The Mindbody Syndrome

Introduction

Chronic pain is a multifactorial and complex condition affecting almost half of the UK
population,[1] and is the leading cause of disability worldwide.[2] Defined as pain lasting > 3
months, chronic pain can be secondary to trauma, malignancy, and infection. However, it is
also a condition in its own right, not purely an accompanying symptom of other ailments.[3]
Primary chronic pain lacks a somatic driver and is instead fuelled by central sensitisation. This
encompasses conditions such as fibromyalgia, migraines, TMJ dysfunction and IBS.[4][5]

Like many persistent conditions, the biological, psychological, and social aspects of chronic
pain are dynamically interlinked (see Figure 1 in appendix),[6] leading to widespread bio-
psychosocial implications; sleep disturbances, fatigue, depression, concentration problems,
relationship difficulties and employment issues.[7] Those living with chronic pain are often
intensely and constantly aware of their body, for some, pain may be the salient feature of
their daily existence. Chronic pain can be a lonely affair: a silent illness which commonly
incites disbelief, poor understanding, and a lack of support from the people in their lives.[7]
Sufferers may find themselves yearning for visible physical manifestations to support their
struggle for credibility.

The Mindbody Syndrome, also known as the Musculoskeletal Mindbody Syndrome (MMS),
Distraction Syndrome, Psychosomatic syndrome, or Tension Myositis Syndrome (TMS), is a
psychosomatic phenomenon pioneered by Dr John Sarno. It theorises that persistent pain is
not exclusively of biological origin, rather, there is growing evidence to suggest that pain is a
physical manifestation of suppressed emotions. A ploy by the brain to distract oneself from
challenging emotions and prevent their conscious expression.[8-11] This theory gives rise to an
alternative treatment approach, one which primarily focuses on unveiling supressed
emotions through techniques such as meditation, expressive writing, and education.
Conventional treatment approaches can result in insufficient pain relief and offer an array of
unpleasant side-effects and potential complications. These treatments typically focus on the
management of pain in day-to-day living, as opposed to finding a cure.

History

Dr Sarno specialised in physical medicine and rehabilitation. In 1965 he was appointed

director of outpatient services at the Rusk institute for rehabilitation. From very early on he
treated and cared for an innumerable number of patients presenting with back, neck,
shoulder, and buttock pain. Initially, his approach to their care focused on identifying a
musculoskeletal or neurological source to their pain; following protocol as directed by his
conventional medical training. However, as Dr Sarno expanded his clinical experience, he
became increasingly troubled by his findings. Often, imaging studies were unable to reveal a
structural source to explain persistent pain, and in those where an abnormality was detected,
pain might be experienced in unrelated anatomical regions.[12] For many years, studies have

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The Mindbody Syndrome

concluded that imaging cannot accurately predict those who will experience pain, because
many patients with structural anomalies can be completely asymptomatic.[5][13-17]

Many physicians became increasingly frustrated with the inconsistent and disappointing
results of conventional treatment techniques. This sparked an endeavour into exposing the
true source of the pain epidemic, and in doing so, interesting parallels were identified
between persistent pain patients. On physical examination, almost every patient was found
to have tenderness, simultaneously, in particular muscle groups, regardless of their
presenting complaint. More than 70% of patients had a past medical history of conditions
such as tension headaches, migraines, IBS, and TMJ dysfunction;[8][9][12]18] conditions known
to involve central sensitisation and have a strong psychological basis.[4][19] Presenting patients
often had stressful life experiences and appeared to share common personality traits; they
were highly motivated, perfectionists, conscientious and responsible.[9][18][20] Lastly, many
patients reported temporary relief with active exercise, heat pads, and massage, the
connecting denominator being an increased blood flow to the painful muscles, and thus an
increased supply of oxygen.[9]

Sarno identified muscles, tendons, and ligaments to be the local culprits of pain but suspected
the true driver to be something more dynamic and intricate; the central nervous system
(CNS). This paved the way to an exciting discovery; Sarno believed one’s emotions could
trigger the autonomic nervous system and induce pain in the muscles, tendons, and
ligaments. With some re-shaping and fine-tuning, Dr Sarno successfully treated almost 10,000
patients, rendering the majority completely pain free.[8][9][12] Other physicians have followed
in Dr Sarno’s footsteps, integrating the diagnosis and treatment of MMS into their daily
practice. They, similarly, have noticed remarkable results.[18][21][22]

The Psychosomatic mechanism

Pain is a protective mechanism, essential for survival. It serves to raise our awareness to
harmful stimuli. The brain is a powerful organ with the capacity for neuroplasticity. In
persistent pain, the brain becomes overprotective and intensifies the warning signals via a
process known as central sensitisation. This hypersensitivity results in the firing of
unnecessary warning signals. Patients might experience increased severity, increased
frequency, reduced pain threshold, and additional pain location sites.

There is convincing evidence to suggest the route cause of persistent pain lies hidden within
the emotional mind. External adversities involving life experiences and trauma can predispose
people to, and perpetuate, centralised pain.[23-28] Additionally, internal psychological conflict
(such as the personality traits discussed later) can contribute to the sensitisation of neural
pathways.[29][30]

The conscious mind is responsible for our mature thoughts, feelings, and memories. It is
controlled, moral and logical, guided by social prohibitions and obligations; all of which we

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The Mindbody Syndrome

are consciously aware of. Conversely, the unconscious mind is a reservoir of feelings, urges,
and irrational thoughts, it is pleasure-orientated, self-involved, irresponsible and, like a real
child; perpetually angry.[8][10][31] Sarno draws on a transactional analysis approach by
suggesting the unconscious mind reflects the “Child” within us, whilst the “Parent” dominates
control over our conscious mind.

The MMS theory postulates that the unconscious repression of powerful negative emotions
such as anger, rage, and grief, can lead to internal conflict, which, once accumulated can
threaten to overflow into conscious awareness. To prevent confrontation with these
frightening and dangerous emotions, the brain creates pain as a physical and very real
distraction.[8-10][18][20] Powerful sources of unconsciously repressed emotions can include;
unresolved childhood trauma, self-imposed pressure as a reflection of one’s personality, and
the pressures of daily living. Consciously supressed feelings of anger, fear, anxiety, and
depression can exacerbate pain and central sensitisation, a consensus which many studies
support,[28][32][33] but Sarno believes they are not the root cause. In contrast, positive emotions
can lead to a reduction in pain.[34-36]

Studies have demonstrated significant brain-related changes when pain transforms from
acute to chronic; a process known as “chronification”. Functional MRI imaging of persistent
pain patients showed an increased activity within brain-related emotional circuitries,
compared to those with acute pain, e.g. the pre-frontal cortex and structures of the Limbic
system; amygdala and cingulate gyrus.[37][38] It is thought that these areas are responsible for
the identification of unsettling emotions and a subsequent cascade of events leads to pain via
the autonomic nervous system (see figure 2 in appendix). However, the precise mechanism
between alexithymia and pain is still not fully understood.[8][18][20]

The Autonomic Nervous System (ANS), a subsection of the CNS responsible for involuntary
functions, has a key role in regulating the circulation of blood flow. When blood flow to tissue
structures, such as muscles and tendons, is reduced, there is a decreased supply of oxygen.[39]
Mild oxygen deprivation causes target tissues to spasm, subsequently causing pain.[8] Over
the years, laboratory evidence has proven the link between oxygen deprivation and pain.
Larsson and colleagues (1994) demonstrated dysregulation of the microcirculation supplying
trapezius muscles in people experiencing persistent pain at the same site.[40] Researchers
have also shown that fibromyalgia patients have an altered underlying distribution of blood
flow which results in mild oxygen deprivation.[41][42] Also, pain disappeared in these patients
when blocking sympathetic nerve fibres (part of the ANS).[43] Blocking these nerve fibres
allowed the blood flow to return to normal, thus relieving the mild hypoxia and dissipating
the pain.

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The Mindbody Syndrome

Personality & Emotions

Intriguing consistencies have been identified in the personality configurations of persistent

pain sufferers. Dr David Schechter describes a “Type T Personality” which predisposes
individuals to persistent pain. This describes dominant traits such as: being highly motivated,
a “goodist” (someone who feels driven to perform good acts for others), a perfectionist, a
people pleaser, quick to judge, responsible, and someone who is self-critical.[20]

Personality traits can exacerbate the severity of symptoms. Individuals who catastrophize,
anticipate uncontrollable pain, or fear the consequences of pain, are more likely to perceive
their symptoms as intense and experience greater functional disability.[44-46] Anxiety and fear
of pain primes the individual to view life through a filter of pain; amplifying their experience
and leading to abnormal brain processing.[37][47] Many emotions share overlapping neural
circuits in the brain e.g. catastrophising and anger regulation, thus highlighting the complex
dynamics of persistent pain.[48] The brain supports a vicious cycle; repressed emotions and
personality traits predispose an individual to persistent pain. Such pain can cause a turmoil of
fear, anxiety, and depression, which in turn exacerbates the experience of pain.

Negative perception of pain leads to behaviour alterations, particularly activity avoidance.

Such avoidance increases the likelihood and maintenance of persistent pain because it
enforces the belief there is nociceptive damage.[49] In essence, pain resulting from activity
becomes a conditioned response.

Diagnosis

Dr Schechter, a former student of Dr Sarno’s, has created a comprehensive diagnostic guide

to MMS, succinctly summarising the key points thus far (Table 1 below). Not all aspects are
required for diagnosis, but it is a helpful guide during patient consultations. A patient
questionnaire has also been formulated to help indicate the likelihood of an MMS diagnosis
(see figure 3 in appendix).[50]

Table 1: Musculoskeletal Mindbody Syndrome diagnostic criteria.[18]

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The Mindbody Syndrome

MMS is a clinical diagnosis requiring thorough history taking and physical examination. Ruling
out structural abnormalities, which might require conventional treatment, is essential prior
to confirming a diagnosis of MMS, for example, sinister conditions such as bone metastases
and cauda equina.

Clinicians are encouraged to explore the psychosocial aspects of patients’ lives, inquiring
about stressful life events, accidents, injuries, childhood & adult abuse, support networks,
emotional awareness, personality traits, and avoidance behaviours. Analysis of how these
variables might be connected to the onset, exacerbation, and mitigation of symptoms, should
be investigated with the patient.[37]

It is common for patients to have exhausted a long list of health professionals in their search
for a cure, often subjected to scepticism from others along the way. Explanation of MMS as a
psychosomatic condition, one which causes legitimate pain and debilitation, should be
emphasised to the patient in order to maximise engagement and enhance trust whilst
examining their emotional wellbeing.

Treatment

The salient features of a successful treatment regimen involves altering patient perception of
pain and improving their emotional awareness. It is important patients accept the absence of
structural anomaly and nociceptive damage; thus, the first port of call is to educate patients
on how psychological distress manifests as physical pain, and the process of central
sensitisation. With this in mind, patients are encouraged to taper off their analgesic
medications and to engage in fear-inducing activities. Expressive writing and emotional
awareness encourages patients to identify their emotions, to understand their connection to
pain symptoms, and to help process any unresolved trauma or psychological conflict.

Numerous studies have demonstrated statistically significant results of a Mindbody

treatment approach for centrally sensitised pain. A case series demonstrates the success of
a Mindbody programme in a cohort of patients using purely the educational and psychological
treatment methods mentioned above. Patients reported pain reduction by up to 65% and
medication use was significantly reduced in 68% of individuals. Furthermore, 77% of patients
who were previously moderately/very restricted are now active without hesitation or only
mild restriction.[18] The authors acknowledge some limitations to this study e.g. the potential
for recall bias relating to prior activity levels and medication use, and the possibility that non-
responders lost engagement due to lack of positive results, thus skewing the results to
patients who experienced favourable outcomes. Neuroscience education as a sole
intervention has also proved effective and superior to basic anatomic and biomechanical
education models commonly used to explain chronic low back pain.[51]

Using a randomised control trial, Hsu et al (2010) found the benefits of expressive writing and
emotional awareness in patients with fibromyalgia. Not only did patients have statistically

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The Mindbody Syndrome

significant reduced pain and increased physical function, but they also had an improved pain
threshold.[22] In conventional medicine, Cognitive Behavioural Therapy (CBT) is considered a
legitimate alterative therapy for persistent pain.[4][52] However, emotional awareness and
expression therapy (EAET) has shown far superior outcomes. Preliminary randomised control
trial showed CBT to have nonsignificant impacts on pain reduction, whilst EAET had positive
results of considerable magnitude.[53]

Although Lumley & Schubiner (2019) review literature supporting the use of additional
treatment approaches e.g. in-vivo exposure therapy, trauma focused psychotherapies, short-
term dynamic psychotherapies, adaptive inter-personal communication therapy, further
discussion of these is beyond the scope of this paper. However, Lumley & Schubiner (2019)
stress the importance of psychological factors and their contribution to “centralised pain”.
Ignoring this, they argue, limits treatment options and efficacy. It is important clinicians
understand the brain’s role in not only regulating pain, but also in its ability to create and
eliminate it.[4]

Conventional treatment

Extensive pharmacological prescriptions, procedural intervention (e.g. steroid injections), and

surgery are some of the currently used treatments for persistent pain management.

The UK faces an opioid crisis with an increase in clinician prescribing[54][55] and an increase in
patient abuse[56] A Cochrane review demonstrates questionable efficacy of opioid use in the
management of persistent pain.[57] Population studies show many opioid users continue to
have persistent pain and poor quality of life.[58] The adverse side-effects and reduced efficacy
of long-term opioid use have been well documented; addiction risk, hyperalgesia,
pharmacological tolerance, and withdrawal symptoms are all ongoing concerns.[59-61]

There is conflicting evidence for the use of steroid injections in the treatment of persistent
low back pain.[62] One systemic review concludes there is limited evidence for its efficacy,[63]
while others state there are benefits, but typically of short duration.[64][65]

Although surgery can be beneficial in some cases, particularly for spinal fractures and
deformities, studies have shown its benefit is limited for back pain caused by degenerative
disc disease.[66] This re-highlights previously mentioned research; MRI findings cannot
accurately predict the development nor duration of chronic pain given that many patients
with structural abnormalities can be completely asymptomatic.[5][13][14][16][17][63] There is
absence of literature directly comparing the efficacy of surgery to MMS therapies, however
some studies do show inadequate pain relief post-surgery in patients with psychologically
traumatic histories. Schofferman and colleagues (1992) reported an 85% higher likelihood of
unsuccessful lumbar-back surgery in patients who have a history of childhood trauma; this
may include mental trauma, sexual, or physical abuse. Whereas only 5% of operations failed
in patients with no childhood risk factors.[67] This study suggests that pain persists because

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The Mindbody Syndrome

surgeons target the spine and do not treat the brain. Another study acknowledges the likely
failure of lumbar surgery in patients with psychosocial pathologies and highlights the
importance of a psychological assessment to identify patients who are better suited to
treatment methods not involving surgery.[68]

NICE guidelines currently recommend only two psychotherapies for persistent primary pain;
CBT and acceptance/mindfulness-based therapies.[52] Numerous studies support their
use.[69][70] However, it has been highlighted that only modest improvements arise with the
use of these therapies.[21][71][72]

Conclusion

The Mindbody syndrome is a psychosomatic condition which presents as persistent pain.

Persistent pain manifests to distract the individual from challenging emotions and psychological
conflict; factors which can predispose, perpetuate, and prolong the experience of pain. This is
achieved through neuroplasticity and central sensitisation. Although science has not yet been
able to provide concrete evidence detailing the specific underlying mechanisms, comprehension
of this condition is continually evolving and there is overwhelming evidence to suggest MMS is a
very real phenomenon. This is indicated by a number of studies successfully treating patients with
Mindbody techniques, functional MRI studies demonstrating emotional areas of the brain are
more active in persistent pain, and the experience of many MMS physicians who have witnessed
the shortfalls of conventional treatments and successfully treated persistent pain
sufferers.[8][9][20] The Mindbody Syndrome is not currently used in mainstream medicine, this
is in part due to the lack of primary research papers supporting its theories. Hopefully, given
time, there will be enough research published to support the implementation of a Mindbody
approach in conventional medicine.

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The Mindbody Syndrome

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Appendix

Figure 1: Biopsychosocial model of pain and consequences on quality of life.[6]

Repressed Unconscious Emotions (e.g.rage)

Abnormal Autonomic Nervous System Activity

Regional Ischaemia (mild)

Oxygen Deprivation (mild)

Muscle Pain Nerve Pain Paraesthesia's Paresis Tendon Pain

Figure 2: The Pathophysiology of MMS.[10]

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The Mindbody Syndrome

Figure 3: TMS patient questionnaire (updated).[50][18]

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The Mindbody Syndrome

Figure 4: TMS Tender points. Presence ≥ 2 is supportive of a TMS

diagnosis but not essential for diagnosis.[20]

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