"My life was filled with excruciating back and shoulder pain until I applied Dr. Sarno's principles, and in a matter of weeks my back pain disappeared. I never suffered a single symptom again. . . . I owe Dr. Sarno my life."--Howard Stern

"John Sarno has changed my life and the lives of everyone to whom I have recommended him. He is a true miracle worker."--Anne Bancroft

"Dr. Sarno has had great success in treating TMS simply by explaining to patients the true nature of their pain. I'm convinced that Dr. Sarno is right and that all chronic back pain should be considered TMS until proved otherwise."--Dr. Andrew Weil, author of 8 Weeks to Optimum Health

"For fifteen years, my life revolved around my back. I took time off from work, conducted meetings lying on the floor, and slept with ice bags. Could this be psychogenic? I had considered Dr. Sarno's idea preposterous, but ten years ago I was talked into seeing him. I haven't had back problems since. If Dr. Sarno is right about other psychogenic pain, America is wasting billions of dollars. What a tragedy."--John Stossel, correspondent, 20/20

"Dr. Sarno describes in clearly written and understandable language how emotions influence and cause illness. . . . He has cured thousands with debilitating chronic back pain and now offers curative approaches to other painful conditions. . . . I recommend this book highly."--Benjamin J. Sadock, M.D., Professor and Vice Chairman, Department of Psychiatry, NYU Medical Center

Like a wildly growing cancer, the problem of pain of all kinds has become, since my graduation from medical school, a major epidemic in most of the industrialized countries of the Western world. The diagnosis and treatment of these disorders in the United States is now a gargantuan industry. The back pain problem alone costs the nation upward of seventy billion dollars a year, and if we add all the modern pain epidemics, such as carpal tunnel syndrome, the figure is probably twice that. One does not hear these medical problems described as epidemics, probably because they are not usually life-threatening, nor is the public fully aware of their financial, social and emotional ravages. That they do not threaten life is the only positive thing that can be said about them, since they can be more physically and emotionally disabling than many seemingly catastrophic disorders. A well-rehabilitated person with paralysis of both legs can lead an essentially normal life, while someone with severe chronic pain may be almost totally disabled, unable to work and capable of very little physical activity.

The immediate and inevitable question is, Why and how did this happen? After millions of years of evolution, have we suddenly become incapable of functioning normally? Are there architectural inadequacies in our bodies that have only become apparent in the last forty years? If these pain disorders are not caused by structural abnormalities, how else can these epidemics be explained?

My early work in the diagnosis and treatment of back, neck and shoulder pain syndromes was decidedly unpleasant and frustrating. The conventional diagnoses and conservative (nonsurgical) treatment methods yielded disappointing and inconsistent results. Even as I explained the rationales for diagnosis and treatment to patients, I was uncomfortable, for the explanations seemed to lack physiologic and anatomic logic. As far back as 1904 doctors had described a painful disorder of the muscles -- variously called fibromyalgia, myofasciitis, fibrositis, fibromyositis -- but no one had been able to identify the exact pathology or cause of the condition. Eventually I began to approach patients as though nothing were known about the cause of back pain. I soon realized the primary tissue involved was muscle. Something was happening to the muscles of the neck, shoulders, back and buttocks.

Because they are easily identified on X ray, most practitioners attributed the pain to a variety of structural abnormalities of the spine, such as normal aging changes, congenital abnormalities or malalignment. Others believed that the muscles were painful because they were weak, sprained or strained. Furthermore, back, neck or shoulder pain was often accompanied by pain and other neurological symptoms in an arm or leg. If, therefore, a structural abnormality was found in the vicinity of a spinal nerve whose destination was an arm or leg, the clinician would be strongly inclined to attribute the symptoms to that abnormality without concern for the rigors of a scientific diagnosis. However, a careful history and physical examination often revealed that the presumed culprit was innocent, that the bone or disc distortion could not account for the findings. Nevertheless, pain was still blamed on the spine.

An unlikely alliance arose among disparate disciplines. Chiropractors, for years roundly criticized by physicians as unscientific, slowly came to be fully accepted into the fraternity of diagnosers and treaters of the back. They had always maintained that structural abnormalities of the spine were the cause of back pain. Since doctors believed the same thing, it was inevitable that chiropractors would become members of the back therapy community. Other members of this therapeutic community are osteopaths, physiatrists (specialists in physical medicine and rehabilitation), orthopedists, neurologists, neurosurgeons, physical therapists, acupuncturists, kinesiologists and a host of others who use special regimens of exercise or massage. What they have in common is the idea that the spine and/or its surrounding musculature is deficient, easily injured and in need of some kind of physical intervention. Surgery is the most drastic and one of the most common.

Because some sort of structurally induced inflammation, whose nature has never been elucidated, is said to be responsible for much of the pain, large numbers of nonsteroidal and steroidal medications are prescribed.

In view of the many diagnostic and therapeutic programs now used in the management of these pain syndromes, any significant disruption in the application of existing therapies would create financial havoc, for the diagnosis and treatment of chronic pain is now a gigantic industry in the United States. But accurate diagnosis and treatment would save enormous amounts of money.

In the early 1970s, in the midst of this burgeoning epidemic, I began to doubt the validity of the conventional diagnoses, and therefore treatment, of the syndromes of neck, shoulder and back pain. A closer look had suggested that back muscles, from the back of the head to the buttocks, were the primary tissues involved. This confirmed the work of all those through the years who described what they called fibromyalgia, fibrositis or myofascial pain. My study of the literature and growing experience with patients suggested that those maladies were part of a pain disorder I call the Tension Myositis Syndrome (TMS). (Myositis means physiologic alteration of muscles.) TMS is a painful but harmless change of state in muscles.

But what of the neurological signs and symptoms in the legs and arms? For a while I thought they must be caused by structural compression in the spine or that mysterious "inflammation" so often cited by other practitioners. As the number of inconsistencies mounted, however, I was forced to the conclusion that the process causing the muscle pain was responsible for the nerve symptoms as well. But what was that process?

When physicians take a patient's history they routinely inquire about past or current medical disorders or symptoms. I found that 88 percent of my pain patients had a history of minor gastrointestinal maladies such as heartburn, pre-ulcer symptoms, hiatus hernia, colitis, spastic colon, irritable bowel syndrome and other tension-induced reactions like tension headache, migraine headache, eczema and frequent urination. Although not all practitioners agree that these disorders are related to psychological or emotional phenomena, my clinical experience as a family physician and my own personal medical history made me quite comfortable with that conclusion. For example, for a number of years I had experienced regular migraine headaches, complete with typical visual "lights" prior to the onset of headache. Someone suggested that repressed anger might be the basis for them. The next time I had the "lights" -- harbinger of a headache -- I sat down and tried to think of what anger I might be repressing. I failed to find an answer, but for the first time in my life I didn't get a headache. It was powerful evidence that migraine headache was caused by emotional phenomena.

It was, therefore, logical to hypothesize that these back muscle pains might fall into the same group of emotionally induced physical disorders. When I put the idea to the test, by telling patients that I thought their pain was the result of "tension," I was astonished to observe that those who accepted the diagnosis got better. Those who rejected it remained unchanged.

In those early days all my patients had physical therapy administered by therapists whom I had briefed to inform patients that the therapy was designed to provide temporary relief from symptoms, but that real recovery depended on recognizing the nature of the process. Those who improved agreed with the diagnosis. This was similar to my experience with migraine: Acknowledgment of an emotional role in the genesis of symptoms somehow banished those symptoms. Many years would pass before I understood the reason for this fascinating, mysterious phenomenon.

At the time, telling patients that I thought their pain was caused by "tension" was difficult. Any physician would scoff at this idea; the average person would be insulted if you suggested that some physical symptom was "in the head." That was a phrase I avoided assiduously because of its pejorative connotation, although the patient often introduced it. Sometimes I was able to explain the connection between tension and pain satisfactorily, but I was quite handicapped because of my own poor understanding of the psychodynamics involved. Instead I talked about certain personality characteristics that appeared to be common in people with TMS and how these characteristics might lead to tension and anxiety. I suggested that the symptoms were a physical rather than emotional expression of anxiety and that people who were hardworking, conscientious, responsible, compulsive and perfectionistic were prone to TMS. I could not provide a clinical definition of the word tension but it was a word with which people could identify. Psychological and emotional were bad words that implied there was something strange about you; I avoided the word psychosomatic because to most people it meant the pain was phony or imaginary. Nevertheless, I continued to make the diagnosis, and my rate of success in treatment began to rise substantially. I now felt I understood the nature of the disorder and could predict with some accuracy who would get better and who wouldn't.

On physical examination almost every patient was found to have tenderness on palpation of (pressing on) certain muscles regardless of where in the neck or back they felt pain. For example, someone might have pain only in the right lower back but on examination felt pain when I pressed on the top of both shoulders (upper trapezius muscles), the small of the back on both sides (lumbar paraspinal muscles), and the outer part of both buttocks (gluteal muscles). This consistent finding strongly suggested that the syndrome originated in the central nervous system (brain) rather than in a local structural abnormality.

By the mid-1970s I had concluded that the majority of neck, shoulder and back pain syndromes, along with the associated pain often seen in the legs and arms, was the result of a psychologically induced process, which made it a classical psychosomatic condition. That is, emotional factors were setting off a reaction in certain tissues in the body that resulted in pain and other neurologic symptoms.

What was the nature of this reaction? The physical therapy treatment consisted of deep heat (delivered as high-frequency sound waves), deep massage and active exercise of the involved muscles. Most patients reported at least temporary relief. Since I knew that these treatment modalities increased the local circulation of blood, it was logical to conclude that the cause of the symptoms was a reduction in blood flow to the involved tissues. The circulation of blood is under the control of a subsystem of the central nervous system known as the autonomic nervous system. Many of the other mindbody disorders (peptic ulcer, colitis, migraine and tension headache) are also mediated through the autonomic system. Nothing could be simpler: Something in the brain decides to initiate this process; autonomic centers are activated, and within milliseconds the circulation to the involved areas is reduced. This means that these tissues are now deprived of their full complement of oxygen, which is almost certainly the reason for the symptoms. This correlated with the finding of two German investigators in 1975 that there was evidence of mild oxygen deprivation in the nuclei of muscle cells of patients with back pain, as well as with studies reported in the medical literature by a team of Swedish rheumatologists in the 1980s.

Since it provided a logical explanation for the symptoms, I proceeded on the premise that oxygen deprivation causes pain. Further, even if the cause of the pain should prove to be some other brain-induced process, it was still apparent that definitive treatment had to be directed at the brain, not the local tissues.

I told my patients there was really nothing wrong with their backs. I explained that they had a harmless condition that must be treated through the mind, not the body. Awareness, insight, knowledge and information were the magic medicines that would cure this disorder -- and nothing else could do it.

In 1979 I instituted the practice of bringing patients together and lecturing them on the physical and psychological details of TMS. The logic was clear: If information was the cure, I ought to be doing a better job of providing it. These lectures now represent the cornerstone of the therapeutic program and appear to be all that is necessary for 80 to 90 percent of those who go on to complete recovery.

My view of the problem in the early 1980s is best illustrated by a letter I wrote to New York Times columnist Russell Baker, whose August 16, 1981, column was titled "Where Have All the Ulcers Gone?" Since I suspected it would be of interest to him, on September 23, 1981, I sent the following letter:

Dear Mr. Baker:

Because you are a well-informed man, I thought you would be interested in knowing the real reason for the decline in the incidence of ulcers, about which you wrote awhile back. Gastric and duodenal ulcers are members of a family of physical disorders which, as you correctly reported, reflect the presence of large quantities of tension. Other members of this villainous family are colitis, spastic colon, tension headache and garden variety allergies, to name some of the most prominent. There is another one, however, which has escaped the notice of the medical community, or rather survived in the guise of being something else, and it is a very important one for it has assumed the role of the previously ubiquitous ulcer. Why this switch should have occurred is a very interesting story, to which I shall return in a moment. This other disorder is none other than the common backache (or neck or shoulder ache). For years it has been assumed that back pain is due to some deficiency of the spine and related structures, but this is merely a diagnostic smoke screen which has successfully obfuscated doctors and other practitioners. In fact, back pain is due to hyperactivity in that same branch of the nervous system which causes ulcers, the stimulus for which is the same old bugaboo, tension.

I am very serious in this assertion and have published my views in the medical literature. However, a certain degree of light-heartedness is appropriate since even the most painful and disabling of these is still reflective of a very benign process -- much more so than ulcers which can bleed or perforate and become rather messy. All of these disorders are members of the same family and represent variants of a similar underlying process, i.e., tension producing physical manifestations, the definition of a psychosomatic disorder. Heart attacks are manifestations of a more serious kind of psychosomatic process and not equatable with peptic ulcer.

Now to the question of why the switch. This is not comprehensible unless one realizes that the purpose of a physical manifestation of tension is to deceive. Our brains have decided that feeling tense, which is the appropriate response to being tense, is too unpleasant to bear and is not as socially acceptable as having something "physically" wrong. And so the brain makes a few adjustments in circuitry and instead of looking and acting like a nervous wreck, presto -- a bellyache or a backache. The reason why the ulcer had to go was that everybody began to realize that it was a phony, that it really meant tension, and that's not socially acceptable.

The old backache has always been what it is now, a tension equivalent, but nobody paid much attention to it until the advent of modern medicine. Here, said the brain, is a natural. Everybody thinks backaches are the last word in a "physical" disorder and so it's a perfect substitute for tension. The ulcer has lost its value -- up the backache as the new but thoroughly hidden standard bearer for the army of the tense.

And so it is that practically everyone you talk to has a backache story to tell. The incidence of all kinds of pain syndromes involving the backside of western Homo sapiens has risen dramatically in the last twenty years or so, while the discredited ulcer is fading into obscurity.

Isn't that a fascinating story?

A few days later I received the following note, reprinted with Mr. Baker's kind permission:

Dear Dr. Sarno:

That's a fascinating story indeed and casts some light on my own "backache." This affliction comes over me after four or five hours at the typewriter when I am performing, as it were, for an audience. It is often particularly bad when I am aware the writing is going badly.

Last week I had occasion to help my son move and warned him that I'd probably have to drop out after a few hours on account of my back. The moving, in fact, was rather enjoyable, at least in the sense that it was mindless labor, fetching, lifting and hauling, performed in a pleasant rustic atmosphere with my mind thoroughly relaxed. After a ten-hour day at it, I remembered my back for the first time since morning, and then only to remark that it hadn't bothered me all day.

Yrs,
Russell Baker

In 1981, I believed that physical manifestations were a substitute for anxiety. Later, a change in concept led me to a much better understanding of the problem and, accordingly, greater effectiveness in treating it. The subtle but important shift was that unconscious emotional phenomena necessitated physical symptoms.

And, of course, ulcers have not faded into obscurity; they are now being attributed to the presence of a bacterium in the stomach. It is my opinion that they are still stress-induced and that the bacterium is merely part of the process. They are not as common as they used to be and do not occur as frequently as the pain disorders.

In 1982 I conducted the first follow-up survey of my patients. One hundred and seventy-seven patients whose charts were drawn randomly from those who had been treated between 1978 and 1981 were interviewed about their level of pain and their functional ability. Seventy-six percent were leading normal lives and were essentially free of pain. Fourteen patients were somewhat improved and twenty-eight (16 percent) were considered treatment failures.

Two important facts about this group of patients should be noted: Before coming to see me most of them had long histories of back pain and had received multiple treatments, including surgery for some, yet they still continued to have severe symptoms; also, I had not screened any of them before they made an appointment. Since 1987 I have interviewed patients calling for an appointment to determine whether they are appropriate for our program. Most of the large population of people with these pain syndromes reject the idea of an emotionally induced process and would, therefore, derive no benefit from our therapeutic program, since acceptance of the diagnosis is essential to a successful outcome. Currently I accept about 50 percent of those who call. When I am criticized for this selectivity I remind my critics that, like a surgeon who will not operate on a poor surgical risk, I am exercising my prerogative to work only with patients who have a reasonable chance for success. This selectivity is not only to my advantage; it spares the potential patient unnecessary expense and aggravation.

Despite this lack of selectivity prior to 1987, a second follow-up survey in 1987 revealed an increase in the effectiveness of the program since 1982. This time we made it more difficult for ourselves and limited the population surveyed to people with CT-scanned documented herniated discs. This abnormality is responsible for most back surgery, yet our experience shows that it is rarely responsible for the pain. One hundred and nine of these randomly selected patients were interviewed. One to three years after treatment, ninety-six (88 percent) were free of pain and leading normal lives, eleven people were somewhat better and only two were unchanged -- a considerable improvement over the 1982 survey.

What was responsible for this significant improvement in our results? I had become more proficient at teaching the nature of TMS and was, therefore, more successful in stimulating confidence in the diagnosis; moreover, in 1985 I discontinued prescribing physical therapy. Although all the therapists were fully aware of the nature of the process they were treating and faithfully reinforced the concept that psychological and not physical factors were responsible for the pain, it became apparent that some patients would focus on the physical treatments, pay lip service to the ideas I was teaching, and have a placebo cure, if any (placebo cure -- a cure based on blind faith and usually temporary). More subtly, by requiring physical treatment two or three times a week, we were focusing patients' attention on their bodies, whereas success in treatment depended on shifting concern from the physical to the emotional. The possible benefit of the physical therapy was heavily outweighed by its negative potential. I believe this played an important role in the improved statistics.

Although a third follow-up survey has not been done, I believe that our results are now even better than they were in 1987. I attribute this to the selectivity process as well as to a major leap in my understanding of the psychology of TMS.

While I was collaborating on a medical paper with a psychoanalyst colleague, Stanley Coen, he suggested that the physical symptoms were probably not a physical expression of anxiety, which had been my working hypothesis for many years, but were the result of what psychoanalysts call a defense mechanism, a term I find somewhat misleading in view of what it does. The purpose of a defense mechanism (in this case physical symptoms) is to divert people's attention to the body, so that they can avoid the awareness of or confrontation with certain unconscious (repressed) feelings. This new understanding of the role of repression was a major landmark in the journey upon which I had embarked roughly fifteen years before. Not only did this idea fit perfectly with the diagnosis, but for the first time I had an explanation of why people got better when they learned about and accepted what was going on. Now it was clear why someone in Peoria, Illinois, might read either of my books on TMS and make a complete recovery without ever having talked to or been examined by me. The mystery was solved. Once accepted by the patient, the knowledge of what was going on destroyed the brain's strategy. Although we had always known that TMS was a brain-induced process, we didn't know why the brain was doing it. Now it was clear that the symptoms were meant to draw the person's attention away from hidden emotions, and that by exposing the undercover operation and thereby ending it, the pain would disappear, as indeed it did.

While these ideas on the mindbody link represent the culmination of a twenty-four-year-long clinical experience, they are, in fact, the starting point for the body of this book. Though they developed out of my experience with the diagnosis and treatment of pain, I believe they have relevance to many medical conditions. Indeed, I believe that everyone has mindbody physical symptoms. Few people, if any, go through life without one or more such manifestations, for they reflect the evolutionary contemporary organization of the human psyche. Most importantly, these manifestations demonstrate that there is no separation between mind and body; that the two are inextricably intertwined. One cannot study the pathology of human disease without factoring in the role of the psyche. My experience with the common pain syndromes has demonstrated the folly of neglecting the emotional component of human illness. In some cases the emotions will play a participatory role; in others they are primary. To neglect this dimension of illness pathology is as great an omission as to ignore the role of microorganisms in human illness.

What emotions could be so terrible as to induce the brain to subject someone to severe physical pain and frightening neurological symptoms? The answer to this question is basic not only to the understanding of these pain syndromes but to the whole range of psychosomatic disorders.

Conflicts rage constantly in the unconscious, born of the various elements that represent the mosaic of the human psyche. These conflicts result in the development of emotions that cannot be tolerated and, therefore, must be repressed. Because these undesirable feelings appear to strive for recognition, the mind must do something to prevent them from coming to consciousness. Hence, the mindbody symptom. This book explores the nature and content of these undesirable feelings and explains why the mind chooses to mask emotional turmoil with physical pain.