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From high school until my mid-20s, I was seized with debilitating stomach issues. They steered most decisions I made—could I go to a picnic in Central Park with my friends if there was no bathroom nearby? Could I make it 45 minutes on the subway to have dinner with my dad?
My primary care doctor constantly dismissed me. He told me that my stomach issues were “all in my head.” He said, “This is what happens to girls in their 20s.” At 25, I was not yet 100 pounds and losing weight, when I was finally diagnosed with a panic disorder and put on antidepressants. My stomach problems disappeared. Forever.
So, were my stomach problems in my head? Yes, but they were also in my body, because the two systems are one system—connected, mind-body. It’s simply that traditional doctors, like my primary care physician—and like many doctors then and now—don’t seriously consider the impact our emotions have on our bodies. In fact, anything without a physical source was deemed medically illegitimate. The term used to describe illnesses like mine was pejorative: psychosomatic. If it’s not visible, either on sight, through an examination, or in scans, reporting symptoms just won’t cut it.
When laypeople hear the term “psychosomatic illness” it immediately brings to mind words like “made up” or “imaginary." Many doctors seem to hear “medically illegitimate,” and often, when it relates to women, “hysterical.”
We can thank Hippocrates for this—he was obsessed with women’s wombs, yet his poor understanding of female anatomy had him inventing a medical malady whereby the uterus becomes unattached from its home, left to wander the body landscape indefinitely, like Jews through the desert.
Despite his outlandish claim that the physical symptoms of hysteria resulted from the psychological damage women felt upon realizing they lacked a penis, Freud was the first person to propose that the mind and the body were in conversation, that when we repress a traumatic memory or refuse to face our psychological pain, it can manifest in physical symptoms.
(Not for nothing, Hysteria was a formal diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1980. True story.)
Decades passed before the causal relationships between patients’ intrapsychic conflicts and their physical symptoms were taken seriously. Chronic illnesses were very often misdiagnosed, mistreated, or simply not treated at all. This is a big part of the reason why America finds itself battling a chronic illness epidemic today.
“For all the shortcomings in the concepts proposed by Freud and Breuer in Studies, the 21st century has brought no great advances to a better understanding of the mechanisms for this [psychosomatic] disorder.” —Suzanne O’Sullivan, from Is it all in Your Head?: True Stories of Imaginary Illness
John Sarno was a professor of rehabilitation medicine at New York University Medical School and an attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine at NYU Medical Center until his death in 2017. A well-dressed and cultured man, small in stature at a mere five-foot-three, Dr. Sarno was old-school in taste, but new-school in ideology. Though he found little use for technology, he was way ahead of his time, which made him a natural punching bag for the many in the medical community who were, well, way behind their time. What he discovered over the course of a decade was—to mainstream medicine—controversial, and led to a great deal of mockery. But to the patients he healed, he was nothing short of a savior.
In the decade after he was appointed the director of the Outpatient Department at the Rusk Institute in 1965, Dr. Sarno realized that more than half of his patients complained of chronic back pain. Back pain, he had been taught in medical school, was due to structural abnormalities of the spine, or injury, and he treated his patients in accordance with his education, but often without success. He had been taught that the traditional treatments would lead to predictable outcomes, but this rarely proved true. Most puzzling was the incongruity between the pattern of pain many of his patients experienced and the findings on physical and radiographic examinations. For example, a patient might complain of pain where scans found no structural abnormality, but have zero pain in another area where scans did find structural abnormality.
This led to Sarno’s first controversial insight: structural abnormalities of the spine seemed to rarely cause pain. If they did, he contended, then why, in the history of the human being, did chronic back pain become an epidemic only in the ’60s? Also, doctors then and now insisted that herniated discs were most often to blame for people’s back pain as they aged, but Sarno pointed out that any student of the spine can tell you that the last intervertebral disc is more or less degenerated in most people by age 20. So why wasn’t his office flooded with people in their 20s?
Still, Sarno could not figure out what was causing such chronic back pain in his patients. Years passed, and even patients who got better relapsed into pain. In the early 1970s, he noticed that many of the ones who did get better appeared to trust him more, while those who doubted him and his methods tended not to improve. He began to suspect that back pain was often psychosomatic.
When he took stock of his back-pain patients, Dr. Sarno found that nearly all of them were perfectionists or people-pleasers. They were highly self-critical, and blamed and often punished themselves for “failing” at even the smallest tasks.
The more post-surgical patients Dr. Sarno saw, and the greater the number of incongruities between MRI findings and symptoms his patients reported, the more he started to believe that structural abnormalities were often not responsible for the pain. He floated the view to some of his patients that their pain might be due instead to unaccessed feelings in their unconscious mind. Upon hearing this explanation, many of them reported experiencing immediate relief from their pain. Dr. Sarno came to believe that in order to understand psychosomatic symptoms, he needed to understand the repressed emotions buried in the unconscious mind.
Their symptoms themselves, of course, were not imaginary. Real physical pain is often caused by emotion. Just think about heartbreak, the physicality of grief when someone you love dies, the scarring ache of rejection, the vibrating chest-filled echo of loneliness. If the emotions you can feel cause such acute physical pain, why wouldn’t the trickier hidden emotions of the unconscious?
Because so many of his patients exhibited mind-body symptoms, Dr. Sarno developed a new theory about the origin of their pain, which he called Tension Myositis Syndrome (TMS). Myo means muscle, but as he got to know the syndrome more intimately, he discovered that TMS also involved the nerves, so he updated its name to Tension Myoneural Syndrome. His theory, centered on the role of emotion as the true cause of pain, was met with immediate scorn from his colleagues in the medical establishment because they felt it was unscientific. And the treatment he developed, which was heavily centered on getting to the root of psychological symptoms, was outright ridiculed.
According to the theory of TMS, when the brain gets upset, it activates the sympathetic nervous system, which reduces blood flow to muscles and nerves, causing oxygen deprivation. The consequence of this chain-reaction is physical pain.
Certain pain, Dr. Sarno postulated, was created to prevent us from perceiving negative feelings and emotions that have been stored in our unconscious mind. The brain creates symptoms to distract us; it thinks it’s helping us by protecting us from experiencing these repressed emotions. The brain can develop any symptom, including sore throat, backache, stomachache, headache, allergies, and skin conditions. We all experience one or more of them over the course of our lives. They are not imaginary or hypochondriacal, they’re human nature.
He could find no other way to explain the development of the symptoms of TMS except to see them as deliberate distractions designed to prevent the painful, seemingly dangerous emotions of the unconscious from becoming part of conscious experience.
Dr. Sarno also believed that the states of anxiety and depression, which are perceived by the individual as forms of psychological malaise, are likewise reactions to what is being repressed, created by the ego as a distraction.
Unlike most medical doctors, Dr. Sarno was not simply open to the connection between mind and body, the very concept became the driving force of his practice. He understood, as many psychologists do, that in childhood and throughout a person’s life, one can deposit anger in the unconscious mind. When this anger is not identified or expressed, it accumulates and becomes rage. When the rage reaches a critical mass in the unconscious and threatens to become conscious, the brain creates pain and other physical symptoms as a distraction, to prevent a violent emotional explosion—much as many people use humor to deflect from their sadness.
Among many other things, children need care, warmth, a secure and safe environment, and guidance. When parents neglect basic needs, or are abusive or careless, this wounds the child’s sense of self, leading to low self-esteem and creating emotional needs that persist throughout their life. We yearn for that which we did not get as children and are permanently sad, hurt, and angry as a consequence, but all that is unconscious. It’s what creates psychosomatic symptoms.
Mind-body disorders originate in the interaction of the unconscious and conscious mind. Our unconscious mind lives in the limbic system, which is the oldest brain on the books, often referred to as our reptilian brain. This primordial system is responsible for our moods and judgements. It has no awareness of its traits, caring little for details or nuance, and it has only two channels: pain and pleasure. In other words, it’s feral.
One reason that feelings persist from childhood throughout a person’s life is because the unconscious is timeless. It’s truly the only part of us that is always living “in the now.”
Above our old brain is our new brain. It’s shinier and has more logical features like morality, ease at communicating, patience, thoughtfulness, and consideration. More importantly, the new brain is conscious of all the traits it possesses. This is our neocortex (think of it as Brain 2.0).
The old and new are often in conflict, struggling for dominance. Sometimes old wins out, but not always. Dr. Sarno posited that one reason for psychosomatic disorders is the ongoing struggle between these two parts of the brain.
The brain, however, is a fantastic student, and we can teach it how to help us heal.
When we become attuned to the idea that some pain is psychological, our brain can take a break from protecting us, and our symptoms can ease. In order to help this process along, Dr. Sarno developed a strategy to identify the possible emotions that can lurk in our unconscious.
Set aside time every day, possibly 15 minutes in the morning and 30 minutes in the evening, to review the following material:
Make a list of all the possible emotions lurking in your unconscious that might be contributing to your physical pain.
Write in your journal about each item on your list—the longer the better. This forces you to focus on the important emotions in your life.
There are a number of possible sources of those feelings: Anger, hurt, sadness, and other forms of emotional pain generated during your childhood or throughout your life; physical, sexual or emotional abuse, including not receiving enough emotional support, warmth, or love; excessive discipline or unreasonable expectations.
Certain personality traits can contribute to emotional pain: If you expect a great deal of yourself; if you drive yourself to be perfect, to achieve, to succeed; if you are your own harshest critic; if you have a strong need to please people, to want them to like you, or if you tend to be very helpful to anyone and everyone.
You should put on your list anything in your life that represents pressure or responsibility: your job, your spouse if you are married, your children if you are a parent, your parents if they are living and, of course, any major problems in your life.
Add to your list those situations in which you become consciously angry and annoyed but cannot express it, whatever the reason may be.
Sit down and think about these things every day, in order to bring your ideas from your unconscious mind into your conscious mind. That’s where they have to get to in order for the brain to stop the protective mechanism, and for the symptoms to disappear.
Dr. Sarno’s method closely mirrors an idea common in many schools of psychology that one of the most important things we can do to resolve unresolved trauma is create a coherent narrative. During this process, many people discover that experiences that may not feel dramatic to them as adults were, in fact, quite traumatizing to them as children—and that trauma remains in them, at the register of the age it was experienced.
Before trying this method, I strongly suggest that you read one of Dr. Sarno’s four published books to understand the explanation behind mind-body disorders, in particular, Healing Back Pain and The Divided Mind: An Epidemic of Mind-Body Disorders. It is also very important to discuss this process with your therapist or doctor.
Unresolved trauma can haunt us throughout our lives, often in indirect ways. As adults, we may attempt to forget or gloss over the past. We may think, “My childhood wasn’t that bad,” or “Many people had it worse than I did.” We don’t realize that we bear these old wounds, and events can trigger involuntary reactions in us —like guilt, shame, fear, or anger—deriving from early-life experiences that we haven’t thought about in years.
Attachment research suggests that it isn’t just what happens to us that affects us—we’re also affected by the extent to which we haven’t been able to feel the full pain and make sense of our experiences. When we don’t deal with our trauma, we carry it with us. We haven’t made sense of our story, and therefore, our past is still impacting our present in countless invisible ways. It influences how we parent, how we relate to our partner, how we feel, think, and operate in the world.
Dr. Sarno, who did not train as a researcher, never conducted formal studies of his methods, saying he preferred to spend his time helping people individually. “My proof is that my patients get better,” he often told his doubters. He expressed disappointment that his ideas weren't widely accepted by his peers, and he acknowledged that many had been chilly toward him.
Yet in recent years, some of his ideas have been validated by studies, like his assertion that there is no correlation between chronic back pain and herniated discs, borne out by research published in The New England Journal of Medicine.
And more professionals are starting to come around. In a recent interview with Oprah Winfrey on 60 Minutes, psychiatrist and neuroscientist Bruce Perry talked about the effect adverse childhood events have on us as adults. “If you have developmental trauma, the truth is you’re going to be at risk for almost any kind of physical health, mental health, social health problem that you can think of,” Dr. Perry said.
Despite these developments, though, there is still no psychosomatic medicine being taught to physicians in medical school. This means physicians continue to rely on the old-school principle that physical pain is always related to structural abnormalities.
Whatever poor treatment and disrespect Dr. Sarno experienced from his colleagues and other medical professionals, the mutual affection he shared with his patients is undeniable. He kept a scrapbook of writings and photos from patients and strangers who wrote about their pain before meeting him, and the ways they claimed he had saved them. Hundreds of people have been helped and often cured by Dr. Sarno’s books, treatment plan, and general approach to medicine. They don’t make doctors like him. Perhaps those who mock Dr. Sarno are the ones who need to take his advice most.
Until next week I am...
DR. SARNO'S BOOKS:
DR. SARNO'S POPULARITY LIVES ON...
There's a fantastic documentary called All The Rage by Michael Galinsky and Suki Hawley.
His patients have set up this Thank You Dr. Sarno site.
Dr. Ira Rashbaum on this podcast episode The Brain & Your Pain
SPECIAL THANKS TO:
for talking to me about medical school and psychosomatic medicine.
How to Live is a newsletter about all things psychological. To read more and subscribe, go to amandastern.bulletin.com
If you want to know more about me, you can read my memoir Little Panic: Dispatches from an Anxious Life.