Tag: muscles

John Sarno’s work on the etiology and treatment of psychosomatic disorders

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.

Reich’s economic model of psychosomatics (2 – the biological core)

Following his discovery of the link between sexual repression and character, Reich inquired into the nature of the mechanism underlying this link. His starting point was the observation that there existed, even if they were hard to codify, characteristic postures and facial expressions which allowed the most unlearned observer to decipher the character disposition of his interlocutor. Reich hypothesized that these resulted from, in the main, hypertonicity of certain functional muscle groups. Almost all muscles display in equilibrium or at rest a natural level of contraction called tonus. When this equilibrium is disturbed by a constant perception of threat, muscles become pathologically hypertonic. The attitude habitually assumed, be it of aggression, mistrust, helplessness etc, then becomes anchored in the muscular economy with attendent effects (though Reich does not discuss this) on skeletal development as well. Reich contends that the somatic and psychic expression of neurosis are functionally identical and mutually reinforcing. The somatic expression he calls the “biological core” of the neurosis. It is similarly this pattern of muscular spasticity which disrupts the orgastic response.

Reich goes on to make his central conjecture, laid out in Function of the Orgasm, that the natural orgasm serves a purpose of discharging vital energy and thereby regulating the energy economy of the body; this is thus a direct somatic parallel to Freud’s libido theory. Disturbances of the orgastic function compel the organism to regulate its energy economy otherwise, whether by reduced energy production (lethargy) or by other, imperfect mechanisms such as compulsive behaviors which only kick in when the tension has reached an unbearable level and then only partly resolve it.

The hypothesis of the “functional identity” of the neurosis and its somatic expression allows Reich to complement then-existing psychoanalytic techniques with a body-oriented approach and, he claims, achieve more consistent results, more rapidly, as well as penetrate some types of neurosis which were less amenable to traditional methods. His espoused technique advocates alternating opportunistically between addressing psychic and somatic blockages. This he called “vegetotherapy” in an allusion to its effects on the vegetative, or what we would now call the autonomic (i.e. involuntary) nervous system. How he did this in practice seems to be less well documented, perhaps because his discovery of the biological core of psychic neuroses leads him into more speculative areas of inquiry and the period of his interest in psychosomatic therapy is as a result relatively condensed, leaving methodology to be developed by others.

This new period in Reich’s life is underscored by a realization that sexual repression has not only somatic effects with psychic correlates – neuroses – but also that these primary somatic effects have in the long term direct secondary chronic effects at the somatic level in the form of illnesses such as cancer, dementia and rheumatic arthritis. This takes the hygienic challenge a long way from treated self-reported actual neuroses with anecdotal curiosities in turn-of-the-century Vienna to treating major plagues of contemporary civilization, both psychic and somatic.

Part 3: Reich’s legacy

On the energy economy of the masochistic body type

Some thoughts from personal experience on this topic. This entry is mainly based on self-analysis, on the basis of which I draw some general conclusions; I freely admit the methodological flaw in this way of reasoning (and even more so since I am not a “pure” example of this body type*), but those who are interested in a more systematic account will anyway refer to the literature on the subject. So:

By virtue of repeated violence and threats of violence during early childhood, the masochistic body type (“Maso”) develops two sets of marked body patterns.

Firstly, spasticity of the following muscles or muscle groups: (i) buttocks and thighs (gluteus medius and minimus, pectinius, quadriceps, rectus femoris, and the hip adductors); (ii) the deep pelvic and perineal muscles (the pelvic floor, which consists of three muscles, and the perineal pouch, see here for photo) involved in defecation and urination as well as in maintaining posture and (iii) the transversus and rectus abdominis muscles.

The original purpose of tensing these muscles was to protect the genitals from damage. The need to protect the genitals also has a symbolic interpretation and charge, insofar as it represents an attempt also to defend the ego from assault. The spasticity of these muscles is naturally paired with a lack of tonus in the muscles which move the hip and pelvis upwards and outwards.

Associated with this, a pattern of breathing is developed in response to pain and assault whereby oxygenation of the pelvic region is reduced, and thereby also its sensitivity to pain. This appears to involve primarily the transversus abdominis muscle, which is the deepest of the abdominal muscles and inserts into the linea alba (the line which runs from the solar plexus downwards). Spasticity of this muscle effectively shuts off energy flow along the front of the body, separating the pelvic region from the abdomen. It also limits the depth of abdominal breathing.

In addition to this, the Maso develops constrictions in the jaw and throat, running as far down as the solar plexus and also involving the pectoral muscles. These constrictions aim at inhibiting the vocal expression of anger and pain. The effect of constrictions in this segment is also to draw the shoulders forward and to compress the sternum from the manubrium (upper part of the sternum) which is compressed by the clavicles until the xiphoid process (region of the solar plexus).

In combination, these two groups of muscular spasticities arch the spine in the form of a C, a posture which expresses and communicates resignation and defeat.

Such spasticities develop in early childhood and inevitably have a permanent developmental impact at the skeletal level. The anatomy in particular of the pelvis/hip area is affected by the imbalance between muscle pairs which results from permanent tension in the adductor muscles.

The Maso’s energy economy is characterized by a high level of primary energy in the genital region but a limited ability to circulate and use this energy, requiring discharge at low thresholds, or otherwise manifesting as anxiety. Essentially, the Maso is unable to tolerate a high level of energy is his body, because of the fact that this energy overcharges the genitals. Compulsive masturbation is a way to avoid anxiety. Anxiety manifests itself because the discharge of energy has been blocked. As anxiety increases, discharge scripts are cathected. These scripts are typically sexual in character and develop into more or less developed forms of obsessive-compulsive behaviour. Such scripts may be actually enacted, or merely direct the expression of sexual desire. The masochistic character also has a tendency to overuse and possible abuse of alcohol. In my case there is also a tendency to compulsive eating and obesity, which is a common, but I am not sure whether general, characteristic of the body type.

Clearly, the therapeutic challenge is to loosen these two sets of primary rigidities and to deepen the breathing so that the pelvic area is better oxygenated.

*) As regards physical body armoring, however, I think this type predominates, both based on self-observation and on theoretical grounds which I omit.