I have been troubled all my adult life by disorders termed, which generally meant dismissed as, psychosomatic. These are disorders for which no physical etiology can be found, although they may have observable physical manifestations. From a psychological point of view, they have also recently been classified as somatoform disorders. As such, I was very interested to discover recently John Sarno‘s work on the subject.
Sarno’s basic premise is that just as emotional conflict can give rise to neuroses, so it also can give rise to pain and other physical conditions. This linkage may be direct, with Sarno positing that localized pain is a result of ischemia ordered by the central nervous system. Such emotional conflicts may also, via mechanisms which are presumably diverse, but which Sarno does not elucidate, result in afflictions to which non-psychological factors also contribute, whether in terms of their etiology or their clinical development. A key feature of Sarno’s posited diagnosis of tension myositis syndrome (TMS) is the variability in its lifetime expression. As such, it is an umbrella diagnosis or metadiagnosis for a variety of syndromes which have in common a non-progressive character. For a fuller discussion, read his 2006 book The Divided Mind.
I suffered in my early teens from clinical depression and situational urinary incontinence. By my mid-teens, this was replaced by muscular fasciculations, which I was convinced for a long time had to be a manifestation of a degenerative condition. Muscular function remained mechanically and electrically normal however, and much later this was officially classified as “benign fasciculation syndrome” (although it has receded, I am not fully free of it to this day). I went on at college to develop chronic fatigue syndrome, which at one point resulted in my being almost unable to walk. I also suffered at that time from migraines and back pain, and peri-orbital migraine was a regular occurrence for many years afterwards. During all this time, there have been no notable biochemical abnormalities observed.
Now I have not been monitoring bodily symptoms against my emotional state for many years and so I cannot provide a full account; it has changed immensely for the better, but I have still had my share of annoying things, in particular abdominal pains, and six or seven years ago Achilles tendinitis. Around May last year I developed plantar fasciitis on the left foot; it took a year to heel but then almost immediately the right foot developed the same symptoms. It has been quite debilitating as strenuous effort has tended to worsen it. All this led me to seek effective relief from the pain in various ways, a subject to which I will return.
Sarno’s notion, therefore, is very appealing. Indeed, given the importance of physical complaints, so called “hysterical conversion“, in the early development of psychoanalysis, it is not quite clear why attention has mostly been subsequently restricted to behavioral neuroses, especially outside of the Reichian tradition. Even if the mechanisms remain obscure, it is attractive to view psychosomatic disorders as somatic forms or expressions of neurosis.
However, I suspect the brain is less involved in mediating this relationship than we think. Sarno claims that the pain is directly generated by the brain as a diversion from unwanted emotions which threaten to break through into consciousness. I fancy this is otherwise: the brain is involved, certainly, in the repression of emotions, and by preventing their expression it prevents their discharge. The bodily symptoms, however, do not necessarily require neurological involvement and may arise on the basis of pure biochemistry. This is illustrated by research on the role of myofibroblasts in the mechanic regulation of connective tissue (see here). To me, the idea that the brain is busy, like some cranky old Wizard of Oz, devising ways to present consciousness with ever-new diversions seems crude, and it is not required to explain Sarno’s clinical outcomes. Variation in the site of pain may have simple biomechanical explanations.
So Sarno’s work is pathbreaking and liberating, definitively contributing to a shift in understanding of psychosomatic disorders, but it nonetheless needs to be taken with the necessary pinch of salt. Sarno offers, in The Divided Mind, no epidemiological data to back up his claim that the syndrome chosen by the brain is a matter of fashion (in a Kuhnian perspective, it is of course much more plausible that it is the diagnosis and corresponding collection of statistics which is driven by fashion, rather than the patient’s symptoms, especially since many of these diagnoses are evidently imprecise). He also offers no evidence to back up the conjecture that local ischemia explains the pain or that this is cerebrally induced (and if so, how). Indeed, the locus of pain is not discussed either, and some statements suggest Sarno does not have a deep understanding of myofascial biochemistry.
Sarno follows the usual path of airbrushing Reich out of the history of psychoanalysis, although it should be obvious that Reich was the first to look at the body and mind as a whole. However, his major error is to follow Freud’s mistrust of the id and misplaced trust in the superego. Freud, as we know, viewed repression as in many ways akin to a virtue upon which civilization depended. Sarno also paints a picture of the “childish, primitive” unconscious as the enemy within, even referring to it, with patent ideological bias, as the “dregs of evolution”, contrasting it to the “ethical and moral” conscious mind, a view hardly conducive to integration and well-being, and one which even Freud would have struggled to maintain (Nietzsche of course having demolished it comprehensively). His negative views of the moral quality of children are particularly depressing in their Calvinist overtones.
Several of Sarno’s statements in relation to brain neurology seem completely wrong: for example he attributes “rational, civilized” behavior to the neocortex, labeling it “that part of the human brain that has been added in the process of evolution”, even though the neocortex developed in the first mammals. The attempted equation between brain structures and Freud’s threefold division of the mind is presented as fact, whereas it is not a notion entertained by any mainstream psychoanalyst or neurologist. Indeed, Sarno oscillates gaily between the unconscious/preconscious/conscious model and the id/ego/superego model as if they were the same thing.
All this aside, this is a book which opened my mind to what now seems like an obvious fact but has long gone unnoticed, namely that the mind does not simply affect the body in vague, unspecified ways but perhaps in very specific ways where a direct link can be drawn between emotional circumstances and pain. It is pretty clear now to me what the circumstances were which led to both episodes of plantar fasciitis, and I am inclined to agree with Sarno that this knowledge is immensely emancipatory.