At the beginning of his medical career, Dr. Sarno wondered why so many of his patients did not heal from pain, and why he couldn't help them recover from this common form of suffering. After years of observation, treatment, and developing insights into the matter, he arrived at a different explanation for the cause of pain, one that is not necessarily rooted in structural changes of the musculoskeletal system.

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Sarno based his new explanation on research that found a decrease in oxygen supply to tissues during pain, and accordingly, he hypothesized that pain is created by a temporary reduction in oxygen supply to supporting tissues of the neck, back, and legs such as muscles, nerves, and blood vessels. Physiologically, this is a very logical explanation; a decrease in oxygen in tissues would cause them to use sugar, and the “burning” of sugar releases lactic acid—one known and common cause of pain.

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This seemingly small change in the theory already holds within it significant psychological potential for those suffering from chronic back pain—the knowledge that the pain does not stem from permanent structural damage, but rather from reversible and changeable physiological alterations, can release much of the tension hidden within the thought that “the damage is forever,” and release many of the fears that burden chronic pain sufferers. 

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Of course, there is another question that needs to be addressed. If oxygen supply to tissues decreases and causes pain, what triggers this reduction, and why does it happen in the first place?

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On this point, Dr. Sarno proposes an interesting theory that links daily psychological processes to the development of pain. In Freud's psychosomatic case studies, we can find the first descriptions of symptoms linking the body to our emotions.

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Freud claimed that these symptoms were related to hysteria and caused by a direct psychosomatic connection. However, Dr. Sarno's explanation is slightly different in that he expands the range of people prone to develop psychosomatic symptoms in our time. In fact, he argues that we are in an era in which psychosomatic or mind–body symptoms are reaching “epidemic dimensions.”

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In the current era, in which we are required to deliver high results under stressful deadlines, perfectionism and the tendency of many to suppress emotions can lead to emotional repression, even of mundane emotions like frustration, anger, or disappointment. According to Sarno, this tendency to repress emotions leads to the accumulation of difficult emotions in the subconscious, and when these remain unattended to, they can manifest through a brain-based series of reactions as chronic pain.

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Another group that is prone to developing chronic pain symptoms are those who have experienced a traumatic event (emotional or physical) in their lives preceding the onset of pain, as well as those who experienced numerous traumatic events in their childhood (a comprehensive study by the CDC and Kaiser Permanente Medical Center confirmed the connection between traumatic life events in childhood and the development of medical problems later in life, including pain; CDC-Kaiser Adverse Childhood Experiences Study).