The majority of back pain resists any sort of treatment or diagnosis because it’s an emotional pain, says Dr John Sarno. Cate Montana investigates
In February 1991, Warner Books published the unassuming title Healing Back Pain by John E. Sarno, MD (sarnoclinic.com), a professor of rehabilitation medicine at the New York University School of Medicine. An attending physician in the Department of Rehabilitation Medicine from 1965 until his retirement in 2012, at first Sarno had no idea his book and seminars about what he labeled “tension myositis syndrome” would change the lives of thousands.
He certainly didn’t anticipate hearing from hundreds of readers that years, and sometimes decades, of crippling back and neck pain had miraculously disappeared after they read his book and followed its suggestions. Certainly, this writer didn’t anticipate that choosing to read his book and write about this syndrome for WDDTY would result in a 90 percent reduction of crippling pelvic and buttock pain that had resisted every treatment under the sun and had been steadily worsening for the last seven years—a pain reduction that, to date, has taken only six weeks.
It all started in the early 1980s, when Sarno had become increasingly frustrated with treating patients for back pain according to the classical model. To this day, that model views back pain as primarily due to structural abnormalities of the spine, most commonly arthritic or disc disorders, compression of nerves due to poor posture, lack of exercise, etc.
“Over the years I became increasingly troubled with the fact that frequently the pattern of a patient’s pain and the findings on physical examination didn’t match the presumed pathology,” he writes. “For example, pain might be attributed to degenerative arthritic changes at the lower end of the spine, but the patient might have pain in places that had nothing to do with the bones in that area. Or someone might have a lumbar disc that was herniated to the left and have pain in the right leg.
“Even more important was the observation that 88 percent of the people seen had histories of such things as tension or migraine headache, heartburn, hiatus hernia, stomach ulcer, colitis, spastic colon, irritable bowel syndrome, hay fever, asthma, eczema, and a variety of other disorders, all of which were strongly suspected of being related to tension.
“It seemed logical to conclude that their painful muscle conditions might also be induced by tension. Hence, the name tension myositis syndrome (TMS).”
Tension myositis syndrome, tension myoneural syndrome, mind-body syndrome, neuroplastic pain, psychophysiologic disorders (PPDs)—the labels are many, but the results of treating specific chronic back and neck pain (and other related conditions) as a brain-induced pain syndrome rather than as structurally based conditions continue to impress.
Sarno’s initial physiological explanation for intractable chronic pain was that TMS begins with highly specific emotions and psychological conditions. These states trigger activity within the autonomic nervous system, resulting in local vasoconstriction (narrowing of blood vessels) and mild oxygen deprivation of certain muscles, nerves, tendons and ligaments. Sarno hypothesized that the lack of oxygen was responsible for the pain.
This correlation has never been proven and has subsequently been dropped as an explanation as more and more studies reveal that “the reign of pain lies mainly in the brain,” as Howard Schubiner, MD (unlearnyourpain.com), put it. He’s a clinical professor at Michigan State University College of Human Medicine.
Chronic back or neck pain (CBNP) is the leading cause of disability in the United States and in most other Western nations. The overwhelming majority of doctors and patients believe pain is almost entirely the result of structural issues, but some studies now suggest 85–90 percent of CBNP cases are nonspecific, with no clearly identifiable peripheral cause.1
Indeed, functional magnetic resonance imaging (fMRI) studies show that the pain response in the brain from an actual injury (for example, a burn) is basically the same as from hypnotic suggestion of a burn or from simply imagining being burned.2
In alignment with this new research revealing the brain’s role as both transmitter and creator of pain, the World Health Organization, in association with the International Association for the Study of Pain, has recently proposed classifying chronic pain as either primary or secondary in nature. Primary pain is defined as neuroplastic or “nociplastic” in origin, meaning it originates in the brain, because there is no clear evidence of actual or potential tissue damage. Secondary pain is defined as neuropathic or “nociceptive,” meaning the brain is responding to a painful physical stimulus with appropriate pain sensations.
“Traditional medical treatments for chronic pain are geared toward correcting an underlying structural pathology in the body,” says Schubiner. “In mind-body syndrome (TMS), there are reversible physiological changes to the brain and nerve pathways, but there is no underlying tissue breakdown.
“Standard treatments don’t address the true causes of these symptoms but try to cover them up. Pain medication, surgery, physical therapy, acupuncture, vitamins, herbs and all the other therapies recommended for these disorders will often provide at most partial or temporary relief because the person has not understood what caused the problem in the first place.”
Tradition dies hard. But many common explanations for chronic pain, such as “old injuries,” are now being revealed for the specious explanations they are.
Anybody who has ever cut themselves, twisted an ankle or broken a bone knows the pain goes away once the injury is healed. On average, a broken bone mends in six to eight weeks. A pulled muscle usually feels fine after a couple of weeks.
“You’re getting older, and your spine is degenerating,” is another common misdiagnosis. Schubiner points out that MRIs reveal 88 percent of asymptomatic patients at age 60 have disc degeneration, and 69 percent have disc bulges. But they experience no pain.
“Everybody experiences spinal degeneration as they age, starting in their 20s,” he says. “But that doesn’t mean there’s automatically going to be pain as a result.”
Studies back up this observation, showing that 56–90 percent of asymptomatic patients given MRIs have bulging discs, degenerative discs, herniated discs, arthritis, spinal stenosis and other common back issues, but no pain or dysfunction. This was true even among those aged 15–30.3
On top of that, a 1992 study controversially showed that only 10–15 percent of people with back pain could be accurately diagnosed using available medical tests,4 and today, over 30 years later, there’s still no gold standard test.
Additionally, Sarno, Schubiner and other researchers have discovered that the majority of patients suffering from CBNP do so during their peak earning years, between ages 25 and 50. The rate of people experiencing it sharply decreases after that—the exact opposite of what would happen if it were age/degeneration related.
So, if not structural issues, what causes the brain to start emitting pain signals, especially to the low back, pelvic and neck regions? Like Sarno, family and sports medicine physician Dr David Schechter in Los Angeles, California (schechtermd.com), points to emotional stress and anxiety.
“Functional MRI studies show that acute pain is experienced in the one part of the brain where you’d expect to see it—in the somatosensory cortex,” he says. “But chronic pain is really experienced more in the amygdala, the prefrontal cortex and other parts of the brain that are linked more to the psychological centers of the brain, executive functioning and other areas that relate to our thought processes, our worries, stress and that sort of thing.”
Sarno believed tension, stress and suppressed emotions lay at the foundation of TMS. “We have a built-in tendency to repress unpleasant, painful, or embarrassing emotions,” he wrote. “Anxiety and anger are two of those undesirable emotions that we would rather not be aware of, and so the mind keeps them in the subterranean precincts of the subconscious if it possibly can.
“The longer I work with TMS, the more impressed I am with the role of anger. We have all learned to repress it so completely that we are totally unaware of its existence in many situations. In fact, I have begun to wonder if unconscious anger is not more fundamental to the development of symptoms than anxiety and, indeed, whether anxiety itself may be a reaction to repressed anger.”
One of the most common things doctors hear from CBNP patients is there seems to be “nothing to explain all this pain.” But as Sarno, Schubiner, Schechter and other physicians familiar with TMS point out, once the patient is led to expose and discuss the trials and tribulations of their life, it’s usually clear that the person has been creating a lot of anxiety. Over time, emotional stress gradually builds up until it reaches a threshold, at which point the symptoms suddenly begin.
“I haven’t published this yet in the medical literature, but I’m creating a new taxonomy of TMS with different categories of causative stressors,” says Schechter. “One of them is obviously the emotional abuse of childhood category, which represents 10–25 percent of all TMS patients. Another category is the acute stressor, like the loss of a loved one or a divorce or career challenges.
“Then there’s the chronic stressor—for example, a musician who’s working as an accountant. It’s not a healthy fit for them. They deal with it to a certain degree, but eventually it comes out. Then there’s the classic personality-driven TMS cases that perfectly match what Sarno discovered.”
Worrier, perfectionist, hard on themselves, often a people pleaser, highly sensitive, somebody who’s concerned about fixing the whole world, who’s very responsible for others—these are the basic personality traits Sarno found in the vast majority of the thousands of TMS patients he worked with over the years. These traits reliably created unconscious tension and an overall buildup of stress in their lives and their bodies.
Many studies show that psychological stress can create “health-damaging behaviors.”5 Post-traumatic stress disorder (PTSD) has long been associated with the development of chronic back pain6 and is known to increase the severity of pain experienced in the body.7
And an article released in the US National Institutes of Health publication Pain Reports in 2023 states that how well or poorly a person mentally and emotionally responds to stress is directly linked to their odds of developing chronic pain.8
Unfortunately, TMS or mind-body syndrome is misdiagnosed in 60–70 percent of patients suffering from CBNP, Schechter says, based on his experience. The patient receives a scary diagnosis of a herniated disc or spinal stenosis that can be helped only by surgery or not at all, causing their stress to skyrocket and the pain to worsen.
And that, apparently, is one of the reasons a proper TMS diagnosis and knowledge about what they’re really dealing with sometimes results in a “miraculous” reduction and even total elimination of long-term pain “overnight.” The stress is identified, “disease” is eliminated, suddenly life becomes bearable and hope blossoms.
Although TMS remains poorly studied and almost completely unknown in both allopathic and alternative health circles, some studies show “psychosocial trauma” has a pronounced impact on neural processes and predicts the later presence and severity of chronic pain. They also show that psychophysiologic symptom relief therapy is highly beneficial for patients with nonspecific back pain.1
“Few patients and even fewer doctors realize that real and severe pain can be caused by stress and unresolved emotions,” says Schubiner. “It’s extremely difficult for people with severe pain, anxiety, depression or fatigue to grasp the idea that their condition is not caused by some kind of terrible physical damage or injury. It’s hard getting that message across, which is the main reason this condition, after over 30 years, remains so poorly known.”
The good news, however, is that more and more people are finally getting a proper diagnosis for chronic pain and other emotionally triggered, stress-related illnesses. “We’re not managing pain, we’re helping people to recover from it,” says Schechter.
“Not everybody gets 100 percent. But some do, and many people get close to it. And if you get even 70 percent relief from pain and dysfunction, you’ve gotten a lot more than anybody else is offering you. And you have a functional life at that point. And that’s a blessing.”
Statistically, the low back–buttock area is the most common location for TMS. But it also affects other centralized (trunk) areas, such as the neck and trapezius regions.
Symptoms usually start out mild or intermittent and eventually develop into a chronic pattern. Sarno identified different kinds of pain when muscles, tendons and/or nerves are affected.
It may be sharp, burning, shock-like and stabbing. Or it may feel like pressure, pins and needles, tingling and/or numbness. There may be weakness in your arms or legs.
And these symptoms can interchange and vary. Sometimes there may be no pain or sensations at all. Sometimes there may be shifting symptoms and inconsistent pain all over the body.
People with TMS usually receive multiple diagnoses over time but get little or no relief no matter what diagnosis is made and what treatment approach is taken. Another indicator is that they’ve typically experienced other tension-related illnesses, such as tension or migraine headaches, heartburn, hiatus hernia, stomach ulcers, colitis, spastic colon, irritable bowel syndrome, hay fever, asthma, eczema, hives, chronic constipation or chronic diarrhea.
Other common TMS symptoms are fibromyalgia, tinnitus, dizziness and vertigo, heart palpitations, eating disorders, OCD, urinary tract issues, temporomandibular joint disorder (TMJ), brain fog, depression and anxiety.
The TMS personality requires love, admiration and respect and strives hard to receive it. They have a powerful drive to achieve and often high levels of competitiveness. They also tend to be highly responsible, self-critical perfectionists who suffer quietly in an effort to avoid being a burden.
The first step in dealing with chronic pain is to get a correct diagnosis. “If there’s a tissue breakdown disorder, then go with traditional medical treatments,” says Schubiner. “But if you’ve been suffering for a long time, the doctors haven’t been able to adequately explain why you’re in so much pain, and your only option is pain medication, then you’re likely to have mind-body syndrome.”
“It helps to have your brain cleared of the other fallacious diagnoses you’ve gotten from your medical doctor or your chiropractor or your acupuncturist,” says Schechter. “It helps to then read and educate yourself about this condition through books and videos and online courses. There are a lot of free materials available.”
Talk to your brain. When there’s pain, move through it as best you can, reminding and reassuring your brain and body that there isn’t anything physically wrong.
Discontinue old therapies, medications, etc. They’re not working because they’re not needed. Continuing their use tells the brain you need them when you don’t.
Get the feelings/emotions out of your head and onto paper. Journaling is very helpful. So is therapy.
Consider the timeline of stresses and your symptoms. Do they coincide? Are you under stress now? Consider your childhood. Are your current stresses related to childhood stresses and traumas? If there was childhood abuse and trauma, Sarno highly advises therapy to help deal with recovered memories and support healthy integration.
Slowly resume physical activity. “I emphasize that people should start slowly but resume their physical activity,” says Schechter. “It’s vital for reframing your brain’s old messaging that ‘This is going to hurt!’
“I sometimes have people swim or walk for five minutes. That sounds like very little, but if you add a minute every other day, suddenly you’re at 30 minutes after four to six weeks, and you’re doing a reasonable amount of exercise.”
“Jane,” age 71, suffered debilitating, “life-altering,” costly back pain starting at age 29. Over the course of 11 years, the Southern California native saw many traditional doctors and received many different diagnoses, including, spondylolisthesis, a bulging disc, a pinched nerve, a herniated disc, different forms of arthritis including gout, even endometriosis.
In addition to allopathic doctors and physical therapists, she also saw alternative medical practitioners including acupuncturists, herbalists, chiropractors, masseuses and a biofeedback specialist. “The message I kept hearing from my doctors and other health practitioners was that I needed to learn to live with this back pain and that it was likely to just get worse with age,” she says.
Then, in 1994, after her most recent neurologist advised she be placed in a body cast for six months, she sat down and read Dr John Sarno’s book Healing Back Pain.
“I was a desperate skeptic at that point, with two young children,” she says. “Both were at school for a few hours, and I lay on the couch, racing through the book.
“And with every paragraph, light bulbs flashed in my brain and I kept thinking, ‘This is me. This is it! Yes, this makes total sense!’ By the time I finished the book, I knew I was cured.”
And she was. She got up, pain free, called her husband at work and announced the miracle. Then she gathered up all her back pain equipment—support pillows, back braces, medications, etc.—and tossed them in the trash. Except for a few twinges after extra-strenuous activity like gardening, hiking and such, she says she’s never had back pain since then.
That said, she quickly points out that “TMS is never one and done because it’s still a reflection of your temperament, your personality.” She says that every few months some sort of symptom will show up.
“But I know the characteristics,” she says. “For example, I was on a deadline and suddenly got an intense earache. At first, I thought it was an ear infection. So, I went to the doctor and she said, ‘You have trigeminal neuralgia.’
“And then it hit me: ‘Wait a minute. I’m stressed on a deadline. My kitchen is being remodeled. This is just a stress response. Okay.’ And that earache disappeared within half an hour.”
A professional photographer in Southern California accustomed to lugging around heavy camera equipment, Chris, age 55, says he was fortunate to have no back issues until he hit his 40s. Then, after getting off a super intense amusement ride at a park one day, his back went out.
“It got worse and worse and eventually led to sciatica,” he says. “I got an MRI done, and it showed an 8 mm disc protrusion that I was convinced for a long time was the fault of that ride.
“And I went through the whole cycle that everyone goes through. I did the physical therapy, then I did the chiropractor, then I did the acupuncture. Finally, after all of that failed, I started thinking about the surgery my doctor kept recommending.”
He was on the phone making the appointment for a microdiscectomy when his doctor casually mentioned he couldn’t lift anything for three or four months after the procedure. Because that would mean he’d have to quit work, it stopped him cold. Out of treatment options, he just tried to live with the increasingly debilitating pain.
Then, one day his wife mentioned Sarno’s book Healing Back Pain. He got a sample chapter, read it and got really angry. “I was like, damn it, this guy is saying it’s all in my head, but it’s not. The pain is real!
“But then I kept on reading and realized that wasn’t what he was saying. And then he started talking about the type of people that this affects. Perfectionist. People pleaser. Someone who’s excessively conscientious. It was all me.”
He read the book. And the pain persisted. So, he read it again. And again. And again. “I had to really stick with it because the knowledge has to really sink into your subconscious,” he says.
“And then I read more books on TMS. I think it took about a year or so, but the pain just gradually started to diminish and finally it left. It was really amazing. This knowledge changed my life.”
Since then, Chris says, he’s had little “flare-ups.” But between the books he still reads and the subsequent work he’s done under the supervision of Dr David Schechter, he’s learned how to get a handle on what’s driving any pain when it shows up.
“You have to plumb the depths of what’s really bothering you,” he says. “And it tends to be really, really existential kinds of things. Like the first episode of back pain was all about me and my wife having trouble having a kid, you know?
“It doesn’t get deeper than that. And we eventually did succeed. So, if something shows up now, I can usually pinpoint what the real cause is. And that’s all it really takes.”
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