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Recently Scott Alexander and a few others have been talking more about the idea of a social contagion, one which spreads real physical problems.
As I’ve argued in previous posts, this social contagion likely causes a number of what we see as purely physical injuries. Many feel that their body is injured. They deal with diagnoses from the medical community such as:
Chronic pain
Fibromyalgia
TMJ
Joint Hypermobility
Some doctors, like John Sarno, have even argued that far more injuries are based on psychological harm, rather than physical, such as:
Hives
Eczema
IBS
Gluten sensitivity/Celiacs
Herniated Discs
The list goes on. These are extraordinary claims, which Sarno backs up with impressive statistics in his book.. Unfortunately I can’t find his paper online, would be curious to take a look if anyone has a link. What Sarno calls the issue, and what other doctors or medical writers such as have supported him in, is a disorder called Tension Myositis Syndrome (TMS.)
The basic mechanism he posits is that our mind uses defense mechanisms to prevent us from thinking certain thoughts. We distract ourselves with drugs, alcohol, fast food, and many other addictions. He thinks that in the modern world, due to our views on physical injury, some people deal with their mind creating physical pain to distract them from emotional issues. This distraction comes out in certain nerves being deoxygenated, which he claims to have proven.
Much of this stress comes from trauma due to unresolved emotional issues, which is pretty standard accepted literature in psychology nowadays. Sarno specifically calls out “anxiety, anger, and feelings of inferiority” as the big culprits, citing that modern life causes many of us to have a lot of anger boiling under the surface. Constraints from work, relationships, illness, loss of loved ones, and in extreme cases childhood neglect or abuse.
To use a more rationalist lens, you could say the most stressor would be status anxiety. Many on the motte have argued that status anxiety is an incredibly common and hidden force that generates massive emotional problems, since the Western world is so hypercompetitive, and it’s difficult to measure up in any walk of life, let alone most. When you don’t feel you're at the top in your work life, social life, or family structure, people get frustrated.
What makes this problem worse is that due to the way modern society operates, we can’t express anger frequently depending on our situation. For those in the PMC, or the business world more generally, it’s considered almost unthinkable to yell at a boss or a client. The whole microaggression concept exacerbates the issue.
Some believe this is a recent phenomena due to stresses of modern life, but I’d argue that the connection between mind and body is far more complicated and older. Writers throughout history would cite feelings of pride which make your chest well, or having your hands tremble with rage. Our minds and bodies are inextricably linked, so it stands to reason that if we have rampant neuroses in our society, some of it would express itself physically.
I’m sure many of those reading this who are more physically active may have an instinctual response of “duh, of course the mind and body are one, it’s the most obvious thing ever.” I’d argue that the inferential distance around this issue opens a vast gulf which is difficult to imagine. If you have not experienced chronic pain, I don’t think it’s something one can confidently model with any real accuracy.
To some degree, patterns of behavior also must matter. A common response to an injury is to exercise, and for most generalized chronic pain issues, this seems to work. The issue arises when someone creates a trapped prior. Basically the idea that they have some condition is so deeply ingrained that the typical fixes don’t work. Many sufferers of chronic pain even admit they think it’s psychosomatic, but still struggle to deal with it. Ultimately Sarno’s method seems to work for them over time. Point is, our modern medical fixation on mechanical causology for injury seems, if not totally wrong, at least to be missing a big piece of the puzzle.
This idea may already swim in the water all around us. After all, we have plenty of colloquialisms such as “trust your gut” or “follow your heart” that suggest a connection. However, the common idea that injuries are almost entirely physical persists.
If true, this hypothesis could be one the discovery of which would shake our society to its roots. Long-lasting physical injuries being caused by emotional pain would alter our entire approach to medicine, let alone overall health or the pursuit of virtue.
It’s important to note that depending on your values, you may prefer the current state of events. If subjecting the emotionally damaged in Western society (most of us) to self-caused physical pain is worth preventing large amounts of anger and other negative emotions from boiling over, that is not necessarily an irrational choice. I’d certainly prefer dealing with one of these issues than living through a revolution or large war.
That being said, it’s a choice we must make without blinders. To ignore the issue entirely is to prevent us from solving it.
This strikes me as extremely unlikely, verging on outright nonsense.
Let's look at the diseases in question, the initial cluster, namely the ones that Sarno isn't alone in suspecting are psychosomatic, share one commonality that they don't have signs but have symptoms, a bit of medical jargon that simply means that they have no visible-to-outsiders characteristics barring what the patient themselves report and feel. The only exception is joint hypermobility here.
This is reasonable enough, practically every doctor alive, especially in psychiatric practise, has seen such cases, and so have I. It's not much of a stretch to think that the human mind can create something as entirely subjective as pain by itself, in a myriad of different presentations. And invasive tests usually find little to no organic changes that could plausibly cause said symptoms.
Now, the ones Sarno thinks are psychologically induced go way beyond the plausibility of the above, for reasons that might not be obvious to non-medical people. So I'll take a crack at why this makes little sense:
First and most obviously, they have physical signs and large changes in a consistent and syndromic fashion. I doubt the brain has the ability to cause sudden histamine release and hive outbreaks no matter how stressed someone is.
Gluten sensitivity is characterized by a testable and obvious change, namely the production of tissue transglutaminase antibodies that are detectable in the blood, prior to confirmation by a biopsy from the intestines. It makes absolutely no sense that the manifestation of anxiety and depression would be the sudden onset of an autoimmune disease with obvious markers! And why to gluten of all things??
Hell, IBD/Crohns are comorbid with depression because they're extremely annoying and debilitating diseases that cause a massive drop in QOL, I'd certainly be sad if not depressed were I diagnosed with that!
Herniated discs?? You can literally see them on MRI most of the time, how exactly is the brain buck-breaking the spine??
All of these diseases have clear non-psychiatric pathologies, and obvious objective changes, and unless someone manages to dig up Sarno's figures and at least 3 or more studies confirming its individual claims, I would toss this in the trashcan without further debate.
Edit: I confused IBS and IBD, there's some debate on whether or not the first has psychological links, and there isn't any obvious etiology that I'm aware of.
Thanks for the detailed response, I’d definitely love to do an adversarial research collab on this at some point if you’re game.
I’ll agree that I think Sarno dramatically overstates his claims in terms of how many illnesses are caused by mental issues. That being said, as you’ve admitted below, the idea of ‘stress’ is clearly a huge gap in our current medical corpus of knowledge. Not only is it a gap, it’s one the medical field seems allergic to probing at anything but the basic level.
As someone who has personally dealt with chronic pain, I can tell you that this sort of psychosomatic technique works extremely well compared to other interventions. I’ve regained full function of my body, after having over five recommendations for surgery by practicing specialists.
I understand why your perspective would be so against this idea, but imagine my perspective here. It’s extremely hard to be charitable to doctors on the chronic pain/fibro front when the evidence for their interventions is so bad and the field stubbornly refuses to look at alternatives to treatment.
No direct evidence but there are large communities of people with similar experiences. Check my NYT link in the original post.
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I've personally never encountered a patient with fibromyalgia, and the very disease isn't a thing in India from what I can ascertain! I looked up the topic here, and barring a few niche websites or news blogs, awareness of the disease seems little to none.
I am willing to grant that psychosomatic pain is real and debilitating, but here, it mostly manifests as stomach issues, though I have seen chronic neuropathic pain of other natures too.
If it worked for you, that's really good! Medicine isn't so well-grounded that we don't have treatments that work despite not having a robust theoretical footing, if I had to embrace such high standards I couldn't aim to be a shrink ;)
My issue with Sarno is that he seems to blanket a variety of diseases that we do understand the etiology of, and issues with correlation and causation, though after the information others presented I'm more open to the idea being investigated.
I'm tempted to think he's intentionally acting out a Noble Lie, as he is caught in a bit of a double bind. On the one hand he needs people to confidently believe his diagnosis, but on the other hand he doesn't have excellent scientific data. So he may be fudging the facts a bit to make it more convincing to patients. I plan to do a follow up post on this if I get the time.
Well yes, that’s the point of a noble lie. It’s in the name - the intellegent elite lie to the public for their own good.
With modern liberal values that’s generally considered immoral, but in the case of psychosomatic pain I can see how it would be useful. A key part of the ‘cure’ is to convince people they aren’t in pain. Using a fake scientific method to give them confidence may be dishonest, but with the amount of people Sarno has helped I can see how he could justify it.
Yep, that’s modern or pre-modern, depending on which historian you ask. Currently we’re firmly in postmodernity.
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Lots of asymptomatic individuals have degenerative disk conditions visible on imaging.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464797/
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I've met a few people that claim to have gluten allergy and consume a gluten free diet (which they claim makes them feel better) but never were tested for it. It could be that a significant percentage of gluten allergies are psychosomatic.
Herniated discs, however, seem indefensible to me. I've never met anyone that claimed to have a herniated disc on a hunch.
I've known someone who thought they had degenerative disc disease, but when she finally actually got scanned all her discs were fine. People talk themselves into medical conditions all on their own more than you think.
On the other hand, this same person eventually got over their back pain by having surgery to stop getting in-grown toenails. Turns out the chronic in-grown toenail problem was making her walk funny, which was straining her back. So, not exactly an example of psychosomatic disease. But people do come up with explanations for the pain they have, sometimes without any medical evidence, so if someone did have back pain due to psychosomatic reasons I could see them thinking they had a herniated disc without ever being checked for it.
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That's not the error type you need to be concerned about. You need to be looking at the people who have herniated discs but don't feel pain from them. They are harder to find because if you don't have back pain, why would you know whether or not you have a herniated disc?
And that's where you'll find the reason why herniated discs are included with fibromyalgia. If everyone who has back pain has a herniated disc, but not all people with herniated discs have back pain, then you can't explain the pain with the disc.
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There’s a recent pilot study that incorporated some of Sarno’s ideas, but only n=11 for the intervention: https://journals.lww.com/painrpts/Fulltext/2021/09000/Psychophysiologic_symptom_relief_therapy_for.13.aspx
Lead author is Professor at Harvard Medical School and an emergency medicine physician, so neither a crackpot nor someone biased toward psychogenic causation. Re: point 4: https://pubmed.ncbi.nlm.nih.gov/23982421/
I find this John Stossell 20-20 report interesting, especially at 9:40, where John discusses back pain with his brother Tom. Both John and Tom Stossell suffered back pain together. John was cured by Sarno, but his brother Tom (a scientist) refuses to even consider the notion. We should be more like John and not Tom in openness to heterodox treatment possibilities. Especially in cases where the institutional bias is strongly against non-physical treatment (less money to be made, back pain physicians out of work and embarrassed, lost respect of medical establishment).
Humans have a long history of non-physical pain etiology, like for instance those caused by hysteria and demons. Consider the Psalms: For when I kept silent, my bones wasted away through my groaning all day long. For day and night your hand was heavy upon me; my strength was dried up as by the heat of summer. I acknowledged my sin to you, and I did not cover my iniquity; I said, “I will confess my transgressions to the LORD,” and you forgave the iniquity of my sin. In this verse, the physical pain caused by sin (which entails social stress, obligation, and personal failure) is ameliorated by voicing one’s faults and pursuing a stress reduction strategy in the form of religion.
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Stress rash (including hives) is a well known phenomenon. The others are a lot less plausible, but that one absolutely happens.
I stand corrected then, increased cortisol can cause hives.
I still don't think the others make any sense.
Have you ever seen a comatose patient with eczema? If the answer is "yes" that pretty firmly disproves this hypothesis, if "no" that means maybe there's something interesting going on there? Unless the reason the answer is "no" is "I don't see many comatose patients".
Even when I was overseeing an ICU, I didn't run into any comatose patients with eczema that I knew of. It's probably a very uncommon combination in the first place.
Right, and thinking about this further it's specifically patients who developed eczema while comatose that we'd care about. Which you definitely wouldn't encounter in an ICU.
You also need environmental stressors for eczema, and you don't get those in the ICU
And it's totally unethical to expose a comatose patient to a known allergen (e.g. latex or betadine if they're allergic) to see if there is a reaction.
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IBS (irritable bowel syndrome), not IBD (inflammatory bowel disease), which you’re referring to (IBD encompassing Crohn’s and ulcerative colitis). IBS is the one with no clear etiology, association with previous diagnosis of psychological trauma and/or anxiety and/or depression prior to onset (as well as recent GI infection), and suspicion of involvement of the gut-brain axis.
…As far as I recall.
That's a typo on my end, I'll fix it. I'm aware that IBS is less clear cut.
Sarno is referring to IBS though, not IBD.
His claims annoyed me enough that I wasn't reading clearly, I've already made an edit!
Fair enough! I found the claims for coeliac and eczema and disc herniation absurd also.
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I had heard that the issue for MRI and herniated discs is that you can see the same indications on a control group that doesn't experience pain.
I'd make a case that Crohn's/IBS-like conditions are simply a set of symptoms. Perhaps there is true-Chrohn's within this. IBS doesn't have a set aetiology in my view though IBS treatments may help the symptoms.
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