Could I trouble you to list the seven categories?
In addition to the four categories I listed above, a fifth is information provided by our five senses (vision, hearing, taste, smell, and touch). For example, if you see an x-ray that shows a bulging disc (vision) and your physician tells you that is causing your pain (hearing), that can be a DIM and make your pain worse. This category can overlap with the category I listed above of what you think and believe. Maybe you saw the x-ray and your physician said nothing about it, but elsewhere you had (mis)learned that bulging disks always cause pain.
A sixth category is things you say. An interesting element of this category is metaphors that we use without realizing their psychological impact. For example, “my knee is like a rusty hinge” and “I have a splitting headache” are DIMs. In contrast, “my meditation releases some pressure” is a SIM.
The seventh category is things happening in your body. Acute inflammation is an example. For many people this is a DIM, but it can be a SIM if you understand the biophysiology of acute inflammation and realize the healing process is underway. Obviously, this category also overlaps with the category of things you think and believe.
Regarding the rage-soothe ratio, the only place I am aware of where Sarno discusses it is on page 29 of
The Mindbody Prescription. His discussion is brief (2 paragraphs) and seems tentative—“I believe a rage/sooth ratio
may play a role in determining when physical symptoms will occur.” (I added the emphasis.) By the rage part of the ratio, I think Sarno means the reservoir of rage—“Patients frequently ask, ‘Why did the pain start now?’ Invariably I reply, ‘Because your rage has reached a critical level; because it now threatens to erupt into consciousness.’” As for the soothe part, Sarno refers to “pleasant elements in a person’s life,” and on page 29 he lists six basic human needs, one of which is “To be soothed (so we seek gratification through food, drink, smoking, sex, entertainment play.)” For Butler & Moseley, the concept of DIMS is much broader than accumulated anger in Sarno’s reservoir of rage, and the concept of SIMS is much broader than pleasant elements in one’s life and gratification through food, drink, etc.
Now for something I think is quite important, namely, a congruence in Sarno’s and Butler & Moseley’s approaches. For Sarno, the key to treating TMS was educating patients about “The Psychology of Psychosomatic Disorders” (to borrow the title of chapter three in
The Divided Mind.) In chapter four, he wrote: “It soon became evident that
knowledge was the key to treating TMS. . . . Another crucial therapeutic element became clear early on as well: the person must not only
understandthe nature of the process but be able to fully
acceptit as well.” (The emphasis is Sarno’s.) As far as I can tell, Sarno does not regard patient education about the process as fitting on the soothe side of the rage/soothe ratio. It is instead the key treatment. For Butler & Moseley, educating patients (albeit about the biopsychosocial model of pain and its neuroscience of basis), is a gigantic SIM if they understand and accept it. But education is their key treatment.
To finish on a bit of a tangent, I think the big difference between Sarno and Butler & Moseley is that they come from different eras. Sarno was a brilliant clinician and keen observer of what did (and did not) work with his TMS patients. He naturally wanted to place what he was seeing with his patients into a coherent conceptual or theoretical framework. The best such framework available at that time was Freud’s hydraulic model and structural theory. Hence Sarno’s reservoir of rage, id-ego-superego conflict, and pain as a defense mechanism. I think Sarno’s reliance on Freud, together with the dominant view in the medical establishment that Freudianism is “unscientific,” accounts for much of Sarno’s lack of success in gaining acceptance by the medical establishment. A fond remembrance of Sarno written by a former patient upon Sarno’s passing that appeared in the New York Times Magazine recounts Sarno’s lack of success in that regard and how “enraging” it was to him. His medical colleagues at NYU regarded him as a laughing stock.
Within the last two or three decades, neuroscientists have learned much about the neuroscience of pain that was unknown during Sarno’s era. With this new body of knowledge available, reliance on Freudian theory is no longer necessary to explain what is going on with psychosomatic pain. Butler & Moseley pay no attention to Freudianism but rather focus on the biopsychosocial model of pain and its neuroscience foundation. While I believe their regard of emotions as DIMs and SIMs is implicit, I wish they would have given some explicit attention to that. More important, though, I think they undoubtedly would agree with Sarno that patient understanding and acceptance of the process that produces psychosomatic pain is the key to treatment. Perhaps their neuroscience foundation, rather than Freudian foundation, will lead to greater acceptance by the medical establishment than Sarno achieved.
Aside from the medical establishment, what about patients? In the
Divided Mindp. 6, Sarno wrote: “After many years of experience it is our impression that not more than 10 to 15 percent of the population would be willing to accept a psychosomatic diagnosis.” I noted earlier that David Butler got a Ph.D. in education to further his “professional love of devising ways to take the complex ‘gifts’ of neuroscience to students, clinicians and sufferers in ways that can change their lives.” Perhaps Butler’s tips in chapters 8 and 9 of
Explain Pain Supercharged about educating patients could raise the percentage. (To temper over-optimism, Butler admits that some people’s misconceptions about pain are so strongly held that the most one can do is plant a seed and hope it will flourish at another time and place when the situation is right for that person.)
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