PDF Summary:The Divided Mind, by John E. Sarno

What if pain really is “all in your head”? In The Divided Mind, physician John E. Sarno details his pioneering theory that many cases of chronic pain are caused by repressed emotional trauma or stress.

This guide explains Sarno’s theory of how and why your brain can produce symptoms in the rest of your body. We’ll then discuss Tension Myositis Syndrome, the term Sarno coined to describe this phenomenon, as well as his method for treating it. Finally, we’ll explore the contributions that other doctors made to The Divided Mind, which describe their experiences learning about and treating Tension Myositis Syndrome.

Our commentary will examine the science behind Sarno’s theories, as well as draw connections to self-help principles that echo his approach of treating physical symptoms with mental and emotional care. We’ll also provide actionables that you can do without the help of a medical professional so you can see if such self-care practices benefit you.

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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.

(Shortform note: Ignoring pain, or the fear of pain, is both difficult and potentially dangerous. This is because pain is a deeply ingrained survival mechanism—it warns you when something is wrong (such as an injury) and teaches you to avoid dangerous situations like touching sharp objects. Therefore, it’s crucial to first get a diagnosis so you can be certain that your pain really is psychosomatic. However, if you do find that you need to overcome pain or fear of pain, Stoic philosopher Marcus Aurelius (Meditations) offers some insight: Pain alone is not harmful to you, and therefore you can endure it if you must. Pain is only a warning; if it’s a “false alarm,” so to speak, then there’s no actual danger in continuing an activity that causes pain.)

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.

(Shortform note: There is a known connection between stress and high blood pressure, but Mann is correct that it’s tenuous; the American Heart Association (AHA) says that the direct link between stress and hypertension is still being studied. However, the AHA also notes that there’s a clear indirect link, because stress often leads people to do things that contribute to high blood pressure. For instance, people who are feeling stressed tend to neglect their physical health, eat unhealthy foods, and overuse alcohol and other drugs.)

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.

Treating Hypertension With Cognitive Behavioral Therapy

Recent research suggests Mann is correct that psychological therapy—helping people to find and deal with the root causes of their stress—is an effective way to reduce blood pressure, though it’s not clear exactly how much of a role repressed emotions play in this process. For example, a 2021 study examining the results from different reports suggests that cognitive behavioral therapy (CBT), which is a type of talk therapy, often helps people with high blood pressure improve their health.

The researchers didn’t directly link CBT with lower blood pressure but noted that it helped treat many different conditions that can cause high blood pressure, such as anxiety and depression. The talk therapy also helped patients on blood pressure medications to follow their treatment plans more closely, which naturally made the drugs work more effectively.

Interestingly, the study also found that CBT patients saw improvements in their cholesterol levels, which the researchers did not link to a secondary cause. Instead, they believe this is because CBT helps to calm the SNS, which controls the body’s threat response—an overactive SNS leads to high cholesterol along with many other harmful conditions.

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.

Mindbody Disorders as Identity Disorders

Leonard-Segal takes a different approach to mindbody disorders: Rather than saying that they’re the result of repressed emotions, she posits that such disorders often come from the patient’s self-image.

This idea reflects what life coach Tony Robbins writes about identity in his book Awaken the Giant Within. Robbins’s definition of identity is “the person you believe yourself to be,” matching Leonard-Segal’s definition of self-image. Robbins adds that your identity doesn’t actually define who you are, but rather what you do—you subconsciously act in ways that align with your identity, impacting your decisions and actions. For instance, if you see yourself as an injured person with chronic pain, you’ll think and act like an injured person with chronic pain.

Furthermore, you’ll naturally resist changing things that you see as core parts of your identity, because that feels like losing a part of yourself (even though it’s really only changing your perception of yourself). Robbins suggests bypassing that defense mechanism by subtly shifting your identity, or building upon it, rather than totally changing how you see yourself. Continuing the previous example, you might stop telling yourself that you are injured, and shift to telling yourself that you were injured, but have now recovered. This approach allows you to grow past your old identity without needing to reject it outright.

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.

(Shortform note: Although we’ve been discussing repressed emotions so far, some experts say that repressing physical sensations (like the pain from an injury) can also lead to psychosomatic symptoms. This helps to explain why some people continue to feel pain long after their injuries have healed. For example, in The Body Keeps the Score, psychiatrist Bessel van der Kolk writes that trauma survivors often experience intense flashbacks that include physical sensations—meaning they aren’t just remembering their past trauma, they’re re-experiencing it with all of their senses. To escape this pattern of reliving their trauma, they often try to suppress those physical sensations, leading to psychosomatic symptoms just like Sarno describes in The Divided Mind.)

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.

(Shortform note: No matter where someone’s condition falls on this physiological-psychosomatic spectrum, a psychologist can be an invaluable part of their treatment plan. For one thing, a mental health professional can help the patient overcome unhelpful thought patterns about chronic pain—such as overstating how much the pain interferes with their life or living in fear of their next pain flareup—thereby helping them resume a more normal life. However, recent research also suggests that a person’s mental state changes how they experience pain; for instance, someone who’s sad, anxious, or frustrated will feel pain more intensely. Therefore, therapy doesn’t just help patients cope with pain, it can actually lessen the pain itself.)

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.

The Harm of Misdiagnoses

Misdiagnosis—incorrectly identifying a patient’s condition—is a widespread and costly problem in health care. For instance, a 2023 study estimated that there could be as many as 50 million to 100 million cases of misdiagnosis each year in the US alone. Most of those misdiagnoses are relatively harmless because most patients don’t have serious or life-threatening conditions. However, around 800,000 US citizens die or become permanently disabled annually because of a misdiagnosis.

While that number is alarming, the researchers also offered cause for hope. Just five conditions (stroke, sepsis, pneumonia, blood clots, and lung cancer) account for nearly 40% of those 800,000 cases. Therefore, finding ways to reduce misdiagnoses on just those five conditions would have enormous benefits for patients and the health care system alike.

An Unexpected Problem: Patients Don’t Believe the Diagnosis

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.

Change Your Beliefs Through Questioning

In Awaken the Giant Within, Tony Robbins writes that you can start to change your beliefs by asking yourself clear, specific questions and then answering them.

Robbins says you should start by choosing one specific belief to examine. So, if you’re the type of patient we discussed above, you believe pain must have a physiological cause. With that in mind, begin asking yourself questions about that belief, such as:

Where did I learn this belief? Who or what taught you that pain must come from the body, and never from the mind? Is that a reliable source for medical information?

Do I know anything that conflicts with this belief? Have you heard stories about people suffering from pain with no medical cause? Do you have any knowledge of biology or psychology that suggests it is possible for the mind alone to cause physical pain?

Why am I holding on to this belief? Why is this idea (pain must have a physiological cause) important to you? What would it cost you mentally or emotionally to let go of that idea? If it turns out to be incorrect, how much would letting go of that belief benefit you? If it turns out to be right after all, how much would letting go of that belief harm you?

It’s a difficult and often uncomfortable process, but by asking questions like these and answering them honestly, you can start to deconstruct your harmful and unwanted beliefs. In this case, breaking down your belief that your pain can’t be psychosomatic would allow you to start recovering from it.