical Center, is the author of 3 books that postulate the theory that most back pain is triggered by psychological origins instead of by a physiological defect.
This phenomenon, which is known as tension myositis syndrome (TMS), may also be the culprit in other pain disorders.
In Part II of his interview with Medscape, Dr. Sarno expands on the mind-body pain connection and highlights in further detail his concepts of back pain diagnosis, the role of emotion in triggering symptoms of pain, and the controversy his pain management concept has fostered in the medical community.
Medscape: You said that there is internal rage and anger in the brain, and that these are responsible for symptoms of back pain, not structural defects.
Dr. Sarno: It becomes clear why the brain produces these symptoms: They are intended to be a distraction to make sure your internal rage does not come out. The unconscious has been described by some writers as a kind of "maximum-security prison" where the brain keeps undesirable feelings or dangerous feelings repressed.
One reason why I've concluded that we all have rage inside of us is because there are other "equivalent" physical states that seem to be serving the same psychological purpose -- conditions that are analogous to back pain. I'm referring to [gastroesophageal] reflux, which is very common; irritable bowel syndrome; headaches; common allergies; hayfever; and asthma. I'm referring to common skin disorders like eczema and others. The skin is a great area that the brain uses to create symptoms. These conditions all serve the same purpose: to keep one's attention focused on one's body.
This is important in medicine. It's all so universal, and it's important to make the right diagnosis. If you make the wrong diagnosis, if you attribute the pain to something structural, or if you say, "The reflux is due to your stomach acting up and you have to take this drug or that drug," then people will continue to have symptoms. This is why the back pain problem is of epidemic proportions in the United States.
Medscape: Just to clarify: You're saying that a lot of these conditions are due to a translation of stresses, anger, rage in the brain to physical symptoms?
Dr. Sarno: No. It's not a translation, the brain is doing this as a protection. Protecting you from the unconscious rage and other bad feelings you might have. The reason childhood things are a factor is because -- and we've known this for over 100 years -- the unconscious has no sense of time. In other words, things that happened to us when we were 8 or 10 years old, if they're emotionally powerful, are still there at the age of 40, 50, 70, or 90.
Medscape: Perhaps we can move on to treatment?
Dr. Sarno: Of course. Now remember, it's not an approach, it's a diagnosis. If you want to know what I do about it therapeutically, and this is very interesting, I teach people what's going on. Believe it or not, doing that will stop the pain in many cases. There is a small army of people out there who have gotten totally better just by reading one of my books. I mean totally better. I get letters all the time from people around the United States telling me how this happened and they can't believe it; they've had the problem for years and read the book. The reason that they get better is because they accept the idea that what is causing their pain is that disorder. That's crucial. That's the point of my teaching my patients. Obviously my patients are those who have not gotten better just from reading one of the books, because virtually all have done that before they come to see me. It's clear that they need something more.
But those who stay with the program will get better. I think most people recover simply by learning in greater detail what's going on, by going into the specifics of the pressures in their lives that are most important and so on.
About 20% of the people who come to see me, who come into my program, cannot apparently get better until they've spent some time working with one of my psychologists. Psychotherapy is needed for about 20% of the patients.
Most patients in the United States cannot accept this diagnosis. So I calculate that I'm working with representatives of perhaps 10% or 15% of the population. Secondly, 99.999% of the medical profession does not accept this diagnosis.
Medscape: Do you get much flak from the medical community?
Dr. Sarno: No, I don't get any flak because there's no occasion for it. Although I do expect to get some flak soon. I've been invited to give a lecture at the 2004 North American Spine Society meeting in October, and that's going to be fun. I've never addressed such a group. I'm going to be telling them about my experience with this disorder. At any rate, I don't get flak; I just get ignored.
Medscape: I guess getting ignored is easier than getting flak?
Dr. Sarno: Easier in one sense, harder in another, because I've always wanted the approval of my peers and I haven't gotten it. Except I've heard from 1 or 2 people in the United States who are very well known in their work in trying to bring objective standards to this whole pain problem, and I have had some approval from them. So that's been very helpful.
Even the majority of psychiatrists don't accept this diagnosis either. Many of the so-called biological psychiatrists believe that these psychological things are the result of chemical changes and they're in the business of treating the chemistry. A lot of people in psychiatry have repudiated Freud and repudiated the idea of unconscious phenomena.
Medscape: Isn't it possible that physical stresses or nerve or tendon damage play a role? Say you sleep in the "wrong" position and your neck is sore the next morning.
Dr. Sarno: No. I'll tell you how that works. The brain will often use some physical incident as a good excuse, a good opportunity, to introduce or start the TMS. But I've had no evidence whatsoever over the years that there are truly physical things that are going on here that the brain is using. It's just that it will introduce the symptoms and, of course, the brain is very tricky that way. The brain is very concerned about these repressed emotions, and very concerned that they not come out. It will act in a very slippery way and introduce symptoms. One of the examples is whiplash.
Medscape: That's a common problem.
Dr. Sarno: Whiplash is usually the result of you being hit from behind in an automobile accident. One of the papers from the medical literature that I reproduced in my latest book was absolutely fascinating in this regard. It was published in the New York Times, where they reported on findings from Norway.
This was a good many years ago now, but Norway at that time was having an epidemic of whiplash. Now, Norway has probably one of the most generous insurance programs in the world. But doctors in Norway were dumbfounded. They couldn't understand why they had so many people in Norway on disability because of whiplash. They wondered if perhaps a generous medical system might have something to do with it. So, they went to Lithuania and did a controlled study there. They got the names of 212 patients in Lithuania who were involved in rear-end collisions and they went out and found 212 controls, and they found that whiplash did not exist in Lithuania. In Norway -- epidemic; in Lithuania -- zero.
They said, "Wow. This is incredible, it must have something to do with social things." Well, of course, it doesn't. Clearly the patients with whiplash were having TMS. And mind/body disorders like TMS will spread in epidemic fashion if they are not correctly diagnosed.
Medscape: But what if imaging, say from a magnetic resonance imaging (MRI) study, depicts a damaged tendon or muscle?
Dr. Sarno: This is my experience -- what the MRI studies show in these people has nothing to do with the symptoms. And I have proven this concept.
Medscape: By "symptoms," you mean pain?
Dr. Sarno: Yes. The pain and the stiffness, there are dozens and dozens of [symptoms]. The ones that are the most frightening are the nerve symptoms -- pain, numbness, tingling, weakness. All of those things are scary. If a patient has them and a doctor finds a structural abnormality, he says he needs surgery. Very simple.
In my experience, and we've demonstrated this by getting these people better, they wouldn't get better if the structural abnormality were responsible for their symptoms. They would get better by being educated, which is what I do.
If you ask, "Why do I think the education makes people better?", I've given an enormous amount of thought to this. There was a contemporary of Freud, Alfred Adler, who observed some of the same things that I've observed, but over 100 years ago. Adler said to teach people. I think we're reorganizing what's going on in the brain and the brain is no longer as afraid of the rage as it was before. Adler used the same term -- rage. I think that's what happens. When I teach people what this is all about, what's going on physically, and what's going on psychologically, I think the rage is no longer as threatening as it was before, and so they don't need to have symptoms.
Medscape: Let's move on to treatment. What should patients with back pain do? What should their doctors do?
Dr. Sarno: The only thing you can say to people in general, if they're interested, is to read the books. The 2 that I recommend are Healing Back Pain and The Mindbody Prescription. There is another book that has a corny title by one of my young colleagues from Vermont: To Be Or Not To Be...Pain-Free: The Mindbody Syndrome, by Marc Sopher, MD. If people read the book and they have the same experience that some people in the United States have had, pain will go away spontaneously.
Medscape: So, what do you recommend? Look at sources of stress, potential emotional upsets?
Dr. Sarno: First of all, personality is number one; remember that. Self-imposed pressure. Be aware of that -- being "perfect," being "good." Secondly, think about all of the regular pressures in your life. And if you are aware that your childhood was not the greatest, that probably is a contributing factor, too. If people look at these things and if they're open to the idea, they may do better.
Medscape: Do you recommend relaxation exercises?
Dr. Sarno: No, no, I do not. This is not a physical disorder and I recommend nothing physical.
Medscape: How should patients deal with the stresses?
Dr. Sarno: The only thing I can recommend, and I hate to do it because it sounds self-serving, is to read the books. That's the only thing out there for them. The last one has the most information about the psychology -- that's The Mindbody Prescription. It tells you what we do and what we try to bring about.
Medscape: Does it walk people through different things they look at? Does it have step-by-step mental exercises?
Dr. Sarno: Exactly. In the last book there's even an outline by a patient from upstate New York. This is one of the patients I never saw but who got better by reading one of the books. He sent me this little program that he designed for himself and I put it in the last book. Actually, I have improved on that and made my own program, but I have to admit that he gave me the stimulus to do it. At any rate, it's there and it's something that people can follow.
Medscape: Have you ever had back pain?
Dr. Sarno: Of course. Not only that, but I've had a half dozen of the equivalents as well. I think it was one of the reasons why it was so obvious to me once I allowed myself to think about this. But because I know what it is, it has never disabled me. And that's the secret -- knowledge, knowledge, knowledge. That's the cure here. Knowledge is the penicillin.
Medscape: And the brain is a powerful thing?
Dr. Sarno: You bet! One should never, never forget that fact.
Medscape Orthopedics. 2004;8(1) © 2004 Medscape
Cite this: An Expert Interview With Dr. John Sarno, Part II: Pain Management Prophet or Pariah? - Medscape - Jun 15, 2004.