Personal Accounts: Anatomy of the Mind

"He is a bright, knowledgeable, dedicated physician and teacher who is compassionate, empathic, and easy to get along with. He performs his duties in an exemplary manner and possesses great diligence and high standards. He handles stressful situations very well." This is a direct quotation from the chair of my department in a letter of recommendation he wrote for me.

After my psychiatric residency training, I was delighted to secure a tenure-track position in the same teaching hospital where I had my training. The job involved clinical work, administration, teaching residents and medical students, and research. It was exciting and challenging, and it would provide opportunities for professional development as well as for me to prove to myself and others what I was capable of. I was thrilled.

I worked hard. I maintained my composure under stress and accepted my responsibilities without question or complaint. I was working as a faculty member with colleagues who a few months earlier had been my teachers, trainers, and mentors. I felt the need to succeed, to please them and not disappoint them, and to be pleased. Although I felt intense pressure, I did not give voice to it; that would have been giving up.

After six months as a faculty member, I began to suffer from low back pain, which gradually got worse. I became obsessed with my pain. I would reach for over-the-counter painkillers before I got out of bed in the morning and several times during the day. I would sometimes take painkillers again while seeing patients for psychotherapy. During sessions with patients I would remain in a semireclined position to alleviate the discomfort I felt. I stopped all my exercise routines and gained weight. I stopped carrying heavy loads, stopped carrying my kids, and stopped driving long distances.

Soon I started to feel fear and anticipatory anxiety before waking up, before taking the first few steps, and before going to bed at night. I slipped into the syndrome—the vicious cycle of pain, bed rest, fear, more pain, fear, fear, and fear. I was compromised by the pain, and I was working to maintain normalcy. I recognized that my pain fluctuated in a capricious and arbitrary way, in both degree and location, extending beyond the boundaries of nerve distribution and of the localization that would result from disk prolapse.

"Daddy, is your back OK?" my kids would ask. "Can you carry me today?" My anxiety developed into a sad mood. My colleagues noticed. "You are not smiling anymore," they would remark. No, I was not smiling; I was in pain, I was in agony, and I had no cause to smile. I was incapacitated.

Because the pain did not improve with bed rest and painkillers, I visited my doctor, who got me into the routine of analgesics, nonsteroidal anti-inflammatory drugs, and eventually narcotic medications. Magnetic resonance imaging showed a disk protrusion between the fourth and fifth lumbar vertebrae. On my doctor's recommendation, I saw chiropractors and physical therapists. Ten minutes after one of my physical therapists told me that only surgery could help, I started having painful sensations down my legs.

I began to follow a treatment routine of lying on my back and applying ice blocks and a hot water bottle. I began mild stretching exercises, and I always used a back brace. After a year, twenty-odd sessions with three different chiropractors, and another 20 sessions with three different physical therapists, I found myself on the operating table having cortisone nerve blocks. Four months later, I was preparing for back surgery.

At that point, my department chair gave me a book to read: Healing Back Pain: The Mind-Body Connection, by John E. Sarno, M.D. (1). Dr. Sarno, whose field is rehabilitation medicine, believes that pain is created in the body as a defense against unconscious rage. In this book he discusses the role of tension and stress in the etiology of back pain. After some experience in treating patients with back and neck pain, he concluded that most of these patients were not suffering from a localized structural lesion but from a more generalized process. This process, he says, is common among people with certain personality traits. Most of these people are hard working and conscientious and are pleasant or nice.

I saw myself in the book. It was embarrassing to realize that I was so typical, but reassuring to learn that my back was probably normal.

Sarno's theory is that the brain produces pain to prevent unconscious rage from becoming conscious and causing unpleasant emotions. The source of unconscious rage may lie in various types of experiences or personality traits—for example, from physical, sexual, or emotional childhood abuse, from abandonment or rejection, from having a perfectionist trait or a "pleasant" personality, and from current life stresses.

Sarno hypothesizes that the autonomic nervous system—normally involved in the fight-or-flight response—causes constriction of blood vessels as a response to unconscious rage. This vasoconstriction leads to ischemia in the back muscles, causing spasm and low back pain, and of the sciatic nerve, causing pain radiating toward or down the leg. Any other part of the body may be affected as well, although most commonly the upper back, shoulders, neck, and arms are involved.

Sarno's thesis suggested that while consciously I was "coping properly and being a compassionate and pleasant person," my unconscious or id was enraged. While outwardly I was handling difficult situations well, I was accumulating anger in my unconscious. The more the pressure, the more the rage.

Reading Sarno's book put me in turmoil. Had I been abused as a child? Certainly my parents raised me to be hard working. They did not believe in the word "impossible." "If you set your mind to it, it can be done," my father would say. As an African immigrant, I was even more determined to succeed, since I was expected to be conscientious and hard working. But don't all young faculty members feel this way? With reflection, I realized that I needed to be liked and respected.

I was reminded too of my father's words some years back: "He works hard, he does a great job, he will become a doctor." Was I angry with my parents? Had my past caught up with me? Was I angry at society for rewarding excellence? According to Sarno, my back pain was a defense, a camouflage, a diversion, or a distraction. It distracted me from being aware of my emotions, and I focused my attention on my body instead of on my mind and my emotions. Thus my pain had released me from a stressful situation filled with anxiety and fear. It was a ticket to the safety of the doctor's office. I felt the need to keep the primitive, angry, selfish, and antisocial feelings repressed, and the pain solved this problem, or so my mind seemed to think.

It also began to dawn on me why my pain was shifting from one part of the body to another—why I was having pain in my left leg when the MRI showed the slipped disk on the right side; why I was having pain in areas outside the distribution of the L5 nerve; why I was given conflicting advice about sitting, bending, exercise, and driving; why nothing worked. The pain was in my mind, not in my back. The pain was caused by tension myositis syndrome. The more the rage threatened to erupt into consciousness, the worse the pain became.

This was a difficult set of notions to face. I knew my anatomy text. I had learned about the etiology of sciatica in medical school. How could I discard basic scientific knowledge that I had held for so long? Would I be betraying my profession?

Becoming aware that the pain served as a distraction from the enormous unconscious rage I felt was the beginning of my recovery. It was as though a heavy weight had been lifted from my shoulders. I became less anxious and less obsessed with my back pain and my physical limitations. I felt I was ready to move on. I realized that my symptoms were due not to the prolapsed disk that appeared on my MRI but to tension myositis syndrome—a generally harmless condition that causes mild oxygen deprivation to the body but can also cause severe symptoms.

I began "talking" to my brain: "Do not distract me with this pain; I am not afraid to confront my feelings, issues, or emotions. Stop playing tricks on me." I started thinking "psychologically" about my repressed emotions and anger. I allowed myself to think about my past and what I had missed during my childhood. I changed my behavior and began to express myself more openly. It is OK to say no, I realized.

I continued to acknowledge my suppressed emotions and freed them from my unconscious. I resumed my normal activities, including my daily exercise routines. I resumed jogging, I discarded my lumbar support, and I stopped my sessions with chiropractors and physical therapists. I resumed playing with my children. The secret was out, and my brain could not play this trick on me again.

Three weeks after I accepted Dr. Sarno's explanation of my pain, I started to get better; the pain in my back lessened, and the pain radiating into my leg vanished. My confidence increased, and I began living a normal life again. Emotionally, I became less anxious about my back, my work, and my family. As the pain lessened in intensity, I had fewer and fewer sad days. "It is good to see you smile again," my colleagues said.

The pain had always been in my mind. The anatomy of my back had been in my mind. The brain had found another way to distract me. For the first time in over a year, my first reaction to the pain was not fear, not anxiety, not a sad mood, and not reaching for painkillers.

Dr. Alao is assistant professor in the department of psychiatry and associate director of the division of consultation-liaison psychiatry of the State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, New York 13210 (e-mail, [email protected]).