Howard Stern described John E. Sarno as a living saint. Stern suffered from intense back pain from years, and the only man who was able to cure him was Sarno. Other celebrities and even a U.S. politician lauded his genius. So what did he discover that was so profound? Essentially, he figured out that many (but not all) pain can be attributed to emotional pain.
In other words, many pain disorders do not have a physical source, but a mental one. Specifically, it was the unconscious that deprived certain parts of the body from oxygen to induce a pain response. But unlike Freud, who thought that the unconscious was a destructive force, Sarno thought that the unconscious was protective.
Pain was how the unconscious took the mind off of the emotional disturbances of life. It was a distraction with a benign motive. But the effects could be crippling. The cure was to acknowledge the emotional sources of pain. And if one could not do so on their own, they should consult a therapist.
Highlights
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.
Nevertheless, despite the absence of proof that the abnormalities are the cause of the pain, the medical profession routinely treats those with surgery—in many cases, exorbitantly expensive surgery—as will be detailed.
A paper published in The New England Journal of Medicine in 1993 entitled “Neuroendocrine-Immune Interactions” concluded with this statement: “Central nervous system influences on the immune system are well documented and provide a mechanism by which emotional states could influence the course of diseases involving immune function.
Whether emotional factors can influence the course of autoimmune disease, cancer and infections in humans is a subject of intense research that has not been satisfactorily resolved at this time.”
The peptide network explains the physical part of the psychosomatic process, but it also explains the placebo effect, namely, how blind faith can lead to the amelioration of symptoms.
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It has been stated already that the placebo effect may be dangerous because of the symptom imperative, but treating the symptom rather than the cause is poor medicine in any event because it is almost invariably temporary, whether or not it leads to a substitute symptom. 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.
Experience suggests that in the United States only 10 to 20 percent of people with a psychosomatic disorder are able to accept the fact that their symptoms are emotional in origin. Many are downright hostile to the idea. Though there are large numbers who seek psychotherapy or psychoanalysis, they represent only a small portion of the entire population. For the majority there is a stigma attached to disorders relating to psychology. Negative words like weird, crazy, kooky, and nuts come to mind. Psychologists and psychiatrists are head shrinkers or “shrinks.” “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.
An article in the May 2004 issue of Natural History illustrates beautifully the limitations of laboratory findings. The author, Robert M. Sapolsky, a professor of biological sciences and neurology, reported on what he identified as a landmark paper published in the journal Science. The investigators followed a population of over a thousand New Zealand children into young adulthood, identifying the incidence of depression, and noting that a proportion of the group being studied also possessed a serotonin-regulating gene known as 5-HTT.
The role of serotonin in depression is well known due to widely used drugs like Prozac. The investigators correlated the incidence of two variants of the 5-HTT gene and depression and found that inheriting the genes only increased the risk of depression in people. The “bad” gene did not produce depression in those who had not suffered major stresses. The author noted, “We all have a responsibility to create environments that interact benignly with our genes.”Another aspect of this problem was enunciated by Stephen
Stephen J. Gould, who wrote in Natural History, “An unfortunate but regrettable common stereotype about science divides the profession into two domains of different status. We have, on the one hand, the ‘hard’ or physical sciences that deal in numerical precision, prediction and experimentation. On the other hand, ‘soft’ sciences that treat the complex objects of history in all their richness must trade these virtues for ‘mere’ description without firm numbers in a confusing world where, at best, we can hope to explain what we cannot predict. The history of life embodies all the messiness of this second, and undervalued, style of science.”
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.
Freud’s view at the time was that the process was “organic”—that is, originating in the body, not the mind—because of the physical findings on examination. 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. I think he would have discovered the truth had he continued to study physical manifestations, but he turned his attention to the neuroses and had very little to say about physical symptoms as his career developed.
Psychosomatic medicine is a ghost, a set of ideas without a body. No one has ever really practiced psychosomatic medicine because its definition and scope have never been clearly established. 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.
Freud’s friend Josef Breuer was the father of psychoanalysis. His famous clinical experience with “Anna O” from 1880 to 1882 has been described by Peter Gay (1988), in his biography of Freud, as “the founding case of psychoanalysis.” When Freud returned to Vienna in 1886, having made the fateful decision to shift from neurology to psychology, he began to work closely with Breuer and to treat patients with hysteria. One of the results of this collaboration was the publication in 1895 of their book, Studies on Hysteria. Their friendship continued for years, with Freud the benefactor of professional, emotional, and even financial support from his older colleague.
But the friendship later foundered on the rocks of conceptual differences.
In Freud’s day, the treatment of hysterical symptoms included what he termed aesthesiogenic methods, such as electricity, the application of metals (such as copper bracelets), and the employment of skin irritants or magnets. For modern readers who might be tempted to adopt a condescending attitude toward such late-nineteenth-century medical technology, it should be noted that present day medicine has its own electrical treatments, including transcutaneous electric nerve stimulation (TENS). And copper bracelets and magnets are the rage with many back pain sufferers.
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.
Their misperceptions aside, Breuer and Freud made fundamental, far-reaching contributions to an understanding of psychogenic phenomena:
• They were aware of the unconscious and explored its nature, thus establishing the idea of the split mind and of the conflict that exists between the more intelligent, ethical, moral conscious mind and the childish, primitive unconscious mind.
• They recognized that hysterical symptoms were generated entirely in the brain without physiological alterations in the body, though they were experienced in the body.
• They first described what I call the symptom imperative, the tendency for symptoms to shift to other locations when they have been relieved legitimately or factitiously, as with a placebo.
• They were aware of the excessive nature of psychogenic physical symptoms.
They observed the clinical phenomenon whereby the psyche will often choose the site of previous physical injury as the locus for symptoms.
• They reported the fact that a patient might have more than one set of psychogenic symptoms simultaneously (e.g., hysterical pain and neurasthenia).
• They made the very important observation that psychogenic symptoms achieve their purpose by powerfully engaging the person’s attention.
• Of even greater significance in understanding psychogenic physical processes, they realized that the psyche represses undesirable emotions. Unfortunately, they were not aware that the purpose of repression was to prevent problematic emotions from coming to consciousness.
• Along with Charcot, they were the first to recognize that pain could be psychogenic. They missed by a hair that it could be psychosomatic psychogenic.
Freud and Adler
Virtually all of contemporary medicine, including most of psychiatry, denies that the brain has the capacity to initiate physical, chemical, or neural changes in the body.
But Adler, Walters, Alexander, and some of their contemporaries in the first half of the twentieth century were fully convinced that brain had this power. That concept is essential to understanding psychosomatic disorders.
According to Adler, the neurotic is motivated entirely by self-interest, having no “goal based on interest in reality, on interest in others, and on interest in cooperation.”
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
Freud’s monumental accomplishments have undergone a good deal of revisionist nitpicking in recent years, but I heartily endorse Jared Diamond’s judgment in the February 2001 issue of Natural History: “Only two scientists within the last two centuries clearly qualify as irreplaceable: Charles Darwin and Sigmund Freud.
To support his claim, Diamond goes on, “To begin with, Darwin and Freud were both multifaceted geniuses with many talents in common. Both were great observers, attuned to perceiving in familiar phenomena a significance that had escaped almost everyone else. Searching with insatiable curiosity for underlying explanations, both did far more than discover new facts or solve circumscribed problems, such as the structure of DNA; they synthesized knowledge from a wide range of fields and created new conceptual frameworks, large parts of which are still accepted today.”
What is quite remarkable is that most modern humans are largely unaware of this other self that exists in each of us and of the impact it has on every aspect of our lives. It is not generally realized that intelligence is not everything, that an intellectual genius may be an emotional baby or a monster. There is no correlation between intelligence and emotional maturity or balance. A case in point is the terrorist activity that dominates so much of the news media these days. Terrorists must be very intelligent to achieve what they do, but they are governed by powerful emotional drives that are neither rational nor humanitarian.
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.”
This mental dichotomy is responsible not only for the common pain disorder I have described in my books, but also a host of other medical disorders initiated by similar psychic processes (gastroesophageal reflux, irritable bowel syndrome, etc.). It is the basis for public health problems of enormous magnitude, but these matters appear to be completely ignored by contemporary medicine.
Freud based his concepts of the id on a study of his patients’ dreams and an exploration of their neuroses. He saw it as having a dark, chaotic character, illogical, irrational, narcissistic, dependent, childish, primitive, and capable of simultaneously contradictory impulses. Of particular importance is the fact that it is timeless. “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. . . .”
Freud observes this very thing: “We must rather attribute [to] the repressed [ideas] a strong upward drive, an impulsion to break through into consciousness.” The unconscious mind, it would seem, wants to join the conscious mind.
Financial problems and illnesses are obvious examples of life pressures and need no further explanation. They are consciously disturbing and unconsciously enraging. But what about getting old and dying? We tend to rationalize. After all, dying is part of life, it’s inevitable, and one must accept it with good grace. But it is a very different story with the child-primitive in the unconscious.
That narcissistic part of our emotional makeup is in a rage at the idea of having to put up with illness, perhaps disability, and the ultimate insult to the individual—death. These feelings, though unconscious, are as real as the ones of which we are conscious. With some of my patients the reaction to aging is the only reason for their symptoms. They may be consciously aware of their fear of aging and death but not of their unconscious reactions, and these are the ones that bring on symptoms.
Placebo
Pain clinics treat pain, sometimes relieving the pain thanks to a placebo reaction (cure through blind faith), but in most cases the pain returns, and so the pain epidemics continue.
Surgeons believe they are treating the cause when they perform surgery for herniated discs, spinal stenosis, malalignments, and the like; but since these abnormalities are usually not the cause of the pain, surgery will either fail or the patient may have a placebo cure. This possible surgical outcome was described in the medical literature by a Harvard professor forty-four years ago. Surgery is a powerful placebo.
Placebo cures (surgical or nonsurgical) are poor medicine because they do not treat the cause. If the results were permanent, we could live with that, but they are not. 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. It means that you must eliminate a symptom by treating the cause, or the brain will simply find another symptom.
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.