Chronic pain is mostly mental

I Have to Believe This Book Cured My Pain
—A science writer investigates the 30-year-old claims of an iconoclastic doctor who said
chronic pain was mostly mental.
By Juno DeMelo
New York Times, Nov. 10, 2021
Every time someone tells me their back’s been giving them trouble, I lower my voice
before launching into my spiel: “I swear I’m not woo-woo, but … ”
Let me rewind a bit. For more than a decade, I had a near-constant throbbing in my left
piriformis, a small muscle deep in the butt. I tried treating it with physical therapy,
ultrasound and Botox injections. At one point, I even considered surgery to cut the
muscle in half in order to decompress the sciatic nerve that runs underneath.
Then, in 2011, I picked up a library copy of the 1991 best seller “Healing Back Pain: The
Mind-Body Connection.” It claimed that, in order to distract the sufferer from repressed
anxiety, anger or feelings of inferiority, the brain creates pain in the neck, shoulders,
back and butt by decreasing blood flow to the muscles and nerves.
The book’s author, Dr. John Sarno, was a rehabilitation physician at New York
University and something of an evangelist, touting a methodology bolstered by
anecdotes from his practice and passionate testimonials from patients like Howard
Stern or Larry David, who described his recovery from back pain as “the closest thing
that I’ve ever had in my life to a religious experience.”
According to Dr. Sarno, nearly all chronic pain is caused by repressed emotions. By
undergoing psychotherapy or journaling about them, he said, you could drag them out
of your unconscious — and cure yourself without drugs, surgery or special exercises. I
chose journaling and began writing pages-long lists of everything I was angry, insecure
or worried about.
I appreciated the tidy logic of Dr. Sarno’s theory: emotional pain causes physical pain.
And I liked the reassurance it gave me that even though my pain didn’t stem from a
wonky gait or my sleeping position, it was real. I didn’t like that no one in the medical
community seemed to side with Dr. Sarno, or that he had no studies to back up his
But I couldn’t deny it worked for me. After exorcising a diary’s worth of negative feelings
over four months, I was — in spite of my incredulousness — cured.
I didn’t think much about Dr. Sarno after that until May of this year, when I found
myself back in physical therapy for a pain in my inner thigh. My physical therapist
assigned me a handful of exercises, and I did them every day. The whole time, I worried:
If physical therapy failed again, would I have to go back to exhaustively cataloging my
woes? Did Dr. Sarno’s claims even hold water?
Pain often starts in the brain.
“The idea is now mainstream that a substantial proportion of people can be helped by
rethinking the causes of their pain,” said Tor Wager, a neuroscience professor at
Dartmouth College and the director of its Cognitive and Affective Neuroscience Lab.
“But that’s different than the idea that your unresolved relationship with your mother is
manifesting as pain.”
Dr. Wager said most scientists now believe that pain isn’t always something that starts
in the body and is sensed by the brain; it can be a disease in and of itself.
Approximately 85 percent of back pain and 78 percent of headaches don’t have an
identifiable trigger, yet few scientists would say that all or even most chronic pain is
purely psychological. “There are also social and biological reasons for pain. In most
people, it’s some confluence of the three,” said Daniel Clauw, a professor of
anesthesiology, medicine and psychiatry at the University of Michigan and the director
of its Chronic Pain & Fatigue Research Center. “I’m sorry, there are a bunch of people
for whom Sarno’s method isn’t going to work.”
Today, a similar approach to Dr. Sarno’s method is emotional awareness and expression
theory, in which patients identify and express emotions they’ve been avoiding. It’s not
only been shown to significantly lower pain in people with fibromyalgia and chronic
musculoskeletal pain, it’s also considered a best practice for treating chronic pain (along
with massage and cognitive behavioral therapy) by the Department of Health and
Human Services.
Pain can take on a life of its own.
But how does the brain cause chronic pain in the first place? Dr. Sarno’s theory that our
brain uses pain to distract us from negative emotions by cutting off blood flow to the
muscles is not backed up by science, according to Dr. Wager.
Instead of blood flow, scientists now look to the nervous system to understand chronic
pain that isn’t caused by nerve or tissue damage. Basically, your brain circuitry
malfunctions, prolonging, amplifying and possibly even creating pain.
Dr. Wager said we don’t fully understand the mechanisms of this, but “we do know that
stressors can promote inflammation in the spinal cord and brain, which is linked to
greater pain sensations.” Early adversity, such as child abuse, economic hardship,
violence and neglect, has also been linked to chronic pain.
Complicating things further: Pain can beget more pain. For example, an injury may turn
up the volume on your pain response to future injuries. Stress may cause pain to persist
long after an injury has healed. And if your back twinges and you start imagining all the
ways it could get worse, that fear can magnify your pain, which may lead you to avoid
physical activity, which then makes the pain even worse. Experts call this the pain cycle.
Here, Dr. Sarno’s notion of the brain triggering pain was partially right. Research shows
that catastrophizing can turn acute pain into chronic pain and increase activity in brain
areas related to anticipation of and attention to pain. This is one of the reasons
clinicians are starting to treat pain disorders similarly to, say, anxiety disorders,
encouraging patients to exercise so they can overcome their fear of movement. Whereas
a socially anxious patient might take small steps toward talking with strangers, for
instance, a patient with back pain might start jogging or cycling.
You can find the off switch.
The bottom line, according to Dr. Howard Schubiner, a protégé of Dr. Sarno, is that “all
pain is real, and all pain is generated by the brain.” Today Dr. Schubiner is the director
of the Mind Body Medicine Program in Southfield, Mich., and a clinical professor at the
Michigan State University College of Human Medicine.
“Whether pain is triggered by stress or physical injury, the brain generates the
sensations,” he said. “And — this is a mind-blowing concept — it’s not just reflecting
what it feels, it’s deciding whether to turn pain on or off.”
So, by this rationale, all pain is in both the body and the brain. Which is why, when my
adductor stopped hurting in July after eight weeks of physical therapy, I didn’t expend
too much mental energy trying to figure out what had worked: the exercises themselves,
my physical therapist giving me the go-ahead to keep exercising, the once-a-week
opportunity to talk with her about my recent move and the other stressors potentially
contributing to my pain or (most likely) all of the above.
In the end, Dr. Sarno was right about exercise aiding, not hampering, recovery and
about the link between emotional and physical pain. But not all chronic pain is
psychological. Dr. Sarno’s Freudian treatment is far from the only one that works. And
few scientists would say that our brain uses pain to distract us from negative emotions
(and definitely not by cutting off blood flow to muscles).
I still think of Dr. Sarno as a savior, and I continue to recommend his books to friends
and family; some have read them — and had success — while others have politely
declined. Yes, Dr. Sarno almost certainly oversimplified and overemphasized the
psychological origins of pain. But he also helped me see that both the mind and the body
are responsible for our physical suffering. And that we’re not powerless to change it.