The Tension Myoneural Syndrome Hypothesis Explained: Q&A With John Sarno, MD

This article originally appeared in "Pain Medicine News" and is archived here for nonprofit educational purposes. It is linked to from Day 24 of our Structured Educational Program.

FEBRUARY 7, 2011
The Tension Myoneural Syndrome Hypothesis Explained: Q&A With John Sarno, MD

Musculoskeletal pain syndromes are commonplace, from bad backs to carpal tunnel. These syndromes often are intractable, leaving patients in pain for years. John Sarno, MD, professor of rehabilitation medicine at New York University School of Medicine, New York City, says that these ailments are psychogenic and can be grouped into one syndrome, which he calls tension myoneural syndrome (TMS). If patients understand this, he believes, their symptoms will simply dissipate. Dr. Sarno has seen more than 10,000 such patients over 30 years, and says roughly three-fourths of them have gotten better. Pain Medicine News recently interviewed Dr. Sarno to discuss his theory.

(This article was originally published as a Web Exclusive on PainMedicineNews .com. Interview by David C. Holzman. Disclosure: This interviewer had carpal tunnel, which was cured by reading one of Dr. Sarno’s three books on this subject.)

PMN: How did you come up with this diagnosis and treatment?

Dr. Sarno: I have always been aware of the importance of emotional phenomena. Years ago, before I established my practice, I developed symptoms of hay fever at the appropriate time during the spring. Yet, I remember asking myself, “Wait: what’s going on with you psychologically?”

For a number of years, in my work I was preoccupied with the problems of rehabilitating people with stroke, spinal cord injuries and other ailments. Little by little, I began seeing patients with intractable pain, which I had always attributed to some structural abnormality. I discovered, however, that in the case of back pain, and in other pain syndromes as well, structural abnormalities often do not correspond to the pain. For example, a study by Maureen Jensen et al. published in The New England Journal of Medicine concluded that “The discovery by MRI [magnetic resonance imaging] of bulges or protrusions [in discs] in people with low back pain frequently may be coincidental.” [Editor’s note: N Engl J Med 1994;331:69-73].

When this is the case, patients who learn about TMS usually can get better. In 1987, I surveyed 109 patients who complained of back pain that they attributed to a herniated disc. After I educated them about TMS, 96 (88%) either became completely pain free or very close, reporting being free of physical restrictions and fear of pain.

PMN: Why do people develop this psychogenic pain in the first place?

Dr. Sarno: The physical pain serves to distract the patient’s attention from emotional pain or rage, which often derives from the pressure people put on themselves to be good or perfect. It’s amazing how often this is a prime factor driving a person’s psychological state. What happens is this: In an attempt to live up to these high standards, something in the unconscious—an inner child—is made very, very angry. I think that’s probably the major dynamic I deal with.

Patients often ask me, “Do you want me to start being nasty?” and I say, “No.” I simply want them to understand that the drive to be perfect angers the unconscious. Once the person recognizes that this is what is happening, they no longer automatically react to pressure with anger and rage. They no longer need the distraction of physical pain.

PMN: What illnesses are caused by TMS?

Dr. Sarno: Besides musculoskeletal maladies, the most common illnesses are gastrointestinal. Migraines and other headaches are classic problems as well. Other ailments include recurrent sinus infections and “globus hystericus,” the feeling you have a lump in your throat despite having no pathology. People also report a broad range of allergic reactions as well as genitourinary problems, particularly involving frequent urination.

PMN: How does the brain produce all of these symptoms?

Dr. Sarno: The brain probably produces these symptoms by slightly reducing the amount of oxygen available to circulate in the body. Your brain has exquisite control of your entire circulatory system. If it wants, your brain can deprive a pinhead-sized portion of your arm of oxygen.

I developed this TMS hypothesis because conventional physical therapy for musculoskeletal manifestations—which gives most patients at least temporary relief—consisted of deep heat in the form of high-frequency sound waves, deep massage and active exercise of the muscles involved. All of these treatments boost circulation. It seemed logical that the brain was causing all this through the autonomic nervous system, which controls blood flow.

Migraines provide an excellent example of this process. The migraine is a condition of spasmodic narrowing of the blood vessels. The narrowing usually takes place in one large blood vessel, such as the carotid. First you experience pain, and if it persists long enough, you may have a stroke. Several studies support this oxygen-deprivation hypothesis.

I believe that unconscious rage is extremely common and leads the brain to produce distracting symptoms. It’s a scary thing that your unconscious rage can lead to serious physical symptoms. I honestly believe that people can die of anger without their doctors ever knowing the true cause.

PMN: To paraphrase a quote about cigars attributed, perhaps apocryphally, to Sigmund Freud, is a bad back sometimes just a bad back?

Dr. Sarno: That’s very rare. In other words, you could have bone disease, which would produce pain, but that’s easily recognized with appropriate imaging. The vast majority of bad backs involve minor abnormalities, which I find are completely benign, but are often blamed for the pain. That diagnosis immediately gets the doctor off the hook. He can prescribe conservative measures or surgery. I would judge that 90% of back, neck and shoulder surgery is unnecessary.

PMN: Do other bodily systems cause similar syndromes?

Dr. Sarno: Some mind–body disorders appear to be mediated by the neuroendocrine-peptide system. These include bulimia, anorexia nervosa and chronic fatigue, which in Freud’s time was known as neurasthenia. In the case of chronic fatigue, physicians from three of the United Kingdom’s royal colleges issued a report in 1996, which suggested that psychological factors were primary causes of pain syndromes, and that therapy consisting of psychotherapy and physical activity was most effective (Chronic Fatigue Syndrome, Council Report CR54. London: Royal Colleges of Physicians, General Practitioners & Psychiatrists). A 1993 paper on neuroendocrine–immune interactions in The New England Journal of Medicine (N Engl J Med 1993; 329:1246-1253) concluded that “central nervous system influences on the immune system are well-documented and provide a mechanism by which emotional states could influence the course of diseases involving immune function.”

PMN: What are the most compelling criticisms of your theory?

Dr. Sarno: I’ve never seen any compelling criticisms. If my ideas represented a threat to the usual practice of medicine, you can be sure many people would be criticizing them. But I don’t think most doctors take it seriously enough to feel they have to do something. Most doctors are like automobile mechanics. Very few are willing to say that the symptoms are the results of a psychosomatic process.

PMN: Is it possible that some alleged “treatments” for some of these diseases are actually distractions in the same manner as the illness? I’m thinking of colonic irrigation, for example.

Dr. Sarno: Colonic irrigation is a placebo. If the person continues to use it, in two, three or four months it won’t work anymore and he [or she] will have to find another placebo. The placebo phenomenon is enormous in medicine.