The Divided Mind: The Epidemic of Mindbody Disorders

by John E. Sarno

the purpose of this repression is to protect the individual, to prevent the painful, dangerous feelings from coming to consciousness and causing even greater distress. The psychosomatic symptoms that accompany this repression, while sometimes extremely distressing, are not some form of punishment but are generated to distract the conscious mind and therefore to assist the process of repression.

For many years we were aware of a consistent connection between the perfectionist tendency and the development of TMS. Though some of our patients denied being perfectionists, they admitted to being hardworking, conscientious, responsible, driven, success-oriented, perpetual seekers of new challenges, sensitive to criticism, and their own severest critics. But it was a long time before I realized that the drive to be good could be equally enraging to the child-primitive. It is yet another pressure. Though both the perfect and the good tendencies are present in most patients I see, the good is often the predominant one. These people are aware that they have a great need to be liked and so find themselves looking for approval in everything they do and going out of their way to be helpful, often at the expense of their own comfort and convenience. If you speak to someone who is an inveterate caretaker, helper, do-gooder, you are impressed by the power of the compulsion that drives them. Typically, they avoid confrontation.

they must, instead, pay attention to the four sources of the rage and emotional reactions: Anger, emotional pain, and sadness that can be traced back to childhood Anger stemming from the self-imposed pressures to be perfect and good Anger generated from the pressures of life Miscellaneous things like guilt, shame, fear, insecurity, and vulnerability that also feed the reservoir of rage

Here is the program I want you to follow: If you have not already done so, read the entire book you are using a bit at a time (Healing Back Pain or The Mind-body Prescription). After that, read the psychology or treatment chapter every day. Pay close attention to what you read, especially when you see things that remind you of yourself. Set aside time every day, possibly fifteen minutes in the morning and thirty minutes in the evening, to review the material I am about to suggest. Unconscious painful and threatening feelings are what necessitates the pain. They are inside you; you don’t feel them. Make a list of all the things that may be contributing to those feelings. Write an essay, the longer the better, about each item on your list. This will force you to focus in depth on the emotional things of importance in your life. There are a number of possible sources of those feelings: a. Anger, hurt, emotional pain, and sadness generated in childhood will stay with you all your life because there is no such thing as time in the unconscious. Feelings experienced in the unconscious at any time in a person’s life, including childhood, are permanent. Physical, sexual, or emotional abuse will leave large amounts of pain and sadness. But not receiving adequate emotional support, enough warmth and love will also result in anger, sorrow, and pain, maybe never felt as a child, but always there in the unconscious. Such things as excessive discipline or unreasonable expectations will a...

We know from experience that the theoretical wall, the barrier separating the conscious from the unconscious mind, cannot be breached from below—that is, the rage will not break through into consciousness—but there is nothing to stop us from intellectually breaching the barrier from above, from saying, “I can use my imagination and think of my unconscious as the basement of my mind. I know what’s down there even though I can’t see or hear it. I have been taught to recognize the inhabitants of my unconscious mind, in all of their dangerous, unflattering detail.” And the unconscious response might be, “He/she has found out what he/she wasn’t supposed to know, and has discovered the closely guarded secret about the rage and other painful or threatening emotions, like hurt and sadness, that go back to childhood. The cover has been blown on this covert operation, so there’s no sense in continuing the pain.”

he now appreciated how extremely inhibited he was when it came to experiencing angry feelings toward his parents.

He feared he would inevitably act on his rage even when he experienced it solely on a private, internal, emotional basis. Therefore, his feelings could threaten his very survival by pushing him to “bite the hand that feeds him.”

How could he possibly love his parents if he felt such an...

People with TMS need to be able to experience themselves in the act of repression of an emotion.

When anxiety, fear, anger, rage, shame, guilt, hurt, sadness, sorrow, perceived undeserved joy, and the like are overwhelming in intensity, they penetrate or bypass the common psychological defense mechanisms. We experience physical symptoms instead of these emotions because the unconscious mindbody considers them to be less painful, less dangerous or harmful than the emotions.

When a patient can observe him/herself in the act of repressing a given emotion in a given moment and almost simultaneously begin to experience the emotion itself, it allows him/her to feel more confident in the mindbody experience, which in turn facilitates healing.

The patient who tells me he is very even keeled, or is always up, or has never ever been depressed no matter what has happened, is likely a repressor.

In summary, if an individual’s hypertension is strictly a matter of genetics and lifestyle, and has nothing to do with psychological factors, I generally employ a diuretic or an ACEI (or ARB), or a combination of the two. Alternatively, I use a calcium channel blocker. These drugs, alone or in combination, should control hypertension in most cases. However, when the hypertension is psychologically linked, patients respond less well to these drugs, and it makes more sense to employ drugs that block the effects of the SNS, such as the alpha and beta blockers.

These symptoms, widespread pain, headache, tenderness at specific body locations, fatigue, sleep disturbance, and irritable bowel syndrome, have been linked together by the American College of Rheumatology to define this condition. There are many other physical complaints that people with this diagnosis can have that involve essentially every body system. Other than specific tender points, the physical examination findings will be normal or not particularly specific and there are no characteristic laboratory tests. Patients generally have lots of physical complaints but actually look quite healthy to the clinician. As with other TMS patients, those with fibromyalgia can be helped if they are open to considering and then accepting that there is a psychological cause for their pain. If they are unable to be open in this way, I have not been able to help them.

Getting better from TMS is learning how to extract yourself from needing recognition from others and learning how to fill that need yourself. It is about learning to parent yourself in perhaps a kinder, gentler, and more benevolent way than one may have actually experienced during childhood. It is learning to lower your expectations of yourself and others and learning that relationships are easier, more genuine, and form stronger bonds under those circumstances. It is learning that if someone seems upset with you, the feeling is often displaced and you are not at fault. It is learning that it is even okay if someone does get angry with you. It is about learning not to be afraid to take care of yourself psychologically, to say “no” when you want to and “yes” when you want to. It is about learning that almost all of the time that you feel guilty, it is inappropriate, in that you cannot be responsible for taking care of everyone’s feelings. People need to learn to do that for themselves.

Patients need to learn that these TMS symptoms are in essence “growing pains.” The TMS patient, for example, is the former child who learned that speaking up might aggravate the frazzled adult in his life, who might get angry; this was scary. The TMS patient is the former child who was never praised unless he accomplished something. The TMS patient is the former child who was abused. The TMS patient is the former child who thought that his parents’ divorce occurred because he was not perfect.

The TMS symptoms come from the psychological conflict that forms in the adult who sees life through the same eyes that he had as a child, when he had little or no power or control over life circumstances, and acts accordingly. The child’s view a...

Sometimes when I give this diagnosis to a patient, the patient misunderstands me and thinks that I am saying that the pain is not real, that it is all in the head. This could not be more wrong and I need to clarify things for the patient. TMS symptoms are physical symptoms, but are generated by a feeling. There are many things that can cause back pain. Some examples include infection, cancer, and a fracture from thinning bone. Emotions are another cause.

They demonstrated a definitive connection between perceived and chronic stress and changes in telomeres, specific areas of the chromosome that are known to relate to the length of cell life and aging.

The patients’ social history The findings of tenderness on physical examination The importance of one diagnosis, one unifying concept: TMS

Dr. Sarno spent a good deal of time obtaining the social history. This includes information about marital status, family history, siblings, and occupational information. Then he asked another question: “How was your childhood?”

Dr. Sarno allowed the patients to do most of the talking, trying to get a feel for different types of conflicts that people may have had in their childhood. If physical, emotional, or sexual abuse had occurred, we had a brief discussion about its impact. Dr. Sarno tried to get a feel for what kind of relationship people had with their parents or guardians.

The next significant question: “Can you talk about your personality, who you are?” He would zero in on issues of perfectionism and goodism. He developed a sense of whether people are people pleasers and/or peacemakers. He explained that this pressure to be perfect and to be good is enraging to the unconscious mind.

issues of life stress that we all have. I was impressed that many people were forthright and insightful about these issues to a large extent. They were willing to accept the idea that stress not only aggravates pai...

there are three sources for unpleasant emotions in the unconscious: childhood anger, emotional pain, and sadness; personality traits such as perfectionism and goodism; and the realities of life. He explained the mechanics of daily study as part of the treatment. People get better by developing a conscious awareness of the sources of unconscious rage and emotional pain.

I never realized how frequent the finding of tenderness on the outside of the thigh is in patients who have chronic low back pain. In Dr. Sarno’s experience, this correlation is approximately 80 percent. Tenderness in the gluteal and lower lumbar region is almost universal in TMS, as is tenderness at the top of both shoulders. Many patients have paraspinal tenderness throughout the lumbar spine, extending sometimes into the thoracic area as well. The tenderness most people have with chronic low back pain is usually present over a very widespread area.

Palpation requires a light to moderate amount of pressure in strategic locations, indicating that the pain is usually in the muscles or the tendons just below the skin. This superficial tenderness indicates that deeper structures, such as the intervertebral disks, are not producing the pain.

the swelling and inflammation from an acute herniation usually settles down within one to two weeks.

The diffuse tenderness that is present in TMS indicates that the central nervous system, the brain-mind, is involved.

It is anatomically impossible for disk abnormalities to produce tenderness in the iliotibial band, a tendon, and the gluteal, quadratus lumborum, lumbar paraspinal, and upper trapezius muscles, as we see in chronic low back pain caused by TMS.

True tendinitis can occur from heavy activity or from athletic activity. It usually subsides within several days to a couple of weeks.

Tenderness findings at the shoulder show a similar pattern of diffuse involvement when TMS is the cause of pain. The upper end of the biceps tendon is a common location for TMS, with tenderness extending several centimeters below the acromion process at the top of the shoulder. Many patients report pain throughout the upper arm, and have several tender areas at multiple locations, especially at the lateral epicondyle of the elbow (the common site for “tennis elbow”). These findings are not consistent with the common diagnoses I used to make, namely, impingement syndrome and tendinitis. These conditions do occur but typically present with very localized findings or aggravation of pain by the “impingement test.”

Rotator cuff tear is another common diagnosis, usually made on MRI. The tear can be either partial or complete in thickness. A complete tear will often produce marked weakness on strength testing due to the anatomic defect.

The typical tenderness in a number of different tendons is a sign of TMS and thus a relative contraindication for rotator cuff surgery.

There is a strong tendency for pain loci in TMS to move from one place to another.

location substitution.

if the psychological need for physical symptoms continues, the brain will continue to produce them until the psychological situation changes for the better.

have the patient complete a pain diagram.

ask them to shade in all the areas of the body where they feel pain or have had pain in the last year. Many people with TMS shade in a fairly large portion of the pain diagram.

I state that stress, tension, anxiety, and anger can cause pain in muscles, tendons, and nerves.

We are talking about physiologic changes that occur in various tissues or organs in the body that are induced by emotions. That is the meaning of psychosomatic.

symptom imperative. It means that you must eliminate a symptom by treating the cause, or the brain will simply find another symptom.

the difference between how we think we should feel about a situation or event in our lives (our conscious emotion) and what we really feel (often the unconscious emotion) becomes psychogenic.

Emotional triggers occur when circumstances, whether dramatic or more subtle, evoke unconscious painful emotions and fuel the need to defend them with a distraction such as physical pain. In other words, real stress is that which evokes unconscious emotions.

First, a controlling parent can be enraging to a child, which is one of a number of painful unconscious emotions that this patient has been protecting.

Her natural tendency to avoid emotions can signal an unconscious fear that if she allows her repressed emotions to go unprotected, they may come pouring out uncontrollably.

Finally, for much of her young adult life her distraction from these painful unconscious emotions has been in the form of achievement in school and subsequently a busy law practice. There was no need for physical pain since she already had plenty of distractions.

the severity and chronicity of one’s symptoms is proportional to the underlying pain that harbors in the unconscious and the triggers that evoke them.

psychosomatic disorders arise from the unconscious mind, which is where emotions reside that, for the most part, we are unaware of. Not only is it not possible to directly access these emotions, but it is not necessary for successful treatment for most individuals. Successful treatment requires one to simply acknowledge that these painful, unpleasant, often threatening emotions exist. It is not necessary to “figure them out.” Treatment is about acknowledging their existence, not changing them. Stress is unavoidable and a part of life. Acceptance, then, not only means accepting one’s pain as psychosomatic, but also coming to terms with our genuine self, both the parts we like about ourselves and the parts we don’t like. Accepting our painful unconscious emotions as part of who we are is not only a step toward successful treatment but a step toward being a more whole human being.

These personality traits are not undesirable—they make us successful, kind, and considerate. But it is essential to understand how these very qualities can contribute to the accumulation of stress, anger, and conflict. The way our brains work, we repress unpleasant thoughts and emotions, which then find a home in the unconscious. This is a very good defense mechanism—it allows us to move on and take care of our responsibilities and be nice people that others like and respect. Unfortunately, we can only hold so many of these unpleasant thoughts and emotions in the unconscious. Accumulated anger, stress, and conflict become rage. This rage wants to rise to consciousness, but we usually do not let this happen. If it were to happen, we might rant and rave and do things that would not be acceptable, things that would make others not think well of us. To distract us from these unpleasant thoughts and emotions, our brain creates pain, real physical pain.