John Sarno is one of my favorite authors. But he is also one of my favorite people. I attribute my complete healing from chronic neck and back pain a few years ago to his discoveries and lifestyle changes that followed. The Divided Mind: The Epidemic of Mindbody Disorders is a treasure trove of scientific insight based on decades of clinical experience treating patients suffering from various chronic conditions. The knowledge and observation contained in this book have helped countless people make complete recoveries (if you don’t believe me, go to www.thankyoudrsarno.com They stopped updating it after the doctor’s passing on June 22, 2017 at age 93).
Reality is that modern medicine has failed in its treatment of most chronic conditions. According to the Partnership to Fight Chronic Disease, more than 133 million Americans, or 44% of the population, suffers from at least one chronic condition, including arthritis, asthma, cancer, cardiovascular (heart) disease, depression and diabetes. Could it be that modern medicine’s failure lies precisely in its inability or unwillingness to understand and implement modern science? If you or someone you know is suffering from a chronic condition and have not received satisfactory treatment, I highly recommend you continue reading.
–> Psychosomatic medicine specifically refers to physical disorders of the mindbody, disorders that may appear to be purely physical, but which have their origin in unconscious emotions, a very different and extremely important medical matter.
–> I gave this book the title The Divided Mind because it is in the interaction of the unconscious and conscious minds that psychosomatic disorders originate. Those traits that reside in the unconscious that we consider the most troublesome, like childishness, dependency, or the capacity for savage behavior, are the products of an old, primitive part of the brain, anatomically deep, just above the brain stem. Evolution has added what is called the neocortex, the new brain, the brain of reason, higher intelligence, communication, and morality. There appears to be an ongoing struggle between these two parts of the brain. Sometimes reason prevails, and at other times The symptoms of hysterical disorders are often quite bizarre. The patient may experience a wide variety of
the more childish, bestial part of human nature is dominant. This duality is one reason for psychosomatic disorders, as will be demonstrated.
–> I undoubtedly will be challenged by the guardians of perceived wisdom for the so-called “lack of scientific evidence” for my diagnostic theories. This is almost ludicrous since there is no scientific evidence for some of the most cherished conventional concepts of symptom causation. The most glaring example of this is the idea that an inflammatory process is responsible for many painful states, for which there is no scientific evidence. Another example: studies have never been done to validate the value of a variety of surgical procedures employed for pain disorders, like laminectomy for intervertebral disk abnormalities.
–> I hoped I could help him, which meant helping him to help himself, because with mindbody disorders, a doctor cannot “cure” a patient. It is the suffering patient who must come to understand his malady… and by understanding it, banish it.
–> Some of these manifestations are commonplace and familiar to all, such as the act of blushing, or the feeling of butterflies in the stomach, or perspiring when in the spotlight. But these are harmless and temporary phenomena, persisting only as long as the unusual stimulus remains.
–> Doctors may refer to this as emotional overlay. In my practice, patients have reported that their pain became much more severe when they were informed of the results of a magnetic resonance imaging (MRI) scan that described an abnormality, such as a herniated disk, particularly if surgery was suggested as a possible treatment.
–> [strange hysterical manifestations include] highly debilitating maladies, including muscle weakness or paralysis, feelings of numbness or tingling, total absence of sensation, blindness, inability to use their vocal cords, and many others, all without any physical abnormalities in the body to account for such symptoms.
–> By contrast, in the fifth psychogenic group, psychosomatic disorders, the brain induces actual physical changes in the body.
–> One of the most intriguing aspects of both hysterical and psychosomatic disorders is that they tend to spread through the population in epidemic fashion, almost as if they were bacteriological in nature, which they are not. Edward Shorter, a medical historian, concluded from his study of the medical literature that the incidence of a psychogenic disorder grows to epidemic proportions when the disorder is in vogue. Strange as it may seem, people with an unconscious psychological need for symptoms tend to develop a disorder that is well known, like back pain, hay fever, or eczema. This is not a conscious decision.
–> The type of symptom and its location in the body is not important so long as it fulfills its purpose of diverting attention from what is transpiring in the unconscious.
–> The postpolio syndrome (pain in parts of the body previously afflicted by polio). Such pain is routinely attributed to the polio, but there is no proof that this is the cause. There is a Latin phrase commonly quoted in scientific circles that refers to this particular kind of misdiagnosis: “post hoc ergo propter hoc.” It means “after this [i.e, polio] therefore because of this,” a classic error in logic leading to a dangerous and unscientific conclusion.
–> [secondary gain] This clever explanation was readily embraced by medical practitioners since it absolved them of responsibility for their failure to help their patients. It was, after all, the patient’s own fault.
–> As noted above, mindbody disorders tend to spread in epidemic fashion: if they are in vogue; if they are misdiagnosed, that is, if the pain is falsely attributed to some purely “physical” phenomenon, like a herniated disc or bacteria in the stomach; and if treatment is readily available and funded by medical insurance.
–> The enormity of the problem is illustrated by an article that appeared in the business section of the New York Times on December 31, 2003. It described how one such expensive treatment, spinal fusion, is being widely performed despite the lack of evidence that it has any value whatsoever. The article went on to point out that the doctors, hospitals, and manufacturers of the hardware used in these procedures all have a financial stake in the performance of this operation. The national bill for its hardware alone has soared to $ 2.5 billion a year.
–> When rheumatologists first became interested in people with these symptoms, they were not able to explain what caused the disorder, but they created diagnostic criteria to define it. That became a kind of medical kiss of death.
–> Carpal tunnel syndrome (CTS) became fashionable in the 1980s. It is another TMS manifestation that has been widely misread by medicine, with predictable results.
–> As early as the 1930s and 1940s leading medical authorities published numerous papers on the psychological basis for migraine, and all noted that migraines were related to repressed rage. In Psychosomatic Medicine (1950), Franz Alexander noted, “The most striking observation is the sudden termination of the attack almost from one minute to another after the patient becomes conscious of his hitherto repressed rage and gives expression to it in abusive words.” Note Alexander’s reference to rage. As will be seen, rage in the unconscious mind is central to understanding virtually all psychosomatic reactions. The groundbreaking work of Alexander and his colleagues (see chapter 2) has been forgotten.
–> A careful history will reveal that in many cases the habit of getting up frequently during the night to urinate is not brought on by a full bladder but by a mild form of insomnia. The person is programmed by the unconscious to awaken and then programmed to have the urge to urinate.
–> The question invariably arises, “Aren’t allergic reactions caused by allergens, like grass pollens?” The answer is yes, but such allergens are merely triggers. They are foreign substances, and the immune system is designed to repel foreign invaders.
–> It is important to recognize that they are not illnesses; they are a part of life, part of the human condition.
–> Experience strongly suggests that anxiety, depression, and obsessive-compulsive disorder (OCD), all purely emotional conditions, are equivalents as well.
–> This is a daring statement, for it presumes to express an opinion about the origin of anxiety and depression, disorders in the domain of psychology and psychiatry.
–> Treating anxiety or depression with medications without in-depth psychotherapy is poor medicine, and may even be dangerous if the symptom imperative leads to a serious disorder like one of the many autoimmune maladies or cancers. These are not fanciful conclusions based on conjecture; they derive from irrefutable clinical experience.
–> Placebos take many forms: surgery, a variety of other physical treatments, and pharmaceuticals. If the celestial architect were to suddenly abolish the placebo effect in humans, there would be economic chaos, particularly in the United States, for much medical treatment today owes its success, such as it is, to the placebo phenomenon.
–> “It’s all in your mind” is almost insulting, implying there’s something strange or weak about you or that the symptoms are in your imagination. This is most unfortunate, since the symptoms are very real, the result of a very physical process.
–> Stress is another matter. Most people will accept the idea of stress, finding it less threatening because they think of stress as stemming from things “out there” that are doing something to you, so it does not imply some personal defect. Much of the research in psychology today has to do with the effects of stress in both health and illness. For example, how does stress make a medical condition like diabetes worse? Or how does a medical condition like diabetes cause stress in one’s life? This is laudable research, but it doesn’t deal with that crucial domain—the unconscious, which is where mind-body disorders begin.
–> The legendary Sir William Osler once remarked that one was more likely to learn about the course of tuberculosis by looking into the patient’s head than in his chest. What has happened?
–> An example of the former is the almost universal tendency to treat the chemical aberrations associated with depression with drugs, as though the altered chemistry was the cause of the depression when, in fact, the reason for the depression is an unconscious psychological conflict and the chemical change is merely the mechanism that produces the symptom of depression.
–> It would appear that modern psychiatry has regressed back to the nineteenth century, when the predominant view of mental disorders was that they were either hereditary or due to brain disease. Freud had not yet introduced the idea that psychology, not physiology, was the important factor in mental disorders. So pervasive was the conventional view, however, that even Freud had trouble disavowing it. Now, despite evidence to the contrary, modern psychiatry suggests that the psyche does not induce emotional states like anxiety and depression and prefers to view them as chemically caused—back to the old nineteenth-century physiology again, albeit in a more sophisticated form. One cannot help but suspect that much of this is simply a repudiation of Freud, which can be dangerous and short sighted. It’s true enough that Freud may have been in error about some details, but his basic ideas on the workings and importance of the unconscious are sound. Our experience with TMS makes that crystal clear.
–> His view was entirely justified by the neuroscience of the time. He further believed that the psyche simply used the symptoms for a neurotic purpose.
–> Hysterical signs and symptoms are out of fashion; TMS is in, with all its variations like low back pain, “sciatica,” neck and shoulder pain, “fibromyalgia,” “carpal tunnel syndrome,” knee pain, hip pain, and on and on. Gastrointestinal symptoms are also in vogue.
–> Either the severity of a symptom, emotional or physical, or the existence of two or more at the same time is an indication of the power of the unconscious conflict within.
–> It is my hope that this book will help remedy that situation and in the process make clear that almost all of the common pain disorders that have afflicted millions through the years are psychosomatic.
–> If the psyche has induced a physical symptom (such as back pain) or an emotional symptom (such as depression), which is then temporarily relieved in some fashion without dealing with the underlying emotional dynamic, the psyche will simply create another symptom to take its place.
–> Freud noted that a physical trauma frequently brought on hysterical symptoms either due to fright or “by the part of the body affected by the trauma becoming the seat of local hysteria.” The same phenomenon is commonly observed in patients suffering from TMS. Often, the “trauma” is both remote in time and of a minor nature, like a fall on the ice and the subsequent onset of buttock pain months later. More commonly, patients with TMS will develop symptoms in association with what might be called perceived trauma, wherein pain comes on suddenly while the person is engaged in some benign physical activity like lifting a suitcase or swinging a tennis racquet.
–> The two men were puzzled, however, by the fact that an unconscious idea, though not sufficiently intense to become conscious, could be strong enough to induce motor paralysis. How could a weak idea produce such a strong effect?
–> The observation that a physical symptom can absorb the person’s attention is very important. It is one of the fundamental concepts of the psychosomatic process, and my colleagues and I have observed it in thousands of people.
–> Physical symptoms, of either the hysterical conversion or psychosomatic variety, are intended to divert attention from emotions in the unconscious so that they will not become overt and thereby known to the conscious mind.
–> Fundamental to Freud’s understanding is that psychic phenomena result in excitation, a term found throughout his writing, implying a kind of energy that produces symptoms of one kind or another and that can be transferred from one sphere of activity to another for psychic reasons.
–> Here is one of the most important of Freud’s errors as it relates to the world of psychosomatic medicine. He believed the pains associated with hysteria were “organic,” and that the brain, which had played no part in producing the pains, simply used them for its own neurotic purposes. He did not recognize that such pains were actually created by the brain to serve a psychologically protective, benevolent purpose. There is a world of difference between these two concepts.
–> It is appropriate to designate Freud as the grandfather of psychosomatic medicine since his genius introduced us to the world of the unconscious mind, a contribution to medical science of inestimable importance. Psychosomatic processes begin in the unconscious and, though it has yet to be widely appreciated by either physical or psychiatric medicine, unconscious emotions are a potent factor in virtually all physical ills. Unfortunately, Freud is not the father of psychosomatic medicine, for he did not realize that his patients’ physical symptoms were induced by the brain to serve a psychological purpose, which is our definition of a psychosomatic disorder. He thought that physical symptoms were “organic,” that is, the result of some physical disorder, and were merely being “used” by the psyche for a psychological purpose.
–> (I recall a priest who had suffered damage to the cortical language areas of his brain from a stroke and when he attempted speech could only produce an embarrassing obscenity.)
–> Dr. Broks described a touching scene when the unfortunate boy was visited by his mother: I watched as she cradled his broken head in her arms. For the time that she was with him, but not much longer, an extraordinary transformation came over his face. It became still. The rage and the random mechanical twitching subsided, and he seemed to regain his humanity. The boy’s reaction to his mother’s loving embrace was evidence that the primitive human brain, which was all he had left, is also inhabited by feelings of love and kinship. We should not be surprised at this, since even lower animals exhibit similar behaviors. But though these loving emotions are present in the human unconscious, they are not dominant. If they were, we would be in nirvana. The residual child, self-centered, narcissistic, dependent, seems to be more influential than the gentler emotions and, in many, the capacity for brutality predominates—which is why the world is the way it is.
–> It is not generally realized that intelligence is not everything, that an intellectual genius may be an emotional baby or a monster.
–> At a personal level there is a battle raging in the unconscious of every one of us between the residual child-primitive that Freud called the id, and the representatives of reason and morality he called the ego and the superego. This conflict is responsible for psychosomatic symptoms. As Freud said in one of his lectures, “To adopt a popular mode of speaking, we might say that the ego stands for reason and good sense while the id stands for untamed passions.”
–> Freud based his concepts of the id on a study of his patients’ dreams and an exploration of their neuroses.
–> “There is nothing in the id that corresponds to the idea of time,” he wrote, “there is no recognition of the passage of time, and—a thing that is most remarkable and awaits consideration in philosophical thought—no alteration in its mental processes is produced by the passage of time. Wishful impulses which have never passed beyond the id, but impressions, too, which have been sunk into the id by repression, are virtually immortal; after the passage of decades they behave as though they had just occurred. They can only be recognized as belonging to the past….”
–> Hence, unconscious anger generated in the mind of a boy often will be alive and equally intense when he is forty as on the day it occurred.
–> Our studies of TMS lead us to conclude that repression serves a protective purpose since the repressed emotions, should we become aware of them, would in some way be dangerous to normal existence or be too emotionally painful to deal with. Freud says that these dangerous inhabitants of the unconscious can be made conscious through the process of analysis. However, in our experience, many repressed feelings and impulses simply cannot be brought to consciousness. It is as though rage, narcissism, sadness, and feelings of dependency or inferiority are permanent residents of the unconscious.
–> It is likely that feelings of low self-regard are also enhanced when the developing infant-child compares itself to the giants all around it. Because of the timelessness of the unconscious, these feelings persist throughout life and are compensated in some people by the drives to be perfect and/ or good and in others by aggressive behavior.
–> Because it is the educator and guardian of the self, one must conclude that it is the ego, perhaps at the behest of the superego, that decides on the protective strategy of repression, which is then reinforced by psychosomatic symptoms.
–> In my experience, the state of anxiety, which is perceived by the individual as a psychological malaise, is a reaction to what is being repressed, created by the ego as a distraction, much as it creates depression and physical pain for the same purpose.
–> The anxiety is free floating, generalized to all aspects of the person’s life. Pain and depression may alternate with anxiety, making it quite clear that they serve the same psychological purpose. This is another example of the symptom imperative, and I have had numerous patients who have exhibited precisely such symptoms. Pain, anxiety, and depression are not symptomatic of illness or disease. They are all part of the normal reaction to frightening unconscious phenomena.
–> Adler further postulated that feelings of inferiority stimulated a striving for superiority, for perfection and high accomplishment.
–> [Alfred] Adler’s views on the subject indicate that he was the first to recognize that the psyche could induce physical symptoms by initiating physiological pathology. He wrote, “The mind is able to activate the physical conditions. The emotions and their physical expressions tell us how the mind is acting and reacting in a situation it interprets as favorable or unfavorable.” Bravo!
–> What a wonder to contemplate: Freud described TMS in 1888, and Adler its physiology, circa 1911.
–> To Adler there were good emotions, like joy or sympathy, which led to socially laudable goals, and bad emotions, like anger, fear, or sorrow, that are characteristic of the neurotic. As with Freud, he considered neurotics to be sick people. Neither Freud nor Adler had the concept that we are all potential neurotics, which is why psychosomatic symptoms are universal.
–> Another Adlerian observation parallels our experience with TMS patients: he found those patients with feelings of worthlessness to be extremely sensitive to criticism. This appears to be a reaction to intense feelings of inferiority. As can be seen, there is considerable similarity between Adlerian psychology and my own.
–> He and others contributing to the literature at the time found that “inhibited hostile tendencies” were important in the genesis of hypertension.
–> That idea was supported by Alexander, who noted that patients who developed hypertension typically gave a history of having been very aggressive during early life, then suddenly, often during puberty, finding that their aggressiveness made them unpopular, became meek and easily intimidated.
–> This is another instance in which the patterns of psychosomatic disorders depend on what is in vogue, and helps explain why disorders like “fibromyalgia” and “carpal tunnel syndrome” assumed such epidemic proportions in the short span of fifteen years at the end of the twentieth century.
–> Most theories, including those of Freud and his followers, considered psychosomatic manifestations as a form of illness representing defective personalities. I strongly disagree. Psychosomatic phenomena are not a form of illness. They must be seen as part of the human condition—to which everyone is susceptible.
–> Wordsworth wrote, “the Child is father of the Man,” and that poetic truth has been validated by scientific observation many times in the last century. Every working day, at our clinic in the Rusk Institute of Rehabilitation Medicine at the NYU Medical Center, we have the opportunity to see and study how childhood experiences and the child in all of us—the timeless, primitive, unconscious mind that operates totally beyond our conscious awareness—continues to influence, and even shape, our adult selves.
–> I’ll admit that this is very familiar to me since I do it all the time, much to the distress of my wife when she is in the car. What is particularly striking about it to me is that my reactions are so immediate and strong—no doubt reflecting the intensity of the inner rage for which they are substituting.
–> We yearn for that which we did not get as children and are permanently sad, hurt, and angry as a consequence, but all in the unconscious. This is the stuff of which psychosomatic symptoms are made.
–> Such tendencies to achieve and be nice are typical of people trying to demonstrate by their performance and behavior that they are worthwhile, not inferior.
–> The terrifying events of September 11, 2001, resulted in a dramatic increase in psychosomatic reactions across the United States, as might have been expected. The majority of us were frightened, but fright doesn’t create psychosomatic symptoms. The reaction to conscious fear is to try to overcome its source, to deny or to rationalize it.
–> Guilt and shame are intolerable to the child-primitive and evoke anger, emotional pain and sadness, and there is no dearth of those emotions among all of us. Many firefighters experienced survivor guilt after 9/ 11, guilt that they did not share their comrades’ death. This reaction is well known from the experience of Holocaust survivors.
–> Those of us who are prone to psychosomatic manifestations usually have a strong need to be in complete control of our environments.
–> Mainstream medicine, hardly aware of psychosomatic phenomena, concluded that the anxiety of 9/ 11 only made existing disorders worse, which it undoubtedly did, but failed to recognize that many people developed symptoms de novo.
–> People exhibiting psychosomatic symptoms have to make an effort to imagine painful or threatening internal feelings and, equally important, reflect on the magnitude of their feelings and their potential for doing great harm. One must learn to think of these unconscious feelings in volcanic terms and understand that their intensity has the potential to wreak havoc in our lives or would simply be too painful to bear.
–> … experience suggests that unconscious rage rather than stress is the active psychological ingredient leading to many serious disorders, including atherosclerosis.
–> Mrs. B’s case history is an excellent example of the effects of the perfect and the good. Looking at her family from the outside, one would think everything was fine. Her medical advisors would say the back pain was due to aging processes in the spine. That kind of naiveté in medicine is the fertilizer that nourishes epidemics of pain. The problem was not in her spine, it was in her life.
–> One is reminded of the Irish novelist Thomas Flanagan’s observation, “We possess ideas, but we are possessed by feelings. They lie too deep for understanding, astir with their own secret life and carrying us with them.”
–> It occurred to me as I reviewed the case of a patient that there are three powerful unconscious realities that often work together to produce a psychosomatic episode. They are: Deep feelings of inferiority Narcissism Strong dependency needs Each of these leads to unconscious anger/ rage and emotional pain. Let us see how these come about.
–> The well-controlled man remains calm and copes well under extreme stress, but beyond his awareness the pressure induces unlimited fury in the unconscious. That idea would embarrass him if he knew about it, and when such a possibility is suggested, he denies it vehemently. Almost always, neither doctor nor patient is aware that self-imposed pressure, which is characteristic of ambitious, accomplished men like Mr. Jones, is possibly more enraging internally than the external pressure we call “stress.”
–> Freud’s attaching importance to “an erotic idea” is consistent with his view at that point in his career that sexual factors were at the root of many neuroses. This was compatible with the mores of the time and may also have been influenced by his own self-analysis. It was not eroticism that was the primary psychic factor in this case but the rage and pain stemming from self-deprivation and loss.
–> The brain practices many similar deceits. Following a legitimate injury, such as a sprained ankle, the brain will sometimes continue generating the pain in the form of TMS long after healing has occurred. It will often locate pain at the site of an old injury, such as a previous fracture, for example.
–> One of the prime characteristics of TMS is that the pattern of symptoms will develop as a result of Pavlovian conditioning. People will experience the kind of symptoms they have learned to expect to experience, just as Pavlov’s dogs learned to associate the presentation of food with the ringing of a bell. Elisabeth von R had pain associated with standing and walking, though there was nothing neurologically wrong with her.
–> She didn’t understand. “What you need in order to get better, my friend,” I said, “is not a leap of faith but a leap of understanding.”
–> My colleagues and I have been successful because we have made the right diagnosis, not because we have found the right treatment. We do not have an “approach” to the problems of acute and chronic pain—we have the diagnosis.
–> Another crucial therapeutic element became clear early on as well: the person must not only understand the nature of the process but be able to fully accept it as well. Not faith, but acceptance of the idea is essential. Blind faith leads to a placebo cure, if any. By contrast, acceptance and acknowledgment produce permanent results. Failure of acceptance is an impediment to “cure” for some patients because inability to accept the concepts of TMS is one of the psyche’s strategies for maintaining the process.
–> Here, then, was another absurdity. Not only could physical pain be psychosomatic, but you could stop it by learning about it! Quite incredible, and to this day I find it hard to believe. It’s almost too good to be true.
–> The fact that my books can “cure” is convincing evidence that our therapeutic program is not a placebo. There is no treatment, no charismatic personal influence—only the acquisition of information, which cannot in any way be construed as a placebo treatment.
–> Repudiate the physical-structural explanation for the pain and attribute it instead to the benign altered physiology, the physical-emotional basis of TMS
–> Patients need to know that epidemics of psychosomatic disorders will occur if the condition has been attributed to “structural-physical” causes, if the disorder is in vogue, and if treatment is available, as demonstrated by the Norwegian experience.
–> One of the dirty little secrets of the medical community is that clinical medicine is clearly not always as scientific as many would like to think. Of the thousands of patients with disc pathology that we have seen over the last thirty-two years, not one has ever developed “permanent nerve damage” after refusing surgery and following treatment for TMS.
–> The first part of the lecture is concluded with a discussion of the important role of fear in the perpetuation and intensification of the syndrome. Patients have been frightened by words like degeneration, disintegration, and herniation, used to describe their structural abnormalities; they have become fearful of physical activity and warned against assuming certain postures (“ never bend at the waist without bending your knees”);
–> What she didn’t know was that during those thirty-six hours the poison of her monumental rage, shame, and pain, which had lain dormant all those years, and which had been stimulated by the meeting, was forcing its way closer and closer to consciousness. The psyche, in a desperate attempt to prevent the explosion of those feelings into consciousness, was making the pain worse and worse. And then the psyche lost. Helen began to cry as she had never cried before, she raged, she wanted to cut her wrists and die. The poison poured out of her and, as it did, virtually all the pain disappeared.
–> a. Anger, hurt, emotional pain, and sadness generated in childhood will stay with you all your life because there is no such thing as time in the unconscious.
–> In fact, feelings of inferiority may be the major reason we strive to be perfect and good.
–> Try hard not to pay attention to your pain. When you find yourself thinking about it, force yourself to think about the psychological things on your list.
–> Knowledge does not eliminate the rage nor change the repressed feelings that are responsible for the rage. It is not certain that even years of analytically oriented psychotherapy could bring about those changes.
–> At each of these points in treatment, therapists must intercede to increase patients’ awareness between underlying emotions and their ability or failure to express them. We also confront all attempts at denial or rationalization.
–> In fact, an increase in consciously experienced anxiety often occurs prior to or during symptom reduction.
–> A frequent occurrence during the process of successful psychotherapy is a fluctuation of symptoms, such as a reduction in pain followed by an increase in pain soon after. This is a more common pattern than a sudden or gradual cessation of symptoms. These changes may reflect the cycle of catharsis and resistance as well as the fluctuations in the patients’ understanding of the true nature of what is causing their disorder, as their old incorrect or self-defeating rationales give way to more adaptive defenses.
–> Psychosomatic individuals often have a troubled history with other medical health professionals. They may have been misunderstood due to the fact that their problems are frequently invisible.
–> We have no control over what we feel, but we can and must exercise control over how we respond to our feelings. The goal of treatment, then, is to enable the patient to respond to his emotional conflicts more adaptively—by means other than developing pain.
–> Hiroku then acknowledged that although she outwardly appeared gracious toward her guests during their entire stay, she felt ashamed of her resentment toward them. According to Hiroku, to experience resentment was tantamount to being selfish, no matter how you actually behaved.
–> Anger is often frightening for people with TMS to embrace because of either the fear of losing control (the perfectionist) or significant worry and concern that the object of the anger will dislike or reject them (the goodist). At other times, embracing anger can be overwhelming because of the possibility of profound hurt and sorrow that often underlies the anger. In these cases anger is like TMS symptoms in that it also protects the person from even more painful emotions.
–> In any treatment regimen one must be aware of the problem of nonconformity—patients who do not take their medications, follow instructions, and the like.
–> Pity me that the heart is slow to learn What the swift mind beholds at every turn
–> I told her that TMS tendon pain in the shoulder was often mistakenly attributed to a torn rotator cuff (whose existence is confirmed by MRI) and arranged to see her in the office.
–> It is not the emotional distress that we feel, but those emotions we have repressed and are unaware of, that leads to hypertension. The process by which we unknowingly keep distressful and threatening emotions from awareness causes persisting stimulation of the sympathetic nervous system (SNS), resulting in persisting elevation of blood pressure. A shift in our awareness, or use of antihypertensive drugs that block the effects of the SNS on blood pressure, or, in the case of episodic hypertension, drugs that help maintain repression, provide the best results in treating this type of hypertension.
–> Without repression, a trauma survivor would be at risk of long-standing psychological problems. Many ultimately recover and move on with their lives, but the pain never truly ends. Others don’t recover well and may be greatly troubled for the rest of their lives.
–> And it would be wrong to generalize from the principles of treatment of people troubled by past trauma to the treatment of those who are not. It might be better to leave the past alone, even if past abuse or trauma is responsible for the hypertension. It is wise to honor a patient’s preference to not explore the past.
–> I could go into considerable detail about the enormous public health problem posed by chronic pain in the United States and most of the Western world, and of the evidence in the medical literature suggesting that psychological factors are an important reason for the epidemic of chronic pain in the United States. The cost to society is enormous, in the range of $ 65 to $ 79 billion annually. The cost in human suffering is incalculable.
–> Retirement, for both men and women, often leads to a drop in self-esteem, further feeding the rage reservoir, as well as sadness and hopelessness. Other senior citizens who continue to work experience anxiety about their ability to compete with their younger colleagues, or anger at having to deal with bosses who are younger and less capable than they are or who have inherited businesses that they were instrumental in starting.
–> Andrea Leonard-Segal, M.D., graduated from George Washington University Medical School, where she was inducted into Alpha Omega Alpha, the medical school equivalent of Phi Beta Kappa. She is a board-certified internist and rheumatologist and is Assistant Clinical Professor of Medicine at George Washington University Medical School. Currently, she helps people overcome chronic pain at the Center for Integrative Medicine at George Washington University Medical Center.
–> I did not understand why we would make a commonly accepted diagnosis of a pulled muscle in the back. The diagnosis was completely presumptive; there were no physical changes to document, no signs of injury, no bizarre physical activity that preceded the onset of the pain. It did not make sense.
–> Many of my patients have been children of alcoholics. Many have been children of divorce, and many have been abused. However, the majority have come from families with hardworking, loving parents who conveyed overly high expectations and hopes for their children.
–> Doing our best all the time is exceedingly difficult work and can lead to frustration and buried anger. My patients are often disappointed if others do not notice the hard work they have done. Low self-esteem needs to be fed by compliments from others. Getting better from TMS is learning how to extract yourself from needing recognition from others and learning how to fill that need yourself. It is about learning to parent yourself in perhaps a kinder, gentler, and more benevolent way than one may have actually experienced during childhood. It is learning to lower your expectations of yourself and others and learning that relationships are easier, more genuine, and form stronger bonds under those circumstances.
–> At some level they were insulted or threatened by this TMS diagnosis. I never try to convince patients who are not open to this diagnosis, because I have learned that when patients erect an emotional barrier, they leave it standing until they are ready to take it down. No one can do this for them. Some of those patients have never returned to see me.
–> It strikes me as curious that people will readily connect a feeling of embarrassment with red cheeks or a feeling of nervousness with sweaty hands but are unwilling or unable to make a connection between anger and pain.
–> It is critically important to human health that we shed our stigma about the nature of things emotional. Toughing things out, burying uncomfortable feelings, and living under stress can lead to physical pain and dysfunction and, most important, serious medical illness.
–> The patient who has recovered from TMS grows into a happier, more comfortable, more peaceful person who sees new paths toward greater personal fulfillment.
–> The laying on of hands and a sympathetic, warm interaction between practitioner and patient can also contribute to symptomatic improvement.
–> Some even told their patients that they might end up in a wheelchair. Andrew Weil, M.D., has referred to this negative conditioning as medical pessimism. With such gloomy prognoses, patients became disheartened and lost hope that they could live a normal life again. This negative conditioning is a major reason for the pain epidemic in the Western world today.
–> There is a nationwide movement to stop stigmatizing people with chronic pain, and to provide appropriate analgesic medication for those with moderate and severe pain.
–> The literature on chronic pain further assumed that most patients were motivated by “secondary gain,” that is, the unconscious desire to be cared for, avoid responsibility, or perhaps get money as a result of their condition.
–> “I am a great believer in TMS, having seen a great many cases of chronic back pain disappear as if by magic when people fall in love or otherwise make radical changes in their emotional and mental life.” The possibility that chronic back pain is psychosomatic was intriguing to me.
–> The next significant question: “Can you talk about your personality, who you are?” He would zero in on issues of perfectionism and goodism. He developed a sense of whether people are people pleasers and/ or peacemakers. He explained that this pressure to be perfect and to be good is enraging to the unconscious mind.
–> Inadequate social history taking must be considered a primary reason that most doctors do not appreciate the true psychological factors that cause chronic pain.
–> Rotator cuff tear is another common diagnosis, usually made on MRI. The tear can be either partial or complete in thickness. A complete tear will often produce marked weakness on strength testing due to the anatomic defect. These tears are fairly common beyond age sixty, probably affecting 30 percent or more of all individuals beyond that age. Yet far fewer patients actually present to an orthopedic surgeon for shoulder pain. Many people tolerate the strength deficit rather well and require no treatment. If a patient has significant pain, and the MRI shows a complete rotator cuff tear, other doctors almost invariably blame the pain on the torn rotator cuff.
–> Patients can be reassured when they have TMS that their back is normal; their neck is normal; their arms and their legs are normal. Reassurance is powerful medicine.
–> The TMS diagnosis is liberating and empowering for patients. It gives chronic pain sufferers their best opportunity to live a full and rewarding life, free of pain.
–> I can’t magically get rid of their pain for them. It is only those who are willing to take responsibility for learning about their condition and doing the daily study program who will be cured of TMS.
–> And what of the positive nerve conduction velocity test? I have concluded that TMS can reduce the speed of nerve conduction. TMS causes mild oxygen deprivation, which can show up when a nerve conduction velocity test is performed.
–> The term inflammation is commonly used to explain pain despite the fact that there is no scientific proof that it exists.
–> In the course of my work I have been greatly impressed with the common misperceptions about the definition of a psychosomatic disorder. Grossly mistaken ideas, like “the pain is in your head,” or “it’s imaginary,” or “the person is a hypochondriac (or mentally unsound),” are universal.
–> It is not unusual to develop a viral illness (the common cold) during a time of emotional stress, the result of weakening of the immune system. We are talking about physiologic changes that occur in various tissues or organs in the body that are induced by emotions. That is the meaning of psychosomatic.
–> If the pain is relieved, one of three things will happen: either it will come back, the brain will locate the pain somewhere else, or the brain will choose another organ or system to produce symptoms. Sometimes it will substitute an emotional reaction such as anxiety or depression. I have referred to this as the equivalency response. This extremely important phenomenon has been described by Dr. Sarno as the symptom imperative.
–> As Dr. Sarno has pointed out, the medical profession is largely responsible for the pain epidemics sweeping the country today because it is unaware of the existence of psychosomatic disorders and ignores the possibility that much of its treatment success can be attributed to the placebo reaction.
–> Before the eradication of polio in the United States, “hysterical paralysis” was a common diagnosis for what was, in fact, a psychogenic (conversion-hysterical) disorder. The paralysis resulting from polio (a structural cause) was the template for the psychogenic paralysis. But when polio was eradicated through the advent of a vaccine, hysterical paralysis became exceedingly rare. During large-scale chemical or toxic exposures such as from war or industrial accidents, many patients who did not have a direct exposure will show up with identical symptoms to those who did. Thus, as the nature of structural illness changes over time and between cultures, so does psychogenic illness.
–> Finally, the media further strengthens these attitudes through the advertising of accident attorneys, coverage of litigation, and advertising of various medical treatments.
–> Culturally, we are a society that promotes and rewards those individuals who blunt their emotions. Being “cool, calm, and collected” is a positive value in our culture. Parents often tell a child who is feeling pain, whether physical or emotional, that “everything is okay” or “you’ll be all right” rather than hug them and allow them to express their distress and thereby validate what they are feeling. Our society is emotionally well defended.
–> However, many individuals would find living life in a more genuine manner more difficult than the physical pain they are experiencing because they would have to acknowledge painful parts of themselves or painful emotions buried deep inside their unconscious mind.
–> With every new nonsteroidal anti-inflammatory drug (NSAID) that has hit the market, I have observed a much greater efficacy for approximately one to two years before its therapeutic value decreases to the level of all the other ones available. Another example is the intense advertising of alternative medicine, particularly that which aims at low back pain.
–> Furthermore, there is intense advertising among attorneys to attract business, whether from an automobile accident, work injury, or injury on someone else’s property. This fuels the notion that someone else is to blame for our injuries, so we are the victims.
–> Similarly, the insurance industry influences the psychogenic process, because it increases the awareness and further legitimizes pain syndromes resulting from injury. Furthermore, it reinforces the victim mentality as well as the monetary value of an injury.
–> The inability to work because of a medical condition, particularly a musculoskeletal disorder, has become more socially acceptable over the last several decades.
–> Why are physicians so reluctant to accept such a concept? The answer is complex and includes our medical training biases as well as our own unconscious emotions. To be able to understand and effectively apply Dr. Sarno’s principles, one must acknowledge their own shadows and painful emotions. Additionally, a physician’s position of authority is compromised with this perspective since patients become empowered by discovering that they have the ability to heal themselves.
–> Dr. Sarno has emphasized the important role that pain plays in distracting one’s mind away from the emotional to the physical. I find that there are other pain equivalents that serve as distractions, one of the most common being the workaholic ethic. I can remember a coworker telling me, “Why would I ever want to take a vacation; I wouldn’t know what to do with myself!” In other words, unconsciously he is saying, “Why would I ever want to sit with my emotions?” It would be too painful for him!
–> To emphasize again, I have found that the severity and chronicity of one’s symptoms is proportional to the underlying pain that harbors in the unconscious and the triggers that evoke them.
–> Ironically, this makes perfect sense. If one acknowledges that his disorder is psychogenic, then he is acknowledging those painful unconscious emotions. He is shedding his defenses and, thus, his distractions.
–> We should not forget the power of these emotions. For many, it is easier to suffer with physical pain than it is to acknowledge the emotional ones. Furthermore, our society is not supportive of expressing those painful emotions we all harbor.
–> The cause of a psychosomatic disorder, and therefore the cure, resides in the mind. Patients become programmed very quickly by well-intentioned advice from various health care providers.
–> I give patients permission to get better and don’t say things that program them to have pain.
–> Many patients with psychosomatic disorders like it when doctors tell them they are damaged goods. It validates their symptom imperative. However, when we doctors do this, we become part of the problem and reinforce the psychosomatic process.
–> Textbooks state that fibromyalgia is of unknown cause and is not curable. I’ve cured patients with fibromyalgia. They are the patients who are willing to look at their problem as a psychosomatic disorder, like the one I described at the beginning of the chapter.
–> With low back and leg pain, for example, if a lumbar spine MRI shows a herniated disc, it is assumed, a priori, that this is the cause of the pain, even when there is a lack of correlation between the location of the herniated disk and the location of the pain and/ or examination findings. Those of us who practice psychosomatic medicine are chided for our lack of “scientific evidence” for the existence of such entities as TMS, but neither do the critics have any evidence for their diagnostic conclusions. They speak of compression and inflammation, but there is not one whit of evidence in the medical literature that supports their diagnostic ideas, despite which they blithely proceed with surgical and other treatments.
–> Unfortunately, a control study would be impossible because therapeutic success in the treatment of TMS requires that patients accept the fact that their symptoms have a psychological basis. If patients cannot repudiate the structural explanation for their pain (a disk problem, a heel spur, carpal tunnel syndrome, etc.) and attribute the pain instead to TMS, they cannot get better. In a control study, patients are assigned randomly to two or more treatment methods. If most of the patients assigned to TMS treatment cannot accept the diagnosis for reasons to be discussed, the study is invalid. The nature of TMS puts us at great disadvantage in such studies.
–> In addition to being difficult to measure with traditional scientific protocols, it is extremely time consuming to treat TMS. It is much simpler to prescribe a pill or recommend physical therapy or surgery than to explain to someone how his very real physical symptoms can have a psychological cause.
–> As a society, we are becoming so passive that we wish to be only recipients of treatment as opposed to active participants in our health and wellness.
–> … TMS is a strategy of the brain to keep unpleasant thoughts and emotions from rising from the unconscious into the conscious mind. The brain, through established physiologic pathways, creates pain as a distraction. By focusing our attention on physical symptoms, we keep these painful thoughts and emotions repressed. This is a very effective strategy, as there is an absolute epidemic of mindbody disorders in our society.
–> Eliminating the pain is startlingly simple. We can banish the pain and thwart the brain’s strategy by simply understanding and accepting that the pain has a psychological causation, that it is not physically based.
–> My number one question was: is it really as simple as getting patients to learn how to think differently? The answer is yes, but with the understanding that the mental work involved may be considerable. It entails forgetting everything you’ve ever been told about your body and symptoms. This can be very difficult for some. I refer to this process as undoing old ways of thinking, and then move on to a discussion of the principles of conditioning. We are conditioned to hold certain beliefs about ourselves, as a result of the explanations and comments of well-meaning health care providers, family, friends, neighbors, coworkers, and the media.
–> I have puzzled over this and concluded that the “rapid” healers are somehow better able to put aside what they have been told in the past and fully integrate the TMS information. They can undo the conditioning that is part of mainstream thought and replace it with this new understanding of how the workings of the unconscious can affect the body and physical sensation.
–> Making a list is like keeping a journal. Many studies have shown that those who write regularly in a journal, about themselves, their thoughts and concerns, are healthier than those who do not. So, start your list or a journal, and add to it or review it regularly.
–> Eternal vigilance is the proverbial “ounce of prevention.” This is why it is necessary to spend some time each day reflecting.
–> I have patients in their sixties, seventies, and eighties running marathons, bicycling across the country, climbing mountains, and participating in other strenuous activities. They are not supermen and superwomen; they are simply folks who have taken good care of themselves and refuse to believe that they are fragile.
–> However, this is not what will eliminate pain. It doesn’t require positive thinking. It requires accurate thinking. Accurate thinking means understanding how psychological factors affect our physiology. Only when we understand this can we truly heal ourselves. It’s not easy forgetting all that you have been told and, in essence, creating a new belief system. As a matter of fact, it is extremely difficult. There are many obstacles, both within and without. Many people speak to me about fear.
–> Celebrating is an important way to reprogram the mind. It helps condition you to think differently about your body and will help you immeasurably to undo the old conditioning and forget all that came before.
–> If you begin to doubt there is a psychological cause, that there could be a physical cause, then the work is undone and the brain’s strategy of creating a physical distraction will triumph. This is part of what I refer to as the calendar phenomenon: preoccupation with the number of days or weeks it will take to get better. By this time, everyone may know of someone whose symptoms vanished immediately after reading the book or shortly after seeing a physician trained in TMS treatment. So, an expectation is created in their mind that their symptoms should recede soon after incorporating this philosophy. They look at the calendar and become upset as days and weeks go by. This is where I tell people to look back at their personalities. The calendar phenomenon is another manifestation of perfectionist tendencies—it is self-imposed pressure to succeed and succeed quickly.