Expert Interview -- Dr. John Sarno, Back Pain -- Medscape Orthopaedics & Sports Medicine

Expert Interview From Medscape Orthopaedics & Sports Medicine

An Expert Interview With Dr. John Sarno, Part I: Back Pain Is a State of Mind

Posted 06/07/2004

Editor's Note:

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, 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.

This is the first of a 2-part interview.

Medscape: I think our readers would be interested in starting off with how you first became interested in back pain. What triggered your interest?

Dr. Sarno: I became interested in back pain when I came to the Rusk Institute here at the New York University Medical Center as head of the outpatient department. I was exposed for the first time in my medical career to large numbers of people with back pain. To make a long story short, after a few years of making the conventional diagnosis and administering the conventional treatments, I came to the conclusion that there was something terribly wrong, because my results were as poor as everybody else's. I found this frustrating and decided I'd better take a closer look at this and really question the diagnosis.

Medscape: In your opinion, what was wrong with the diagnoses of back pain? What did you find?

Dr. Sarno: When I started to look into it, I found that large numbers of people in whom the pain was being attributed to some structural abnormality actually had a totally different disorder. It was a disorder in which the pain was very real, but it was initiated by emotional factors.

Medscape: Emotional factors such as...?

Dr. Sarno : It primarily had to do with the stresses in patients' lives and, interestingly enough, the stresses that they put on themselves. Once I began to make this diagnosis and to deal with it accordingly, for the first time I began to have success. And of course that's why I started to write books about this. But here in the United States virtually no one in the medical profession is willing to consider this diagnosis. That's, incidentally, very, very important. I do not have an approach to dealing with pain but rather the stresses that cause it.

Medscape: Are the stresses that lead to back pain, as you say, very common?

Dr. Sarno: It is more than back pain. What we can refer to as stress-related disorders have turned out to be more widespread: It's low back, upper back and neck; it's pain involving the knees, pain involving the feet. From what I understand from an article in the New York Times, there were 10 million people in the United States with foot pain, which is an epidemic. And all of these pain syndromes have spread in epidemic fashion in the United States over the last 30 years -- precisely because they are mind/body disorders that have been incorrectly diagnosed, and therefore, as far as I'm concerned, incorrectly treated. I want to make that clear: The major factor is not what treatment one employs but what diagnosis one makes.

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.

Medscape: According to your theory, structural abnormalities don't even contribute to the condition.

Dr. Sarno: In my experience they have nothing to do with the problem in many cases. I can't say in 100% of instances, but in many, many cases I've concluded that they have nothing to do with the problem. Of course, my proof is that my patients get better. They couldn't possibly have gotten better if the pain were due to the structural abnormality.

Medscape: If there is a structural abnormality, doesn't it need attention?

Dr. Sarno: No, no, no, no, no, that's the whole point. From what I've been able to gather, you see there's so much material in my books and really we're trying to capsulize this now.

Here's an example: There was a paper published in 1994 by a doctor and her colleagues in the New England Journal of Medicine . They performed MRIs on about 98 people who had no history of back pain. The researchers found normal discs in only 36% of the people. Everyone else had bulges, herniations of various kinds, and so on, and yet no pain. That's the kind of information that doctors in this country totally ignore.

Medscape: Who was the lead author of that study?

Dr. Sarno: Maureen Jensen. This and other studies are referenced in my books.

Medscape: Do you have a name for this oxygen-deprivation disorder?

Dr. Sarno: Yes. Incidentally, it's a name that's become somewhat obsolete, but, since I've used it in 3 books I continue to use it -- tension myositis syndrome (TMS). It's called a syndrome because it has so many different manifestations. In the late 1980s, I realized that nerve involvement was also part of the syndrome and then later, tendons, too. In fact, I now believe that nerve involvement is much more important in the syndrome than muscle involvement.

Medscape: Can we back up and see how you came to the idea that oxygen deprivation was behind all of this?

Dr. Sarno: First of all, there are some papers that suggest that. Clinically it was because I had observed, when I was doing conventional treatment in prescribing physical therapy, that the things that seemed to relieve the pain temporarily, but pretty definitely, included deep heat in the form of ultrasound, deep massage, and active exercise. All 3 of these increase the local circulation. I said to myself, "That probably is what the brain is doing to produce the pain; it is reducing the blood flow."

Medscape: Do you have physiological studies or cellular samples to show what's going on, as proof?

Dr. Sarno: The studies that were done to demonstrate this were done by a rheumatologist on fibromyalgia. In my experience, fibromyalgia is nothing more than a severe form of TMS. Rheumatologists got interested in fibromyalgia in the 1980s and did studies. One group in Sweden did 2 studies that made it very clear that mild oxygen deprivation was the reason for the pain in the muscles in people with fibromyalgia. This supported what I had concluded on clinical grounds.

Medscape: Can you elaborate?

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

Medscape: These all contribute to pain?

Dr. Sarno: Things of this sort could contribute to a reservoir of rage that I believe we all carry around inside of us. This is part of the human condition in Western society. It's because we're all under such pressure, and so many of us are conscientious and hardworking.

Medscape: So you're saying it's a psychological problem?

Dr. Sarno : It turns out that the rage is the primary difficulty.

Medscape: This is a very different approach from other back-pain professionals.

Dr. Sarno: Yes, it is.

Next...Part 2 of Medscape's interview with Dr. John Sarno, and a report from the front lines concerning the back-pain management controversy.

An Expert Interview With Dr. John Sarno, Part II: Pain Management Pioneer

Editor's Note:

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.

This phenomenon, which is known as tension myositis syndrome (TMS), may also be the culprit in other pain disorders.

In Part II of his interview with Medscape, Dr. Sarno expands on the mind-body pain connection and highlights in further detail his concepts of back pain diagnosis, the role of emotion in triggering symptoms of pain, and the controversy his pain management concept has fostered in the medical community.

Medscape: You said that there is internal rage and anger in the brain, and that these are responsible for symptoms of back pain, not structural defects.

Dr. Sarno: It becomes clear why the brain produces these symptoms: They are intended to be a distraction to make sure your internal rage does not come out. The unconscious has been described by some writers as a kind of "maximum-security prison" where the brain keeps undesirable feelings or dangerous feelings repressed.

One reason why I've concluded that we all have rage inside of us is because there are other "equivalent" physical states that seem to be serving the same psychological purpose -- conditions that are analogous to back pain. I'm referring to [gastroesophageal] reflux, which is very common; irritable bowel syndrome; headaches; common allergies; hayfever; and asthma. I'm referring to common skin disorders like eczema and others. The skin is a great area that the brain uses to create symptoms. These conditions all serve the same purpose: to keep one's attention focused on one's body.

This is important in medicine. It's all so universal, and it's important to make the right diagnosis. If you make the wrong diagnosis, if you attribute the pain to something structural, or if you say, "The reflux is due to your stomach acting up and you have to take this drug or that drug," then people will continue to have symptoms. This is why the back pain problem is of epidemic proportions in the United States.

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.

Most patients in the United States cannot accept this diagnosis. So I calculate that I'm working with representatives of perhaps 10% or 15% of the population. Secondly, 99.999% of the medical profession does not accept this diagnosis.

Medscape: Do you get much flak from the medical community?

Dr. Sarno: No, I don't get any flak because there's no occasion for it. Although I do expect to get some flak soon. I've been invited to give a lecture at the 2004 North American Spine Society meeting in October, and that's going to be fun. I've never addressed such a group. I'm going to be telling them about my experience with this disorder. At any rate, I don't get flak; I just get ignored.

Medscape: I guess getting ignored is easier than getting flak?

Dr. Sarno: Easier in one sense, harder in another, because I've always wanted the approval of my peers and I haven't gotten it. Except I've heard from 1 or 2 people in the United States who are very well known in their work in trying to bring objective standards to this whole pain problem, and I have had some approval from them. So that's been very helpful.

Even the majority of psychiatrists don't accept this diagnosis either. Many of the so-called biological psychiatrists believe that these psychological things are the result of chemical changes and they're in the business of treating the chemistry. A lot of people in psychiatry have repudiated Freud and repudiated the idea of unconscious phenomena.

Medscape: Isn't it possible that physical stresses or nerve or tendon damage play a role? Say you sleep in the "wrong" position and your neck is sore the next morning.

Dr. Sarno: No. I'll tell you how that works. The brain will often use some physical incident as a good excuse, a good opportunity, to introduce or start the TMS. But I've had no evidence whatsoever over the years that there are truly physical things that are going on here that the brain is using. It's just that it will introduce the symptoms and, of course, the brain is very tricky that way. The brain is very concerned about these repressed emotions, and very concerned that they not come out. It will act in a very slippery way and introduce symptoms. One of the examples is whiplash.

Medscape: That's a common problem.

Dr. Sarno: Whiplash is usually the result of you being hit from behind in an automobile accident. One of the papers from the medical literature that I reproduced in my latest book was absolutely fascinating in this regard. It was published in the New York Times , where they reported on findings from Norway.

This was a good many years ago now, but Norway at that time was having an epidemic of whiplash. Now, Norway has probably one of the most generous insurance programs in the world. But doctors in Norway were dumbfounded. They couldn't understand why they had so many people in Norway on disability because of whiplash. They wondered if perhaps a generous medical system might have something to do with it. So, they went to Lithuania and did a controlled study there. They got the names of 212 patients in Lithuania who were involved in rear-end collisions and they went out and found 212 controls, and they found that whiplash did not exist in Lithuania. In Norway -- epidemic; in Lithuania -- zero.

They said, "Wow. This is incredible, it must have something to do with social things." Well, of course, it doesn't. Clearly the patients with whiplash were having TMS. And mind/body disorders like TMS will spread in epidemic fashion if they are not correctly diagnosed.

Medscape: But what if imaging, say from a magnetic resonance imaging (MRI) study, depicts a damaged tendon or muscle?

Dr. Sarno: This is my experience -- what the MRI studies show in these people has nothing to do with the symptoms. And I have proven this concept.

Medscape: By "symptoms," you mean pain?

Dr. Sarno: Yes. The pain and the stiffness, there are dozens and dozens of [symptoms]. The ones that are the most frightening are the nerve symptoms -- pain, numbness, tingling, weakness. All of those things are scary. If a patient has them and a doctor finds a structural abnormality, he says he needs surgery. Very simple.

In my experience, and we've demonstrated this by getting these people better, they wouldn't get better if the structural abnormality were responsible for their symptoms. They would get better by being educated, which is what I do.

If you ask, "Why do I think the education makes people better?", I've given an enormous amount of thought to this. There was a contemporary of Freud, Alfred Adler, who observed some of the same things that I've observed, but over 100 years ago. Adler said to teach people. I think we're reorganizing what's going on in the brain and the brain is no longer as afraid of the rage as it was before. Adler used the same term -- rage. I think that's what happens. When I teach people what this is all about, what's going on physically, and what's going on psychologically, I think the rage is no longer as threatening as it was before, and so they don't need to have symptoms.

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.

Medscape: Have you ever had back pain?

Dr. Sarno: Of course. Not only that, but I've had a half dozen of the equivalents as well. I think it was one of the reasons why it was so obvious to me once I allowed myself to think about this. But because I know what it is, it has never disabled me. And that's the secret -- knowledge, knowledge, knowledge. That's the cure here. Knowledge is the penicillin.

Medscape: And the brain is a powerful thing?

Dr. Sarno: You bet! One should never, never forget that fact.

Disclosure: Pippa Wysong has no significant financial interests or relationships to disclose.
Disclosure: John Sarno, MD, has no significant financial interests or relationships to disclose.