The Divided Mind

John E. Sarno

• Publisher: HarperCollins e-books
• Year: 2009
• ISBN:
  9780061860584
• Topic: Médecine
• Subtopic: Anesthésiologie et gestion de la douleur

The Divided Mind is the crowning achievement of Dr. John E. Sarno's distinguished career as a groundbreaking medical pioneer, going beyond pain to address the entire spectrum of psychosomatic (mindbody) disorders.

The interaction between the generally reasonable, rational, ethical, moral conscious mind and the repressed feelings of emotional pain, hurt, sadness, and anger characteristic of the unconscious mind appears to be the basis for mindbody disorders. The Divided Mind traces the history of psychosomatic medicine, including Freud's crucial role, and describes the psychology responsible for the broad range of psychosomatic illness. The failure of medicine's practitioners to recognize and appropriately treat mindbody disorders has produced public health and economic problems of major proportions in the United States.

One of the most important aspects of psychosomatic phenomena is that knowledge and awareness of the process clearly have healing powers. Thousands of people have become pain-free simply by reading Dr. Sarno's previous books. How and why this happens is a fascinating story, and is revealed in The Divided Mind.

ONE

WHAT IS PSYCHOSOMATIC MEDICINE?

I remember the first time John R came into my clinic in 1996. He was a successful businessman in his early forties, well dressed and fit, radiating confidence. He seemed altogether at ease and self-assured—until he bent to sit down. Abruptly, his movements slowed and he became so cautious, so fragile, so tentative that he was suddenly a caricature of the driving, confident man who strode through my door only moments before. His body language made it clear that he was either experiencing excruciating pain or feared the pain would strike him if he made the slightest wrong move.

As a medical doctor, I could empathize with his suffering. My specialty is mindbody disorders, and I see cases like this every working day. I hoped I could help him, which meant helping him to help himself, because with mindbody disorders, a doctor cannot “cure” a patient. It is the suffering patient who must come to understand his malady…and by understanding it, banish it.

As we went over John R’s history, a picture began to emerge of an interesting and satisfying life. Married, three children. His own business, which probably took up too much of his time, but was doing well. I also heard a familiar litany of suffering and pain—a chronic bad back of mysterious origins, sometimes inducing such severe pain that he could not get out of bed in the morning. His long and unsuccessful search for relief—experiments with alternative medicine, prescription drugs, and finally, in desperation, surgery—immensely expensive and only temporarily successful. Then the sudden onset of brand-new ailments: sciatica, migraine headaches, acid reflux—the list of maladies went on and on.

As a physician, my heart went out to him. It was my job to help him. But I could only lead. Would John R follow? Would he understand the profound interconnectedness of mind and body? Would he grasp the awesome power of buried rage?

To the uninitiated, there is often something mysterious about mindbody medicine. In truth, the relationship of the mind to the body is no more mysterious than the relationship of the heart to the circulation of the blood, or that of any other organ to the workings of the human body. My first interview with John R indicated he would be open to the idea of mindbody medicine. Within a month of beginning treatment, his pains, which had tortured him for much of his adult life, simply disappeared, without the use of drugs or radical procedures. I still get an annual Christmas card from him. In his most recent one he reported that he continues playing tennis and skiing. Last summer he and his oldest boy walked the entire Appalachian Trail. The pain and the equally unexplained other disorders have not returned.

Many of my patients have an initial difficulty grasping the full dynamics of the mindbody syndrome. It is one thing to accept the concept that the mind has great power over the body, but quite another to internalize that knowledge, and to understand it on a deeply personal basis. Even when my patients come to fully appreciate the central element of the equation—that it is their mind that contains the root cause of their physical distress—they may continue to stumble over the secondary details, unable to accept the reality of their own buried rage, and remain puzzled over the fact that their own mind can make decisions of which they are unaware.

Sometimes it helps my patients to understand the mindbody connection if they step back and look at it from a broader perspective. Psychosomatic disorders belong to a larger group of entities known as psychogenic disorders, which can be defined as any physical disorders induced or modified by the brain for psychological reasons.

Some of these manifestations are commonplace and familiar to all, such as the act of blushing, or the feeling of butterflies in the stomach, or perspiring when in the spotlight. But these are harmless and temporary phenomena, persisting only as long as the unusual stimulus remains.

A second group of psychogenic disorders includes those cases in which the pain of a physical disorder is intensified by anxieties and concerns not directly related to the unusual condition. An example would be someone recently involved in a serious automobile accident whose pain may be significantly worsened by concerns about his or her family, job, and so on, not about the injuries. While mainstream medicine tends to ignore almost all psychogenic manifestations, it generally acknowledges this type, recognizing that symptoms may worsen if the patient is anxious. Doctors may refer to this as emotional overlay. In my practice, patients have reported that their pain became much more severe when they were informed of the results of a magnetic resonance imaging (MRI) scan that described an abnormality, such as a herniated disk, particularly if surgery was suggested as a possible treatment.

The third psychogenic group is the exact opposite of the second: it covers cases in which there is a reduction of physical symptoms in an existing disorder. In one of the earliest studies of pain, Henry Beecher of Harvard reported that in a group of severely wounded soldiers in World War II, it was found that despite the severity of their injuries they often required little or no analgesic medication because their pain was substantially lessened by their becoming aware that they were still alive, being cared for and removed from the dangers of deprivation, hardship, and sudden death.

By far the most important psychogenic categories are the fourth and fifth groups, hysterical disorders and psychosomatic disorders. Hysterical disorders are mostly of historical interest, although the psychology of both is identical. My experience has been primarily with psychosomatic disorders.

The symptoms of hysterical disorders are often quite bizarre. The patient may experience a wide variety of highly debilitating maladies, including muscle weakness or paralysis, feelings of numbness or tingling, total absence of sensation, blindness, inability to use their vocal cords, and many others, all without any physical abnormalities in the body to account for such symptoms.

It is clear from the nature of hysterical symptoms that their origin is indeed “all in the head,” to take a pejorative phrase commonly used to refer to psychosomatic symptoms. The absence of any physical change to the body indicates that the symptoms are generated by powerful emotions in the brain. Just where in the brain, no one can say for sure. One medical authority, Dr. Antonio R. Damasio, has suggested that these emotion-generating centers are located in the hypothalamus, amygdala, basal forebrain, and brain stem. The patients perceive symptoms as though they were originating in the body when the appropriate brain cells are stimulated. These symptoms often have a very strange and unreal quality about them. One of the nineteenth-century pioneers of psychiatry, Josef Breuer, likened them to hallucinations.

PSYCHOSOMATIC DISORDERS

By contrast, in the fifth psychogenic group, psychosomatic disorders, the brain induces actual physical changes in the body. An example of this would be tension myositis syndrome (TMS), a painful disorder that we will examine at greater length. In this condition, the brain orders a reduction of blood flow to a specific part of the body, resulting in mild oxygen deprivation, which causes pain and other symptoms, depending on what tissues have been oxygen deprived.

One of the most intriguing aspects of both hysterical and psychosomatic disorders is that they tend to spread through the population in epidemic fashion, almost as if they were bacteriological in nature, which they are not. Edward Shorter, a medical historian, concluded from his study of the medical literature that the incidence of a psychogenic disorder grows to epidemic proportions when the disorder is in vogue. Strange as it may seem, people with an unconscious psychological need for symptoms tend to develop a disorder that is well known, like back pain, hay fever, or eczema. This is not a conscious decision.

A second cause of such epidemics often results when a psychosomatic disorder is misread by the medical profession and is attributed to a structural abnormality, such as a bone spur, herniated disc, etc.

A 1996 study in Norway suggests there is a third condition that fuels such epidemics: the simple fact that medical treatment may be readily available. A paper published in the journal Lancet in 1996 described an epidemic in Norway of what is called “whiplash syndrome.” People involved in rear-end collisions, though not seriously injured, were developing pain in the neck and shoulders following the incident. Norwegian doctors were puzzled by the epidemic and decided to investigate. They went to Lithuania, a country with no medical insurance, and on the basis of a controlled study determined that the whiplash syndrome simply did not exist in that country. It turned out that the prevalence of whiplash in Norway had less to do with the severity of rear-end collisions than with the fact that it was in vogue; doctors couldn’t explain the epidemic and the ready availability of good medical insurance for treatment!

The most important epidemics of psychosomatic disorders are those associated with pain. As will be discussed below, they have become the ailments du jour for millions of Americans. They are “popular” and most of them have been misdiagnosed as being the result of a variety of physical structural abnormalities, hence their spread in epidemic fashion.

What is the genesis of a psychosomatic disorder? As we shall see, the cause is to be found in the unconscious regions of the mind, and as we shall also see, its purpose is to deliberately distract the conscious mind.

The type of symptom and its location in the body is not important so long as it fulfills its purpose of diverting attention from what is transpiring in the unconscious. On occasion, however, the choice of symptom location may even contribute to the diversion process, something that is common with psychosomatic disorders. For example, a man who experiences the acute onset of pain in his arm while swinging a tennis racket will naturally assume that it was something about the swing that hurt his arm. The reality is that his brain has decided that the time is ripe for a physical diversion and chooses that moment to initiate the pain, because the person will assume that it stems from an injury, not a brain-generated physical condition that caused the pain. How does the brain manage this trick? It simply renders a tendon in the arm slightly oxygen deprived, which results in pain. This is how “tennis elbow” got its name. If that sounds bizarre, diabolical, or self-destructive, you will see later that it is in reality a protective maneuver. My colleagues and I have observed it in thousands of patients.

But in time, such a symptom may lose its power to distract. Then the psyche has another trick up its sleeve. It will find another symptom to take its place, one that is viewed by both patient and doctor as “physical,” that is, not psychological in origin. For instance, if a treatment—let’s say surgery—neutralizes a particular psychogenic symptom, so that the symptom loses its power to distract, the brain will simply find another target and create another set of symptoms. I have called this the symptom imperative and it has enormous public health implications, because psychogenic symptoms are commonly misinterpreted and treated as physical disorders. All of a sudden, the “cured” patient has a brand-new disorder that demands medical attention. More distress. More time lost. More expense. This will be documented as we proceed.

Statistically, the most common psychosomatic disorder today is TMS, which I have described in its many forms in my previous books. I gave it that name because at the time of publication of the first book in 1984, it was thought that muscle (myo) was the only tissue involved. Since then, I have come to learn that nerve and tendon tissue may also be targeted by the brain; in fact, it now appears that nerve involvement is more common than muscle. Accordingly, a more inclusive name, like musculoskeletal mindbody syndrome, might be more appropriate. However, because the term TMS is now so well known, I have been urged by my colleagues not to change it, so TMS it remains.

DISORDERS MEDIATED THROUGH THE AUTONOMIC-PEPTIDE SYSTEM

How does the brain induce symptoms in the body? There are a number of ways, but by far the largest number of psychosomatic conditions are created through the activity of the autonomic-peptide system. The autonomic branch of the central nervous system controls the involuntary systems in the body, such as the circulatory, gastrointestinal, and genitourinary systems. It is active twenty-four hours a day and functions outside of our awareness. The word peptides has been added because peptides are molecules that participate in a system of intercommunication between the brain and the body and play an important part in these processes.

The most common disorders produced through this system are those of TMS, described above. These disorders afflict millions and cost the economy billions of dollars every year in medical expenses, lost work time, compensation payments, and the like.

Other conditions include:

• Gastroesophageal reflux

• Peptic ulcer (often aggravated by anti-inflammatory drugs)

• Esophagospasm

• Hiatus hernia

• Irritable bowel syndrome

• Spastic colitis

• Tension headache

• Migraine headache

• Frequent urination (when not related to medical conditions such as diabetes)

• Most cases of prostatitis and sexual dysfunction

• Tinnitus (ringing in the ears) or dizziness not related to neurological disease

The theories advanced here are based almost exclusively on work done with TMS, but there are many less common mindbody disorders (like reflux) whose symptoms are also created by the autonomic-peptide system. We refer to these as equivalents of TMS since they are the result of the same psychological conditions that are responsible for TMS. What put me onto the possibility that the pain I was seeing in the early 1970s was psychosomatic was the fact that so many of the pain patients had experienced these equivalent disorders, all of which I knew to be psychosomatic. That realization suggested that the pain disorder I was seeing was also psychosomatic.

WHY TMS IS PAINFUL

As I stated earlier, the altered physiology in TMS appears to be a mild, localized reduction in blood flow to a small region or a specific body structure, such as a spinal nerve, resulting in a state of mild oxygen deprivation. The result is pain, the primary symptom of TMS. The tissues that may be targeted by the brain include the muscles of the neck, shoulders, back, or buttocks; any spinal or peripheral nerve; and any tendon. As a consequence, symptoms may occur virtually anywhere in the body. The nature of the pain varies depending on the tissues involved: muscle, nerve, or tendon. In addition to pain, nerve involvement brings with it the possibility of feelings of numbness and tingling and/or actual muscle weakness. These reflect the function of nerves, which is to bring sensory information to the brain and carry movement messages to the body, either or both of which may be affected in TMS. The fact that patients recover rapidly when they are appropriately treated suggests that the tissues involved—nerve tissue being the most sensitive—are not in any way damaged but only rendered temporarily dysfunctional.

Because so few members of the medical profession recognize mindbody disorders for what they are, the pain of TMS is commonly attributed to a structural abnormality, such as the ones that often show up on x-rays, computed tomography (CT), or MRI scans. Following is a list of the most common ones:

Abnormalities of the intervertebral disc due to wear and tear, aging, etc., including:

• Narrowing of the disc space, indicating that the disc has lost substance

• Bulging of the disc, due to pressure from the material inside the disc (the nucleus pulposus)

• Herniation of disc material

Abnormalities of other spinal bone elements, referred to as spondylosis (immobility and fusion of vertebral joints) including:

• Bone spurs around spinal bone joints (“pinched nerve”)

• Enlargement of ligaments in the spinal canal

• Narrowing of the spinal canal due to the changes above (spinal stenosis)

• Spondylolisthesis (malalignment of spinal bones)

• Scoliosis (an abnormal side-to-side curvature of the spine)

• Abnormalities of tendons of rotator cuff muscles in the shoulder

• Tears of the knee cartilage (meniscus)

• Normal aging changes in the knee, called arthritis

• Changes in the hip caused by aging changes (arthritis)

• Bone spurs in the heel of the foot

• Many others less common conditions

In my experience, the majority of these abnormalities are not responsible for the pain. The cause of the pain is TMS, plain and simple. Nevertheless, despite the absence of proof that the abnormalities are the cause of the pain, the medical profession routinely treats those with surgery—in many cases, exorbitantly expensive surgery—as will be detailed.

To further complicate the problem, there are a number of soft tissue disorders that are also blamed for ...