- Editor's Note - John E. Sarno, MD, is a pivotal figure
in the arena of pain management because of his hotly debated approach
to the diagnosis and management of back pain.
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- Dr. Sarno, Professor of Clinical Rehabilitation Medicine
at New York University School of Medicine, and Attending Physician at
The Rusk Institute of Rehabilitation Medicine at New York University
Medical Center, is the author of 3 books that postulate the theory that
most back pain is triggered by psychological origins instead of by a physiological
defect.
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- This phenomenon, which is known as tension myositis syndrome,
may also be the culprit in other pain disorders.
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- Dr. Sarno sat down with Medscape's Pippa Wysong to spotlight
how he became interested in pain management and outline how he came to
structure his precepts for freeing his patients from back pain.
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- This is the first of a 2-part interview.
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- Medscape: I think our readers would be interested in
starting off with how you first became interested in back pain. What triggered
your interest?
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- Dr. Sarno: I became interested in back pain when I came
to the Rusk Institute here at the New York University Medical Center as
head of the outpatient department. I was exposed for the first time in
my medical career to large numbers of people with back pain. To make a
long story short, after a few years of making the conventional diagnosis
and administering the conventional treatments, I came to the conclusion
that there was something terribly wrong, because my results were as poor
as everybody else's. I found this frustrating and decided I'd better take
a closer look at this and really question the diagnosis.
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- Medscape: In your opinion, what was wrong with the diagnoses
of back pain? What did you find?
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- Dr. Sarno: When I started to look into it, I found that
large numbers of people in whom the pain was being attributed to some
structural abnormality actually had a totally different disorder. It
was a disorder in which the pain was very real, but it was initiated by
emotional factors.
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- Medscape: Emotional factors such as...?
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- Dr. Sarno: It primarily had to do with the stresses in
patients' lives and, interestingly enough, the stresses that they put
on themselves. Once I began to make this diagnosis and to deal with it
accordingly, for the first time I began to have success. And of course
that's why I started to write books about this. But here in the United
States virtually no one in the medical profession is willing to consider
this diagnosis. That's, incidentally, very, very important. I do not have
an approach to dealing with pain but rather the stresses that cause it.
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- Medscape: Are the stresses that lead to back pain, as
you say, very common?
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- Dr. Sarno: It is more than back pain. What we can refer
to as stress-related disorders have turned out to be more widespread:
It's low back, upper back and neck; it's pain involving the knees, pain
involving the feet. >From what I understand from an article in the
New York Times, there were 10 million people in the United States with
foot pain, which is an epidemic. And all of these pain syndromes have
spread in epidemic fashion in the United States over the last 30 years
-- precisely because they are mind/body disorders that have been incorrectly
diagnosed, and therefore, as far as I'm concerned, incorrectly treated.
I want to make that clear: The major factor is not what treatment one
employs but what diagnosis one makes.
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- Medscape: Can you describe some of the diagnostic features
you use? What about the physiology?
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- Dr. Sarno: Let me tell you very briefly about the physiology.
I've based my findings on clinical experience and the way patients reacted
to conventional treatments, as well as through material from the clinical
literature. What is actually causing the pain in these people is not the
herniated disc, or some of those other structural things, but a condition
of mild oxygen deprivation, which is brought about by the brain simply
altering the blood flow to a particular area. This mild oxygen deprivation
is what causes pain in muscle.
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- Take sciatica as an example. There are a number of spinal
nerves going into the leg via the sciatic nerve and the brain would mildly
oxygen-deprive them. That would then, of course, give you pain in the
leg, and give patients feelings of numbness and tingling. It would also
produce actual weakness. But doctors have assumed that these changes and
symptoms in the leg were the result of some damage to nerves in the low
back -- as a result of herniated discs and things of that sort.
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- Medscape: What exactly does the oxygen deprivation do?
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- Dr. Sarno: It produces symptoms. Oxygen is a crucial
substance for normal function. You can't do without it for more than a
few minutes or cells begin to die. When there is even a minimal reduction
in the oxygen supply to a tissue, say a muscle, a nerve, or a tendon --
those are the 3 tissues that we realized the brain might target in order
to produce this disorder.
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- Medscape: Are you saying that this oxygen deprivation
is the underlying cause for all back pain?
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- Dr. Sarno: The underlying thing in this diagnosis, yes.
If it involves a tendon around the knee, for example, the patient will
have a painful tendon there. Invariably a magnetic resonance imaging
(MRI) study will be done and doctors may find a minor tear of the meniscus,
the cartilage, in the knee and say, "That's where the pain is coming
from."
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- Invariably there are alternative explanations. For example,
shoulder pain is very common now. With MRI studies demonstrating abnormalities
of the rotator cuff, immediately doctors and radiologists will say, "That's
causing the pain." So, for every area in which people have pain,
one can find structural abnormalities of one kind or another.
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- Medscape: According to your theory, structural abnormalities
don't even contribute to the condition.
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- Dr. Sarno: In my experience they have nothing to do with
the problem in many cases. I can't say in 100% of instances, but in many,
many cases I've concluded that they have nothing to do with the problem.
Of course, my proof is that my patients get better. They couldn't possibly
have gotten better if the pain were due to the structural abnormality.
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- Medscape: If there is a structural abnormality, doesn't
it need attention?
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- Dr. Sarno: No, no, no, no, no, that's the whole point.
From what I've been able to gather, you see there's so much material in
my books and really we're trying to capsulize this now.
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- Here's an example: There was a paper published in 1994
by a doctor and her colleagues in the New England Journal of Medicine.
They performed MRIs on about 98 people who had no history of back pain.
The researchers found normal discs in only 36% of the people. Everyone
else had bulges, herniations of various kinds, and so on, and yet no pain.
That's the kind of information that doctors in this country totally ignore.
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- Medscape: Who was the lead author of that study?
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- Dr. Sarno: Maureen Jensen. This and other studies are
referenced in my books.
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- Medscape: Do you have a name for this oxygen-deprivation
disorder?
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- Dr. Sarno: Yes. Incidentally, it's a name that's become
somewhat obsolete, but, since I've used it in 3 books I continue to use
it -- tension myositis syndrome (TMS). It's called a syndrome because
it has so many different manifestations. In the late 1980s, I realized
that nerve involvement was also part of the syndrome and then later, tendons,
too. In fact, I now believe that nerve involvement is much more important
in the syndrome than muscle involvement.
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- Medscape: Can we back up and see how you came to the
idea that oxygen deprivation was behind all of this?
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- Dr. Sarno: First of all, there are some papers that suggest
that. Clinically it was because I had observed, when I was doing conventional
treatment in prescribing physical therapy, that the things that seemed
to relieve the pain temporarily, but pretty definitely, included deep
heat in the form of ultrasound, deep massage, and active exercise. All
3 of these increase the local circulation. I said to myself, "That
probably is what the brain is doing to produce the pain; it is reducing
the blood flow."
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- Medscape: Do you have physiological studies or cellular
samples to show what's going on, as proof?
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- Dr. Sarno: The studies that were done to demonstrate
this were done by a rheumatologist on fibromyalgia. In my experience,
fibromyalgia is nothing more than a severe form of TMS. Rheumatologists
got interested in fibromyalgia in the 1980s and did studies. One group
in Sweden did 2 studies that made it very clear that mild oxygen deprivation
was the reason for the pain in the muscles in people with fibromyalgia.
This supported what I had concluded on clinical grounds.
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- Medscape: Can you elaborate?
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- Dr. Sarno: Now let me tell you something interesting.
Having said this, it wouldn't make any difference if there were a half
a dozen other explanations for the pain, as long as it was clear in one's
mind that the brain was doing this. That the brain was producing symptoms
-- and this is the heart of the matter and this is what's extremely important
-- we haven't gotten into the psychology yet. But the brain was producing
symptoms in order to protect the patient from psychological trauma, turmoil,
something of that sort. And I came to that conclusion only after many,
many years. I wasn't ready to say that until I published my book, The
Mindbody Prescription, in 1998.
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- Medscape: So we're shifting from a physical cause to
a psychological cause?
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- Dr. Sarno: What has been clear right from the beginning
is that people were responding to stressful situations in their lives.
Even more interesting, people were responding to the pressures and the
stresses that they put on themselves. I came to realize that people who
tend to be perfectionists -- that is, hard-working, conscientious, ambitious,
success-oriented, driven, and so on -- that this type of personality was
highly susceptible to TMS.
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- Later, I realized that there is another kind of self-induced
pressure, and that is the need to be a good person. This is the need
to please people, to want to be liked, to want to be approved of. This,
too, like the pressure to excel or to be a perfectionist, is a pressure
and seemed to play a big role in bringing on this disorder.
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- Medscape: How would you say this all plays a role?
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- Dr. Sarno: You might say, "What is wrong with trying
to be perfect and trying to be nice and good?" Nothing is wrong in
terms of our conscious lives. However, in doing this work I had to become
very knowledgeable about the unconscious mind. Sigmund Freud's work is
critical in this regard because he introduced us to the idea of the unconscious.
I realized that these self-imposed pressures were causing some difficulty
inside our minds. There's a leftover child in all of us that doesn't want
to be put under pressure, and indeed it can get very, very angry. It began
to look as though the primary factor psychologically here was a great
deal of internal anger to the point of rage.
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- Medscape: So this is the crux of your theory, that it
has to do with internalized pressure and rage?
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- Dr. Sarno: Self-imposed pressure is one of the sources.
It's difficult to understand because one has to think in terms of what's
going on in the unconscious mind. There are other kinds of pressures
that are equally important, the ones that life puts upon us. Pressures
from our jobs, our personal lives, our marriages, our children, and so
on. It turns out that these pressures were equally disturbing to this
leftover child inside of us.
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- Then a third category, which is also extremely important,
are the angers that might be left over from childhood. These can extend
all the way from outright abuse to what I call subtle abuse. Say, parents
that expected too much of a child, or parents who didn't provide enough
emotional support.
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- Medscape: These all contribute to pain?
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- Dr. Sarno: Things of this sort could contribute to a
reservoir of rage that I believe we all carry around inside of us. This
is part of the human condition in Western society. It's because we're
all under such pressure, and so many of us are conscientious and hardworking.
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- Medscape: So you're saying it's a psychological problem?
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- Dr. Sarno: It turns out that the rage is the primary
difficulty.
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- Medscape: This is a very different approach from other
back-pain professionals.
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- Dr. Sarno: Yes, it is.
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- Medscape: You said that there is internal rage and anger
in the brain, and that these are responsible for symptoms of back pain,
not structural defects.
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- Dr. Sarno: It becomes clear why the brain produces these
symptoms: They are intended to be a distraction to make sure your internal
rage does not come out. The unconscious has been described by some writers
as a kind of "maximum-security prison" where the brain keeps
undesirable feelings or dangerous feelings repressed.
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- One reason why I've concluded that we all have rage inside
of us is because there are other "equivalent" physical states
that seem to be serving the same psychological purpose -- conditions that
are analogous to back pain. I'm referring to [gastroesophageal] reflux,
which is very common; irritable bowel syndrome; headaches; common allergies;
hayfever; and asthma. I'm referring to common skin disorders like eczema
and others. The skin is a great area that the brain uses to create symptoms.
These conditions all serve the same purpose: to keep one's attention focused
on one's body.
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- This is important in medicine. It's all so universal,
and it's important to make the right diagnosis. If you make the wrong
diagnosis, if you attribute the pain to something structural, or if you
say, "The reflux is due to your stomach acting up and you have to
take this drug or that drug," then people will continue to have symptoms.
This is why the back pain problem is of epidemic proportions in the United
States.
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- Medscape: Just to clarify: You're saying that a lot of
these conditions are due to a translation of stresses, anger, rage in
the brain to physical symptoms?
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- Dr. Sarno: No. It's not a translation, the brain is doing
this as a protection. Protecting you from the unconscious rage and other
bad feelings you might have. The reason childhood things are a factor
is because -- and we've known this for over 100 years -- the unconscious
has no sense of time. In other words, things that happened to us when
we were 8 or 10 years old, if they're emotionally powerful, are still
there at the age of 40, 50, 70, or 90.
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- Medscape: Perhaps we can move on to treatment?
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- Dr. Sarno: Of course. Now remember, it's not an approach,
it's a diagnosis. If you want to know what I do about it therapeutically,
and this is very interesting, I teach people what's going on. Believe
it or not, doing that will stop the pain in many cases. There is a small
army of people out there who have gotten totally better just by reading
one of my books. I mean totally better. I get letters all the time from
people around the United States telling me how this happened and they
can't believe it; they've had the problem for years and read the book.
The reason that they get better is because they accept the idea that what
is causing their pain is that disorder. That's crucial. That's the point
of my teaching my patients. Obviously my patients are those who have not
gotten better just from reading one of the books, because virtually all
have done that before they come to see me. It's clear that they need something
more.
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- But those who stay with the program will get better.
I think most people recover simply by learning in greater detail what's
going on, by going into the specifics of the pressures in their lives
that are most important and so on.
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- About 20% of the people who come to see me, who come
into my program, cannot apparently get better until they've spent some
time working with one of my psychologists. Psychotherapy is needed for
about 20% of the patients.
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- Most patients in the United States cannot accept this
diagnosis. So I calculate that I'm working with representatives of perhaps
10% or 15% of the population. Secondly, 99.999% of the medical profession
does not accept this diagnosis.
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- Medscape: Do you get much flak from the medical community?
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- Dr. Sarno: No, I don't get any flak because there's no
occasion for it. Although I do expect to get some flak soon. I've been
invited to give a lecture at the 2004 North American Spine Society meeting
in October, and that's going to be fun. I've never addressed such a group.
I'm going to be telling them about my experience with this disorder. At
any rate, I don't get flak; I just get ignored.
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- Medscape: I guess getting ignored is easier than getting
flak?
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- Dr. Sarno: Easier in one sense, harder in another, because
I've always wanted the approval of my peers and I haven't gotten it.
Except I've heard from 1 or 2 people in the United States who are very
well known in their work in trying to bring objective standards to this
whole pain problem, and I have had some approval from them. So that's
been very helpful.
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- Even the majority of psychiatrists don't accept this
diagnosis either. Many of the so-called biological psychiatrists believe
that these psychological things are the result of chemical changes and
they're in the business of treating the chemistry. A lot of people in
psychiatry have repudiated Freud and repudiated the idea of unconscious
phenomena.
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- Medscape: Isn't it possible that physical stresses or
nerve or tendon damage play a role? Say you sleep in the "wrong"
position and your neck is sore the next morning.
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- Dr. Sarno: No. I'll tell you how that works. The brain
will often use some physical incident as a good excuse, a good opportunity,
to introduce or start the TMS. But I've had no evidence whatsoever over
the years that there are truly physical things that are going on here
that the brain is using. It's just that it will introduce the symptoms
and, of course, the brain is very tricky that way. The brain is very concerned
about these repressed emotions, and very concerned that they not come
out. It will act in a very slippery way and introduce symptoms. One of
the examples is whiplash.
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- Medscape: That's a common problem.
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- Dr. Sarno: Whiplash is usually the result of you being
hit from behind in an automobile accident. One of the papers from the
medical literature that I reproduced in my latest book was absolutely
fascinating in this regard. It was published in the New York Times, where
they reported on findings from Norway.
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- This was a good many years ago now, but Norway at that
time was having an epidemic of whiplash. Now, Norway has probably one
of the most generous insurance programs in the world. But doctors in
Norway were dumbfounded. They couldn't understand why they had so many
people in Norway on disability because of whiplash. They wondered if perhaps
a generous medical system might have something to do with it. So, they
went to Lithuania and did a controlled study there. They got the names
of 212 patients in Lithuania who were involved in rear-end collisions
and they went out and found 212 controls, and they found that whiplash
did not exist in Lithuania. In Norway -- epidemic; in Lithuania -- zero.
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- They said, "Wow. This is incredible, it must have
something to do with social things." Well, of course, it doesn't.
Clearly the patients with whiplash were having TMS. And mind/body disorders
like TMS will spread in epidemic fashion if they are not correctly diagnosed.
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- Medscape: But what if imaging, say from a magnetic resonance
imaging (MRI) study, depicts a damaged tendon or muscle?
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- Dr. Sarno: This is my experience -- what the MRI studies
show in these people has nothing to do with the symptoms. And I have proven
this concept.
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- Medscape: By "symptoms," you mean pain?
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- Dr. Sarno: Yes. The pain and the stiffness, there are
dozens and dozens of [symptoms]. The ones that are the most frightening
are the nerve symptoms -- pain, numbness, tingling, weakness. All of
those things are scary. If a patient has them and a doctor finds a structural
abnormality, he says he needs surgery. Very simple.
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- In my experience, and we've demonstrated this by getting
these people better, they wouldn't get better if the structural abnormality
were responsible for their symptoms. They would get better by being educated,
which is what I do.
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- If you ask, "Why do I think the education makes
people better?", I've given an enormous amount of thought to this.
There was a contemporary of Freud, Alfred Adler, who observed some of
the same things that I've observed, but over 100 years ago. Adler said
to teach people. I think we're reorganizing what's going on in the brain
and the brain is no longer as afraid of the rage as it was before. Adler
used the same term -- rage. I think that's what happens. When I teach
people what this is all about, what's going on physically, and what's
going on psychologically, I think the rage is no longer as threatening
as it was before, and so they don't need to have symptoms.
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- Medscape: Let's move on to treatment. What should patients
with back pain do? What should their doctors do?
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- Dr. Sarno: The only thing you can say to people in general,
if they're interested, is to read the books. The 2 that I recommend are
Healing Back Pain and The Mindbody Prescription. There is another book
that has a corny title by one of my young colleagues from Vermont: To
Be Or Not To Be...Pain-Free: The Mindbody Syndrome, by Marc Sopher, MD.
If people read the book and they have the same experience that some people
in the United States have had, pain will go away spontaneously.
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- Medscape: So, what do you recommend? Look at sources
of stress, potential emotional upsets?
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- Dr. Sarno: First of all, personality is number one; remember
that. Self-imposed pressure. Be aware of that -- being "perfect,"
being "good." Secondly, think about all of the regular pressures
in your life. And if you are aware that your childhood was not the greatest,
that probably is a contributing factor, too. If people look at these things
and if they're open to the idea, they may do better.
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- Medscape: Do you recommend relaxation exercises?
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- Dr. Sarno: No, no, I do not. This is not a physical disorder
and I recommend nothing physical.
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- Medscape: How should patients deal with the stresses?
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- Dr. Sarno: The only thing I can recommend, and I hate
to do it because it sounds self-serving, is to read the books. That's
the only thing out there for them. The last one has the most information
about the psychology -- that's The Mindbody Prescription. It tells you
what we do and what we try to bring about.
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- Medscape: Does it walk people through different things
they look at? Does it have step-by-step mental exercises?
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- Dr. Sarno: Exactly. In the last book there's even an
outline by a patient from upstate New York. This is one of the patients
I never saw but who got better by reading one of the books. He sent me
this little program that he designed for himself and I put it in the
last book. Actually, I have improved on that and made my own program,
but I have to admit that he gave me the stimulus to do it. At any rate,
it's there and it's something that people can follow.
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- Medscape: Have you ever had back pain?
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- Dr. Sarno: Of course. Not only that, but I've had a half
dozen of the equivalents as well. I think it was one of the reasons why
it was so obvious to me once I allowed myself to think about this. But
because I know what it is, it has never disabled me. And that's the secret
-- knowledge, knowledge, knowledge. That's the cure here. Knowledge is
the penicillin.
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- Medscape: And the brain is a powerful thing?
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- Dr. Sarno: You bet! One should never, never forget that
fact.
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- http://www.medscape.com/index/section_1517_0
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