To effectively treat chronic back pain, look not to a patient’s anatomy but to the psyche, says John E. Sarno, MD, professor of clinical rehabilitation, New York University.
Dr. Sarno contends that for the vast majority of patients with back pain—and other hard-to-pin-down pain problems—the root is not physical, it is psycho-emotional. And so should the treatment be.
Unless there is overt physical pathology, physical modalities, be they surgical, manipulative, or pharmacologic, usually fail because they only address the external manifestation of the disorder, not the processes driving it, said Dr. Sarno, an attending physician at the Rusk Institute of Rehabilitation Medicine, New York.
By positing a psycho-emotional etiology he stressed that is not implying that the pain is imaginary. “The pain a patient experiences is very real, and it is taking place in the body. But its roots are in the psyche,” he told Holistic Primary Care in an interview.
Over the last 27 years, the former Army medic has treated roughly 11,000 patients with a program based almost entirely on consciousness—on teaching patients to recognize and deal with repressed emotions and unconscious impulses which he believes play a critical role in pain syndromes. He claims a long-term efficacy rate of over 75% in appropriately selected patients.
The TMS Diagnosis
“It is a matter of correct diagnosis,” he said. “I make a diagnosis not ordinarily made by most physicians.” That diagnosis, not yet widely accepted by mainstream medicine, is Tension Myositis Syndrome (TMS). It posits that back pain and other chronic pain reflects physical processes initiated by the brain as a diversionary tactic to keep conscious focus away from emergent rage or other undesireable emotions. In other words, the physical pain is a red herring.
In Dr. Sarno’s model, the brain responds to unacceptable emotions before they impinge on awareness by increasing autonomic activity, which results in vessel constriction, leading to mild oxygen deprivation—on the order of about 5%—at various sites in the body. This is the direct cause of the muscle pain and the palpable muscle contracture.
While there is preliminary evidence from a Scandinavian research team showing autonomically induced microvascular constriction and oxygen deprivation are at least theoretically possible, this mechanism has not yet been verified.
The brain typically “chooses” areas of the body where there’s already some mild structural abnormality or injury. But he argues that many of the structural abnormalities cited as causes of chronic pain—including “herniated” or “compressed” discs, scoliosis, spondylolisthesis, could not reasonably cause the persistent, sometimes continuous pain experienced year after year by many patients.
Don’t Blame the Discs
Dr. Sarno is particularly critical of the “disc problem” etiology, which sends many patients to what he feels is unnecessary though lucrative surgery. An MRI study at Hoag Memorial Hospital, Newport Beach, CA, showed that 64% of a cohort of 98 men and women with no pain and no symptoms at all, had significant disc abnormalities on MRI (Jensen MC, et al. 1994. N Engl J Med, 331(2):69–73). “If discs were the problem, these people should have had pain,” commented Dr. Sarno.
To make a diagnosis of TMS, he first rules out serious pathology like tumors, fractures or degenerative diseases. In essence, a patient with TMS has nothing really “wrong” anatomically—a point he stresses to his patients.
The therapeutic strategy hinges on moving patients away from physical fixations and into the realm of psychodynamics. The TMS model is unashamedly Freudian. Dr. Sarno believes Freud’s description of the conflict between infantile emotions and super-ego repression is essential to understanding what happens with TMS.
“Any emotion generated by the unconscious that is undesireable, embarrassing or unacceptable for whatever reason is repressed. That is normal. Because they are unconscious, we are completely unaware they are there.” But when these emotions intensify—either by life stressors or particular personality factors, they threaten to emerge. “The purpose of TMS is to enhance repression, to ensure the unconscious emotions remain unconscious.”
Sources of unconscious rage include physical, sexual, or emotional abuse in childhood, and disrupted or inadequate bonding with parents. The rage is often accompanied by shame, inferiority and helplessness.
Dr. Sarno said his discovery of TMS back in the mid-1960s came about, “by being totally unsuccessful in treating based on conventional diagnoses. I became disenchanted, because I wasn’t getting good results. Then I made certain connections. Many of these (back pain) patients also had stomach symptoms, allergic disorders, all sorts of stuff I knew was basically psychosomatic. So I started to think maybe the pain syndromes were as well.”
Mainstreaming Mind-Body Medicine
That sort of thinking, though still not fully embraced by the pain management mainstream, is not nearly as radical now as it was 30 years ago. According to Richard Weiner, PhD, executive director of the American Academy of Pain Management, many pain specialists are turning their attention to the mental, emotional and spiritual components of the chronic pain syndrome.
“Dr. Sarno was an early advocate of the mind-body connection, and he captured a broad picture of what it means to be a pain patient,” Dr. Weiner told Holistic Primary Care. “If a patient is in pain for six months or more, it is chronic. And after a good history and physical to rule out treatable physical causes, you can assume most of these patients have psychosocial or emotional issues.”
Dr. Weiner added that he and a growing number of pain specialists share Dr. Sarno’s reluctance to send back pain patients for surgery. The essential point on which he differs with Dr. Sarno is in being, “more cautious before suggesting that just because a CT or EMG doesn’t show an active physical problem does not mean there is not one present.”
The TMS Personality
While TMS seems to be an equal opportunity disorder in terms of ethnic and racial prevalence, Dr. Sarno believes particular personality traits predispose to it: perfectionism, self-criticism, tendency to compulsion, relentless desire to be “good” and to please others, need for approval, tendency to feel guilty. These can induce their “shadows”—feelings like resentment, irresponsibility, and anger at the demands of life.
“A lot of people think stress is ‘out there’ somewhere. They have no idea that the biggest stressors are internal—the pressures we put on ourselves.” The combination of self-imposed pressures to be “good,” coupled with life pressures (family matters, marital disharmony, young children, elder care, job stress, financial problems) against a matrix of deeply unconscious anger is, basically, the recipe for TMS.
He believes similar psychodynamics underlie a host of seemingly epidemic, difficult-to-treat modern disorders like fibromyalgia, chronic GI syndromes like “irritable bowel,” temporomandibular joint dysfunction, and carpal tunnel syndrome.
In evaluating a new patient who has nagging pain, consider the circumstances of onset and ask about current life situations. For example, the “tendinitis” that only occurs with one particular type of activity or in certain settings may point to the patient’s emotional triggers.
Managing Patients with TMS
Dr. Sarno’s therapeutic approach is not about sending patients into primal rages, though in some cases—about 20%—he does refer patients to psychologists who can help them “bleed off” rage in small amounts. Rather he works with them to bring consciousness into the unconscious well of emotion, instructing them to identify possible sources of unresolved emotions, and what triggers and exacerbates them. It is about teaching people to think psychologically.
He encourages patients to resume all normal activity as soon as they feel significant reduction in pain. Inactivity is not only physically detrimental, it also perpetuates a sense of powerlessness, and the Sarno strategy is all about empowerment.
Response time is variable. Typically, he said, patients improve within 2–4 weeks, provided they accept the notion that the root cause is psychological and they diligently do their “homework.” Other cases take 2–3 months. Someone who fundamentally rejects the idea that the cause is psychoemotional will not benefit. Dr. Sarno said at this point, he does not work with individuals—and there are many—who insist on an exclusively physical causation.
Patients are not the only resistant ones. Dr. Sarno said he has encountered tremendous resistance from physicians over the years. He attributes this to medicine’s general squeamishness about all things Freudian, its fascination with laboratory tests—there is no “assay” for repressed rage—and of course, its love of expensive procedures.
A number of younger physicians who trained with Dr. Sarno have integrated the TMS concept into broader practice. David Schechter, a Los Angeles family physician and sports medicine specialist who studied with Dr. Sarno in New York, said primary care physicians typically have the innate psychological attunement to be able to recognize when a pain syndrome has a primarily psychological root. But working with the patient is another matter.
“If you’re sitting there, and your gut feeling tells you there’s something psychological going on, you have to be able to look the patient in the eye and tell them you think it’s got more to do with emotions, psychology and stress than with their anatomy. That’s hard to do, because patients want to be accepted and have their pain validated.”
Dr. Schechter is not as quick as his mentor to dismiss physical findings like disc bulges as irrelevant to back pain syndromes. But he believes the TMS concept is applicable in a large number of these cases. Even if there are frank physical problems, there may also be psychological factors exacerbating them.
“You always have to ask, ‘Where is this pain coming from in this human being?’ Because it is not just a back or a neck. It is a human being, and that’s where the psychosocial complexity comes in,” said Dr. Schechter.
Dr. Sarno has described the TMS model and his treatment strategies in 3 books: Mind Over Back Pain, Healing Back Pain, and The Mindbody Prescription. A lecture, also titled The Mindbody Prescription, outlining the essential features of his approach is available on videotape. All can be ordered from Dr. Sarno’s website: www.healingbackpain.com, or by calling 1-800-263-6939.
