What’s The Divided Mind by John E. Sarno about? What if pain really is “all in your head”?
In The Divided Mind, John E. Sarno explains his theory of how and why your brain can produce symptoms in the rest of your body. He calls this phenomenon Tension Myositis Syndrome, and has created a method to treat it.
Read below for a brief overview of The Divided Mind.
Overview of The Divided Mind
In The Divided Mind, John E. Sarno details his pioneering theory that many cases of chronic pain—such as back pain, neck pain, migraines, and repetitive stress injuries—are caused by the mind’s tendency to create physical symptoms in response to repressed emotional trauma or stress. Many of Sarno’s patients report that this approach helped them find relief when mainstream medicine failed.
Sarno (1923-2017) was a practicing physician but was best known for his best-selling books (including The Divided Mind, published in 2006), which explain his holistic approach to pain management, encompassing both physical and psychological causes. Sarno earned his M.D. from Columbia University in 1950. He then served as an attending physician at the Rusk Institute of Rehabilitation Medicine at New York University Medical Center, where he’s said to have treated over 11,000 pain patients and cured 90% of them.
The Mind and Body Connection
Sarno begins by saying that many painful medical conditions are psychogenic, meaning “created by the mind.” He refers to such conditions as mindbody disorders, emphasizing that they are mental as well as physical. (Shortform note: You’ll also see these conditions referred to as psychosomatic, which means the same thing: “psycho” refers to the mind, and “somatic” refers to the body.)
According to Sarno, these disorders exist because of the deep connection between your mind and your body. In simple terms, your mental health and physical health are intrinsically linked—therefore, if one suffers, the other will too.
In this section we’ll discuss Sarno’s theory of how mindbody disorders develop, and how Sigmund Freud’s ideas laid the foundation for Sarno’s work today.
How Mindbody Disorders Develop
According to Sarno, repressed stress and unconscious emotional factors like anger, anxiety, or trauma can lead to physical symptoms through the following process:
First, the mind tries to repress or suppress deep-seated emotional issues and stressors that are difficult to face consciously, which creates a state of unconscious emotional tension. In fact, that’s why Sarno titled this book The Divided Mind: He says that mindbody disorders originate from the conscious and unconscious parts of your mind working against each other.
To distract from this underlying tension, the brain produces physiological symptoms—for example, reduced blood flow, oxygen deprivation, or muscle spasms. These physiological changes manifest as pain, headaches, gastrointestinal problems, fatigue, and other symptoms.
According to Sarno, when you suffer from these symptoms and seek medical help, you’re usually diagnosed with some kind of physical illness and treated accordingly. However, since the root cause is psychological, such treatment doesn’t solve the underlying problem, and the symptoms inevitably come back.
Therefore, Sarno criticizes contemporary medicine for overemphasizing physical abnormalities as the root causes of pain. He argues that neglecting people’s underlying psychology often leads to unnecessary medical treatments and surgeries, which could be avoided with a better understanding of mindbody disorders.
The Freudian Roots of Mindbody Theory: Hysterical Disorders
Sarno credits Freud, the founder of psychoanalysis, as one of the earliest thinkers to recognize the connection between the mind and physical symptoms that had no discernible structural or biological cause.
Freud believed that many of his patients’ complaints like paralysis, pain, and sensory loss were actually “conversion symptoms,” meaning psychological distress converted into physical symptoms. He labeled these conditions as hysterical disorders, and theorized that they stemmed from subconscious psychological conflicts and repressed emotions.
In Freud’s work, Sarno saw parallels with his own theory of how repressed emotions can unconsciously trigger physiological changes and pain. He built upon Freud’s early insights about psychosomatic disorders and applied them specifically to chronic pain issues like back problems, migraines, and repetitive strain injuries. This culminated in Sarno’s concept of Tension Myositis Syndrome, which we’ll discuss in the next section.
Tension Myositis Syndrome
Sarno coined the term Tension Myositis Syndrome (TMS) to describe the condition he believes is actually behind many chronic pain disorders, which are often diagnosed as purely physical problems.
“Tension” refers to the muscle tension and blood vessel constriction that the brain triggers in specific areas of the body, causing decreased oxygen flow to those areas. “Myositis” means muscle inflammation, which is one of the most common causes of chronic pain.
How Sarno Treats TMS
Sarno says that his treatment for TMS focuses on helping patients become aware of repressed feelings like anger, anxiety, or guilt and process those feelings in a healthy way. He then outlines his specific approach to treating TMS as well as other disorders (such as fibromyalgia) that, according to Sarno, may be psychosomatic.
Self-Awareness and Psychological Help
First of all, Sarno emphasizes the need to educate patients about how the mind can create real physical symptoms as a way to mask emotional issues. He then instructs each patient to keep a journal and to write down any recurring thoughts, powerful emotions, or sudden insights that they experience, paying special attention to thoughts related to anger and other negative feelings. Through this journaling process, Sarno’s patients work to build self-awareness and pinpoint any significant sources of emotional tension, anxiety, or trauma that may be contributing to their physical symptoms.
Once uncovered, the patients must actively face and work through those repressed thoughts and feelings. This step often involves psychological counseling and therapy. Remember, Sarno’s patients have been repressing their emotions because they were too much to handle—they often need professional guidance and support to help them finally resolve those negative feelings.
Finally, Sarno encourages his patients to resume normal physical activity as much as possible, using their newfound understanding of mindbody disorders to overcome their fears of causing themselves more pain. He also frequently teaches psychological techniques, such as positive affirmations, to help patients rebuild the relationship between their mind and their body. For instance, they might start each day by looking in the mirror and saying “I am not injured, I am not broken, I am healthy and strong.”
By proving their physical capability to themselves, and reinforcing it with psychological techniques, patients can overcome their mindbody disorders.
Contributions From Other Doctors
The second half of The Divided Mind consists of a series of essays by other doctors about their experiences with mindbody disorders. This includes learning about them, treating them, and in some cases, recovering from such disorders themselves.
High Blood Pressure as a Mindbody Disorder
Samuel J. Mann teaches clinical medicine at Weill Cornell Medical College and treats patients at NewYork-Presbyterian Hospital. He specializes in treating hypertension, and is particularly interested in the connection between repressed emotions and hypertension.
Most people believe that constantly feeling stressed raises the risk of developing high blood pressure. However, Mann argues that research and treatments focusing on feelings of stress have failed to support this theory; the link between stress and hypertension remains tenuous, and stress-reduction techniques don’t reliably reduce blood pressure.
In contrast to that common belief, Mann says that repressed emotions—the stresses people don’t feel—are the real link between stress and high blood pressure.
He writes that keeping upsetting feelings at bay requires the sympathetic nervous system (SNS) to stay constantly active. The SNS controls the body’s threat response, part of which is to increase heart rate and blood pressure. In the short term, this ensures that the body’s muscles are well-supplied with oxygen, so they’re ready to fight or to run at a moment’s notice. However, if the SNS is always engaged, then the person’s blood pressure is constantly elevated; in other words, they have hypertension.
Therefore, uncovering repressed emotions and helping the patient to resolve them is an effective way to treat high blood pressure; much more so than stress-reduction techniques like muscle relaxation and deep breathing exercises. Alternatively, drugs that interfere with the SNS’s ability to affect blood pressure also show promising results in treating this type of hypertension.
Joint and Back Pain as Mindbody Disorders
Andrea Leonard-Segal is a rheumatologist and a clinical associate professor of medicine at George Washington University. She specializes in treating chronic pain and takes a holistic approach that addresses both physical and psychological causes of pain.
When Leonard-Segal herself developed back pain that didn’t go away with standard treatments, she went to Sarno as a patient. That was when she learned about mindbody disorders and the psychological causes of pain. Sarno’s treatment cured her, and she’s been using his principles of mindbody medicine in her practice ever since, with a particular focus on treating TMS.
TMS Patients Think They “Should” Be in Pain
Leonard-Segal says that the only common thread between many of her patients is the belief that they’ve seriously hurt themselves. Their injuries—if they have any—are often minor and would normally heal on their own. However, because the patient thinks they’re hurt, the pain continues.
Furthermore, the mindbody disorder often compounds itself because the patient comes to believe that the chronic pain means they’re frail and weak. As a result of that belief, they actually start to feel even minor pains more severely and struggle to recover from injuries and illnesses that should pose no threat at all.
Leonard-Segal’s treatment for TMS is similar to Sarno’s, but she adds that her goal is to give her patients the benefit of an outside perspective. In other words, Leonard-Segal helps her patients to see themselves as she sees them: healthy, strong, and capable. She says that, once her patients internalize that new self-image, they usually make full recoveries.
Diagnosing Physical Versus Psychosomatic Disorders
Douglas Hoffman is an orthopedist with decades of experience in sports medicine. He takes a particular interest in how psychological and social factors lead to mindbody disorders in otherwise healthy people.
Hoffman makes two important observations about mindbody disorders:
1. Even when a condition is psychosomatic, it often has a physical trigger. For example, someone who twisted their ankle while running might still feel pain in that ankle years later. This makes it difficult to diagnose a mindbody disorder because it seems obvious that the cause is physical: In this case, the ankle must not have healed properly.
2. Physiological conditions and psychosomatic conditions aren’t a simple binary, but instead exist on a spectrum. In other words, chronic conditions often have both physical and psychological causes. Therefore, the doctor must determine on a case-by-case basis how much the patient’s psychology is contributing to their condition.
Hoffman says that the best way to diagnose a patient is to get a thorough history and conduct a complete physical exam. From there, the doctor can create a differential diagnosis: a list of conditions, both physical and psychosomatic, that could explain the patient’s symptoms. The patient’s medical history is crucial because it will include psychological conditions such as depression and anxiety that would make psychosomatic disorders more likely. It will also note if they’ve ever been diagnosed with a psychosomatic condition before.
Hoffman adds that traditional treatments for pain like painkillers and physical therapy reinforce the idea that there’s something wrong with the patient’s body. This makes it harder for them to recover from their mindbody disorder. Therefore, it’s crucial to identify whether the patient’s condition is physical or psychosomatic because the wrong treatment plan could prevent their recovery or make their condition worse.
An Unexpected Problem: Patients Don’t Believe the Diagnosis (illness denial)
Hoffman adds that one major challenge in treating mindbody disorders is getting the patient to accept their diagnosis. This is because, like many doctors, patients usually believe that pain must be the result of a problem with the body.
Not only does this seem logical—how could they be in pain if nothing is wrong?—that lesson gets constantly reinforced by the world at large. For instance, many people spend their lives treating headaches with painkillers, minor injuries with rest and ice, and so on. As a result, they learn from a young age to treat only physical causes of pain, and are never taught that their minds can produce similar symptoms.
Overcoming that programming so the patient can recover from a psychosomatic disorder is difficult, often impossible. Hoffman says that many people reject the idea that pain can exist without a physiological cause, and therefore they never repair the connection between their mind and their body.
