Back Pain and Anorexia

Back pain. Responsible for billions of dollars in lost worker productivity, it’s one of the most common and disabling illnesses in America today.
And one of the most puzzling. Orthopedists, osteopaths, chiropractors, acupuncturists, and other health-care professionals all have different ideas about its causes and treatment. One controversial approach posits that most back pain is due entirely to emotional factors which cause benign physical changes in the body.

John E. Sarno, M.D. is Professor of Clinical Rehabilitation Medicine at the New York University School of Medicine and attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine at New York University Medical Center. Over the past 25 years, he has treated many thousands of patients with disabling back pain through educational lectures and claims a 90-plus percent success rate. He has written extensively on the subject, including his two most recent books, Healing Back Pain (Warner 1991) and The Mindbody Prescription (Warner 1998).

According to Sarno, most back pain is caused by tension myositis syndrome (TMS), a condition in which repressed rage causes the brain to select certain parts of the body for mild oxygen deprivation. The most frequently targeted areas are the neck, shoulders, and middle and lower back. Although “myo” means muscle, Sarno notes that nerves and tendons can also be involved.

Sarno’s theory, which draws heavily on psychoanalytic concepts, posits that the driving force behind back pain is unconscious or repressed rage. The pain serves as a distraction to prevent the sufferer from dealing with terrifying thoughts. According to Sarno, the rage is comparable to dangerous criminals in a maximum security prison. Unacceptably frightening thoughts exist below the level of consciousness but are constantly struggling to reach awareness.

Sarno says that there are three sources for the rage: past anger; a sense of inferiority; and daily life pressures. Past anger may involve childhood traumas such as sexual or extreme emotional abuse. Daily life pressures include work deadlines, taking care of children, and even positive life events such as getting pregnant or married.

One of the most interesting parts of the theory involves the sense of inferiority. It is more fully described in The Mindbody Prescription. According to Sarno, the “child,” what Freud called the “id,” is an illogical, narcissistic part of the unconscious that is easily angered. A desire to be perfect, to do “good,” and other self-imposed pressures enrages the “child,” adding to the reservoir of anger.

So what does all this have to do with anorexia nervosa?

Sarno posits the existence of “TMS equivalents,” other psychosomatic conditions besides back pain, which proceed according to the same model. These include such common ailments such as tension headache, migraine, constipation, diarrhea, and certain allergies. In addition, Dr. Sarno identifies a category of more serious illnesses in which TMS may play a role, including high blood pressure, arteriosclerosis, and even cancer.

On page 184 of the appendix to The Mindbody Prescription, Sarno suggests that eating disorders are psychosomatic in nature and follow the TMS model: “I have had many patients who have moved from more severe psychosomatic manifestations to milder ones: bulimia or anorexia nervosa to back pain, for example. My interpretation is that they have improved psychologically and no longer require the powerful distraction.”

Similarly, on page 130, he notes: “The more deeply repressed the rage, the greater the potential for serious illness. That idea is, of course, highly theoretical.”

It is not surprising that emotions play a powerful role in the development of anorexia nervosa. Previous articles on this topic page have stressed the psychological factors involved in eating disorders (see “The Psychological Basis of Anorexia Nervosa,Part I and Part II”). What makes Dr. Sarno’s theory unique is that it attempts to explain a whole host of illnesses, from mild to severe, with a single, unifying “mindbody” model.

As stated previously, the theory is highly controversial. Most members of the medical community reject it, preferring a “structural diagnosis” for back pain (e.g., disc herniation or degeneration). It should also be noted that Dr. Sarno has no psychoanalytic training, although he professionally associates with psychotherapists whom he recommends for patients with more intractable emotional difficulties. And although he believes that most back pain is due to TMS, Dr. Sarno stresses the importance of having a thorough medical examination to rule out serious disease.

Among Dr. Sarno’s supporters are Benjamin J. Sadock, M.D., professor and vice chairman of the Department of Psychiatry at NYU Medical Center, and Dr. Andrew Weil, a graduate of Harvard Medical School well-known for his writings on complementary medicine and mindbody phenomena. On page 4 of the May 2000 edition of his newsletter, Self Healing, Dr Weil writes: “According to John Sarno, MD, a physician who has greatly influenced my thinking on the subject, back pain can be a defensive mechanism. The unconscious mind may distract you from uncomfortable emotions by keeping back muscles in spasm.” On page 4 of the October 2000 edition of Self Healing, Dr. Weil adds: “Many patients have told me that just reading one of Dr. Sarno’s books has given them a new perspective on their situation, helped them focus on relaxing the affected muscles, and resolved their pain within a short time, often forever.”