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.
Dr. Sarno sat down with Medscape’s Pippa Wysong to spotlight how he became interested in pain management and outline how he came to structure his precepts for freeing his patients from back pain.
Auszug aus dem Interview mit Medscape
An Expert Interview With Dr. John Sarno, Part I: Back Pain Is a State of Mind
June 07, 2004
Medscape: Can you describe some of the diagnostic features you use? What about the physiology?
Dr. Sarno: Let me tell you very briefly about the physiology. I’ve based my findings on clinical experience and the way patients reacted to conventional treatments, as well as through material from the clinical literature. What is actually causing the pain in these people is not the herniated disc, or some of those other structural things, but a condition of mild oxygen deprivation, which is brought about by the brain simply altering the blood flow to a particular area. This mild oxygen deprivation is what causes pain in muscle.
Take sciatica as an example. There are a number of spinal nerves going into the leg via the sciatic nerve and the brain would mildly oxygen-deprive them. That would then, of course, give you pain in the leg, and give patients feelings of numbness and tingling. It would also produce actual weakness. But doctors have assumed that these changes and symptoms in the leg were the result of some damage to nerves in the low back — as a result of herniated discs and things of that sort.
Medscape: What exactly does the oxygen deprivation do?
Dr. Sarno: It produces symptoms. Oxygen is a crucial substance for normal function. You can’t do without it for more than a few minutes or cells begin to die. When there is even a minimal reduction in the oxygen supply to a tissue, say a muscle, a nerve, or a tendon — those are the 3 tissues that we realized the brain might target in order to produce this disorder.
Medscape: Are you saying that this oxygen deprivation is the underlying cause for all back pain?
Dr. Sarno: The underlying thing in this diagnosis, yes. If it involves a tendon around the knee, for example, the patient will have a painful tendon there. Invariably a magnetic resonance imaging (MRI) study will be done and doctors may find a minor tear of the meniscus, the cartilage, in the knee and say, „That’s where the pain is coming from.“
Invariably there are alternative explanations. For example, shoulder pain is very common now. With MRI studies demonstrating abnormalities of the rotator cuff, immediately doctors and radiologists will say, „That’s causing the pain.“ So, for every area in which people have pain, one can find structural abnormalities of one kind or another.
Dr. Sarno : Now let me tell you something interesting. Having said this, it wouldn’t make any difference if there were a half a dozen other explanations for the pain, as long as it was clear in one’s mind that the brain was doing this. That the brain was producing symptoms — and this is the heart of the matter and this is what’s extremely important — we haven’t gotten into the psychology yet. But the brain was producing symptoms in order to protect the patient from psychological trauma, turmoil, something of that sort. And I came to that conclusion only after many, many years. I wasn’t ready to say that until I published my book, The Mindbody Prescription, in 1998.
Medscape: So we’re shifting from a physical cause to a psychological cause?
Dr. Sarno: What has been clear right from the beginning is that people were responding to stressful situations in their lives. Even more interesting, people were responding to the pressures and the stresses that they put on themselves. I came to realize that people who tend to be perfectionists — that is, hard-working, conscientious, ambitious, success-oriented, driven, and so on — that this type of personality was highly susceptible to TMS.
Later, I realized that there is another kind of self-induced pressure, and that is the need to be a good person. This is the need to please people, to want to be liked, to want to be approved of. This, too, like the pressure to excel or to be a perfectionist, is a pressure and seemed to play a big role in bringing on this disorder.
Medscape: How would you say this all plays a role?
Dr. Sarno: You might say, „What is wrong with trying to be perfect and trying to be nice and good?“ Nothing is wrong in terms of our conscious lives. However, in doing this work I had to become very knowledgeable about the unconscious mind. Sigmund Freud’s work is critical in this regard because he introduced us to the idea of the unconscious. I realized that these self-imposed pressures were causing some difficulty inside our minds. There’s a leftover child in all of us that doesn’t want to be put under pressure, and indeed it can get very, very angry. It began to look as though the primary factor psychologically here was a great deal of internal anger to the point of rage.
Medscape: So this is the crux of your theory, that it has to do with internalized pressure and rage?
Dr. Sarno: Self-imposed pressure is one of the sources. It’s difficult to understand because one has to think in terms of what’s going on in the unconscious mind. There are other kinds of pressures that are equally important, the ones that life puts upon us. Pressures from our jobs, our personal lives, our marriages, our children, and so on. It turns out that these pressures were equally disturbing to this leftover child inside of us.
Then a third category, which is also extremely important, are the angers that might be left over from childhood. These can extend all the way from outright abuse to what I call subtle abuse. Say, parents that expected too much of a child, or parents who didn’t provide enough emotional support.
An Expert Interview With Dr. John Sarno, Part II: Pain Management Prophet or Pariah?
June 14, 2004
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.
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.