A Skeptical Look at the Theories of Dr. John Sarno

Illustration of the pain pathway in René Desca...

Did your repressed rage light this fire?

I have recently noticed several comments on the blogosphere which compare the ideas of Dr. John Sarno to some new pain science concepts that I discussed here. While there may be some superficial similarities, there are some very important differences that I would like to clarify in this post.

First, Sarno’s theories are generally considered to be untested and speculative, and are looked upon with significant skepticism by mainstream science. Sarno himself admitted that his theory is not accepted by 99.99% of the medical community. (But Andrew Weil, Mehmet Oz and Howard Stern are fans!) By contrast, the basics of pain science that I discussed in previous posts are very well accepted (despite being generally ignored), and are supported by a great amount of research and solid theory by many leading neuroscientists.

While this does not prove that Sarno is wrong about anything, it at least demonstrates that his theories are quite different from the pain science principles I have outlined in various posts on this blog. So let’s review his major claims and compare them to some of the basics of modern theories on pain.

Sarno’s controversial theory – tension myositis syndrome

Sarno’s theory is that a great deal of chronic pain, including most back pain, is caused by a condition he calls Tension Myositis Syndrome or TMS. The basic idea is that TMS is initiated in the brain, not the body, as a result of the brain’s psychological need to repress deep emotional issues such as anger. According to Sarno, the brain creates pain as a “distraction” to avoid dealing with troubling emotions. The brain does this by using the autonomic nervous system to restrict blood flow to certain tissues of the body, resulting in hypoxia and then pain.

Sarno treats patients by convincing them that their anger or rage or whatever emotion being repressed is the true cause of their pain and that there is no actual damage to the body parts that hurt. Patients are encouraged to return to normal activity, cease physical therapy and possibly undergo psychological therapy. According to Sarno, once the client recognizes the symptoms for what they really are, they go away.

Modern pain science – the neuromatrix theory of pain

Now let’s compare Sarno’s theory to the core claims of pain science. Modern theories of pain are well exemplified by what is now called the neuromatrix theory of pain, based on the work of Ronald Melzack and Patrick Wall, and more recently articulated in some excellent research, articles, and books by Lorimer Moseley.

The neuromatrix theory embodies a fundamental paradigm shift from the way scientists viewed pain for hundreds of years. Beginning with René Descartes, pain was considered to be the simple consequence of the brain reading pain signals (called nociception) from the body. Under the Cartesian view, pain is an input from the body which the brain perceives passively like a paper receiving ink. Based on this idea, we would expect to see a simple one to one relationship between tissue damage and pain.

But that is not what we see. Scientists have extensively documented a huge variety of circumstances under which there is little or no correlation between tissue damage, nociceptive signaling, and pain. For example, some people suffer extreme pain with no tissue damage at all, as in the case of phantom limb pain. Some people are temporarily pain free after suffering very severe injuries in an emergency situation. Many people without back pain show herniated discs or other spinal abnormalities on MRIs. These results help prove that physical harm is neither necessary nor sufficient to cause pain.

The neuromatrix theory explains the disconnect between physical harm and pain by viewing pain as an output of the brain, not a preformed input from the body. When a body part is damaged, nerve endings send a nociceptive signal to the brain containing information about the nature of the damage. But no pain is felt until the brain interprets this information and decides that pain would be a good way to encourage action that will help protect and heal the damage. The brain considers a huge amount of factors aside from just the damage signals in making this decision, and no two brains will decide the same thing. Many different parts of the brain help process the pain response, including areas that govern emotions and past memories. The “neuromatrix” is simply the combination of brain areas that produce pain when activated. Given the complexity of the matrix and the many parts of the nervous system forming it, the processing of harm signals from the body can be upregulated, inhibited, interpreted, and misinterpreted in a stunningly wide variety of complex and interactive ways.

The neuromatrix theory explains a wide variety of previously unexplainable evidence related to pain, such as why placebos work, why someone can experience pain with no tissue damage, why someone can have significant tissue damage without pain, and why pain can be significantly affected by non-nociceptive sensory information, thoughts, memories, emotions, and social interactions.

TMS vs. the Neuromatrix

Now let’s compare the neuromatrix theory to Sarno’s theory to compare similarities and differences.

First, Sarno is correct that chronic pain often results more from processes in the brain than from any significant tissue damage in the body. He is also correct that emotions such as anger or stress can be major contributors to pain. In fact, studies have shown that job satisfaction is an excellent predictor of back pain, and that MRI results showing herniated discs or torn rotator cuffs are nowhere near as predictive of pain as you might imagine.

Despite the support that the neuromatrix theory gives to some aspects of Sarno’s claims, he does not cite to it in his writing. This should raise concern because he has written three books on pain without citing to current pain science. (I will admit that I only read the most recent book and just browsed the others.) Sarno instead spends a great deal of time discussing Freud, the ego, the superego, and other archaic metaphorical concepts.

I would guess that the reason Sarno ignored the science relevant to his theories is that it directly contradicts them in a fundamental way, which is this. The neuromatrix theory proposes that the purpose of pain is to encourage you to take action to prevent or heal harm to the body. TMS proposes that the purpose of chronic pain is not to protect the body, but to repress emotion. To accomplish this goal, the brain harms the body by inducing hypoxia – on purpose! Here we have two polar opposite explanations of the brain’s intentions in relation to chronic pain – one is that pain is intended to protect the body, the other that pain is the result of the brain’s attempt to harm the body. Sarno’s view seems completely counterintuitive and raises several questions.

First, why is it necessary to create pain in order to repress emotion? Surely there are more effective ways to distract us from uncomfortable emotions than pain, such as compartmentalization, denial, projection, obsession, neuroses, work, etc. Why does pain help repress emotion better than these mechanisms?

Second, even if pain is a good way to repress emotion, is it really worth the price? Why is repressing emotion so important that we need to create disabling pain to do it? It is hard to imagine how such a function could have evolved. Why would natural selection create people who feel back pain when they have repressed rage?

If the mental mechanisms causing TMS actually exist, they presumably evolved recently, because only highly social animals such as humans would have any conceivable need to repress emotions. I can imagine that the ability to repress anger would be useful to get along harmoniously with other tribe members. But why would back pain be the best way to go about repressing the anger? Back pain makes you irritable, disagreeable and unable to perform useful work – these are hardly qualities that will assist you in getting along with members of your tribe. From the evolutionary perspective, it is very hard to imagine that the brain was designed by natural selection to harm the body as a way to repress emotion. (But as a way to get attention or empathy? Maybe.)

Third, even assuming the brain would have some good reason to create pain in order to repress an emotion, why would damaging the body through hypoxia be the chosen mechanism? Pain science tell us that the brain is perfectly capable of creating pain without any nociceptive signaling from the body. Accordingly, it would be theoretically unnecessary for the brain to damage the body in order to cause pain. Damaging the body to cause pain is a circuitous, inefficient and costly path to accomplish a goal that seems pointless and counterproductive.

In sum, Sarno is correct that the brain and emotional stress play a big role in chronic pain, but his proposed mechanism for how this relationship works appears implausible and inconsistent with what we know about pain science. In the next post I’ll discuss whether there is any evidence that Sarno’s therapy is effective, and argue that any potential benefits from his therapy are much better explained by the neuromatrix theory than tension myositis syndrome.

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27 Responses to “A Skeptical Look at the Theories of Dr. John Sarno”

  1. Great post. I have read all of Sarno’s books many times, and while I don’t agree with all of his Freud-based beliefs, I do agree with some of his theory. One of his weaknesses is, he goes to great lengths of the how and why, but very little “treatment” other than his “knowledge cure.” He refers resistant cases to psychotherapy. In regards to the evolution aspect, the person that repressed their rage would probably be more “evolved” i.e the person with a highly developed cortex that acts considerate, and socially correct in the modern world, and doesn’t go around expressing their anger and “socially uncacceptable emotions” verbally and physically would have to according to Sarno repress the anger. In fact it is because we have evolved to inhibit/override our baser primitive instincts the repressed urges get “stuck” in the nervous system. And it more socially acceptable to have the disease of the day (back pain currently, ulcers in the 50’s, depression in the 90’s, etc) than to say “I’m mad at my boss.” Two of Sarno’s key ideas are the “symptom imperative” in which the repressed emotions will inevitably come out physically somehow, “if it’s not one thing, its another,” and “equivalency” in which the ANS will “choose” pain vs. OCD, vs. other mind body ailments such as high blood pressure. I.e. the chronic pain IS OCD. The pain is the “drug of choice.” The mind will supposedly choose something that has been “learned”, i.e CNS pathways that have been sensitized, weather that is to the GI system, certain regions of the body (Peter Levine refers to a painful body part as one that has been dissociated, ie. the brain has remapped to dissociate the region-dissocation being physcially local ischemia or mild hypoxia-same thing). And the hypoxia is thought to be mild and temporary, not permanent or destructive. Also when faced between yelling at the boss and getting fired and having a ruined career (unevolved person), the lesser of two evils may be to “choose” subconciously the back pain, or the headache or the OCD or the vocal dystonia or whatever the reflexive “go-to” mind body syndrome is stored in the circuitry of the individual’s insular cortex. A better “treatment” book that takes the “best” of Sarno’s hypotheses and uses evidence based ideas is “Unlearn Your Pain” by Dr. Howard Schubiner, MD. He focuses on “learned (sensitized)” neural pathways-the amygdyla, ANS, etc, and the importance of activating the DLPFC.

    • Thanks for the comments Amy, very interesting. I definitely believe that there is significant adaptive value in repressing anger but don’t think that pain is a good way to get that done. I also believe that stress can cause pain, but not that it causes you to choose it. I could imagine that the brain would choose pain to get attention or sympathy, but not as way to repress emotion.

  2. Excellent rebuttal of some of the more problematic aspects of Sarno’s work. There are other reasons for avoiding the treatment that Sarno deduces should be carried out and that is the lack of evidence to support catharsis as a treatment for so-called ‘repressed’ emotions. In fact, there is good evidence to suggest that expressing emotions such as anger, particularly through cathartic means, serves only to exacerbate the experience of distress.
    What seems to be a more helpful approach to both emotion regulation and pain is to recognise the thoughts that occur, test their validity and helpfulness, and manage behaviour in such a way as to honour what is important. This is at the heart of the CBT approach to pain management, and the newer wave of therapies such as Acceptance and Commitment Therapy.

    • Thanks Adiemusfree,

      Interesting ideas about catharsis, I think I have heard similar things from my wife – she is a psychotherapist. Since Freud, people tend to think of repressed emotions as like a pressure cooker – some day it will burst if you don’t blow off steam. But it ain’t a pressure cooker. What’s a better analogy? Maybe a bad habit?

  3. I spent six weeks working in Sarno’s department in New York in ’73, right out of school. I remember being totally unimpressed, and I knew absolutely nothing. His theory leaves a great deal to be desired, as you have wonderfully pointed out – but his publicist is a genius.

    Don’t forget that Regis Philbin is also a big fan.

  4. Great article! (Though I’d dispute your social-means-late assumption about evolution. Mammals have been highly social since before they were mammals.)

  5. The reality of all this is that Sarno was on to something that was important clinically and was completely different than the clinical models he was supposed to work with. .Imagine being an atheist in the vatican!It is obvious that like many Dr’s he was not a scientist. In my experience the hurdle is to convince yourself/others that the model of pain/damage is not the way it works, nor is our concept of how we work as an ego or personality intuitive to us. Despite all the great scientific “break throughs” we havent really improved on the bhuddas “aggregate” approach to creation of the self and suffering.The problems presented here are, if we throw Sarno under the bus we run the risk reinforcing the damage/pain model to many people,and if we push Sarno’s model on people, we run the risk of well read and thought out people with some current science in them ,to ignore a very valid approach to many current muscoleskeletal problems that individuals and society are dealing with.I would very much like to see more discussion of current treatment techniques that are standing on Sarno’s shoulder.
    Rod
    ps-I really enjoy your posts and approach to things.You aren’t shying away from trying to grab smoke!

    • Rod,

      Thanks for the comments. Yes Sarno is in some ways a step in the right direction and I don’t want to throw him under the bus. Interesting you should mention atheists in the vatican because I am just finishing up a post inspired by this one which will apply Dan Dennett’s ideas about “deepities” to the phrase “mind/body connection.”

  6. This is a great post Todd. You have done a good job of both describing the neuromatrix model and the shortcomings of Sarno’s. I am only somewhat familiar with Sarno having not been able to get through any one of his books cover to cover. There is something really annoying about his theory and the broad generalizations he makes about people with back pain, actually I find it rather insulting. Not to mention he seems to find no reason for any kind of physical therapy, or any other approach like Feldenkrais. By the way, if you read or re-read the Potent Self by Feldenkrais, there is a good deal of writing about what he sees as the short comings of the Freudian/Reichian model of catharsis and this idea of having to express anger as if it were steam built up in the pressure cooker. Thanks for all the great posts!

  7. Todd,

    Tomorrow’s blog post in Range of Motion at SomaSomple.com is about this thread.

  8. Todd,
    Another great post. Thanks.
    I know several people who suffered with long term back pain, who were in the “pain results from tissue damage” school, whose pain subsided after reading Sarno. They were all *extremely* skeptical before reading the book, and only did so to placate friends. Also, they all dismissed the Freud stuff. Maybe, for them, Sarno was right for the wrong reasons.
    –Jim

  9. hello Todd,
    thank you for your very interesting post. Every post makes me think. I know that negative emotions can afflict pain and anger especially. Anger activates some regions of the brain like anterior cingulate cortex, amygdale and brainstem involved in Neuromatrix(Damasio et al.2000)and also reduces endogenous opiod activity (Bruhel et al. 2002,2003).
    I don’t know if repressed anger is more important than showed anger but I think that Dr Sarno has broken tradinonal approach to many body disorders. I don’t agree with Dr Sarno on some aspects, I don’t think that no treatment is necessary, I think that an integrated work on learning about pain processes and a refine of the body maps with a CBT approach is the best. We have to understand more and more about brain networks.
    Have everyone a nice sunday

    antonello

  10. I advise to read this book:

    Fabrizio Benedetti, The patient’s brain, the neuroscience behind the doctor-patient relationship, Oxford Univerity press, 2011

    kind regards
    Antonello

  11. In this book there is much food for thought. Please let me know what you think after you read it, I’m really interested in your and others opinion.

    Thank you

    Antonello

  12. Great post!
    working as an manuell therapist for 20 years,mainy chronic pain patients Sarno opened my eyes for the “body-mind” conection 15 years ago.
    Negative emotions(anger,fear,anxiety etc) can be felt as bodily pain ,no dought about that,in my point of view.
    If you dont consider your inner negative thoughts/thinking as potentional rat poison you will not be able to heal your body.
    Your thoughts are connected to your cells in your brain,muscles,skinn etc.
    In my clinical practise i use alot of cognitiv therapy,pain education(Butler,Moseley) ,feldenkrais etc.as an active mental and physical approach ,selfeducation, in order to maintain in balance.

    BUT we have to be awer of that even though the paitent may have lot of “cognitiv fuzz” the patients painproblem might be a mechanical dysfunction.(yes i know that the pain is an output from the brain)

    Sorry about my badly written english

    RIN

  13. I WOULD JUST LIKE TO LET YOU ALL KNOW THAT DR. JOHN SARNO HAS DISCOVERED THE MAGIC BULLET FOR MOST OF TODAYS ILLNESSES, SYMPTOMS, AND SYNDROMES.HOW CAN I BE ABLE TO MAKE SUCH A BOLD STATEMENT? BECAUSE I HAVE HAD MORE OF THESE ILNESSES, SYMPTOMS AND SYNDROMES THAN ANYONE COULD POSSIBLY HAVE HAD. HORRIBLE BACK PAIN, FIBRIMYALGIA, CHRONIC FATIGUE SYNDROME, EPSTEIN BAR SYNDROME,CHRONIC CANDIDIASIS, TMJ, SWOLLEN JOINTS, SWOLLEN LYMPH NOTES, CHRONIC SORE THROAT, MIGAINE HEADACHE, SCIATICA AND THE LIST GOES ON AND ON.I AM CURED OF ALL THESE PROBLEMS AND HAVE BEEN FOR OVER 11 YEARS AFTER APPLYING DR. SARNO’S THEORY. ALL OF THESE CONDITIONS HAVE THE SAME CAUSE AND THE SAME CURE. THIS MAN IS THE GENIUS OF OUR LIFETIMES AND IS THE PIONEER AND FOUNDER OF TMS AND ONE DAY WILL BE RECOGNIZED AS ONE OF THE GREAT DISCOVERERS IN AMERICAN HISTORY. NO I HAVEN’T LOST MY MIND, I’M JUST ESTATIC THAT I WAS LUCKY ENOUGH TO FIND SOMEONE THAT HAS DISCOVERED THE CURE TO MOST OF TODAYS ILLNESSES. AND I’M ONE OF THE BEST EXAMPLES YOU COULD GET WITH OVER 100 SYMPTOMS AND SYNDROMES.I WAS MISERABLE UP TO 11 YEARS AGO. EVERYONE WITH ANY OF THE PROBLEMS I’VE HAD OR ANY KIND OF PROBLEM WHATSOEVER SHOULD NOT ONLY READ HIS BOOKS BUT STUDY THEM AND PRACTICE THE KNOWLEDGE IN THEM. THE PROBLEM IS THAT THE SCIENTIFIC TYPES OUT THERE THAT TRY TO DISPEL HIS THEORY DO NOT HAVE FIRST HAND EXPERIENCE LIKE I DO. ITS EASY TO JUDGE A BOOK BY ITS COVER. ONLY WHEN YOU ARE DESPARATE AND HAVE NO WHERE TO TURN WILL YOU SOMETIMES FIND THE ANSWER. THANK GOD I DID, THE CURE IS OUT THERE JUST WAITING FOR YOU ALL. BACK TO SCIENTIFICALLY SPEAKING IT’S A KNOWN FACT THAT THE SUBCONCIOUS MIND CONTROLS EVERYTHING IN THE BODY, NOT THE CONSCIOUS MIND, RIGHT. AND SINCE THE SUBCONCIOUS MIND CONTROLS EVERYTHING IN THE BODY WE MUST ALL AGREE THAT IT CONTROLS ALL PAIN AND FEELINGS THAT WE HAVE RIGHT. SO IF WE CAN CONTROL AND MAKE THE SUBCONSCIOUS DO WHAT WE TELL IT TO DO LIKE CUT OUT ALL PAIN, SYMPTOMS, SYNDROMES ETC. AND MAKE US HAPPY AGAIN THAN ALL OF THAT WILL GO AWAY-ABSOLUTELY AND POSITIVELY RIGHT!! DR. SARNO’S ONLY FLAW MIGHT BE THAT HE DOES NOT ELABORATE ENOUGH ON HOW TO DEAL WITH AND CONTROL OUR SUBCONSCIOUS MINDS. IT’S REALLY QUITE SIMPLE, JUST PRACTICE 5-10 MINUTES A DAY AND YOU’LL BE CURED OF ALMOST ANY AILMENT! THERE ARE MANY BOOKS ON THE SUBCONSCIOUS MIND, AND I SUGGEST YOU ALL READ AS MUCH AS YOU CAN ON THE SUBJECT AND MOST OF ALL YOU MUST BELIEVE IN THIS WHOLEHEARTEDLY. FINALLY, I KNOW THIS WAS EXTREMELY LONG BUT I’D LIKE TO SAY I OWE MY LIFE TO DR. SARNO. DON’T TAKE MY WORD THAT HE’S THE REAL THING, TRY TO MAKE AN APPOINTMENT TO SEE HIM IN OFFICE IN NEW YORK. BE EXPECTED TO WAIT 3-6 MONTHS FOR YOUR FIRST APPOINTMENT. OH, AND BY THE WAY HE ONLY SEES NEW YORK RESIDENTS. SORRY FOR BEING SO LONG WINDED. THANK YOU.

  14. Hiya

    Interesting post – I think the key thing is

    “In sum, Sarno is correct that the brain and emotional stress play a big role in chronic pain,”

    I have used Sarno’s TMS techniques to cure my RSI – and have met with (and spoken online with) a large number of people who have also had great success using this approach. Now, it is perfectly possible that the mechanism that Sarno proposes is incorrect – certainly things have moved on medically in the 25 years or so since he first wrote The Mindbody Prescription. Nevertheless there is significant evidence that the methods he proposes (mediation, journaling, GET, talking therapies) do have a big impact on chronic pain conditions….

    There is a pretty comprehensive list of abstracts on the subject here (http://tmswiki.wetpaint.com/page/Annotated+Bibliography) which may be of use if you want to look at the medical evidence for the efficacy of the TMS techniques….

  15. Dear Todd,
    thanks very much for this blog. I am a rheumatologist who moved to New Zealand and I am doing a mindbody healthcare integrated paper at AUT. I have started to see these types of symptoms which are very meaningful in my rheumatology practise. I think that some of the problem is that as biomedical physicians we are illiterate in up to date psychological and psychotherapeutic interventions when we do see ‘stories’ behind disease. There are huge problems developing an evidence base – aside from the pain models- when often n=1, no one person has had a life experince like any other. Dr Sarno like all of us thinks his experience of a group of patients ay in American rehab centres tells us about all patients with back pain when it doesnt. This is reductionist thinking. As you have quite rightly pointed out Dr Sarno is often right for the wrong reasons. As I am currently reading around alsorts of new disciplines including neuroscience, phenomenological philosophy, psychotherapy, and dipping into both academic and ‘popular’ self help books about chronic pain I can see that we have all become too specialised to communicate with our patients as whole persons. As if you didnt have enough to read I am recommending another book- Meaningful disease by Dr Brian Broom which attempt to combine these disciplines in a useful way, and is readable. We have started a mindbody trust to help integrate the mind and the body in healthcare in ways other than in chronic pain. We are also doing mixed methods qualitaive research to try and overcome the loss of data when individuals are excluded from research in preference to ‘cohorts’. I also wonder if you would mind writing an article for the Postgraduate Medical Journal (BMJ group) on chronic pain. I am commissioning editor.

    Best wishes
    Dr Karen Lindsay

    • Karen,

      Thanks for the information. Glad you like the blog.

      And thank you for the offer to write an article. I am flattered but can’t imagine what subjects I could discuss with sufficient expertise to merit inclusion in a professional journal. What did you have in mind? My only post graduate degree is legal. Perhaps I could write something on legal liabilities stemming from giving unqualified medical advice?
      If you want a discussion of pain science and the role of emotions and thoughts in regard to pain and the immune system, I would recommend talking to a recognized expert in the field such as Lorimer Moseley. How do Broom’s theories square with what Moseley has to say? At first glance, he seems to fall into some of the same trap as Sarno.

      That being said, I would love to help if I can. Let me know what you have in mind.

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